Easy Ways to Prevent Serious Injuries in Pitchers

Hello All,

I know normally I talk about how certain mechanical or muscular flaws can be a cause of injury in pitchers. Today however I wanted to give some really quick and easy ways to prevent injuries. Too many highly talented and well paid major league pitchers have been placed on the DL secondary to these types of easily preventable injuries. So I came up with 5 quick tips of things I see all the time and I wish guys would just stop doing.

Ok here we go.

#1 – DON’T BAT  LEFT HANDED IF YOU ARE A RIGHT HANDED PITCHER

Tim Lincecum bats left handed, exposing his $12M /year arm to a 95 mph fastball. Why would you do this? Its not like his bat is a great contributing factor to the giants offense. This really makes no sense to me. You can’t be that much better left handed than you are right handed. Bat righty Timmy, don’t take that chance.

#2 – RAILINGS ARE NOT FOR JUMPING OVER

Ryan Dempster found himself with a broken toe that put him on the DL after casually trying to jump over the dugout railing. It takes two seconds to go around buddy.

# 3 – DON’T GET ANGRY

We all know Brian Wilson has a crazy streak in him, and that’s why we all love him. But last year when he took his rage out on an innocent Gatorade tub with a bat, we all cringed. The last thing giants fans needed was Wilson to be out with a strained shoulder from swinging that bat in rage.

Other pitchers have broken hands from punching walls when upset. Bottom line – don’t get angry you’ll just get hurt.

# 4 – WATCH YOUR STEP

We have seen this so many times; pitchers or position players running in from the field into the slippery dugout and down those oh-so-difficult steps. One slip and fall later and they are on the DL for a sprained ankle or back injury. Just read the sign boys and watch your step.

# 5 – DON’T WARM UP 100 FEET FROM THE PLATE

I love ATT&T park. It is my favorite place on the planet. However, I’m waiting for the day someone warming up in the bullpen gets nailed by a foul line drive down the line. Its unnecessary; build our boys a pen !!

So five simple ways to prevent injuries in pitchers.

Don’t worry next week I’ll be back to writing the nerdy stuff.

Happy Friday everyone, and GO GIANTS.

House

Brian Wilson – Tommy John

Its true.

Our beloved bearded wonder will not be closing this year. But long before the wonderful run in 2010 and the beard that became a San Francisco sensation, Brian Wilson’s elbow underwent significant stress to the point of a ligament rupture and the long rehabilitation of Tommy John Surgery.

I thought this would be an appropriate time to give ya’ll a run down of Tommy John surgery, what some of the main reasons for it are, why Brian Wilson may be looking at his second, and what that means for him trying to come back an All-Star closer.

First off a little about what Tommy John surgery is, and why it is used so much in baseball.  The Ulnar Collateral ligament (or medial collateral ligament) is made up of three different bundles of fibers that runs along the inner aspect of the elbow. The job of the the UCL is to provide stability at the elbow, especially when the shoulder is externally rotated like the cocking and acceleration  phases in pitching (below )

Because the UCL’s job is to protect the elbow during the throwing motion, overtime the UCL can weaken and eventually rupture, causing instability at the elbow and an inability to throw. Poor throwing mechanics and weakness in the muscles of the shoulder, trunk and even lower body, have been found to relate to a pitchers likelihood of injury at the elbow.  The number 1 factor in UCL tear is bad mechanics, and the number 2 is overuse. You put them together and you are an injury waiting to happen.

The details of poor mechanics are for another blog, but one thing that stands out and is something you can look for when watching for mechanical flaws is where the elbow and shoulder are when the lead foot makes contact. You want the arm up and in what we would call external roation, meaning it is just about ready to come forward and release the ball. When you see the arm below the shoulder it means the shoulder and elbow are behind the trunk and legs and puts a tremendous amount of stress on the shoulder and elbow. Looking at Strausburg (tore UCL in first season in the majors) and Cain ( hasn’t missed a start in his 7 years in majors) you can see a difference.

