Winter 2013 - Lawrenceville

SPORTS MEDICINE MAGAZINE
WINTER 2013
SPORTS MEDICINE
Interval
Sports
Programs
MAGAZINE
By: Lloyd van Pamelen, PT, CSCS
Tips for
Asthma
& Exercise
By: Thomas Chacko, MD
Common Neck
Injuries
Encountered
in Wrestling
SPORTS MEDICINE MAGAZINE
By: Tuan Bui, MD &
Andy Truong, BS
Ankle Bracing
and Taping
By: Sarah Bailey, ATC
Periodization:
The Training Plan
SPORTS MEDICINE MAGAZINE
By: Gary Schofield, Jr. ATC/L, CSCS
G
There are 2 R’s
in Recovery
By: Ann Dunaway Teh, MS, RD, LD
Osteochondroses and
Apophyseal Injuries in the Young Athlete
By: Thomas F. Byars, MD
MVPs of Sports Medicine
THE SPORTS MEDICINE & ORTHOPAEDIC
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Letter
from the
Editor <<<
Winter 2013
Contents Page
R
Features
>Editor’s Note /// Gary A. Levengood, MD /// 3
>Interval Sports Programs ///
By: Lloyd van Pamelen, PT, CSCS /// 4-5
>Tips for Asthma & Exercise: ///
By: Thomas Chacko, MD ///
6
>Common Neck Injuries Encountered in Wrestling ///
By: Tuan Bui, MD & Andy Truong, BS (4th year medical student) ///
8-10
>Ankle Bracing and Taping: Should we do it to Prevent Ankle Sprains? ///
By: Sarah Bailey, ATC///
11-12
>Periodization: The Training Plan ///
By: Gary Schofield, Jr. ATC/L, CSCS ///
14-16
>Osteochondroses and Apophyseal Injuries in the Young Athlete ///
By: Thomas F. Byars, MD ///
18-19
Gary A. Levengood, MD
>Chief of Sports Medicine,
Gwinnett Medical Center
>Orthopedic and Sports Medicine
Consultant to the GHSA
>Founder and Owner,
Sports Medicine South, LLC
>Editor, Gwinnett Sports Medicine Magazine
>There are 2 R’s in Recovery ///
By: Ann DunawayTeh, MS, RD, LD ///
20-21
Kaylee Rosenberger
Contributing Editor
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2 GSMM
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team of professionals as vast as the clients we serve. Through earnest
design ideology, collaborative efforts, and concise consideration for the
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Contributing Photographers | Ann Borowski
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phone: 770-237-3475
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krosenberger@sportsmedsouth.com
Be a
GSMM
Contributor
ecently was asked to travel to France as a keynote
speaker at the 37th Annual GECO Conference. We
talked about several technological advancements in
the field and highlighted the most recent innovative
practices available to us as Orthopaedic Surgeons. I personally
spoke on a performing an I-Total Uni Compartmental Arthoplasty
in conjunction with replacing a torn ACL and the additional benefits
the patients receive as an outcome of this procedure. Typically an
I-Total Uni Compartmental Arthoplasty does not include the reconstruction of an ACL; however, I have found that patients in their 50’s
to 60’s, who are not yet candidates for a Total Knee Replacement,
can increase the longevity of their knee when the surgery also includes the reconstruction of their ACL. Since the combination in this
procedure is relatively innovative, my presentation led to several
questions from the audience. One question in particular took me
off guard; an audience member asked, “Why does a 60 year old
deserve a new ACL?” For those of you who are familiar with the
changes we are seeing in the medical world, this question may not
seem so inappropriate. Through increased regulations, each day
we encounter more obstacles in getting procedures approved for
patients, and the question seems to no longer be, “can this procedure benefit this patient?,” but rather, “is the patient deserving of
this benefit?” While regulation agencies are pushing to claim that
a beneficial procedure is unnecessary; I consider it rational that a
procedure that adds to the overall quality of a patient’s life should
be regarded as needed. As the nation’s average life expectancy
increases, it is not unreasonable to conclude that even a 60 year
old could live actively for an additional 20 years. It is our job as doctors to promote ways that our patients are able maintain the highest
quality of life available to them and push to never stop finding new
ways to better service our patients.
It is this same belief that the Gwinnett Sports Medicine Magazine
stands behind. Through educational articles, we strive to promote
ways not only our community doctors can better service their patients, but we also like to reach out directly to the parents, citizens,
and athletes of our community so that they too can safeguard the
quality of life that they desire. If you have a topic that you want to
know more about or a concern you want featured, please contact
Gwinnett Sports Medicine Magazine so that we can continue to
serve your needs.
If you would like to submit an article or are
interested in advertising opportunities
in GSMM please contact Gary Levengood
at krosenberger@sportsmedsouth.com or
770-237-3475 ext. 113
GSMM 3
Interval Sports Programs <<<
Interval
Sports
Programs
/// By: Lloyd van Pamelen, PT, CSCS
I
nterval sports programs and, more
specifically, interval throwing programs
provide a structured, graduated return
to practice and games. With any progressive “return to sports” program,
there is both an art and science to designing and then following each step
of the program. In specific cases of
surgery (i.e. shoulder surgery or elbow
surgery in the thrower), the athlete will
be given a very specific interval throwing program that will take months to
complete. Most other injuries can and
should include a similar, albeit shorter, interval program that incorporates
essentials principles integral to every
post-operative protocol.
Here’s the science part:
interval programs need
to initiated, especially following a major injury or surgery, by
the athlete’s physician and performed under the supervision
of the rehabilitation team (athletic trainer, physical therapist,
physician). These programs emphasize repetition of proper
form at progressive levels of effort and volume over time.
