By Scott Livingston
B.SC., CAT(C), CSCS, Founder ReconditioningHO
As Christmas 2011 was nearing, we were slowly ramping up for the holidays in anticipation of all the wonder in our two and half year- old daughter?s eyes. Santa Clause was still real, and we had already begun the soon to be tradition of hiding the Elf on the Shelf.
That time of year is always a time of family reconnection, but when you have a little one, it means so much more!
For a number of years while I worked in the National Hockey League, it had meant squeezing in a few precious days with my wife and family, and maybe getting some much need rest. While I was with the Canadiens though, often we would play the night before Christmas Eve, and then launch on a flight to Tampa or Fort Lauderdale on Boxing Day, squeezing the holiday was the operative word.
This year however, I was a few years past my career as an NHL strength and conditioning coach and athletic therapist, and I had forgotten about the crunch of Christmas, instead enjoying the fact that I had a little more time to connect with my crew.
As the days towards Christmas passed and the advent calendar was reduced to empty boxes, I received a phone call from my good friend Graham Rynbend, Head Athletic Therapist for the Montreal Canadiens. He was troubled with the case of number 79.
Andrei Markov?s days as an NHL all-star were behind him. His career had been a struggle since shortly after I left the team in 2009 when we got hit by a series of difficult injuries. The first was a freak injury, his tibialis anterior tendon being severed by the skate of his own goalie, Carrie Price. Then after completing the rehab and returning, not long after he would tear his ACL.
Two seasons effectively trashed because of big injuries was tough on him, and as he came off the rehabilitation of the ACL tear returning for the later part of the 2010-11 season, fate would fall upon him again as he entered a corner to challenge for a puck, and his ACL repair failed him.
The summer of 2011 he would again work through a rehabilitation program to get ready for the impending season.
There were lots of articles in the paper, lots of predictions of when he would return.
There was a lot of pressure!
As the 2011-12 season opened the anticipation of his return rose. The clock on his rehab protocol was coming to an end, and as it evaporated so too did the patience of the media and the Canadiens fans.
Where was number 79, when was he going to return?
In the background things were not going well. Andrei?s knee kept blowing up on him all summer, the medical team was being challenged by the rehab and finally as he was trying to re-integrate into practice in the early season with no success, a decision to scope the knee again and send him down to FLA to work with the surgeon?s people was imposed upon the medical team.
Andrei returned not really in any better place, the knee was still not behaving, and time had run out, management?s patience had run out.
Graham?s call to me was not something I would have expected.
I had reached out some months earlier when I heard from Andrei that his knee rehab wasn?t progressing the way he had hoped, but Graham?s hands were tied, management wanted his rehab to be done in house.
But Graham and I had a trust born of many years of friendship, and of our close work during the eight years I spent with him and the Habs. He knew about the Reconditioning systems I used to rebuild athletes, he?d seen me hone my practice through my time in the league. He also knew that I had continued to practice and refine these skills as I left the league and continued to pursue training and rebuilding Olympic athletes.
My wife and I had built a business around this concept of Reconditioning, the art and science of integrating therapeutic practice and performance coaching, and we had begun managing some very challenging injury cases and coming up with some unique solutions.
Graham believed I could help, and he finally convinced management to give it a shot, they were all out of bullets.
One might wonder in reading this, what could be so unique or different about Reconditioning from traditional rehabilitation?
The answer lies in two fundamental paradigm shifts. The first one is understanding the ?why??
As you know in therapeutic practice the assessment follows the Cyriax process. Work through the subjective, then the objective findings, special tests and palpation, and then render a form of differential diagnosis.
Name that tune! He has a patellar tendonitis, he has a capsulitis, he has a torn ACL.
And if he has a torn ACL, he gets one of a number of surgical interventions and then you follow a progressive protocol to rehabilitating that ACL repair.
But why did he tear the ACL in the first place?
Yes, sometimes it?s a moot point and a 220 lbs. forward fell on his leg, but sometimes there is a mechanism that seems to appear out of nowhere in a movement he?s done 1000?s of times before. Could it be that there are mechanisms of movement in
the body that might be driving un-usual stress through that knee?
And even as we run through the process of the rehab, are we paying attention as therapists and performance professionals to how the systems above and below that repaired knee are dealing with the change in that knee.
What are the dominos of surgical intervention?
For one, the removal of the ACL removes the proprioceptive feedback loop that the ACL is so crucial in providing to the CNS. How much torque is going through that knee? Is it being
mitigated and managed by the muscles around the knee? Are those muscles involved in the pathomechanics of that knee lighting up when
they are supposed to light up, or are they just a little slow, or nowhere to be found?
