Rafael Nadal's recent injury

I hate to be right when predicting a player's injury, especially a player that I like. From my analysis of this video, I predicted in my blog last week that Rafa Nadal would become injured.

When you evaluate using the principles of Diagnostic Motion Evaluation (DME) you understand at the point at which there is non fluid motion or when there is a compensation occurring, that is the location of a dysfunction.

In observing this video of Nadal's preparation for return of serve, you will see that when he shifts his body in the direction of his forehand, there is immediate compensation of movement at his Right pelvis/ hip and knee immediately followed by the movement the Right foot.

Using DME principles I hypothesize that his thoracic dysfunction contributed to his back injury in the Australian Open and is causing stress to his Right knee. Since the compensation in his pelvis/hip occurs immediately upon movement toward his Left side and movement begins at the Trunk,  the location of his first dysfunction is in his trunk. Because the compensation occurs at the Right pelvis/hip and the shared connective tissue attachment that is most proximal to this location is at the level of Rib 6 via the attachment of the iliocostalis lumborum provides further evidence that the first place to treat Nadal would be to identify the dysfunction located at the level of Rib 6.

If you would like to learn more about Diagnostic Motion Evaluation, click here

It is important to note that there also appears to be a number of subsequent dysfunctions down the kinetic chain.
                                                 

When you observe the still photos above you will see the difference in the position of Nadal's trunk with his forehand and backhand photos. Again his first compensation occurs at the mid thoracic spine at about the level of Rib 6, this is why his back appears unlevel.

When comparing the still photos above you should notice several other locations of dysfunction. In my classes I tell students that wrinkles in clothes are an indication of movement.Where the wrinkles stop are often areas of restriction or dysfunctional tissue.

In comparing the wrinkling of the clothes in the above photos and in the video,  when Nadal is moving toward his forearm there are  fewer wrinkles at; the level of his lower back and his Right pelvis and thigh. These dysfunctions may too have contributed to his back injury and should be addressed.

Lastly, in the video and the photo above you will notice premature and excessive Right femoral (thigh) internal rotation and in the forearm photo you can even see his part of his Right knee cap. (to compare femoral internal rotation you will compare the Right leg in the forearm picture with the Left leg in the backhand picture). This would not be a problem if Nadal's Right lower leg would move into internal rotation as well, but in the video you will notice that it does not and there is immediately compensation with his Right foot moving. Therefore there also seems to be a dysfunction at the level of the Right knee. This is why I feel that his Right knee will continue to be a problem for Nadal.

Over the weekend one of the commentators predicted that Rafael Nadal would beat the record for all time Grand Slams. Unless his team resolves these dysfunctions, I foresee continued health problems and a decline in his performance in the future.

I hope that I am wrong about this.

Rafa Nadal's knee a ticking time bomb for reinjury

I always get excited when I can tell where and why a person has pathology simply by observing them move.

I was given this camera angle from the  2013 US Open that showed the back of Rafa Nadal from the baseline.

I noticed on his preparation for return of serve, when he rotates his his right femur (thigh bone) internally (toward the middle), he gets premature and excessive motion at his right knee and needs to he compensate for this lack of motion by moving his right foot (see video above). If you look at the wrinkles in his shorts (a technique that I teach in my classes) you will notice that he has more wrinkles his left shorts leg than his right. Only when he compensates at his foot does he achieve the rotation in his femur that he needs. (you may need to view the video several time and utilize the pause button to see it).  

At that point I searched the Internet to confirm that Rafa's right knee was the one that had sustained injury.

I was correct that it is in fact Nadal's right knee that has been giving him problems over the years. The abnormal forces acting on his right knee, at least from watching this video,  have not been completely addressed by his rehabilitation team. 

When we lack of movement in a particular area we make it up elsewhere.

Can you guess where the lack of motion, aka. dysfunction is? shoot me an email to sigproed@gmail.com ( I will post the answer next time)

Unless and until this dysfunction is correctly identified and rectified,  it is just a matter of time before he sustains another injury to his right knee.

