Brian Schiff’s Blog

One of the biggest issues I see today in youth sports is an abundance of overuse and preventable musculoskeletal injuries due to improper conditioning, lack of recovery or both. In the current era of sports specialization and the hyper-competitive pursuit of college scholarships, an athlete can unknowingly be placed in a comprising position with respect to his/her physical and mental health. Coaches and parents may push a player to participate in a weakened or vulnerable state.

Now, more than ever, athletes who do focus in on a singular sport need a year-round training plan to match their year-round sport demands. In order to stave off injury and avoid burnout, a successful plan must accomplish the following:

1. Implement de-loading periods along with scheduled rest in the training and competitive cycles
2. Periodize the training to peak at the desired times
3. Allow for adequate time to ramp up training and sport specific activity in order to condition the body for the high demands of the sport and safely move from the athlete’s “floor” to the “ceiling”

A surefire recipe for injury and soft tissue failure is progressing training loads too fast, where the athlete often endures too much acute workload without enough time to build up an adequate amount of loading tolerance or chronic workload. I see this frequently in baseball pitchers (shoulder and elbow pain), female soccer and basketball players (patellofemoral pain), along with many athletes who suffer soft tissue strains including hamstring, hip flexor and groin injuries.

Tim Gabbett, published an excellent clinical commentary in the October edition of JOSPT (1) that highlights the importance progressing training loads to minimize injury risk and optimize performance. Specifically, he discusses the concepts of “floor”, “ceiling” and “time” as it relates to developing rehab and performance plans.

Floor – the athlete’s current level of capacity

Ceiling – the capacity needed to perform the specific acuities of their sport

Time – an athlete can safely progress from the floor to the ceiling when afforded enough time

Further, Tim discusses how an injured athlete can actually fall behind in conditioning and end up in the “basement” in terms of training capacity. This presents additional challenges in getting the injured athlete back safely, particularly if it is in-seasonwith a shorter time window. He presents an option of raising the floor when an athlete enters rehab or if he/she will be on an extended break from training to ensure the loading capacity not drop below the floor to the basement, but rather increase the height of the floor, perhaps allowing the athlete to eventually reach a higher ceiling (greater loading capacity) later on.

According to Gabbett, there are 5 key ways to ensure athletes are prepared for competition:

1. Maintain adequate training load during the offseason and while injured.
2. Identify the ceiling and make sure the training load is in line with the sport’s demands.
3. Assess individual differences in training tolerance. We need to consider young versus older athletes, injuries, training history, aerobic fitness and physical deficiencies to do this properly.
4. Identify and prepare for the most demanding parts of competition.
5. Coaches need to plan enough time to move from the floor to the ceiling considering the physical demands of the sport, capacity needed to perform these activities, and individual limiting factors that may impede the ability to meet these demands.

Having spent a considerable amount of my career working with high level amateur and professional athletes, I am well aware of the narrow windows of time to compete and recover with weekend tournaments and professional schedules. It takes a lot more time to get in elite shape and only a few days to begin detraining. Cross training, smart and progressive rehab and clear communication with coaches, training staff and the athlete is essential in managing an injury for a high level athlete.

In addition, I always tell my athletes the only thing worse than not competing at all is going out and performing poorly. Without proper training and rehab plans, athletes will eventually fail mechanically. I often encourage the athlete to communicate clearly in terms of pain response on a scale of 1-10 during, immediately after and for the 24 hour period following rehab to assess the body’s response to loading. Using these concepts and the floor, ceiling and time as discussed by Tim Gabbett, strength coaches, sport coaches and rehab professionals can all refine their methods to put the athlete in the best position to succeed and reduce injury risk.

References:

1. Gabbett TJ. How much? How fast? How soon? Three simple concepts for progressing training loads to minimize injury risk and enhance performance. J Orthop Sports Phys Ther. 2020 Oct;50(10):570-573.

I am currently working to attain my transitional doctorate in physical therapy (tDPT) at Northeastern University. As I continue to work full time as a clinician, it has been really cool to apply the learning with my current caseload. At this time, I am in a motor control class that is both fascinating and challenging. In week three, we examined pain and the impact it has on neuroplasticity (the brain’s ability to adapt or change).

In the sports medicine realm, I generally think many practitioners solely focus on the musculoskeletal system or physical impairment. As such, interventions are developed around tissue constraints, ROM deficits, weakness, etc. Too often, we look past the power and impact of the brain and how it plays a vital role in healing and return to play. For some patients, there is a maladaptive response to injury/surgery and a hypersensitivity of the central nervous system or central sensitization that occurs. Pelletier (2015) notes that structural and functional changes can occur. (1)

Two critical concepts to consider here are:

1. Sensory amplification – sensory and motor representations change resulting in perceptual changes in body image, motor control changes, and even a persistence or amplification of pain
2. Experience dependent plasticity – patient’s response to pain is related to prior experience and may experience maladatpive imprinting where the pain outlasts the physical insult

Kleim (2008) gives a great lesson on experience dependent plasticity and states that learning is essential for the brain to adapt to damage self taught behavioral changes can be maladaptive or positive and specific forms of neural plasticity and associated behavioral changes are dependent on specific kinds of experience (2). While one would assume that chronic pain is rare in athletes, I would counter and say it is probably just overlooked as we tend to expect athletes to “push through the pain” because of the driven culture we live in. Coaches, parents and even teammates can affect the mindset around injury and recovery.

