My clinical question is in endurance athletes what is the most effective program to prevent medial tibial stress syndrome?
I decided I wanted to pursue this question after my internship experience with DCI. Many injuries and pain the performers had were due to medial tibial stress syndrome and a few of these injuries progressed to injuries more strenuous such as stress fractures. Among 150 members, each day I saw on average 40 members with complaints of lower extremity pain. The main complaints of the members were calf pain and shin splints, arch issues, iliotibial friction syndrome, and hip flexor tightness. My clinical placement this semester is with cross country and cheer and dance. Both of these sports are also more likely to have lower extremity injuries and for cross country it is very likely that at some point in their lives they have experienced shin splints. I believe this research will result in a beneficial strategy for these groups of athletes to prevent lower extremity injury. My ultimate goal with this is to come up with a prevention program that I can suggest to other DCI medical staff and athletic trainers to help prevent lower extremity injuries such as medial tibial stress syndrome.
My investigation committee is Beth Funkhouser, ATC, Joe Lynch, ATC, and Mike Caro, CSCS. I chose these people to be a part of my committee because they are all heavily involved in literature and I know they will be beneficial when it comes to finding evidence and journals. I specifically chose Mike Caro as my content expert because he is highly competent in creating prevention programs himself so he must have evidence to support his practice.
I am excited to work on this PIO question and to ultimately turn it around into something beneficial for clinical practices.
Often times when students are in the clinic there may be times where a preceptor does something one way and it will be completely different from what the student has read in a textbook or has experience with other preceptors or clinicians in the past. I think when this happens it is important to not freak out and automatically assume what they are doing is wrong. A way I like to approach this difference is by asking the preceptor or clinician how they found this technique and what resources they have used. This to me is a good way to learn a new technique or skill. However, they are times where I find myself seriously questioning if what the preceptor is doing is truly effective or achieving the goal they have explained. In this case I would go and ask another preceptor if they can explain it to me. As a student I would never want to over step a preceptor’s way of practice, but If I found something they are doing wrong after looking into everything by text and by other clinicians then I might ask about the technique described in the text. Preceptors are people too and they make mistakes. I wouldn’t want to embarrass anyone. I believe if I just ask about what the texts say and they are actually doing something wrong this would make the preceptor go back into their textbooks and references and hopefully he or she would make the correction. Most importantly to me as a student I wouldn’t want to offend and over criticize the way someone practices. If at the end of the day someone will not change and they are truly wrong, then you just have to ignore it to the best of your ability and cover yourself in case something bad were to occur and there is a legal pursuit.
This weekend I had a really exciting time during the rugby match verses Radford University. This was my first time getting to watch a rugby match so it was interesting to see how plays and tackles actually happen compared to how it happens during practice. One thing that I found interesting was that as an athletic trainer I was able to run out onto the field while the game was still in play. This is different than any other sport. With this rule it made it important to do a scene safety evaluation before running out onto the field. The first injury of the game was definitely the most exciting. There were two Radford guys going in for a tackle on one of our player who pulled a spin move and got out of the way. The two Radford guys smacked faces and immediately fell to the ground. It was scary because one guy wasn’t moving at all and the other was just barely moving. At first it definitely seemed like a cervical spine injury. Upon inspection there was blood everywhere. The certified athletic trainer and I went to the guy who wasn’t moving at all. Once I saw that he was verbal and moving and the certified was handling him I went to the other guy. I saw that he had bit through his lip and I put my gloves on. As I was pulling gauze out of my kit to apply, the player was screaming at the other guy saying, “shake it off man, we need to get back into this game” and tried to run off. I had to be very firm and tell him to come back and that he wasn’t going to play anymore. It was evident that he needed stitches. The other player who wasn’t moving finally was stable enough to walk off the field. I was instructed to call 911 once I got to the sideline because we hadn’t been able to control the bleed from his two-and-a-half-inch laceration on his forehead. I gave the operator my location and stated the issue, but just as I did it the player’s parents came and were able to take him to the emergency room. Before they left we were able to control the bleed. It stopped because once he sat up blood flow from his face was lower. We sent both players to the emergency room for stitches. The rest of the game was just ankle sprains and cramps. I got to run out onto the field 5 or 6 times. It was exhilarating. I really enjoy the level of intensity of this game. This experience allowed me to see something I wouldn’t typically in any other sports. It also required me to act quickly which tested my ability to manage injuries under pressure. This weekend inspired me to want to work with sports similar as a career such as hockey, wrestling, or boxing.
