To follow Dr. Nick’s post from last month, we will be touching on a few different topics we see on the performance training side. This is how we begin our approach to all our athletes that come into the facility. Whether it’s a shoulder issue they come to us about or a brand new athlete to our facility that needs their initial assessment done. It is our outline on how we begin to build an athletes program. We may lose you here, this is pretty in-depth stuff.
Most athletes have abnormal motion, our job is to teach them how to control it. Structure dictates function, function dictates whether there is dysfunction. We need to get the athlete to start in proper alignment. The shoulder internally rotates the humerus between 7000-8000 degrees per second. Throwing a baseball is the most violent motion in all of sports. MRI’s reveal that more than 80% of shoulders in baseball players have tears in the labrum or fraying in the UCL. The difference is how many of those are symptomatic? Studies have shown about 30% of the shoulders had symptoms. To help keep the athletes asymptomatic or “healthy”, we like to start by looking at the resting posture and active assessments.
We like to look for adducted posture (scaps are pulled together) puts the elbows behind the shoulder and drives the humeral head forward. If we see this, it can mean we need to look at rhomboids being over active because the rhomboids are a scapular downward rotator. This can determine where the humeral head goes. We usually use a wall slide variation to fix this. Most baseball players over forward rolled shoulders. If the athlete is in extension (anterior pelvic tilt) the head of the humerus can be driven forward in the GH Joint and the lat is pulling down the scap. The lat’s fascia connects to the pelvis, as you can see all the muscles are effected by each other.
Extension posture is seen very often in the baseball population. A few things we look at in our screens that may cause this type of posture are; breathing patterns, resting posture, anterior core stability and control, over head flexion, thoracic mobility, scapulohumeral rhythm, hip mobility, how much internal/external rotation of the hip/shoulder the athlete has, knee stability and ankle mobility.
When we look at internal rotation of the shoulder we look at both active IR and ER. The lat being an internal rotator to the humerus, (Dr. Nick Thurlow will talk about this later) we see an over work of the lat when it comes to strength and conditioning programs dealing with baseball players. When the lat is over worked it can cause scapular depression, the anterior shoulder capsule to drive forward and drive some one into gross extension. The lat being the dominate muscle that it is can deviate the glenohumeral joint and cause scapular dyskinesia also known as a SICK Scap.
Lat tightness and glenohuemral instability all go together. Shoulder instability implies a certain symptom is present. Acquired external rotation drives more anterior instability of the glenohumeral joint. Working with a baseball population where we see guys with the ability to externally rotate more than the normal population, we never want to stretch the shoulder into external rotation. This will increase the instability and irritate the biceps tendon which can pick up the stability role when instability is present. When you have anterior shoulder issues there more than likely is something else going on. (nick talk about this)
First we need to know what a healthy shoulder is before we can discuss a SICK scap. There are three primary motions that take place at acromioclavicular joint. They are internal/external rotation, anterior/posterior tilting and upward/downward rotation. All of the motions take place on the scapular plane. If you train in our program you will hear the coaches say work in the scapular plane, what we mean by that is we want the humerus 15 degrees in front of the frontal plane. Scapular upward rotation occurs when the arm abducts more than 30 degrees and at the acromioclavicular joint perpendicular to the scapular plane. The glenohumeral joint is surrounded by a very loose capsule that tightens when the humerus is abducted. There are three ligaments in the glenohuneral joint. Those being superior (anterior and inferior joint stability), middle (anterior joint stability) and inferior (anterior joint stability). As you can tell these ligaments along with the rotator cuff provide dynamic reinforcement. The most common dislocation of the glenohumeral joint is anteriorly. The labrum adds support to the humerus sitting in the glenoid fossas well as The rotor cuff. This is why we get the athlete into throwing positions instead of static positions to test for faulty patterns.
As soon as the gelnohumeral joint begins to abduct the capsule tightens and increases joint stabilization. The deltoid is the prime mover along with the supraspinatus for abduction of the shoulder. The anterior deltoid is the prime mover for flexion. Scapular humeral rhythm is what happens when the shoulder moves over head and how the scapula upwardly rotates and how congruent with the humerus. What we are looking for is 55 degrees of upward rotation of the medial border of the scap. This is why we use wall slides, yoga push ups and some soft tissue work to round out the upper back.
