The Bergen County Baseball Tournament is Almost Here…

The Bergen County Baseball Tournament is Almost Here…

Dr. Michael O’Reilly, DPT

 

Baseball may be America’s favorite pastime, but is the throwing motion we all know so well actually detrimental to your body? It does not have to be! Trust me, I would like to preface this article by stating you would be hard pressed to find a more avid baseball fan than myself. As a 2008 NJ Group 3 Baseball State Champion, with a younger brother who is a pitcher at the collegiate level, I feel as if the sport of baseball is part of my DNA. I have recently returned to the Northern New Jersey area as a Doctor of Physical Therapy, and although my lifelong passion for the sport remains strong, I cannot help, but to cringe when I look at the biomechanics associated specifically with the upper extremity necessary to meet the high demand required to produce an explosive high velocity throw. Unfortunately, within the last decade there has been a significant rise in baseball injuries specifically involving a pitcher’s throwing elbow. According to Yankees team physician Dr. Christopher Ahmad and Glenn Fleisig, the leading authority on pitching biomechanics, pitchers began suffering ligament damage as far back as Little League. High-pressure travel teams, increased velocity among elite pitchers, high-intensity inning totals and insufficient arm conditioning, have contributed to a flood of shredded elbows, they contend (Fortenbaugh D, Fleisig GS, Andrews JR.). In addition, from Jeff Roberts’ 2014 article, staff writer from NorthJersey sports, “Matt Harvey believes his own youth odometer played a role in his injury. He said his surgeon, noted orthopedist Dr. James Andrews, agrees the injury may date back to high school.” Furthermore, a study by Dr. Romeo at Rush University Medical Center and others finds that 15- to 19-year-old athletes make up nearly half the number of injuries requiring Tommy John Surgery. Another jaw dropping statistic: the amount of high school athletes requiring the Tommy John procedure increases by 10 percent each year. At this time, one may reflect on the data I have presented thus far and truthfully ask themselves, is it even possible to maintain the health of my arm or is the prolonged health of my arm more like winning the lottery?

One can briefly define the throwing motion as a complex and coordinated body movement that essentially culminates with a violent ballistic movement pattern of the upper extremity with the propulsion of a ball towards a target. Through this specific movement pattern an athlete is exposing and challenging his muscular structures to endure physiologic kinematic loads well beyond their natural capacity. An intricate relationship between the dynamic stabilizers of the upper extremity, predominantly including the four muscles of the rotator cuff (subscapularis, supraspinatus, infraspinatus, teres minor), pectoralis major, serratus anterior, and latissimus dorsi, and the static stabilizers which are composed of tendons and ligaments, is required to simultaneously supply the range of motion, force, and stability of the glenohumeral joint. Frequently, the overhead athlete presents with shoulder pain secondary to the repeated tensile overload instilled upon the posterior structures of the glenohumeral joint capsule. Interestingly enough, the shoulder joint also known as the glenohumeral joint, allows for the most degrees of range of motion to occur versus any other joint in the human body. Since the throwing motion occurs almost exclusively at ninety degrees of shoulder abduction, the inferior glenohumeral ligament and capsule act as the primary static anterior restraint. The deltoid muscle functions to lift the humerus while the rotator cuff adjusts the position of the humeral head on the glenoid. Are we still only talking about the shoulder here? Yes, but as we take a deeper look into the composition of our body and the existing synergistic relationships associated with performing the throwing movement pattern, it should not come as a surprise that the entire kinetic chain is responsible for performing a throw. According to recent literature, Kibler and Chandler calculated that a 20% decrease in kinetic energy transfer from the lower extremity and trunk to the throwing arm required a 34% increase in rotational velocity at the shoulder in order to generate the same amount of force at the hand. Thereby concluding, more force is required at the shoulder to achieve peak velocity during a throw if the kinetic chain is in any way disrupted. On the other hand, optimization of the kinetic chain has the potential to lessen the demand at the shoulder while continuing to increase the peak velocity of the pitch. Assess the whole body!

