The Ultimate Guide to Treating Ankle Sprains

A Humdinger No Doubt   Ankle sprains. Such a bugger to deal with.   Ankle sprains are one of the most common injuries seen in basketball. The cutting, jumping, contact, fatigue, and poor footwear certainly don’t help matters. Damn near almost every game someone tweaks an ankle. Treating ankle sprains in-game provides quite a different perspective. Rarely in the clinic do we work with someone immediately post-injury. Instead, we deal with the cumulative effects of delayed treatment: acquired impairments, altered movement strategies, and reduced fitness. The pressure is lower and the pace is slower. You shed that mindset with the game on the line. You must do all in your power to get that player back on the court tonight, expediting the return process to the nth degree. I had a problem. Figuring out the most efficient way to treat an ankle sprain was needed to help our team succeed. I searched the literature, therapeutic outskirts, and tinkered in order to devise an effective protocol. The result? We had 12 ankle sprains this past season. After performing the protocol, eight were able to return and finish out the game. Out of the remaining four, three returned to full play in two days. The last guy? He was released two days after his last game. It’s a tough business. The best part was we had no re-sprains. An impressive feat considering the 80% recurrence rate¹.    Caveats aside, treating acute injuries with an aggressive mindset can be immensely effective. Here’s how.

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Course Notes: Cantrell’s Impingement and Instability, 2015 Edition

Third Time’s a Charm  A trip home and hearing Mike Cantrell preach the good PRI word? I was sold. Impingement and Instability is one of those courses that I could take yearly and still get so many gems. In fact, I probably will end up taking it yearly—it’s that good. I took I&I last year with Cantrell (and the year before that with James), and the IFAST rendition was a completely different course. Cantrell provided the most PRI clinical applications I have seen at any course, which is why he continues to be one of my favorite people to learn from. Basically, if you haven’t learned from Mike yet, I pity you. Get to it! I have way too many gems in my notes to discuss, so here are a few big takeaways.

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Manual Therapy Musings

When I think About You… Prompted by some mentee questions and blog comments, I wondered where manual therapy fits in the rehab process. To satisfy my curiosity, I calculated how much time I spend performing manual interventions. Looking at last month’s patient numbers to acquire data, I found these numbers based on billing one patient every 45 minutes (subtracting out evals and reassessments): Nonmanual (including exercise and education) = 80% Manual = 20% Modalities = 0%!!!!!!!!!!!! Delving a bit further, here’s my time spent using PRI manual techniques versus my other manual therapy skill-set: PRI manual = 14% Other manual = 6% As you can see, I use manual therapy a ridiculously low amount; skills that I used to employ liberally with decent success There’s a reason for the shift I want my patients to independently improve at all cost and as quickly as possible. The learning process is the critical piece needed to create necessary neuroplastic change; and consequently a successful rehab program. Rarely is learning involved in manual therapy.

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Course Notes: PRI Cervical Revolution REMIX

Note: I made some errors on the first rendition of this blog that were corrected after speaking with Eric Oetter. Courtesy to him, Lori Thomsen, and Ron Hruska for cleaning up some concepts. Four Months Later When the Lori Thomsen says to come to Cervical Revolution, you kinda have to listen. I was slightly hesitant to attend since I had taken this course back in January. I mean, it was only the 3rd course rendition. How much could have changed? Holy schnikes! It is simply amazing what four months of polishing can do. It was as though I attended a completely different course. Did I get it all figured out? No. But the clarity gained this weekend left me feeling a lot better about this very complex material. This is a course that will only continue to get better with time; if you have a chance to attend please do. Let’s now have a moment of clarity.   Biomechanics 101 The craniocervical region is the most mobile section of the vertebral column. This mobility allows regional sensorimotor receptors to provide the brain accurate information on occipital position and movement. The neck moves with particular biomechanics. Fryette’s laws suggest that the cervical spine produces ipsilateral spinal coupling in rotation and sidebending. The OA joint, on the other hand, couples contralaterally. C2 is the regulator of cervical spine motion; much like the first rib regulates rib cage movement. C2 is also important for the mandible, as it balances the cervical spine during mandibular

