Ep 191: SPORTS CORNER in the WNBA, with Dr Kala Flagg

[00:00:04] [SPEAKER_02]: Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality

[00:00:09] [SPEAKER_02]: research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic

[00:00:15] [SPEAKER_02]: and Sports Physical Therapy. It's great to have you listening today.

[00:00:22] [SPEAKER_00]: Joining us today on JOSPT Insights is Dr Kala Flagg, who is Head of Rehabilitation for

[00:00:27] [SPEAKER_00]: the Washington Mystics. She's also a former professor and DCE at Howard University Department

[00:00:31] [SPEAKER_00]: of Physical Therapy. She's the owner of Team Sports Injury Consulting and has over 20 years

[00:00:36] [SPEAKER_00]: of experience in the field of physical therapy. My name is Dan Chapman, owner of Summit Physical

[00:00:40] [SPEAKER_00]: Therapy and Performance in Baltimore, Maryland.

[00:00:43] [SPEAKER_03]: And I'm Chelsea Kuman, a physical therapist and athletic trainer at Stanford University

[00:00:46] [SPEAKER_03]: Athletics. Dr. Kala Flagg, thank you so much for joining us today on JOSPT Insights. I am

[00:00:52] [SPEAKER_03]: so excited to get into high-level basketball with you.

[00:00:55] [SPEAKER_03]: Absolutely.

[00:00:56] [SPEAKER_03]: Okay, so your experience in, I mean, all things high-level basketball, but specifically you're

[00:01:01] [SPEAKER_03]: working in the WNBA right now, so on the women's side. We want to go into our typical sports

[00:01:06] [SPEAKER_03]: corner with you, get an idea of kind of the demands of the sport. At this point, we know

[00:01:10] [SPEAKER_03]: what basketball is all about. Those demands can vary by position to get into that and then

[00:01:15] [SPEAKER_03]: hit on injuries and how we can best treat these athletes. So would love to get your insight

[00:01:20] [SPEAKER_03]: onto the demands of high-level women's basketball.

[00:01:23] [SPEAKER_01]: Thank you so much for having me. It's great to be here to be able to talk with you. It's

[00:01:28] [SPEAKER_01]: an exciting time in women's basketball, not just on the professional level, but, you know,

[00:01:33] [SPEAKER_01]: the college level as well. And I even have multiple friends and family members sending me things like,

[00:01:39] [SPEAKER_01]: have you seen this high school player? You know? So I think that there is definitely a lot of

[00:01:47] [SPEAKER_01]: interest in, and rightfully so, in the women's basketball game right now. And I'm very happy to

[00:01:53] [SPEAKER_01]: be a part of it. You know, we're all familiar or mostly familiar with the game of basketball.

[00:01:59] [SPEAKER_01]: You know, it's five positions on the floor for each team. You know, you have the, basically,

[00:02:04] [SPEAKER_01]: they call them the one through five. You have your shooting guard, your point guard, your,

[00:02:08] [SPEAKER_01]: well, those should be switched to point guard, shooting guard. You have your power forward.

[00:02:14] [SPEAKER_01]: You have your regular forward. Sometimes it's a flex position. It's generally a fast-paced game.

[00:02:21] [SPEAKER_01]: You know, somebody said to me the other day that women's basketball has pretty much gone from,

[00:02:26] [SPEAKER_01]: you know, having maybe one or two players on the team who could make a layup and everybody else that

[00:02:31] [SPEAKER_01]: just kind of like ran the floor to really having five dynamic players on the floor. You know, of course,

[00:02:37] [SPEAKER_01]: you have your shooting guards, which are usually the smaller players that kind of get in position

[00:02:42] [SPEAKER_01]: and score a lot of the points. But now you also have the bigs who are shooting three-pointers and who

[00:02:48] [SPEAKER_01]: are, you know, really creating a lot of the plays. And so it's a lot of fun to just kind of see that

[00:02:56] [SPEAKER_03]: develop. You hit on the positions a little bit. What are the difference in demands on some of those

[00:03:01] [SPEAKER_03]: positions? So some people are shooting more. Some people are moving a little bit differently.

[00:03:05] [SPEAKER_03]: Do they have different, like, jump, change of direction, running demands? Or are they all pretty

[00:03:11] [SPEAKER_03]: similar?