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So many times, athletes and parents alike are singularly focused on the physical rehab necessary after an injury.  Often, what the athlete is not talking about is the psychological impact of the injury.  Suddenly, their identity and self worth may come into question.  They feel disconnected from teammates and coaches.  Their daily routine consists of rehab and not practice/play.  Deep inside their head they are quietly wondering, “Will I ever be the same again?”

Aside from some of the obvious questions that race through an injured athlete’s mind, one of the biggest and most often unspoken concerns is the fear of re-injury.  Having worked with athletes of all sports, ages and abilities, I have seen firsthand how important it is for an athlete to go through a functional and sequential progression that assures that they are able to run, jump, cut, pivot and decelerate again without pain or instability.

I have worked with hundreds of athletes over the course of my career that have suffered ACL injuries.  The longer I practice, the more I become convinced that we probably have been pushing or allowing these athletes to go back to their sports before they are really ready (physically and/or mentally).  Six months has long been the benchmark for most orthopaedic surgeons.  The graft is well healed, but often the mind and body are not really ready.

While I have seen athletes who have great strength, stability, hop testing scores above 90% and look good on movement drills, sometimes these same athletes still have asymmetrical squat patterns, FMS scores lower than 14 or apprehension about returning to their sport.  In addition, fear of re-injury is a big factor that impacts confidence and readiness to return to activity.

Consider some of these facts about modifiable factors with return to sports after ACLR from the May/June 2015 Sports Health Journal:

• Motivation, confidence, self-efficacy, optimism and low fear are associated with a greater likelihood of returning to preinjury level  after athletic injury and ACLR
• Lower fear of reinjury and greater pyschological readiness to return to sport favored returning to preinjury level after surgery
• Combinable data from 10 studies suggests that fear of reinjury, psychological readiness to return to sport and one’ subjective assessment of knee function were predictive of level of return to sport
• As many as 1 in 2 athletes who do not return to their preinjury level of sport report the main reason is fear of reinjury

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Photo from Bleacher Report

Shoulder surgery is a big concern for any professional pitcher.  I am currently rehabbing two MLB pitchers (one from a labral repair and the other from a Tommy John procedure and obviously not JV pictured above). They are doing great so far in their early rehab, but time will tell if they make it back to their pre-injury pitching levels.

Overuse injuries in youth baseball players is always a huge concern I have.  In fact, I speculate that early wear and tear may contribute to injuries seen down the road in HS, college or the pro ranks.  I know from coaching and observing that more youth coaches need to familiarize themselves with pitch count guidelines and rest/recovery recommendations that Little League baseball now endorses.

As a sports physical therapist who sees 12 year-olds with RC problems and torn UCLs and as a father/coach of a 10 y/o left-handed pitcher, I have a strong passion and vested interest in the welfare of baseball pitchers. While research does not equate increased injury risk with throwing curveballs and sliders to date per se, both of my MLB clients advise against it until athletes turn 14 or 15.

For  information on injury prevention and pitching guidelines for youth, check out this website:

http://www.asmi.org/research.php?page=research&section=positionStatement

Today’s blog post focuses on outcomes following surgery for elite pitchers.  The following information was just published in the Jul/Aug 2013 edition of Sports Health by Harris et al. based on literature review based on these outcome measures:

Primary = pitcher’s rate of return to sport (RTS) at the same level prior to injury

Secondary = rates of RTS regardless of level, performance upon RTS and clinical outcome scores

“Elite” was defined as throwing in at least one game in MLB, minor league (A, AA, or AAA) or all collegiate divisions.   Six level I-IV studies were included with enrollment from 1976 – 2007, and there were 287 elite male pitchers who underwent shoulder surgery with 99% on the dominant throwing shoulder.  Most pitchers (276) were professional with a mean career length of 6.58 years.  Post-operative clinical follow-up within these studies was 3.62 years.

Primary diagnoses treated:

• RC tear = 120 (43%)
• Internal impingement = 82 (30%)
• Labral tear = 74 (27%)

Surgical procedures performed:

• Labral repair (157) or labral debridement (99)
• RC repair (29) or debridement (162)
• Thermal capsulorrhaphy (63)
• Subacromial decompression (42)

The statistics reveal more debridement of the labrum (61%) and rotator cuff (85%) versus repair.  This is not necessarily surprising given the desire to minimize surgical intervention and loss of motion.

Return to Sport Data

1. The overall rate of return to sport was low at 68%.
2. Mean time to return to competitive pitching in a game situation was 12 months (range = 9 -17)
3. 22% of MLB pitchers never pitched again in MLB
4. Only 14% returned to competitive pitching in the same season as labral surgery
5. No one returned to competitive pitching in the same season after rotator cuff surgery
6. Reynolds et al reported a median of 2 seasons of pitching after debridement of partial thickness cuff tears
7. Mazoue and Andrews reported a mean of 0.7 seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair

Performance declined for the 3 seasons prior to surgery and then gradually increased for 3 seasons afterward, but generally did not reach pre-injury levels.

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