It doesn't seem to be affecting his play at this year's the Australian open. 

Let's see how he does in the finals.

Snow, Rain, Ice! Fall Prevention Advice

We are now firmly into the winter season and while many of us have a reprieve from the blistering cold we must be concerned about slipping on the ice and snow. 

Falling is a potentially fatal circumstance that claims the lives of over a half a million Americans each year. 

Slipping in particular carries with it the most consequence for fatal injury as people are more likely to hit their pelvis, spine or head.

Slips are caused when our base of support, our feet, move beyond our center of gravity (out from under us). 

To assess your risk from falling as a result of a slip try the following.

Pretend to stand on the face of a clock (12 o'clock is forward, 6 back, 3 to your right and 9 o'clock to your left).  With your feet parallel and shoulder width apart, pretend that the soles of your feet are cemented to the floor as you move your body and legs toward each of the clocks directions. You will realize that the direction that is most difficult to maintain your balance is the 6 o'clock this direction. This is the direction of movement that occurs with slipping.

I experienced this phenomenon twice recently during my vacation up north. One fall occurred on flat ground the other was down four concrete steps and happened in spite of my holding on to a handrail.

Given that my balance is pretty good, I became concerned for my patients and began to think what could be done to have prevent slips and what advice would I give for falling? 

I came up with the following: 

1. Bend your knees about 10 degrees: This lowers your center of gravity and increases your weight bearing over the front of your foot. This will do 2 things, it will counteract backward momentum and allow more weight over your toes allowing you to grip onto the floor. 
2. Flex your trunk forward. This will also counteract the momentum of a slip backward and will give you move time to react in the air to better position yourself for impact. 
3. Maintain contact with the ground continuously. ie. skate over a slippery surfaces.  You have much greater balance when 2 feet are on the floor versus one.  
4. Use devices that will assist with traction such as:  crampons, a walking stick or ski poles.  These will provide traction and additional bases of support on the icy or slippery snow 
5. When going up or down stairs face the railing with your body and place both hands on it.  Go up or down the stairs sideways. This is the 3 and 9 o'clock movements and you have greater balance with sway over the sides of your body versus the 6 o'clock direction. 

Falls do happen and if you should fall remember the following:

1. Don't panic: When you panic you tense your muscles which prevent them from absorbing shock. Think of the drunk driver who walks away from a devastating crash with barely a scratch.   
2. Try to land across a broad surface and multiple body parts. This will disburse the impact of the fall through your body rather than target it at one specific spot.
3. If you are falling backward try to rotate your pelvis to land in the middle of one butt cheek. It is usually the most padded area of a person's body. 

This is where I fell in both instances. My bruises were nasty but I would take it any day over a fractured coccyx or blow to my pelvis.

Long Term Results from Patient treatment

I always say that the hardest aspect of therapy is achieving carry over in our patients.

The challenge as see it are the following:

1. We have been taught to evaluate and treat a diagnosis and not patient functioning.
2. Virtually any person off of the street is going to present with many areas of hypertonic tissue, restrictions, decreased range of motion and neuromuscular dysfunction. We have not been how to know which of these factors are in fact causing a particular person's problem.
3. We are taught to look at the body part as isolated structures when in fact the dysfunction is not anatomically close to it.

Great results are achieved knowing exactly what is causing your patient's limitation.

Our classes are designed to teach you how to it. Here is the proof.

A few weeks ago, Targeted Evaluation and Treatment of the Pelvis, Pelvic Floor and Coccyx was hosted in NYC.

This class format involves the students evaluating and treating real patients during the final hour.

I had the opportunity to follow up with our patients 2 weeks later and here is what I learned:

100% of them reported that they continue to experience the benefits from their treatment.

72% of our patients have not required additional therapy after their visit. Of the other 28% one patient continues to receive therapy but on a different body part.

