Professional Triathlete, Ironman, and Olympian Joanna Zeiger Interviews Achieve Sports Medicine Co-Owner, Gina Pongetti Angeletti
Gina Pongetti Angeletti, MPT, MA, CSCS, ART-Cert.
Achieve Sports Medicine Co-Owner
Joanna: What is the most important piece of advice you give to athletes who are coming to you with a long-term injury?
Gina: Long term, or chronic injuries, are the hardest for athletes to deal with. For many reasons, often athletes do not seek medical help or opinion until it progresses to a more complicated treatment protocol, as well as after compensations have already taken place (see below).
- PTSD (Post-Traumatic Stress Syndrome) from past injuries and treatment that did not go well
- Mistrust of medical professionals, how they diagnosed things, lack of communication, lack of accuracy
- Timing in the course of training for a race- the attitude of “I will deal with it after”
- Cost-benefit- weighing the cost of treatment including money, resources, time, energy, stress, with the benefit, and if the pain can be self-convinced to be “not bad enough”
- Chronic nature of an injury, thinking that it “always” comes and goes, and will go away soon
- Resource allotment- not enough time in the day, perceived, to prioritize treatment (driving, time away, home exercise programs, etc.)
- Health insurance- issues with insurance coverage, not wanting to do self-pay
- Expert availability: the best people are too far away, no one is an endurance sports expert in the area
- Technology mistrust/unfamiliarity: telehealth visits are available, and athlete does not think that they will help
- Self-worth: not thinking that you are good enough, or worthy enough, to make treating yourself a priority
- Equipment frustration: having been through too many running or cycling shoes, not wanting to switch again and risk subsequent issues like blisters, mis-fitting, etc.
- Identifying with being injured: people don’t want to admit that they are actually hurt, and they believe that even though they experience pain, they aren’t “injured” unless they admit it. It is a mindset issue based off of fear of being inadequate or potentially having made a training mistake
- Self-assessment fear: people don’t want to talk to their coaches and get brutally honest feedback about their swim or run form, and what actually may have made them, or contributed to them being, Injured. Especially with chronic and long-term, or repetitive injuries, there usually is a mechanics issue. This leads to also being scared to point out that their coach may have missed something as well, as some revere their coaches, and some coaches perceived egos get in the way of their athletes being open and honest with them. In reverse, some athletes are so confident in their training, and coaches do not want to lose them or are not confident enough in the relationship that they have built, that they don’t want to approach the athlete with “should have’s” because of fear that they may feel threatened, judged, or even may consider leaving to find the “grass is greener” scenario
- Pain: fear of pain of the actual treatment. Examples are pain of stretching, pain with rolling, hands-on, manual treatment with PT can be uncomfortable, etc.
This means complete rehabilitation includes treating the compensatory patterns as well as restoring biomechanics. This means a full assessment including but not limited to:
- Visual/video assessment of old running/active videos and pics if available to check positioning and form, both at the start of a race and end (if possible)
- gait evaluation
- DorsaVi gait assessment and movement
- Further testing pre- and post- fatigue, varied aspects of workouts
- Analyzing workout logs for micro and macro cycles (pending coach education level, understanding of exercise physiology)
- Assessment of nutritional and physiologic contributors (vitamins, absorption, blood tests, inflammatory markers, etc.)
- ground reaction force evaluation
- strength testing
- jump testing, power production and repetitive jumps to check speed and ground time/reaction
- flexibility of entire LE
- SIJ and pelvic assessment including ilium position
- nerve/tension relationships in the entire LE
- spine assessment for all three planes of motion (front/back, side/side, and rotation)
- ART (Active Release Techniques) assessment for intersegmental motion and relative motion
- ROM (Range of motion) testing
- Abdominal and core control during functional motion
- FMS (Functional Movement Screening) if needed
- And more!
The advice that I give them for the future is to be aware when patterns start, and when pain lingers, and do something about it the acute stages, not trying to treat yourself or “hope” that it will go away. Keeping a log is the most important. It allows us to track everything from equipment changes/relative age and use, to pain perception and how one “feels” in a given day, or even the day after.
When they are in treatment, the focus of my advice giving is two-fold. First, be patient with the process, it may take as long to fix as it took to create. Second, most likely we will have to unravel the compensatory patterns and fix secondary issues as well as find the primary issue…and this takes time. If you want your Achilles to feel better for next week, we can make that happen. If you want to make sure that the 6 months that you have had pain this round, and the four times it has happened in the past doesn’t occur again, then we have to peel the layers to determine cause and effect.
