Lumbar Spine Stress Injuries in Baseball Players

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Low back pain can be very debilitating in an athlete, especially in an adolescent baseball player trying to make it through his season. More specifically, I have noticed an increase in lumbar spine stress fractures in baseball players and it is quite disturbing and frustrating!

I wanted to dive deep into this rabbit hole, as I always do. Low back pain is way too common in youth athletes. I wanted to know why it’s happening so often and try to figure out a solution for my clients.

It can get complicated so I will try to simplify the process.

My goals:

  1. What is a stress fracture or a stress reaction?
  2. How common is this injury in youth sports compared to other sports and age groups?
  3. What is the typical clinical presentation?
  4. What are some clinical tests that PT’s can use in the clinic?
  5. Demonstrate a typical treatment of a young athlete with a low back stress injury?
  6. What are the expected outcomes?

Pain is Complicated

Low back pain can take on many etiologies. Pain, in and of itself, is extremely complicated and very personal.

It can manifest in different ways for each person. In this post, I want to talk about the athlete with an acute injury. Specifically, the youth and adolescent baseball player.

Many factors can contribute to someone’s pain including stress, anxiety, medical history, their environment, support system, etc.

This topic is a bit more personal because of what do on a daily basis. I see a ton of youth athletes with a variety of injuries. Plus, I was diagnosed with spondylolisthesis (bilateral fracture in the spine and some shifting of the vertebral body) while a junior in college so I’ve lived it myself!

Recently, I’ve started to see a lot more athletes with low back pain as a result of a stress reaction or fracture. It really made me wonder what was truly causing this in the 12-18 year old athlete.

Video example

courtesy of pitching coach Anthony Meo of The Farm Baseball Waltham, MA

As you can see in the video, the pre-injury video shows how long the pitching motion is for this athlete. His throwing arm is wrapped around his body which forces him to keep his weight back.

His arm is trailing his body significantly and he tries to make up for it by hyperextending his back. His timing is way off and his arm is not keeping up with his forwardly moving body.

You can see in the post-injury video that he is much more balanced. His arm also has better timing with his body. He is driving toward home plate with his lower body while maintaining a better upper body sequence

There are many issues going on here but you can see the significant changes that were made after the injury to help him improve his mechanics and hopefully prevent a future injury.

LUMBAR STRESS INJURIES DEFINED

Stress Reaction Defined

Basically, a stress reaction is the early breakdown of the bone without a clinical diagnosis of a true fracture. Often times, a suspected fracture will be diagnosed as a stress reaction. On MRI, there is only edema noted in the area and not a true fracture.

I hear a lot of people talk about fractures in different terms. Simply stated, a fracture is a crack, break, defect in the bone. Whether it’s a hairline fracture or a gross disruption of the bone may determine prognosis but the bone has been compromised.

taken from: Link
taken from: Link

Obviously pain is an early sign but it needs to fit the clinical presentation. Has there been a history of excessive activity or a change in the volume of playing?

Factors to consider in a baseball player with low back pain

I usually have to dive a bit deeper into the player’s life to figure out the root cause. It’s often something very overlooked but is often the main contributor.

These are just some, off the top of my head, that may be involved in the athlete’s predicament and that may nee to be changed.

It is an early indicator that something is wrong and it can progress to a stress fracture if not carefully treated. We’ll talk treatment later on so be patient!

How common is a stress reaction in youth sports?

As with any research, it is quite mixed and will heavily depend on the sport that you are tracking. From what I can see, if a kid has low back pain for greater than a week, then that’s a pretty good sign that a more serious injury may be present.

For example, this retrospective case study from 2017 showed that 30% of pediatric cases with low back presenting to this hospital were diagnosed with spondylolysis.

Specializing in a single sport was not associated with an increased risk of spondylolysis when compared with multisport athletes. Male athletes were 1.5 times more likely to have a spondylolysis than female athletes.

Males with LBP who participated in baseball had the highest risk of being diagnosed with a spondylolysis, followed by soccer and hockey.

Females with LBP who participated in gymnastics had the highest risk of spondylolysis, followed by marching band and softball. I will refer to my good friend Dave Tilley and his website for his professional judgment on this one. Based on what I see at our facility, I’m not surprised.

As I usually tell my clients and their families…I’m going to treat this as a spondy until proven otherwise.

More Research on Spondylolysis Prevalence

According to recent research, it looks as if persistent pain for 1-2 weeks is associated with a positive MRI diagnosis for spondylolysis in 33-40% of the kids scanned. You can read the abstracts here and here if you’re interested in more.

This study out of New York showed that the most common athletic activities associated with spondylolysis were:

  • Soccer (19.3%)
  • Basketball (17.2%)
  • Lacrosse (9.4%).

Of note, 71% of the children in this study were male and the most common level to have the spondy was at L5.

Do keep in mind that false positive results are pretty prevalent in patients getting an MRI for low back pain.

Don’t treat the MRI (or x-ray!)

This systematic review looked at the incidence or prevalence of incidental findings on MRI in asymptomatic pediatric patients. The results are pretty eye-opening too!

