Shoulder Labrum Tears: 5 Exercises Before Jumping into Surgery

Pain with or without clicking deep in your shoulder may indicate an injury to the labrum.  The glenoid labrum is a layer of cartilage within the socket of your shoulder joint.  It plays an important role in stabilizing your shoulder during pushing movements, overhead reaching and sports that involve throwing.  Repetitive overhead throwing in baseball players often leads to breakdown of the labrum.  Repetitive pressing or pushing movements in the gym can also irritate your labrum.  Trauma such as falling on an outstretched arm or bracing yourself during a motor vehicle accident can injure your labrum.

Surgery is often recommended to repair a torn labrum.  However, exercise can also be a very effective treatment option.  Non-operative management includes non-steroidal anti-inflammatory drugs and steroid injections to decrease pain and inflammation.  Physical therapy and exercise also plays an important role in recovering full function of the shoulder.  This article outlines a game plan for rehabilitating your injured shoulder after a labrum injury.

Glenoid labrum tear

Surgery or No Surgery for Glenoid Labrum Tears?

Both surgery and a non-surgical approach can lead to satisfactory results in 66% to 85% of people with labrum tears.  A small study published in The American Journal of Sports Medicine suggests nearly half of those with labrum tears do well with surgery.  The same may be true for those who pursue non-surgical treatment.  Regardless of treatment, it appears that 80 to 85% report satisfactory results 2 to 3 years later.  However, the level of satisfaction and return to sport in overhead athletes is closer to 66%.  This is understandable given the demands baseball pitchers and tennis players place on their shoulders.

Patients with labrum injuries should undergo 3 to 6 months of non-surgical treatment before considering surgery.  If this approach fails your doctor may recommend surgery.  Rehabilitation focuses on improving shoulder range of motion and strengthening the rotator cuff and shoulder blade muscles.   Below are videos of 2 important stretches and 3 commonly prescribed strengthening exercises you can perform in your home.

Cross Body Stretch

This stretch addresses tightness in the back of your shoulder which are prone to tightness in overhead athletes.  The infraspinatus, teres major, and teres minor muscles can become shortened from repetitive throwing or weight training.  This stretch is performed lying on your side with your hips and knees bent.  Your involved shoulder and elbow are positioned in 90 degrees of flexion.  Your hand of the uninvolved arm grasps your elbow and gently pulls it across the body.  You want to feel a mild stretch on the outside or back of your shoulder.  Hold this position for 30 seconds.  The stretch is typically performed 2 to 3 times each session.

Sleeper Stretch

The cross-body stretch is superior to the sleeper stretch for improving shoulder range of motion in young baseball players.  However, the sleeper stretch is the more popular of the two stretches.  Start in the same position as the cross-body stretch.  However, with the sleeper stretch, your wrist and forearm are gently moved down towards the table.  You want to feel a mild stretch on the outside or back of your shoulder.  Hold this position for 30 seconds.  Perform 2 to 3 stretches each session.   For most people, both the sleeper and cross-body stretch do not need to be performed.  My personal experience, and the best available evidence, suggests the cross-body stretch is the most beneficial for improving range of motion.  Choose which one works best for you.

Shoulder Flexion in Side-lying

It is important to strengthen your shoulder muscles while limiting stress on the labrum.  The biceps tendon attaches on to the labrum.  Strong contractions of your biceps muscle can pull on the upper part of your labrum.  Therefore it is desirable to perform strengthening exercises which minimize biceps activity.  Perform shoulder flexion raises in a side-lying position to minimize biceps activity and thus strain on your labrum.  Start on your side holding a light dumbbell.  Your elbow remains straight as you raise your arm slightly overhead.  Your arm remains parallel to the floor as you perform the movement.  Perform 3 sets of 10 to 20 repetitions several times per week.

External Rotation Diagonal

Stand holding a resistance band in one hand.  Anchor the band at knee to waist level.  Start with your hand positioned in front of your opposite front hip pocket.  Your elbow remains bent at a right angle throughout the exercise.  Perform the movement by flexing and rotating your arm across your body.  You should end up in a position similar to the arm cocking part of throwing.  Hold this position 1 to 2 seconds.  Reverse the movement back to the starting position.  This is a great exercise for the rotator cuff and lower trapezius muscle.  Perform 3 sets of 12 to 20 repetitions several times per week.

Prone Row to External Rotation

Position yourself on your stomach with your arm hanging over the side of your bed or a treatment table (if available).  Hold a light weight.  Usually 1 or 2 pounds is enough to begin with.  Perform a high row with your elbow in line with your shoulder.  Pause 1 to 2 seconds then rotate your hand upwards towards the ceiling.  Hold this position 1 to 2 seconds.  Reverse the movement back to the starting position.  This is another great exercise for the rotator cuff and lower trapezius muscle.  Perform 3 sets of 8 to 12 repetitions several times per week.

