This past month, the National Collegiate Athletic Association (NCAA) voted to remove cannabinoids from the banned substance list. 

I applaud this decision. Not because I support uncontrolled self-dosing of marijuana but because I have long been a firm believer that our messaging was not effective and that the testing approach did not accomplish the desired effect of overall deterrence. In explaining the decision, the NCAA noted a lack of scientific evidence that marijuana provides a competitive advantage and further acknowledged the ineffectiveness of the existing policy of penalizing athletes after positive tests. Rather, a harm-reduction strategy implemented at the institutional level is the preferred approach. 

Did you ever wonder what a nanogram is? Or why 150 nanograms/milliliter (ng/mL) were set as a threshold for a positive test that sent each athlete toward a required counseling session, suspensions, community service and other forms of punishment? In a world where we practice evidence-based medicine, we have neglected to make a correlation between nanograms and how they specifically can impair one’s cognitive and physical performance. 

Consider the following hypothetical situation: Two teammates meet up on a given night, and they each smoke the exact same amount of marijuana. Let’s assume there are no previous amounts in their system. Two weeks later, they are both called in for a random drug test. The results reveal that one of the individuals tests positive at 155 ng/mL while the other tests negative at 145ng/mL. One enters “the program”; the other is not required to. Merely by genetics, hydration status, ability to excrete, dietary habits and a host of other factors, despite testing so close to one another they are managed very differently. 

Imagine for a second if you will that as compared to zero, 145 ng/mL and 155 ng/mL are essentially the same amount of tetrahydrocannabinol (THC) in one’s system. Would it make more sense to better understand what that amount of THC in the system does to performance rather than impart a penalty to one athlete and not the other? Do we even know that an arbitrary number of 150 ng/mL impairs everyone in the same manner? Think about alcohol. While we know that the blood alcohol content (BAC) of 0.08% represents legal impairment for driving, we do not have similar impairment thresholds for THC. Doesn’t every person react differently to different amounts of alcohol despite an impairment threshold? Wouldn’t it make sense, therefore, that individuals are also affected differently using different amounts of marijuana? Perhaps some individuals demonstrate cognitive deficiencies and reaction-time deficits with just 40 ng/mL of THC in the system. Yet others who yield highly positive tests may develop a tolerance to THC and not necessarily show the same performance deficits. The key here is to understand that in a harm-reduction model, we should focus on individual use and individualized interventions. What works for some does not work for others. Abstinence is not an effective form of messaging. Neither is just telling athletes that marijuana is bad. We have tried and failed for decades using these approaches. The solution is tying the outcomes of individual THC use to the identify of an athlete — being an athlete. 

This is not to say that counseling interventions and mental health are not important. Quite the contrary. Among many other reasons, understanding why individuals partake in marijuana use, and helping with coping mechanisms, justifies such interventions. Counseling, however, should not be viewed as a punishment. These must be meaningful and trustworthy sessions, or the athlete will view them as checking a box in order to keep playing. A team approach to messaging is essential, and mental health professionals are a welcome addition to the support staff. 

So, what is a nanogram? A nanogram is a measure of weight equal to one billionth of a gram. Can something this small in the body be so impactful and deleterious to performance? Is there really a difference between 145 and 155? Is it a one-size-fits-all approach? I suggest that moving forward, we begin to ask more relevant and meaningful questions in an effort to obtain more factual and practical information. We can measure so much now with the technology made available to us. It is time that we apply this technology toward assessing the correlation of THC in the body with metrics that matter and the factors that athletes view to be important to them. 

As our thinking advances, we will also better learn about the many other non-euphoric cannabinoids (e.g., CBD, CBG) and the therapeutic effects that they may provide related to sleep, inflammation, pain, anxiety, recovery and who knows what else. There is a wealth of information yet to be learned once we break down the single word “cannabis” into the various entities that it is comprised of.  

Change is difficult. Change can also be exciting. The change of the cannabis classification by the NCAA will have ripple effects for athletes and those physically active of all ages. 

Read Dr. Konin's recent article "The Cannabis Shift: How We Educate and Message is Key" in the latest issue of Current Sports Medicine Reports.

Jeff G. Konin, PhD, ATC, PT, FACSM, FNATA, FNAP, is a clinical professor and director of the Doctor of Athletic Training program at Florida International University. He is a frequent speaker at conferences on the topic of cannabis and athletic performance and consults with numerous athletic programs at various levels, delivering contemporary cannabis education to coaches, athletes and support staff. 

Following anterior cruciate ligament reconstruction (ACLR), athletes often exhibit altered knee biomechanics during running, such as reduced knee flexion angles and extensor moments of the surgical limb compared to the nonsurgical limb, healthy controls and the preinjury state. These altered biomechanics persist well beyond the standard course of rehabilitation and may impair athletic performance, increase susceptibility to a second injury and contribute to the risk of developing post-traumatic knee osteoarthritis. 

Athletes are commonly cleared to resume running around 12 weeks post ACLR and are encouraged to do so at a slow speed while gradually building up running volume. Few, if any, clinical criteria are used to guide this return-to-run process, including a formal assessment of running mechanics. There is a need to identify or develop novel clinical strategies that positively improve surgical knee loading during running in athletes post ACLR. 

Based on clinical observations, we became interested in exploring the potential utility of manipulating running speed as a method to alter knee biomechanics during running in athletes post ACLR. Our initial hypothesis was rooted in the fact that healthy athletes demonstrate increased knee flexion angles and knee extensor moments with an increase in running speed. Thus, this easily modified characteristic could have the potential to improve knee extensor demand of the surgical limb and potentially lead to more symmetrical running mechanics. 

