Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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I must admit that I am always looking for new ways or tools to enhance my practice and work as a sports physical therapist. I recently completed the necessary hours of training to perform dry needling in the state of North Carolina. I trained with Myopain Seminars and have nothing but great things to say about their courses.
For those unfamiliar with trigger point dry needling (TDN), it is a treatment gaining traction in the therapy world. Dry needling is a treatment that involves a very thin needle being pushed through the skin to stimulate a trigger point. Dry needling may release the tight muscle bands associated with trigger points and lead to decreased pain and improved function for those suffering from pain related to muscular dysfunction.
Trigger points may ultimately refer pain to other sites, and research indicates that TDN can reduce acidity in the muscle and clear out pain propagating chemicals. The picture below is an example of me performing trigger point dry needling to the upper trapezius of a 16 y/o female.
This particular client had been suffering from an inability to lift the arm above shoulder height and marked shoulder pain since September 2013. She also mentioned having headaches at school. Clinically, she was diagnosed with multi-directional instability and scapular dyskinesis by the referring MD. We began working on a scapular stabilizer and rotator cuff strengthening program in late November that was helping to diminish pain and increase function. However, she continued to c/o pain in school, stiffness and headaches.
In the past, I wrote a post about Crossfit and shoulder pain based on a 38 y/o male client of mine. Click here to read that post. In my prior entry, I discussed differential diagnosis of rotator cuff and labral pathology, as well as my treatment approach for that client.
If you follow my blog, twitter feed or webinars, you know I treat a lot of Crossfit athletes. Recently, I worked with a 25 y/o female suffering from marked shoulder pain that was keeping her out of the gym.
Below are the key findings from her intake on 8/30/13:
- Onset of left shoulder pain on 8/8 related to snatches
- Right hand dominant
- Intermittent pain if sleeping on her left side
- Full AROM
- Mild weakness with supraspinatus and external rotation on left
- Positive impingement signs
- Positive O’Brien’s test (labral test)
- Positive sulcus sign bilaterally (indicates multi-directional instability or MDI)
Sulcus sign
Treatment intervention
- Rhythmic stabilization and PNF exercises
- Rotator cuff and scapular strengthening
- Closed chain stabilization training
- Game Ready (cryotherapy)
- Home program issued at visit #1
I saw the patient once per week and she did her home program for 4 weeks. At week 4, we gradually began allowing her to do some modified gym workouts but still no snatches or full overhead work. She was pain free at this time and all impingement/labral signs had resolved. At this point she returned to some wall ball drills (limited height) but still no snatches.
The client’s final visit was on 10/2/13. Her Quick Dash percentage of perceived shoulder dysfunction was now 0%. She was symptom free, but more importantly she had a great understanding of how to modify her lifts, loads and volume based on her multi-directional instability. She was now aware of how her instability impacts her shoulder in “at risk” positions and in the face of fatigue. This brings me to the primary reason for this second post related to Crossfit and shoulder pain.
In my initial post, I focused on overuse and shoulder inflammation as a result of poor mobility, muscle imbalances and a lack of physical preparedness to do high intensity exercise like Crossfit. On the other end of the spectrum lies the unstable shoulder.
Hypermobility and/or shoulder instability is a major problem for those doing Crossfit in light of the following:
- Many lifts and exercises put the shoulder in “at risk” positions
- Poor glenohumeral joint stability places more stress on the rotator cuff and long head of the biceps
- With the AMRAP approach and train to failure nature of the WOD, fatigue is a given and this means the stabilizing muscles that matter most will often fail leading to a much higher injury risk
Key Takeaways
- My client had secondary rotator cuff and bicipital irritation related to primary instability
- Rest and a combined stabilization and cuff/scapular strengthening exercise program was effective in resolving her symptoms within 30 days
- High load/high volume overhead lifts and those that place the shoulder at end range pose a higher injury risk for those with MDI or anterior instability
- Shoulder stability work trumps mobility work in those with shoulder instability – this often runs counter to traditional approaches that tend emphasize better mobility (one program does not fit all)
Closing thoughts
We must keep in mind that the shoulder is inherently unstable in order to allow us the freedom of movement necessary to perform the various tasks and exercise. With that said, repetitive movements and lifts can create micro and/or frank shoulder instability over time. Those with a history of shoulder subluxation/dislocation/instability are a high risk group to begin with. Adding high loads to failure places the shoulder in a fatigue and compromising state. As a coach, competitor or health professional, we must remember that even the best intentions and coaching can fail us if the risk of a lift outweighs the reward.
