Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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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:
- Educate parents and coaches through talks and seminars
- 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
- Reach the athletes directly through arm care screenings, FMS evals and professionally directed throwing programs
- 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
- 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.
I readily admit I have had an aversion to abdominal exercises that involve straight leg lowering since my days in pee wee football where we were forced to do lifts and holds a few inches above the ground. Some will relate to a modern day version of this exercise known as “six inches.”
As someone with tight hip flexors and who has personally suffered from sciatica in the past, I am NOT a fan of abdominal training that exposes the lumbar spine to large loads and undue risk related to exercises that involve long levers (e.g. throw downs, scissors, etc) and place high shear force on the spine.
I was reminded of why I feel this way in a fitness class this past week. I take a cycle/core class at my local gym and have done a traditional spinning class twice per week for 3 years. After 45 minutes of cycle, we move to a fitness room for core. I have done this new format for three weeks. This week we were asked to do a series of exercises which included “banana rolls.” If you are unfamiliar with this move, check out You Tube for some video demos.
While this exercise may be effective for core strengthening, I can honestly say as one who has never done the move before that trying to execute it as part of a continuous sequence of movements without rest between the moves was very hard to do with proper form. The fatigued state encouraged using momentum and straining to simply get the movement done (not to mention the fact my greater trochanter was sore from the rolling on the hard aerobic floor).
The next day I woke up with low back pain. My back has not hurt like that in years. In light of the role the iliopsoas plays by virtue of its attachment on the lumbar spine, we must consider the impact of reverse muscle action and how it creates shear on the lumbar spine during movements that rely on stabilization with the legs extended against gravity. Additionally, for those clients like me with muscle tightness, increased lumbar lordosis and a history of low back disorders, health and fitness professionals must consistently evaluate safety and efficacy as well as trying to challenge clientele in a workout session.
For all of these reasons, I increasingly rely on neutral spine anti-extension and anti-rotation training exercises in my programming for athletes and clients of all ages and abilities. That is not to say I never do rotational or active movements. They are appropriate given the right order, progression and demands of the respective individual. I just think we must consider form and risk versus reward in exercise programming.
The exercise video below illustrates how to use sliders in a tall plank position to accomplish great core activation and hip/shoulder stability without stressing the lumbar spine with long lever movements. Keep in mind that quality should override quantity in terms of deciding repetition schemes. Do not let the desire to fatigue clients cause form to suffer as this may increase injury risk.
For more specifics on the execution and progression/regression of this particular exercise, click the link below to read my most recent exercise column for PFP Magazine.
Suffice it to say I will not be doing banana rolls again. While I am not completely discarding the exercise, I do think it should be done in a non-fatigued state and taught incrementally if done at all. Most importantly, we as fitness professionals must always remember to program exercises based on fatigue and skill level, while carefully weighing risk versus reward in group or individual sessions.
Many people struggle with faulty posture (forward head and rounded shoulders). Tightness in the pec major or pec minor can negatively affect the body. Often, the throwers I see suffer from tightness in this region. Any overhead athlete can be affected as well as the person who sits and types all day long in the office.
The video below reveals how to use a trigger point ball and block to work on soft tissue tightness. I like the TP ball and baller block from Trigger Point for this exercise sequence.
For more information on this technique and its application, click here to read my online column for PFP magazine. Note: the final “W” motion in the video is not described in the column article, but it is another option that can be included.
One of my favorite quotes from a well known fitness professional, Alwyn Cosgrove, is: “Exercise is a drug. If we give the right drug in the right dose – everything works. But, if we give the wrong drug or even the right drug in the wrong dose, we cause more problems than provide solutions.” In essence, dosage matters a whole lot. This means that getting it just right is also not by accident, but by careful analysis and exacting prescription.
After a thorough evaluation, exercise selection and progression must be predicated on the end goal for the athlete. Where are they now? How do I get him/her back to 100% Understanding the injury itself, training and medical history as well as inflammation and healing time frames is important, but that is just one part of the equation.
For those with experience, you already know athletes heal differently and no two injuries are ever just alike. Addressing the mental components outlined in my previous post, Return to Play: Part 1 (The Athlete’s Mindset), is the starting point. Next, you must formulate a plan to physically mend, challenge and prepare the athlete’s body to return to its previous functional level.