Some of the patient's reports include:

1. The ability to ascend and descend step over step rather than using only 1 foot.
2. They are without buttock and back pain.
3. Improved walking distance by double.
4. D/C of pain meds.
5. Decreased need to get up at night to urinate and improved flow of urine.

As an educator it is thrilling for me to see my student's achieve such great results!

If you are not getting carry over or great results in your patients you are probably treating the wrong thing.

Help Save Our Profession

I recently met an entrepreneur who told me that he had just purchased a PT practice. 

Sadly, my advice to him was not to have a well trained staff, but a good billing agency.

Our conversation continued about the reimbursement changes to insurance and Medicare, prospective payment in some states, and penalty for billing multiple codes.

If you are fed up and saddened by the current state of our profession, here a quick way to help to change it in less than 3 minutes. (it took me 2 minutes 37 seconds)

You and your; patients, family and friends can write your Senators and State Representative regarding the Medicare cap using the APTA legislative action portion of their web site. 

Below is the link for APTA members:

https://www.apta.org/aptalogin.aspx?redirectto=http://www.apta.org/apta/advocacy/lac.aspx?navID=10737423155

Non members of APTA and people from the community can the link to this address and advocate. 

http://capwiz.com/amerpta/issues/alert/?alertid=62327476

Our future as well as the future of every American citizen is impacted by this legislature. 

Please put these links on your facebook page and send out emails to everyone you know. 

Why treat the coccyx?

1. The coccyx serves a vital role as an attachment site for a number of muscles, tendons and ligaments of the spine and pelvic area, including the pelvic floor.
2. It is part of several spinal nerve conduction pathways.
3. It is the base of support of the urogenital system, reproductive system, digestive system.
4. It is the base of support and shares ligaments and muscular attachments with the sacrum, pelvis, spine and entire axilla skeleton. Think about a house built on a crooked foundation, if the coccyx is off everything structure above it will be off.
5. The dysfunction of this structure is pandemic.

What has been so fascinating to me is to witness after treating only the coccyx,  the changes in motion in areas that are not even close in proximity to it, such as the neck and shoulder.

Evaluation and treatment of this structure can be physically and emotionally sensitive to a patient therefore the therapist must be skilled and experienced in this technique.

In developing my On-Live seminar Targeted Evaluation and Treatment of the Pelvis, Pelvic Floor and Coccyx class, I have greater appreciation of this structure and even developed and new way to evaluate and treat it.

There are a only few spots left in our upcoming class in NYC. Click here for details.

Is hybrid learning the wave of the future?

In the latest PT in Motion (November 2013) there's an article about hybrid learning which is being taught at the DPT program of Nova Southeastern University in Tampa, Florida.

In their program hybrid learning consists of the students learning their lessons online for 3 weeks and coming into the University for 4 days of "face-to-face"hands-on learning per month.

The professor interviewed for the article confessed that she didn't agree with this type of model when they began implementing it four years ago. Now  she finds it a more beneficial way of implementing education to their students.

This model is very similar to the On-Live classes that I have developed for Signature Allied Strategies.

Part of this model is having patients with dysfunctions that are appropriate for the class come to the Live event and the participants will treat them.

At my last class, I was thrilled to see the results that my students were achieving in these patients. To me it is a direct testament that they have absorbed the material.

There is no greater satisfaction as a teacher to know that your students have learned.

Not only does the therapist have exposure to the material before and during the class but they are able to go back and review the online lessons after the live event is over for an additional 30 days.

The teacher is available throughout the entire process to answer questions.

Experience it Hybrid learning for yourself

Our next On-Live event is Saturday November 23rd at in NYC. Only a few slots left

Targeted evaluation and Treatment of the Pelvis, Pelvic Floor and Coccyx

I have also decided to provide FREE additional On-Live components to our  Live Seminar:
Balance and Fall Prevention Course in Teaneck Nov. 22& 24th

I truly believe that this is an amazing model and will be implemented by more companies and educational universities in the future.

If you are interested in hosting an On-Live event at your facility, contact us at sigproed@gmail.com. Please note that we are currently booked until Spring of 2014