 

Let us briefly breakdown the biomechanics associated with traditional phases of pitching, according to evidence based literature (Seroyer ST. Nho SJ, Bach BR, et al.):

 

Wind-Up: The windup phase positions the pitchers lower extremity and trunk for the most effective performance of the kinetic chain. During the windup, the pitcher keeps his center of gravity over his stance leg for as long as possible to allow for max generation and transfer of momentum and force to the upper extremity. The lower extremity and trunk serve as the main force generators of the kinetic chain.

Stride and Early Cocking Phase: Stride length allows for longer time for trunk motions to occur which allows for increased energy production for transfer to the upper extremity. During this phase, the pitcher’s pelvic rotation reaches maximum velocity and is immediately followed by the upper trunk rotation. Pelvic rotation may be limited secondary to the landing of the stride foot too far closed in front of the stance foot. The abdominal obliques fire eccentrically here to prevent excess lumbar hyperextension during torso rotation and flexion. The stance leg during this phase is providing pelvic and trunk stability via the concentric firing of gluteus maximus. As the upper extremity rotates, the throwing shoulder is experiencing a moment of external rotation. The serratus anterior and scapular retractors position the glenoid in upward rotation and retraction to provide a stable base allowing the humerus to rotate.

Late Cocking Phase: During this phase the pelvis reaches its maximum point of rotation, but the trunk continues to rotate. Increased maximum external rotation within the throwing shoulder allows for more elastic energy transfer to the ball during acceleration because this phase enables the accelerating forces to act over the longest distance. Maximum shoulder internal rotation torque occurs just before maximum shoulder external rotation is achieved. At this point of late cocking, maximum valgus torque is experienced at the elbow. The flexor and pronator muscles of the forearm generate a counter varus torque. In addition, the scapula must upwardly rotate to allow for 90-100 degrees of humeral abduction to occur without impingement at the shoulder. Eccentrically, the subscapularis, latissimus dorsi, and pectoralis major are firing.

Acceleration: the pitchers subscapularis, pectoralis major, and latissimus reach maximum concentric activity producing violent internal rotation of the throwing shoulder.

Deceleration: During the deceleration phase the teres minor, posterior deltoid, and infraspinatus are responsible for dissipating the extreme internal rotation forces as the throwing arm continues to internally rotate and adduct. This is a common theory as to why glenohumeral joint internal rotational deficits are seen in overhead throwers. Furthermore, at this time the upper and middle trapezius, rhomboids, and serratus anterior are firing to stabilize the scapula. This is known to be the most violent phase of the throwing cycle resulting in the largest amount of joint loading. It is the job of the external rotation musculature to dissipate these violent internal rotation forces.

   Cutting edge evidence based literature specifically relevant to our baseball community suggests baseball players are prone to present with acute losses in multiple movement patterns involving their throwing dominant upper extremity. Immediately after throwing a baseball, the research indicates at the upper extremity responsible for throwing, there has been found to be approximately a ten degree acute loss of shoulder internal rotation, with additional range of motion reductions noted including elbow flexion and extension, and shoulder cross body adduction (DiGiovine NM, Jobe FW, Pink M, Perry J.). The restricted movement patterns have been found to be associated with an accumulation of eccentric trauma to the musculature responsible for controlling the high intensity angular forces and velocities necessary to light up the radar gun and throw with authority across the diamond. Furthermore, glenohumeral joint anterior capsule laxity combined with posterior capsule tightness, and bony adaptations, limit the functional mobility of the overhead athlete. Unfortunately, as the range of motion continues to develop further into restricted patterns, the body is forced to compensate elsewhere throughout the kinetic chain to combat the overwhelming forces and high demand required for the athlete to perform the throwing movement pattern. For example, a range of motion deficit at the elbow has the potential to increase the demand at the wrist and the shoulder in order for the upper extremity to achieve the required movement pattern necessary to perform a throw.