  • Degenerative disc disease (prevalence 19.6%)
  • Disc herniation/protrusion (prevalence 2.9%)
  • disc height/narrowed disc space (prevalence 33.7%)
  • Spondylolisthesis/spondylolysis (prevalence 2.3%)
  • annular tear and/or nerve root compression (prevalences ranging from 4.5-51.6%)

Pretty amazing to see the prevalence of false positives read on an MRI in a pediatric population. We need to be able to clinically diagnose these first then use the MRI scan to further determine a course of action.

Baseball specific injury rates

In this study from 2015, the proportion of High School baseball players with a low back stress fracture was 3.3%. So, a typical AAU baseball club of 100 kids will have 3 kids that have a stress fracture.

They also reported that High School girls sustained more stress fractures (63.3%) than did boys (36.7%) but for overall injuries and not just in the low back. This seems consistent with what I see in my practice, as well.

In college, 12.1% of the stress fractures noted in this NCAA study from 2017 were in the low back. Women experienced stress fractures at higher rates than men, more often in the preseason, and predominantly in the foot and lower leg.

Baseball Specific low back pain

This nice review of the literature discusses low back pain in general athletes. They went on to further discuss baseball and “the asymmetric baseball postures and motions lead to asymmetric spondylosis in right and left sides and cause mechanical degeneration in intervertebral discs.”

In this study, “students who played baseball were 3.2x more likely to experience LBP in their lifetime only behind volleyball which had an odds ratio of 3.8. 

The repetitive nature of the baseball specific movements and a preponderance to specialize in one sport can definitely affect these injury rates.

The role of mental stress and low back pain

The role of stress, particularly mental stress on bone development, has been studied too. Our teenage athletes are under a tremendous amount of stress at home and socially. This study from 2017 discussed the emerging concept of mental stress as an important player in bone adaptation and its potential cross-talk with physical stress.

Essentially, mental stress can have a negative impact on normal hormone production. Hormones are needed to maintain normal bone health. A shift in normal hormone regulation can negatively affect a youth’s growth and healing capabilities.

They went on to say that there is “compelling evidence has recently emerged that biochemical and psychoneuroendocrinological maladaptations caused by mental stress are not only also relevant for bone quality, but may furthermore considerably interact with physical stress.”

Clinical Presentation of a Spondylolysis or Spondylolisthesis

Clinically, pain is the guide here. It’s often described as a pretty sharp pain that is localized to the site of the injury.

There is rarely a referred pain down the leg or the buttocks. The pain is often close to the spine at the level of the injury.

In this study, activities involving repetitive hyperextension and/or extension rotation of the lumbar spine were described as painful in 98% of the patients.

Pretty powerful statement. In my examination, I look to recreate these symptoms with these exact movements.

Many use a single-legged position, also known as the Stork Test, to test for spondylosis. I’ve simplified the test to just include regular standing on 2 feet to simulate regular daily movements.

A standing extension test can also be used to assess end range extension and rotation irritability. I find this test (see video below) is a great way to begin to hone in on a diagnosis.

I find that pain in full hyperextension and rotation is a pretty powerful indicator of a stress reaction or fracture. It is similar to the standing position that I described above. However, the prone position takes the postural component out of the picture and may help to better isolate the location of the lesion.

I also like to have the patient get in the prone position and use different levels of active extension to help guide my clinical examination.

Again, people will report pain that is very close to the spine and that replicates their pain.

Any young athlete with low back pain for greater than 1 week should be assessed for some kind of bony issue in their low back.

That’s not to say that we will always find something.

But I just think that in younger athletes, this prevalence is all too common and needs to be ruled out to prevent further low back issues.

Treatment for Spondylosis in Baseball Players

Muscle tenderness too

Patients will usually have tenderness right at the region in which they have pain. I suspect it’s the muscles that stabilize those lumbar segments.

The multifidi and most likely quadratus lumborum are often implicated. Soft tissue work of any kind can have positive effects on muscle tightness. The athlete should perform some self-myofascial release with a foam roller or light pressure with a baseball in the affected muscles.

Manual therapy can also be utilized to feel tissue density and help to pinpoint the exact location of their muscle soreness. By utilizing this, I can help to better educate the athlete for their home exercise programs.

Manual Therapy can be helpful

In this photo below, you can see I am applying direct pressure with my elbow right into the muscles of the low back. The patient will usually give me feedback and tell me if I am in the right area. Muscle soreness is often detected and after a short amount of time, the symptoms should decrease.

In the short term, manual therapy can help with some of the acute symptoms. For long-term changes to occur, activity modification and exercises that involve low back, hip and core strengthening are critical.

Soft tissue work to the muscles of the low back in an athlete with low back pain.
Soft tissue work to the low back in an athlete with low back pain.

My treatments for kids with low back pain are pretty simple. I want to rest them from the repetitive activities, such as swinging a bat or even throwing a baseball.

Brace or no brace?

Also during this time, the athlete will most likely have to wear some form of a back brace to prevent excessive lumbar extension and rotation. One particular brace is called a Boston Brace. It was developed by doctors at Children’s Hospital in Boston, MA.

The research is unclear and can favor both methods of treating with or without bracing. A study in 1986 showed that bracing ‘restricted at least some gross body motion to approximately ⅔ to ½ of no-orthosis values.’ The restrictions we’re most pronounced when wearing a larger Thoracolumbosacral orthosis (TLSO) versus just a corset.

If the goal is to restrict motion, then it seems as if a brace will accomplish that. Most research shows about 40-65% restriction in motion no matter the brace. This paper showed similar findings as well.