They are designed to minimize chances of re-injury and emphasize good warm up and stretching. As related to throwing, the athlete needs to have pain-free range of motion (dependent on injury or surgery, at least a few weeks to a few
months prior to throwing) of the involved joint along with good
muscle power and resistance to fatigue. If the athlete is allowed to compensate or throw improperly, even if pain-free, it
4 GSMM
habits, decreased performance, and increased chances of the same or another injury to return. An example
would be allowing an runner with a stiff knee to run full
speed on the track; he or she would almost be certain to
develop calf and/or hip soreness in addition to his or her
knee pain. If the athlete doesn’t “look right”- whether it’s
throwing a baseball, kicking a soccer ball, or performing
any activity relating to his or her sport- he or she is not
ready and may need more time with the interval program
and may even need more time with rehabilitation prior to
resuming the interval program
The art of designing these interval programs is in the
adjustments. There are a multitude of reasons that can
either accelerate or delay an interval program. If your
athlete is not seeing his doctor or rehab professional the
same day or day after throwing, it is important for you, as
a parent, to gauge his or her “bounce back” following the
day’s throwing activity. During the recovery process,
it is also important to differentiate “normal soreness” as
compared to “pain” with your athlete. Atlanta Braves
Team Doctor Emeritus, Joe Chandler MD, frequently
recommends that young, prepubescent throwers simply
should not have any pain at all with their throwing. For
older throwers, having a dull, diffuse aching sensation
in muscles and tendons that goes away within 1-2 days
after throwing is typically “normal.” However, experiencing sharp pain that deep into the joint or having a duller
pain that lasts for a few days is not normal and should
be consider a reason to stop throwing and, until further
consultation with your doctor, forego the interval throwing program.
As for actually performing or assisting your child
with an interval program, make sure he or she warms
up properly before throwing. Have your athlete “get
a sweat on” by warming up the entire body by jogging
and using a dynamic warm up routine for the upper
and lower body. This should not take much longer
than 10-15 minutes. With throwing, make sure the
athlete utilizes a four seam grip (fastballs always precede change ups and breaking balls) and incorporate
his or her legs into the throwing. American Sports
Medicine Institute (ASMI, Birmingham AL and Pensacola FL) has long advocated utilizing a Crow-Hop method,
even at 30-45 feet. It is essential that athlete try to throw
with normal mechanics while still have a slight arc on the
path of each baseball throw. Throwing programs typically start at 30 or 45 feet and, progressively over time
as based on injury, surgery, and athlete’s throwing mechanics, build up to a “long toss” distance of 120 to 180
feet. For example, athletes who are recovering from UCL
reconstructions (Tommy John surgery), follow a 7-10
month throwing program that incorporates 30-45 of
“catch”, long toss, “flat ground” mechanics, and
then “off the mound” bullpens, all at progressive
effort levels and progressive volumes.
As parents, don’t feel like you need to follow a custom interval program for the recovery of every ache
and pain your child feels. Remember that “common sense” is your best guide. Just as you would
never allow your child to run full speed immediately
after an ankle sprain or hamstring strain is the same
reason you would not allow your child to pitch full
speed off the mound immediately following a strain
of the shoulder or elbow. Always be patient and
always remember that form and technique, even at
50% effort, as has great value if repeated several
times prior to “full return” to practice and games.
As stated by many professional pitchers and pitching coaches, velocity comes from being able to repeat good, efficient mechanics, over and over again.
Most importantly, interval throwing programs are
safest way an athlete can transition from injury to
full recovery.
GSMM 5
Tips for
Asthma &
Exercise
/// By: Thomas Chacko, MD
D
o you cough, wheeze
and have a tight chest
or shortness of breath
when you exercise?
If yes, you may have
exercise-induced
asthma, or sometimes called exercise-induced
bronchoconstriction. This
happens when the breathing tubes in your lungs constrict with exercise, causing symptoms of asthma.
Symptoms that may occur if you have
exercise-induced asthma are:
•Wheezing
•Tight chest
•Cough
•Shortness of breath
•Chest pain (rarely)
Exercise-induced asthma symptoms may start a few minutes after you begin exercising, and they may continue to
worsen for another 10 minutes or so after you’ve finished
a workout. It’s possible to have symptoms both during and
after exercise.
Feeling a little short of breath or fatigued when you work
out is normal, especially if you aren’t in great shape. But
with exercise-induced asthma, these symptoms can be
more severe.
6 GSMM
An estimated 300 million people worldwide suffer from
asthma, according to the World Health Organization, and
strenuous exercise makes it worse for many people. Recent studies have shown that asthma is common in elite
athletes, affecting approximately 8% of Olympic Athletes.
Some of the world’s top athletes, including Jackie Joyner
-Kersee, Jerome “The Bus” Bettis, and Dennis Rodman all
were known to have asthma. They were at the top of their
game because they took their asthma seriously, and did
the right precautions to keep their asthma under control.
If you suspect you have exercise-induced asthma, you
should discuss this with your doctor. The history would be
helpful to see if the symptoms are due to asthma versus
deconditioning or another cause. Also a breathing test
(spirometry) would be helpful to get an objective assessment of lung function, and how well you may be breathing.
Generally the first line treatment is an albuterol (rescue)
inhaler. This can be used 15-20 minutes before exercise
to help keep the airways in the lung open. Also, possibly
using a mask to warm the air may help the prevent constriction when exposed to cold air. There is a wide array
of other controller medications (from pills to various types
of inhalers) that can help with both general and exerciseinduced asthma.
