Ski and Snowboard Injuries

By: Dr. Laura Wenger, PT, OCS

Is anyone else as ready as I am to see those first flurries of fall come down? When the weather starts changing and ski swaps start becoming a regular weekly occurrence, I’m sure I’m not the only one that starts dreaming of powder days at the resort and in the backcountry. In fact, in the US alone, over 18 million people skied or snowboarded at least once during the 2011-2012 winter season, and with the rate of growth in those sports we can only assume that number has grown over the past couple of years.(1)

We all know the risks of skiing and snowboarding that are present, as it’s rare to come across someone who doesn’t have an “epic” yard-sale story. I’ll never forget the day last winter that I hit a patch of “brown snow” in the backcountry and completely went flying head over heels as my momentum had been completely halted due to the snow friction transition. Luckily, I just stood up, found my skis, and shook off the snow that had accumulated in my jacket to continue the rest of my journey down to the car and a warm drink. Unfortunately, not everyone is so lucky, and as PTs in a mountain town we tend to see our fair share of skiing and snowboarding injury aftermaths.

laura-backcountry-skiing

A recent study from The Orthopaedic Journal of Sports Medicine compared surveys that were taken at Big Sky Resort in Montana in 1996 and 2013 to see how the amounts and types of skiing and snowboarding injuries have evolved over time as the sports have become more and more popular.1 In 1996, 85% of the injured participants surveyed were skiers and this number dropped to 73% in 2013, showing that there were more injured snowboarders (possibly related to more snowboarders being on the hill).1 The average age of those being injured stayed 34 years old between the two time periods but, in general in the survey, injuries were occurring more often for those in the 46-55 year age group.1 Some great news is that the number of participants wearing a helmet jumped from only 6% in 1996 to 84% in 2013!1 It seems like people are wising up with helmet use in an effort to reduce their risk of head injury.

In terms of what body parts are more frequently injured in skiers, it looks like the knee still is the winning joint totaling to about 28% of all injuries both in the past and more recently.1 However, the proportion of shoulder and arm injuries increased significantly for both skiers and snowboarders, and those types of injuries continue to be the most common in snowboarders totaling 33% of all injuries in 2013.1 Also of note, the number of injured participants who had never received any professional instruction increased from 19% in 1996 to 30% in 2013, and the number of injuries that occurred while using rental equipment increased from 27% to 39% in the most recent survey.1 This suggests that more infrequent and novice skiers are the ones that are the most likely to be injured.

Granted, this is only based of surveys taken from one ski resort in the country. However, it is interesting to see the trends that have occurred over the years as these sports continue to evolve and grow in participation. Hopefully you will be one of the lucky ones that will avoid injury this coming snow season. However, if you do happen to be one of those folks that sustains an injury while out on the hill this year, know that you can count on a qualified group of physical therapists to get you back out as soon as possible to enjoy another powder day.

  1. Patrick E, Cooper JG, Daniels J. Changes in Skiing and Snowboarding Injury Epidemiology and Attitudes to Safety in Big Sky, Montana, USA: A Comparison of 2 Cross-sectional Studies in 1996 and 2013. Ortho Journal Sports Med. 2015;3(6). doi:10.1177/2325967115588280

The Squat: Part 3

By: Jeff Yaskin, PT, MPT, MTC, CSCS

This is the final installment of the squat series, where we will discuss the myriad of ways you can incorporate squatting into your workout. In part one we discussed the many health benefits that simply squatting provides throughout the day. In part two we discussed some of the fine nuances of form that make a proper squat and those that are detrimental in terms of poor form. As we discuss the various ways that you can incorporate squatting into your workouts, remember that you are in charge of your body and how it works. Many of the squats that we will discuss will be fine for a person to perform if they own perfect movement mechanics but for someone who is movement challenged these squats may very well aggravate your system.

I will breakdown the squatting by starting with the least challenging or the least functional squatting and then slowly progress to the most challenging and the most functional. Notice that I lumped the words challenging and functional together which was done on purpose. Typically, but not always, a movement that is very challenging to perform also has a high correlation to function. Full body movements that are challenging to the central nervous system are such that the exercise becomes self limiting. Mindless repetitions cannot be performed and these self limiting exercises seem to help asymmetries, movement pattern problems and minimize the chance of incurring a repetitive trauma type injury. Are you ready??? Here we go.

Barbell Back Squat
Barbell Back Squat

The barbell back squat has been around since man invented the barbell. This type of squat is the least functional for a number of reasons. The first being – what type of daily activities do you perform where you have a load on your back and you repetitively squat up and down. Rarely if ever. The second issue is that with the back squat you can have absolutely horrible form and still complete the squat which of course is a bad idea to continue this habit. Second, because the bar is on your back you can perform this type of squat with fairly heavy loads and again still complete the movement which will place unnecessary stress on your spine. Third, because you can lean forward with the weight on your back, you increase the lever arm on your spine which ramps up the stress on the lower lumbar discs and, again, place unnecessary loads on the spine. Many traditional athletes and coaches still swear by this type of squat as being the holy grail of training but in recent years we have seen many new age coaches understand the limited carryover of this type of squat to actually improving their athletes performance on the field. I should mention that the picture that I choose above displays horrible form yet the squatter was probably successful in lifting the weight. Personally, I would never encourage anyone to perform this type of squat.

