Month: November 2011

An Updated Look at Femoroacetabular Impingement (FAI)

Over the weekend I posted a video at HockeyStrengthandConditioning.com of a former (and hopefully future) division 1 lacrosse player that I’ve worked with over the last few months at Endeavor Sports Performance. What makes this player unique is that he’s undergone 4 hip surgeries (2 on each side) secondary to femoroacetabular impingement (FAI) and bilateral sports hernia surgery. The video alludes to the importance of recognizing individual limitations and teaching the athlete how to move within his or her own confines.

Working with this athlete also highlights the importance of understanding these so-called abnormalities. When he first came to Endeavor, light jogging wasn’t even an option. In other words, his range of motion was so poor, damage so significant, and overall comfort level with athletic movements so degraded that we really had to start slow. A few months later, he’s sprinting, cutting, and jumping explosively and without pain; he’ll be the first to tell you that he’s never felt better. My ability to effectively work with athletes like this stems directly from the amount of time I’ve spent studying the relevant research. I think this information is valuable for anyone that trains anyone, but if you work with hockey players, it’s absolutely essential. The amount of research in this area has exploded over the last decade; understanding the causes and implications of FAI will help you more effectively train players that present with these injuries (which is most) and help to prevent unnecessary complications.

Illustrating “normal” hip joint anatomy and FAI abnormalities

Below is a brief review of some of the current literature:

High prevalence of pelvic and hip magnetic resonance imaging findings in asymptomatic collegiate and professional hockey players

MRI findings from 21 professional and 18 NCAA D1 players; all were asymptomatic
14 (39%) dysfunction of adductor-rectus abdominis insertions
25 (64%) hip pathologic changes
30 (77%) have MRI finding of hip or groin pathologic abnormalities

The prevalence of cam-type femoroacetabular deformity in asymptomatic adults

Retrospective analysis of CT scans from 419 randomly selected patients from 2004-2009 that were taken for problems unrelated to the hip
Of the 215 male hips (108 patients) analyzed, a total of 30 hips (13.95%) were defined as pathological, 32 (14.88%) as borderline and 153 (71.16%) as normal.
Of the 540 female hips (272 patients) analyzed, 30 hips (5.56%) defined as pathological, 33 (6.11%) as borderline and 477 (88.33%) as normal.
This highlights the prevalence of these injuries in asymptomatic individuals, especially men. This means that, in the general population, roughly 1 in every 3-4 men that you train will have an underlying hip abnormality. The prevalence of these findings in hockey players is drastically higher (see above).

Prevalence of cam-type femoroacetabular impingement morphology in asymptomatic volunteers

200 asymptomatic individuals (111 females, 89 males; average age 29.4 years) had an MRI taken of their hips.
14% of the volunteers had at least one hip with CAM impingement
10.5% had CAM on either the right or the left side; 3.5% had CAM in both hips
22 of 28 individuals (79%) who had CAM were men; only 6 (21%) were women.
22 of 89 (24.7%) men had CAM impingement, compared with only 6 (5.4%) of 111 women.

Hip flexor muscle fatigue in patients with symptomatic femoroacetabular impingement

Comparison of hip flexor strength during submaximal isometric and repeated maximal dynamic contractions in those with and without FAI.
FAI participants exhibited significant hip flexor weakness compared to the controls
No changes were noted in fatigue indices between the two groups
Authors noted that those with FAI tend to have adductor and hip flexor weakness. It’s easy to look at these weaknesses and point to them as potential causes of FAI secondary to poor femoral head control. That said, it’s also worth noting that the bony overgrowth limits hip adduction and hip flexion and may cause weakness secondary to neurological inhibition, especially as bony end-range is approached.

Can we predict the natural course of femoroacetabular impingement?