*Hint, hint, the majority of pitchers who are coming into the clinic with elbow pain present with ipsilateral scapular dyskinesia (your shoulder blade is not moving the way it should be!)…coincidence? Did you develop elbow pain from prolonged scapular dyskinesia?

   This is where our athletes delve into the dangerous zone of either seeking appropriate skilled manual therapeutic treatment, recovering properly, and successfully making his next scheduled start at a physically optimal level, or “toughing it out,” developing poor biomechanics which ultimately become adopted and habitual, eventually leading to an increased injury rate. For our dedicated athletes who truly aspire to compete at the next level, and are always seeking that competitive edge, what would you do? Do you want to roll the dice on something that you tirelessly work at, day in and day out?

Do you know when your throwing mechanics begin to fail you? How does fatigue truly play a factor in a pitcher’s mechanics? Let’s take a look at what some of the experts are saying:

 

“We know that when you pitch, you’re 36 times more likely to become injured if you pitch when you’re tired, when you’re fatigued,” according to Dr. James Andrews, inventor of Tommy John Surgery and founder of the American Sports Medicine Institute (ASMI), and Kevin Wilk, lead physical therapist at ASMI (Hartigan, Matt).”

With fatigue, pitchers tend to become more upright with their trunk, achieve less maximum shoulder external rotation, and decrease their knee flexion at ball release. Their mechanics ultimately CHANGE which leads to a change in the distribution of forces on the body and an alteration in the kinematic chain. Inefficiency throughout the kinetic chain as we have already mentioned, can increase the kinetic requirements of the shoulder to maintain top velocity and performance (Seroyer ST. Nho SJ, Bach BR, et al.). As a Physical Therapist it is not only important to notice these subtle changes in the pitching motion, but we need to continue to educate our athletes on the significance of endurance training followed by implementing a plan of care SPECIFIC to the athlete to keep our athletes healthy and performing at their optimal level.

 

What should you do after you pitch? Poles, Ice, Tempo-Runs, Rest? As previously discussed, there is no exact formula every single pitcher can use to expedite the recovery process. However, there are a few items I would like to shed some light on based upon recently published research. Ice still works; the literature continues to support from a neurophysiological standpoint in the acute phase, that ice is beneficial for recovery for a multitude of reasons. As we transition away from the world of modalities, I am an advocate for dynamic cardiovascular conditioning. Ultimately, the main goal of an aerobic based conditioning program for the baseball pitcher who walks into my clinic, is to elicit a parasympathetic response from the Autonomic Nervous System to enhance his body’s ability to recovery more efficiently. Chronic adaptations to the body from a consistent aerobic exercise regimen include an increase in the oxidative capacity of musculature via a proliferation of mitochondria in both number and size, improved capillary density, and an increased presence of oxidative enzymes (Burkhart SS, Morgan CD, Kibler WB). Furthermore, there is an improved transfer of body heat within the body due to a larger plasma volume and an improved efficiency of thermoregulatory processes. Although the benefits from aerobic conditioning are clear cut, it is essential to avoid neglecting the anaerobic component of the conditioning program, because if you think about it, when you pitch your body is utilizing both aerobic and anaerobic systems, right? The answer is yes.

Although, evidence based research suggests existing tendencies and links between sport specific movement patterns, and the development of physical impairments, the anatomical composition of each athlete is completely different. As a Physical Therapist it is essential to develop and utilize skilled manual therapeutic techniques specific to the athlete, while maintaining proper knowledge of the sport and position. To optimize the physical potential of ten pitchers, there will have to be ten different manual therapeutic regimens developed and effectively utilized. Every athlete has their unique physiologic limitations which should not be stretched past; there is no room for “cookie cutting” in this profession, and as an athlete you should demand the best for your body. The key to properly addressing my overhead athlete includes a simple yet effective phrase: assess, and reassess. I open up my Doctorate of Physical Therapy “toolbox” and apply the manual therapeutic technique in which my athlete’s body based upon my professional assessment, will respond optimally to. Just like in any other profession, success is determined by: Results, results, results. My job is to optimize the physical potential of my athlete, incorporating theories of length-tension relationships, neurophysiologic responses, impairment minimization, and movement restoration, among others, and I love my job. I am not a pitching coach, nor do I pretend to be, because I find learning and staying within the scope of practice of your profession to be a fundamental pillar for the success of the athlete.