[00:03:12] [SPEAKER_01]: Yeah. I mean, I think it really depends on the cast of people that you have on your team.

[00:03:18] [SPEAKER_01]: We, from year to year, you know, may have varying skill levels at every position. There have been

[00:03:26] [SPEAKER_01]: bigs or the centers who are six foot five, you know, women who run the floor really well.

[00:03:33] [SPEAKER_01]: They tend to do a lot of jumping off of one foot, a lot of pivoting. So we have to really kind of take

[00:03:41] [SPEAKER_01]: a look at their movement patterns and make sure that we are training them in the multi-planar,

[00:03:46] [SPEAKER_01]: you know, ways as opposed to the bigs who just kind of like, I'm going to run down the floor,

[00:03:51] [SPEAKER_01]: I'm going to get under the basket and, you know, I'm going to try to make something happen or get a

[00:03:58] [SPEAKER_01]: rebound, right? And then you have the guards who, we have some guards who, when we're monitoring

[00:04:05] [SPEAKER_01]: mileage and accelerations and decelerations in practice, we have some guards who are consistently

[00:04:11] [SPEAKER_01]: over what we would consider the average for that day or where we want people to be for that day,

[00:04:17] [SPEAKER_01]: because they are players who are typically guarding the best players. They are very shifty.

[00:04:25] [SPEAKER_01]: They run very fast and they stop very quickly in order to be able to create space for themselves

[00:04:31] [SPEAKER_01]: or for their teammates. So for me, I think it's very much an individualized thing. I tried to,

[00:04:38] [SPEAKER_01]: you know, look at the team as a whole and work with my colleagues and the performance staff to make sure

[00:04:43] [SPEAKER_01]: that we kind of get generalizations, but also kind of pull out the outliers and say,

[00:04:51] [SPEAKER_01]: okay, no matter what's happening, this person is going to be on the higher end of, you know,

[00:04:57] [SPEAKER_01]: the conditioning spectrum. Whereas no matter how much we try to get this other person in shape,

[00:05:03] [SPEAKER_01]: they are always going to be the last one down the floor. They are going to accumulate, you know,

[00:05:08] [SPEAKER_01]: low levels and we're probably going to have to sub them pretty, you know, frequently in order to make

[00:05:13] [SPEAKER_01]: sure that they have the time to recover. So, you know, we have what we want to see and then we have

[00:05:19] [SPEAKER_01]: what the player presents with and we try to work within those ranges as much as possible.

[00:05:25] [SPEAKER_03]: Yeah, that's awesome. That's a good insight that that game can change so much and being able to

[00:05:31] [SPEAKER_03]: differentiate or know how to ask those questions, not just assume like a shooting guard is going to

[00:05:37] [SPEAKER_03]: be all over the floor like that. There might be more of a facilitator, right? And being able to ask

[00:05:41] [SPEAKER_03]: those questions. So based on those demands, what kind of, what are like the top injuries that you

[00:05:48] [SPEAKER_03]: are seeing in this game? You're saying the game is changing a little bit. Like has that changed?

[00:05:53] [SPEAKER_03]: I'm curious.

[00:05:55] [SPEAKER_01]: For a lot of years, and I've been doing this for almost 25 years now, you know, you expected to see

[00:06:01] [SPEAKER_01]: a couple of ACL tears each year. You expected to see, you know, the frequently sprained ankles,

[00:06:08] [SPEAKER_01]: the patellar tendonitis, Achilles tendonitis, and some of those things are still very much

[00:06:14] [SPEAKER_01]: present. You know, you have a jumping sport. So there's going to be a lot of tendon loading. There's

[00:06:20] [SPEAKER_01]: going to be a lot of joint rotational forces that are going to happen. You know, it's a contact sport.

[00:06:28] [SPEAKER_01]: So there's some things that you just can't avoid. So those are still there. I think what we're paying

[00:06:34] [SPEAKER_01]: more attention to is how all of those things kind of playing together and looking at, are there ways

[00:06:43] [SPEAKER_01]: that we can holistically treat a player in order to prevent certain things like the low back pain

[00:06:53] [SPEAKER_01]: that may be due more to posture because their pecs and anterior shoulder muscles are too tight? So it's

[00:07:04] [SPEAKER_01]: changing, you know, the way that they hunch over. They're not able to activate their posterior chain.

