Brian Schiff’s Blog

I recently relased an article on coaching mistakes in our local market.  In it, I talk specifically about 5 critical mistakes coaches make with respect to athletes.  The article will likely ruffle some feathers.  I am not anti coaches in any way (I am one).  However, I do believe coaches need to be educated about how to integrate training to maximize sport performance and reduce injury risk.

Today, I witnessed another example of how good intentions coupled with lack of proper insight about the impact of conditioning can harm an athlete.  We had a new lacrosse athlete in our facility today working with one of my performance coaches.  At the end of the session, my coach asked me to look at the athlete’s knee as the client apparently had anterior knee pain.

The staff member and father informed me that the lacrosse player’s coach was having everyone on the team not participating in a fall sport train for the Columbus half marathon coming up in October.  The aim was simply to accomplish team building (an admirable goal) and keep them fit.  You may know where this is heading.

I performed a movement screen on the athlete and discovered decreased hip strength and reduced ankle mobility.  The player had obvious imbalances on both sides, left greater than right.  The player then mentioned shin splints on the left leg as well for the past week (now 3-4 weeks into the 1/2 marathon training).

So, after performing a thorough knee eval, I concluded the athlete has anterior knee pain and left sided shin splints related to muscle imbalance and overuse with the recent addition of 4 days of distance running.  Is running bad?  In a word, no.  But this type of running for this particular athlete is not helping further performance goals.

The father enrolled the athlete in our program to work on speed, agility and power for lacrosse.  The bottom line is that this 1/2 marathon training is going to work against the very training adaptations my staff is working to achieve, not to mention now causing more knee pain and shin splints.

I am not opposed to the idea of scheduled conditioning for athletes not participating in a sport.  However, coaches need to step back and ask themselves what is the best way to condition their players for optimal performance and injury prevention.  In this scenario, I have all the confidence in the world the coach has the very best intentions for his players. 

Unfortunately, the results may be less than expected here – more importantly they may be counterproductive as the wrong energy system training and adaptations are being emphasized, while some players may suffer injury.

In my professional opinion, the player should probably consider dropping out of the half marathon training for three very important reasons:

1. Resolve pain and shin splints
2. Focus on fixing muscle imbalances
3. Maximize the training with us

This seems so simple, right?  Well, I see situations like this every week in my facility.  I see too many injured athletes.  Why?  In many cases it has to do with faulty conditioning principles or over training.  My mission is to educate coaches about how best to blend injury prevention with performance conditioning relative to their respective sport.  We have to remember that one size never fits all either.

Thoughts, comments or questions?  Let me know.  I am happy to address them in a constructive and positive public forum.

Over the past few weeks I have had numerous questions and comments on the blog about SLAP tears.  So, I thought I would add another post with more in depth information on classification of tears, typical treatment and outcomes.  This is a relatively common injury that many know so little about.  To see a diagram, click here.

Different types of SLAP tears

1. Type I – Fraying of the edge fo the superior labrum
2. Type II – detachment of the biceps anchor from the glenoid labrum (most common)
3. Type III – Bucket handle tear of the superior labrum with otherwise normal biceps anchor
4. Type IV – Bucket handle tear of the superior labrum extending into biceps tendon causing detachment of the biceps anchor

Other surgeons have expanded on these classifications as well, but i will not go into that depth here.  You should know that some sub classify type II tears into anterior, posterior and combined anterior and posterior lesions.  In effect a SLAP tear can cause a microinstability thereby leading to articular sided rotator cuff tears.  In plain terms, a posterior labral tear could create a posterior partial thickness rotator cuff tear and an anterior labral tear could create an anterior cuff tear.

The shoulder exam itself often reveals pain with passive external rotation at 90 degrees of abduction (picture the cocking phase of throwing here).  Weakness and instability may also be present depending on the type of tear and if there is already a cuff injury present as well.  There are a number of diagnostic clinical tests done including the O’Brien test, Speed’s test, crank test and biceps load test to name a few.  Many have been successful at confirming labral pathology.  In the end, the MRI is the gold standard in confirming an injury.

Non-operative treatment is often unsuccessful in most cases.  Patients with Type I tears may do better than most (JOSPT February 2009).  Therapeutically, we often see GIRD.   GIRD stands for glenohumeral internal rotation deficit, meaning the affected shoulder has significant posterior capsule tightness and decreased internal rotation (common among overhead athletes and throwers).  Restoring this motion may prevent injury that often occurs between the supraspinatus tendon and the posterior superior labrum.  Research is unclear if GIRD increases risk for a labral tear.

