Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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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§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:
Weakness in the gluteus maximus and gluteus medius is often cited in contributing to patellofemoral pain, IT band problems, hip pathology and even back pain. Furthermore, activating the glutes and minimizing tensor fascia lata (TFL) activation is preferential to avoid synergistic dominance with abduction exercises. This is a common finding on my clinical exams.
Photo from Myers
In the February 2013 issue of the Journal of Orthopaedic and Sports Physical Therapy (JOSPT), Selkowitz et al. examined several exercises to determine which ones had the highest gluteal-to-TFL muscle activation (GTA) index. The clam exercise proved to be the best with an index value of 115. The second highest exercise was a sidestep with elastic resistance with a value of 64.
The other three exercises to score a GTA index of 50 or higher were: Unilateral bridge (59), quadruped hip extension w/knee extended (50) and quadruped hip extension with knee flexed (50). Below is the clam executed against a wall as described in the study referenced.
Clam with resistance
Additional research done by Wilcox and Burden (published in the May issue of JOSPT) suggests that a neutral spine alignment and 60 degrees of hip flexion is the best position for gluteal activation during the clam. This study was done without resistance but offers additional insight to positioning. I try to mimic this hip flexion angle in the standing single and double leg versions I employ with mini-bands as part of my gluteal activation series in the clinic as well.
Single Leg ER (left)
In the Selkowitz study, participants performing the sidestep were instructed to step to the left replacing 50% of the distance between the feet in the start position and follow with the right leg also stepping at this 50% increment. This was then repeated to the right to return to the starting position for a total of 3 cycles.
This exercise has one of the lowest TFL activation and reinforces proper frontal plane mechanics and can be used with clients and athletes to reduce anterior knee pain and injury risk. To increase resistance and/or difficulty, bands can be moved to the ankles or a band can be applied above the knees and at the ankle. In my practice, I typically have clients sidestep for 10 yards in one direction (using the 50% rule) and then repeat moving back to the other side for 10 yards.
Sidestep
Another option is to perform the sidestep exercise with a staggered stance. For example, lead with the right leg forward moving to the right and vice versa. Again, small steps replacing 50% of the original stance is best to ensure quality work.
Staggered sidestep
For additional information on execution and application for these exercises, click on the links below for the online columns I wrote for Personal Fitness Professional Magazine:
Sidestep with elastic resistance
The FMS is a great tool to uncover asymmetry and movement dysfunction in fitness clients as well as patients in the clinic who are ready to transition back to sport. I have been using this tool consistently for 2.5 years in my practice. One of the questions I have asked myself about the screening tool is how reliable is it?
Click here for an earlier post I wrote on this topic regarding what it tells us as practitioners. One of the challenges with any screen or test is not only validity but reliability. In the April edition of the Journal of Strength and Conditioning Research, we gain some new insight regarding intra and interrater reliability via 2 new articles.
The first article discusses a controlled laboratory study where repeated measures were used to investigate how experience using the FMS and clinical experience as an athletic trainer (AT) affects the intrarater reliability of FMS testing. The raters (17 men and 21 women who were recruited from the university’s athletic training clinical staff and academic programs), with different levels of FMS and clinical experience (AT students, AT or AT with at least 6 months experience using the FMS) viewed each of the 3 videotaped models.
None of the AT students or AT members had seen or used the FMS previously compared to the AT group with at least 6 months of experience. Each group rated the models on each of the FMS exercises according to the script presented by the lead investigator. A week later the raters watched the same videos again in a different randomized order and rated each model on each exercise.
The intersession scores were examined to establish intrarater reliability of all participants. In addition, the intrarater reliability of different groups of participants (students and clinicians) was compared to infer differences about the influence of clinical experience as an AT along with previous experience using the FMS.
Results:
- Average FMS score was 13.68 +/- 0.98
- There was moderate intrarater reliability was observed when all participants were analyzed
- The AT group with experience had the strongest intrarater reliability followed by the AT group (no experience)
- The AT students demonstrated poor reliability with a large 95% confidence interval
Key takeaways:
- Previous research by Minick et al. had established excellent agreement on all components of the FMS among expert and novice raters indicating strong interrater reliability, but authors point out that is first study to look at intrarater reliability
- This helps establish reliability of assessment giving more credibility to using it as an effective assessment tool
- All raters were either AT’s or AT senior undergraduate students – need to include other professionals in future studies to confidently apply the external validity of the results in this particular study
- Primary limitation of this study is the fact that video was used as opposed to live assessment
- Possessing clinical experience and experience with the FMS strengthens intrarater reliability so learning to use the tool with other experienced clinicians may be wise to improve validity
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.
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