One of the first steps to controlling exercise-induced
asthma is finding the right help. This should be discussed
with your doctor or possibly an asthma specialist. They can
help figure out the cause of your symptoms and develop a
treatment plan that can keep you exercising.
Asthma did not stop elite athletes from success on the
track, field, or court and it should not stop you from doing
what you would want to do!
What’s been
Happening at
GMC...
December 6th | Gwinnett Touchdown
Club’s end of the season Award Banquet
at the Gwinnett Marriott
December 15th | GHSA Football
State Championship, Norcross High School
6A Champs
December 21st | Rivals of Gwinnett
All-Star Football Game and
The Linda Jones Memorial Scholarship
presentation at
Peachtree Ridge High School
Coach Dave Hunter at Gwinnett
Touchdown Club’s End of Season banquet
February 9th | Get Heart Smart an interactive wellness expo at the
Gwinnett Center (Convention Center)
8am-noon
Norcross High School 6A Champs
Tim Simmons, ATC, program director for GMC
Sports Medicine Program, is seen here working
with Malliciah Goodman just days after his appearance at the Senior Bowl. Goodman, who just finished up his senior season as a defensive end for
the Clemson Tigers, is preparing for the NFL Draft.
Photo by: Amy Motteram
Common
Neck Injuries
Encountered
in Wrestling
/// By: Tuan Bui, MD &
Andy Truong, BS (4th year medical student)
T
he thrill of victory and agony of defeat
are distinctive
traits that have
us longing the
drama of competition we so
breathlessly
crave. It goes
without saying
that the oldest
and
arguably
most intensive
sport is no exception.
Like
most adrenaline soaring activities, the exhilaration of
wrestling does not exist without a risk of injury. Steadily,
injuries have inescapably become a way of life for those
that participate in this unrelenting sport. In a wrestling
match, comprising of two formidable competitors, vigorous pulling and pushing of the neck can lead to minor or
major cervical injuries in an attempt to leverage, throw,
or trap an opponent in hopes to score points or win by a
decisive pinfall.
Cervical neck injuries in particular, are some of the
more serious injuries encountered at the high school and
collegiate levels of wrestling with an injury rate second
only to football according to the NFHS- and NCAA-Injury Surveillance System. Fortunately, most neck injuries
sustained in wrestling are minor, but rarely, serious injuries involving the spinal cord do occur. The most common etiology of these neck injuries is simply attributed
to hyperflexion and hyperextension. More importantly,
8 GSMM
though, is the extent and location of the disease and
its implicating factors. The magnitude and direction of
force, in combination with alignment (or malalignment)
of the neck upon impact, are determinants strikingly
evident during takedowns and awkward landings.
Contusions, or bruises, are minor injuries frequently
developed when small blood vessels beneath the skin
rupture, allowing blood to seep from injured vessels
into surrounding tissues. This commonly manifests as
a black and blue skin discoloration caused merely by
trauma. “Stingers” or “burners,” also known as brachial plexus neuropraxia, are peripheral nerve injuries caused by forceful lateral flexion of the neck that
send painful sensations coursing down the shoulder
and arm. Nerve root compression or traction, at the
neural foramina, are the most commonly suggested
mechanisms. Regardless, impairments are usually
transient in nature with complete resolution in seconds or minutes.
Herniated discs, fracture-dislocations, and slipped
vertebrae tend to pose a much more pressing threat.
Due to the proximity to the spinal cord, circumferential bulging of spinal discs and fragments of dislocated bone may effortlessly impinge the traversing
spinal cord or nerve root. Spondylolisthesis is another rare condition with similar perils. Here, vertebral
bones are anteriorly displaced due to a fracture or
instability of the facet joint. The spinal column then
slips forward, narrowing the space inside the spinal
canal causing traumatic spinal stenosis. Trauma to
the spinal cord, if present, may vary from a contusion
to a complete transection. Corresponding disabilities
range immensely from temporary weakness to lifelong paralysis or death.
Common Neck Injuries Encountered in Wrestling <<<
“Like most
ad ren al i n e
soaring activities,
the exhilaration
of wrestling does
not exist without
a risk of injury.”
Athletes traditionally complain of pain, swelling, discoloration, and stiffness as functional
range of motion may be diminished and neck
motion becomes discomforting. Sprains and
strains are the most common cervical injuries
and are the result of overuse, stretching, and/
or excessive force. Sprains are injuries to ligaments, while strains are injuries specific to
muscles or tendons. It may be difficult to differentiate one from the other and oftentimes occur simultaneously. Muscle spasm, a common
sequela characterized by a tight muscle that is
tender to the touch, is designed to inhibit movement and protect weakened muscles. Normally
the neck is capable of absorbing forces by dissipation through the normal lordotic cervical
curve, resistance of paravertebral muscles and
ligaments, and cushion of intervertebral discs.
Sprains and strains are incurred anytime demand of resistance is stronger than the muscle
and ligament can tolerate.
Early management and diagnosis is essential
to promptly establish an appropriate course of
treatment. If a spinal injury is suspected, adhering strictly to spinal protocols is crucial. In the
absence of a physician or qualified health care
personnel, victims should not be mobilized unless imminent danger makes this unavoidable.
Physicians must err on the side of caution and
rule out serious problems, keeping in mind that
most cervical injuries are sprains or strains.
Routine radiographs remain the initial imaging
study of choice; however, advanced MRI and
CT may be necessary to delineate or further investigate a clinical suspicion when radiographs
are inconclusive.
GSMM 9
>>>Common Neck Injuries Encountered in Wrestling
In conjunction, neurologic examination is a tool often
used to localize pathology via correlative neuroanatomy, by testing reflexes and strengths of corresponding dermatomes and myotomes. Long-term manifestations may not be immediately apparent, thus serial
evaluations are warranted.