So why do we see impingements? Impingements prevent full range of motion. It is likely the humerus will glide superiorly into the subacromial space. The more the abduction of the arm the the greater the impingement. The subacromial impingement will be seen early in abduction as the AC joint will be more at the top end of abduction. There may be bone spurs present, scapula and GH may be unstable, lack of t-spine mobility, increased IR, and as everyone knows the hot topic of breathing patterns.
I Hope this was not to geeky for you, hope you read all the way through this lengthy post. We will explain more next time on how to prevent humeral gliding and increasing posterior cuff strength from a training stand point.
This is part one of a four-part series where we will discuss common mistakes and misconceptions while working with baseball players.
Approaching Shoulder Injuries in Baseball Part One: Nick Thurlow, PT, DPT
With baseball season underway pitchers and position players alike are likely beginning to experience the rigors of high school baseball and the demands it places on their arms. These demands can lead to a myriad of shoulder issues, including impingement, bicep tendonitis, scapular dyskinesia, labral pathologies, and instability, just to name a few. Oftentimes, this brings the athlete to a physical therapist, chiropractor, trainer, etc. where a generic range of motion assessment combined with orthopedic special tests may recreate their symptoms. The provider then attempts to resolve these symptoms by addressing just that, the symptoms. Pain (ice, e-stim, ultrasound), tightness (Dry needling, stretching, foam rolling, massage), weakness (internal/external rotation exercises, scapular strengthening) are addressed in an attempt to make the athlete feel better and perform their best. However, as the athlete returns to sport they oftentimes struggle throughout the season with their symptoms. Coaches, parents, providers might chalk it up to too much playing time, not enough treatment, or improper offseason preparation.
The Problem: Feeling better DOES NOT equal moving correctly.
The Solution: Identify the Root Cause.
In order to identify the root cause of a shoulder injury (or any injury), we use a functional movement assessment tailored specifically to baseball players so that we can identify neuromuscular inhibition (we’ll talk about this later). Rather than using active and/or passive range of motion, a functional movement assessment will reveal movement dysfunctions throughout the athlete’s entire kinetic matrix. Possibilities include (but are certainly not limited to) squat asymmetries, decreased single leg stability, decreased thoracic and/or lumbar mobility, or ultimately dysfunctional arm patterns. Regardless, it is our responsibility to identify and correct these dysfunctions so that the entire body can work together as a matrix in order to throw a baseball and decrease the likelihood for shoulder problems. It is NOT our responsibility to make the athlete simply feel better. Athletes can feel better with rest, athletes can feel better with modalities, and athletes can feel better with manual therapy. But if we can make that athlete move correctly, not only will they feel better, they will perform optimally.
But why was the athlete moving wrong in the first place: neuromuscular inhibition. It is the primary ingredient in the recipe for injury and put simply, neuromuscular inhibition is the muscle’s inability to contract properly due to a lack of proper nerve stimulation (think lightbulb in a lamp flickering because it’s not plugged in right). If the muscle(s) cannot contract properly, the athlete will not move correctly, resulting in their shoulder symptoms. So if we identify the movement dysfunction and work to eliminate the neuromuscular inhibition causing it through our patented manual therapy technique, the athlete will feel better, but most importantly, move correctly.
If you have any questions please feel free to contact Dr. Thurlow at (720) 502-7023 or by calling our Loveland office at (970) 593-9300
Dr. Nick Thurlow, PT, DPT
In part two of this series, we will discuss Lat tightness, Glenohumeral instability and scapular dyskinesia. Stay tuned!
Most of a typical person’s day is spent at work. It should be no surprise that a good portion of the patients we see at One80 are coming to us due to job related injuries. Just like athletes who do active warm ups prior to exercise and use proper equipment in order to minimize the risk of injury, everyone should be preparing themselves for the activities of work.
Work related injury can range from a stiff neck due to poor ergonomics, a lumbar disc injury from lifting a heavy box, foot pain from improper shoe wear, or shoulder pain from repetitive reaching. Just by changing a few things, like your desk set up, doing a pre-work warm up, assessing footwear, and learning proper body mechanics, you can decrease the chances of a work-related injury.
Assess your workstation
Follow these tips to decrease the likelihood of cervical issues, thoracic outlet syndrome and carpal tunnel problems.