Barbell Front Squat
Barbell Front Squat

The barbell front squat is a common exercise to those who know the Olympic lifts. It is a much more challenging exercise than the barbell back squat and for many reasons a much more functional exercise. First by the nature of having the barbell across the front of the shoulders and resting on the fingers much less weight can be used than during the barbell back squat. Since less weight can be used during this squat, there is less strain on the lower back and that is always a plus. Second, because the weight of the barbell is resting on the shoulders and fingers the spine or trunk must be upright and if the trunk starts to lean forward you are surely going to drop the weight forward. The fact that the spine/trunk must stay very upright also places less strain on the lower back. Third, because the shoulders, elbows, wrists and fingers are stretched to maintain the front rack position this helps maintain a level of flexibility in these joints that is not stressed in the barbell back squat. This exercise has more carryover to daily activities then the barbell back squat. I recommend this type of squat even for beginners.

Barbell Overhead Squat
Barbell Overhead Squat

The king of barbell squat exercises. This exercise is the most challenging barbell squat exercise because the arms are now holding the entire weight of the barbell in an overhead press position. This type of squat demands maximum thoracic extension, scapula mobility and shoulder stability. Plus while the thoracic spine is staying in extension the lumbar spine is slightly flexing at the bottom of the squat requiring a high level of core flexibility and stability. This type of squat demands thought while you are performing the exercise so it is very central nervous system (CNS) intensive. You can not perform mindless reps of this exercise while watching the TV at the gym, the overhead barbell squat requires total focus. When you become proficient in performing this exercise with heavy weight, normal daily activities will seem like a breeze. This exercise will also carry over into improving other functional activities such as sprinting and jumping. I recommend this type of squat for intermediate level lifters.

Goblet Squat
Goblet Squat

The Goblet Squat is probably the most functional dumbbell or kettle bell based squat. Look at the position of the kettle bell, it is exactly in the same position you would be carrying an item that you needed to squat down to the floor with. While the overhead barbell squat requires more coordination, flexibility and stability, the goblet squat more closely resembles a daily activity therefore has more carryover to enhancing a movement you are more apt to perform. That is what training is all about. Proper form in the goblet squat allows an upright trunk which stays in neutral allowing the hips, knees and ankles to perform all the motion. This is congruent with the principles we discussed in the Squat Part 2. If you have never squatted before as an exercise this is probably the best introductory weighted squat for you to incorporate in your training. I highly recommend this type of squat even for those who have never lifted a weight before in their life.

Dumbbell Overhead Squat
Dumbbell Overhead Squat

The Dumbbell Overhead Squat is another variation of the overhead squat. Obviously holding separate weights in each hand instead of a bar places more challenge and demand on this exercise and that is a good thing. If you have an asymmetry in one shoulder vs the other this type of squat with typically expose that issue. That is why these challenging and purposeful exercises are wise to perform periodically because they help you realize a movement issue by challenging the CNS and your musculoskeletal system. A barbell back squat will not challenge the system like this squat will and therefore a shoulder or trunk or hip problem might go unnoticed. I perform this type of squat once a month as a warm-up for heavier barbell overhead squatting simply to test my movement. I recommend this type of squat as a warm-up or test but not as a heavy exercise unless you are an experienced lifter.

Pistol Squat
Pistol Squat

Life is not all about being on two feet all the time. Think about sports, are you on both feet all the time. Rarely! The majority of sports require running, sprinting, cutting, decelerating, hopping or jumping. This predominantly requires each leg to be able to perform independently of what the other leg is doing. This requires near perfect trunk control to be able to balance and coordinate the action of standing on one leg and allow full weight bearing through maximal range of motion. This is not a beginner exercise! Only those desiring maximal athletic performance and bulletproof joints should perform this exercise. As a prerequisite you should be able to perform all of the above squats with at least bodyweight as resistance prior to trying the pistol squat. If you have any known back, hip, knee, ankle or foot malady this squat is not for you. This squat should also be performed without resistance first to see if you own the balance, flexibility and control required. Then once you display competency external resistance can be added. The risk and reward for this squat should only be accepted for the extreme athlete therefore I am highly cautious in recommending this exercise unless I have observed your movement level.

squat-3-7

The Candle Squat
The Candle Squat

Are you serious? The candle squat as created and probably only able to be performed by Jerzy Gregorek. For those of you unaware of this man’s ability, I implore you to visit The Happy Body website where Jerzy outlines a baseline level of nutrition, flexibility, strength and stability that is unparalleled. If you were looking for the gold standard in squatting than this is platinum. This gentleman’s ability to move makes me absolutely jealous. A picture is worth a thousand words so I will stop writing. If you are even remotely close to possessing the ability to perform this squat then stop reading my blog as reading any further could only surely cause you some level of dysfunction and we wouldn’t want that.

Conclusion

To summate all that we have discussed in this three part series on the squat, I must confess that there is surely an awful lot that I have not discussed or by constraint omitted. The subject of squatting is vast and the breadth of information fills whole books. The important point that I wanted to convey over the past few months on this blog is the importance of correct daily squatting.

Just like your motor vehicle requires oil changes, tire air pressure checks and other routine maintenance your body requires daily squatting as maintenance for baseline musculoskeletal health. Your body requires other daily movement different than squatting to maintain its health as well. Dr. Kelly Starrett has come to the conclusion that 10 minutes a day in the deep squat is a good baseline. Proper daily squatting is similar to eating whole food for your nutrition and getting eight hours of sleep a night in terms of health for your body.

I encourage readers to educate themselves on their own performance by having your movement assessed by a professional. Having your movement assessed by a trained individual can be enlightening, eye opening and explain if you have been consistently injured or stuck in a rut with your performance. Please call our office and I will be glad to run you through a functional screen. Two people who possess near perfect movement ability and should therefore be emulated are Jerzy Gregorek, who was mentioned earlier, and Steve Cotter of IKFF and kettle bell fame. Both of these people can be found on YouTube and their websites on the internet. Here’s to your health, happy holidays and happy new year!