Because FAI is so strongly associated with future osteoarthritis, these authors sought to determine whether age of total hip arthroplasty was related to certain radiographic findings and/or activities.
Given the complex and dynamic nature of these injuries, it’s not surprising that they weren’t able to find a relationship through their methods. That said, I think they hit the nail on the head with their conclusion: “Hence, considering the high prevalence of FAI-related radiographic findings, we conclude that not every radiographic abnormality requires treatment.”
This highlights the importance of not taking every positive radiographic finding and shipping the player off to the surgical table!

Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: a case series

Analyzed 37 hips (average age: 25 years) with BOTH a sports hernia and FAI. Patients were athletes competing at the pro (8), college (15) elite high school (5) and competitive club (9) levels.
Evaluation occurred at an average of 29 months post surgery (wide range of 12-78 months though)
Of 16 hips that had athletic pubalgia (sports hernia) surgery as the index procedure, 4 (25%) returned to sports without limitations, and 11 (69%) subsequently had hip arthroscopy at a mean of 20 months after pubalgia surgery.
Of 8 hips managed initially with hip arthroscopy alone, 4 (50%) returned to sports without limitations, and 3 (43%) had subsequent pubalgia surgery at a mean of 6 months after hip arthroscopy.
Thirteen hips had athletic pubalgia surgery and hip arthroscopy at one setting. Concurrent or eventual surgical treatment of both disorders led to improved postoperative outcomes scores (P < .05) and an unrestricted return to sporting activity in 89% of hips (24 of 27).
While it’s impossible to make any accurate inferences, I’d be interested to see how these numbers may differ if the athletes were in sport programs with medical professionals that truly understood the implications of the abnormalities and could teach the players how to move within their limits.

In my experience, most players do very well when they understand the limitations in their joint anatomy and are taught how to move within these confines. Because the primary suggested mechanism underlying athletic pubalgia involves a tug of war across the pubic symphysis between the adductors and abdominals AND because those with FAI tend to have very dense/fibrotic adductors, many players will benefit from some soft-tissue work in this region, especially in the area of the proximal adductor magnus attachment. Also, because posterior capsule density can push the femoral head forward in the joint and put excess stress on the anterior/superior labrum, this is another area worth having a manual therapist look at. The manual method itself is less important than the proficiency of the therapist. It can be tough to find someone that is comfortable working in that area, but it is well worth the trouble when you do!

To your success,

Kevin Neeld

P.S. If you’re interested in learning more about hockey hip injuries and associated assessments and corrective strategies, I highly encourage you to check out my presentation “Hockey Hip Assessments: An In-Depth Look at Structural Abnormalities and Common Hip Injuries”, which is now available at Hockey Strength and Conditioning

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Current Ice Hockey Research

I’m really looking forward to this week. On Wednesday I’m taking off for Lincoln, Nebraska for a 4-day course called Advanced Integration from the Postural Restoration Institute. Lincoln isn’t exactly the most ideal December destination (I would have preferred they host the course in St. Maarten), but the course is going to cover integrated ways to assess for and apply corrective strategies for the hip and thoracic dysfunctions covered in two previous courses that I’ve taken. Should be a great experience.

It’s been a while since I’ve touched on some of the “newer” hockey-related research, so I wanted to give you a quick update on what’s been going on in the literature. Some of these studies are over a year old, but I’m coming across them for the first time.

Accuracy of professional sports drafts in predicting career potential
This was an interesting study looking at the relationship between games played and draft round in NFL, NHL, NBA, and MLB athletes drafted from 1980-1988. The analyses included 4,874 athletes over that time span. The assumption is that games played is indicative of career success. Naturally, there are some inherent limitations to using such a general marker of success, but overall I think it’s probably the best choice, especially in consideration of the intent to make generalizations across several sports. As would be expected, they found a significant difference in games played across draft rounds, and a significant negative relationship between draft round and games played (earlier draftees played more games). However, the authors note that draft round accounts for only 17% of the variance in games played. In other words, while the relationship between draft round and games played may be statistically significant, the relationship between draft round and future professional success is extremely weak. This provides support for the long-term athletic development model, as it’s evident that early successes (indicated by being drafted early) do not always develop into later success at the professional level. I’ve written quite a bit about this in the past, but this same concept can be applied when looking at how dominant peewees play at the midget level, how dominant midgets play at the junior or college level, and how dominant college players play at the pro level. Development is a long-term process!