Keyboard: Place the keyboard directly in front of you, your arms should hang comfortably and your elbows should be at a 90 degree angle. Adjust the slope of the keyboard so that your forearms, wrists and hands feel comfortable, and avoid resting on hard edges.
Mouse: Make sure the mouse is located immediately to the right or left of your keyboard. Use a mouse that fits well in your hand.
Monitor: The middle of the screen should be at eye level and directly in front of you so there is no need to turn your head. The monitor should be approximately two feet away from you. If you find yourself leaning forward or backwards, you may need to check your eyesight.
Sitting vs standing: Standing desks and workstations have become very popular recently. We are big fans of using both a sitting and standing workstation in order to change position throughout the day. If you don’t have a standing option, try to get up every 15-20 and take a short walk around your work area. Spending some of your workday sitting on a physioball is another great way to put your body in a different position and engage different muscles.
If your job involves lifting, pushing, pulling, reaching, squatting or maybe even throwing, there are a few things you should due to avoid injury:
Are strong enough for the job? Employers usually give a baseline assessment to new hires in order to make sure they can tolerate the job. This doesn’t mean you are in great shape, it just means you meet minimum requirements. Employers would be smart to include a gym membership or an onsite work out area with some type of exercise education in order prevent on the job injury.
Use a daily warm up routine. Once again, a savvy employer would integrate an active total body warm up into the work day. In as little as 10 minutes, many workman’s compensation claims could be eliminated. This plan would also educate employees on the dangers of stretching, foam rolling, massage, etc.
Report injuries immediately. The faster you assess and treat an injury, the faster you can recover. Having either an onsite medical professional (PT, ATC, MD) or one close by that your company contracts with, can make the difference in missing a week or a month of work.
Break it up. Try to avoid doing the same task repetitively or sitting in one position all day. Take a quick break to do a functional movement pattern or take a short walk. No time? No room? No clue what a functional movement pattern is? Ask One80, we can show you that you do have time, you do have room, and the exercises are easier than you think.
As you can see, some easy preventative ideas can keep employees and employers from falling into the workman’s compensation rut. If you’d like One80 to help your company design a specific prevention plan or provide rehabilitation services, give us a call and add us to your team. As always, “Think Different. Live Well.”
One of my favorite things to talk about is MoStreBility because it has so much to do with what we do as physical therapists, coaches, trainers, and professionals throughout the medical community. Before we get too far, let’s first take apart the pieces of MoStreBility, which are motion, strength, and stability.
Motion – The ability of a joint to experience full motion, actively, both with and without load, in a functional plane (a-planar). We want our athletes and patients, healthy or injured, to obtain full, active, functional range of motion. Be careful when talking about motion, it is NOT synonymous with “flexibility.” Stay tuned for the pitfalls of flexibility in a future blog.
Strength – Strength is what gets us in and out of the end range of motion. It’s what produces the power for us to do work at our highest level of performance. It is what gives our joints stability allowing them to function efficiently and avoid breakdown. One huge component of strength that many people, including medical and performance experts, forget about is that: strength (more specifically neuromuscular facilitation) is what allows normal joint motion. When people say, “I need to get my motion back,” they forget that motion is directly dependent on strength.
Stability – This is the ability to move from one position to another, under a load, without a loss of strength or reduction in performance. A stable joint will neither move too much (hypermobile) or too little (hypomobile). We want joints to go through full range of motion, with normal tension (supplied by muscle) so unnecessary tension, compression and shear are not being transferred to tissue such as a ligament, cartilage, or bone.
So, motion + strength + stability is MoStreBility. And if you have MoStreBility, your chances of being injured are little, your chances of recovering from an injury are much greater, and your performance level increases. Without MoStreBility, you may have motion, but you don’t have the strength or the stability to make that motion safe. Let’s look at an example of a runner who’s healthy, but has some hip pain.
After performing a functional screen, we conclude that a patient doesn’t have enough internal hip rotation. If we’re just looking for motion, we can simply stretch the hip rotators by using external pressure to force joint motion. We could also find the “tight” muscles that are limiting motion and massage or foam roll them. Both of these scenarios will get us motion. But what did we sacrifice to get that motion? We sacrificed strength, and we sacrificed stability. The patient then runs a 5-10K with great range of motion, poor strength, and poor stability. What’s going to happen? Decreased performance, increased risk of injury, and joint breakdown.