At this moment, my plans for after graduation are either to go to grad school or go find a job. I still need to add schools to my list to apply for, but I really want to go to University of North Carolina. I have read about their post graduate program and it seems like a program I really want to be a part of. Some things I want to do in the near future is get a campus tour of Chapel Hill and have a conversation with the program director. In addition to University of North Carolina I am looking into Pennsylvania State University and Possibly at University of Tennessee. I need to do more research on post graduate programs in areas that I would like to be. So far these three schools are the only ones I am considering. I have looked at requirements for these grad schools and I meet the criteria for most of them, with the exception of a GRE score. Something I am doing right now to prepare me for grad school is that I am trying to boost my GPA. Right now I have a 3.550 which is good, but when I start applying I would like to have a 3.6 or higher overall GPA. I don’t think GPA is a large determining factor, but if I can get it higher then this would be one more benefit to my application.
My other plan is to go find a job after graduation. This would be the case if I do not go to one of those graduate schools for whatever reason. I would prefer to work in a college or high school setting. I would also like to stay within Kentucky, Virginia, North Carolina and Tennessee. Over the summer I got to travel A LOT of the united states; Through living in and around these areas long enough I have come to find these are just places I enjoy and find comfort in.
Essentially, I will be applying for a few schools and probably double the amount for jobs. I think this will give me a good variety of options so when it comes time to decided what I do after graduating from Emory & Henry I know I will have given myself as many open doors as possible.
In addition to responding to my prompt, this week I had some clinical excitement. This weekend I have been traveling with my golf team. We are at the Bridgewater Invitational. I had just finished a hole when my coach pulls up and asks me to look at one of my teammates hands. He explains she had hit hard behind the ball and she felt her hand pop and they had been icing it. My immediate thought was that she had probably just slightly strained her wrist. Once I finally saw her and looked at her hand I knew it was much worse. I didn’t have enough time to do a thorough eval, but could visibly see a lump on the top of her hand. I manual muscle tested her flexor digitorum which was 1/5. I also took her fingers through passive range of motion, both flexion and extension were 10/10 painful. In my short eval I could only determine she had strained it. I instructed my coach to contact the hosting team’s coach to call the Bridgewater AT to the course. I was surprised because they were able to get an AT to her pretty quickly. She ended up going to an urgent care where they did imaging and determined she tore her flexor retinaculum. Although I am sad my teammate is injured, I’m proud she was able to push through her pain and finish her round. I am also happy I was able to be a part of a first response to an injury at the golf tournament. Although I wasn’t able to do much, I was able to relay enough information to get my teammate the necessary help she needed.