In addition to this stretching the posterior capsule, it is critical to strengthen the scapular muscles and rotator cuff to restore optimal mechanics and motion between the humerus and scapula.  Due to poor posture, flexibility issues and muscular imbalances, the average person may have an altered scapulo-humeral rhythm.  If non-operative treatment fails, one typically opts for surgery.

Arthroscopic surgery is the standard procedure today with debridement of the labrum and reattachment via sutures.   In many cases, surgeons debride rotator cuff tears with less than 50% torn, while opting for primary repair if greater than a 50% tear.  According to a leading surgeon, David Altchek, he will excise a longitudinal biceps tear that is less than 1/3 of the diameter of the tendon, while optiong to repair one that is greater in size back to the major portion of the tendon.

Common rehab timetable 

• Max protection for 0-3 weeks in sling with limited external rotation and overhead activity
• No biceps strengthening for 2 months
• Focus on motion restoration in weeks 3-8
• More aggressive strengthening begins at week 8
• Return to throwing begins at month 4 in most cases

These are some rough guidelines and progressions vary based on each case and the type of tear and associated damage as well as desired activity level.  About 90% of patients experience good to excellent results with Type II repairs in the short to mid term follow-up, but there is not extensive long term data out there.  It should also be noted that throwers and overhead athletes tend to exhibit lower satisfaction with repsect to return to pre-injury levels after surgery.  Recent studies also seem to indicate throwers with an overuse related injury do not do as well as those with a specific traumatic injury resulting in a type II tear.

I hope this post is helpful for those suffering from labral tears or who suspect they may have one.  It is an intricate injury but quite disabling to function with long term implications for the health and function of the shoulder.

Ever have a persistent ache in the shoulder with certain exercises in the gym?  I am talking about a nagging pain along the top or end of the shoulder with bench press, flies, dips, military press or even pull-ups?

Well, one of my staff members has just this type of pain.  He first asked me to look at his shoulder about 6 weeks ago.  I felt there was nothing substantially wrong with the rotator cuff or labrum and recommended he work on rotator cuff and scapular strengthening while backing off the heavy strength training (he is a natural body builder preparing for a show).

He told me about 2 weeks ago that it was still not better.  He complained of more site specific pain along the AC joint.  There was no obvious subluxation present but he was tender right along the end of the clavicle.  I suggested he see a shoulder specialist I know.

The AC joint below (joined by ligaments not visible on x-ray)

His MRI results revealed a micro fracture of the distal clavicle.  Doc says he can continue to train but needs to back off the weight on bench press and avoid pull-ups.  I also suggested he skip dips and he has been now for some time.  So, what caused it?  Good question as he only recalled pain when doing flies during a workout a few months back. 

Could this have caused it?  Maybe.  Pulling the arm across or toward the mid line of the body brings the clavicle into close approximation with the acromion of the shoulder.  There may have been a loading moment (especially with heavy dumbbells) where he strained the joint.  Or, perhaps it was the result of repetitive micro-trauma as the result of lots of heavy chest work.

Regardless, the take away points here are:

• Repetitive upper body lifts (especially those requiring lots of clavicle spinning, elevation and rotation like pressing, dips, pull-ups, and upright rows) may cause stress to the AC joint. 
• Flies do cause approximation and in people with any AC joint arthritis mild compression of the AC joint as the arm comes toward mid line
• Chest movements are likely to affect pain as the pecs attach directly to the clavicle
• Obscure chronic shoulder pain may be related to AC joint irritation that does not show up on an X-ray
• Shoulder pain with lifting may be related to AC joint pain rather than rotator cuff dysfunction in some cases

As a general rule, I caution all my clients over the age of 35 to go easy on the dips for sure as I find this one exercise more than any other tends to flare up an arthritic AC joint fast.  That is the double edged sword of strength training – repetition is necessary to get results but the repetitive nature is capable of taking good exercises and wreaking havoc on the body long term.  Form matters as does avoiding harmful range of motion with lifting.

In the end, let your shoulder guide your decision making in the gym.  In my staff member’s case, he will be fine and recover 100%, although he will likely have to modify his lifting and endure some pain as he pushes on toward his competition.