Educating medical professionals, coaches, referees,
and wrestlers is fundamental for the safety and wellbeing of all participants; especially the importance of knowing and following rules, dangers of moves performed
improperly, and benefits of stretch and exercise. Prevention is possible through proper conditioning by highly
trained and experienced coaches. Regular exercises
and stretches focused on the neck will increase strength,
endurance, and flexibility to better withstand repetitive
force and injury from fatigue or overexertion. Mastery of
techniques should be encouraged as trivial details, such
as keeping the chin up during takedowns and exact positioning when executing neck bridges or vicious cradles,
may unexpectedly prevent catastrophic events. Use
of properly fitting safety equipment must be enforced, at all times during training and competition.
Ankle Bracing
and Taping:
Should we
do it to Prevent
Ankle Sprains?
Prehabilitation is another preventative strategy,
which is a sport-specific conditioning program tailored to each therapy, steroid injections, or surgical
intervention. athlete with drills targeted at enhancing areas of weakness and honing imbalances.
Minor injuries, such as sprains and strains, are
often self-limiting and resolve with rest. Applications of ice and heating pads may hasten recovery
time. Furthermore, your physician may prescribe
anti-inflammatory medications, muscle relaxants,
and/or a neck collar to support and prevent more
injury. Eliminating pain and swelling and regaining
full strength and range of motion without pain are
the goals of treatment. Rehabilitation is cornerstone to ensuring a safe and timely return to activity. Returning too soon can worsen injuries and
lead to permanent damage. Most recover in a few
days or weeks, but returning to activity is based
on recovery, not time transpired. Serious injuries or
persistent symptoms may require medical attention
that necessitates further testing, physical therapy,
steroid injections, or surgical intervention.
/// By: Sarah Bailey, ATC
A
B:8.875 in
T:8.375 in
S:7.625 in
T:5.375 in
12 GSMM
B:5.875 in
S:4.875 in
www.euflexxa.com
nkle
sprains
are some of the
most common
injuries seen in
athletics 1,2,3,
particularly
sprains to the
ligaments on
the outside, or
lateral, aspect
of the ankle.
Since this injury can be
very painful and cause significant loss of playing time and
higher risk for additional ankle sprains many athletes, coaches, athletic trainers, physicians, and parents hope to avoid
the hassle and frustration of ankle sprains altogether. Caretakers consider many options for the prevention of ankle
sprains: What is the best way to prevent damage to ankle
ligaments? Is there a way to protect ligaments with bracing or taping? What is the most effective way to reduce an
athlete’s risk of ankle sprains? These questions have been
on the minds of researchers for many years. We evaluated
the most current research and will shine some light on this
highly debated topic.
To make the best decision for an athlete when considering prophylactic devices, one should understand the necessary components in making such a device effective. Rapid,
unexpected, or uncontrolled joint motion compromises ankle ligaments and causes a sprain. Ligaments limit specific
movements determined by the location of the ligament. So, it
stands to reason that when motion is limited ligaments are not
as easily compromised. This is the goal of athletic tape and
braces: limit excessive motion of the ankle joint by physically
reducing motion. The restriction should not be complete, as
athletic activities require the ankle to be somewhat mobile.
A study done by Cordova, Ingersoll, and Palmieri 1 evaluated 19 studies aimed at determining the efficacy of prophylactic ankle support. The study found that all forms of external stabilization, whether taping, semi rigid bracing (such
as AirCast Sport Stirrup), or lace-up bracing (such as Active
Ankle) restricted range of motion before and after exercise.
An overwhelming amount of the data suggested either form
of bracing over taping due to the natural stretching and degradation of traditional athletic tape with normal activity 1,2. The
external support methods permitted an actively appropriate
amount of motion in the joints, but slowed down the rate at
which these motions occur. This slowing of the angular velocity and strain rate has been attributed to protection of ankle
ligaments 1,2. Some research suggest that even though taping may loosen within as little as 20 minutes of activity, it will
provide the brain with a type of queue that may help the body
keep better control of the joint.
A final and important part of prophylactic devices is the cost
of using devices and if this cost outweighs the cost of treating an injury. A study by Olmsted, Vela, Denegar, and Hertel 3 took both of these issues into consideration and found
that bracing is significantly cheaper than taping, regardless
of whether the purpose is proactive or reactive protection,
when using these methods daily for practice and games. Taping both ankles for one athlete, using one roll of quality tape
per ankle at approximately $1.37 per roll, for a typical season
of 13 weeks and accounting for six days of activity a week
when taping would cost about $213.72; buying the same athlete a brace for both ankles at approximately $35 per brace
that lasts for the entire season will cost about $ 70. Not only
is bracing more cost-effective than taping over the duration of
a season, it has been noted in many studies to be statistically
more effective than tape 1,2,3. The cost of seeing a physician,
bracing or taping after an injury, physical therapy needed and
follow up visits with a physician or specialist is far greater than
either the cost of taping or bracing. (cont. on page 14)
GSMM 11
>>>Ankle Bracing and Taping: Should we do it to Prevent Ankle Sprains?
Although it is fairly clear that some form of prophylactic
measure will help athletes participating in most sports, is
there any reason to think that using these devices could
inhibit the athlete in any way? Research suggests that
healthy athletes are not statistically different muscle reaction to normal activity whether braced or not 4. This
means that the muscles used to help stabilize the ankle
are not affected by the use of braces or taping. Another
study suggested that bracing may even help with stability
when an athlete’s muscles become fatigued due to normal practice or game situations and are no longer able to
provide the ankle with normal dynamic support 5. Another
study showed greater patient satisfaction when using a
brace after an injury when compared to those who used
strictly taping after an injury 6.
