Spring training has begun, and youth baseball players all over the country are starting to practice and prepare for their upcoming seasons. My very own 14 y/o son has started his 8th grade season, while having been working with his travel team on the weekends since mid December.
As a physical therapist, former player, father, and assistant coach on his 14U team, my first concern is always the health of a player. I see several baseball players in my sports medicine practice ranging in age from 9 year olds to MLB platers. Diagnoses include internal impingement, SLAP tears, little league elbow/shoulder, OCD, UCL sprains, rotator cuff tendinitis, instability, fractures and scapular dyskinesia.
One of the hardest things to do in my profession is get inside the head of a young athlete. Many will refrain from mentioning pain for fear of letting down a parent or coach, or out of concern for losing playing time. Society has become too focused on early specialization and winning from an early age. In addition, “travel baseball” has been somewhat diluted and water down by lots of dads who want their sons to play year-round. I often see kids being abused on terms of too little rest or improper recovery after they pitch and catch.
The biggest, most athletic and hardest throwing kids undergo the most strain as they are asked to shoulder the load at pitcher, catcher and shortstop early on. Many coaches are counting innings in tourneys and not pitches based on tournament guidelines. Too many kids are pitching on consecutive days without proper rest all in an attempt to win meaning less tournaments at a young age. Fortunately, we are making progress in the sports medicine world thanks to the efforts of Dr. James Andrews and others.
High schools are adopting pitch count regulations this year, and MLB along with Dr. Andrews has developed their site, www.pitchsmart.org, to spread education about injury prevention in youth pitchers. Dr. Christopher Ahmad is on the advisory committee for PitchSmart.org, and he is also the lead author on a new paper detailing an injury assessment tool for young baseball players, The Youth Throwing Score.
It is no secret that elbow injuries have been on the rise in MLB as well as all levels of baseball. I see far too many adolescent baseball pitchers in my clinic with medial elbow pain. Often it is related to pathological GIRD and proximal imbalances in the shoulder complex.
Researchers have been studying biomechanics for years. It has long been a belief that younger pitchers should focus on fastballs and change-ups, while minimizing curveballs. Currently, the prevailing thought and latest evidence seems to suggest that velocity may be the bigger risk factor or determining factor in leading to UCL injuries.
A paper in the August 2016 edition of the American Journal of Sports Medicine from Rush University Medical Center sought to determine factors associated UCLR among MLB pitchers. The hypothesis was that those pitchers who underwent UCLR would have a higher pre injury pitch velocity.
This retrospective case controlled study looked at data for pitch velocity, type and number for every pitcher and game were gathered from the PitchFx database from April 2, 2007 to April 15, 2015. Data from 2013 - 2015 was excluded to avoid lead in time bias, as pitches in these seasons may contribute to injuries in pitchers who have not yet undergone UCLR. Pitchers were classified as control, pre injury or postoperative.
So, I just returned from the Combined Sections Meeting for the APTA that was held in Indianapolis. There was lots of great networking and presentations to be sure. I attended sessions on ACL rehab/prevention, femoroacetabular impingement, elbow injuries in throwers, running gait analysis, and shoulder plyometric training with the legendary George Davies. I thought I would give you my top 10 list of helpful nuggets I picked up over the weekend in no particular order of importance.
1. Performing upper body plyometrics has no effect on untrained subjects so don’t waste time putting it into the rehab program, where as it does benefit trained overhead athletes. The one caveat is it also increases passive horizontal external rotation so keep this in mind when working with athletes who have shoulder instability.
2. A new study coming out in 2015 in AJSM revealed no major differences in throwing kinematics between those following UCL reconstruction (Tommy John) and age-matched controls. This is good news for those worried about pitching mechanics after the procedure.
3. According to Dr. Reiman at Duke, the orthopedic hip exam does a better job of telling us they do not have a labral tear than it does telling us they do have an intra-articular problem. The tests have poor specificity. In fact, he goes on to say that the “special tests are not that special.” That brought a chuckle from the crowd including me. Bottom line - we are not really able to conclusively say “yes you have a labral tear based on my exam today.
4. Reiman also feels we must consider look for mechanical symptoms during the lowering portion of the Thomas test, while considering the fact that fat pad impingement may cause anterior hip pain as opposed to joint pain. Again, things are not always as they appear in the “FAI” crowd so we need to take a great history, look at the classic tests and also see how squatting and loading affects the hip.