The Squat: Part 2

By: Jeff Yaskin, PT, MPT, MTC, CSCS

In this second of three part series on the squat we will discuss foot placement, form and posture which aid in making a more efficient squat. In the first part of this series I discussed some of the important reasons as to why we should squat. Before I delve into specifics about aspects of squatting I want to remind the reader of some important details. First we all learned how to place ourselves in the squat position by starting on the ground first and allowed trial and error to “find” our own perfect squat form. No teacher stood next to us giving us cues or suggestions or tips—we simply kept trying and trying until we “got it” and we probably smiled when we achieved our first squat. My point is that it will truly take “you” to take yourself through trial and error and possibly endless repetition to slowly improve your squat. No one can do this for you but you.

Chances are you are past your teenage age years if you are reading this and years of sitting in classrooms, traveling in cars, making poor exercise choices and the litany of other daily environmental dysfunction has tarnished your once stellar squat. You are not alone. Very few young people today even in their college years possess an unblemished squat. Whole movement like a squat demand that multiple joints, muscles, fascia, motor control and lack of pain are working in total harmony. That ankle sprain you experienced in middle school, the torn ACL you injured on the ski slopes or that hip pain you developed while training for a marathon might already predispose you to a poor squat. The take away here is to acknowledge if you already are aware that you possess a movement problem. How well do you know yourself?

squat-1

I’ve met people who know how fast it will take them to hike up Smelter Mountain within a few minutes but have no idea if they can squat well. Similarly, some people are oblivious to how well they can lunge or how well they can balance on one leg. Can you stand with your knees straight and touch your toes or touch the floor? Knowing how you move with just the force of gravity and the ground underneath you is the most basic movement information you should know about yourself. Why? Because from the second you left your mothers womb till about 12 months of age that is exactly the environment in which your brain learned how to move.

Your body, gravity and the ground- let the learning begin!
Your body, gravity and the ground- let the learning begin!

Yes you learned how to move. Most of the other primates and all other mammals popped out of mommy and within minutes to hours are up on their feet and walking around. Their nervous system was hardwired with the basic locomotion software to get them moving within day 1. You and I and every other human that ever walked this earth and every human that will ever walk this earth learned how to move through progressive patterns building on each other and culminating into efficient walking. Your brain is learning every second of the day you are awake. You are either learning something new every second or reinforcing something you already knew. You can always teach an old dog new tricks as long as the old dog wants to learn them.

Our brains’ awesome ability to continuously learn is a double-edged sword. It’s double-edged, because you can’t cherry pick what you want it to learn and what you don’t. What ever you are experiencing at the moment your brain is taking in the experience and learning something from it. When we were babies and learning to move we were full of mobility and a desire to move. We didn’t have sprained ankles, torn ACLs or unhappy hips, we were basically free from dysfunction and our brain learned how to move based on this clean slate. Once we developed handed-ness that was the beginning of dysfunction. The more asymmetrical you are in terms of what one side of your body can accomplish vs the other increases your risk of injury while you perform daily activities. Previous injury to a body part increases your risk of injury. Your brain has learned to overcome this issue.

At the top of the hierarchy about what your brain cares about is not how well you squat. It cares about survival! When you were younger and running around the yard and tripped on your knee you got up, assessed the situation and because your knee didn’t hurt “that” bad you kept running around. Except now instead of running around with flawless gait you are limping a little. Your brain doesn’t care, good or bad, you are experiencing a new way to move, right or wrong, optimal or not—you are still learning and you are learning how to run with a limp. The more you run with a limp the more your brain is learning a new pattern of running and if you continue to run in this new fashion your brain will totally re-write its software pattern. Until, you start running “normally” again and then your brain will re-learn the original pattern and your running pattern should return to its near original efficient pattern. Your brain cares about your survival. If you are still alive and you run with a limp, your brain is ok with that. Are You?

The most amazing thing that scientists have discovered in our universe and you own one! This guy can be your best friend or your worst enemy- be good to yourself!
The most amazing thing that scientists have discovered in our universe and you own one! This guy can be your best friend or your worst enemy- be good to yourself!

Why bring up how your brain learns? Because your squat pattern has probably been
slowly progressing into an inefficient pattern through the years or maybe you simply don’t squat at all. That is good news! You have realized your current baseline and since your brain has the ability to learn, you can learn a new and more efficient squat pattern. All you need is the desire and the right path. Let’s see if you are ready!

This simple test tells me that you are not ready to squat.
This simple test tells me that you are not ready to squat.

Stand up with your feet together and keep your knees straight. Now bend forward and touch your toes. Can’t reach your toes? YOU are not ready to SQUAT!

Why not?

Your hips are not bending enough. If you try practicing a full depth squat your back will be flexed forward to such a degree that it will be dangerous for your lower lumbar discs. There is a saying in physical therapy that proximal stability allows distal mobility. For every action there is an equal an opposite reaction. Therefore distal mobility allows proximal stability. If your hip joint which is distal to your core is stiff then reflexively your core cannot be stable. I have good news for you. You can still squat but off of a box. Off of a box you say. Does that sound strange. It shouldn’t because you do it everyday and have since you were in kindergarten. What kind of a box am I talking about — a chair!