By far, I help more people with knee and shoulder problems in my profession.  As a therapist and fitness pro, I often use lingo that some do not fully understand.  In fact, I often find myself analyzing gait patterns of people at the grocery store and even the ringmaster at the circus this past weekend. LOL

I guess I am a biomechanics geek of sorts.  It just seems as if faulty mechanics stick out like a sore thumb for me wherever I go.  Now, when it comes to bony alignment, you can thank  your parents to a large degree for your shape and knee alignment.

Obviously, girls have wider hips so they naturally tend to exhibit greater tendencies to have valgus overload (knees cave in with squatting or landing) than males.  However, other factors that contribute to valgus overload are:

• Hip tightness (adductors and IT Band)
• Hip weakness (gluteus medius)
• Foot pronation (flatter or collapsing arch)
• Pain (which leads to compensation)
• Improper muscle firing patterns

So, we know valgus is bad.  Does this mean neutral and varus are free from worry.  Not so.  I have seen many people with neutral alignment fall into valgus due to imbalances, poor muscle memory and faulty motor patterns.  Varus knees are often subject to excess stress (compression) along the inside of the knee and gapping along the outside of the knee stressing the lateral collateral ligament.  Valgus knees offer increased compression on the lateral knee and gapping along the medial knee stressing the medial collateral ligament.

In the end, you simply want to know your alignment and then assess how gravity and ground reaction forces impact your joints.  Squatting and gait provide ample cues.  Once you know the imbalances, you can address them with exercises. 

I helped do orthopedic screenings last night for a local high school and noticed a few steady trends:

1. Nearly all of the soccer players had varus knees
2. All of the offensive and defensive linemen had valgus knees
3. Cheerleaders had the best single leg squat strength and balance
4. About 75% of the athletes I saw had less than exemplary single leg dynamic strength/balance

I included two very different pictures below of high school female soccer players doing a drop landing test from an 18″ box.  Obviously the valgus landing is more predictive for ACL and knee injury.

Minimal valgus at landing

Significant valgus at landing

Obviously the girl in the second picture has a higher inherent risk of a serious non-contact knee injury.  I recommend a knee prevention program for all cutting and jumping athletes, but when you see this type of valgus loading   sound the alarm and be sure to implement a corrective exercise plan to reduce injury risk.

I am putting the finshing touches on my ACL prevention DVD as I write this.  You can still take advantage of the pre order sale if you act now.  Visit www.fitknees.com for more info.

In all my years as a therapist and strength and conditioning professional, I have seen many active people affected by stress fractures or stress reactions.  If you are a runner, you may have experienced such a thing.  Likewise, people beginning a new exercise program or rapidly increasing training volume and/or intensity may be at increased risk for such an injury.

Common stress reaction injuries and stress fractures include:

• 5th metatarsal stress fracture
• Shin splints
• Medial tibial stress syndrome (MTSS)
• Tibial and fibular stress fractures
• Femoral neck (hip) stress fracture
• Spinal stress reactions/fractures

Runners, soccer players and gymnasts are often the groups of athletes most likely to suffer these types of injuries.  The repetitive impact leads to breakdown in the bone or bone edema (swelling in the bone).  What starts out as a mild ache may quickly turn into sharp pain if you fail to heed the warning signs.

Signs and symptoms of stress injuries or stress fractures include: aches or pain with increased loading (running, jumping, and stress at extreme ranges of motion), decreased range of motion, decreased strength and altered gait patterns.  Pain may lessen after resting a few days, but often returns as soon as you resume higher impact activity in the case of a stress fracture.

In my practice, I see these injuries much more often in females.  This is likely in part due to calcium deficiencies and and perhaps biomechanicaldifferences that increase force on the joints and bones.  Women also lack strength in comparison to men and weakness equates ot less force dissipation and higher chances ofinjury.  Typical treatment is rest, ice and anti-inflammatory meds.  In some cases immobilization and restricted weight bearing is necessary to allow full healing.

Below is a picture of a metatarsal stress fracture:

If you have a persistent nagging ache or pain in the foot, shin, hip or spine, see your doctor to rule out a stress injury with an x-ray.  These injuries are easily treated when diagnosed early on.  In some cases, neglect may necessitate an operation to remedy the problem.  Once you return to training, it is essential to go slow and use the 10% rule each week (not increasing mileage, volume or intensity more than 10% per week) and using a pain dictated progression in regard to exercise.