As I have said before, anyone who decides to do Crossfit MUST get a proper assessment prior to starting to reduce injury risk. Ideally, this assessment would begin with a full FMS to help uncover any mobility or stability issues and asymmetry. Keep in mind research reveals that females will almost always score a 3 on shoulder mobility and many may be hypermobile. Conversely, they tend to score lower (1 in many cases) on the trunk stability push-up. Any pain with screening would necessitate a referral to a PT or MD for further evaluation.
Trainers cannot be asked or expected to catch multi-directional shoulder instability. However, they can and should be aware of relative risk, anatomical tendencies and red flags that may predispose clients to injury. For those wanting to be the best in the business, I would suggest developing a system for assessing clients and partnering with allied health professionals like me to incorporate best practices in their business. Perhaps most importantly, trainers and coaches must be willing to adapt, limit, or eliminate exercise that does not fit the needs and abilities of the clientele.
The random nature of the WOD makes it difficult for unassuming clients to judge how best to fit in the Crossfit model if they have a dysfunction or injury concern. My goal is always to empower people with knowledge about their body and sound advice for optimal training. For those intent upon getting back to Crossfit after injury, I work hard to normalize their function and offer tweaks and modifications to prevent re-injury. Prehab is a must for this population. But in the end, some shoulders will simply not be able to handle the rigors and intensity of Crossfit.
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§ion=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
- The overall rate of return to sport was low at 68%.
- Mean time to return to competitive pitching in a game situation was 12 months (range = 9 -17)
- 22% of MLB pitchers never pitched again in MLB
- Only 14% returned to competitive pitching in the same season as labral surgery
- No one returned to competitive pitching in the same season after rotator cuff surgery
- Reynolds et al reported a median of 2 seasons of pitching after debridement of partial thickness cuff tears
- 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.
I work with several overhead athletes ranging from swimmers and tennis players to professional baseball pitchers. One consistent issue I see is tightness in the anterior chest wall coupled with poor scapular activation and stability. For that reason, I often turn to snow angel exercises. I wanted to share two variations I have written on before. The first version utilizes a foam roller. The movement is performed throughout a full arc of movement upward and downward.
Top position
Bottom position
Click here for more details on the execution of this exercise
This is an excellent exercise that can be integrated as part of a warm-up/movement prep session as well as used in recovery and the cool-down to address soft tissue tightness in the chest, facilitate proper posture and encourage scapular retraction and depression.
I often use this exercise in combination with pec minor myofascial release and thoracic spine extension mobilization on the roller. It is a staple in all of my rehab and prehab programs with all of my overhead athletes.
The second version involves moving to an upright position and can prove more challenging. The exercise is also designed to promote scapular stability. When done properly, the client will demonstrate proper upward rotation (avoid tipping and winging of the scapula) on the ascent, and then emphasize recruitment of the rhomboids and lower trap to achieve proper downward rotation on the descent.
It can be a very fatiguing activity and somewhat frustrating for clients when starting out. Be sure to cue them accordingly, and let them know it may not be easy to keep full contact. It may also be necessary to utilize soft tissue mobilization for the pecs/lats as well as stretching beforehand to promote a more normal movement pattern.
Top position
Mid position
Bottom position
In this anti-gravity version fatigue becomes more of an issue, so emphasizing quality movement and using less repetitions may be indicated. Do not push through any painful motion.
Click here for more details on the execution of this exercise
I always look for exercises that allow me to actively elongate traditionally short muscles while encouraging proper muscle activation of weak/poorly recruited muscles. This exercise does just that. If you are interested in the impact of pec minor tightness and shoulder impingement, check out the article from JOSPT below:
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