[00:07:09] [SPEAKER_01]: And then we're getting the low back pain in that respect. What are they doing from the ground up?

[00:07:15] [SPEAKER_01]: Are they getting tendinitis because of the jumping? Are they getting tendinitis because they're not able

[00:07:20] [SPEAKER_01]: to load properly into their foot and ankle and their knee is taking the majority of the pressure?

[00:07:28] [SPEAKER_01]: Is their pelvis tilted one way or the other because of tight structure? So I think all of that is coming

[00:07:35] [SPEAKER_01]: into play a lot more and just kind of trying to address that from a movement quality standpoint.

[00:07:42] [SPEAKER_01]: What does that mean day to day? What does that mean game to game? And are there changes that we can

[00:07:49] [SPEAKER_01]: make that will realistically impact this? Or do we need to work within their quote unquote dysfunction

[00:07:57] [SPEAKER_01]: and just try to make that the best for them? And I'm seeing more of that, not just in our

[00:08:03] [SPEAKER_01]: organization, but across the board.

[00:08:06] [SPEAKER_03]: We talked to Maggie Bryant, who's at the LA Clippers, for like the men's side of high level

[00:08:11] [SPEAKER_03]: basketball things. And she said some of the same things. So like the foot and ankle, how important

[00:08:14] [SPEAKER_03]: that is like being able to look up the change, it might not just be that their quad is tight and

[00:08:20] [SPEAKER_03]: that's why their knee is hurting. The foot and ankle influencing all of that is important. But yeah,

[00:08:25] [SPEAKER_03]: no, that's interesting that she said the same thing. That foot and ankle is a real big key.

[00:08:28] [SPEAKER_03]: And she also said that the shoes playing into it. Do you see that as well? I mean, I don't know if

[00:08:33] [SPEAKER_03]: there's actually a lot of women's specific basketball shoes. Are they just playing in the men's?

[00:08:37] [SPEAKER_01]: There are a few more. So like Sabrina Ionescu has a shoe and Brianna Stewart has a shoe and

[00:08:43] [SPEAKER_01]: Elena Deladon has a shoe. And, you know, so all of them are a little bit different. But yeah,

[00:08:48] [SPEAKER_01]: a lot of it comes down to sponsorship. You know, these players get shipped tons and tons of shoes.

[00:08:56] [SPEAKER_01]: You know, I've seen players who literally have 10 boxes of shoes, meaning there's probably five

[00:09:04] [SPEAKER_01]: pairs of shoes and five to six pair of shoes in each box. And there may be three different types

[00:09:10] [SPEAKER_01]: of shoes, but multiple colorways. Each of those shoes, even if it's the same shoe, but a different

[00:09:16] [SPEAKER_01]: color, I'd still make them bring me both sets of shoes and say, okay, you know what? This purple one

[00:09:23] [SPEAKER_01]: pronates a little bit more than the white ones that you were wearing. Or I've noticed that it's cut a

[00:09:30] [SPEAKER_01]: little bit lower below your ankle than the previous pair that you were wearing. So sometimes those things

[00:09:36] [SPEAKER_01]: happen in the shoe companies are not necessarily looking for that. They may have just changed their

[00:09:41] [SPEAKER_01]: material slightly or, you know, the last may have changed a little bit. And so they're just sending

[00:09:48] [SPEAKER_01]: them the same shoes saying, oh, this is a, you know, a different color of the same product, but it can

[00:09:53] [SPEAKER_01]: make a big difference in a basketball player. And I've seen there's been sometimes where, you know,

[00:09:59] [SPEAKER_01]: players, if they find one shoe and we can kind of agree that, okay, this allows you to be stable on

[00:10:05] [SPEAKER_01]: the floor. It's not too thick. You can feel your feet. Your toes have enough room. It's not putting

[00:10:11] [SPEAKER_01]: pressure in places where it should, this is the shoe you stay with. And I'll allow this other color,

[00:10:16] [SPEAKER_01]: but these three colors, there's some sort of variation that we can't go with. But yeah, the shoe

[00:10:22] [SPEAKER_01]: thing is, is really big. I hope to see more women getting shoes in the near future. I'm not really

[00:10:29] [SPEAKER_01]: sure, you know, all of what it requires to do that. But I do hope that it becomes more and more

[00:10:35] [SPEAKER_01]: of a thing because there are some subtle differences between, you know, men's feet and women's feet.