This semester my clinical goals are: I want to get better at therapeutic interventions by being responsible for 3 different rehabs this semester; I want to prepare for the BOC by doing 10 questions from a BOC prep book in my 2 weakest domains when I am in the clinic; I want to remember special test and MMT better by reviewing 5 every time I am in the clinic. So far I have had the most progress with my second goal, I want to prepare for the BOC by doing 10 questions from a BOC prep book in my 2 weakest domains when I am in the clinic. My preceptor, Joe Lynch, has been very helpful in ensuring I accomplish this goal. Every time I am in the clinic I do ten questions and the next time I am in the clinic we review them and do another 10. I think this will help me because researcher shows that having to think about material I have not thought about in a while will actually make me learn it better. My two weakest domains from the practice Board of Certification exam I took were Domain IV, Treatment and Rehabilitation, and V, Organization and Professional Health and Well-Being. Considering I am just now taking the class which covers domain V and I scored 73% correct, I am not too worried about this domain. I really need to review and recover domain IV. This is an important domain not only because it is a large portion of the exam, but it is things I need to know well in order to be a good athletic trainer. My other two goals need to be worked on more. There are a couple athletes I am able to work on often, but I feel like it is not as often as I would like. This just depends on my and the athlete’s schedule. The 2 patients I would like to work with the most are cross country runners. One is a female who had an ACL surgery in high school who complains of tightness throughout her lower chain. Upon inspection, she lacks terminal extension in her surgery leg 3 years post-surgery. So far we have been working on flexibility and activating her VMO to reeducate it to fully extend her leg. This is a patient I have had the most contact with, but often times schedule conflicts happen. Another athlete I would like to work with just is never in the clinic when I can be there. He is experiencing Over training syndrome. I would like to see how this is affecting him and be a part of the rehab process. This is something have never truly dealt with so I think it would be interesting to be a part of. My final goal I just have not got to yet. I think when I run out of questions in the one BOC book I am working on now I will ask Joe to start helping me with this goal. With this goal, I think I just need to be drilled and work hard on not only memorizing the test and how to do them but, really ingraining the important tests into my head so I know which test will be more helpful than not during an evaluation. Overall, I think I am making good early progress on my goals. These are definitely achievable and reasonable things I will accomplish over this semester.
This week included my final preseason as an un-certified athletic trainer. This pre-season was very different for me compared to any other preseason before. This year I came a week late because I was still traveling with DCI’s Oregon Crusaders as they concluded their season. While everyone here was learning advanced techniques and helping out with football, I was keeping 150 band members healthy as they finished their last 3 shows of the year. While I definitely was making good connections and gaining good experience, there was still a part of me that missed being at Emory & Henry for pre-season. It was always super fun to come back and go over emergency techniques. It’s a good time to see how you have improved on those techniques and compare to the previous pre-season.
As a senior I feel very different compared to any year before. Having my summer experience with DCI has taught me so much on how to create good connections with my athletes, how to think quickly to resolve an issue, and most importantly to be confidence in my evaluations and not rely on my preceptor to double check me on everything I do. Not having to be scared of being wrong and having a preceptor correct and check me on everything is liberating. I feel very confident in my skills and my techniques. Of course I still need to learn finesse in some areas, but now after having my experience with DCI I feel confident and excited for my future as an athletic trainer.
I don’t believe three years ago I could have ever predicted how well I would be doing or feeling about being an athletic training student as I do now. My growth as an athletic training student has definitely influenced my interactions with my patients and preceptors. I have many athletes who choose to come to me for specific things because they trust me or they like the way I do something. I also have athletes recognize my good work and my frequency in the clinic. This makes me happy to know I can make an effect on people in a positive way to where they want to come be treated and tell their teammates to come to the clinic as well. As for preceptors, I feel like I have earned a good level of respect. At times it feels almost like the preceptors are my co-workers. They know I am a dependable student and if they need me to help them, I will be there and if I ever need help from them I know I can count on any preceptor to help me.
I am excited to begin this semester and refine my skills as an athletic trainer.
I have always had decent communication skills, but I have also always been a more reserved quite person. This year I have really opened up in my socialness and this has helped me in the clinic. It is much easier for me to talk to coaches, doctors, other professionals and patients because I have opened up more. Communication is an important skill to have. It is the main method of how we evaluate injuries and it is a key factor in being a professional. I have had a few examples with my rehab patient where communication has been really important. The most recent one was when she had her wisdom teeth removed and she was in a lot of pain, but she was reluctant to tell me or the certified athletic trainer about it. This lead to other issues of where I would find out second had that she was in pain and though my rehab was too difficult. Another time where communication was important with her was when we were just getting to know each other. She had a bad experience with athletic trainer at her old school, so I knew it was going to be important for her to feel comfortable. Fortunately for me, my patient is a talker and I am a good listener. I think this made her feel more comfortable because she felt like she was getting better attention than she was at her other college. Our communication went from awkward every time we talked to a nice conversation. I think it is also important that communication is able to develop as a relationship is built, especially when forming a professional relationship. It is always good to have a good first impression when forming a professional relationship and the way you speak and carry yourself in a conversation is going to leave an impression on anyone you talk to.