Here’s a version that our local docs have been using that is less cumbersome and not as embarrassing to wear as a teenager!

Brace used to help restrict motion during a low back stress fracture
Brace used to help restrict motion during a low back stress fracture

These are just some of my quick and easy exercises to help promote movement in the spine.

Obviously, I want to avoid painful motions like lumbar hyperextension and rotation. I still want to promote some sort of motion to build confidence and promote muscle recruitment in that area.

Specific treatment ideas for low back pain

I like foam rolling or some form of self-myofascial release to the area. This will help the muscles to feel better if done multiple times per day. See the video below

Some would say motion is lotion and I tend to agree! I like to use active range of motion through the cat-cow video below.

Cat-Cow exercise to promote active motion in the low back

Some general guidelines for returning to baseball

From what I’ve seen, most baseball players need at least 3 months of active rest.

I’ve written about my general low back treatment philosophies in a previous blog post.

You can find that post here .

Active Rest is key

I generally want to begin a general strength training program at around 6-8 weeks following the diagnosis. It Is critical to include restricted range of motion exercises to avoid painful hyperextension. These exercises are restricted to avoid excessive extension that may place extra stress on the low back. I prefer to bias flexion type exercises like squats, lunges and step-ups.

I like to closely monitor their form and symptoms. We don’t want any pain at all in that region…a very important concept!

I like to perform these exercises for at least six weeks to get a good base of strength in the lower body and core.

Lose the brace at 12 weeks

At about 12 weeks, they will come out of the brace and we can begin to be a bit more aggressive in our strengthening. Again, we are avoiding hyperextension type movements in the low back. We prefer to stay in a flexed or neutral spine as much as possible.

I also like a supine dead bug exercise to promote a flexed spine with active motion. See the video below.

Throughout this time, we encourage cardiovascular exercises that involve the stationary bike. This seems to be a safe modality that allows the athlete to work up some sweat but also maintain a relatively flexed spine, which is usually pain-free.

Unrestricted activities at 5-6 months

At around 5 to 6 months post-diagnosis, we encourage for pain-free activities that involve strength training for the whole body. There are no limits in range of motion in the athlete is free to work out. We then encourage more functional activities that involve rotation. This will allow them to replicate the motions involved with hitting and throwing.

Return to sports at 6-8 months

On average, it seems as if a patient recovering from a low back stress fracture will need at least 5 to 6 months before I would feel comfortable having them return to their support. These injuries usually happen in a younger population so the risk for re-injury is pretty high if they return to their sport too quickly.

I believe the risk is high because of their underdeveloped muscular system. Their bodies are growing and tremendous stress may be placed upon their joints with excessive activities. A slow progression back to their sport is critical.

Concluding thoughts on stress fracture injuries in youth athletes

Baseball players face numerous challenges during their training.

As you can see, numerous injuries can result and not just to the shoulder and elbow.

Low back pain injuries are all too common but are often preventable. It seems as if the volume of throws and hits may play a huge role. It is up to the coach, physical therapist, or athletic trainer to monitor this workload for each athlete.

There is no exact science but listening to the athlete is critical. A well-balanced training program that addresses some of the obvious weaknesses is key.

Treating Patients with Low Back Pain

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My thoughts on treating low back pain

As many of you may know, I have been practicing physical therapy since 2003. Throughout that time, the clear majority of my patients have had injuries to their extremities. Yet, I somehow was able to ‘avoid’ treating patients with low back pain (LBP). As has been with most of my career, I wanted to share my thoughts on treating low back pain and how I went from completely confused, to utterly intimidated and finally to embracing a common injury.

My early years of LBP rehab and confusion

When I first graduated from PT school, I worked in an outpatient sports medicine practice in North Carolina. I saw a little of everything. There, I was mentored by a very senior PT who specialized in low back pain.

She tried to introduce me to the rotated innominate (didn’t even know what that meant at the time) and how she could fix people with those issues. I looked at the charts of her patients and they had been coming for years.

To me, that seemed like they trusted her and she was helping them. Then I realized quickly that maybe there was more to the story. Maybe she was or wasn’t helping them, but I could never say anything. Something was working so this new grad just went with it.

She would spend hours of her time explaining the pelvis and how we could influence its position. My mind just couldn’t grasp the biomechanics. To this day, I think I’ve blocked out many of the concepts because they just didn’t make sense to me.

They even sent me to an Institute of Physical Art class out in western NC. Again, I couldn’t grasp it which is ironic because I’m very much a biomechanics type guy when it comes to the extremities.

The back was just a mystery to me!

Nothing against the IPA course, but it didn’t jive with me. I just couldn’t apply it to my patients when I didn’t understand it in the 1st place.

Going back to my rotated innominate… I just faked it that I could feel the sacral torsion or the elevated ASIS.

As a new grad, I didn’t want to seem like my palpation skills sucked so I went along with the process. I just never applied it to my patients. I just did exercise with them, because that’s all I knew.

The Evolution of my LBP Fear

When I moved to HealthSouth in Birmingham, AL we had a separate spine department that was run by 2 PT’s. You know what that meant, I didn’t treat any spine patients!! Not sure why they did that, but I wasn’t going to complain.

This trend continued on when HealthSouth had a little accounting issue and Champion Sports Medicine was founded in late 2004.