Tips for Getting Started

Symptoms of a labrum injury can range from a minor annoyance to debilitating.  In many people it severely limits overhead activity and the ability to carry out routine daily activities.  The right exercises can help.  For the best results, exercise 3 to 5 times per week.  Infrequent or random exercise will do you little good.  Give these 5 exercises a shot for at least 3 months and see how things go for you.  If you want more help give us a call.  Our physical therapists can help you find additional exercises right for you and supplement these with manual therapy treatments.   You don’t have to keep suffering and you have options other than surgery.

Band Rotator Cuff Exercises for Baseball: Part 2

Nearly 50% of all baseball pitchers experience shoulder or elbow pain that limits participation at some point in their careers.  The repetitive stress of overhead throwing leads to overuse injuries of the shoulder and elbow.  However, many of these overuse injuries are preventable.  Exercises targeting the rotator cuff are one such approach.  In a previous article (Part 1) we wrote about free weight exercises for the rotator cuff.  Resistance band or tubing exercises are also commonly used to assist in reducing injury risk.  This article discusses the role of band exercises for the rotator cuff as part of a warm-up or conditioning program.

Band or tubing exercises are an important part of pre-throwing warm-up routines for some baseball players.  There are several solid products designed specifically for baseball players.  I recommend any of these: J-Bands, ArmCare2Go, and Kbands.  Band or tubing programs typically include several exercises to activate muscles important in the throwing motion.  They are conveniently performed in the bullpen, dugout, and locker room or on the sidelines.  These same exercises are also important components of rehabilitation and long-term arm care conditioning programs.  The goal of these programs is to maintain high levels of strength and endurance in the shoulder muscles.  Particular attention is given to the rotator cuff and scapular stabilizers because they play a key role in reducing injury risk.

Overview of Band Rotator Cuff Exercises for Baseball Players

During the throwing motion, large forces are generated from the lower body.  Energy is then transferred through the core to the arm.  The arm’s primary function is to dissipate these forces in order to minimize stress to the shoulder and elbow.  Band exercises are a great way to prepare the upper body muscles prior to throwing.  Under these circumstances, 5-7 exercises are performed as part of a warm-up.  One set of 30 repetitions performed in a controlled fashion is recommended.

As part of a conditioning program, these same exercises can be performed for multiple sets 3 to 4 times per week.  It is important to keep in mind; arm care exercises are integrated into a total body conditioning program including the lower body and core.  The following 5 rotator cuff exercises can be integrated into a long-term conditioning program or as part of an individualized warm-up.

Band Diagonal Flexion Pattern

Stand or kneel with a band anchored to a solid base at the side.  The hand begins positioned in front of the opposite hip with the palm facing the body.  The movement of this exercise resembles drawing a sword.  The hand moves across the body and upwards.  The finish position includes rotating the arm so the thumb is pointing behind the body.  As you lower the arm back to the starting position the palm rotates back to face the body.   This exercise activates all rotator cuff muscles at moderate to high levels.  It also performed in a fashion similar to the throwing motion.  This makes it ideal to incorporate into any pre-throwing warm-up.

Band Internal Rotation @90 Degrees

Stand or kneel with your back to the band anchored to a solid base. With the shoulder elevated and the elbow bent, begin with the shoulder in external rotation similar to the arm cocking phase of throwing.  Move the shoulder into full internal rotation and then return to the starting position while maintaining the shoulder and elbow positions.   A common mistake is to gradually allow the arm to drop during the exercise.   This exercise results in high activation of the subscapularis muscle.  This rotator cuff muscle functions to stabilize the shoulder joint and accelerate the arm towards home plate.

Band External Rotation @ 90 Degrees

Stand or kneel facing a band anchored to a solid base. With the shoulder abducted and the elbow bent, begin with the shoulder in internal rotation.  Move the shoulder into full external rotation similar to the arm cocking phase of throwing.  Slowly return to the starting position while maintaining the shoulder and elbow positions.   A common mistake is to gradually allow the arm to drop during the exercise.  This exercise activates all rotator cuff muscles at moderate to very high levels.  It is performed in a position similar to the arm cocking and early acceleration phase of throwing where high stress is imparted on the shoulder and elbow.

Band Throwing Acceleration

Stand in a lunge stance holding the band or tubing with the throwing arm in a position of abduction and external rotation.  This is similar to the arm cocking phase of throwing.  Begin the exercise by moving the arm across the body similar to the acceleration phase of throwing.  Shift your body weight from the rear to the front leg as you perform the throwing motion.  Return to the starting position in controlled fashion shifting your bodyweight back to the rear leg.  This exercise results in very high activation of the subscapularis and teres minor of the rotator cuff.  The subscapularis functions to accelerate the arm towards home plate.  The teres minor acts to stabilize the shoulder and control the upper arm during the acceleration and follow-through phases of throwing.