Tommy John surgery is used for a player that has significantly torn or even ruptured their UCL. The repair involves using an unimportant ligament from the  opposite forearm, threading it through the ulna and humerus of the dominant arm, and allowing the new ligament to scar down and add stability to the elbow. Many times the player may have increased velocity following the surgery secondary to the ability of the new ligament to withstand more force than the original. I learned personally in my time interning with the padres that many players view tommy john surgery as a positive, thinking that they will have the surgery and a year later will be throwing 3-5 mph harder.

Not necessarily the case.

AT BEST a player will throw off the mound for the first time a year after having TOmmy John, however it can be up to 18 months, and only 80% of pitchers that have the surgery make it back the level they were throwing at before. However over time that graft can deteriorate, and without changing the mechanics, one can find themselves right back where they started.

Brian Wilson was pitching on borrowed time. And if you look at how his release point has changed in the last three years, you can see this damage to his elbow started a while back.  The graph below represents his horizontal release point and you can see the release point continued to decrease dramatically and that puts tremendous stress on the elbow.

Now lucky for Wilson he stopped pitching before it ruptured and it sounds the the MRI is showing only grade II sprain. In a pitcher that hadn’t had the surgery yet Tommy John might be appropriate, however Brian Wilson may opt out of it and try and rehab it without surgery secondary to the much poorer outcomes of a second surgery.

Of course, all of baseball hopes he comes back.

Moral of the story though?

If it breaks and you fix it, make sure you address WHY it broke to begin with.

GO GIANTS,

House

Tim Lincecum vs Trevor Bauer

This blog could be very extensive, however I’m going to try and keep it short and sweet. If you do not know who Trevor Bauer is yet, you will.  He was the 3rd overall draft pick by the Arizona Dbacks  in the 2011 draft from UCLA ( go bruins!). Bauer may have gone number 1, except he does not fit the typical build of a major league pitcher.

Sounds a little like someone I know😉

Tim Lincecum is 5’11” on a good day and a whopping 165 lbs soaking wet. And although Trevor Bauer is a more typical 6’2″ he only weighs in at 185 lbs. Both pitchers overcome their physical disadvantages with mechanical advantages, and although Trevor admits to utilizing many of Tims mechanics they do differ in a few ways.

Both pitchers have a long stride length, although Trevor can be deceiving because is is quite a bit taller so its not quite as much as Tim’s 127% stride length.  Looking at the two pictures below , both pitchers are just about to strike the ground  their lead foot.

If you look at their right arm it doesn’t take a physical therapist or pitching coach  to see the difference. Tim is still very early in his motion; meaning he has to get his arm from this position into the full external rotation position very rapidly. The disadvantage is the force on the shoulder, the advantage is the hitter will see the ball very late. With Trevor you can see how far his arm is behind him as his foot comes down, meaning his shoulder and arm will have to catch up to his body and put a lot of force on the shoulder.
When you look a little later in the motion, now both their chests and hips are facing the batter.  What I notice most in this phase of their motion is the differences in elbow flexion. When you see more flexion in this position I worry about how much force the elbow is taking. The ligament that protects the elbow in this position is strongest at 80 degrees. So anything more or less puts more stress on the elbow.
Lastly is the difference in follow through.
Tim has the iconic high leg lift, while Bauer uses more of this arm to follow through. Most people will say the follow through doesn’t really matter as far as mechanics, however as a physical therapist I think it does. When Tim lifts his leg, he uses his lower body to help decelerate his arm. Without the leg lift the muscles in the back of the shoulder and back must work harder to slow the arm down, and those muscles can be then prone to fatigue and injury.
So those are a couple of my thoughts on the two. Both are excellent at using mechanical advantages to succeed. I do worry about the longevity of Bauer, so we’ll see how that plays out. People worried about Tim too and he seems to be doing just fine for now.
Just about 1 week until the season starts and I couldn’t be more ready!
House

Platelet Rich Plasma Injections – Treating chronic injuries in top athletes

In the recent years, elite athletes like Alex Rodriguez, Closer Joe Nathan and golfer Tiger Woods have undergone the new fad in rehabilitation called Platelet Rich Plasma Therapy. Rodriguez underwent a treatment of these injections last month in Germany for chronic problems in his knee and shoulder. In Europe, and now recently in the United states, an increased trend has emerged of using  the PRP injection because its promising alternative to surgery and decreases time on the DL. So I thought I’d write a quick little note about it since you’ll start to hear more and more about this treatment in baseball and other sports.