Again, no spine patients on my schedule for ~ 10 years. Rarely, a patient would be on my schedule for more than a visit or 2 before I’d move them to the “Spine PT.”

Spine Scaries

I just didn’t have an interest in the spine and from what I had seen and heard, I didn’t agree with many of the ‘theories’ out there. I watched other PT’s look for limitations in individual spinal segments from the cervical spine to the sacrum…and even the coccyx (mind blown!).

Any time someone tried to teach me their assessments, I could never feel what they were feeling. No one felt limited or rotated unless I pushed a little harder with one thumb, then all of them were ‘rotated.’ I’m right handed so everyone seemed left rotated because I could push harder into the patient’s anatomy with my right hand.

So again, my faith in spine rehab dwindled and I built my practice around sports medicine and post-op injuries. That’s my niche but I knew that when I moved to Boston to help open Champion PT and Performance that I would have to make my skills better.

My current Approach to low back rehab

My career has been about simplifying my approach to physical therapy. In my earlier days, people were trying to help me (definitely grateful) but conceptually I just couldn’t grasp it.

I knew that there were very small the joints in the spine, but I just couldn’t ‘feel’ the millimeter or 2 of motion that was present. My palpation skills were dismal, but it turns out we may not be able to palpate what we think we’re palpating. (research) (More research) (even more research)

With that, I needed a game plan for my big return to my hometown, Boston.

My Macro Views

In my head, I could conceptualize watching someone move and trying to figure out if a movement dysfunction was the culprit. More of a macro view of the person instead of a micro view, like looking at individual joint segments.

My macro approach often came back to a strength issue or a simple overuse issue that led to back pain. We often blow this off and don’t account for it in our education and treatment.

Don’t Overcomplicate it!

In PT, we try too hard to complicate things.

Let’s think about it, if someone has pushed their tissues beyond their physiological limits (whatever that means), then something has to give.

In my opinion, most people that I see have overuse injuries as a result of overactivity or inactivity. It’s that simple. They’ve either pushed their muscles/joints beyond their capacity and the body is giving a warning.

Or they just don’t do enough to maintain, and the body is pissed off.

Answer in the details

For example, I see many people with non-specific low back pain that are active. Either playing baseball or working out. But, when you dive a bit deeper into their lives, they may have just started a new program that had more volume (weight training volume, more swings of the bat, more deadlifts).

It’s often stories of their (in)activities that are directly contributing to their current state. Never mind if you dive even deeper, then they reveal a stressor in their lives that MAY also be adding to their pain.

I am certainly not a pain science expert, but I can add up 1+1 and realize that life stress + physical stress can play a HUGE role in someone’s experiences of pain.

How I treat Low back pain

So what I do is pretty simple.

I assure my patients with lots of education and encourage early motions. Like any other joint, our body needs to move. Our joints need to move.

The last thing I want to do is discourage someone from moving.

I need to create an environment that is relatively pain-free and creates confidence in their ability to move. Trust me, I’ve been there!

What helped me, you ask?

I had an acute low back spasm a few years ago that was awful!

Advil, foam rolling my low back (what seemed to be my quadratus lumborum), soft tissue work to my low back (again, maybe my QL) and general low back/hip muscles and exercises. No one told me that I had a rotated innominate or that I had too much motion at L5/S1.

I don’t even know what that means.

All I did was try to move each day with a little less pain. I did things like Cat-Cow and dead bugs. I also did clams and bridging. I stretched my hip flexors and tried to squat a bit. I just did anything to promote a safe and pain-free movement.

It built confidence and it built function.

Most people need that after they hurt their back. I know we’re always looking for the reason why the pain occurs. We try to blame the anatomy or the biomechanics because we’re ‘movement experts’.

Keep it Simple

But I say we need to take a step back and realize that it can be even simpler than that. If we sit 8 hours a day, then we’re stagnant and our tissue capacity dwindles. Imagine sitting all day then randomly try to go play 18 holes of golf!

The muscles, tendons, ligaments and anything else in that area are not conditioned for the 90+ strokes it will take to finish the frustrating round.

You wouldn’t try to run a 10K without training for it 1st. Your legs and the cardiovascular system just wouldn’t allow it.

It’s the same thing with the concept of sitting all day then trying to be active. It often won’t work. You need to train the tissue!

Final Thoughts on Low Back Pain

If anything comes out of this blog, I hope it takes some of the scary thoughts that are out there and simplifies them a bit. The human anatomy is so much more complicated than we think. We can’t just blame a rotated innominate or left rotated lumbar spine segment for the dysfunction.

All of the systems seem to play a role but as PT’s we think we can control a couple of them.

I say build tissue capacity by a general strength training program that builds confidence in the client. Let them leave feeling super positive about themselves and I guarantee that your outcomes will be so much better.

No worrying about fake palpation, popping backs and charts that are years deep of short term relief. Hope I didn’t offend anyone but sometimes the truth hurts and I want my readers to hear my simple perspectives.

Now get out there and embrace your next low back pain patient (but don’t worry about the cavitation!)

The Week in Research Review, etc 12-24-18

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The Week in Research Review, etc 12-24-18 only had two posts to social media this week but hopefully two very helpful posts for your practice.

The back pain post was a repost from a previous time but I thought it was very important to share it again. I also put a new post from my YouTube channel where I discussed patellar mobility assessment for instability. Check the post out at the link here or below to see the full version.

