Brian Schiff’s Blog

Femoroacetabular impingement (FAI) is now a common term in orthopedics. When I first started practicing physical therapy the term did not exist. As a matter of fact, I was told my hip had a bone spur in the early 2000’s, and I am sure it would now be classified as FAI. If you are unfamiliar with it, click here to read a prior post on the basics of it.

Today, as clinicians we face the tough task of helping patients overcome hip pain related to overuse injuries, acute strains, osteoarthritis, myofascial pain, etc. One of the biggest challenges is definitively identifying the etiology of hip pain. Hip pain can be extra-articular (outside the joint) or intra-articular in nature (in the joint). Consider this retrospective study published in AJSM in 2015 by Naal et al. on sonographic presence of groin hernias and adductor tendinopathy with FAI.

Differential diagnoses when ruling in/out FAI include:

• Adductor (groin) strain
• Rectus femoris strain or avulsion
• Iliopsoas tendinitis
• Athletic pubalgia
• Trochanter pain/bursitis
• Femoral neck stress fracture
• Osteitis pubis
• Cancer
• Genitourinary issues
• Low back pain

The list above is certainly not all inclusive. The key to obtaining a more accurate diagnosis involves taking a thorough history, performing a comprehensive exam, and getting appropriate imaging. Click here to learn about a paper on the diagnostic validity of tests to predict intra-articular hip pathology. Soft tissue pain related to muscle strains should improve with rest and treatment, whereas joint pain related to FAI is usually consistently painful or worse with increased repetitive activities such as running, dancing, twisting, jumping, cutting, etc.

Patients with FAI will often cup their hip and make what is referred to as the “C sign” when describing where they feel the pain.

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Have you ever experienced a significant injury? If so, do you remember wondering if you would ever be whole again? Pain, fear and the inability to do your sport or physical activity can cripple the human spirit.

Over my 21 years as a physical therapist and fitness professional, I have witnessed how powerful the mind is and how critical it is to have the right mindset to overcome physical obstacles. Some people are mentally stronger than others – period. With that said, adversity and pain has a way of testing the spirit and will of an individual.

In any given week, I see at least 5-10 patients rehabbing an ACL injury. The injury, surgery and rehab is physically and mentally grueling. The injury itself takes the athlete away from his/her passion or sport immediately, while presenting them with a long path back to full health. Many suffer an identity crisis as they become isolated and away from their peers. Physical therapy that fully restores function is a must in this group of patients. For more on what complete ACL rehab looks like, click here to read one of my previous posts.

Fear of reinjury and persistent knee symptoms are common reasons for a lack of return to play after ACL reconstruction. Click here to read an abstract regarding kinesiophobia in this group of patients.

With any injury, it is only natural to worry about the outcome. Clients often wonder quietly whether they will be able to return to their previous level of play. In this post, I want to talk about the elephant in the room for patients coming back from an injury, and that is a legitimate fear of reinjury.

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Blood flow restriction (BFR) therapy/training is one of the newer and more exciting techniques being used in the sports medicine field. I received training with Owens Recovery Science and have been utilizing personalized blood flow restriction (PBFR) therapy in my clinic since November 2017 using the Delfi personalized tourniquet system (PTS).

What exactly is BFR?

It is the application of a specialized tourniquet system to the proximal arm or leg, which is inflated to a personalized and specific pressure to reduce blood flow to an exercising extremity. For the lower extremity, the occlusion pressure is 80%, whereas the upper extremity pressure is usually set at 50%.

The application is brief and intermittent, usually lasting about 6 minutes per exercise. For most clients, a total of 3-4 exercises are used leading to 24-30 minutes based on the specific exercises prescribed. Typically, to increase strength and hypertrophy a person would need to lift a significant amount of weight (greater than or equal to 60% of a 1 repetition maximum). With PBFR you can create significant strength and hypertrophy gains with loads as low as 20% 1RM.

We utilize the Delfi tourniquets as suggested with the Owens training course. You can see the PTS and tourniquets below:

What is the science behind this training tool?

The landmark study by Takarada published in 2000 revealed that significant hypertrophy gains are seen with occlusion and the use of lighter training loads. There is an increase in muscle protein synthesis as well as growth hormone secretion. Below you find some links to abstracts from Takarada’s work:

https://www.ncbi.nlm.nih.gov/pubmed/10846023

https://www.ncbi.nlm.nih.gov/pubmed/10642363

https://www.ncbi.nlm.nih.gov/pubmed/11128848

In addition to hypertrophy, there also appears to be an application for preventing disuse atrophy simply using occlusion. This may prove very beneficial for clients who are non-weightbearing after an injury or surgery, yet not able to perform much resistance training.