So if you fall into this category of not being able to touch your toes in standing you need to work on the flexibility of your hips and work on box squatting. Box squatting is like squatting with training wheels on and I have clients squatting off low stools and benches all day long. For those of you that can touch your toes please read on.

Perfect!
Perfect!

So you can bend forward in standing with your knees straight and touch your toes. Now you are ready to squat down to full depth. Place your bare feet about shoulder width apart or a little wider. Keep your feet facing straight ahead. Start lowering yourself down with a combination of bending your knees and flexing your hips. Try to keep your spine as vertical as you can. As you are lowering down try to actively push your knees outward using your hip muscles. Also as you lower yourself down keep your heels flat on the floor. If this a real struggle or impossible then we need to possibly re-assess matters. There are 3 big aspects of the squat we need to respect. Heels down. Feet facing straight ahead. Knees tracking over toes or tracking wider. Period.

Why do my heels have to be on the ground? When your heel bone, calcaneus, is on the ground then the posterior chain of your body becomes activated. The posterior chain is comprised of all the muscles on the back side of your body. If your heel comes off the ground the base of your support naturally becomes less and you are now performing a balancing act versus a stable squat. If your heel comes off the ground then your knee will pass over your toes considerably and the pressure in your knee can reach dangerous levels. This brings up the conversation of shoes with a raised heel, boots or “heels”. If you are wearing footwear with a raised heel and your job, workout or daily life requires you to squat repetitively expect to experience some anterior knee pain sooner or later. You were designed to walk, stand, squat, lunge, jog, sprint, jump, hike, dance and step all without a raised heel — so stop wearing them!

Heels down, knees happy!
Heels down, knees happy!
Very fashionable- Let me know how your knees feel when you are 50!
Very fashionable- Let me know how your knees feel when you are 50!

Why do my feet have to face forward? This makes it much easier for your knees to track over your toes or on the outside of your feet. The more your feet toe out the more you have to push your knees out even wider. So if your feet are facing forward when you squat and your knees buckle inward, push your knees out. If you can not because your hips are too weak then stop squatting. If you squat with your knees buckling inward you stand a good chance of injuring your meniscus, medial collateral ligament or your anterior cruciate ligament or a combination of the three. We talked earlier about your brain and the fact that its learning all the time. If you squat with your knees bucking inward and then perform that repetitively then you are learning how to squat poorly and this will create a hard habit to break. Also when you actively use your hips to push your knees out wide and your feet face forward you tend to elevate the arch in your foot— simply another bonus.

squat-8

There is one caveat.

Do you have hip anteversion or retroversion? This is where the femoral neck is rotated forward or backward instead of normal alignment. If this is the case then your knee will naturally be rotated inward in the case of femoral anteversion. If your hip is retroverted then your knee will be facing outward. Similarly, your feet will face the same direction as your knee. You may have noticed throughout your life that you walked pigeon toed (feet facing towards each other) or walked more like a duck (feet facing outward). Now, it is wise to have a physical therapist check this status as you could simply have hip tightness which is giving a false positive that your hips are rotated. If that is the case you want to start walking and squatting with your feet and knees straight. If you have true hip anteversion or retroversion then a concession needs to be made about your feet placement. Get this checked out!

We need to check this out first!
We need to check this out first!

Are you afraid that pushing your knees out wider than your feet is just as bad as allowing them to collapse together? Fear not! There are no anatomical structures that are in peril when we push the knees out wider than the feet during a squat.

Good Bad
Good Bad

The last aspect of squatting we will discuss is keeping the spine in neutral and trying to keep the spine as vertical as possible. Keeping the spine in neutral is a much safer position for the spine and forces the hips into more flexion. The hips are designed for this flexion and maximizing hip flexion keeps the glute muscles working properly. When the spine is more vertical during a squat the pressure on the lower lumbar discs decreases. This is a win-win!

Spine Neutral-YES! Spine Flexed-NO!
Spine Neutral-YES! Spine Flexed-NO!
Outstanding!
Outstanding!

I will conclude this part two on the Squat with some more images and then a final thought. The third and final installment of this series will elaborate on how to incorporate the squat into your exercise program.

No!
No!
No!
No!
Yes!
Yes!
Yes!
Yes!
Yes!
Yes!
Yes!
Yes!

squat-18

Why is it that non domesticated cultures squat so well? Maybe because they don’t know what a chair is? They probably don’t know what a TVA is? or a posterior glute medius nor an external oblique muscle? Why is that? Because they just simply squat as a sitting position. They don’t focus on reductionism nor muscle function. They simply squat be cause that’s what they have always done and if its not broke why fix it. They have not introduced chairs because, why bother, they already know how to sit. This begs the question- who is the more advanced society? The one who forces their society to sit in a non-functional way creating dysfunction? or the one who perpetuates challenging yet functional squatting in their culture? I’ll let you make up your own opinion.

The Squat: Part 1

By: Jeffrey Yaskin, PT, MPT, MTC, CSCS

Do you know how to squat? Squatting is an activity that we should be performing many times throughout the day, hopefully, without even thinking about it nor realizing we are doing it. We don’t think much about walking from one spot to another and nor should we think much about squatting from a standing position down to the ground. Squatting is very healthy for the musculoskeletal system and as well as for the gastrointestinal system. It is also a very functional movement. Somewhere along the line, unfortunately, some people have come to the conclusion that squatting is bad for you. In this first of a 3 part series on squatting, we will touch on the functional aspects of squatting.