The goal of Physical Therapy for our baseball players here at The Spine and Health Center, typically revolves around enhancing our athletes sport specific movement patterns. Physical Therapy addresses the soft tissue mobility of our athletes through a multitude of the most modern skilled manual therapeutic techniques supported by evidence based literature. As our athletes are approaching the midpoint of their season, the key for them is to MAINTAIN not GAIN. What I mean by this is, at this time in the season it is most important for our athletes to go into the weight room and train with consistent sets, repetitions, and weight, versus trying to achieve personal bests. Save the personal best competitions for the off-season. It is key for the overhead athlete to maintain the full range of motion specifically, but not only, at the shoulder joint, to the exact degree on a consistent and daily basis. Participating in skilled Physical Therapeutic manual treatment is essential to successfully maintain a pitcher’s proper biomechanics throughout the duration of a grueling season, especially in Bergen County, New Jersey, where our climate occasionally influences a pitcher’s recovery timetable. Physical Therapy is an invaluable resource to the preservation of the health of all of our athletes.

The Take Home Message for all of the athletes reading this article:

Would you rather pitch in “X” amount games this season fluctuating between 55-90% of your physical potential, or would you rather prepare for success properly and pitch in “X” amount of games this season at 100% of your physical potential every single time you toe the rubber? Allow Physical Therapy to optimize your physical potential.

Advice: Avoid overuse and actively engage in proper baseball specific recovery programs which include: Nutrition, Quality of sleep, and Skilled Manual Therapy (Reinold, M).

Side Note: I would like to encourage every athlete reading this to quickly assess their shoulder mobility EVERY SINGLE time before they throw a baseball. The idea here is to essentially prevent gradual loss of range of motion through self-assessment.

What does your self-assessment say about the quality of your movement pattern and your range of motion?

How can you self-assess?

  1. Supine with knees bent to prevent lumbar hyperextension, “squeeze your core and bring your thumbs up and overhead to the floor” (Reinold, M)

      

Recently discussed items within the clinic relevant to the baseball community:

How does your thoracic vertebrae play a role in your velocity?

Can ankle hypomobility be related to this recent onset of shoulder soreness at my throwing shoulder?

How does your body pH and temperature play a role in the recovery of your arm after you pitch?

Why is the appropriate balance between mobility and stability at your scapula-thoracic joint essential for pain free success on the mound?

In order to light up the radar gun with explosive velocity, is strength training the best option for me?

 

References:

Reinold, Mike. Inner Circle Dashboard. Webinar Archives: How to Assess Overhead Shoulder Mobility, How to Perform and Advance Rhythmic Stabilization Drills, 5 tweaks to Make Shoulder Exercises More Effective, 4 Keys to Staying Healthy During the Baseball Season. https://innercircle.mikereinold.com/. Accessed 3/13/2016.

Seroyer ST. Nho SJ, Bach BR, et al. The Kinetic Chain in Overhand Pitching: ITS Potential Role for Performance Enhancement and Injury Prevention. Sports Health: A Multidisciplary Approach. 2010; 2 (2): 135-146.

Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology. Part I: pathoanatomy and biomechanics. Arthoscopy. 2003; 19 (4):404-420 (PubMed)

DiGiovine NM, Jobe FW, Pink M, Perry J. An eletrocmyographic analysis of the upper extremity in pitching. J shoulder Elbow Surg. 1992; 1(1):15-25(PubMed)

Kibler WM, Chandler J. Baseball and tennis. In: Griffin LY, editor., ed. Rehabilitation of the Injured Knee. St. Louis, MO: Mosby; 1995:219-226

Gowan ID, Jobe FW, Tibone JE, Perry J, Moynes DR. A comparative electromyographic analysis of the shoulder during pitching: professional versus amateur pitchers. Am J Sports Med. 1987;15(6):586-590 (PubMed)

Reinhold MM, Gill T.J. Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes, Part 1: Physical Characteristics and Clinical Exanination. Sports Health: A Multidisciplinary Approach.