So, as a parent or a coach attempting to create a preventative measure for keeping the ankles of an athlete
healthy, there are many issues to consider. First, consider
the need for preventative measures. Some sports, such
as volleyball and basketball, typically have higher rate
of ankle injury than do golfers or swimmers. Second, determine which method protection will provide the most
appropriate protection. Last, consider the cost of the prophylactic devices. Consider each athlete in his or her unique situation to determine what may be the most effective method of
ankle sprain prevention. We hope we have given coaches
and parents an educated insight into the world of taping and
bracing and equipped each with the power to make a well
informed decision for the athlete and child.
Prescription for a
Great Banking Relationship
References
Cordova ML, Ingersol CD, Palmieri RM. Efficacy of prophylactic ankle support:
an experimental perspective. J Athl Train 2002;37(4):446-457.
Wilkerson GB. Biomechanical and neuromuscular effects of ankle taping and
bracing. J Athl Train 2002;37(4):436-445.
Olmsted LC, Vela LI. Denegar CR, Hertal J. Prophylactic ankle taping and
bracing: a numbers-needed-to-treat and cost-benefit analysis. J Athl Train
2004;39(1):95-100.
Kernozek T, Durall CJ, Friske A, Mussallem M. Ankle bracing, plantar-flexion
angle, and ankle muscle latencies during inversion stress in healthy participants. J Athl Train 2008;43(1):37-43.
Shaw MY, Gribble PA, Frye JL. Ankle bracing, fatigue, and time to stabilization
in collegiate volleyball athletes. J Athl Train 2008;43(2):164-171.
Lardenoye S, Theunissen E, Cleffken B, Brink PRG, de Bie RA, Poeze M. The
effect of taping versus semi-rigid bracing on patient outcome and satisfaction in
ankle sprains: a prospective, randomized controlled trial. BMC Musculoskeletal
If you are looking for a real personal
banking relationship with bankers
Disorders. 2012;13:81.
who will get to know you by name,
understand the needs of your practice
and take the initiative to help you
reach your objectives - look no further.
We can prescribe just the right
Casey Brogdon
Physician’s Banking Specialist
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Periodization: The Training Plan <<<
Periodization:
The
T ra i n i n g
Plan
/// By: Gary Schofield, Jr. ATC/L, CSCS
A
couple
of
years ago,
my
wife
bought me
a GPS navigator
for
Christmas
and I LOVE
it! I am one
of
those
men who refuse to ask
for
directions and end up turning around fifteen times whenever
we go somewhere. It drives my family crazy! Now, I just
put the address in and “poof” not only do I have a map
but a voice guiding me and warning me of the next turn,
road and traffic.
One night I was heading home from the weight room
and was caught in the Atlanta rush hour traffic and rain
(not a good combination!). I took out the Garmin and
within a few minutes had a “shortcut” to get around the
unyielding maze of cars.
That shortcut got me thinking. I have a sign in my
training center that states “There are no shortcuts to
anywhere worth going.” I wonder how many athletes or
coaches come into the training center everyday looking
for that shortcut around the “traffic” of training. Hard
work is brutal. It is unyielding. What I have found is that
the great athletes don’t look for the shortcuts. They are
not looking for a pill to take, a shot to inject, or some
fad workout. They are the first ones in the weight room
and the last ones out. They leave their mark. They
execute the plan. Periodization, simply stated, is that
plan. Periodization is a way of organizing training into
units that focus on specific skills and athletic abilities.
The concept may seem new to many coaches but it has
been around since the birth of the Olympics and made
popular by the Soviets.
14 GSMM
The basic idea is that by manipulating both training volume (sets, reps, etc.) and intensity (% max, rest intervals,
etc) the athlete can reach peak condition at the appropriate time and reduce the risk for injury, fatigue and overtraining. This article will attempt to review the basic forms
of periodization and demonstrate how it can be applied
in training the multi-sport athlete. This is a topic that stirs
arguments and can instill confusion. I’d rather avoid both.
Realize that what works for one athlete, coach, or team
may not work for you. However, the more you know and
understand the plan behind the program, the better we will
be able to reach our goals.
The Mesocycle. The mesocycle consists of a grouping of microcycles, generally 4-6 microcycles to create one mesocycle (see
Table A.) Just as the microcycle, there are four basic mesocycles
to choose from: Hypertrophy, Strength, Power and Peak Phases. The goal of the hypertrophy phase is to generally increase
conditioning and build lean muscle mass through an increase
in volume (sets and repetitions) and a decrease in intensity (%
of maximal effort). The strength phase is obviously designed to
focus on increasing muscular strength by gradually decreasing
the volume while increasing intensity. Both the hypertrophy and
strength phases generally last 4-6 weeks. The power phase attempts to introduce speed to the strength workouts. Exercise
selection become important during this phase. Plyometric exercises as well as complex lifts (combination of strength exercise
with a plyometric exercise) become common. Again a decrease
in volume is followed with an increase in intensity. Generally
during this phase the rest interval between exercises increases
to allow for power development as the body will not produce
speed and explosion in a fatigued state. Finally, the peak phase
prepares the athlete to produce the highest levels of strength,
power and speed with low volume and high intensity exercises.
The power and peak phases typically last 2-4 weeks.