A child naturally squats to interact with objects on the floor. If you have children aged 1 to 5 and they are playing with items on the floor they simply squat down and “sit” in the squatting position with no issue until they are ready to stand. What you do not see is a child that age bending over to reach the same object on the floor. “The squat position is typically acquired after 10-12 months of development”(1). Squatting is more stable than standing which is why children adopt it earlier than standing. “ Standing in free space is not typically achieved until a child reaches 12-14 months of development”(2). Why squat over bend? Squatting is more stable and places less stress on your joints. Bending over in a standing position is less stable and places much more stress on your lower back. Interestingly, at this young age no one tells nor teaches the young child to perform this activity, it is innate. We all squatted this way and it begs us to question, why did we stop as we became older.

Correct
Correct

Incorrect
Incorrect

Were you glued to the TV watching the Olympics this summer? I believe it was during the wee hours of the night that the Olympic Lifting portion was telecast. With the explosion of Crossfit as an exercise philosophy, Olympic Lifting has become mainstream. The two lifts are the clean and jerk and the snatch. Both start in a deep squat position with the bar on the ground. Lift the bar with an upright trunk to the chest and stabilize yourself in another deep squat with the bar resting on your shoulders. In the clean and jerk, the second squat you have the bar resting on your shoulders and then you stand up pressing the bar overhead. “The clean tells you a lot about an athlete”(3). In the snatch, the second squat you have landed with the bar pressed overhead and then you stand up with the bar pressed overhead. “Nothing will tell you more about an athlete’s range of motion and understanding of the midline stabilization and torque principles than the snatch”(4). Both lifts are extremely technical and require copious amounts of time training to fully master. Any Olympic Lifting coach worth their mettle will agree that both of these lifts begin and end with a perfect squat.

Clean and Jerk
Clean and Jerk

Snatch
Snatch

If you have ever been to a train station in one of the older and smaller Italian towns and have to use the restroom you were probably met with a hole in the ground. What am I supposed to do with that? Squat! That’s right squat down and do your business. Prior to the invention of the toilet we defecated as humans by deep squatting. “Squatting has been the natural defecation position for humans since time immemorial “(6). If you have ever been exercising outside and had to move your bowels you simply squatted down and no problem. “There is a muscle that encircles the gut like a lasso when we are sitting or standing, and it pulls the gut in one direction, creating a kink in the tube “(7). “Squatting leads to a nice straight intestinal tract, allowing for a direct, easy exit “(8). I know many of us are dog owners and how does your dog poop? Sitting? No they squat down! “Hemorrhoids, digestive diseases like diverticulitis and even constipation are common only in countries where people generally sit on some kind of chair to pass their stool.”(9) So for the health of your bowels add more squatting to your daily routine.

You’ll be #1 at going #2
You’ll be #1 at going #2

Properly functioning pelvic floor muscles are synonymous with deep squatting and are necessary for pelvic stability and proper bowel and bladder health. “Once below a parallel squat, a quad dominant individual will not be able to maintain balance. This person will fall backward, unable to release tension in the quadriceps to allow the glutes, pelvic floor and core musculature to take over and stabilize” (10). A stable squat involves proper balance of the quads, glutes, pelvic floor and core muscles. The pelvic floor muscles become eccentrically lengthened during a deep squat. Squatting increases the size of the pelvic outlet by 1-2 cm vs standing position. “By forcing the upper leg bones (femur) to act like levers on your pelvic bones, you can widen your pelvis opening by 20-30 percent” (11). Squatting with knees pushed out wide increases tension in the hip adductor muscles pulling on the pubic bones and opening the pelvic canal. The levator Ani muscles (pelvic floor muscles) counter the pull from the adductor muscles. This helps keep them healthy and functioning properly. Properly squatting deep throughout the day helps to keep the pelvic floor muscles functional.

Pelvic Floor Muscles These are the foundation of your core!
Pelvic Floor Muscles
These are the foundation of your core!

One way to assess your squat and muscle balance is Durango is a through a Functional Movement Screen(FMS). This is a seven-part screen for people without pain who want their basic movement ability profiled. This movement screen was created in 1998 and currently is standard practice in assessing Special Forces Operators, NFL-NBA-NHL-MLB players and Olympic athletes. Guess what movement is the first tested in the FMS? The Overhead Squat. Watching a person squat with their arms in an overhead position is very telling about that person’s movement health and efficiency. “Extremity mobility, postural control, pelvic and core stability are well represented in the deep squat movement pattern. The deep squat is a move that challenges total body mechanics and neuromuscular control when performed properly” (5). Are you starting to understand how important the simple squat is in our daily lives? We are certified in assessing the FMS and would be happy to screen you as part of our free injury screen program.

The FMS is #1
The FMS is #1

Thus far we have discussed many reasons to squat daily. Its functional and it helps to maintain the health of the viscera, hips,and pelvic floor musculature. In the second and third parts of this squat analysis we will closely look at what is considered a proper way to squat and the many faults related to squatting poorly.

References:

(1), (2): Kobesova, A, Safarove, M. and Kolar, P. Dynamic neuromuscular stabilization: Exercise in the developmental positions to achieve spinal stability and functional joint centration. In: Hutson, M. and Ward, A (Eds.), Oxford Textbook of Musculoskeletal Medicine. Oxford University Press: 66-83, 2015.

(3), (4): Starrett, Dr. K. Becoming a Supple Leopard: The ultimate guide to resolving pain, preventing injury, and optimizing athletic performance. Victory Belt Publishing: 183, 195, 2013.

(5), (10): Cook, G. Movement: Functional movement Systems. On Target Publications: 90, 196, 2010.

(6), (7), (8), (9): Enders, G. Gut: The Inside Story of Our Body’s Most Underrated Organ. Greystone books: 17, 18, 2015.