So first of all lets start with what the heck are platelets?

Basically blood has 3 components: red blood cells, white blood cells and platelets. Plasma is the liquid component of the blood, mostly its made of water (which is why you should drink it more!) Platelets are mostly thought of as clotting agents…they help form the scab sick people like to pick. However they do so much more than that by removing dead tissue, promoting healing, and regenerating healthy tissue.  Normally 6% of blood is made of platelets, however PRP works by increasing the percentage to 94%.

The idea is that if you put a concentrated amount of the good stuff into an area thats not healing, good things will happen.

In the baseball world, the injection is being used for players with chronic tendonitis in the knee, shoulder, wrist, elbow and ankle. When tendons have to overwork ( like throwing 90 miles an hour over a hundred times) time and time again, they can thicken and become injured. The injured tendons heal by scarring down, which actually makes the tendon less able to perform a task like throwing a baseball. Tendons have very poor blood supply and therefore don’t heal well. So what sports medicine doctors are doing is drawing blood from the player, spinning the blood and removing all the red and white blood cells, and injecting the platelets into the specific tendon that has scarred down. This then jump starts healing.

Players that have the injection are usually then instructed to not move or use the joint for up to 6 weeks. After that they are freed to go back to baseball activities. The benefits are that you are using your own blood, and it can be a much quicker recovery than having surgery. Of course PHYSICAL THERAPY is a very important step before and after the injections to prevent the problem from coming back.

Keep your eye out this season for the PRP injection….

HOUSE

Athletic Pubalgia – Nick Markakis and Ryan Zimmerman

A surgery this week to Baltimore Orioles outfielder Nick Markakis caught my attention. His case is very interesting and something I thought I’d share with you all. Markakis initially injured himself last September while stealing 2nd base when his belt buckle dug into his pelvic area and caused him immediate pain. This injury was re-aggravated while diving for a catch in right field on the last game of the year, causing him the inability to remain in the game. After the season was over Markakis had an MRI and was diagnosed with a bone bruise and instructed to rest. After adequate rest time, and no change in his symptoms, another MRI was perform and muscle tears in his rectus abdominus (Athletic Pubalgia ) were diagnosed, and recently surgically repaired.

Baltimore Orioles - Nick Markakis

Earlier in the 2011 season Washington Nationals third baseman, Ryan Zimmerman, underwent a similar surgery to repair torn muscles in his abdominals. Zimmerman didn’t have a specific injury to his abdominals, however continued to have persistent abdominal pain that progressed and was eventually diagnosed as Athletic Pubalgia.  Although he was told 6 weeks, it was nearly 12 weeks before Ryan Zimmerman was back in action for the Nationals.

Although Athletic Pubaligia, is often called a “sports hernia” it is not a hernia. The term “sports hernia” is sort of an umbrella term that refers to any tear of muscle, tendon or ligament in the lower abdomen or groin. These tears can occur with quick sudden changes in direction, forced hip movement with the foot planted, or with forceful exertion of the abdominal muscles. It is commonly found in athletes who participate in sports that involve repetitive twisting and turning such as football, baseball, soccer, ice hockey, rugby and tennis. It can cause abdominal/groin pain, increased pain with sprinting or twisting, pain with coughing or sneezing, pain during and after activity and minimal pain at rest.