So far Meg and I have reviewed 5 articles for our clinical question, “In active population ages 17- 25, could cellular changes in the tendon contribute to or result in chronic tendinopathies?” After reading over these 5 we have 2 very strong articles that we believe truly answer our clinical question. One of the articles we read went in depth on the debate of whether tendinitis is really an ‘-itis’. I liked this article because it gave many examples of research to prove both sides. It also gave us a lot of information on the chemical side of tendinopathies which is what we were truly going after with this question. The other article we read talked in depth on collagen and explained how there are different kind of collagen that is turned over every time there is a stress on it. This article is giving us more of a biological side of the question we asked. Both of these article together have a strong case to answering our question. With our research at this point, I feel comfortable saying the answer to our question is yes, cellular changes in the tendon do contribute to tendinitis.
With these 2 articles we are nearly finished with our project and pulling together the bottom line. Along with this we are also getting a presentation ready because we will both be achieving a goal we set for ourselves last semester; We will be presenting at Ampersand day on April 20th. We are both super nervous for this, but I am excited for what we will be able to present. We still have 2 more weeks until we present. We plan on finishing up our project sometime this week then finishing our presentation next weekend. With all that done we plan to have a meeting with our committee to review our work and make sure it is presentable for ampersand day.
I think doing clinical questions every semester is a good way for us to practice doing research for when we go to graduate school or even next year when we another big research project. Our clinical question that we have developed over our junior year is something I am truly excited about. We have put in quality work that I hope will show through on our presentation.
This week I had 2 attempts and 7 masteries.
This week was a challenging week for my rehab patient. She had just come back from break where she had her wisdom teeth removed. Her first few days back she was struggling really hard to manage the pain. She canceled her rehab on Monday due to pain. She did come in on Tuesday, but she was noticeably exhausted. She struggled through the rehab I had made for her. I didn’t believe it was hard for her at all. I took into account that she would be in pain and made it easy for her. While she did not tell me she thought it was hard during the rehab, I later found out that she perceived it to be extremely difficult. This led to her canceling on Wednesday as well. She came in on Thursday and still seemed tired and worn out. This rehab I had for her was significantly simplified. All I had her do was: single leg figure 8 jumps, drop calf raises, cone drill, plank, ankle 4 ways. After these exercises, I did a massage on her calves to reduce tightness and I did an ultra sound on arches to help with her plantar fasciitis. Then on Friday she came in and Chaypin had created a rehab for her that was much more challenging than the one I had. We did the more challenging rehab and she completed it perfectly fine with no reported pain or discomfort. She seemed to be in a better mental state and seemed like she was in a lot less pain than she had been over the whole week.
What I learned over this week is to be able to listen and observe the patient to understand and accommodate to the patient’s needs. It was clear that she was in pain and miserable on the first couple days of the week even she did not tell me she was tired or in pain. It is very important to communicate. There was a lack of communication on my patient’s side. For the future I know I will have to encourage her to be more communicative. Steps I have taken to make this easier is to be a good listener for her and I gave her my cell phone number so that if she has questions or needs to reschedule I am easily reachable to her.
This week I have two attempts and one mastery.