(11): Russell, J.G.B., “Moulding of the Pelvic Outlet”,J. Obstet. Gynaec. Brit. Cwlth, Sept. 1969, Vol. 76, pp. 817-820.

Sitting is the New Smoking

By: Dr. Laura Wenger, PT, OCS

There has been a phrase circulating in the media over the past few years that can be quite alarming for the average American who finds themselves sitting for most of the day for work, hobbies, or simply by choice: “Sitting is the new smoking”. Now, I don’t even have to get into how bad smoking has been proven to be for our health and the good news is that many people in our society agree with that and have taken measures to remove smoking from their lives. However, sitting is a common theme during our day-to-day activities in our country, so much so that “data from adults in high-income countries suggest the majority of time awake is spent being sedentary”.1

What are the implications associated with sitting that give it such a bad rep? Some of the highlights of the negative effects related to a lack of physical activity include increased risk of type 2 diabetes, cardiovascular disease, stroke, some cancers, and even premature mortality.1 Needless to say, all of those negative effects are things that we do not want in our lives. However, because of the nature of much of our work, many of us are relegated to sit at a desk for eight hours a day, five days a week. So, what, if anything, can we do to counter the negative effects of our required sitting?

A lot of us are required to sit often for our jobs. How can we change that?
A lot of us are required to sit often for our jobs. How can we change that?

A group of researchers recently sought out to find the answer to that exact question. They analyzed 16 high-quality studies with data from over one million people. I’ll repeat that last part – they had date from over one million people, meaning that the researchers had a lot of data to base their results off of! What they found was that those people who were more physically active, getting in at least 60-75 minutes per day of moderate intensity physical activity, seemed to have no increased risk of mortality even if they did have to sit for more than eight hours per day.1 That gives hope to those of us who are required to sit for that extended period of time due to our jobs, hobbies, etc. that, by making sure we get the right amount of activity into our day, we can come out in the end with no higher risk of mortality related to all that sitting.1 Other factors to take into consideration are how to decrease your total amount of sitting time to less than four hours per day, as those folks tend to have lower risk of mortality associated with sitting.1 Is there any way you can get a standing desk or, even better yet, a treadmill walking desk to use at your day job? Can you fit in the 60-75 minutes of moderate physical activity into your lunch break, by doing such activities as taking a brisk walk?

Just remember, you’re not “doomed” if you have to sit for roughly eight hours (or more) a day. However, you have to be active in order to counteract the negative effects of the time you spend sitting! If you need help with figuring out more ways to work activity into your lifestyle and especially to prevent injury while doing so, schedule an appointment soon with one of our specialized physical therapists to find out your options.

  1. Ekelund U, Steene-Jahannessen J, Brown WJ, et al. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonized meta-analysis of data from more than 1 million men and women. The Lancet. Avail online 28 July 2016. https://dx.doi.org/10.1016/S0140-6736(16)30370-1.

Functional Movement Screen and Health Fair Update

By: Dr. Laura Wenger, PT, OCS

One of the fun things that we get to involve ourselves in within the community is participating in health fairs. Over the past year, representatives for Tomsic PT have made their way to various health fairs, such as in local companies like StoneAge and La Plata Electric Association as well as the La Plata County Health Fair for county employees. One of our favorite things to do at health fairs, besides meet you all and teach you about various benefits of physical therapy, is the Functional Movement ScreenTM. This is especially the case in regards to our PT, Jeff Yaskin, PT, MPT, MTC, CSCS as he achieved his certification in the Functional Movement ScreenTM in 2011.

Some of you may be wondering, “Great, but what is the Functional Movement ScreenTM (FMSTM) ???”. The idea behind the FMSTM is that it can be used as “a screening test [used] to identify specific movement dysfunctions that may be related to musculoskeletal injury risk.”1 The screen looks at seven movement tests that are meant to assess overall body mobility, stability, coordination, and postural control, with a score associated with each test.1 After each test is performed and graded, the scores are added together to come up with a final score that may be used as an indicator of injury risk.1 Of note, the test is meant to be used on an uninjured person, as the presence of pain on any test requires an automatic score of zero with further assessment recommended.1 That’s why we think this is a great screening tool to use at health fairs since we do end up speaking with a large amount of folks who aren’t yet injured and wonder how physical therapy can be beneficial for them.

There is a lot of research out there regarding the FMSTM, but a recent study sought to find out whether or not the performance of just one of the seven tests that makes up the screening could be used to predict performance on the entire FMSTM.1 The reasoning behind this study was so that the researchers could attempt to identify one of the tests as a “red flag” tool to be used quickly and easily to fast-track the need for further assessment regarding heightened risk of injury.1 The researchers found that there may be a meaningful relationship between the performance of the deep squat test (see the picture below) with the overall FMSTM score in the sense that better scores on the deep squat were related to better FMSTM performance overall.1 They also found that the converse would be true in that the odds of scoring poorly on the FMS (indicating potentially higher risk of injury) were 3.56 time greater for the individuals who scored poorly on the deep squat test.1

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You may notice that most of our PTs already use the deep squat test during our evaluations of various lower extremity and spine problems, and this research backs up the fact that our assessment of this may be helping us build a better idea of what an individual’s risk for injury or overall functional movement (or dysfunctional movement) is like.1 To learn more about the FMSTM and how it may help us identify your risk for injury (or how to guide our treatment if you are already injured), give us a call to schedule an appointment with any of our qualified PTs.