TABLE A
Phase
Intensity
Volume
Rest
Duration
HYPERTROPHY
50-70%
3-5 x 8-20
2-3 min
4-6 wks
STRENGTH
70-85%
3-5 x 4-8
2 min
4-6 wks
POWER
85-95%
3-5 x 2-5
3-5 min
4 wks
PEAK
93%+
2-3 x 1-3
4-6 min
2-4 wks
Linear Periodization
The traditional training plan is the Western Method, or the
Linear Periodization model. This model breaks down a program into 3 basic training units: the microcycle, the mesocycle and the macrocycle.
The Microcycle. The microcycle is the smallest training unit,
consisting of at least 2 training sessions but typically covers
one full week of training. There are four basic microcycles
to choose from: Base, Load, Deload to Reload and Performance Phases. The Base Phase introduces exercises as
well as technique to the athlete. The Load Phase places an
increase in both volume and intensity with the exercise selection. It is always important to demand technique and form
even under increased stress. If form and technique devolves,
the athlete is not prepared for the Load Phase or the exercise selected is inappropriate. This is essential when training young athletes. The Deload to Reload phase allows the
athlete to recover and regenerate following the two previous
cycles. The central nervous system becomes overloaded after 2-3 weeks of stressful training and this week allows the
nervous system to recover for the next phase. Finally, the
Performance Phase is where the athletes attempt to reach
high levels of performance under set volume and intensities.
This phase allows the athlete and coach to determine if the
plan is on track and meeting the goals of the program.
Weekly Schedule:
The Macrocycle. The largest of the training units, the macrocycle
contains all mesocycles in the annual training plan. The goal of each
macrocycle is to develop all athletic skills and abilities of the individual. Usually a testing and evaluation period follows a macrocycle.
Non-Linear Periodization
Another training system that is growing in popularity is the non-linear or conjugated periodization model. Whereas linear periodization separates training skills and abilities (conditioning, strength,
power, etc.), conjugated periodization attempts to couple the different training abilities each week. In order to do this it uses three
basic forms of training: Max Effort, Repetition Method and Dynamic
Effort (see Table B.) as defined by Vladimir Zatsiorsky in The Science and Practice of Strength Training.
Maximal Effort Method (ME). This technique
is defined as “lifting a maximal load against a
maximal resistance” (Zatsiorsky). The conjugated system is not a percentage-based program and has the athlete listen to his body during each maximal effort workout. Instead of
lifting for a set percentage, the athlete will lift
up to a 5, 3 or 1 rep max that day. Due to the
increased stress on the CNS, the athlete must
change exercises at least every two weeks to
avoid overtraining. Generally, there is one day
designated for maximal effort upper body exercise (bench) and one day designated for lower
body exercise squat, deadlift) each week.
“If you don’t know where you are
going, you’ll end up someplace
else.” – Yogi Berra
GSMM 15
>>>Periodization: The Training Plan
Specialized Care, Personalized Rehabilitation,
Gwinnett SportsRehab
Repetition Method (REP). Defined as “lifting a nonmaximal load to failure. It is proposed that during
the final repetitions, the muscles develop maximal
force possible in the fatigued state” (Zatsiorsky).
This method is employed to maintain other abilities
such as functional hypertrophy (lean muscle mass
building) strength endurance and recovery. This
method is often employed by many crossfit athletes
and/or boot camps.
Dynamic Effort Method (DE). Defined as “lifting a
nonmaximal load with maximal speed” (Zatsiorsky).
The percentage of weight lifted during this phase
depends on the training experience of the athlete.
The goal of this method is to increase speed and
rate of force development. Low volume is required
to avoid fatigue and to maintain maximal speed in
movement. Plyometrics may be included under this
method of exercise.
TABLE B
Weekly Schedule:
DAY
METHOD
FOCUS
OPTIONS
MON
MAX
EFFORT
LOWER
BODY
SQUAT/
DEADLIFT
WED
MAX
EFFORT
UPPER
BODY
BENCH
PRESS
FRI
DYNAMIC
EFFORT
LOWER
BODY
SQUAD/
JUMPS
SUN
DYNAMIC
EFFORT
UPPER
BODY
BENCH/
MED BALL
What is best?
Many great coaches and athletes use linear periodization as well as non-linear. Many combine the
two and create hybrid versions. What you need to
remember is that there is NO one best method of
training, just the method that best works for you.
The goal of all athletes and coaches should be to
increase their knowledge so that they know WHY
they do what they do. This is a HUGE topic that I
didn’t do justice to. It doesn’t even cover systems
like Crossfit that argue real life is variable and you
shouldn’t have a set plan, just constant variability.
But I have to agree with Yogi on this one. I have
a plan. When people are relying on me to deliver
them somewhere, I don’t want to set out and end
up taking them somewhere else!
Be a
GSMM
Contributor
If you would like to submit an article or are
interested in advertising opportunities
in GSMM please contact Gary Levengood
at krosenberger@sportsmedsouth.com or
770-237-3475 ext. 113
16 GSMM
Injuries that occur on a playing field, at home or at work can cause frustrating timeouts. With the help of
our sports medicine and rehabilitation specialists, the time on the sidelines can be spent restoring strength
and mobility for a safe return to the action.
The highly-qualified staff of physical and occupational therapists at
Gwinnett SportsRehab offer comprehensive assessments and treatments
for all types of injuries and diagnoses.
For more information about our facilities and services located in both
Lawrenceville and Duluth, visit gwinnettmedicalcenter.org/sportsrehab.
gwinnettmedicalcenter.org
Osteochondroses
and Apophyseal
Injuries in the
Young Athlete
T
/// By: Thomas F. Byars, MD
he pediatric skeleton lends itself to
injuries unique to
the young athlete,
including
various
apophysites
and
osteochondroses.
