And not just “learned” because you read about it in class but you haven’t really had the chance to use it. I mean the things that you suddenly see in a new light, that you got to experience first-hand and manipulate, etc. I was inspired to write this because I haven’t written in awhile…and I wanted to see how much I’ve learned since going through some decently weird groin pain and working with a large number of athletes at one time. I learned the hard way not to expect athletes/patients to react the same way I do to things, but I’m definitely using my own experiences to see what has/hasn’t worked in general. And hopefully I can consider these more as I go off to grad school.
- Isometrics are just one thing…you need more. Ok, an obvious statement. These are always first in the line of defense. But there are some exercises that tend to be more isometric in nature than others. For example — isometric groin exercises are pretty easy, but actual moving ones that involve body weight as a main resistance are difficult to think of and to execute. And that’s where exercises like the Copenhagen adductor exercise comes in! What a beauty.
- What is your intent? I would say that all muscles, especially for athletes, need eccentric work. Back to the Copenhagen exercise — think about how unpredictable sports are, and how frontal plane movements almost constantly need work…the exercise is basically body-weight loaded, which is exactly what happens in sport. And the eccentric phase in the Copenhagen involves a lot more of the whole body than just the leg itself — even the obliques! Obviously you wouldn’t start out with this if it were a real groin tear, but if it was just some minor discomfort/preventative rehab, it’d be a good exercise. So always ask yourself why you’re doing an exercise…and come up with an actual answer.
- Isometrics need to be done in all the different ranges! I noticed that my hip external rotators (with hip flexed to 90) were irritated when I was stretching them…and when I was activating them in the shortest position (max external rotation). It’s not just about the stretch, it’s also about the muscle being able to relax, “shorten”, and activate in a different “length”. So there’s two parts to this — passive “adjustment” to the short or long length of muscle, as well as active…activations of the muscle in those various lengths. These really help with mobility and control.
- What planes are you using in rehab? I stumbled again upon an infographic that I saw maybe last year — there are glute exercises that involve vertical loading, horizontal loading, rotational/lateral loading, and then combos (from Bret Contreras, the glute guy!). The glute is a bit of a unique muscle, but this kind of thing can apply to other muscles. Some muscles have multiple jobs, such as hip rotation AND flexion (psoas, for example). You have to think about the mechanism of how someone was injured (which plane of movement[s]), how they used to move vs. how they move now, etc. Also, if muscles cross over two joints, like the psoas again, how does that change what you do? What area was affected? There’s a lot to consider but you can see that it’s important to provide stimulus in different planes, just like sport.
- Exercises that don’t really look like core exercises can be core exercises. Nearly every exercise can be a core exercise. The core is not just the rectus abdominis. It’s also the transversus abdominis, obliques, QL, back extensors/rotators…and sometimes the lats and the glute mediuses like to get involved. Fun! I am definitely excited to work more with athletes who have back/groin issues and see how I can help them. I’m also looking forward to learning about more than just muscular issues…spondys, disc herniations/degeneration, etc. Because although neuromuscular “stuff” has a lot of my attention, I need to be more well-rounded.
- Think: progress, progress, more progress. How can you progress exercises to challenge the body differently and move them towards returning to sport in the most efficient way possible? Whether it’s coordinating multiple movements together, changing surfaces, adding weight, making it one leg or one arm, changing positions, etc… always think about it. You can’t just keep increasing the weight or else they’ll breakdown. One of my favorite ways to progress is to add props/obstacles and additional movements (ex. cable/band reverse lunge → hip flexion drive). And then later, speed comes into play (whether they are post-op or even just dealing with a small niggling pain).
- Also, keep it simple. Yes, rehab can be very creative and fun, but don’t do things just to show off how creative you can be. Be purposeful. Give your patients what they need, not what you want them to need. I’m so guilty of this because I’ll find or come up with some interesting-looking exercise to challenge them…but it only looks fancy/flashy, and doesn’t necessarily do the right thing. I remember doing this in my last clinical rotation — I definitely had fun, but I would definitely do it differently now! But I was just learning and I would never have learned this lesson if I didn’t try those new things.
- Challenge people. Give them heavy rehab exercises so they can get back to strength training and sport, in later stages, of course. They say that limb strength should be about 90% of the uninjured limb (but recently I’ve also seen that you really can’t compare it to the other side because there are almost always differences, even if it doesn’t appear that way), and you aren’t going to get there unless you’re giving them exercises and loads that actually help with muscle development.
- Time and compliance — this isn’t really something new, but of course after working with a middle school population with limited time/supplies… I realized that you don’t always have the resources to come up with complex rehab plans and such. Whether you’re limited by supplies or the room you have to work, or how willing the kids are to do the rehab, how much they care…it’s going to be tricky. I know there will be times I spend ages on a rehab plan and it won’t work out due to some unforeseen circumstances. I know that I’ll have to really assess deficiencies and trace my injury evaluations back to the root because knowing the basics will keep me from getting overwhelmed.
- Split days — I really do think you’ll get the most success when you provide 2 different days of rehab. It definitely keeps people from getting bored, but it also gives you a way to do 6–8 exercises instead of just 3–4, just as an example. In my own “rehab”, for example, I’ll do the Copenhagens every day, but I’ll do different balance exercises, glute activations, hip rotation work every other day.
I’m sure there are more things, but it’s midnight and I’m exhausted so I believe it’s time to hit the hay. A lot of this stuff I understood previously, but only on the surface, such as the things about the isometrics or progressions…so this is a bit of a new take on them, I suppose. I hope to write things like this every few months so that I can keep track of all the things I’ve learned about specific topics, not just the latest “thing” that’s caught my eye.
