We can’t just keep cutting on athletes or anyone else for that matter. Every time an athlete undergoes a procedure to fix one problem, another issue is likely to pop up. This statement should be considered 100% true unless procedures are put in place during rehabilitation or prehab to address the actual, root cause of the problem. These new issues can lead to other injuries, which are termed “compensation injuries”, may be noticed during the rehab or upon return to sports participation. This should be done only by an athletic trainer, therapist or physician trained to look for such compensations, rather than guessing at the potential compensations.
“When an athlete suffers an injury that requires surgery, he must absolutely undergo the recommended surgery to repair the damage,” said Dr. Stephen Shoemaker of Torrey Pines Orthopaedic Medical Group in La Jolla, California. “However, it’s the rehab that now becomes the most important part of the process to ensure the athlete recovers from the procedure.”
This is the key to return to sports activity. In addition to rehab of the injured area, protocols should now be put in place to address the compensation patterns the athlete will develop immediately following the injury and subsequent surgery.
In some cases, the injury may be caused by contact. Such an injury typically may the easiest to recover from physically, but may require more to overcome the psychological trauma associated with the contact. However, non-contact injuries are usually an indication of an inability of the person suffering the injury to absorb the forces properly. This type of injury may be the most difficult to fully recover from as the contributing factors are lead by inefficiencies of the person’s body which may go undetected during rehab.
To help gain a clear picture of what is being said here, we must understand a couple factors. There are several types of forces at play in any given activity. For this writing, we will just refer to them as : 1) action forces, which we’ll define as the forces which are imparted upon a body part (muscle, bone ,or joint). Action forces are trying to escape the muscle, joint or bone (segment) during motion in multiple movement planes and directions. The other force to be mindful of is 2) Reaction force, which is the force the the body exerts to attempt to control those forces trying to escape the body part (bone, muscle, or joint).
The athlete’s muscles must exert reaction forces by activating the muscles of the body affected as the action forces are at work escaping the body. If the athlete’s muscles are unable to properly control and redirect the action and reaction forces, an injury occurs. In the case of an athlete who suffers a non-contact knee injury, the action forces absorbed by the knee were too powerful (or in some cases the forces moved too quickly) for the muscle to react and protect the joint. At this point injury occurs.
Example: Forces imparted upon and exerted by the human body are much like the forces we feel in a car in going around a turn or when stopping. If we go too fast around a turn or don’t press on the brakes appropriately, the force may be too much for a driver to redirect the vehicle. A crash or failure to stop is likely to occur.
Much like the driver of a car, an athlete must redirect the forces or injury will occur. The severity of the injury depends largely on the amount and type of forces and the person’s ability to react efficiently to control them.
If the injury is to the ligaments of the knee, the muscles typically failed to respond in time or the force was too great to absorb efficiently. As a result, the ligaments of the joint were left to fend off those forces but failed. Ligaments are not capable of withstanding extreme forces and just like a rubber band will snap when stretched past their limits. In addition, this can cause a simultaneous injury inside the joint to the meniscus (cartilage). In some cases, the ligaments will stretch but not tear. In the case of an injury inside joint to the meniscus, but not the ligaments, the friction forces (linear or rotational) may have caused damage. This typically occurs when the ligaments themselves have more laxity or flexibility or the direction of the force was greater than the maximum flexibility of the ligaments in that direction.
The human body is the greatest machine known to man. It is a great compensator for forces acting upon it and often, through human efforts (reaction), redirects the body to reduce the impact of forces. The body will always find a way to do the “task” we ask it to perform as long as the physical strength and flexibility required to perform the task is present. This means that if we ask the body to jump using both legs equally, the body will perform the task with weight distributed as evenly as the body is capable of while absorbing and disbursing the forces as the body sees fit (compensation).
In a recent post, I discussed Greg Oden’s injuries and the results of my findings after conducting a 3D-biomechanics evaluation of his walking, running, squatting, and jumping motion. The data obtained when analyzed alone shows that Greg had developed significant compensations to address his body’s inability to absorb forces appropriately in both of his legs. Greg Oden can be the great player he once was in college and dominate professional basketball. This can be done with much less rehab than he has already undergone and possibly no further surgical procedures. (This decision for additional surgery is left to the athlete and experts in soft tissue repair and evaluation).