Physical Therapy First to Treat Low Back Pain

[ICYMI} Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs. Frogner et al Health Serv. Res. 2018

The Week in Research Review, etc 12-24-18This study compared the differences in opioid prescription, health care utilization, and costs among patients with low back pain (LBP) who saw a physical therapist as the first point of care, at any time during the episode, or not at all.

Patients aged 18-64 years with a new primary diagnosis of LBP, living in the northwest United States, were observed over a 1-year period.

Patients who saw a PT first had:

  • a lower probability of having an opioid prescription (89.4 percent),
  • any advanced imaging services (27.9 percent),
  • and an Emergency Department visit (14.7 percent), yet 19.3 percent higher probability of hospitalization.

Interestingly enough, 80% of the patients in the sample had no PT at all. Furthermore, 8.7% saw a PT first and 11.5% saw a PT later (avg 38 days). The most common provider seen 1st was a chiropractor.

Assessing for Patella Instability

Assessing Patella Mobility

💥Assessing for Patella Hypermobility💥

This Instagram snippet shows how I assess a patient with suspected patella hypermobility who may have sustained a subluxation, dislocation or instability episode.

To see the full video at my YouTube Channel, click the link here!

Basically, we’re looking at how mobile the patella is when the knee is locked at full extension compared to when the knee is flexed to about 25 degrees.

Normally, the patella should become relatively stable when the knee is flexed to 25 degrees because it engages the trochlea groove.

In patients with underlying patella hyper-mobility, the amount of mobility with the knee slightly flexed will be similar to when the knee is in full extension (and not locked into the trochlea groove).

This is often the case when the patient’s trochlea groove is too shallow to offer bony stability.

The test should help the clinician gain a better understanding of the patient’s anatomical make-up and prognosis for the long term.

Check out the full video at my YouTube Channel.

The Week in Research Review, etc 11-12-18

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This week in research review for 11-12-18 we focused a bit more on assessment and also dabbled in some basic treatment strategies for the back and shoulder. Check out the topics below and like them or comment on Instagram to keep the conversation going…thanks all!

 

  • A quick fix for a sore low back?
  • Knee Fat Pad Testing and Diagnosis
  • How to Assess the Elbow for a Tommy John (UCL) Sprain
  • Lumbopelvic control on shoulder and elbow kinetics in elite baseball pitchers
  • Full Can or Empty Can? – by @mikereinold

 

Looking for a quick fix for a sore low back?

I’m speaking from personal experiences when I post a few of the common exercises that have helped me tremendously in the past.

I’m not saying that this is all you have to do but I do think that new onset of low back soreness, you know that tightness that you feel on either side of your spine, can be somewhat alleviated with some foam rolling and active range of motion.

I would definitely include more focal strengthening of the core like deadbugs and bird dogs, squats, deadlifts (when they’re ready), etc.

But for the purpose of this post, I think some foam rolling and motion to the area can take the edge off of someone’s soreness and get them feeling a little better. That’s my goal for many and hopefully those small gins can add up to big gains in the long run!

Do you utilize these techniques as well? If you don’t, then I suggest that you try! They’ve helped me numerous times and continue to help me when my soreness gets a bit out of control.

Tag a friend who may want to check out this post…thanks!

Thanks @corrine_evelyn for the demos!

 

Knee Fat Pad Testing and Diagnosis

Here’s an excerpt from a previous blog post where I talked about anterior knee pain fat pad irritation. Link in bio!

Keep in mind, my differential diagnosis is all over the place at times. With knee pain you need to consider:

Meniscus (see my previous blog post)⠀

ITB

Osteochondral lesion

Patella tendonitis

Pes anserine bursitis

MPFL sprain

Hamstring strain

Plica syndrome

MCL/LCL

Tumor

Infrapatellar fat pad irritation can be functionally debilitating. I believe it presents itself pretty often in the clinic, more than most PT’s realize.

Use this test to see if it truly is a fat pad issue.

 

How to Assess the Elbow for a Tommy John (UCL) Sprain

In this excerpt from my YouTube channel, I discuss the tests that I use to help identify an elbow sprain, typically seen in the baseball players that I treat.

In the full video, I discuss:

✅Joint Palpation

✅Seated Milking Sign

✅Prone Valgus Test (maybe a new one for you!)

✅Supine end range External Rotation with Valgus Extension Overload (VEO)

I also wrote a blog post about this topic so hopefully you’ll go to my site and read a bit more about this.

If you treat baseball players of all ages, then you should know how to diagnose a UCL sprain.

 

The influence of lumbopelvic control on shoulder and elbow kinetics in elite baseball pitchers

Laudner et al JSES 2018.

This study looked at 43 asymptomatic, #NCAA Division I and professional minor league baseball pitchers. They measured the bilateral amount of anterior-posterior lumbopelvic tilt during a single-leg stance trunk stability test.

The Level Belt Pro (Perfect Practice, Columbus, OH, USA) was used to assess anterior-posterior lumbopelvic control. The LevelBelt Pro consists of an iPod–based digital level secured to a belt using hook-and-loop fasteners.

This test has been used and studied previously by Chaudhari et al (JSCR 2011) and he showed that pitchers with less lumbopelvic control produced more walks and hits per inning than those with more control.