Joanna: When you’ve worked on an athlete for a prolonged period of time and they don’t recover, at what point do you suspect that the injury has been misdiagnosed and what do you recommend?
Gina: There are 5 reasons why people do not recover:
- Method: diagnosis is not fixable using the methods that are being used (i.e. “fixing” a meniscus tear through PT is not possible)
- Diagnosis: Diagnosis is incorrect
- Compliance: The patient is being non-compliant or not fully open and not doing their part in the process (i.e. not doing home exercises, riding more that you say that you are, not being honest about reporting pain, etc.).
- Inept Care: The health care professional you are seeing is not treating it properly with the highest level of techniques and modalities. Continuing education, research, self-education, and reading are all very important in staying on top of your profession
- Hidden Diagnosis: MD is diagnosing based on radiographic evidence only (i.e. MRI was “negative” for a spine stress fracture, but it was actually a false negative, meaning that the diagnosis exists but the films did not pick up on it, etc.)
There are many ways of course to treat these issues. Medicine, in general, is a very large algorithm. Your original chart may include 35 different options of possible diagnosis. For example, knee pain can be tendinitis, ITB issues, bursal irritation, alignment, ligament damage, etc.). Using an if/then approach work in almost all cases, as long as options are completely open or completely eliminated to guide you on your path. Similarly, to stubborn healing, pathways for treatment are the same. Each time you use a patient you have to make sure that your variables have not changed. Are they still doing their home program? Have you asked, recently, if they have been biking more than they are telling you? Have the objective symptoms changed, thereby altering the diagnosis? Are you getting stale in your treatment or are you constantly, as a provider, planning short term and long-term interventions?
Surgical intervention, of course, is something that many do not want to jump in to. Treating with a more conservative and non-invasive approach many suggest, and athletes choose to try first. For example, plantar fascia tears, if small, can often do well with aggressive PT. However, at times, patient will start PT without an MRI, due to cost, time, willingness, and historical treatment success. At some point, as long as there is patient compliance and proper techniques used for treatment, it is time to reassess. Did you do a full gait eval? Is the local problem simply a result of hip/gluteal weakness and gait abnormalities? Is it time to get an MRI or a diagnostic ultrasound to determine if there is a tear or nerve entrapment? Is it time for surgery and performance shut down? These are all variables to consider.
Sending for a second opinion must involve a practitioner who takes the time to complete a full medical history, which often is the culprit for a missed diagnosis even more than actual objective evidence.
Joanna: Athletes can be impatient when it comes to injury recovery. How do you keep an athlete on track with their long-term rehab plan?
Gina: With the amount of elite athletes I work with, it is important to sense their personality, assess what type of learner they are, as well as their motivation (extrinsic, intrinsic, money, passion, family pressure, loyalty, not knowing what else to do with their life, and so many more). In knowing that makes the athlete tick, short term and long-term goals can be set. For most sports, if the injury is most likely to be fixed, we backtrack from their A race, or competition, as to when we would like to be doing certain workouts/volume, but it is not necessary, and when it is necessary to be at a certain point.
Often, the impatience comes from high level athletes having traits of detail obsession, some aspects of OCD, if they are older and have been at a high level for a while, they will overanalyze situations, as well as working in the factor of trust. If the athlete trusts their therapist and medical team, they will be more likely to be patient. Knowing that the coach and medical staff communicate is the biggest issues in my offices regarding impatience. If I speak to the coach on a regular basis about what they are released to do, intensity and volume related, constant objective improvements can still be made. There is a psychology aspect to my job that I think takes a regular provider to a completely higher echelon- team player, motivator, cheerleader, and being able to have personal and professional experiences with the sport to provide empathy and not just sympathy for any given situation.
It is a good idea for all athletes to have a working relationship, whether active or passive, with a sports psychologist. Mindset during training is as important as mindset during recovery/injury. Many have books, online programs, daily assessments, training that people can go through. E-visits are amazing as well and can really make a difference in breaking down barriers to treatment and follow through.
Joanna: Rehab itself can cause pain. How do you help an athlete balance the pain from rehab with the benefits of recovery?