Band Throwing Deceleration

Stand in a lunge stance holding the band or tubing with the throwing arm in a low position.  This is similar to the follow-through or ending phase of the throwing motion.  Begin the exercise by moving the arm back and up towards a position of abduction and external rotation (arm cocking position).  Shift your body weight from the front to the rear leg as you perform this motion.  Return to the starting position in controlled fashion shifting your bodyweight back to the front leg.   This exercise results in very high activation of the teres minor.  The teres minor acts to stabilize the shoulder and control the upper arm during the acceleration and follow-through phases of throwing.  This exercise emphasizes an eccentric muscle action similar to how the rotator cuff functions during throwing.

Closing Thoughts on Band Rotator Cuff Exercises for Baseball Players

Arm overuse throwing injuries for the baseball player can derail a career.  However, many of these injuries are preventable. These 5 exercises are only a small sample of band rotator cuff exercises for baseball players which can be helpful. They can be performed during any part of a pre-throwing warm-up or year-round training program. Your physical therapist can perform an individual assessment and design an exercise program based on your deficiencies and goals. The objective is to increase the baseball player’s likelihood of a long injury-free and successful career. Contact us today if you questions about which exercises are right for you.

 

6 of the Best Middle Trapezius Exercises

Your trapezius is a large broad muscle spanning your upper back.  It has attachments to the spine, shoulder blade, and collar bone.  Your trapezius is divided into 3 parts: the upper, middle, and lower portions.  As a whole, your trapezius plays an important role in overhead function.  Your middle trapezius is also responsible for retracting or pulling back the shoulder blade.  Poor function of your middle trapezius has been associated with shoulder, neck, and elbow pain.  Thankfully, there are a variety of middle trapezius exercises that will decrease your pain and improve function.

The Role of Middle Trapezius Exercises in Overhead Sports

Your middle trapezius plays an important role in in positioning and controlling movement of the arm during overhead sports.  This is especially true in sports such as baseball and swimming.  During baseball pitching, the middle trapezius is activated at very high levels to control the position of the shoulder blade as the pitcher’s arm accelerates towards home plate.  Youth pitchers with a history of shoulder pain have less strength in their middle trapezius compared to pitchers without pain.

In swimmers, weakness of the middle trapezius is associated with shoulder pain and disability.  Also, athletes with shoulder impingement exhibit poor timing of their middle trapezius muscle.  As a whole, weakness and poor timing of the middle trapezius can place excessive stress on other areas of the arm.  This predisposes the athlete to poor performance or injury.  The 6 exercises in this article are simple examples of how to train your middle trapezius.

Prone Row

Begin lying on your stomach holding a dumbbell.  Starting with your arm in an extended position, perform a row.  Your elbow stays close but not all the way against the side of your body.  Hold the top position for 1-2 seconds before slowly lowering the weight.  It is important to pull the shoulder blade back as you raise your elbow.  Avoid overextending and shrugging your shoulder.

Prone Shoulder Extension

Begin lying on your stomach with the arm holding a dumbbell.  Starting with your arm in an extended position, raise your arm up with your elbow straight.  Your elbow stays close but not all the way against the side of your body.  Hold the top position for 1-2 seconds before slowly lowering the weight.  It is important to pull your shoulder blade back as you raise your arm.  Avoid overextending and shrugging your shoulder.

Prone Horizontal Abduction in External Rotation

This is my “go-to” exercise for strengthening the middle trap.  Lie face down with your arm over the side of a table or bench.  Be sure to keep your neck in a relaxed neutral position resting on your other forearm.  With your thumb up and arm straight lift toward the ceiling at a 90-degree angle (the 9:00 and 3:00 positions of a clock).  This position is aligned with the muscle fibers of the middle trapezius.  Be careful to avoid shrugging your entire shoulder as you raise the arm.  Instead, think about tilting the shoulder blade backward as you raise your arm.  Pause at the top of the movement before returning to the start position in a controlled manner.

Prone Lower Trap Raise

This exercise strengthens all ports of the trapezius.  Lie face down with one arm over the side of a table or bench.  Be sure to keep your neck in a relaxed neutral position resting on your other forearm.  With your thumb up and arm straight lift toward the ceiling at a 45-degree angle from your head (the 10:00 and 2:00 positions of a clock).  This position is aligned with the muscle fibers of the lower trapezius.  Be careful to avoid shrugging your shoulder as you raise your arm.  Instead, think about tilting the shoulder blade backward as you raise your arm.  Pause at the top of the movement before returning to the start position in a controlled manner.