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I just returned from the Sports Physical Therapy Section’s annual conference in Las Vegas. There were plenty of great presentations from various industry leaders. I thought I would take a moment and summarize a few key points from the conference that may be helpful to clinicians and consumers alike.

The conference theme was the power of innovation. Hot topics covered were blood flow restriction therapy, cupping, dry needling, eccentric loading for tendiopathy, weighted ball training, and kinesiotaping and laser therapy to name a few. Below are some takeaways worth mentioning:

• Blood flow restriction (BFR) training can be used to help reduce muscle atrophy after surgery, improve muscle protein synthesis and provide a way to increase strength with loads as low as 20-30% of 1RM for clients unable to tolerate heavy loading
• BFR is not superior to nor a substitute for high intensity training (need to push weight to see best strength gains), but it can be used as an adjunct to training. It also produces an increase in IGHF1 after exercise.
• BFR should not be used before higher intensity activities such as HIT, plyometrics, SAQ, etc.
• Clinicians and strength coaches should consider Olympic lifting derivatives as an alternative to traditional lifts if there is concern with catch phases or biomehcanical/physical concerns. Examples include high pulls/snatch pulls instead of traditional cleans and snatches.
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In my previous post, I outlined the history and findings related to my son’s medial elbow pain. Since publication of that blog post, I have since been given the results of his MR arthrogram and have further updates. If you did not read the prior post, you can click here to read it.

Initially, my concern was tendinitis or more of a flexor/pronator strain given his mild yet persistent soreness and response to rest. The imaging revealed that his UCL was pristine, the radiocapitellar joint liked good, no osteophyte formation or really any inflammation in the soft tissue. The surge told me he had to look closely, but there was evidence of mild fluid around the apophysis. So, in essence, there was some overload/strain being placed on the growth plate.

Given that my son’s growth plates are still open at age 15, he was experiencing some overload (apophysitis) rather than strain on the UCL itself. Had he been skeletally mature, there likely would have been more stress being placed directly on the ligament itself. So, this was good news for all of us.

We received the results on Tuesday October 31. With clearance to pitch last weekend as tolerated by the MD, I elected to have my son throw a bullpen last week. He threw 25 pitches on Wednesday night (one week ago) and was at 100% and pain free. As such, I let him throw 40 pitches in our showcase game last Saturday. He again threw pain free. Now that Fall baseball has ended, we will shut him down for some extended rest and focus on arm care and overall strength and conditioning as he continues his HS workouts.

Some key takeaway points for players, parents and coaches:

• Never dismiss pain that occurs with throwing
• Educate players about throwing related soreness/tightness (such as lactic acid build up that would be typical after a start on the mound) so they can differentiate that from true pain
• If velocity, mechanics or performance in a player suddenly drops, be suspicious of a potential injury knowing that most players will try to throw through it (look for shaking/rubbing of the arm, grimacing or other body language that is outside the player’s normal routine)
• If you suspect an injury, seek out an immediate assessment from a knowledgeable physical therapist and/or MD who treats baseball players as they will do a more comprehensive evaluation and uncover the root cause of dysfunction faster
• Getting imaging in a higher level player will provide peace of mind for the athlete, parent and coach allowing for proper care and progression back to pitching as evidenced in this situation
• Managing pitch counts, innings pitched and recovery between appearances will be instrumental in preventing or reducing injuries

In the end, we must rely on the athletes to communicate what they re feeling. Often, pitcher push through fatigue and pain in the spirit of competition. It is imperative that we advise against this in order to promote long term health and prevent more serious injuries. I know I feel fortunate that my son’s injury was not serious at all.

Moving forward, I will adjust his off season and in-season throwing to ensure he actually conditions his arm with more frequent throwing (not pitching) to ensure his endurance is better, as I feel this may have been a factor in his overuse scenario. While he threw a weekly bullpen this summer, he only threw on average 2 days per week on top of that. He threw daily in middle school ball last year and never had any arm related issues on the mound.

Each player is different in terms of their build, pitching capacity, arm talent, etc. With that said, I think it is important to analyze their performance over the year based on innings pitched, pitch counts, rest between outings, strength program, throwing programs and perceived fatigue to evaluate what works bets for the player. Educating players and parents about arm care and health management strategies will reduce injuries and facilitate long term success for pitchers that have a chance to play in college and beyond.