Dr. Jack Dolbin BS, DC, CSCS

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Most Proud

• Josh
• Jill
• Rachel
• Christian
• It didnt just happen Eisenhauer

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Uniqueness of a Sports Medicine Practice

• Patient
• Motivation
• Responsibility

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Patient Preference
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Notable Patients
Steffi Graff
Karen Corr
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Karen Corr
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Somethings money cant buy
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Cardinal Principle

• People dont care how much you know, Until they
  know how much you care. Zig Ziglar

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Definition of a Sports Chiropractic Practice

• A branch of Chiropractic concerned with the
  effects of exercise and sports on the human body,
  including treatment and prevention of injuries
  and Performance enhancement

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Necessary Training for the role of Team
Chiropractor in
High School
College
Club Sports
Recreational Athletes
Professional Sports
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Basic Concepts of Sports.

• Body is built of circular planes of motion

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Athletic performance is linear
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Uniqueness of the Chiropractic Evaluation
6. Performance enhancement
5. Injury prevention
4. Biomechanics
3. Motion deficits as it relates to injuries
2. Evaluation of the Kinetic Chain
1. Cause oriented
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Uniqueness of the Chiropractic Treatment
Wellness
Time
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Kit
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Think Nervous System
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Think Chiropractic
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Questions

• Can upper cervical input affect the vagus nerve
  and as a result visceral function?
• Can Thoracic input affect sympathetic chain
  function and as a result circulation?
• Can a sprained ankle cause entrapment syndrome in
  the shoulder?
• Does stretching the hamstring stretch inroad the
  hamstring and prevent hamstring strains?

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Questions

• Is fascial release due to fascial stretching or
  neurological feedback?
• Is muscle spasm muscular or neurological?
• Pain ? Alignment or Motion?
• a. David Cassidy DC Ph.D- Kirkaldy-Willis MD.

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• Think outside the box
• Think in my box
• Hit the escape button on your cerebral computer
  and in this seminar develop treatment and rehab
  protocols that conform to both anecdotal and
  scientific evidence. E.B.P.

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Saturday Morning
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Concepts of Diagnosis of Sports Injuries
Site of injury or Kinetic Chain
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D D Palmer

• It is unwise to teach adjusting unless it is
  taught intelligently.

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True or false ?

• If you hear hoof beat donot think Zebras.
• Eliminate the Zebras first
• Always look for pathology first.
• Example In calf pain consider DVT
• In Shoulder Pain consider lung pathology

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Diagnosis
Dr. Jack Dolbin Session 6
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Javelin Thrower
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Javelin Thrower
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Priorities

• The best things in life are not things
• Harry Bertsch
• Hermy Bavier
• Ron Boris
• Amanda Driscoll
• Josh Bertsch
• Dad

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Ron Boris
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Concepts of Diagnosis of Sports Injuries
Cause as it relates to exceeding the tensile
strength of the tissue
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Fracture dislocation
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Concepts of Diagnosis of Sports Injuries
Biomechanical concepts of causation
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Concepts of Diagnosis of Sports Injuries After
you eliminate the Zebra
Motion deficits as major causative factor In
Physical Diagnosis look for soft tissue
restrictions and Fascial Adhesions
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• If dysfunction alters the efficiency of the
  musculoskeletal system, there is an increase
  demand for energy. Not only for increased
  activity but for normal activity.
• Increase demands on the cardiovascular system

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Evaluation of the Kinetic ChainCore stability
Peripheral Velocity
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• ART
• Asymetry
• Range of motion
• Tissue Texture

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Concepts of inflammation and repair
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Treatment Protocols

• Phase 1 Acute Inflammatory Phase
• Question Does inflammation cause pain or does
  pain cause inflammation?
• For a long time pain has been summarily dismissed
  as the outcome of direct stimulation of sensory
  nerve endings by injury and the pressure of
  inflammation exudates. This opinion completely
  neglects the observation that pain often
  initiates the inflammatory response and may
  become less severe as that process gains speed.
  Robbins pg.44
• Goal is to control the pain and inflammation
• PRICE
• Protection
• Rest
• Ice
• Compression
• Elevation

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Cryotherapy

• Are the effects of cryotherapy related to deep
  tissue cooling or its effect on the activation of
  skin receptors thus neurological?
• Pain causes inflammation Robbins pg.44
• IJATT Volume 18 Issue 5 September.