Examination of birthplace and birthdate in World Junior ice hockey players
This study examined 566 junior ice hockey players from the U.S., Canada, Sweden, and Finland that competed in the International Ice Hockey Federation World U20 Championship between 2001 and 2009. They found a consistent relative age effect (RAE) across ALL FOUR countries, and that players were less likely to be from major cities. They also noted that there was no interaction between RAE and birthplace. For those of you that aren’t familiar, RAE refers to a phenomenon whereby players born earlier in the calendar year (e.g. January-March births) are relatively older than those born later in the calendar year (e.g. October-December births), and therefore are more developed and perform at a higher level compared to their age-matched peers. This leads to these players being selected as “more elite” and being provided with better development opportunities (play at higher levels with more ice time and better coaches, more positive reinforcement of them being “elite”, more exposure opportunities, etc.). This is strictly a consequence of our rush to identify early talent, which inevitably cheats many potential high-performers out of development opportunities strictly because they were born later in the year. This finding also prevails in the NHL. Turns out if you want to create an NHL player, you need to cluster your romantic endeavors around April and May!

Intragame blood-lactate values during ice hockey and their relationships to commonly used hockey testing protocols
This study looked at blood lactate levels in 6 NCAA division 1 hockey players during certain shifts in the first and third period of a game. They found that players’ blood-lactate values ranged from 4.4 to 13.7 mmol/L with a mean value of 8.15 (+2.72) mmol/L. As a general statement, the thought is that the ability for the body to provide energy using primarily aerobic systems diminishes around work intensities that results in blood lactate levels ~4 mmol/L. This is obviously an over-generalization, but will suffice for our purposes here. The findings of this study are far from groundbreaking, but highlights the intensity and fatigue accumulation associated with typical hockey shifts. This should not be interpreted as evidence AGAINST the use of aerobic training for hockey players. Quite the contrary. It’s the adaptations from aerobic training that facilitate an expedited recovery from these intense work bouts, AND that can minimize the metabolic damage associated with prolonged high intensity work (e.g. provide more energy from aerobic systems at higher intensities, so to somewhat spare the lactic system).

That’s a wrap for today. In a couple days I’ll be back with research updates on a common hip abnormality that is leading many players to get surgery. Stay tuned!

To your success,

Kevin Neeld

P.S. I also wanted to remind you that I’ve added an “ebook only” option to Ultimate Hockey Training, so if you don’t want to shell out for shipping a physical copy, you can now get instant access to the entire package digitally here: Ultimate Hockey Training

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Hip Stabilization Exercises

Over the last few years, I’ve written and talked quite a bit about preventing hip injuries in hockey players. Unfortunately, things like adductor and hip flexor strains have become accepted as “part of the game”, and now we’re seeing a surge of femoroacetabular impingement, labral tear, and sports hernia cases. The underlying mechanisms to many of these injuries can be pretty complex, but once you get it, many of these cases can be prevented.

A few months back, I posted a video on how to assess for a pretty common structural “abnormality” that we see in hockey players known as “version”. More specifically, players can have unilateral or bilateral ante- or retro-version. If you missed the video, take a few minutes to watch it below:

In the past, I’ve worked with a lot of players that complain of groin pain that present with associated weakness. It’s important to point out that pain completely changes function, often in unpredictable ways. This is one of the reasons that training or playing through pain can lead to additional problems down the line. Compensations are inevitable. Specific to these cases, often times the cause of the pain and weakness is a misaligned pelvis. As a quick anatomy review, each hemi-pelvis integrates with the spine via the SI joint in the back and with each other via the pubic symphysis in the front.

