Reactive vs Proactive Athletic Wellness

Depending on where you are in the country, preseason is underway for fall sports. No matter what level, most teams require some form of pre-participation exam. These annual appointments are designed “to screen for injuries or medical conditions that may place an athlete at risk for safe participation."¹ Regrettably, there is not a standardized exam in the US, resulting in a wide range of effectiveness. The National Athletic Trainers' Association Position Statement includes the following guidelines for designing an exam:

• Medical and Family Health History

• General Health Screening

• Cardiovascular Screening

• Neurological Screening

• Orthopedic Screening

• General Medical Screening

• Review of Medication Use

• Nutrition Assessment

• Heat- and Hydration-Related Illness Risk Factors

Considering all the areas assessed, it is important a medical physician (MDs or DOs) supervise these exams. Missing from that list however, is a Functional Movement Assessment. Both ATCs and PTs can be instrumental in helping you establish an athletic baseline.²

By evaluating basic movement patterns, any strength imbalances or compensatory strategies can quickly be identified. Check out our instagram post on the functional assessment I used with the Warriors Dance Team for the 2021-2022 preseason screens!

Your provider can review any significant findings with you, helping you understand how they may be impacting your performance. But if the findings from your assessment don’t correspond with pain, should you still address them?

Short answer: It depends. 

As clinicians, it is important to take the whole athlete and their goals into account. Understanding the demands of the sport and the anticipated load throughout the season is one piece of the puzzle. A rising high school freshman basketball player with lower extremity strength imbalance may have been fine playing at the middle school level 3-4 times per week. However, once introduced to the demands of a varsity squad- weight lifting, practices 5 times a week, and a heavier competition schedule- may no longer thrive. It is reasonable to anticipate that they will begin to experience lower extremity joint pain at some point during the season. By providing them a short home exercise protocol that addresses the imbalance, they may be able to avoid the scenario altogether.

A semi-professional golfer will expectedly present with a strength imbalance dominant to non-dominant side rotation due to the demands of their sport. Assuming their regular strength and conditioning includes bilateral rotational power and deceleration work, minimal changes may need to be made.

Ultimately, we believe that sports medicine should be proactive not reactive. While it is impossible to avoid injury in sports entirely, athletes can train more effectively based on their individual strengths and demands.

To learn more, check out these articles:

1. Wingfield K, Matheson GO, Meeuwisse WH. Preparticipation Evaluation: An Evidence-Based Review. Clin J Sport Med 2004; 14(3):109-122.

2. Conley KM, Bolin DJ, Carek PJ, Konin JG, Neal TL, Violette D. National Athletic Trainers’ Association Position Statement: Preparticipation Physical Examinations and Disqualifying Conditions. Journal of Athletic Training 2014;49(1):102–120.

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Daily Foam Rolling

Myofascial release is a hands-on technique using sustained pressure to the connective tissue restrictions to relieve pain and restore motion. But does it work? Dr. Betsy Webb certainly thinks so, stating “this is one of the most common modifications I suggest to patients. Maintaining soft tissue and joint mobility is so important in preserving joint health and building strength.”

According to a systematic review conducted by Beardsley and Škarabot, myofascial release can help to increase flexibility and reduce soreness. Regular maintenance helps with joint and soft tissue extensibility and mobility, will improve tissue length and pliability and its ability to accept force and load. This allows the body to do more work with less strain overall. Methods like foam rolling, gua sha and massage can improve arterial and vascular endothelial function, or the flow of blood and lymph through the tissues. Self-myofascial release allows for consistent and cost-effective management. Athletes of all levels most commonly use a foam roller or ball of varying density.

Despite being versed on the benefits, Betsy has trouble incorporating soft tissue work. “I love working on strength and cardio work,” she laughs, “but often under prioritize mobility in my own physical fitness. I know how valuable mobility work is, yet I struggle to incorporate it into my routine.” As part of our Athlete Within Challenge, Betsy agreed to spend 10 minutes foam rolling everyday for two weeks. Here’s how it went:

As with any new habit, the most challenging part about for Betsy was adherence. “I started out really strong for the first week but then the weekend hit and falling out of my daily routine made it more challenging to stay diligent,” she says. Sound familiar?

In order to stay consistent, Betsy found three different techniques to be most helpful: routine, external accountability, and increased accessibility. “I found using an alarm worked really well. I set an alarm for 9:15 every night to remind me.” (As an added benefit, myofascial release can also help to improve parasympathetic nervous system activity, allowing us to mentally and physically calm down so our bodies can regenerate. Soft tissue work in the evening can set you up for a great night’s sleep!)

Betsy shared her goals with her fiancé, finding that having “someone to hold me accountable, who knew to remind me if I hadn’t done it for the day” helped to keep her on track. The last thing she found to be helpful? Relocating her foam roller. “I ended up putting it next to the tv,” says Webb, “so that when I would sit down to watch tv at night I would see the roller and be reminded to use it.”