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Inflammation and Repair ( innate

• Tissues respond to injury with a set of
  genetically programmed mechanisms to replace the
  damaged components and to restore normal function.

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Inflammation
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Classification of Injury

• Acute Injury Normal anatomy and normal
  physiology followed by abnormal anatomy and
  abnormal physiology.
• a. One-Time microtrauma.
• Chronic Injury Building up for a period of time.
• a. Represents the tip of the iceberg of entire
  derangement of physiology
• Repetitive microtrauma overload
• a. Rotator Cuff Tendonitis
• b. Plantar fascitisc.
• c. Achilles Tendonitis

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Inflammation and Repair

• Two types of Inflammation
• Acute
• Chronic More then 3 months cause central
  pathway changes.

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Acute Inflammation

• Vascular
• Exudative
• PMN

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Proliferative stage Healing stage

• Vascular
• Proliferative
• Fibroblast

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Chronic Inflammation, pathological stage

• Increase type 3 collagen formation
• No cellular matrix
• Increased neovascularization
• Increased fibrosis
• Central pathway changes
• Result of improper healing and continued
  irritation of tissue

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Acute Inflammation
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Chronic Inflammation
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Tendon Injuries

• Structure of Tendon
• Pathology
• Pain
• Treatment Strategies

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Tendon Structure

• Ground Substance 68
• Collagen 30
• Elastin 2
• Tenocytes Found between collagen fibers
• 1. Collagen, proteogylcans, glycoproteins,
  Respond to loads.

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Extracellular Matrix

• Collagen Gives tendon tensile strength
• Ground substance Nutrition, allows for
  elongation and friction free movement of tendon
• Glycoproteins energy storage

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Tendon Function in Athletes

• Provide movement to Joints
• Store energy to be released with activity
• Afferent proprioception
• Protect muscle from strain

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Tendon Pathology

• Result of exceeding the tensile strength of the
  tendon or not allowing sufficient time between
  loading.
• Increases fibrosis and cross links in matrix
• Increased neovascularization
• Replacement of Type 1 with Type 3 Collagen.
• Pain can be independent of pathology and
  inflammation.

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Stages of Tendon Pathology

• 1. Reactive tendinopathy
• a . Short term adaptive thickening as a result of
  acute tensile overload or compressive overload
• b. Can return to normal if overload is
  discontinued or sufficient time between overload.

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Stages ( continued)

• 2. Tendon Dysrepair
• a. Ongoing load to a reactive tendon
• Separation of collagen
• Increased vascularity
• Increased proteogylcan and collagen production
  without a normal matrix structure

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Stage 3

• 3. Degenerative Tendinopathy
• a. Extreme changes to the matrix and cells
  including death and apoptosis
• b. Large areas of the matrix are disordered and
  filled with debris, vessels, and little collagen
• .

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Cause Intrinsic

• Intrinsic Motion deficits in kinetic chain
• Asymetry pronation
• Muscle weakness or tightness
• Age, flexibility, previous injury, somatotype.
• Genetic profile ABO. Vitamin C deficiency
• Strength, BMI.

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Cause extrinsic

• Training Errors Load/volume
• Overload Eccentric overload
• Underload Immobilization
• Tendons cannot rupture unless pathological
• Tensile strength 1364-2310 pounds/cm2
• Ex. Achilles goes through a prerupture
  tightness.

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Inflammation and Repair

• Ischemia- Induced Muscle Damage
• Usually seen in compartment syndromes. Results
  from damage to vessels causing ischemic injury.
• Seen in exhaustive endurance activities.
• Extent of the injury is proportional to the
  duration of the pressure.
• Nerve injury may result as a result of increase
  pressure.
• Healing will be achieved with little or no damage
  if the damage is limited to individual fibers and
  blood supply is restored without delay.
• Can result in significant scar tissue formation
  if delayed resulting in excessive cell death.

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Injections not primary Tx.

• Injections cause very poor healing and a return
  of symptoms with activity

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R P Nirschl, MD

• There is not scientific data to suggest anti
  inflammatories have any healing properties.
• Healing is accomplished by restoring normal
  biomechanics through rehabilitation and the use
  of manual techniques
• Keys enhanced peripheral aerobics,( Oxygenation,
  nutrition, colllateral circulation)

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Nirschl ( cont)

• Collegen induction
• Strengthening, alignment, enhanced biochemical
  changes associated with endurance training.