These three connection points (SI joint on each side and pubic symphysis in the front) form a continuous loop. Because of their integration, one segment become misaligned will necessarily result in a misalignment at another segment. For example, an SI joint being out of whack can lead to a shift in the other SI joint and/or the pubic symphysis. Alignment can be compromised from contact, and/or instability secondary to poor or asymmetrical movement patterns, postures, and strength. Misalignments can refer pain to a number of places throughout the thigh, hips, and lower back, but a common one that we see relates to pubic symphysis irritation. When there is excessive movement across the pubic symphysis, the cartilaginous disc that helps improve the contact area of the two adjoining bones becomes inflamed. This is referred to as osteitis pubis and is one of the most overlooked sources of groin pain. These cases are frequently treated with injections to reduce the inflammation, which is effective in putting a band-aid over the pain, but completely overlooks the cause.

In these cases, asking the athlete to squeeze something between their legs while lying with their knees bent will reproduce the pain radiating from their groin up into their hip AND strength will be poor. Many times, a simple “SI readjustment” from a physical therapist or chiropractor will restore alignment and the pain will be gone and strength restored, instantly. At this point, the athlete has a more neutral alignment, but has demonstrated that they’re prone to slipping back into misalignment (and pain, and weakness). Following readjustment, it’s important to incorporate strengthening exercises that put multi-directional bilateral stress across the hips. These exercises serve to improve the integrity of the hip in a neutral position, which will help ensure that they player doesn’t fall in and out of alignment and progressive degenerate the joint. The exercises in the video below were a few that we’ve used at Endeavor in cooperation with Ned Lenny, a really bright physical therapist in Cherry Hill, NJ. Enjoy.

To your success,

Kevin Neeld

P.S. I’ve added an “ebook only” option to Ultimate Hockey Training, so if you don’t want to shell out for shipping a physical copy, you can now get instant access to the entire package digitally here: Ultimate Hockey Training

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Hockey’s Original Recovery Drink

I hope you had a great weekend. David Lasnier and I headed into West Chester, PA for the USA Weightlifting Sports Performance Coach Certification. We’ve been teaching Olympic lift variations for years, but it’s always good to hear it right from the source. I think we both picked up a few good cues that will help refine the learning process a bit.

Last week I discussed, from a nutrition and program design perspective, the idea that living in a “high intensity mode” can be detrimental to recovery and therefore to subsequent performance. The hockey season is long, and if players and coaches aren’t conscious and proactive about their recovery, they’re going to break down toward the middle/end of the season. Recovery is key to long-term excellence. If you missed those posts, you can check them out here:

Essentially this idea boils down to teaching your body to appropriately balance the sympathetic and parasympathetic nervous systems. If you’re not familiar with this terminology, these systems are often oversimplified as:

Sympathetic: Fight or flight (or freeze)
Parasympathetic: Rest and digest

While they’re often discussed as opposing systems, the reality is that they work in a complimentary fashion to create the appropriate environment for the body to be successful. Different strategies have been proposed to monitor the “state” an athlete is in, as athletes that start to get stuck in a sympathetic state or thought to be overstressed/under-recovered/overtrained, which can progress to an even more severe state of parasympathetic dominance if left unchecked. Again, it’s not that one system is good and the other bad, it’s that both need to be emphasized at appropriate times.

I recently came across a study that provides powerful information on how hockey’s original recovery drink physiologically impairs recovery.

Hockey’s Original Recovery Drink
I remember an old teammate of mine from Delaware called me a couple years after I graduated and said, “Neeld, how do I lose fat, while binge drinking 5-6 days per week?” If you’re even remotely health conscious, the futility in this question may strike you as comical. The truth is that many players have a somewhat related question in that they want to know how they can minimize the damage of alcohol without giving it up completely. And I think that many of the nutrition “experts” will quickly lose the attention of older players when they put their anti-alcohol foot down. Is it good for you? Not by a long shot. Will players give it up completely? Not by a long shot, and they’ll shut you out completely if that is your expectation.