Side-Lying ER

Lie on your side holding a dumbbell with your elbow bent.  Place a towel roll in the armpit to increase activation of your rotator cuff during the exercise.  Rotate your arm upwards maintaining the elbow against the side of your body.  Hold the top position for 1-2 seconds before slowly lowering the weight.  It is important to pull your shoulder blade back as you raise your arm.  This increases activation of the middle and lower trapezius muscles.

Prone Row + ER

Lie face down with your arm over the side of a table or bench.  Be sure to keep your neck in a relaxed neutral position resting on your other forearm.  First, perform a high row with a pause at the top.  From this position externally rotate your arm upwards towards the ceiling.  Pause at the top and reverse the sequence back to the start position.  Be careful to avoid shrugging your shoulder as you raise your arm.  Instead, think about tilting the shoulder blade backward.  This exercise results in high activation of the rotator cuff, middle trapezius, and lower trapezius.

Closing Thoughts about Middle Trapezius Exercises

The middle trapezius is often neglected in rehabilitation and conditioning programs.  However, this muscle plays a very important role in overhead function and sports.  Middle trapezius exercises should be included as part of a well-rounded strengthening program.  These 6 middle trapezius exercises can be easily performed in the gym or at home.  It is not necessary to perform all 6.  Instead, select 2 or 3 which you are comfortable performing.  Start with light weights (2 to 3 lbs).  Multiple sets (2 to 3) of 10 to 20 repetitions, a few times per week is recommended.  Contact your physical therapist if you need help getting started.

Low Back Pain in Athletes

Low back pain in athletes occurs at an alarmingly high rate.  Various studies suggest one- to two-thirds of athletes will experience low back pain during a competitive season.  Athletes are required to perform high-speed movements often with excessive loads.  Sports such as golf, baseball, gymnastics, hockey, and tennis require repetitive rotational movements that stress the bones, joints, and discs of the spine.   Repetitive rotation and extension (arching backward) with high forces at fast speeds contributes to injuries of the spine discs and bony structures.  Injured athletes must learn to control and dissipate these forces.  Thankfully, rehabilitation exercises can help the injured athlete get safely back to their sport.

Low Back Stress Injuries in Athletes

Stress reactions and stress fractures of the spine are common in young athletes.  The spine of children and adolescents are susceptible because the bones are still developing.  Spondylolysis is a crack or stress fracture in one of the vertebrae of the low back.  Most commonly, the stress fracture occurs in the fifth vertebra of the lumbar spine (L5).  In some cases, the stress fracture weakens the bone and the vertebra starts to shift or slip forward out of place. This condition is called spondylolisthesis.

Spondylolysis

In children and adolescents, this slippage most often occurs during a growth spurt.  The severity of the slippage is graded from 1 to 4.  Most athletes with grades 1 and 2 respond very well to a period of rest and rehabilitation.  The injured bone heals with rest from any repetitive rotation and extension movements involved in their sport.  Rehabilitation targets strength of the trunk muscles to help relieve stress on the healing bone.  Some higher-grade injuries may require surgery to stabilize the spine.

Research Support for a Safe Return to Sport

Athletes with stress injuries of the spine require a minimum of 3 months rest from their sport.  The severity of the injury and the nature of the sport may require longer periods of rest.  One study found excellent return to sport rates after 4.6 months of rest and rehabilitation across a number of sports.  A recent study showed baseball (54%), soccer (48%), and hockey (44%) to have the highest prevalence of stress injuries in boys.  Gymnastics (34%), marching band (31%), and softball (30%) were found to have the highest injury rates in girls.  Athletes in these sports may benefit from longer rest and rehabilitation periods.

A 2017 study from the Children’s Hospital in Columbus, OH investigated the timing of referral to physical therapy in athletes with stress injuries of the spine.  Athletes who began physical therapy sooner were able to make a return to sport 25 days earlier than those who delayed treatment.  The early physical therapy group returned to sport at approximately 3 months.  The delayed physical therapy group returned after 4.5 months of rest and rehabilitation.   These studies suggest appropriate rest and early rehabilitation foster a safe and timely return to sport.

Common Rehabilitation Exercises for Athletes with Low Back Pain

Early rehabilitation for stress injuries of the spine begins with controlling pain and normalizing mobility.  Most athletes experience a significant reduction in pain once they are removed from sports activities.  Trunk and hip strengthening exercises begin in non-weight bearing positions such as on the back, side, or all-fours position.  Athletes are instructed on how to maintain a neutral spine position to minimize stress to the healing bone.  The curl-up and heel hover are two exercises that are initiated once the athlete can control this neutral spine position.

After the athlete can maintain a neutral spine in non-weight bearing positions exercises are progressed to kneeling and standing.  The athlete is taught to control rotation and extension of the spine through exercises such as the chop and Pallof press.