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Dr. Hal S. Blatman

• As long as you donot take anti-inflammatory
  medication after you play ( tennis) the shoulder
  will heal itself.
• Shoulder will heal in 3-4 weeks
• If patient goes to PT and still no resolution the
  ortho will operate
• Result Short tendon, short muscle and a staple.

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Leadbetter, WB. MD

• Treatment by persistent efforts to turn off the
  bodys defence mechanism is not substitute for
  finding the cause of the problem.
• NASIDS 2500 deaths per year.
• Local injection of steroids has systemic effects
  Suppresion of adrenal function.

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Mobilization

• The strength of healed tendons is superior to
  that of controls where mobilization was delayed.
• An augmentation of extrasynovial tendon healing
  by continuous passive motion has been
  demonstrated in the rabbit model

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Immobilization

• Type 1 fibers are most affected
• Cartilage deterioration, bone and ligament
  strength loss and increased stiffness.
• Rehabilitation can counteract these changes by
  introducing motion with protection and loading.

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Effects of Immobilization

• For each week of immobilization there is a 20
  loss of strength in joint.

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Inflammation and Repair

• Remodeling and Maturation
• Process begins about 6 days after the fibroblasts
  begin to lay down collagen tissue.
• Collagen is laid down randomly initially
• Depends on the appropriate mechanical loading.
• The hallmark of remodeling is the orientation of
  new fibers

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Inflammation and Repair

• Immobilization of a healing wound has been shown
  to compromise wound strength as a result of the
  failure of collagen to be oriented along lines of
  stress.
• Mobilization and loading has been shown to result
  in stronger healed tissue.
• Tissues must heal in the presence of motion.

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Adaptation

• Body adapts over a period of time to chronic
  injuries. The Dx must look for these adaptations
• Weakness and tightness in gastrocnemius in
  Achilles tendonitis
• Elbow tendonitis tightness of wrist extensors
• Rotator Cuff tendonitis Infexibility in
  posterior RC muscles and weakness in scapular
  stabilizers and post cuff muscles.

Note Entire Kinetic Chain must be searched and
evaluated
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Adaptations

• Acute exacerbation of a chronic injury Result
  from symptomatic treatment leading to return to
  athletic activity. Results in a recurrence of
  previous symptoms or new symptoms as a result of
  acute injury in kenetic chain.
• 1. Ankle Sprain
• - return to competition- Groin strain
• 2. Rotator Cuff tendonitis
• - return to competition- lateral epicondylitis

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Adaptation

• Chronic Adaptations
• 1. No overt symptoms
• 2. Pattern of abnormalities that lead to
  decreased function and performance

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Negative Feedback Vicious Cycle

• 1. Tissue overload complex
• a. Failure of Tensile strength
• b. Subject to microtrauma
• 2. Tissue Injury complex
• a. Disrupted
• b. Producing Symptoms

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Negative Feedback Vicious Cycle

• 3. Clinical Symptom Complex
• Pain
• 4. Functional Biomechanical Deficit Complex
• a. Decreased flexibility
• b. Decreased Strength
• c. Muscle imbalances

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Negative Feedback Vicious Cycle

• 5. Sub-clinical adaptation complex
• a. Activities the athlete uses to compensate for
  altered mechanics.
• 1. Running on the outside of foot to compensate
  for heel pain.
• 2. Over reaching in swimming to compensate for
  decreased ROM in the low back
• 1. Tissue overload complex

Cycle begins again
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Treatment Not Pain by Numbers
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Mechanotherapy

• The physiological process where cells sense and
  respond to mechanical loads.
• Various forms of exercise and or movement
  prescription promote repair and remodeling of
  tendon, muscle, articular cartilage and bone.
• Mechanotransduction Maintains normal
  musculoskeletal structure in the absence of
  injury. Homeostasis
• Mechanotherapy Treatment of injuries using
  exercise prescription or manual therapy

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Mechanotherapy

• The process where the body converts mechanical
  loading into cellular response.
• Three phases
• A. Mechanicalcoupling Trigger
• B. Cell-Cell communicationcommunication
  throughout a tissue to distribuite the loading
  message.
• C. Effector responseResponse at the cellular
  level to effect the response that will produce
  the necessary materials to correct alignment.