5. More experienced pitchers do not drop the glove side arm, but instead tend to move their body toward the glove to conserve angular momentum and overcome small moments of inertia. Less experienced pitchers rotate their trunk sooner in pitching cycles whereas pitchers who threw at higher levels rotated later and produced less torque at the shoulder. Consequently, many players with higher elbow valgus torque and distraction force at the shoulder rotate too early.
I see plenty of pitchers in my clinic ranging from 12 y/o travel baseball players to MLB guys. My own son is a left handed pitcher so I am always carefully watching his mechanics, pitch count and arm care. There has been much written about glenohumeral internal rotation deficit (GIRD) and total shoulder motion over the years.
Today, I wanted to recap a nice article that was recently published in the American Journal of Sports Medicine by Wilk et al. looking at deficits in glenohumeral passive range of motion (PROM) and the increase in elbow injury risk.
This prospective study was done over an 8 year period from 2005-2102 and looked at PROM of both throwing and nonthrowing shoulders of all major and minor league pitchers within a single baseball organization. The measurements were taken with a bubble goniometer during spring training. See images below from the journal article for how measurements were taken:
In sum, 505 exams were performed on 296 pitchers. Motion was assessed in supine with the arm abducted to 90 degrees and the arm in the plane of the scapula. One examiner stabilized the scapula, while another measured total rotation and passive flexion. Elbow injuries and days missed because of injuries were assessed and recorded by medical staff. Throwing and nonthrowing measurements were compared, while additional testing was done to find significant associations between shoulder motion and elbow injury, as well as odds of an elbow injury.
One of the most difficult problems to treat in the clinic is chronic pain related to tendinopathy. More specifically, the Achilles tendon, patella tendon and elbow extensors often present challenges for doctors and clinicians alike when it comes to effectively reducing or resolving pain. Over time, people develop chronic inflammation or even little tears in the muscles running up to the lateral epicondyle.
There have been many studies done looking at PRP over the past 5-10 years. The debate continues, however, with respect to its efficacy in terms of results, especially given the fact that patients must currently pay out of pocket for the procedure. I have written two earlier posts on PRP that you may be interested in reading as a back drop for this one:
Currently, my approach to treating these injuries involves an approach focused on soft tissue mobilization via instrument assisted soft tissue mobilization, stretching, strengthening and a trial of iontophoresis in most cases. We also offer dry needling at our facility and this has been effective in reducing pain. I will talk more about this point later as it relates to the prospective multi-center trial summarized by Mishra et al. in the February 2014 edition of the American Journal of Sports Medicine.
Before I get to the study, I thought it would be pertinent to provide some straightforward information on PRP as it is a question that comes up with patients on a regular basis. Essentially, the process is as follows:
1. Collect 30-60 ml of blood form the patient’s arm
2. Blood is then placed in a centrifuge. The centrifuge spins and separates the platelets from the rest of the blood.
3. A syringe is then used to extract 3-6ml of the platelet-rich plasma
4. The concentrated platelets are then injected into the elbow (or site being treated)
The thought behind PRP is to increase the growth factors up to 8x, which promotes temporary relief and stops inflammation. The question is how successful and cost effective is this process? Consider that opting for surgery will run between $10,000 and $12,000 figuring in costs for the surgeon, hospital/surgery center, anaesthesiologist, etc. PRP injections will cost upwards of $1000, so one would think that would be a favorable option for insurers if surgery could be averted.
What about cortisone injections? They are widely used as a survey of 400 members of the American Academy or Orthopedic Surgeons found that 93% had administered a corticosteroid injection for lateral epicondylar tendinopathy. According to Bisset et al (Br Med J 2006) and Lindhovius et al (J Hand Surg Am 2008) cortisone injections do provide short term pain improvements but also result in a high rate of symptom recurrence. There are other potentially harmful side effects from injections including: reduced collagen synthesis, depletion of human stem cells, depigmentation, and enhancement of fatty and cartilage like tissue changes that can lead to tendon ruptures.
So, the big question is whether or not tendon needling with PRP is an effective treatment option for chronic tennis elbow suffers. Mishra and his colleagues set out to examine this with a double blind, prospective, multi-center randomized controlled trial of 230 patients. In the study, the patients were teated at 12 different facilities over 5 years. All patients had at least 3 months of pain/symptoms and failed conservative treatment.