Anti-extension and anti-rotation exercises are emphasized during the later stages of rehabilitation.  The strength and endurance of the trunk muscles are progressively challenged with these exercises.  All exercises should be performed with a neutral spine and in a pain free manner.

Closing Thoughts on Low Back Pain in Athletes

Low back injuries can be frustrating for the young athlete.  Appropriate rest and rehabilitation can expedite a safe return to sport.  These 6 exercises are only a sample of the types of treatments that can help.  Meet with your physical therapist and get started on the road to recovery.  Your physical therapist will continually assess your injury and progress your exercise program based on your goals.  The objective is to get you back to your sport as quickly and safely as possible.  Contact us today if you have questions about which treatments are right for you.

Thoracic Outlet Syndrome: 5 Exercises to Help

Thoracic outlet syndrome (TOS) refers to compression of the major nerves and blood vessels in the area between the neck and shoulder.  More than 90% of cases involve compression and irritation of the nerves as they pass through the thoracic outlet.  It is less common for the blood vessels to be involved.

Common symptoms of thoracic outlet syndrome include pain in the neck, upper back, shoulder, arm, or hand.  It is also common to experience numbness, tingling, and weakness of the arm, hand, and fingers.  Symptoms are aggravated with overhead positions or activities such as throwing a baseball.  Also, repetitive tasks such as prolonged typing exacerbate symptoms of TOS.

Anatomy of the Thoracic Outlet

Thoracic outlet syndrome exercise

There are 3 components to the thoracic outlet extending from the neck to the front of the shoulder.  The 1st component is the interscalene triangle.  Nerves exit the neck and pass between the two scalene muscles.  Abnormalities of these muscles can contribute to compression or irritation of the nerves.  The 2nd component of the thoracic outlet is called the costoclavicular space.  This is the area between the collar bone and first rib.  Abnormalities of the first rib or an extra rib sometimes called a “cervical rib” can lead to irritation of the nerves or blood vessels.  The 3rd component of the thoracic outlet is the area between the pectoralis minor muscle and the rib cage.

Treatment for Thoracic Outlet Syndrome

Treatment for TOS begins with rest from any aggravating activity such as overhead sports (baseball pitching) or repetitive tasks such as keyboarding.  Referral to a physical therapist is the next step.  Physical therapy for thoracic outlet syndrome targets the 3 primary compression sites.  Manual therapy techniques and stretching exercises target the scalene muscles, first rib, and pectoral muscles.   Nerve gliding exercises are prescribed to improve the health of the irritated nerves.  Postural correction exercises are also an important component.  A slouched or flexed posture closes down the space of the thoracic outlet and increases irritation of the nerves and blood vessels.  Finally, pain-free strengthening exercises for the shoulder and upper back muscles are prescribed based on the patient’s individual needs and goals.

Scalene Muscle Stretch

Stretching the scalene muscles alleviates irritation of the nerves and blood vessels within the interscalene triangle.   Begin sitting with a strap or belt draped over the affected shoulder.  Pull down on the strap towards your opposite hip.  Side-bend the neck away from the affected side and slightly turn towards the affected side. Finally, perform a gentle chin tuck to increase the stretch in the side of the neck.  Hold this position for 30 seconds.  If you experience symptoms during the stretch, start with shorter hold times and work up to 30 seconds.

First Rib Self-Mobilization

Improving the mobility and position of the first rib alleviates irritation of the nerves and blood vessels just below it.   Begin sitting with a strap or belt draped over the affected shoulder.  Pull down on the strap towards your opposite hip.  Side-bend the neck toward the affected side.  Look down to the armpit.  This position relaxes the scalene muscles so the forces are directed to the rib.   While holding pressure with the strap, perform 10 slow and deep breaths to mobilize the rib.

Pec Minor Stretch

Improving pectoralis minor length and mobility will alleviate irritation of the nerves under this muscle.  Begin lying over a foam roll under the hips and spine.   With the elbow bent allow the arms to fall down towards the floor.  Fully exhale and relax in this position for 30 seconds.  It is important for your spine to maintain contact with the foam roll.  If you experience symptoms during the stretch, start with shorter hold times and work up to 30 seconds.

Trapezius Muscle Strengthening

To strengthen the lower trapezius muscle lie face down with one arm over the side of the table or bench.  Be sure to keep the neck in a relaxed neutral position resting on your other forearm.  With the thumb up, arm straight, elbow slightly bent, lift toward the ceiling at a 45-degree angle from your head (the 10:00 and 2:00 positions of a clock).  This position is aligned with the muscle fibers of the lower trapezius.  Be careful to avoid shrugging the entire shoulder as you raise the arm.  Instead, think about tilting the shoulder blade backward as you raise the arm.  Pause at the top of the movement before returning to the start position.