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Alpha Motor Neuron

• Most tissue texture abnormalities result from
  altered nervous system function with increased
  alpha motor neuron activity maintaining increased
  muscular hypertonicity and altered sympathetic
  nervous system function.

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Law of Least Action

• Maupertius The quantity of action necessary to
  effect any change is the least possible, the
  decisive amount is always the minimal, the
  infintesimal.

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Arnt-Schultz Principle

• Weak stimuli increases physiological activity
  while strong stimuli inhibits or abolishes
  physiological activity.

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• When properly utilized, manipulative procedures
  have been noted to reduce pain, Increase the
  level of wellness, and in helping the patient
  with a myriad of disease processes.
• Philip Greenman DO, Professor of Biomechanics
• Michigan State University School of Osteopathic
  Medicine

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Goal of manual medicine

• The goal of manual medicine is to restore
  maximal, pain free movement of the
  musculoskeletal system in postural balance.
• Dvorak J, Dvorak V,Schneider W Manual Medicine
  1984,

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Proprioceptive System

• Gentle and precise manipulation elicits an
  internal sensory feed back response designed to
  stimulate the bodys self correcting mechanism.
• Speak to the brain through the joint
• Jean- Pierre Barral, DO

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• An intact proprioceptive system is more relevant
  for the shoulder than for any other body segment
  from the standpoint of functional stability.
• Syncrony of motion in executing any motor skill
  depends on this delicately balanced feedback
  system.

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Proprioception

• This feedback system must be free of even the
  slightest disturbance such as pain, fatigue,
  weakness, or muscular spasm that could
  contaminate the messages and lead to abnormal
  joint kinematics.

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Treatment

• Deal with tissue pathology
• Eliminate motion deficits in kinetic chain
• A. subluxations causing afferent proprioception
  deficits and overload.
• Begin to load the injured tissue progressively
• Emphysis on eccentric loading
• Eliminate provocative activities while under care
• Progressively integrate active care protocols

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Treatment

• Eliminate mechanical blockages to the free flow
  of fluids and nerve flow to the CNS and target
  tissue.
• Eliminate bind
• Turn on the muscles, tendons, ligaments
• Vascularise the tissue

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Break the inhibition cycle.

• Getting the restricted joint released
• Releasing tight muscles
• Deep fascial work to wake up the neuromuscular
  system
• Functional rehab to retrain muscles
• Always look for immediate functional change

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Keys to technique application

• 1. Get under that bodys defense mechanism
• 2. Activiate proprioceptors turn on the muscles
  PNF, MPT, ME
• 3. De-activiate aberant proprioceptive impulses
  Nimmo, Strain/Counterstrain
• 4. Decompress the joint Create negative joint
  pressure Circulation
• 5. Release tissue tension
• 6. Get the ligaments firing

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Myofascial Release

• Gaining increased attention within the health
  care community.
• Recent studies at Harvard and U of Vermont School
  of Medicine on Cell-Cell communication within the
  deep fascial elements.
• Warren Hammer Soft Tissue the key to the
  outcomes we have seen over the years.

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Deep Fascia

• A bodywide communication system
• Involved in myofascial force transmission
• Fascia is a sensory organ and is relevant in
  proprioceptive and nociceptive function and
  relevant in shoulder and low back pain and
  dysfunction.

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Myofascial Release

• MFR after repetitive strain injuries increases
  myoblast differention and improves muscle repair.
• University of Arizona J Appl. Physio 2012 Jun 7.

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Myofascial Release

• Cyclic stretch plays a critical role in the
  myoblastic response by activating the
  fibroblastic activity and Nitric Oxide release.
• Regulates myogenesis and mechanotransduction.
• Duke University Am J Cell Physiol. 2007 June 292.

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Techniques

• Muscle Energy Techniques
• Trigger Point Therapy
• A. Nimmo, Strain/Counter strain,
• Ligamentous Articular Strain Sutherland
• Motor Point Therapy PNF ART
• Impulse Adjusting
• Manipulative Techniques
• Cyriax Cross Fiber Tech.