It’s apparent by the history of multiple injuries suffered and surgical procedures, that Greg has muscles in certain areas of his body that fail to contract on time or possess enough strength to absorb and distribute the forces appropriately throughout his body. In kinesiology and biomechanics, first and foremost, we must evaluate the sequence of forces as they move through the body. In walking, running, and jumping, the first joint to store and release energy is the big toe on each foot. If an athlete is jumping using both legs, they must begin to squat which transfers vertical energy downward towards the ground (through the feet). Once that energy reaches the ground, it begins to release upwards along the same path on which it was delivered to the ground. If the path downward was flawed because of muscle imbalances, weaknesses, or neuropathy (disruption of the nerve signal), the muscles and joints are overloaded and an injury may occur.
In the case of Greg Oden’s patella tendon related injury, the forces of gravity were attempting to return his 7 ft tall, 270 pound body to the ground during landing following a leap in the air. On the way to landing, Greg’s muscle imbalance is likely to have caused an overload of the muscles and joints along the way. This improper absorption of forces caused the injury. As a result of his own imbalances, Greg was a ticking time bomb.
Once on the court, his patella injury would be considered a freak accident by the casual observer and fans. At which point, Greg may be labeled injury prone (due to his history of injuries) or God only knows what other names fans and the media would label him. However, because Greg has had years to develop the compensations for weaknesses related to previous injuries, it was destined to happen unless those weaknesses and imbalances were addressed. To diffuse the bomb, recovery efforts could take as little as 4 weeks to 12 weeks, putting Greg back in action provided no other surgeries are needed to repair damage already done to his body. However, if surgery is taken as an action to repair the damage and alleviate the pain or discomfort he is suffering without addressing the true weaknesses, the recovery period is guaranteed to be significantly longer.
Most of us agree that an epidemic exists in our country with respect to the growing problem of childhood and adult obesity, however, another epidemic is at work as well. The epidemic I speak of us is the growth of injuries in sports: both chronic and acute. Despite the existence of fitness training, sports performance, and sports rehab facilities popping up faster than fast food franchises, injuries are still growing, and most are repetitive injuries.
Chronic injuries occur because we are so quick to dismiss our health related issues. If our car starts to make noises or smell funny, we take it into the mechanic. If we wait too long, the problem gets worse and other problems surface. When it comes to our body, we are very quick to ignore the signs and symptoms which enables the problem to worsen. In ignoring the problem, we typically shift the stress to other parts of our body until we can no longer get around it.
I was fortunate enough to conduct the entire rehab program for a 14 year- old high school female basketball player who suffered bi-lateral (right and left knee) ACL injuries within 9 months of each other. I started her rehab following her second ACL tear. That athlete and many others were able to avoid future injuries because we addressed the muscle imbalances and root causes of the injuries. The most neglected part of her prior rehab was rotational instability above and below the joint. At the moment, rotational instability following knee surgery is not address at all in rehab. But in reality, rotational instability must be addressed early in rehab along with more emphasis placed on the strength and proprioception of her lower leg and feet (not just the quadriceps and hamstrings muscles).
That 14 year-old girl is now a two months shy of her 18th birthday and just completed her senior season of high school basketball with no further occurrence of injury in any part of her body. While the level of play is not the same as professional sports, the demands on the body of a high school athlete are relative to their physical development, as are the demands of a professional athlete. (This is just one example.).
It’s time for a new standard of care for taking care of our bodies. All of those who work with athletes and everyday people should work to obtain objective measurements and strive for physical balance and symmetry. In “data” we trust not “speculation and guesswork”. Every fitness trainer, coach, or physical therapist should rely on their eyes first and then call upon experience second to evaluate what they saw. We must apply the principles of human movement to rehab focusing on how the body performs the exercise not just the completion of the exercise. At this point, we should implement customized rehab programs based on the athlete instead of current protocols which are based solely on recovering from the surgical procedure or the injury.
Everyone has an opinion but we need to eliminate the guesswork. As an industry, all professional who work with people in sports performance, rehab, and medicine need check our opinions at the door and do what’s best for the athlete rather than trying to keep our our jobs. “Do no harm” is the first objective. However, harm is done unintentionally to the athlete if standardized protocols for rehab continue to be the standard of care for injuries.
There are a lot of experts who may disagree with my posts and I welcome their feedback. I will gladly post any rebuttal or response to any post on this blog provided they are done in a tasteful and respectful manner. I reserve the right to reject comments and posts that contain profanity, are personal attacks, or lack foundation. All opinions are welcome just remember that youth athletes, parents, and others view my blogs. So I welcome and encourage respectful debate and comment.