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Brian Schiff’s Blog

Injury Prevention, Sports Rehab & Performance Training Expert

Archive for 'elbow'

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.

stephen-strasburg

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.


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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.


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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.

total-shoulder-rom

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:

wilk-total-motion-measurement

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.


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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.

tennis-elbow

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:

2011 – An Update on Platelet Rich Plasma

2011 – Platelet Rich Plasma and Rotator Cuff Repairs

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)

clinical-prp-injection

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.


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So, one of my biggest pet peeves as a PT is seeing athletes hurt as a result of poor coaching and training.  Overuse injuries provide lots of clients for my practice.  While this is good for business, I would really like to help prevent these injuries.  I need your help.  It all starts with education and a willingness on the part of health and fitness professionals to advocate strongly for our young athletes.

Consider the following scenario: a 14 y/o freshman left-handed pitcher presents for rehab to recover from Little League Shoulder. He was hurt on the second day of his high school’s fall conditioning program.  He was being forced to throw in excess of 200 feet.  His exact words were, “I was sore after day one, but I felt my shoulder explode on the second day of the program.”  Think this is a coincidence?  Hardly.

Another player from the same school (a sophomore right hander) is also in my clinic recovering from an avulsion fracture of his medial epicondyle that he too suffered on the second day of the same throwing workout.  I emailed the left-handed pitcher’s father with details about throwing biomechanics and how they decline with long distance throwing.  I also expressed my concern over the coach’s aggressive throwing program.  The father emailed back and said he too disagreed with the throwing program.  However, the coach simply told him his son had “not been properly coached” prior to getting to his program.  Are you kidding me?  Look at the images below to appreciate the type of damage done by overzealous throwing programs.

Coaches need to be more accountable to their training programs and philosophies.  Both of these players are missing no less than 3 months of baseball because the coach is clueless about the impact of aggressive long toss and how it may actually be detrimental to his players as opposed to actually improving their throwing technique/performance.

Click here for an article summary in JOSPT related to throwing biomechanics

So, how do we make a positive impact and prevent unnecessary injuries like the ones I have discussed?  I feel we need to look at the following strategies:

  1. Educate parents and coaches through talks and seminars
  2. Network with high school athletic trainers to ensure they have some feedback/input with respect to preventive training philosophies as well as a direct pipeline to coaches
  3. Reach the athletes directly through arm care screenings, FMS evals and professionally directed throwing programs
  4. Team with high profile baseball players or coaches who understand the game at the highest level and will spread the message in a positive and constructive manner
  5. Participate in CEU course for coaches and present on throwing programs, shoulder strengthening and mobility training

Based on these two cases, I am brainstorming ways I can become more of a “voice” in the baseball community in my area.  It is tough to convince pushy parents and misguided coaches that young kids don’t need to throw curveballs or that pitchers should probably not be forced to throw over 200 feet in hopes of increasing arm velocity.  But, we need to step up and make a difference or more young kids will be suffering from tendinitis, Little League Elbow/Shoulder, labral tears or other overuse injuries.

Click here for an abstract reference with respect injury risk and innings pitched per year

As a father, coach, educator and physical therapist, my personal mission is to make a difference in the lives of those around me. I know many may simply be unaware that there is a better or safer way.  As the emphasis on early specialization continues to grow in our country, now is the time to take action and help stop many of these injuries.