The middle trapezius is trained in a similar fashion.  To target the middle trapezius perform the movement with the arm straight out to the side.  This corresponds to the 9:00 and 3:00 positions of a clock.  Strengthening both the middle and lower trapezius will orient the shoulder blade so that irritation of the nerves in the thoracic outlet is diminished.

Closing Thoughts About Thoracic Outlet Syndrome

Thoracic outlet syndrome can be debilitating and negatively impact your quality of life.  Not everyone with TOS has to suffer.  These 5 exercises are only a small sample of the types of exercises that can help.  Meet with your physical therapist and get started on the road to recovery.  Your physical therapist will continually assess your injury and progress your exercise program based on your goals.  The objective is to decrease pain and give you your quality of life back as quickly as possible.  Contact us today if you are experiencing symptoms suggestive of TOS or if you have questions about which treatments are right for you.

 

Rotator Cuff Exercises for Baseball Players: Part 1

The health of the rotator cuff muscles is crucial for the baseball player. The rotator cuff is composed of 4 small muscles connecting the shoulder blade to the upper arm bone. The 4 muscles are the supraspinatus, infraspinatus, teres minor, and subscapularis. The primary function of the rotator cuff is to maintain the ball of the shoulder centered within the socket of the shoulder blade. Weakness, fatigue, or injury to the rotator cuff results in abnormal movement of the ball within the socket. For the baseball player, this may lead to pain, loss of throwing velocity, poor performance, and injury. Thankfully, exercise targeting the rotator cuff can reduce injury risk for the baseball player and improve performance.

The Rotator Cuff During Throwing

Rotator Cuff Anatomy

There are 6 sequential phases to baseball pitching. The rotator cuff is most active during the arm cocking through arm deceleration phases. These are the phases where the greatest stress is placed on the thrower’s shoulder and elbow. Subsequently, most overuse injuries occur due to repetitive stress during these phases. A strong and healthy rotator cuff is essential to withstand these stresses.

A classic study performed by the late Dr. Frank Jobe and his colleagues revealed the activity levels of the rotator cuff during the different phases of pitching. The supraspinatus muscle is most active during the transition from the stride to the arm cocking phase. This muscle centers the ball within the socket as the arm is being raised. The infraspinatus muscle is most active during the arm cocking phase as the shoulder maximally externally rotates. The teres minor’s primary role is to assist with decelerating the arm after ball release. And finally, the subscapularis is highly active as it contributes to arm acceleration.

 

Phases of Baseball Pitching

The Rotator Cuff and Injuries in Baseball

Numerous studies have proved an association between rotator cuff weakness and injury in baseball players. A 2015 study showed baseball players with ulnar collateral ligament injuries had significantly less rotator cuff strength compared to healthy pitchers. An earlier study found high school baseball players with pre-season supraspinatus weakness were more likely to sustain arm injuries during the regular season. Research performed in Japan found rotator cuff imbalances were associated with shoulder and elbow injuries in high school pitchers. Finally, research on professional pitchers shows pre-season weakness of the supraspinatus and infraspinatus muscles are associated with in-season injuries requiring surgery.

Rotator Cuff Exercises for Baseball

For good reason, baseball players are encouraged to perform regular rotator cuff exercises as part of a year-round arm care program. The specific exercises performed are based on the scientific research showing which exercises elicit the highest activation of the rotator cuff. Baseball players are also creatures of habit and routine. The individual preferences of the athlete should always be considered when selecting exercises. Some athletes prefer exercising with resistance bands while others prefer more traditional free weights. The 4 exercises which follow can be performed with light dumbbells, usually between 2 to 8 pounds. In part 2 of this article, we will cover some of the most beneficial resistance band exercises for the rotator cuff.

Closing Thoughts on Rotator Cuff Exercises for Baseball Players

Arm overuse throwing injuries for the baseball player can be debilitating and derail a career. These 4 exercises are only a small sample of rotator cuff exercises for baseball players which can be helpful. They can be performed during any part of a year-round training program. Your physical therapist can perform an individual assessment and design an exercise program based on your deficiencies and goals. The objective is to increase the baseball player’s likelihood of a long injury-free and successful career. Contact us today if you questions about which exercises are right for you.

 

Hamstring Strains: 5 Exercises for Recovery

Hamstring strains occur at high rates in sports which require running and sprinting.One of every 3 injuries in soccer is hamstring strains.  Other sports with high injury rates include baseball, football, and track and field. These injuries can be very frustrating for athletes because of the long rehabilitation time. Return to sport may take several weeks or 2 to 3 months based on the severity of the injury. Also, nearly 1 in 3 hamstring injuries will recur and many of these happen within the first 2 weeks of returning to sport.  Thankfully, rehabilitation exercises can help athletes can back in the game and avoid re-injury.