When I graduate and I am licensed I see myself working in a performing arts setting. This can be anywhere from stunt doubles, ballet, Disneyland performers, Cirque Du Soleil, and Drum Corp International. I have always enjoyed performing arts. This stems from me being in marching band from middle school to college. I also have a great appreciation for other arts and how physical and taxing they can be on the body. Therefore, my dream job is to be able to enjoy the art my patients create and know that I was a key part in being able to keep the performer healthy. A normal day in my career would include preparing the performers for their upcoming show and maintaining their bodies to be in peak performance. Because performers can be any age my patient population can vary greatly. I find this aspect to be very exciting because I would be able to apply so much more of my knowledge in one setting. In one day I may be working on a 15-year-old, 20-year-old, and 30-year-old. While many injuries and prevention will be similar, there will also be other considerations to take into account. Many of these athletic trainers also travel with their patients. Something I have always wanted to do is travel and see new places. This setting would give me the opportunity to work and do what I enjoy and see the world at the same time. In order for this to become a reality I have to do something to put myself into a position to get an opportunity. So far I have applied to an internship with Drum Corp International and I have been looking for other summer internships to get me connected to the type of people to make my career come true. Other things I have been doing is trying to keep my grades up and raise my GPA in order to get into the grad school of my choice. I am also working hard to become a good clinician so when I am certified I will be able to be more reliant on my skills rather than being doubtful on my decisions.
This week I had 7 attempts and 2 masteries.
This year National Athletic Training Association has created, “Compassionate Care for All” as the slogan for National Athletic Training Month. I really like this slogan because I am already a naturally compassionate person, so I feel this is like a goal I can truly follow through on. I’m the kind of person that doesn’t doubt how a person feels. If a person tells me something is wrong I will want to help them, this is our job after all. I have heard other people say, “so-and-so is only here because they want the attention, they don’t have anything wrong with them.” There is a possibility this could be true, but we should also be some of the first people to see signs of psychiatric changes in our athletes too.
I think it’s important for athletic trainers and all health care providers to be compassionate towards their patients. We have all experienced a “bad doctor”. I feel like a large component to a bad doctor is a lack of compassion and attention to the patient. Anyone who feels like they are just pushed through isn’t going to feel cared for. This is especially important for athletic trainers. It’s possible that if one athlete you treat doesn’t feel cared for with you they could tell other people about their experience. This could be detrimental to both the athletic trainer and the whole sports team. Compassionate care for all sends a message that we care no matter what and we have a holistic approach. An athlete isn’t just an ACL tear, they are a human being with a soul and emotions and we should treat them as such.
This week I had 10 attempts in my clinical packet.
We feel like this more cellular and biological approach will provide us with more information. We are hoping to be able to progress this again next semester into possibly doing our own personal research, and being able to contribute to literature. Our committee we have chosen is Beth Funkhouser, Melissa Davis, Scott Pennington, Brandon Surber, Chandler Copeland, and Joseph Vess. We chose Beth to be on our committee because she was the initial inspiration for our project last semester and is very helpful in finding us pilot research for us to begin looking at. We chose Melissa because she has a lot of experience with many different teams. This may be useful especially later when we decide to narrow our research further. Scott is an athletic training alumni from Emory & Henry and now is in the DPT program in Marion. We were able to meet with him this week and he sounds very interested and willing to help us out a lot. I think for this clinical question we will need help in combing through what minimal research is already out there, and he is one person who seems eager to help us out. Not to mention he was once in our shoes and will be very helpful in putting the final touches on our research. Brandon and Chandler are two seniors in our program who have really inspired us to push ourselves hard and want to present our work at Ampersand day. Not only have they been inspirational to us, but they have also done a lot of research on tendons and may be help in finding research, refining our work, and asking questions that we may not have asked ourselves. Last, but not least is Joe. He has the connections to get us to be able to present our work and will be crucial in being able to further our plan for next semester’s research.
Overall, Meg and I are excited to see what we will find. We have a few articles that we have looked over and believe this will be a good project for us.
This week I had 2 Masteries and 5 Attempts in my clinical packet.