This isn’t quite how it works

That said, it’s important to provide players with the necessary information to allow them to make decisions for themselves. On that note, I recently came across an interesting study related to alcohol consumption and recovery: Alcohol Has a Dose-Related Effect on Parasympathetic Nerve Activity During Sleep

In possibly the most appealing study ever offered to college students (I’m sure they weren’t at a loss for volunteers on this one), researchers took 10 sufficiently aged students and had them consume 0 (control group), 0.5 (low dose), or 1.0 g (high dose) of pure ethanol per kg of body weight about 2 hours before they went to bed. On the nights that they consumed the alcohol, they wore a non-invasive device to monitor electrocardiological activity throughout the night.

They found that alcohol consumption increased the students’ heart rate, decreased heart rate variability (HRV), and increased the Low Frequency/High Frequency ratio of HRV, with higher doses being associated with more significant changes. Taken together, these results indicate that, as the title indicates, alcohol consumption leads to a shift toward a sympathetic state by both increasing sympathetic activity and inhibiting parasympathetic activity, with greater degrees of consumption leading to a more significant shift toward a sympathetic state.

Practical Implications
From a practical standpoint, these results can be taken to mean that alcohol impairs sleep quality. While this seems like a pretty straight-forward concept, it directly conflicts with the conception that many players have that alcohol actually helps them sleep. It may help your eyes shut, but your body isn’t resting and recovering during the night.

To help relay this information in more practical terms, let’s take a look at the doses used in the study for three players:

Weights

Players 1: 180 lbs = ~ 82 kg
Player 2: 200 lbs = ~ 91 kg
Player 3: 220 lbs = ~100 kg

Alcohol Dosage

Player 1: 82 kg x 0.5 = 41g of ethanol (low dose); 82 kg x 1.0 = 82 g of ethanol (high dose)
Player 2: 91 kg x 0.5 = 45.5 g of ethanol (low); 91 x 1.0 = 91 g of ethanol (high)
Player 3: 100 kg x 0.5 = 50 g of ethanol (low); 100 kg x 1.0 = 100 g of ethanol (high)

Beer Dosage
A typical beer with 4.5% alcohol content contains about 16 g of ethanol.

Player 1: Low Dose- ~2.5 beers; High Dose- ~5 beers
Player 2: Low Dose- ~3 beers; High Dose- ~5.75 beers
Player 3: Low Dose- ~3 beers; High Dose- ~6.25 beers

In other words, it doesn’t take much to significantly impair sleep quality. More importantly, more is worse. Alcohol consumption doesn’t need to be an all or nothing experience. Having a couple beers after a tough game isn’t ideal, but having a dozen will have a significantly detrimental effect on the player’s recovery. On a related note, light beer with a lower alcohol content and less calories looks good on paper, but if it’s between 2 Magic Hat #9s and 12 Coors Lights, then drinking the heavier beer may be a better option.

Also, knowing that processing alcohol will impair sleep quality, it seems logical to shut down your drinking as far before your typical bedtime as possible. Because going to bed and waking up within an hour of the same times everyday (at least as much as possible) is important for establishing an optimal circadian rhythm, this means that drinking after night games should be kept to a minimal (as a habit, exceptions are inevitable), as should drinking during trips that involve significant changes in time zone (e.g. east coast teams playing on the west coast or any North American team playing overseas).

Take Home
Alcohol’s impairment in sleep quality can facilitate a viscous cycle. Because they slept in a more sympathetic state, they’ll wake up feeling less rested and lean on coffee or other forms of caffeine to help kick start their day. Like alcohol, caffeine also pushes them toward a sympathetic state. These habits, superimposed on an already sympathetic lifestyle (training, practices, games, travel, relationship stress, schoolwork for junior/college players, etc.) doesn’t allow athletes to shift back into a parasympathetic state, which significant impairs their ability to recover.

