Tennis elbow or lateral epicondylitis is a common condition physical therapists typically see. More often than not, tennis players are not the primary patient population with this condition. Instead, its the desk worker or handyman. Tennis elbow can be tricky to treat as a young clinician or when you do not have much experience with it.
Understanding what tennis elbow really is and how to explain it to your patient correctly is important to establish a proper treatment program. As with other overuse injuries, most of the recommendations I give to patients include finding what activities produce the most pain (triggers). I wrote in more depth on tennis elbow is this article below. Check it out for information on the condition and home exercise treatment options for your patients with tennis elbow.
- Brian Schwabe, PT, DPT, SCS, CSCS
One of the things that I am constantly thinking about in the clinic (and outside of it) is how motor control, movement, and learning can be improved. We all had a basic course on this in PT school but it goes so much deeper than that. Every athlete is different and some are motivated to improve a task based on their past experiences and some are motivated by fear of failure. Just as important though is the internal and external environments that drive the athlete's ability to perform the task. In the below article I talk about some of my thoughts on this....
Concussions are a hot topic these days and with more sports residencies forming, many clinicians will need to know about this subject. However, we must also understand what tools are out there to use. When new tools come out we must educate ourselves on the subject. Furthermore, we have to understand how to communicate and educate to parents, athletes, and coaches correctly. It is very important to make sure they understand the process when dealing with concussions. See this post below.
I recently had a post-op ACL patient who complained of hamstring tightness. While this is a common problem following ACL surgery, there is often other reasons for the hamstrings presenting as "tight". Once swelling is under control it is important to look at the underlying causes of what can make hamstrings seem tight or overactive.
Usually there are 1 or 2 causes for this:
- Stiffness of the hips (primarily hip flexors, TFL)
- Poor lumbopelvic control
Lets assume that the hip flexors and TFL are overactive, which is a common problem these days. If we respect the anatomy and the pull it has on the pelvis then we can understand how an anterior pelvic tilt can cause the hamstrings to be overactive. Treating this is easy, either work on the flexibility of the hips flexors if it is a true length problem, or work on the soft tissue mobility if it is a tone problem.
However, sometimes the problem is the lumbopelvic control. If the core is unable to control the pelvis then one can fall into an APT. Being sure to address motor control of the core (hips/TA) is important to re-establish normality of the pelvis. This being said, be sure to also address diaphragmatic breathing and good lat tone to ensure you are not missing any components!
One of the biggest mistakes I see new grads and students make when going through an evaluation is the order of testing they do things in. Also, the amount of testing they do. For example, screening out the entire body with every ROM test, special test, and manual muscle test may be great for insurance companies but it may not be the best use of your time. Instead, I suggest looking at standing tests first (when applicable of course) and then table tests.
The reason I like standing tests first is because I can screen out movement first and follow that up on the table to break things down further. An easy example is the single leg squat. When I look at the single leg squat I am having the patient perform the squat like they normally would, no cueing. If I see a movement impairment then I am next trying to figure out if it is a motor control problem, strength problem, ROM problem, or a combination of the three. There are many ways I would screen this out (assistance, etc). In other words, is it a stability problem or a mobility problem first? By jumping to on table tests first one may assume that because the glute med was weak that is the problem. This may not be the case. Instead, try to use your table tests to help rule in or out your theory.
An interesting article came out in Forbes today. It talked about the change in how NFL draftees are preparing for the NFL combine. Each year agents have to pitch to their clients and these days having a facility for their clients' needs are crucial. The reason why this is important to us sports physical therapists is because as we continue to evolve we will become part of this system more and more. I have treated many NFL draft hopefuls who are going through rehab leading up to and after the draft. Many times they have a facility to do their training and understanding how their process works is very important. Knowing how to communicate between the agent, doctor, and strength coaches can become very difficult when all of them are in different places. However, understanding why and how these players are being treated is vital to making their process successful.
Be sure to understand everyone involved in the player's care. It's a team effort.
As I continue to evolve and improve my skill set I have noticed a strong tendency for improper breathing techniques with patients. Especially with athletes, breathing can be the difference between allowing a patient to fully recover and not. What I mean by that is the way our breathing is affects everything. PRI does a fantastic job of going into depth with this ever evolving idea. Many patients who struggle from neck and shoulder problems for example can contribute it to breathing incorrectly. Below is a good refresher video for the mechanism of breathing. Take a look and think about this with some of your patients.
We often prescribe glute and core exercises in our clinical practices. Yet year after year I see only 4-5 used by students and residents. I'm a big fan of having a large exercise bank to choose from to make sure we keep things fresh and progressive as needed. Here are just a few of my favorites.....
The tuck jump is a useful and practical evaluation and return to sport test. Many people forget about the tuck jump when going through their return to sport criteria but I think it is an undervalued test. Lets go through some of the things the tuck jump helps with....
- Looking at valgus of the knee's before, during, and after the jump
- Control- Are their thighs parallel during jump? Do they favor one side?
- Foot contact: Shoulder width apart, foot placement, foot timing, How hard are they landing?
- Plyometric: Technique and power- is their a pause? Are they landing in same spot each time? What do they look like in the flight of the jump?
I recently went through four different return to sport cases with my patients this past month. Three were ACL and one was an internal impingement case. Each time I make decisions about return to sport I consider the patients characteristics. While the research tells us certain tests are good, they don't always apply to our patients. Digging deeper to make sure you take each case on an individual basis is more important.
Take an ACL patient that is very low tone for example. They are going to have a very difficult time gaining strength throughout their rehabilitation. Furthermore, imagine if they were a mechanical mess. Clearly this is an example of a patient who may need some extra work and a much longer recovery time. So how would I approach one these patients? First I would look at the time frame and their requirements for the sport. A patient who is low tone and an MMA fighter would be out for at least 9-10 months due to the extreme positions their sport requires. But a patient who is low tone and baseball player may be able to return sooner depending on his position and mechanics. Again, it's all patient dependent. Another thing I might look at for a low toned patient is how their strength is transferring to both mechanics and power. Often times I've seen these low toned athletes get strong but struggle with controlling that strength. Spending additional weeks and months on mechanics can make all the difference. Lastly, how is their psychological state? I recently had an athlete that did well with his return to sport testing but was not confident in returning to game action. Did I return them? No, I didn't because mentally they needed to feel confident. This is where referring out to a sports psychologist can be useful. Furthermore, my approach with that patient has changed to provide additional encouragement and show them how good they have performed in the clinic.
Returning athletes back to their sports can be difficult. We must take into account so many variables (fatigue, strength, pain, psychology, mechanics, biomechanics of sport, power, etc). Most importantly though we must individualize it and understand the characteristics each patient presents with.
|The Student Physical Therapist||
Sports Physical Therapy