Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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I recently featured this exercise in my online column for PFP Magazine. This is a great arm care exercise that should be part of every overhead athlete’s routine, especially my throwers. I like to use these types of exercises to prepare the shoulder for higher level lifts as well as serve as staples of an in-season or off-season arm care program.
Click here to read the full column.
High school baseball season is upon us. My son is a high school junior and recently verbally committed to pitch for a Division 1 school. He has worked hard to earn that offer, but the part most people do not see is the arm care and recovery work we do for him behind the scenes. Below is a recent picture of him in action.
I see lots of baseball players in my clinic ranging from 10 year olds to my MLB guys. One of the biggest issues I confront in my players (more commonly pitchers and catchers) is a condition known as internal impingement. While not the same thing as subacromial impingement, it still can impact the rotator cuff. Essentially, there is friction that causes irritation and in some cases injury to the rotator cuff and/or labrum. This usually manifests as pain in late cocking and the inability to throw hard without pain. Pitchers report decreased velocity and catchers struggle to thrown down to second with their their normal ease.
One of the most common issues leading to this is a loss of total shoulder motion on the throwing arm. Most notably, some players display significantly less internal rotation (IR) range of motion. Some loss of internal rotation is normal and expected over time provided they gain enough external rotation (ER) on the throwing side to counterbalance the asymmetry. Often, too much throwing early in the season or a big jump in pitch count/intensity/volume coupled with the ROM loss causes pain. This can occur suddenly or gradually build up over a few outings or games.
In the case of shoulder pain and dysfunction, the lower trapezius and serrates anterior are often implicated as part of the problem. Research has shown that these two muscles often fatigue and don’t contribute equally to the force couple between them and the upper trapezius that facilitates upward rotation of the scapula.
Building scapular stabilization and dynamic stability is a must for those doing repetitive overhead activities such as throwing, swimming, serving, or work-related tasks. It is a given that asymmetries will exist, so optimizing the strength of the rotator cuff and scapular stabilizers is paramount to prevent injury and recover from overuse syndromes.
To strengthen the lower trapezius, one of my ‘go to’ exercises is the lower trap raise. It can be done with just the weight of your arms or using light dumbbells. The link below includes the full description for the exercise, and I also embedded the video below.
http://fit-pro.com/article-4137-Lower-trap-raise.html
In the next column, I will include a serratus anterior exercise using a kettle bell as a follow-up to this post.
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.
In most gyms and training circles, people are performing bench press or push-up exercises. There is no doubt in my mind that repetitive heavy full range bench press causes many of the labral and cuff injuries among males I have seen over the years These injuries are often the attritional type – developing over many months and years.
What about push-ups? Is the force development pattern the same? Are they safer? Honestly, I believe in keeping the elbow at a point at which it does not drop below the plane of the body (bench press) or move above the body (push-up). Essentially that means keeping to a 90 degree angle or less. Why? Well, regardless of load, I feel the real risk is not so much in the motion itself but the very repetitive manner in which it occurs with external loads, often lending itself to acquired anterior shoulder laxity, strain on the proximal biceps anchor (think SLAP lesions) and secondary shoulder impingement. The picture below hurts my shoulders just looking at it, and over time this technique will hurt your shoulders too.
But, I say all that to set up today’s post. In a recent article in the February edition of the Journal of Strength & Conditioning Research, David Suprak et al. looked at the effect of position on the % of body mass supported during traditional and modified push-ups.
The study looked at 4 static positions in 28 males (about 34 years old) who were highly trained and members of the special forces or SWAT team (the up and down position for regular and modified push-ups) to determine the change in body mass (BM) supported by the upper body in different ranges of motion. The down positions studied were at approximately 90 degrees (the lowest depth I safely recommend) and all holds were performed for 6 seconds.
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