Hopefully you understand the underlying thought process. Players are going to make their own decisions and there will always be exceptional circumstances. That said, it’s important for players to understand what “ideal” is, so that they know when they’re venturing in the other direction. The more time players live in ideal circumstances, or said another way, the less time they spend venturing in the other direction, the better their performance will be over both the short- and long-term.

To your success,

Kevin Neeld

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This Week in Hockey Strength and Conditioning

I hope you’ve had a great week. David and I are heading out to West Chester, PA for the USA Weightlifting Sports Performance Course certification over the weekend. I grew up in West Chester, so it’ll be great to stop in to see my parents and spend some time in my old stomping grounds.

Things picked up a bit this week at Hockey Strength and Conditioning. Before I get to that, if you missed my two articles from earlier in the week, you can check them out at the links below:

While these posts approach somewhat different concepts, one of the underlying take homes from both is that we need to be adept at STRATEGICALLY implementing stressors. In this vein, stress doesn’t just refer to those from training or competition (although, these will make up a significant proportion of the total stressors for in-season players), but also dietary, environmental, psychological, and social stressors (amongst others!). Stress is cumulative and needs to be mediated or “overtraining” will result. Overtraining can just as accurately be described as “under recovery” as it’s possible to drive someone into a state of overtraining without ANY training stressors at all.

Also, I wanted to remind you that today is the last day to pick up your copy of Joe Dowdell and Mike Roussell’s Peak Diet and Program Design Summit Package for $100 off. They’ve added a special bonus from Pat Rigsby (great for those of you that may own your own training business) AND a new payment plan. If you’re interested, check out their program here: Peak Summit Package

Moving on to this week’s content at Hockey Strength and Conditioning…

Mike Potenza kicked things off with a new “Youth Training Program” that emphasized lateral speed training. This exercise series, which Mike demos in the videos, is a great way to teach young players how to accelerate, decelerate, and change direction while maintaining proper body position. In other words, it drives performance through body awareness. For higher level players, under the assumption that they’ve developed these qualities already (not always a safe assumption), these are still great exercises to incorporate into off-season programs or toward the end of a warm-up at any time of year. Great stuff from Mike.

Click here to check out the program >> Youth Program: Lateral Speed Teaching

Darryl Nelson added an exercise video of two variations of a lunge complex, one using a valslide and one without it. I’m not exactly sure how Darryl builds these into the program, but they seem like great options for a warm-up or to build some low-intensity “hip mobility” or “lower body” work into an upper body day or full body lift where you want to back off the legs a bit.

Check out the lunge matrix video here >> Left Middle Right Reverse Lunges

The second part of my article series on developing youth training programs for an entire youth hockey organization just went up. This series gives you an inside look into my philosophy and approach to designing a program for a local youth club. As this is a question I get a lot (typically from a coach at one specific level), I think the article series will have a lot of valuable information in it for those of you that don’t necessarily train people for a living, but are left to your own devices for your hockey club. In my (unbiased) opinion, the strength of this series is that I don’t necessarily suggest that you need to do it EXACTLY how I do, but understanding my philosophy underlying the approach I take will help you apply concepts that seem most relevant to your situation. As I always say, there’s a madness to my method!

Check out the article here >> Youth Hockey Training Blueprint: Part 2

Make sure you check out these threads on the forum too:

Motivation
1 Leg Cleans?
Athlete Metabolism Issue
Hockey’s Original Recovery Drink

That’s a wrap for today. As always, if you aren’t a member yet, I encourage you to try out Hockey Strength and Conditioning for a week. It’ll only cost $1, and if it’s not the best buck you’ve ever spent, I’ll personally refund you!

To your success,

Kevin Neeld

P.S. Last chance to save $100 on this: Peak Summit Package

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