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Course Notes: BSMPG 2015

#Bestconferenceevaahhhhh I shipped off to Boston to attend my first ever BSMPG summer symposium. And it was easily one of the best conferences I’ve ever been to. There was an excellent speaker lineup and so much of my family. Art Horne really put on a fantastic show. If you haven’t been to BSMPG before, put it on your to-course list. It is one of the few courses that has a perfect combination of learning and socializing. I hope to not miss another. Instead of my usual this person talked about that, let’s look at some of the big pearls from the weekend.   Why Sapolsky Doesn’t Get Ulcers In one quote Robert Sapolsky summed up my current foundational premise to rehabilitation and training: “The stress response returns the body to homeostasis after actual or potential threats.” ~ Robert Sapolsky   Regardless of what your malady is, it can probably be linked back to the stress response gone awry. The specifics become irrelevant because the stress response occurs nonspecifically. This response works best against acute crises. Guess how we screw it up? Chronic stressors. Human stressors are quite different from other species’ as we have the capability of inducing this stress response psychosocially. Gazelles on the Serengeti don’t have to worry about student loans.   We can see how chronic stress becomes an issue when you look at what occurs in the stress response: Glucose travels to the bloodstream to mobilize energy. Increased cardiovascular tone, heart rate, and blood pressure. Decrease long-term building projects such as

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Course Notes: PRI Interdisciplinary Integration 2015

A Stellar Symposium Back in April I had the pleasure of finally attending PRI’s annual symposium, and what an excellent learning experience. The theme this year was working with high-powered, extension-driven individuals. The amount of interdisciplinary overlap in each presentation made for a seamless symposium. Common themes included the brain, stress response, HRV, resilience, and drive. These are things altered in individuals who are highly successful, but may come at a cost to body systems. If you work with business owners, CEOs, high-level athletes and coaches, high level positions, straight-A students, special forces, and supermoms, this symposium was for you. And let’s face it; we are both in this category! There were so many pearls in each presentation that I wish I could write, but let’s view the course a-ha’s. The Wise Words of Ron Ron Hruska gave four excellent talks at this symposium regarding high performers and occlusion. Let’s dive into the master’s mind. People, PRI does not think extension is bad. Extension is a gift that drives us to excel. Individuals who have high self-efficacy must often “over-extend” themselves. This drive often requires system extension. Extension is a consequence, and probably a necessary adaptation, of success. If this drive must be reduced to increase function and/or alter symptoms in these individuals, we have to turn down the volume knob. How can we power down these individuals? Limit alternate choices – These folks take a wide view of a task Set boundaries – These folks attribute failure to external factors Making initial

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The Road to an Alternating and Reciprocal Warrior: You down with ENT?

This spans an entire treatment over a year’s time. Here’s part 1 Part 2 Part 3 Part 4   “Yeah you know me.” ~ Naughty By Nature  You know how sometimes when you are treating someone that individual eventually reveals fairly important information that he or she forgot about. Yeah that was totally me. I’ve always had a stuffy nose as far back as I can remember; especially in the winter. The only time breathing felt incredibly easy was when I was eating paleo in college. I have progressively been losing my sense of smell as well. Must be old age right? When I spoke with Lori Thomsen about my recent experience, she mentioned at Pelvis that attaining neutrality in certain areas but not others could lead to a “pressure cooker” phenomenon. For example, if I have someone with a neutral neck and thorax, lower extremity symptoms may possibly be more common. In my case, I had a neutral pelvis at the time my wisdom teeth were pulled. Pull out wisdom teeth and my nasal airway goes crazy. Guess where the pressure went? It was time to see an ENT. ENT Begins After viewing my CT scan and airway, my ENT concluded I have patho-scoliosis. More specifically, airway scoliosis. He found a deviated septum and some enlarged turbinates. These two factors could have a large impact on my breathing capabilities. To me this made a lot of sense. If you read this article, a nostril will drive air to the ipsilateral lung.