After the run, they will most likely say something like, “I felt good for a while, but now my hip is really tight and hurts even more.” If we don’t know any better, we give them another massage, send them home with a handout of 5 pre-run stretches, and sell them a foam roller. Eventually they stop running, continue to run with pain, or find someone who understands MoStreBility.
Early in my career, before the One80 System had been developed, I began looking at my patient’s pain and injuries through a different lens. I compared and contrasted patient symptoms and wondered if there were similarities amongst the injuries I was treating.
I knew that the recipe for injury was a combination of certain ingredients at a specific moment in time. So, I asked myself: If I can prevent these components from integrating, can I prevent the injury from occurring?
On the flip side, I wondered: If I eliminated these certain “ingredients” after an injury had already occurred, could I eliminate an existing injury altogether?
Just like baking an apple pie, there must be specific ingredients mixed together to produce the end product. Without flour, apples, or eggs, your apple pie can’t exist, therefore your injury can’t exist. Similarly, in order to have an injury (either chronic or acute), the following four ingredients must have collaborated at the time of injury.
1. Gravity – Gravity is what keeps us attached to the earth but also causes joint compression. Since we can’t eliminate gravity in our every day lives, we had better figure out how to live with it.
2. End Range of Motion – We experience range of motion every day. This occurs even more frequently and at extreme levels if we’re dealing with an athletic individual. Athletes are successful because they are able to get their joints in and out of end range of motion quickly, efficiently, and safely. If we restrict our bodies from performing in extremes of motion, we would eventually loose motion and become limited in our functional abilities.
3. Transverse Plane Motion – All functional movement has some type of transverse plane or twisting component to it. Whether someone suffers a hamstring pull, ACL tear, shoulder impingement, ankle sprain, or herniated disc, it’s due in part to the lack of transverse plane control. If we eliminated our ability to twist in the transverse plane, we would become robotic and very limited in our daily lives. So, we once again, need to live productively with this ingredient.
Experiencing the above ingredients is inevitable, but the next ingredient is a wild card that can be removed (effectively preventing future injury AND reversing current injury) provided the proper measures are taken.
4. Neuromuscular Inhibition – In order for a muscle to fire correctly, it has to be stimulated by a nerve. If a nerve impulse doesn’t stimulate the targeted muscle at the appropriate time, with the appropriate amount of facilitation, the muscle either will not contract on time, or it won’t contract with enough force. This misfiring will negatively affect joint motion and stability. Therefore, when a joint reaches the end range of motion, and there is a transverse plane component, and gravity is applying pressure, and the muscle is unable to stabilize it, either acute injury will occur or chronic joint breakdown will continue. But, if the there is normal neuromuscular facilitation (nerve/muscle communication) providing joint stability, the fourth ingredient in the Recipe for Injury is eliminated and the joint is safe.
So how can we live with the first three ingredients in the recipe and get rid of the fourth one?
Surprisingly, lot of things that physical therapists, physicians, strength and conditioning experts, and coaches do, actually cause neuromuscular inhibition.
By simply asking patients to eliminate common strategies like stretching, foam rolling, massage, joint manipulation, and shoe inserts (just to name a few), and replacing them with active warm up, muscle specific isometrics, barefoot walking, and functional (sport specific) movements, our patients eliminate neuromuscular inhibition and recover from a variety of injuries in as little as 2-3 visits.
All this apple pie talk has got our mouths watering! Here is one of our staff member’s favorite apple pie recipes. Enjoy!
1 pie crust
½ cup unsalted butter
3 tablespoons all-purpose flour
1/4 cup water
2/3 cup brown sugar
1/4 cup white sugar
8 Granny Smith apples (peeled, cored and diced)
*optional: your favorite caramel cubed candy
- Preheat oven to 425 degrees F. Melt butter in saucepan and stir in flour to form a paste. Add water, brown sugar and white sugar. Bring to a boil. Reduce temperature and let simmer.
- Place the pie crust in the bottom of your pan. Fill with apples and sprinkle on caramel candies. Cover with a lattice work of crust. Gently pour the sugar and butter liquid over the crust. Pour slowly so that it does not run off.
- Bake 15 minutes in the preheated oven. Reduce the temperature to 350 degrees F (175 degrees C). Continue baking for 35-45 minutes, until apples are soft.
If you have questions on this entry, feel free to give us a call at (970)593-9300.
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