[00:10:41] [SPEAKER_01]: You know, one of the things that I try to bring into working with female athletes is if you have low back

[00:10:51] [SPEAKER_01]: pain, SI joint pain, some sort of, you know, frequent hamstring strains, things like that,

[00:10:58] [SPEAKER_01]: maybe it's not just that. Maybe we're looking on the surface and maybe we need to address some pelvic

[00:11:04] [SPEAKER_01]: floor issues that may be there that may be, you know, once you kind of start asking questions,

[00:11:10] [SPEAKER_01]: it's kind of like, yeah, kind of have had problems there or I've had, you know, some such issues. So I have a

[00:11:19] [SPEAKER_01]: little bit of background in that, but not anywhere near enough to be able to call myself a pelvic floor

[00:11:25] [SPEAKER_01]: therapist. So thankfully, there's some really good pelvic floor PTs in our area. You know, I even tell the men,

[00:11:32] [SPEAKER_01]: like, hey, if you have somebody who you think might benefit, this is not women's health. This is pelvic floor.

[00:11:38] [SPEAKER_01]: We all have a pelvic floor. Let's, you know, see if we can turn over another stone and find something

[00:11:45] [SPEAKER_01]: that maybe we wouldn't have noticed otherwise that could be the key to the hip pain, to the,

[00:11:51] [SPEAKER_01]: you know, inability to create intra-abdominal pressure and appropriate, you know,

[00:11:56] [SPEAKER_01]: lumbopelvic stability. Let's figure out if there's something else going on.

[00:12:00] [SPEAKER_03]: Yeah. Not just with like the players who have had babies.

[00:12:03] [SPEAKER_03]: Right.

[00:12:04] [SPEAKER_03]: It's, yeah, it's, it's everybody.

[00:12:06] [SPEAKER_01]: There's so much more that we can do and I'm happy that the WNBA is starting focus groups and

[00:12:13] [SPEAKER_01]: women's health. I would floor is one of them that they are starting in hopes that we haven't really,

[00:12:19] [SPEAKER_01]: we'll probably will pick up once the season ends, but there's a lot of different ways that we can go.

[00:12:26] [SPEAKER_03]: If I can kind of summarize your, like all of the common injuries. So we have kind of the classics,

[00:12:31] [SPEAKER_03]: ankles, knee sprains from that rotation, and then some tendinopathy stuff, some soft tissue stuff.

[00:12:38] [SPEAKER_03]: But then you're saying at the high level, it's really important to take a look at above and below,

[00:12:42] [SPEAKER_03]: right? So starting at the foot to look up and then also right low back pain. Well,

[00:12:46] [SPEAKER_03]: what are our shoulders doing? Right. And that's important at that high level. So what are some,

[00:12:51] [SPEAKER_03]: besides that, because that's really good stuff for treating high level. Any other key

[00:12:57] [SPEAKER_03]: takeaways that you want people to know, therapists out there who are, end up with an elite basketball

[00:13:03] [SPEAKER_03]: player in front of them, some key things to keep in mind. Oh, and then also you brought up the really

[00:13:07] [SPEAKER_03]: key point of making sure that they're, you know, how they play their position. Anything else you want

[00:13:13] [SPEAKER_01]: to spread the word on? Yeah. One thing that I typically will tell people, especially therapists who may be

[00:13:20] [SPEAKER_01]: new to the team sports space or who may get an athlete in their clinic for a period of time,

[00:13:28] [SPEAKER_01]: I always say, don't get overexcited to do all of the big things, right? Find out what this player,

[00:13:38] [SPEAKER_01]: what this athlete needs. And even if it's the smallest thing, you can really help us a lot by just

[00:13:45] [SPEAKER_01]: doing those, those little things by just helping to fine tune some of those areas that will allow

[00:13:52] [SPEAKER_01]: the larger movements, the bigger, the more advanced skills to happen more easily and pain-free. I think

[00:13:58] [SPEAKER_01]: sometimes people get so excited that they have an athlete in their clinic or, you know, they've seen