Also, pitchers with less lumbopelvic control have been shown to have an increased likelihood of spending more days on the disabled list than those with more control (Chaudhari et al AJSM 2014).

“The results of our study show that as lumbopelvic control of the drive leg decreases, shoulder horizontal abduction torque and elbow valgus torque increase.”

Have you tried this simple test? I will say that having the ability to detect millimeters of motion is clinically difficult.

It is good to see such a simple test utilized clinically can help aid in determining the need for more core/hip exercises for our pitchers. In all, I think it’s a safe bet to incorporate these exercises in all pitchers’ programs.

 

Full Can or Empty Can?

– by @mikereinold 

Great Post by @mikereinold on which motion is BEST to isolate the supraspinatus during arm elevation. I know you can’t isolate the supraspinatus but numerous studies have (Kelly et al 1996, Reinold et al 2004) shown that the full can (or thumb up position) is better than the empty can position.

Check it out below! 👇🏼

Full Can or Empty Can? – by @mikereinold⠀⠀
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🧠 WANT TO LEARN MORE FROM ME? Head to my website MikeReinold.com, link in bio.⠀⠀
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I’m still surprised after all these years that I still see the empty can exercise kicking around. I analyzed these two movements many years ago in an article in JOSPT and showed that the full can exercise (thumbs up 👍) had similar EMG of the supraspinatus with lower levels of deltoid EMG, while the empty can (thumbs down 👎) had higher levels of deltoid EMG.

Why does this matter?

Well, think about it. If you are performing this exercise you probably are trying to strengthen the rotator cuff. And if you are weak and performing an exercise with more deltoid, the ratio of cuff to deltoid will be lower and you’ll have more potential for superior humeral head migration.

Plus, let’s be honest, the empty can just hurts… It’s also a provocative test, and I don’t like to use provocative tests as exercises. 😂😂😂⠀

 

The Week in Research Review, etc 7-29-18

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Last week was the 1st of my research review that summarized my social media posts from the previous week. It seemed to be well received so I figured I’d continue it. My goal is to help summarize some of the research that I found interesting and package it nicely for my readers.

Each photo contains a link back to a social media feed where you can see the conversation that ensued and maybe chime in…or just be a passive reader and see where the conversation went. You never know where the conversation may go on social media…so be ready! haha!

Socioeconomic Factors for Sports Specialization and Injury in Youth Athletes Jayanthi et al Sports Health Journal 2018.

This study looked at the effect of socioeconomic status (SES) on rates of sports specialization and injury among youth athletes.

They looked at injured athletes between the ages of 7 to 18 years that were recruited from 2 hospital-based sports medicine clinics. They compared these with uninjured athletes presenting for sports physicals at primary care clinics between 2010 and 2013.

They concluded that:
✅High-SES athletes reported more serious overuse injuries than low-SES athletes
✅More hours/wk playing organized sports
✅Higher ratio of weekly hours in organized sports to free play
✅Greater participation in individual sports

I applaud the authors for attempting to bring this very difficult collection of data into a formal research paper. I will say some of the statistics and standard deviations may not make the conclusions as powerful.

I do think this is a good paper to help educate our athletes on injury rates, especially in those that specialize in 1 sport.

What do you think? Tag a friend that may benefit from this article!

From #Twitter’s @retlouping that perfectly sums up what I’ve observed recently on social media with many PT’s.

For some reason, pain science has overtaken most diagnosis and treatment conversations.

It’s as if you get bullied into talking pain science and ignoring our clinical judgment and diagnosis skills. I understand there’s a constant tug-of-war between the biomechanical PT’s and the pain science PTs.

But as usual, the answer usually lies somewhere in between and both groups are correct. The biomechanics of an injury are often important as well as the language we use to explain these tissue biomechanics.

To my fellow clinicians, especially the newer grads and #dptstudent, remember this little cartoon for every future encounter.

Yeah, speak to people in non-threatening tones (in my world it’s just being respectful) but trust me, they WANT to hear what could be going wrong or what may be causing their pain.

Don’t blow off their symptoms and don’t go into depth about pain science because they won’t understand.

Trust me, the clinicians that try to do that often end up losing their patients in the long run.

I hear these stories day after day of people coming to me because the last PT either only talks to them or made them ONLY do strength exercises and it didn’t help their pain.

The PT didn’t listen to them and was so blinded by their pain science background that they ignored the person sitting right in front of them. Remember, the person sitting there will tell you what is going on and what treatment will most help them feel/move better.

Influence of Body Position on Shoulder and Trunk Muscle Activation During Resisted Isometric Shoulder External Rotation Krause et al Sports Health 2018.

The purpose of this study was to examine ER torque and electromyographic (EMG) activation of shoulder and trunk muscles while performing resisted isometric shoulder ER in 3 positions:
✔️Standing
✔️Side-lying
✔️Side plank

Using surface EMG and a hand-held dynamometer, the researchers tried to determine EMG activity of the:
✔️infraspinatus
✔️Posterior Deltoids
✔️Mid traps
✔️Multifidi
✔️External/internal obliques (dominant side)
✔️External/internal obliques (non-dominant side)

EMG values for the infraspinatus were greatest in the side plank position. In general, EMG values for the trunk muscles were also greatest in the side plank position.

✅Their Conclusions: If the purpose of a rehabilitation program is to strengthen the rotator cuff, in particular, the infraspinatus, the side plank is preferred over standing or side lying. If the goal is to simultaneously strengthen both the rotator cuff and trunk muscles, the side plank position again is preferred.