Our recent study, published in the July 2024 issue of Medicine & Science in Sports & Exercise_®, sought to characterize the relationship between running speed and knee mechanics post ACLR. Using longitudinal running data from the Badger Athletic Performance database, we analyzed changes in knee angles and kinetics (e.g., peak knee extensor moment) with changes in speed, ranging from 2.68 to 4.47 m/s (10 min/mile to 6 min/mile), at both early (3.5-7 months) and late (8-13 months) time points in 55 collegiate athletes post ACLR. We found that when athletes ran faster, peak knee flexion angles and knee extensor moments increased similarly in both the surgical and nonsurgical limbs, regardless of time postoperatively. 

This finding challenges the common clinical dogma that faster running speeds may worsen biomechanical imbalances post ACLR. Instead, it suggests that higher speeds do not exacerbate between-limb asymmetries; however, they also do not improve asymmetries. In other words, simply running faster will not fix the asymmetry problem. 

It is important to note that this study looked at the immediate effect of modifying running speed and that running speed was not controlled during the athletes’ rehab. It is unclear if prescribing a specific running speed for a period of time throughout the rehab process will have a different effect on running symmetry. We also observed persistent asymmetries in knee biomechanics during running beyond the typical course of rehabilitation. Future work should focus on developing strategies to improve running symmetry in athletes following ACLR. 

This work further highlights the importance of keeping speed consistent within an individual when assessing changes longitudinally. This is an important consideration for both researchers and clinicians, particularly when utilizing a limb symmetry index ([surgical/nonsurgical] *100) measure, as we found that limb symmetry indices were inflated at faster running speeds even though the absolute between-limb differences were the same across speeds. 

Clinicians should feel confident incorporating running speed modification into their rehabilitation plan, knowing that it does not increase asymmetries, but they should also be aware that this strategy does not resolve between-limb asymmetries. Lastly, we encourage clinicians to monitor running mechanics in their patients following ACLR, even if this is as simple as using a two-dimensional video to assess peak knee flexion angles. 

Keith Knurr, DPT, Ph.D., received his Doctorate in Physical Therapy and Ph.D. in clinical investigation from the University of Wisconsin–Madison. He also completed a sports physical therapy residency at UW Health. Dr. Knurr is currently an assistant professor within the Department of Orthopedics and Rehabilitation at the University of Wisconsin–Madison. His research focuses on better understanding the impact of lower extremity joint injuries and surgeries on long-term joint and overall health in collegiate athletes. He is an active member of ACSM, the American Academy of Sports Physical Therapy and the Academy of Physical Therapy Research within the American Physical Therapy Association (APTA). 

Bryan Heiderscheit, P.T., Ph.D., is the Frederick Gaenslen Professor in Orthopedics and vice chair of research for the Department of Orthopedics & Rehabilitation at the University of Wisconsin. He is the director of Badger Athletic Performance with UW Athletics, founding director of the UW Health Runners’ Clinic and co-director of the UW Neuromuscular Biomechanics Laboratory. Dr. Heiderscheit’s research is aimed at understanding and enhancing the clinical management of orthopedic conditions, with particular focus on sports-related injuries. Support for his research includes the NIH, NFL, NBA and GE Healthcare. He is a fellow of APTA and member of the NFL Soft Tissue Injury Task Force. 

The first instinct many exercise professionals have is to share their extensive knowledge with their client; the relationship moves in one direction, from the professional with the expertise to the client who’s hired them for their expertise. And in general, that’s the idea — exercise pros solve problems, design interventions and help people advance in their journey. 

But taking a step back from this model has some benefits too. Pros who take the time to assess their own assumptions, listen in on their client’s perspective and learn to ask more out-of-the-box questions can often get a lot more done in their sessions. Getting good outcomes for clients requires rapport and insight, and the path to both starts with knowing what to ask. 

For instance, “How are you feeling today?” is a standard open-ended question. You might hear “Pretty good,” or “Sore” or “Honestly, that workout yesterday killed me.” What if you were to instead ask, “What do you feel in your body right now?” The answers might be a bit different. If you have an established relationship with the client, you might even ask them something more unorthodox, like, “If what you’re feeling right now were a color, what would it be?” It’s not necessarily the case that their answers to such questions will give you a deeper insight into what’s going on with them, but it will teach you a bit about how they think — and it will build rapport between the two of you. 

Keep a few important points in mind during this process. First, know your boundaries. Open-ended questions can get you into personal territory pretty quickly. Decide what you’re willing to share and discuss, and what you aren’t. Second, try to steer the conversation toward a sense of calm. There will be times during exercise sessions, of course, when being calm is the last thing that’s needed. But overall, figuring out what makes your clients comfortable and calm will do wonders for their fitness journey. Third, work toward resilience. You don’t want your clients to rely on you completely for their motivation, validation and emotional well-being. After all, you can’t make them get off the couch and come to their session, and that’s the hardest step of all. Helping them find those things within themselves is key to progress. 

Finally, see if you can help your clients to take a 30,000-foot view of their situation. Well, maybe just a tad lower — encourage them to imagine they’re in a helicopter peering down on themselves and the situation they’re in. Ask them to describe it in detail. Zooming out on a problem, difficulty or goal (a) makes it seem smaller and (b) lets you see all of the moving parts at play much better than the view from the ground. Perspective is key. 

If you’d like to learn more about building rapport with beautiful questions, view this condensed infographic, or check out a more in-depth video from Wellcoaches. 

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