The hamstrings consist of three muscles: the semitendinosus, semimembranosus, and the biceps femoris. The three muscles originate from a common tendon on the pelvis. The hamstrings cross the hip and knee joints attaching just below the back of the knee. During high-speed running the hamstring muscle is commonly injured as the leg is swinging from a bent to an extended position in preparation for landing. During this phase of running, hamstring muscle activity is extremely high to control the length of the muscle.

Hamstring Injury

The Most Effective Approach to Rehabilitating Hamstring Strains

Research indicates there are 3 types of rehabilitation exercises which assist in recovery from hamstring strains. Agility exercises which involve changes of direction simulating sport movements reduce re-injury rates. These exercises can be initiated early after the acute injury. Trunk or core stabilization exercises are also effective at reducing risk of re-injury.  And exercises which lengthen the injured hamstring can speed up an athlete’s return to play.

The remainder of this article highlights 5 rehabilitation exercises for hamstring strains.  Three of these exercises are intended to progressively lengthen the injured hamstrings.  These are the active hamstring stretch, the “diver”, and the “glider”. Lengthening exercises are performed slowly and through pain-free ranges at first. Aggressive stretching can delay recovery. As the athlete improves, the speed and range of motion of these exercises are gradually increased.

Trunk stabilization exercises are designed to strengthen the muscles of the spine, hips, and pelvis. Strengthening the hamstrings and all surrounding musculature is important to reduce the risk for re-injury. Keep in mind, the hamstring muscle group originates from the pelvis. The position of the pelvis during running can influence the length and activity of the hamstring muscles. Increasing strength of the injured muscle itself builds resilience and promotes a safe return to sport.

Active Hamstring Stretch

Lie on your back holding the thigh of the leg to be stretched. The opposite leg remains straight. With the upper thigh maintained in a vertical position, slowly extend the knee.  Pause at the point where a mild stretch is felt in the back of the thigh. The stretch should not be painful. Gentle stretching of the hamstring is helpful for recovery. Aggressive stretching of the hamstrings can delay your recovery. Hold this position for 3 to 5 seconds, and then lower the leg back down.  Perform 3 sets of 12 repetitions once per day.

Cook Hip Lift

Begin by lying on your back with your hips flexed and feet lined up with the shoulders.   Pull the knee of the uninjured leg up to the chest. It is helpful to place a small towel roll or ball in the crease of your hip. Lift your toes off the floor and perform a bridge from the other leg. Be sure to achieve the bridge position by extending through the hips, not the low back. Hold this position for 2 to 3 seconds then return to the starting position. Typically, 2 to 3 sets of 10 to 15 repetitions are performed on each side once per day.

Bridge Walk-Out

Begin by lying on your back with your hips flexed and the feet lined up with the shoulders.  Perform the bridge by lifting both hips from the floor.  Hold the bridge position and alternately walk the feet out away from the body.  It is important to maintain a level pelvis throughout the exercise.  After 2 to 3 steps walk the feet back to the starting position.   Lower the body back down in a slow and controlled manner between each repetition.  Typically, 3 sets of 6 to 8 repetitions are performed once per day.

Hamstring “Diver”

This exercise resembles a simulated dive. Stand on the injured leg with the knee slightly bent. Bend forward at the hip while simultaneously stretching the arms forward. The back should remain flat. The opposite knee remains bent as the hip extends. This exercise should be performed very slowly in the beginning. As a progression, the speed and range of motion can be increased. Typically, 3 sets of 6 to 8 repetitions are performed every other day.

Hamstring “Glider”

Begin from a standing position with one hand holding on to a support. The legs are slightly split. All the body weight is on the heel of the injured (front) leg with the knee slightly bent. The motion is started by gliding backward on the other leg (wearing only a sock) and stopped before pain is reached. The movement back to the starting position is performed with the help of the arms, not using the injured leg. Begin slowly in a pain-free range of motion. Progression is achieved by increasing the gliding distance and performing the exercise faster. This exercise requires slightly more recovery between each session. Typically, this exercise is performed 3 times per week for 3 sets of 6 receptions.

Getting Started with Exercise After a Hamstring Strain

Rehabilitation for hamstring strains should begin early after injury. Pain-free agility and trunk stabilization exercise are initiated immediately. Lengthening exercise can be safely performed soon after injury when supervised by a licensed physical therapist. The progression of an athlete’s rehabilitation program is based on specific criteria. Your physical therapist will continually assess your injury and progress your program. The goal is to return the injured athlete as quickly and safely as possible. Contact us today if you have had a hamstring strain or simply have questions about which treatments are right for you.