  1. Clifton DR, Grooms DR, Onate JA. Overhead Deep Squat Performance Predicts Functional Movement ScreenTM Score. Intl J Sports Phys Ther. 2015;10(5):622-627.

Health Update- Running and Physical Therapy

By: Dr. Laura Wenger, PT, DPT, OCS

Running season is upon us! We here at Tomsic PT are keeping up with the latest races more in the form of sponsorship these days. We had the privilege of sponsoring the Narrow Gauge 10 Mile race over Memorial Day Weekend and had a blast answering questions, stretching out, and taping runners following the race. We were also excited to see our former co-owner, Dave Rakita, running this race for the 39th time! Now, if that isn’t inspirational, I don’t know what is. We are looking forward to the continued running season and our upcoming sponsorship of the Durango Double Trail and Road Half Marathons on October 8th and 9th. If you are running or spectating, make sure you keep an eye out for our booth as we will be setting up shop right behind our clinic on the river trail.

Narrow Gauge 10k- 1
Narro Gauge 10k- 2

Running season is exciting but, unfortunately for some, picking up the pace of mileage and speed comes with aches and pains. Research has estimated that 20 to 80% of runners get injured each year, which is a large amount of people when you consider that over 15 million people are running each year in the US.1 As physical therapists, we get really excited about watching people move, and I especially love to do treadmill running analysis. Because of the large amount of runners that are injured each year, we undoubtedly see many folks in the clinic who benefit from running assessments. Oftentimes, we will suggest that people alter the way that their foot strikes the floor with each stride as a way to decrease biomechanical stresses placed on their ankles, knees, hips, and spine. A recent study sought to find out whether or not retraining footstrike patterns actually does reduce knee pain, improves biomechanical measures, and/or influences the risk of ankle injuries.1

The researchers completed training subjects for eight sessions over two weeks with a focus on switching their footstrike pattern from a rearfoot strike, where the heel hits first, to a forefoot strike, where the mid-foot hits first.1 They compared the group of trained subjects to another group of runners who received no training, but continued their running program.1 The researchers found a number of positive effects in the training group, including:

  • Significantly reduced knee pain1
  • Improved biomechanics at the knee with reduced collapsing inward of the knee1
  • Improved ankle range of motion consistent with the forefoot strike pattern1

What’s great about this study is that the effects of the training not only were noticeable directly after the two-weeks training period but also further out at a one-month follow-up.1 What that tell us is that, when we re-train a person on the treadmill to alter their footstrike patterns, the effects can continue well beyond our treatment which is the ultimate goal of teaching the body new and more effective ways to move. If you are a runner and are experiencing an injury or looking for ways to prevent injury, call us to schedule an evaluative appointment for a running analysis with one of our specialized physical therapists.

  1. Roper JL, Harding EM, Doerfler D, Dexter JG, Kravitz L, Dufek JS, Mermier CM. The effects of gait retraining in runners with patellofemoral pain: A randomized trial. Clinical Biomechanics. 2016(35):14-22.

Health Updates- Hiking and Cardiovascular Health

Hiking is a favorite pastime for folks of all ages here in Durango. Whether it’s a quick and steep in-town hike or a long and likely more-steep hike in the vast San Juan and La Plata ranges surrounding us, you are likely to stumble upon other hikers on the trails enjoying the beautiful vistas, heart-pumping ascents, and quad-burning descents. This is especially true in the mid-summer months when the wild flowers are in full effect and the increase in altitude can offer a reprieve from the higher temperatures in town.

Here I am with an extra load enjoying the view from the top of a recent hike.
Here I am with an extra load enjoying the view from the top of a recent hike.
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So, why am I bringing up hiking if we already know it’s a very popular activity in our neck of the woods? Well, you may have already realized from my previous blog posts that I love to learn about the greatest and latest research on many body-related topics. Due to my curiosity, I decided to look and see what kind of evidence is out there regarding one of my favorite activities. The good news is that I found an interesting study from a group of Austrian researchers that was published in 2015 regarding hiking and the effects on cardiovascular risk factors in an older population.1

The group of researchers followed a group of 14 men and 10 women in their mid-60s who participated in a 9-month hiking program.1 (Side note: For Durangoans, mid-60s is hardly considered elderly as the title of this study might suggest!) The program consisted of a single weekly hike that allowed the participants to reach a goal of approximately a 1,640 foot altitude gain within 3 hours.1 The participants were subject to a line-up of testing before and after the 9-month program in order to assess various factors of their cardiovascular health.1 The researchers found that there was no significant change in the cardiovascular profile of the participants before and after their weekly hiking program, however the group was found to be in good health before they even started the program.1 For those in the group that had untreated high blood pressure before they started the study, they had reduced blood pressure at the end of the 9 months indicating a positive change.1 The potential benefits of weekly hiking may have been more evident if there were more people in the group of participants that had sub-par cardiovascular health to begin with, but this was less evident in an already-healthy group.1

So, whether you are in good or bad cardiovascular shape, engaging in a weekly hike will certainly not harm you. Get out there and enjoy those flowers in the surrounding hills that we get to call home! If you are curious on how to begin safely hiking or continuing your current hiking program while keeping your body free of injuries, speak to a PT soon so they can help you figure out the best cardiovascular and strengthening plan for injury prevention.

  1. Gatterer H, Raab C, Pramsohler S, et al. Effect of weekly hiking on cardiovascular risk factors in the elderly. Z Gerontol Geriatr. 2016;48(2):150-3.