So is it worth the time? After the two weeks were up Betsy’s body was thanking her. “Foam rolling is something I know I should do more of, especially for my thoracic spine, but never was able to get into a routine." Like so many of our patients, Betsy saw tremendous benefit from going back to the basics: “After the first week I felt good but not too much different, but a full two weeks really started to make a difference in how I felt from a mobility standpoint.” The true payoff for myofascial release work is in the consistency. Studies have yet to show if any of these improvements in flexibility and tissue quality have longterm effects once treatment is stopped. “I fully intend to maintain this behavior. As I saw with the two weeks, the longer I remained consistent the better I felt,” states Webb.

Our vote? Yes to myofascial release!

Looking for Dr. Betsy Webb? As of July 1st, she will be practicing in the Chicago Area!

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Superbill Best Practices

Choosing to work with a provider not covered by your insurance has advantages and disadvantages. It can be gratifying to do your research and select the practice that best meets your needs, and in some ways, simplified to know exactly what you owe from the start. However, paying the full amount for services can add up.

Every patient is eligible to receive itemized medical receipts, or superbills, detailing their care with us. These receipts can be submitted to most insurance plans for reimbursement consideration, as well as qualify for select employee wellness incentives or tax credits. Because reimbursement costs the insurance companies money, the process is often tedious. We’ve put together our top four suggestions on how to maximize your returns, taking full advantage of your plan:

1 Gather your paperwork

Most insurance companies still require you fill out a paper application with your plan information to mail in along with your superbill. We recommend printing and filling out one application, leaving the date blank. Make copies of this, and reuse for each submission adding the individual dates each time. 

2. Read the fine print

Double check which payment options you select for your reimbursement. Some forms offer the choice to make payments to the providing clinician instead of the patient, aka YOU. Selecting the wrong option could require you to wait much longer to receive payment. 

3. Increase your odds

Submit your receipts individually, as soon as you receive them. It's a 6 week process, at minimum, and your insurance could require more information from your clinician.Having to resubmit decreases your chance of payment.

4. Pay it forward

Share any feedback from your insurance company with our team. Remember, they are looking for any reason to not pay out on claims. If they don't cover the services billed, we can work with you to better understand what they will cover in the future

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As the Director of Operations + Patient Success, Shannon navigates our Out-of-Network team. After pairing you with the best provider for your goals, she continues to be an essential part of your care by ensuring you have all the information you need for insurance claims.

For specific questions, or for help managing an existing claim, schedule a call

Back At It

To wrap up our section on lumbar disc injury, Nina and I break down some of the most common patient questions we receive. As an AT, Nina is accustom to triaging athletes in pain, helping them find confidence in their plan of care.

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SV: For the past month, we’ve been sharing the latest research on lumbar disc pathologies. As a recap, what are your top three take aways for experiencing back pain?

NS: We’ve covered a ton of information on this topic recently, looking at the impact of pregnancy as well as injury. The overall takeaway is that each individual’s experience can be different- this goes for symptoms and solutions. That’s why personalized care can have such a big impact for back pain. Similarly, there isn’t one guaranteed strategy for managing a lumbar disc injury. A combination of treatments, including soft tissue work, stability and mobility exercises, and pain management, is typically needed. Last, use this as an opportunity. For most people, an injury like a disc herniation can be a catalyst to make adjustments to their behaviors, allowing them to emerge stronger than before.

SV:  How does this differ from the type of back pain caused by pulling a muscle?

NS: Discogenic pain has a different quality; many patients report feeling sharp, electric sensations, while others complain of weakness. Nerve pain can “travel,” sending irritation down one or both legs. Muscle spasm often accompanies a disc injury- it’s a protective strategy. Muscles of the back will automatically tighten above and below the injured disc to limit movement. This tightening makes it difficult to use muscle systems, or groups of muscles designed to support compound movements, effectively.

Pulling a muscle, or overusing a muscle, can usually be correlated with a specific action or activity. You may feel tight, or restricted. This should resolve, or feel considerably better, in 72 hours if it’s just muscular.

SV: Here’s a popular combo question- do patients need to get imaging for this type of injury? How likely will they need surgery?

NS: It’s a valid question- too often, we only hear about worst case scenarios for injuries. Unless you’ve suffered a traumatic injury, like a car crash, we don’t typically recommend imaging right away. Rehab exercises and pain management will be the most productive first steps. If you eventually need surgery down the road, being as strong as possible going in will dramatically help your recovery!

Surgery makes the most sense for patients who have a high risk of complications- like if your herniation or displacement is so severe you may cause permanent damage to your spinal column- or for those who haven’t succeeded with conservative care after a number of months.

We’re big believers that patients should be the center of their plan of care, with a variety of clinicians and specialists, coaches and supporters surrounding them. Without a different perspectives, you can overlook options. Ask questions, get second options- be your best advocate!

SV: Once someone injures their back, does that mean they can never workout or play sports again?

NS: In the vast majority of cases, definitely not! Most patients are able to return fully to their previous level of activity. Like any major injury, it will take dedication and focus to recover. It’s essential to allow your body enough time to heal, and to correctly learn, or re-learn, movement patterns. Look for rehab practitioners that understand the demands of your activity, and can help get you there. Stopping at 65-75% better increases your chance of re-injury significantly.

SV: With back pain being one of the most prevalent injuries, how can someone lower their risk for injury?