The bottom line is that there can be reason?s for the hyper-stress of the ACL before it tears, like an inability to manage torque from above through the hip as an example, or a change in tibial pathway driven from below in an ankle that doesn?t respond and move quite as well as it once did (perhaps one in which the tib anterior tendon has previously been severed?)
These are not traditional thought process in the classic rehab paradigm.
Get the knee moving, get the range of motion back, get the strength back, challenge the capacity of the leg, increase the demand, increase the fitness, challenge coordination and proprioception, add some plyometric stress, integrate specific movement demands, begin skating again, throw in some subjective or objective testing, pass the protocol stages, and viola ACL rehab complete, time to play hockey again.
All of this under the intense pressure of return, the cost per man game lost, the anticipation of that players return in turning around a season, or a losing streak.
In this big process, the sensitivity to ?why? it happened in the first place, and what might have been, or is driving the overstress on that knee can get lost.
On December 27, 2011, just after I had celebrated my third Christmas with my little one, I was in Premiere Performance (P2) evaluating number 79. I had seen him for a two-week stint after the first surgery mid-way through his rehab just to oversee him before he left for Russia. There were issues with how he managed deceleration in both hips with lateral hoping, but I wasn?t given the time or the license to intervene. I knew going in to this evaluation, that this was probably a big part of the problem.
You see, if you can?t decelerate through the hips there is a long slow lag in breaking that appears, and what it translates into is a higher level of torque driving through the knee. The hips are the main breaks in all forms of multi-plane movement in the lower body, and if they aren?t working well, unfortunately the knee and back take a beating. Coincidentally, or not so coincidentally, he had back pain as well.
And the ACL is directly in the path of torque, it is in fact there to prevent it from damaging the knee.
As I looked at Andrei the day after boxing day, the road looked long. I tried to encourage him that this was fixable. I could see in his eyes that he knew it might not be, and that his career might be coming to a close. There was a sort of desperation and yet trust in his stare. Andrei was never a man of many words. When I told him I thought we could fix it, he just shrugged and said ?Ok, I trust you?.
My hypothesis after assessing him; improve trunk set up and control, get his hip function back, teach him how to use his hips effectively, and then pattern it into his skating and change of direction, and he?ll be able to play again. So simple, right?
Not really. That?s the second paradigm shift, what you do off the ice has to be connected to what you do on the ice.
I told Graham I would do my best, he needed to give me time, he needed to hold the dogs at bay, and allow me to truly re-build Andrei from the ground up. Andrei didn?t use his trunk effectively, this in turn transitioned into his hips, which in turn drove the knee issue, and fixing it was going to be a long process of re-learning how to move well before moving with speed and agility, and then finally on skates.
So, we set out on this reconditioning plan, slowly adding layers of movement demand, always returning to and understanding where the faults lied. Teaching Andrei about his issues so he would actually own his reconditioning process and connect with what he needed to do better.
With the constant diligence of Graham and therapy team supporting the Reconditioning program, the knee behaved, Andrei began to move more smoothly and confidently, the quality improved substantially, and as we added demand he responded well.
A smile began to appear on his face. Maybe there was a chance!
In early March we began the process of linking everything Andrei had learned about how to move off the ice, to how he needed to move on the ice. The most challenging process in Reconditioning, because this is when the CNS returns to default. This is when the athlete believes, ?I know how to skate, druke?, and now it?s time to get back to business.
?But you were skating when you tore your ACL both times, right??, I remind him, ?and unless you make some real change to the way you skate, you might just be in for another rude awakening.?
?Ok, I do what you tell me?.
Several weeks of working on that connection to the ice, the re-integration into practice, managing through fatigue and 1-1 challenge, and finally the re-integration into a game was not without its difficulties, but with a few weeks left in the NHL season in the spring of 2012, Andrei Markov took to the ice again at the Bell Center.
He finished the rest of the games in the season, and then spent most of his summer with me continuing to re-build.
Upon his full return in the 2013-14 season he never missed a game after that, for the next five season?s he was an Ironman.
Each summer we would set out to make him just a little bit better than he was the year before, always focused on quality of movement regardless of quantity. You see, this is the crux of
Reconditioning, remove the impediments to movement, challenge the system to tap into what is available, link it to higher and higher demand, all the while staying connected to the quality.
Building a more robust athlete, building an Ironman!
Scott and Jaime Livingston are certified athletic therapists and certified strength and conditioning coaches who practice the art and science of Reconditioning. They are on a mission to change the way injuries are perceived, how they are managed, and indeed how they are mitigated through the integration of therapeutic practice and performance training. You are welcome to join them on their #ReconditioningRevolution by enrolling in their Reconditioning Specialist program. www.reconditioninghq.com