Primary care physicians treating the
athlete and parents
and coaches training young athletes
need to be aware of
normal and abnormal variations in the
pediatric skeleton
as well as common sites of injury. An understanding of
the pathophysiology, clinical presentation, diagnosis,
and treatment of these common overuse injuries will allow for the best care of the young athlete and safest
return to sport.
Osteochondroses, or “bone-cartilage conditions”, are a
heterogeneous group of injuries to the growth plates and
areas around the growth plates (epiphyses, physes, and
apophyses). This group of disorders of unknown origin
results from a disturbance in the natural process of ossification (or transition from cartilage to bone) in growing
bones. Proposed etiologies include rapid growth, heredity, anatomic characteristics, trauma, dietary factors,
and a disruption in vascular supply. Osteochondroses
follow a unique series of events beginning with necrosis
of bone and cartilage. This is followed by revascularization and reorganization with healing tissue, removal of
dead bone and tissue, and finally replacement with new,
well-formed bone and cartilage.
Apophysites are a subset of osteochondroses occurring at the bony attachment sites of musculotendinous
units. An apophysis develops as a secondary center of
ossification (bone tissue formation). Irritation at this attachment site is called aophysitis. Areas of the body
most often affected include the hip, knee, foot, elbow
and back.
18 GSMM
Hip Pain
Originally described independently in 1910 by Legg,
Walderström, Calvé, and Perthes, Legg-Calvé-Perthes
(LCP) is a hip disorder that results from partial interruption
of the blood supply to the immature femoral head. The exact cause of the vascular interruption is unknown. It typically occurs in children between 4-8 years of age, with boys
affected 4-5 times more often than girls. Patients present
with hip pain, an intermittent limp, and often referred pain
to the knee with limited hip abduction and internal rotation.
Hip radiographs will demonstrate varying degrees of fragmentation, flattening, and sclerosis of the proximal femoral
growth plate. The goal of treatment in LCP is to maintain hip
range of motion and hip congruency. Poor prognostic factors
include age older than 6 at disease onset, greater degree of
femoral head deformity, hip joint incongruity, and decrease
hip range of motion. Initial treatment regimens include rest,
physical therapy and anti-inflammatory medications. Surgical interventions are performed to contain the femoral head
in the acetabulum.
Knee Pain
In 1903, Robert Osgood (a US orthopaedic surgeon) and
Carl Schlatter (a Swiss surgeon) concurrently described the
disease that now bears their names. Osgood-Schlatter disease (OSD) is one of the most common causes of anterior
knee pain in children and adolescents. It is caused by repetitive traction of the patellar tendon on the tibial tubercle
ossification center or apophysis (traction apophysitis) which
results in inflammation and pain. Symptomatic patients are
usually between 10-14 years of age, up to 30% will have
bilateral involvement, and nearly 50% of patients are involved in regular athletic activity. Patients have moderate to
severe tenderness, swelling, and prominence of the tibial
tubercle. Radiographs often show anterior soft tissue swelling and may reveal fragmentation or ossicle formation anterior to the tubercle. OSD is usually a self-limited process
that responds well to rest, ice massage, and nonsteroidal
anti-inflammatory drugs (NSAID’s). Stretching and physical
therapy to improve quadriceps and hamstring flexibility can
help reduce symptoms.
Osteochondroses and Apophyseal Injuries in the Young Athlete <<<
In 1908, Johansson (a Swedish surgeon) and SindingLarsen (a Norwegian physician) discovered this variant of
OSD during a winter Olympic qualifier event in Scandinavia.
Although considered a different entity, the etiological factors
behind Sinding-Larsen-Johansson are very similar to OSD.
Patients are typically slightly younger at age of onset and
bilateral involvement is less common. Point tenderness is
localized to the inferior pole of the patella. Radiographs may
show soft tissue swelling and some layering at the inferior
patellar pole. SLJ is also a self-limited process that responds
to the same interventions as recommended for OSD.
Köhler first described a condition in 1908 when he detected characteristic radiographic findings of the tarsal
navicular. Köhler’s disease usually occurs in children between the ages of 4-9 and involves characteristic fragmentation of the navicular bone in the midfoot. Medial
midfoot pain and a unique limp with the child walking on
the lateral aspect of the affected foot are common presentations. Radiographs usually reveal navicular sclerosis, flattening, and fragmentation. Most symptomatic
cases benefit from application of a short leg walking cast
for 4-6 weeks.
Foot Pain
Elbow Pain
BS Sever first characterized Sever’s disease in 1912. In
Sever’s, the Achilles tendon exerts tensile forces on the
calcaneal apophysis which then results in heel pain during
activity, specifically running and jumping. It typically affects
children between 8-12 years of age, and is particularly prevalent in athletes involved in cleated sports and/or during a
growth spurt. Physical examination often reveals point tenderness over the posterior heel at the insertion of the Achilles
tendon on the calcaneus, as well as heel pain with medial/
lateral calcaneal compression. Treatment involves relative
rest, ice massage, analgesics, heel cups and a home-based
stretching program to address heel-cord tightness.
Medial epicondyle apophysitis affects throwing athletes
and is commonly known as “Little League Elbow”. Frequent throwing results in repetitive shear and traction
stress across the medial epicondyle growth plate. Patients present with localized tenderness over the medial
epicondyle. There may be mild tenderness in early phases of injury but it can progress to severe pain, swelling,
and avulsion fractures if left untreated. Radiographs often lag behind symptomatology but may show increased
sclerosis and fragmentation at the medial epicondyle.