It’s important to have a holistic approach to an athlete’s rehab because at the end of the day they are still a human being, not just an ankle sprain. The athlete could be sick, or depressed, or has bad eating habits. All of these can affect the outcome of a rehab. I had an example of this with my rehab patient. She had been telling me about how her roommate had an ear infection and that it is apparently contagious, and eventually she got it too. This caused her to have to miss a few rehabs, but we have to be okay with this. No good will come if I have her do balancing exercises and she can’t balance and is nauseous. For me this means I have a few days of rehab already written up for her, but I also know I might have to be ready to scale it back on the reps and weight because she may lose some strength after being sick. Ultimately it important to have some humanity when doing a rehab. Make sure they are still progressing but if they are not then look into some other personal factors that could be affecting them.
This week I had 8 attempts in my clinical packet.
There are many roles an athletic trainer has during a rehab. We become a new factor to an athlete’s daily life when we start a new rehab. It’s important to create a good connection with the athlete because this will open them up more and help us figure out how they feel and especially what they are experiencing throughout their injury. If we have a good line of communication open between the athlete, then this makes it easier to find out how to progress them. Something I do when I add a new exercise or add more repetitions is ask the patient how it feels and if it’s too hard, too easy, or just right. This allows me to make modifications as needed for the next time we meet. I also think it is important to have a variety of exercises. Specifically, with my rehab patient, she has an ankle sprain, but she also has a lot of general leg weaknesses. Sometimes when she is doing a balancing exercise I noticed she drops her knee in. After noticing this, I have added some leg exercises into her rehab because it would be horrible if she finished her ankle rehab then turned around and tore her ACL. I feel like a have a pretty decent connection with my rehab patient. She is very open about talking about her daily life. She tells me about her classes, and her crazy roommate, but she also feels comfortable in asking me if I can do something for her in her rehab and asks how things I do work. With how open she is I feel like I have a good understanding of when to push her and when too pull back on some exercises. Another way I can tell if she is struggling with something is if it takes her a long time to complete the exercise. It’s interesting because she doesn’t particularly complain, but if I ask her later how that exercises was she will tell me it was hard. Some people are slow because they are methodical, some people are slow because they are lazy and they drag it out with a lot of breaks; I just happen to notice that if an exercise is particularly hard for her she is slow, but she will complete the exercise anyway.
This week I had 1 attempt and 2 masteries in my clinical packet
My most interesting and mildly challenging evaluation I have ever done was on a middle school basketball player’s wrist. He had tripped and fallen on an out-stretched hand. He came in really calm and his complaint was that his wrist would click every time he bent it and that it hurt to move. Immediately I knew I had to rule out a fracture. I did palpations and felt crepitus around his lunate. I then did Range of motion and a mobility for all of his carpals. His range of motion was normal, but as he stated, there was a pop every time he flexed and extended his wrist. At this point I was a bit confused. I thought there may have been a dislocation because of how mobile his carpals were, but then I checked them bilaterally; while there was a bit more mobility on the injured side, it seemed relatively normal for him. Then I went into some special tests. I did a couple of percussion tests, but it was hard to isolate the carpals. I also did a squeeze test on his forearm which was positive. I was stuck between a radial ulnar sprain, a lunate fracture, and a lunate dislocation. At this point is when my preceptor helped me think through the process. He reminded me of his age and how we need to be worried about growth plate injuries and greenstick fractures. He also stated how when we are young our joints are very loose which explains the amount of mobility I saw in his wrist. What I learned from this evaluation is that sometimes there are parts of the history you don’t ask, but you need to take into account. In this instance, obviously I see a young boy and an injury around the joint, but I didn’t think of it as a factor that would play into the evaluation. Maybe because I’m more used to an older population, this just slipped my mind. Now I know for the future I will need to be more cognizant of age and other factors that are implied but not asked.
This week I had 12 attempts and 0 masteries in my clinical packet.
This is where I do my weekly clinical blog assignment. There is either a prompt I am responding to, or I just talk about something exciting I saw during the week.