Below are some BIG mistakes I have either made along the way or witnessed in my career:
- Prescribing exercise solely based on the diagnosis – while logical and not entirely off base, we must learn to think globally and make sure we assess the whole athlete as opposed to isolating one area. In my early days, I tended to focus on the affected area where symptoms were prevalent. Keep in mind the symptoms may simply be the result of another weak link in the chain. The FMS, SFMA and myofascial chains have taught us the importance of kinetic linking
- Pushing too hard too fast – progressing sessions simply based on what the athlete tells me as opposed to properly moving through a sound functional progression with specific criteria needing to be met prior to moving on to the next phase of rehab can cause more harm than good. While you may be able to go faster in some cases, do not get too greedy without satisfying set goals along the way. You do not want to reinforce a poor movement pattern. A misstep here may cause a recurrence of the injury, perpetuate inflammation or weaken healing tissue.
- Not pushing the athlete hard enough – it is paramount that we assess client response “in the moment” rep to rep and set to set as opposed to just session to session. Observe form and fatigue, but do not let the athlete coast or get bored with the lack of progression. Understanding and applying fundamental exercise physiology principles and recognizing periodization is necessary to ensure complete restoration.
Now, on the my next big point. I strongly believe you need to know how HARD the exercises you suggest are in order to effectively prescribe them. One of my primary philosophies is that I will not prescribe exercises I cannot do. Not only is this critical for teaching proper form, it is a must to gage fatigue, workout demand, recovery needs and so on.
Possessing a solid grasp of volume and intensity is also essential. For example, having an athlete who is 6 weeks post-op with a bone-tendon-bone ACL autograft reconstruction do too much eccentric quad loading will inevitably lead to anterior knee pain or patellar tendonitis. Would you do 10 separate eccentric quad exercises (2-3 sets of 10-15 each) in one hour ? I do not do this type of volume on my healthy knee, but I have seen rehab done this way. We must always keep a watchful eye on load, time under tension and overall volume throughout the rehab process. The proper balance is critical.
I have spent the past 16 years helping athletes get back to their sport or desired activity following an injury. Whether dealing with muscle strains or ACL ruptures, every injured client shares the same goal of making a full recovery and getting back to their previous activity level. My purpose in writing a blog series on this topic is simply to share some pearls I have picked up along the way and to help others learn from my mistakes and successes.
Beyond the severity and nature of the injury itself, there are several considerations that play a significant role in the rehabilitation process including: the athlete’s emotions, goals, mental toughness, age, experience, previous medical history, relationships with parents/coaches/teammates, innate movement patterns, etc. I feel the first and perhaps most important step in the recovery process involves connecting with the athlete on an emotional level.
Injured clients want to know that their medical team (MD, PT, ATC and strength coach) really care about their well being, that they truly understand the impact of the injury on his/her life, and that they can provide the skilled care necessary to restore the body to its prior level of function. Too many times, we as health care professionals speak first espousing all our expertise and often forget to LISTEN enough. Our athletes want to feel special during this low point in their life.
Pearl #1 – Spend more time listening on the first meeting/visit to gain a thorough understanding of how the injured athlete “feels” and views their current injury. I spend the majority of my eval time interviewing the client to allow them to describe their physical symptoms, but more importantly fully elaborate on their goals, perceptions and thought processes surrounding the rehab timeline and expected outcome. Knowing how they feel (afraid, angry, depressed, etc) is essential in order to connect as well as properly motivate/coach throughout.
Many athletes (especially those who have been injured before) tend to want to dictate how things will go or pre-determine when they will be able to return to the playing field. I will re-direct them, but it is wise to listen to them tell you what did not work for them in the past. Mistakenly, they often compare their injuries to past experiences of their own or peers. While prior experience dealing with the same injury is helpful mentally preparing for the recovery process, it is critical to remind the athlete coach and family that no two injuries are exactly alike and that the recovery process will be guided by specific milestones and processes as opposed to “what happened in the past.”
Pearl #2 – Thoroughly educate the athlete on his/her condition, the anticipated timeline for return to sport and the implications for pushing too hard and fast in rehab. Never assume he/she does not want to know all the details. Emphasize that your goal is to return to sport as soon as possible but in a safe manner that ensures adequate recovery and minimizes the risk for re-injury. Telling your athletes the “why” behind each and every decision (exercise selection, reps, sets, practice limitations, etc) will help put the athlete at ease early on and foster trust and collaboration. This is an absolute must. To ensure success, we need the athlete to honestly and openly communicate throughout. I tell every athlete I work with that we are a team dedicated to the same goal – this achieves buy in from them up front as they see I am fully committed and invested in them.
In almost all cases, I find the athletes fear losing their starting position and/or letting down the coach far more than long term damage to their bodies. As such, I tell them it really is okay to rest and recover. They seemingly feel guilty about not contributing and their self-worth may markedly diminish. Recognizing this and encouraging them to be patient, stay the course and see the light at the end of the tunnel is very important. You see, the emotional and psychological healing is a HUGE part of the process during rehab. Being an advocate for the patient and not the sport provides security and emotional support for the injured client.
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