Makes sense but good to see the research and have concrete evidence to back up what we think actually goes on.

Tag a friend who may be interested in this research paper!

Reliability of heel-height measurement for documenting knee extension deficits. Schlegel et al AJSM 2002

Prone heel-height difference of 1cm equates to 1.2 degree difference in knee extension ROM.

Do you use this method to assess knee ROM? I still measure knee extension ROM is supine but find this method helpful as well.

I know my friend and colleague @wilk_kevin has measured this way for many years. i originally saw his use this technique at @ChampionSportsM

I don’t want people to confuse this with prone hangs for knee extension ROM. I am not a fan of that method as I’ve stated in the past.

This is a method to assess knee extension differences, particularly after an ACL reconstruction. I have gone back to using this method for some people that have subtle ROM differences side-to-side.

The patella position (on the plinth or off) did not matter in the study and thigh girth did not appear to make a difference.

I would recommend stabilizing the pelvis to prevent excess ROM from occurring at that region and to better isolate the knee joint.

Have you tried this method? Tag a friend who may benefit from using this ROM method…thanks!

Evidence-Based Best-Practice Guidelines for Preventing #ACL Injuries in Young Female Athletes: A Systematic Review and Meta-analysis Petushek et al AJSM 2018.

Injury prevention neuromuscular training (NMT) programs reduce the risk for anterior cruciate ligament (ACL) injury.

Eighteen studies were included in the meta-analyses, with a total of 27,231 participants, 347 sustaining an ACL injury.

The overall mean training amount was 57 sessions totaling 18.17 hours (roughly 24 minutes per session, 2.5 times per week).

They concluded:

✔️Interventions targeting middle school or high school–aged athletes reduced injury risk to a greater degree than did interventions for college or professional-aged athletes.

✔️Continued exposure to neuromuscular training throughout the sport season seems to enhance prophylactic effects of NMT.

✔️NMT interventions were effective for female basketball, and handball athletes and interventions including various athletes were potentially effective (eg, soccer, basketball, and volleyball).

✔️ Interventions included some form of implementer training (eg, instructional workshop, video, or brochure) on proper program implementation.

✔️Programs including more landing stabilization and lower body strength exercises during each session were most effective.

🤔Programs including balance, core-strengthening, stretching, or agility exercises were no more effective than programs that did not incorporate these components.

✔️ Specifically, programs that included more landing stabilization exercises (eg, drop landings, jump/hop and holds), hamstring strength (eg, Nordic hamstring), lunges, and heel-calf raises reduced the risk for ACL injury to a greater degree than did programs without these exercises.

✅ Wow, lots of great information here. Please share this with a friend or colleague who may benefit from knowing this information.

Hope that helped to catch you up on my posts from this week.

Do you like these weekly updates? Let me know if I should continue…love your feedback!

Thanks for reading!

The Evolution of a Physical Therapist

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I’ve been a practicing Physical Therapist since 2003. I’ve observed a lot, talked to a bunch and read a lot. By all means, I am no expert! The evolution and growth of a physical therapist can take many roads.

I am always learning and listening but at times I do become complacent (that’s human nature). I’d be the 1st to admit that. I sometimes get stuck in my ways despite what others are saying in the literature or on social media.

I think that’s the great thing about social media…it keeps me listening. It has helped me to evolve and keep me on my game.

Ultimately, what has kept me on my game has been my desire to give my patients the best care that I can give them. I would expect the same from my own personal healthcare provider (I have a PCP, dermatologist, and a rheumatologist).

We have a responsibility to be the best for our patients. There are a lot of people chirping their opinions all over the place s I wanted to take this time to reflect on how I’ve seen many PT’s grow.

I’ve always wanted to write this post but I was inspired by my friend and co-owner of Champion Physical Therapy Mike Reinold when he posted this graphic on his Instagram feed.

I’d like to briefly chat about the evolution of a physical therapist through my eyes.

There seems to be a general development that occurs in the PT world- most are good but I’m beginning to see a side that is a bit disheartening. Maybe it’s a social media thing but I think we need to take a step back and re-evaluate for a second.

We’re always looking for a protocol to guide our patients. Here’s my attempt at the phases of a PT…Hope you enjoy (some of it is tongue-in-cheek so don’t get all crazy on me!)

The New Grad DPT student

This is the hungry, newly crowned physical therapist looking to break into the profession. Their eyes finally on the prize but probably scared to death (I hyperbolize). No more clinical instructors to guide you. No more reliance on someone else to lead the way. The plan of care is all yours!

Looking at your schedule for the next day or week, you may see that eval that worries you. Someone on the schedule with a diagnosis of “LBP” or a post-op ACL.

It was easier to treat these when your CI called the shots and you could observe, help and chime in with your thoughts and treatments. Accountability was minimal but the rewards seemed grandiose when the patient emerged with better function.

  • When is it safe to push an ACL?
  • How fast should one start strengthening after a rotator cuff repair?
  • When is it safe to start a throwing program after a Tommy John surgery?
  • What do you tell the patient when they come in with their 1st episode of acute low back pain and how do you treat it?

These are just a few of the challenges a new grad has to face.