Gina: A big misconception in the care of injuries is that it will be pain free! Society as a whole has been so focused on pain (the bandwagon conversation about over prescription of narcotics is a whole separate and very important topic…). Currently, in order for people to get “better” from a various number of ailments, pain control is the first go-to for most practitioners. There is true scientific evidence that people heal better when pain is under control (breathing, relaxation, hormone production, depression, sleep, etc.). However, the “easy” way out, often, is cortisone injections, pain pills that simply mask symptoms, and anti-inflammatories (that just at times make you train harder when you see improvements and feel better from the meds!). Treatment of acute injuries should often be focused equally on pain control as much as on inflammation control and healing/function. In chronic conditions, the body often “forgets” about prioritizing healing, decreasing attention to the area. Therefore, often treatment entails a resurgence, purposely, of inflammation, friction, blood flow, fascial release, scar tissue removal and more. Simple touch and light massage are not going to “fix” most things. At times, pressure has to be applied to get deep enough. Needles are inserted to cause contractions in order to release sitting tension. Manual techniques are performed to release adhesions that take force and pressure. For the greater good in the long run, the perception of pain is often needed.
Pain provided by the PT, purposely, is often to be tolerated only if is to be expected. If a technique is being used that may help in moderation but may cause pain if overdone, then the communication between the patient and therapist is of utmost importance. Stretching tissue, strengthening muscles, mobilizing joints, and re-establishing range of motion is often painful. The importance of the therapist educating the patient on their safe “window” is the end goal.
Joanna: Returning to sport is generally the primary goal for an athlete. What do you do to help get them back in action in a timely fashion without compromising their recovery?
Gina: For a majority of injuries, a full sport limitation is never suggested. Unless it affects the whole body, like adrenal fatigue or a communicable disease…there is always something that can be done in the clinic or on the playing platform.
For injuries that are of a specific joint or area, such as the knee, you can always be working “up and down” the kinetic chain on the hip above, and on the ankle below. Odds are, unless it as a traumatic injury, such as a fall, balance, proprioception, strength, core stability and flexibility played into the cause of the injury. Most of the time, it s a combination of those variables, or an imbalance in the body, that leads (especially with repetitive sports) to chronic injuries and bad habit formation with compensations. You can get creative, for instance, with working core and hip strength when the ankle is in a boot- simply kneel, lay down, or use resistance bands.
If the person is dealing with an injury that will lead to a secondary complication because of the treatment, you can anticipate this to make the second stage easier. For example: if someone had rotator cuff surgery and they were going to be in a sling, then while in the sling, work on cervical and thoracic joint mobilization, relaxation of the upper traps (which will get tight from posture in the sling) and so much more. Often limitations allow the athlete to focus on another weakness in their skill set. If you cannot run because of the impact aspect, but you can bike, then training can be modified for different goals in a single-event focus.
Returning “timely” is always a delicate balance of being conservative enough that the injury rehabilitation is done properly so that reoccurrence is less likely, and aggressive enough to take into consideration schedule of performance, age (high school prep to college, amateur turning pro, pre-Olympic year, etc.) and severity of the injury.
Analyzing this package of variables is the only way to decide where on the spectrum treatment intensity will be. A caveat is, of course, that some injuries require protocol rest with no ability to change that, such as recovery from surgical procedures and immobilization.
Joanna: What guidelines do you give an athlete in terms of doing their sport while injured – i.e., complete rest vs. modified training?
Gina: My guidelines are based on the mechanics of the sport, in all aspects. For instance, a triathlete may swim intensely with an ankle sprain in a water-approved brace and bike as well in that brace but be completely limited in running until healed. If available, the AlterG unweighting treadmill can allow the athlete to run, modified, by decreasing body weight so that the athlete can still maintain cardiovascular intensity without risk of re-injury, pain, and compromised healing.
Some motions need to be completely limited- like no jumping, or you cannot put pressure through your wrists. Therefore, the limitations make up our mind for us. Modified training is always the goal, as long as it is not going to drag out the recovery process into longer rehab or span multiple years/seasons.
There is also a fine line between limitations based on pain, and limitations due to mechanics and stress. A great example of this is distal IT band irritation. Some will say that running is what causes them pain, and biking does not. The MD may want to avoid pounding stress, but then allows the athlete to bike. Although true, because the athlete does not have pain on the bike, silently it is delaying recovery due to creating inflammation due to the constant bend and straighten of the knee. So, as a medical professional, I have to pull people back from activities that they think are harmless because of physics, biomechanics and inflammation control.
Joanna Zeiger is also the author of The Champion Mindset: An Athlete's Guide to Mental Toughness