Fortenbaugh D, Fleisig GS, Andrews JR. Baseball Pitching Biomechanics in Relation to Injury Risk and Performance. Sports Health: A MultiDisciplinary Approach. 2009; 1(4): 314-320.

Hartigan, Matt. This App wants to fix our baseball injury epidemic. https://www.fastcompany.com/3032375/this-app-wants-to-fix-our-baseball-injury-epidemic

Roberts, Jeff. Baseball Injury Epidemic hits pitchers from Little League to MLB. http://archive.northjersey.com/sports/baseball-elbow-injury-epidemic-hits-pitchers-from-little-league-to-mlb-1.1026957?page=all

Romeo Orthopaedics. High School Coaches must implement a pitching limit for young baseball players. http://www.romeoorthopaedics.com/high-school-baseball-requires-pitching-limit-for-players/

Batman, Paul. Fatigue and Recovery in Aerobic Exercise. Group Exercise. 12/29/2010. http://www.mygroupfit.com/printeducationarticle.aspx?article=3457

 

Avoiding and Treating Heel Pain

Avoiding and Treating Tendon Dysfunction

Dr.Bruce Buckman PT, DPT, ART

 Background

 It has been reported that approximately 1 in 10 individuals will develop chronic heel pain with nearly 2 million Americans affected annually. Furthermore, tendinopathies of the Achilles tendon affect 2% of the general adult population. The typical report of pain presentation of plantar heel pain includes excruciating pain with the first few steps after waking up in the morning, prolonged sitting and with prolonged weight bearing activity. These symptoms often reduce throughout the day as compared to first thing in the morning, but lead to significant functional limitations and even prolonged disability.

Identifying the Problem

A tendon is an anatomical structure that connects muscle to bone, examples include the Patella tendon and Achilles tendon. A tendon is an inherently strong tissue; however, just as with muscular injuries, tendons are subject to overuse. Overuse injuries to tendons often occur with constant and repetitive loading in biomechanically flawed positions. Characteristic changes occur in the tendon structure, resulting in a tendon that is less capable of sustaining repeated tensile load (Cook JL, Khan KM, Kiss ZS, et al). Tendon injuries can occur in the mid-tendon, which is often the case in Achilles tendonitis/osis; however, most tendon pathology arises from the insertion of the tendon to the bone such as with patellar tendonitis/osis.

Tendonitis, Tendonosis, and Tendinopathyathy

The suffix “itis” implies acute (of recent onset/new) injury with inflammation. Different from acute injury with inflammation, tendon”osis” implies chronic (long term) pathology or degeneration without inflammation. Finally Tendon”opathy” simply refers to a disease of a tendon.

Can Exercise Improve Tendon Function?

Research suggests that eccentric exercise affects both the tendon structure as well as pain by increasing collagen production in abnormal tendons with both short and long term. Furthermore, recent research has added that exercise with a combination of manual therapy (hands on approach to treatment) provides greater clinical benefits in terms of function than just exercising and using modalities such as heat, ice, ultrasound, electric stimulation etc.

Eccentric, Concentric and Isometric Contractions

When you consider a muscular contraction, you may think of a simple motion such as a heel raise. During the initial part of the heel raise your triceps surae (calf muscles) are concentrically contracting (or shortening); however, what about the second portion of the exercise? During the descending portion of the heel raise, the triceps surae must control the decent of the weight being held or else your heel would simply drop towards the ground. Here, these muscles are contracting eccentrically, meaning contracting while simultaneously lengthening. On an unrelated note, isometric contractions involve a static muscle activation without associated movement. Consider the same heel raise exercise; however, after raising heels from a neutral position, your heel maintains in the same position for approximately 45 seconds, here your triceps surae muscles are active as to maintain the heel off position, but are not causing physical movement of a structure.