Insurances are daunting. People can be daunting. You greatly influence the functional outcomes of that person sitting in front of you. Your words and actions matter but you don’t know that yet.

I often compare this stage to a new NFL quarterback who struggles to read defenses and rushes the ball when he throws…oftentimes to a defensive back waiting for an easy interception. He wasn’t anticipating that defense and got nervous. The game was moving too quickly and he can’t keep up with the schemes.

This is the new grad, a simplified version, but one that tries to do a lot but has minimal experiences and abilities to “read the defense.” The game is moving quickly and your decisions often come with little confidence.

But don’t worry, the game will slow down a bit.

2-5 years out and Feeling Confident

At this point, you’ve seen a bunch. You better understand the complexities of people, the medical system and how to kinda manipulate your way through. You realize that you can do it but your school studying was only a small prep for reality.

You’re motivated, finding your groove and beginning to get comfortable. There are still some questions but you don’t have to rely on the other PT’s in your group to help with progressions.

Pubmed has hopefully become your greatest ally, hopefully.

Although I do run into many that rely on Facebook and Twitter for their ‘research’. There’s always a post looking for advice on progressing a meniscus repair or return to a sport after an ACL.

I’ll often direct them to PubMed because just feeding people research is not helping them in the long run. They need to know where to find the information and learn how to interpret it.

The game is slowing down and your confidence is growing. Some even think they’re super-confident and try to ‘take on the world’. They are the ones out on social media leading the charge for change. A revolution of sorts…that their way is better than what has been done the past 5, 10, 20, 40 years!

They’re seeing their practice through rosy glasses with blinders. Blind to the fact that there are many before them who equally tried to champion a cause only to find out there’s more to it. The journey, although it seems triumphant and vigilant, falls short.

There will always be a new treatment technique, new modality a new system that is promising better outcomes. Your words, although seemingly loud, fall on so many deaf ears because the ship is going to steer itself. You’ve tried to lead the charge only to learn that the profession of PT is bigger than you.

You can only control what happens within your practice, or the few people that follow you on Instagram.  Although those ‘followers’ are often bots of some sort, pretending to like your content.

It’s a strange world out there, your words are seemingly wise, but there are so many out there shouting similar words that it gets drowned out. You think your experiences, although limited in the grand scheme of things, should guide your practice and the people that ‘follow’ you.

This, my friend, is where you’ve gone wrong. You have a ways to go. In fact, you’ll never get there. You’ll realize that each day presents a new challenge that doesn’t fall into a predefined mental algorithm.

When you have this revelation, then I think you’re ready to explore the next phase of your growth curve.

5+ years- beyond

The chart above calls you an expert but I’m not 100% a fan of this. No one in our field is truly an expert because there are challenges way above anything we could ever control.

Each personality that enters into our facilities presents with life stories that have shaped their pain, their expectations, and their outcomes.

But you know what, it’s at this stage that you realize that you are only a small piece of the puzzle. You can only help guide the process based on your plethora of experiences.

You’ve stayed on top of the literature and have altered how you practice. You no longer think that your way is the best but have dabbled in many other systems and taken a bit from all of them. Your way is NOT the best way.

You also have come to realize that there are always outliers out there. You know the ones that think the extreme positions are the best for all patients.

For example, there’s a huge social media push that says “manual therapy sucks”. No one should use manual therapy and you’re only wasting your time.

The flip side arguments say that there are many people that have a shifted inominate (whatever the hell that means) or a rib that is out of place. That therapist has been pounding on that pelvis or relocating that rib 1x per week for 52 weeks and has that patient convinced that they need more visits.

These are the outlier PT’s (I’m not speaking for other professions so don’t try to sucker me in) that are loud on social media but don’t necessarily represent the majority.

You see, the majority are trying to do it correctly (at least I think they are). The young PT that is 2-5 years out only sees those outliers as a challenge to his/her practice and is trying to yell at them. When in reality, you’re speaking to the minority, the group that barely exists.

You should be speaking to everyone else. The ones on social media that have taken a middle-of-the-road approach. They are doing their best, are on facebook looking for advice and busting their butts in the clinic.

They are limited by resources, time and updated knowledge. These are the people hungry to learn but are stuck somewhere in the 3 categories above.

These therapists are the ones you should be trying to chat with. You recognize that your vast experiences can help them.

It’s when you have this breakthrough that I think you’re ready to enter that last growth phase. You’re confident in your practice and willing to share. You speak to other groups, you publish clinical research, and you review research papers for journals.

To me, this is the utmost level and should be where most of the PT’s strive to get. Your knowledge continues to grow as you read. Each patient experience and interaction is another mental data point that sharpens your practice. These data points will blend in with your research readings and produce a so-called ‘expert’.

I invite you to challenge yourself by aligning with a clinician or group that produces clinical research, reviews journals and stays on top of the literature. Until then, don’t talk the talk unless you can walk the walk.

Some will think I’m being harsh, but I think you’ll have the realization, like I did back in the day, that our PT profession is bigger than us. Control what you can control and keep the ultimate goal in mind- THE PRIORITY IS TO GIVE THE BEST CARE FOR OUR PATIENTS, ALWAYS!

I’ve written about this before…about empowering the patient and keeping them in the driver’s seat. Check it out here.

I’d love to hear your comments. Please share with your friends, new grads and experienced PT’s. Social media has given many a voice but the loudest voices are not always the wisest voices!