Muscles and Tendons Involved in Athletic Pubalgia

There are several muscles of the abdomen and groin that attack to the pelvic bones and serve to stabilize the joint during twisting motions. In the picture to the left you can see the rectus abdominus (your six pack muscles ) attach to the bone of your pelvis, as well as your External Obliques, the hip flexor and groin muscles. You can see that with repetitive swinging, tremendous amount of stress will be placed on this structures and eventually micro tears and tears can occur. It has been theorized that an athlete may be prone to this injury if muscle imbalances are present with strong adductor (groin) muscles and weak abdominal muscles. The strong going muscles can create a pull that can overpower the abdominals and make these muscles prone to tears.

The surgery to repair these torn muscles is similar to reconstruction of the knee. The surgeon with re-attach the muscles down to the bone using sutures that will provide stability. After the surgery, the athlete can expect to be walking the same day, however will be limited in lifting and baseball activities for up to 6 weeks. The most important part of rehabilitation for Nick Markakis, as well as anybody else, is to address the imbalances that contribute to this injury. If those imbalances are not addressed in rehabilitation he may continue to have pain and possibly re-tears in the future. This could be the reason it took Ryan Zimmerman longer than expected to return. Markakis will be focusing on stabilizing with his abdominals (rectus, obliques and transverse ) more, and firing his going muscles less.  My guess is Markakis will be at 100% be the second week of the regular season, should everything go as planned in rehab.

Thats all for now. Hope that makes sense.

Football playoffs means baseball season is right around the corner. GO NINERS.

Blessings,

HOUSE

References

Sueki, Derrick, and Jacklyn Brechter. Orthopedic Rehabilitation Clinical Advisor. Maryland Heights, MO: Mosby Elsevier, 2010. Print.

“MLB News | MLB.com: News.” The Official Site of Major League Baseball | MLB.com: Homepage. Web. 08 Jan. 2012. <http://mlb.mlb.com/news&gt;.

Home Page. Web. 08 Jan. 2012. <http://coreperformancephysicians.com/&gt;.

How Effective is Internal Rotation Stretching?

 

I ask myself this question a lot when putting someone on a stretching program.

The most common injuries in baseball players involve the shoulder and elbow, and pitchers are more prone to these injuries than positions players (1). These injuries include SLAP tears, shoulder impingement syndrome, rotator cuff pathology, and Ulnar collateral ligament tears. Researchers that specialize in baseball injuries have found that it is common for pitchers to display a loss of internal rotation and a gain of external rotation in their dominant arm (2). This loss of internal rotation, or GIRD, has been proven to put a player at a much higher risk for injury that can sideline them and possibly require surgery (2,3). There have been several studies with both major league and collegiate players that have shown how beneficial stretching the shoulder can be in reducing the amount of shoulder internal rotation loss for a  (4, 5). However I often wonder if players can actual make changes to their range of motion that are significant and will last.

A significant study came out in 2008 that demonstrated the effects of the “sleeper stretch” immediately on shoulder mobility, however were unable to determine whether or not this would have lasting effects on injury prevention.

The Sleeper Stretch

There is much debate about what causes the change in shoulder mobility, however most people agree there is some component of soft tissue changes, and the defecit can be improved with stretching. A recent study looked at what the long term effects of stretching was on professional baseball players (5) They looked at players after 3 years of being in a stretching program and found them to have better shoulder mobility than those that had been stretching for less than 3 years. Those players were performing a few stretches DAILY for 3 years. Seems like a lot, I know. Their program was the following:1) passive internal rotation stretching 2) cross body stretch

Passive Internal Rotation Stretching

Cross Body Stretch with Scapula Stabilize

 

The most recent study demonstrated that the loss of internal rotation is neither permanent or necessary, and that ideally with stretching the player will maintain the gained external rotation with no loss of internal rotation. Although it may take up to years for these changes to become permanent.

Interesting.

Stick with the stretching boys.

