 Lateral ankle sprains are among some of the most common sports medicine injuries each year. We often see this injury with basketball players as we did recently with Kawhi Leonard in the NBA playoffs. However more often than not, unless its a grade III sprain, we can get our athletes back on the court or field pretty quickly. Yet it seems like this is an injury that is often prolonged because of a few critical mistakes early on in rehabilitation. Let's talk about what you can do to quickly get your athletes back in the game. Critical Points to Consider There are a few questions you have to ask yourself when an athlete comes in to see you. First, do they have a broken ankle? Refer to the Ottawa Ankle Rules when considering if they need an X-ray. More often than not they don't if they can walk and are not tender to touch over bony areas. Second, do they have a high ankle sprain? While less common, this does occur. Be sure to take a through subjective report to understand the mechanism of injury and previous injury history. The last thing to be sure to consider is what the athlete's practice and game schedule is like. If you can get your athlete in to see you everyday for the first few days you can do a lot of good right away to get things moving in the right direction. Treatment The most important thing is to begin bringing down the swelling. Contrast baths, manual flushing, and elevation of the leg is typically very effective early on. However, one mistake I often see is therapists do not tape or compress the athlete after treatment to continue to improve the swelling. My favorite technique that I learned is a horseshoe technique that is great at improving swelling. Another technique you can use is squid taping with K-tape which is also effective. Lastly, if you don't have access to tape I would suggest having your athlete pick up a compressive sleeve. The next part of rehabilitation is the ROM and strengthening part. Range of motion should start immediately as the ankle will stiffen up from the pain and swelling. Working on ROM exercises such as ankle circles, ankle pumps, and calf stretches in the beginning are fine but as the pain tolerance improves using half kneeling ankle mobilizations against a wall or manual techniques can make big differences. As far as strengthening goes, I typically like to start manually resisted ankle strengthening quite early as I can control the range of these strengthening exercises. Typically I will start by having my athlete match my pressure so it is more of an isometric contraction but will gradually open up the range. Other exercises include towel scrunches, marbles, ankle theraband, calf raises, and lots of core and glute retraining. Many research studies have shown the importance of strengthening glutes after ankle sprains and quite frankly it just makes sense to keep the body stronger above. In addition, improving work capacity early on can make the transition back to the court/field much easier. I like to get my athletes on the bike as soon as possible. If they cannot tolerate a bike I will get them going on the upper extremity bike. Lastly, working on proprioceptive balance exercises early on is important for furthering rehab. Start with just single leg balance and progress to unstable surfaces and using arm and leg drivers to change planes of motion. Summary 1. Control swelling: - Contrast Baths, Manual flushing, Elevation of leg, compression sleeve, K-tape, Horseshoe tape technique (favorite) 2. Range of Motion: - Ankle pumps, Ankle circles, Baps board, Calf stretching (towel stretch, against wall, slantboard), Half kneeling ankle mobilizations against wall, Manual mobilizations, Bike for early movement or upper body bike to keep them in shape 3. Strengthening: - Ankle/Foot: Manually resisted 4 way ankle strengthening to ankle theraband to calf raises, towel scrunches, marbles. Glute and core retraining. 4. Balance: - Single leg balance, SL balance w/ eyes closed (stay close by), SL balance on airex, SL balance with arm and/or leg drivers to challenge further planes of motion 5. Work Capacity: - Get them on the bike or upper extremity bike (if you have access to one) ASAP to keep them moving and in shape. AlterG is great for retraining gait and running - Dr. Brian Schwabe, PT, DPT, SCS, CSCS *Check out the Insider Access video on my return to sport progression & testing for ankle sprains*  For more advanced examination and treatment techniques, check out The Insider Access Page. Our goal is to help you improve your clinical reasoning, exercise prescription, and manual techniques.
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 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. http://blog.paleohacks.com/tennis-elbow/ Brian Schwabe, PT, DPT, SCS, CSCS Board Certified Sports Clinical Specialist in Physical Therapy/Strength & Conditioning Coach/Fitness & Medical Writer Sports Physical Therapist in Los Angeles, CA  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.
http://www.thesportsperformancept.com/blog/concussions  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! - Brian Schwabe Board Certified Sports Clinical Specialist in Physical Therapy/Strength & Conditioning Coach/Fitness & Medical Writer Sports Physical Therapist in Los Angeles, CA
  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. - Brian  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. - Brian 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..... Glute Exercises:
Core Exercises:
- Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS Looking for advanced sports and orthopedic content? Take a look at our BRAND NEW Insider Access pages! New video and lecture content added monthly.  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? - Brian
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