[00:14:04] [SPEAKER_01]: the videos and, oh, you can do all these things. Let me see if I can challenge you. And sometimes the

[00:14:09] [SPEAKER_01]: challenge is in being able to achieve stability in their foot while their ankle is moving or vice versa,

[00:14:17] [SPEAKER_01]: being able to create stability in their spine or appropriate timing of movement through their spine

[00:14:25] [SPEAKER_01]: and their pelvis while they are supine, moving to a half kneeling position, moving to a standing

[00:14:33] [SPEAKER_01]: position, moving to running. Like it's that simple. It doesn't have to be, we did a hundred reps of,

[00:14:40] [SPEAKER_01]: you know, jumping off of a box, you know, with a single leg and landing, you know, in a, on a BOSU ball.

[00:14:48] [SPEAKER_01]: So sometimes the smallest things are the most effective because they're going to get enough reps of the

[00:14:54] [SPEAKER_01]: others. But if they can build the neural pathways to understand how some of those smaller movements

[00:15:01] [SPEAKER_01]: work when they're on the floor, then they're going to save themselves from a lot of trouble down the

[00:15:09] [SPEAKER_01]: road. And quite honestly, during the season, pre-season, we don't always have a lot of time

[00:15:14] [SPEAKER_01]: to work on those things. So if it's the off season, if it's a break, those are the times we really have

[00:15:21] [SPEAKER_01]: to maximize some of those, you know, fine tuning kind of things.

[00:15:27] [SPEAKER_03]: And that's great advice. Simple and small. It doesn't, don't change the world. Simple and small.

[00:15:31] [SPEAKER_01]: That's all. Be creative. And if you see something, you know, reach out or, or, you know, communicate.

[00:15:36] [SPEAKER_01]: We use a huge amount of information from our data scientists, from our performance team. And so,

[00:15:45] [SPEAKER_01]: you know, none of us operate in silos. We all need each other in order to be able to do our jobs well.

[00:15:51] [SPEAKER_01]: So, you know, also I would say just be willing to learn, be willing to let somebody else lead certain

[00:15:59] [SPEAKER_01]: parts of what would maybe be considered rehab because in a return to play and a return to fitness,

[00:16:06] [SPEAKER_01]: especially when you have other players, you don't have time to take them through,

[00:16:09] [SPEAKER_01]: you know, a 30-minute lift and 20 minutes of court impact preparedness and sprints.

[00:16:18] [SPEAKER_01]: You don't have time to do that. So you're relying on your performance team to pull out, okay, this is

[00:16:23] [SPEAKER_01]: where they were before. These are the numbers we have, or these are the numbers we have on other

[00:16:28] [SPEAKER_01]: individuals that play their position. So this is kind of where we may need to be in order to get

[00:16:33] [SPEAKER_01]: them back out there and able to, to play in the games. Be willing to work as a team. We are the team

[00:16:40] [SPEAKER_03]: within the team. Okay. Well, hey, Kalah, that was an incredible amount of knowledge to spread

[00:16:47] [SPEAKER_03]: on these awesome athletes. Thank you so much for taking the time to go over all that with us. I

[00:16:52] [SPEAKER_01]: really appreciate it. Absolutely. Thank you so much, Chelsea. I truly appreciate the opportunity to do

[00:16:56] [SPEAKER_00]: this. So once again, we want to thank Dr. Flagg for sharing her time, knowledge, and experience with

[00:17:01] [SPEAKER_00]: us as well as you. And as always, we want to thank you for listening to JOS PT Insights.

[00:17:10] [SPEAKER_02]: Thanks for listening to this episode of JOS PT Insights. For more discussion of the issues in

[00:17:15] [SPEAKER_02]: musculoskeletal rehabilitation that are relevant to your practice, subscribe to JOS PT Insights

[00:17:21] [SPEAKER_02]: on Apple Podcasts, Spotify, TuneIn, Stitcher, Google, or your favorite podcast app. If you like JOS PT

[00:17:29] [SPEAKER_02]: Insights, help others find us. Tell your friends and colleagues and rate and review us. To keep up to

[00:17:35] [SPEAKER_02]: date with all the latest JOS PT content, be sure to follow us on Twitter, we're at JOS PT, and Facebook,

[00:17:41] [SPEAKER_02]: we're JOSPTOfficial. Talk with you next time.