Physical Therapy Protocols for Achilles Tendinopathyathy

The exercises listed below are helpful in preventing and improving tendon pathologies; however, they should not be performed without proper evaluation by a physical therapist in order to determine proper dosage and prescription. To find out more contact us now!

Plantar Fascia Rolling        

Why focus on the bottom of the foot for pain in the back of my ankle you ask? Understanding anatomy is key! The plantar fascia inserts to the dorsal aspect of the calcaneus, which happens to also be bone in which the Achilles tendon attaches to (more posteriorly and superiorly). If your plantar fascia is tight, it certainly will affect the kinetic chain by increasing passive tension on the Achilles tendon. Rolling this structure is not “fun”, plain and simple, it hurts for most, but has a drastic impact on foot and ankle health!

Intrinsic Muscle Activation

The intrinsic foot muscles help to stabilize the arch of your foot and improve the biomechanical forces dispersed through the foot with simple activities such as walking to more complex activities such as running, cutting and jumping. Strengthening and activating these muscles will help to improve pain by improving functional movement patterns, thus reducing risk for re-injury.

Self Plantar Fascia Massage

Taking rolling to the next level, massaging the bottom of the plantar fascia will be imperative for the improvements of kinetic chain mobility. While doing so, observe the distal (far) attachment of the plantar fascia to the digits, this means that flexing and extending your toes passively with your non massage hand will sensitize the massage in order to create the best response to treatment.

Triceps Surae Foam Rolling

As always, rolling is imperative prior to stretching, rolling relaxes tissue prior to stretching the tissue out. This is important because stretching a tonic or tight muscle can actually cause more pain in an irritated irritable musculotendonus structure.

Gastrocnemius and Soleus Muscle Eccentric Activation (Heel Raises)

Properly performing this exercise depends on the location of pain, for mid belly Achilles tendon pathology, perform on a step. Start by raising your heels up in the air to the top of motion and slowly lower yourself back down below parallel. This exercise will help to strengthen the posterior lower leg muscles and reduce recurrent pathology.

 

 

Gastrocnemius and Soleus Stretching

The gastrocnemius is the large posterior lower leg muscle that crosses both the knee and the ankle joints, as seen below. What this means is that in order to effectively stretch this muscle both the knee and the ankle need to be taken into consideration (extended). To stretch the soleus muscle, the knee is slightly flexed secondary to this muscle not crossing the knee joint. Flexing the knee will eliminate some of gastrocnemius’ tension allowing for a deeper and more effective stretch.

References

O’Brien M. e anatomy of the Achilles tendon. Foot Ankle Clin 2005; 10(2): 225–38.

Cook JL, Khan KM, Kiss ZS, et al. Asymptomatic hypoechoic regions on patellar tendon ultrasound: a 4-year clinical and ultrasound follow-up of 46 tendons. Scand J Med Sci Sports 2001; 11: 321–7.

O’Neill, S, Watson PJ, Simon, B. Why are eccentric exercises effective for Achilles tendinopathy. The International Journal of Sports Physical Therapy 2015; 10: 552-63.

Cleland JA, et al. Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: A multicenter randomized clinical trial. Journal of Orthopedic and Sports Physical Therapy 2009; 39: 473-86.

Cook, JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med 2009;43:409–416.

Exercise of the Week #34 – Band Resisted Rows

Are you performing your exercises correctly? At The Spine and Health Center of Montvale, we see many patients performing rows initially with poor form. The key points to remember are keeping the shoulders down, chest up, and pulling back by squeezing the shoulder blades together to get the elbows to end up at approximately a 90 degree angle. Check out the examples of the incorrect and correct ways to perform rows in this week’s video.

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