NS: Regular physical activity will help to protect against a number of ailments and injuries. Particularly with the recent transition to virtual learning and working, movement is even more important, as we are naturally more sedentary in this scenario. Adding in tri-planar exercise, including linear, lateral and rotational work, can help make sure you’re prepared for whatever life throws you! If you’re new to exercise, or struggling with home exercise routines, setting up an appointment to work with a clinician or coach can give you the confidence you need to move safely.

SV: At Physical TheraPT, as many of our patients know, we love staying current on the latest innovations in exercise and rehab equipment. What’s your favorite product out there right now for back pain patients?

NS: For patients still in the early stages of recovery, I really like the biofeedback cuff. This deconstructed blood pressure cuff helps increase awareness of pelvic stability and highlights how well someone is able to maintain a braced position when you add on movement. For those who are out of pain, and show progress with more challenging exercises, the 3D strap is my favorite. Don’t be deceived by the simple nature of this piece of equipment! It adds rotational load to almost any movement pattern, allowing athletes to adapt and practice in a safe environment.

Buy on Amazon

SV: Last question- what’s your go-to strategy for pain relief with this type of injury?

NS: Finding a position of comfort that you can rest in. Back injuries can feel unrelenting- having a position that gives you some relief is critical in the beginning stages of recovery. Laying on a firm surface, resting on your back with knees bent and feet planted, referred to as Hook-Lying Position, is generally safe for most patients. Others may find relief with a bit of light traction, leaning into your elbows at a counter, or floating in a pool.

Mama Bear Energy

To wrap up our section on lumbo-pelvic pain, I had a chance to chat with Kathleen about how to manage this from the patient perspective. Kathleen is our unofficial in-house champion of new moms. Her passion for this population is obvious- read more on how she views rehabilitation and fitness as crucial to pre-natal and postpartum health.

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SV: For the past month, we’ve been sharing the latest research on lumbo-pelvic pain during pregnancy. As a recap, what are your top three take aways for mom-to-be who's been experiencing back pain?

KM: Sure thing! First, and maybe the most important take away, low back in pregnancy shouldn't be considered just part of the process, something you have to endure. There's no need to be in pain unnecessarily! Next, we have to think outside the box to find an exercise activity that feels right for you during these weird times - whether it’s strength, pre-natal yoga, pilates, or aquatic. Many yoga and pilates studios are offering virtual classes during the shelter-in-place orders. Last, don’t be afraid to speak to your doctor. Advocate for the support you need to help make your pregnancy as comfortable as you can be. Working with a skilled clinician, like a PT or ATC, to address your specific needs can not only reduce pain but also keep you and your baby healthy throughout the pregnancy.

SV:  How does this differ from the type of back pain someone who's not pregnant might experience?

KM: Back pain in pregnancy stems not only from the obvious changes that are occurring in the woman's body from the growing baby, but is also impacted by the hormonal changes that create ligamentous laxity in preparation for childbirth. The pain itself can evolve throughout the pregnancy, shifting in location, intensity and ancillary symptoms. Additionally, lumbo-pelvic pain can coincide with altered balance as the center of mass moves with the growing belly.

SV: According to some, back pain is practically inevitable during pregnancy. What could someone trying to get pregnant do to proactively prepare physically?

KM: Any muscle weakness or joint instability coming into the pregnancy will increase the difficulty of dealing with the demands of pregnancy. Get started now! It’s smart to be proactive, working on strength and overall fitness to prepare for pregnancy!

SV: Pregnancy is NOT easy. Some moms may be feeling overwhelmed just thinking about adding exercise to their day, while others might be eager to feel better and get back to their routine. Can you talk through what a home program might look like?

KM: As we shared, the American College of Obstetricians and Gynecologists recommends 30 minutes of moderate intensity exercise most days of the week throughout pregnancy. This could be a 30 minute walk at a pace in which you can still talk, a 45 minute prenatal yoga or pilates class, or a 30 minute home routine that you could even split up into 15 minutes in the morning and 15 minutes in the evening. Exercises will vary between individuals, but all expecting mothers should include stability, core strength, and proper squat and hinge techniques in their programs. Upper body strength is a great bonus, too!

Postpartum it is important to give your body the time it needs to heal; it is recommended to rest 6 weeks before starting exercise post-childbirth. If feeling unsure where to start, meet with a professional who can guide you through a program to safely get you back to exercising.

SV: At Physical TheraPT, as many of our patients know, we love staying current on the latest innovations in exercise and rehab equipment. What’s your favorite product out there right now for pregnant patients?

KM: There’s been a lot of chatter about abdominal binding postpartum by a certain celebrity. Do your own research on what makes the most sense for your recovery; too much downward pressure following delivery isn’t always safe. Bao Bei Maternity offers physio-designed appropriate support garments for both during pregnancy and postpartum. Check them out at www.baobeimaternity.com or on instagram at @baobeimaternity

SV: Last question- what’s your go-to strategy for pain relief with this type of injury?

KM: Heat can be very helpful - whether a warm bath or a heating pad on the couch with your feet up, this is a great strategy for both pain relief and stress reduction.