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Course Notes: Pelvis Restoration Reflections

Pelvises Were Restored It was another great PRI weekend and I was fortunate enough to host the hilarious Lori Thomsen to teach her baby, Pelvis Restoration. Lori is a very good friend of mine, and we happened to have two of our mentees at the course as well. Needless to say it was a fun family get-together. Lori was absolutely on fire this weekend clearing up concepts for me and she aptly applied the PRI principles on multiple levels. She has a very systematic approach to the course, and is a great person to learn from, especially if you are a PRI noob. Here were some of the big concepts I shall reflect on. If you want the entire course lowdown, read the first time I took the course here.  Extension = Closing Multiple Systems  This right here is for you nerve heads. It turns out the pelvis is an incredibly neurologically rich area. What happens if a drive my pelvis into a position of extension for a prolonged period of time? I’ve written a lot about how Shacklock teaches closing and opening dysfunctions with the nervous system. An extended position here over time would increase tension brought along the pelvic nerves. Increased tension = decreased bloodflow = sensitivity. We can’t just limit it to nerves however, the same would occur in the vasculature and lymphatic system. We get stagnation of many vessels. Perhaps we need to think of extension as system closure; a system closing problem. Flexion will be

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Recognizing and Changing Nonverbal Communication Disorders: An Interaction Approach

I was at my local coffee shop the other day chatting with my barista as she prepared my drink. Once it was all said and done and I paid, she wished that I had a glorious day. Glorious is not a word you hear often and definitely caught me ear. You might even say it was salient! I have this thing when someone uses an uncommon descriptor. When this occurs, I typically try to use an even more ridiculous descriptor. I especially like to apply this method to wish someone a better day than I. For example: Joe Blow: “You have a good day.” Me: “You have an even better day.” Glorious is a bit more difficult to top, but in the blink of an eye I was able to respond: “You have a splendiferous day.” Stupid? Yes. Did I get a laugh and a smile? Absolutely. Me doing this silly little thing with people is irrelevant. What is relevant is the speed that I was able to apply this quip. I spouted this word quickly because it fit a common pattern. Pattern recognition is huge in athleticism, medicine, and a multitude of other life facets. But how often do we think of pattern recognition when we interact with individuals? Being able to differentiate what both verbal and nonverbal communication one uses is critical in ensuring a favorable interaction with someone. And if your patient or client doesn’t like you? Fugetaboutit. Let’s look at a very common pattern that if you allow

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The Road to an Alternating and Reciprocal Warrior: Wisdom Teeth Extraction

This spans an entire treatment over a year’s time. Here’s part 1 Part 2 Part 3 The Saga Continues I’ve been through vision, I’ve had dental integration, I’ve put in the PRI activity homework, maximized my PRI testing, and feel a new man. Yet neutrality eludes me. It is a state of mind I could once feel by the power of glasses and splints, but the nervous system learns and accommodates. I topped out. But of course, I knew that would be the case from my very first session with Ron. “You gotta get those wisdom teeth pulled.” ~Ron Hruska By virtue of the dentist I integrate with, the time came. And here are the results. Zac B.E. (Before Extraction) So at this point in my life the large HRV gains I initially had were dropping and I was still having some neck tension. Training was feeling so-so. Test-wise, the videos below show what I look like. Here’s my squat And my toe touch. Upper quadrant tests And lower quadrant tests Mandibular movements And some cervical movements My pelvis is consistently neutral and I can shift and squat with the best of ‘em. But I still present with restrictions in my thorax, neck, and mandible (BBC/RTMCC). These limitations are likely present because of a  bony block called wisdom teeth. As you can see, the maxillary (top side) wisdom teeth limit the excurision of my lateral pterygoids for lateral trusive movements. My hope is by removing these guys I will get

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9 weeks with Bane, I mean Zac…Oops Sorry Wrong CI

Note from Zac: This is my first guest post, and to start things up is the one and only Trevor Rappa. Trevor was my intern for the past 9 weeks and he absolutely killed it. Here is his story. It’s very exciting for me to get to write a guest post for Zac’s blog that I have read so many times and learned so much from. The experience I have had with him over these past 9 weeks has been incredible and I hope to share some of it with all of you that read this. He challenged me to think critically in every aspect of patient interaction: how I first greet them, which side of them I sit on, the words I use, and how I explain to the patient why I chose the exercises they’ll go home with. All of this was to create a non-threatening environment to help to patient achieve the best results they can. He also taught me how to educate patients with a TNE approach, incorporate other interventions such as mirror therapy into a PRI based treatment model, and deepened my understanding of the neurologic concepts behind performance. Therapeutic Neuroscience Education Perception of threat can lead to a painful experience which will cause a change in behavior. It’s the PT’s role to introduce a salient stimulus to attenuate the perception of threat in order to cause a positive change in experience and behavior (Zac and I came up with that, I really like it). Pain

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