Industry Update- Manipalooza and Empathy

By: Dr. Laura Wenger, PT, OCS

In late April of this year, I had the pleasure of attending a three day course in Denver dubbed “Manipalooza”. This course was put on by a PT educational group called Evidence in Motion, which is led by many important names in physical therapy research including Dr. Tim Flynn, Dr. Julie Whitman, and Dr. John Childs. Despite the name, the conference was not all about manipulations, which is a technique that physical therapists use to provide a high-velocity low-amplitude thrust during joint mobilization. The course also included speakers who addressed the group regarding interesting and relevant information, such as pain science and concussion diagnosis and treatment. One of the speakers that interested me the most was Dr. Larry Benz, DPT, OCS, MBA, MAPP, as he spoke about a term that is very important in the field of physical therapy: empathy.

Let’s first take a look at the definition of empathy in a medical context. As described by Hojat et al.,

“[We] define empathy in the context of medical education and patient care as a predominantly cognitive (as opposed to affective or emotional) attribute that involves an understanding (as opposed to feeling) of patients’ experiences, concerns, and perspectives combined with a capacity to communicate this understanding. An intention to help by preventing and alleviating pain and suffering is a characteristic of empathy expressed in the context of patient care.”1

One of the things that Dr. Benz touched on during his lecture was the difference between empathy and sympathy. It would be one thing for us, as physical therapists, to be sympathetic toward your pain and elude that. However, being empathetic to your pain and trying to understand your experience and perspective allows us to further help to come up with solutions to your problem, whether it be chronic pain or an acute injury.

May 2016- Empathy

A strong sense of empathy, I believe, one of the things that sets physical therapists apart from other healthcare professionals. And, not only do I believe this, but patients do, too. A recent study sought to examine the meaning of caring from the perspectives of patients undergoing physical therapy.2 The results of this pilot study indicated that physical therapists have “embraced caring as a core value in clinical practice that reflects a deep commitment to patient-centered care.”2 Some of the main examples that the study found regarding patient perceptions of their physical therapists included such statements as, “[my therapist] seems to take an interest in patients beyond just the medical stuff,” and “I think [physical therapists are] pretty good about explaining ‘hey this is what’s going on with this and this is what you’re probably going to experience’”.2 These examples of valuing the patient as an individual and providing reciprocal and ongoing communication are excellent examples of caring, which is very much a part of being an empathetic healthcare provider.2

As healthcare providers, we strive to be empathetic so that we can understand the needs of each patient as an individual. Come and learn what makes physical therapy the optimal solution for healing with an empathetic provider at Tomsic Physical Therapy by scheduling an appointment with one of our specialized therapists today.

  1. Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182-1191.
  2. Greenfield B, Keough E, Linn S, et al. The Meaning of Caring from the Perspectives of Patients Undergoing Physical Therapy: A Pilot Study. J Allied Health. 2010;39(2):e-43-47.

Health Update- Mountain Biking versus Road Cycling Injuries

By: Dr. Laura Wenger, PT, OCS

Ellen pushing it hard on the trail.
Ellen pushing it hard on the trail.

In early May, Ellen and John participated in the 12-hours of Mesa Verde in a team of four riders representing Tomsic PT. Although they experienced a little bit of rain and mud on the course, it was a perfect day for riding compared to last year when the race was canceled one lap in due to inclement weather.

Luckily, all of our team members came out of the race unscathed. A recent study out of Telluride, Colorado looked at cycling versus trail riding injuries finding that, unfortunately, not all riders are that lucky!1

John ripping it up on the 12 Hours of Mesa Verde course.
John ripping it up on the 12 Hours of Mesa Verde course.

Here are some quick facts that Dr. Kotlyar from the Telluride Medical Center found:

  • In 2013, 8.5 million Americans participated in mountain biking.1 The popularity of the sport has been steadily increasing and has become increasingly popular with the development of lift-accessed terrain so that ski resorts can find purpose during the summer months.1 As we know in Durango, you don’t need a lift to access great trails, but many folks find appeal in skipping the grueling uphill that some trails require.
  • When comparing biking injuries, about 70% of the injuries are related to mountain biking where the other 30% are related to road cycling.1 Dr. Kotlyar’s study only looked specifically at injuries that went through the Telluride Medical Center Emergency Department, which turned out to be 304 biking-related injuries over the period of three years.1
  • Injuries to the thoracic, or chest, region happen more regularly during mountain biking.1 Also, trail injuries happened to be more common in males and older riders also happened to be the ones suffering more injuries to the thoracic region.1
  • Head injuries occur more often during road riding.1 In addition to that, injuries that occurred while road cycling were more likely to require transfer to a higher level of care than injuries sustained on trail.1
  • 70% of the injuries reported occurred in males.1 This is consistent with the report that there is a 71 to 86% male predominance in bicycle-related sports.1
  • The most common biking-related injuries are lacerations, abrasions, and contusions (64%), with arm, wrist, or hand fractures making up the remaining majority (26%).1 The good thing there is that the more severe injuries, such as head, thoracic, or abdominal injuries, are less common.1

Biking, in both mountain and road forms, is a very popular sport in Durango and a common recreational activity that our patients want to be able to get back to. Along with the common lacerations, abrasions, and contusions that were seen in the Emergency Department at Telluride Medical Center during this study, we also tend to see a lot of the musculoskeletal aches and pains that come along with road or trail crashes. As your orthopaedic specialists in Durango, we would love to help you get back in the saddle. Call us to schedule your appointment today!

  1. Kotlyar S. Cycling Injuries in Southwest Colorado: A Comparison of Road vs Trail Riding Injury Patterns. Wilderness & Environmental Medicine. 2016. 1-5.