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Cyriax Crossfiber

• Mobilize Scar tissue
• Breakdown Adhesions
• Allows muscle to broaden
• Controlled Inflammation Prolotherapy research
• Pain modulation
• 1. Right Location
• 2. Right amount of pressure

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Cyriax Continue

• During first 24-48 hours. Light mobilizing
  maximum of 5 minutes.( usually less if at all)
• After 48 hours 5-15 minutes
• Muscle Injury Across the relaxed muscle to
  facilitate broadening. Followed by eccentric
  exercise or Faradic.
• Tendon/Ligament Injuries Across the ligament in
  an elongated position.
• Every other day maximum.

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Lateral Ankle Sprain
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Rotator Cuff Tendonitis
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Muscle Energy Technique

• Limb is moved into the restrictive barrier.
• Patient actively attempts to move the limb with
  the Physician resisting the movement
• Hold 5-7 seconds, 3-5 times. Followed by
  inspiration/expiration.
• As tissue releases move to next barrier
• Followed by articular correction if necessary

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Muscle energy

• Isometric Contraction of shortened muscle.
• Improves resting length
• Increase Joint movement
• Improves overall range of motion.
• Inhalation/Exhalation as activating force

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Achilles Tendon Injury
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Iliopsoas Release
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Strain/CounterstrainLawrence Jones, DO

• Patients somatic dysfunction is treated by
  placing the restrictive barrier in a passive
  position thus relaxing the tissue and promoting
  dissipation of inflammatory exudates.
• Contact the motor point where the nerve pierces
  the fascia and enters the muscle belly.
• Hold using respiratory mechanism until release is
  felt.

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Sutherland

• Balanced ligamentous tension/ Ligamentous
  articular strain Techniques
• All joints are balanced ligamentous articular
  mechanisms.
• The ligaments provide propriceptive information
  that guides the muscular response for positioning
  the joint and the ligaments themselves guide the
  motion of the articular compoments

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BLT/LAS

• Position the joint so all forces within the
  articular mechanism converge on one specific
  point. This point becomes the fulcrum around
  which shift will occur
• Use the respiratory mechanism to articulate the
  joint.

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Impulse Adjusting

• Percussion cadencee Seguin 1838
• Manual Vibrations Kellgren mid 1900
• Janse, Wells, Howser 1947
• Repetitive Thrusts Maitland 1964
• Fuhr Activator
• Colluca-Keller Impulse Adjusting

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Impulse Adjusting

• By Stimulating the Golgi Tendon organs the
  shortened muscle lengthens. Myotendinous
  Junction.
• Pacinian Corpusles Stimulated when skin is
  stimulated rapidly. Respond to high velocity
  changes in joint position.
• Reset Neurological bed. Bone and muscle belly
• Activates mechanoreceptors
• Can be alternative treatment to myofascial
  release.

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Nimmo ( TPT)

• Receptor Tonus How much pressure?
• Break Myotatic Reflex
• Reduce concentration of calcium ions
• Ischemic Pressure when released vascularises the
  tissue

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Joint Mobilization/Manipulation

• Mobilizes fixated Joints
• Improves Range of Motion in Dysfunctional
  segmments.
• Activates mechanoreceptor in Joints Pacinian and
  Ruffini corpucles.
• Allows for normalization of afferent
  proprioception
• Decompresses the Joint

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Deep Fascia

• A bodywide communication system
• Involved in myofascial force transmission
• Fascia is a sensory organ and is relevant in
  proprioceptive and nociceptive function and
  relevant in shoulder and low back pain and
  dysfunction.

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Procedure For Sports Injury

• History 7 Point History Minimum
• Observation of injured part
• Inspection of Injured part
• Examination Palpation, Range of Motion
• Provocative tests.
• Evaluation of motion deficits in the kinetic
  chain.
• Treatment Manual Medicine Prescription

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Post-Check

• Evaluate the effect of your treatment
• A. Did the muscles get strong
• B. Is their gait better
• C. Can they lift their arms more easily
• D. Can they bend forward or backward with less
  pain.
• A successful input/adjustment changes function
  and breaks the vicious cycle.

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Break the inhibition cycle.

• Getting the restricted joint released
• Releasing tight muscles
• Deep fascial work to wake up the neuromuscular
  system
• Functional rehab to retrain muscles
• Always look for immediate functional change

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Goal of Treatment

• Restore normal Function to dysfunctional region.
• Function must be the focus of treatment
  protocols.
• Increase tensile strength of tissue
• Deal with ART in kinetic chain
• Must be Evidenced Based.