Comparison films of the contralateral elbow often highlight the differences in the throwing and non-throwing
arm. Prevention is often the best strategy and should
include careful enforcement of pitch limits and restricted
use of breaking balls. Many in the sports medicine field,
including this author, discourage throwing any breaking balls (curves, sliders, etc.) until 13-14 years of age.
Successful treatment involves a finite period of throwing
cessation and a structured return-to throwing rehabilitation program designed to improve core/hip strength deficits and correct mechanical throwing errors.
Panner’s disease, first described in 1927, is the most
common cause of lateral elbow pain in children below
age 10. It is characterized by avascular necrosis and
degeneration of the lateral distal humeral ossification
center, or capitellum. Of particular importance is that
Panner’s may not be associated with physical activity.
Patients present with lateral elbow pain, swelling and
stiffness, usually with a noticeable loss of extension in
the elbow. Almost all cases are self-limited and resolve
completely with rest and conservative management.
Back Pain
In 1921, Scheuermann first described a juvenile osteochondrosis affecting the vertebral bodies. It can cause
back pain with a rigid kyphosis or humpback deformity.
Disturbance of the vertebral end plates causes anterior
vertebral body wedging, resulting in kyphosis during a
growth spurt. The exact etiology for this growth disturbance is not known. It affects girls and boys equally between 10-12 years of age. Physical examination findings
include a rigid, humpback deformity that does not correct
with extension, an important distinction from postural
roundback. Most patients do not need surgical correction, an option reserved for patients with mature skeletons, a curve greater than 75 degrees, and pain.
GSMM 19
There are 2 R’s in Recovery <<<
There
are
Eating carbohydrates mixed with protein (15 to 25
grams of high quality protein) has been shown to
be of the greatest benefit to help with recovery after
strenuous activity as it also helps rebuild muscle.
Good examples of a rich carbohydrate and protein
source are:
2 R’s in
Recovery
/// By: Ann Dunaway Teh, MS, RD, LD
W
hat you eat and drink after exercise is
just as important as what you do before and during exercise. Particularly
in sports such as basketball, wrestling,
soccer and swimming where tournaments and back-to-back events are common with little time
to recover. By paying attention to your recovery nutrition, you
set yourself up to recover faster and be in better shape for the
20 GSMM
next workout or competition. There are two main components
to proper recovery nutrition: replenish and rehydrate.
There is a 60 minute window after exercise where your body
is at its peak for replenishing muscle glycogen, the stored
form of carbohydrate, which acts as an immediate energy
source for the muscles during activity. After strenuous exercise or competition, these stores are depleted and need to be
replenished as soon as possible for better recovery.
Low fat chocolate milk
Yogurt with cereal topping
Low fat cheese and crackers
Peanut butter on whole grain toast
Fruit and yogurt smoothie
For optimal replenishment of muscle glycogen after strenuous activity lasting more than 90 minutes, aim to eat 0.5
grams of carbohydrate for every pound of body weight every 2 hours for 6 to 8 hours after long workouts lasting
more than 90 minutes. For example, a 150 pound person
would require 75 grams of carbohydrates, which is equivalent to 300 calories (1 gram of carbohydrate = 4 calories).
This is easily accomplished by planning ahead and having handy one of the above suggested examples of a carbohydrate and protein source so it can be eaten immediately after a tough practice or game. Then follow-up with a
meal as soon as possible that also contains carbohydrate
and protein. A few hours later another snack can be eaten.
Use your hunger as a guide and make good choices for
quality foods which provide good nutrients such as fruit,
vegetables, whole grain breads, and lean protein rather
than foods with little nutritional value such as chips, candy
and soda.
Rehydration is the second key to proper recovery. Just
because it is winter and cold outside, doesn’t meant that
hydration is less important. It may be less obvious when it
isn’t hot and sweat rates are lower, but focusing on staying
well hydrated at all times can go a long way to help with
performance as well as recovery. The best hydration plan
is one where you drink fluids regularly and have at least
one clear to pale yellow urination a day.
Water is the preferred method of replacing fluid losses
after exercise. For adults, drink 24 ounces of fluid for every
pound lost during exercise and for children and adolescents, drink 16 ounces of fluid for every pound lost during exercise (weigh yourself before and after exercise to
determine pounds lost). Sports drinks are appropriate for
workouts lasting more than 90 minutes, or 60 minutes in
hot and humid conditions. Drinking fluids at a cooler temperature makes them more palatable and encourages people to drink more.
To get the most out of workouts and gain a competitive edge do not ignore the 2 R’s in recovery: Replenish muscle glycogen by eating carbohydrates mixed with protein and Rehydrate with
plenty of fluids.
References:
Clark, N. Sports Nutrition Guidebook. Champaign, IL: Human
Kinetics; 2008.
Rosenbloom CA, Coleman EJ, eds. Sports Nutrition: A Practice Manual for Professionals. Chicago, IL: American Dietetic
Association; 2012.
www.dunawaydietetics.com
GSMM 21
GET BACK IN THE ACTION.
Choose Atlanta’s sports medicine specialists.
Sports injuries can unexpectedly take you out of the game.
That’s why the Sports Medicine Program at Gwinnett Medical
Center–Duluth is dedicated to helping all athletes prevent
injury, heal and manage pain.
With Atlanta’s most experienced team of sports medicine
specialists, we help thousands of professional and everyday
athletes spend less time on the sidelines. Our convenient
surgical, imaging and rehabilitation facilities ensure we
get athletes back to full strength faster.
For a physician referral, call 678-312-5000 or visit us on
the web at gwinnettsportsmed.com.
Gwinnett Medical is a proud recipient of the
2012 Healthgrades® America’s 100 Best™ Hospitals