 

House

REFERENCES

  1. Wilk, KE, Meister K, Andrews JR. Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports med. 2002;30(1):136-151.
  2. Bukhart SS, Morgan CD, Kibler WB. The Disabled Throwing Shoulder: spectrum of pathology. Part 1:pathoanatomy and biomechanics. Arthroscopy. 2003; 19(4): 404-420
  3. Dines, JS, Frank JB, Akerman M, Yocum LA.. Glenohumeral Internal Rotation Deficits in Baseball Players with Ulnar Collateral Ligament Insufficiency. Am J Sports Med. 2009; 37(3): 566-570.
  4. Laudner, KG, Spines, RC, Wilson, JT.  The acute effects of sleeper stretches on shoulder ROM. Journal of Athletic Training. 2008; 43(4) 359–363.
  5. Lintner, D, Mayol, M, Obinna, U, Jones, R, Labossiere, D. Glenohumeral Internal Rotation Deficits in Professional Pitchers Enrolled in a stretching program. Am J Sports Med. 2007; 35(4): 617-62

 

 

 

 

 

 

 

 

 

 

A lesson from Residency

Every once  in a while I forget where I am. Every once in a while, I forget why I wanted to be here in the first place. Some days just blur together. Sometimes I see my patients as my work, and  I don’t even blink. Its just another day.

But its never just another day.

Its funny, and by no means coincidental, that I find myself in a rut of daily routine, and then out of nowhere something will snap me out of it and remind me just why I wanted to be doing this .

Today was one of those days.

In many ways, residency has taken over my life. I find myself more stressed, more fatigued, and less social than I ever was in PT school. There are many days I lose the joy of being able to help people to the demands of going through a program that sets high standards and expects a high level of skill. I often worry far more about myself than I do about my patients.

This last week so many things have been on my mind, and most of them have been about myself. Residency will be over in six months and my bosses, family members, and myself are all starting to ask too many questions. What are MY plans for next year? What job will I take? Where will I go? What can I get next? Life choices are coming up for me and I’ve spent so much time focusing on them lately, I’ve lost sight of why I am here.

5 years ago, I opened a phone book and called the very first physical therapy clinic listed: Agape Physical Therapy, in hopes of getting a job as an aide. I figured since “agape” means godly love, it would be a great place to start. Later that day I was at the clinic getting trained. NOT coincidence. 3 days later I watched a women take her first steps in over 3 years following a stroke, and decided right then and there that I wanted to do that for the rest of my life.  I worked at Agape for 2 years, under two of the most caring, compassionate and skilled therapists I’ve ever met. They gave me my first exposure to physical therapy. They inspired me to impact the lives of our patients. They encouraged me to apply for PT school, and supported me every step along the way. Today, on my lunch break, I received word that one of the therapist that guided and molded me so much had fallen very ill.

The news effected me greatly, and my afternoon was difficult to get through. God however, like He always does with his perfect timing, gave me a great reminder of why He has me here. I went to the waiting room this afternoon to get my patient, and nearly dropped to my knees when I saw him. You see, I’ve been seeing this patient for nearly 6 months now. He is a young kid (20 is a young kid ok) who had a bullet rip through his sciatic nerve, and leave him with the inability to walk without a brace on his paralyzed foot and a walker. When he first came to me he said the only thing he wanted was to be able to walk without a walker. He told me he was so embarrassed to walk down the street, being so young, and needing  walker. So we decided together that was the goal, to get rid of that walker and give him a chance at returning to his normal life. His mother, who comes with him to every appointment, him and myself have been working tremendously hard to make that happen for him.

6 months later, he stood up from his chair in the waiting room, no walker, and walked towards me with the biggest and best smile I’ve ever seen.

And my insides went to mush.

Indescribable.

And I thought back to 5 years ago, back at Agape physical therapy, and remembered why I was here.

To my fellow therapists, and friends that are just about to graduate and step into the field for the first time: may we never forget the opportunity we get each and every single day to impact the lives of those God has entrusted into our hands.

“Let no one ever come to you without leaving better and happier. Be the living expression of God’s kindness: kindness in your face, kindness in your eyes, kindness in your smile.”
-Mother Theresa