Kinetic Chain Exercises Linking the Shoulder and Hip

Overhead activities such as throwing require proper sequencing of different body parts.   The lower body, trunk, shoulder, arm, and hands are considered links in a chain.  If any of these links are not functioning properly, the chain is compromised.  Effectively using the body as a kinetic chain maximizes overhead athletic performance and reduces injury risk.  Shoulder rehabilitation programs now integrate the kinetic chain theory for a broader approach versus focusing only on isolated muscles.

Exercises targeting the shoulder muscles receive a great deal of attention in overhead athletes and rightfully so.  The rotator cuff and scapular muscles are important for dissipating high forces created from throwing.  However, most of the energy created during throwing occurs from the lower body and trunk.  Weak links in the lower body often result in additional stress to the shoulder and elbow during throwing.  Therefore, including exercises that incorporate all links of the kinetic chain are beneficial.

lower body strength throwing

 

Lower body exercises such as the squat and lunge can be integrated with common shoulder rehabilitation exercises.  Total body exercises which incorporate resistance bands or tubing are ideal for integrating links of the kinetic chain.  This article described only 3 exercise examples.  However, there are many other variations which can be developed based on the athlete’s profile and goals.

Overhead Squat with “Y”

Stand holding a resistance band in both hands with the shoulders flexed and elbows straight.  Perform an overhead “Y” by raising both hands with the elbows straight.   Maintain this overhead “Y” position as you perform an overhead squat.  Try to reach a maximum depth of the squat without compromising the upper-body position.  Maintain the overhead “Y” until completion of the set.  Perform 8 to 10 repetitions per set.  This exercise integrates the gluteus maximus, rotator cuff, low back muscles, and trapezius.

Lunge with “T”

Stand holding a resistance band in both hands with the shoulders flexed and elbows straight.  Perform a “T” with both arms by pulling the hands and shoulder blades back with the elbow straight.   Once in the “T” position, perform a reverse lunge with one leg.  The “T” position is maintained until one alternating repetition is performed on each leg.  Reset the “T” before completing the next repetition.  Perform 6 to 8 slow and controlled repetitions on each side.  This exercise activates the gluteus medius, gluteus maximus, lats, and trapezius.

Lateral Band Walk with “W”

Perform an exaggerated sideways walk with a resistance band just above the knees. Remain in an athletic position keeping the toes pointed straight ahead.  It is important to push the knees apart against the resistance band in order to activate the hip muscles.  The shoulder blade and rotator cuff muscles are activated by using a second resistance band in the hands.  Make a “W” with the elbows in order to achieve scapular retraction.  Take 3 steps to the right followed by 3 steps back to the starting position.   Also, think about pulling the elbows to the opposite back pocket.  Perform 6 to 8 slow and controlled repetitions to each side.  This exercise activates the gluteus medius, gluteus maximus, rotator cuff, and lower trapezius.

Closing Thoughts

Combining lower body exercises with traditional shoulder rehabilitation exercises is beneficial for overhead athletes.  Muscles throughout the entire body function in a coordinated sequence during baseball and softball throwing.  Resistance bands have gained popularity in the baseball and softball communities as part of pre-throwing routines and strength and conditioning programs. These shoulder-focused exercises train only a limited number of links in the kinetic chain.   A wiser approach is to integrate upper body resistance band exercises with dynamic, full-body exercises.  Talk to your physical therapist if you are unsure about which exercises are best for you.

 

 

Abdominal Oblique Injuries in Rotational Sports

Abdominal oblique injuries, also known as side strains, are common in rotational sports such as baseball, tennis, golf, and track and field.  These injuries are characterized by a sudden, sharp onset of pain near or on the side of the rib cage.  The injury usually occurs during some type of rotational movement such as swinging a bat, club or racket; or throwing a ball.

Trunk rotation plays an important role in generating and transferring power during sport.  It is through the trunk or core, that forces are transferred from the lower body to the shoulder and arms. Activities such as throwing and swinging require the core muscles to both stabilize the trunk and create force in order to transfer power to the upper body.

Anatomy of the Abdominal Oblique Muscles

The core includes the thoracolumbar, abdominal, pelvic, and hip musculature.  These muscle groups provide trunk stability to allow integrated limb movements, such as throwing and swinging, to occur. The abdominal core muscles include the rectus abdominis, transversus abdominis, internal oblique and external oblique.  Most abdominal injuries occur in the internal and external oblique muscles.  Less commonly, injuries can occur to the intercostal muscles between the ribs themselves.

The Role of the Oblique Muscles in Sport

The internal and external oblique muscles are responsible for flexion and rotation of the trunk.  They also provide trunk stabilization during complex sports movements.    Poor mobility of the hips or thoracic spine can contribute to excessive stress and compensation through the trunk muscles during swinging or throwing.  Rehabilitation often addresses hip mobility with manual therapy techniques performed by the physical therapist.  An imbalance between right and left side oblique muscles are also common is in sports such as golf and baseball.  This may place excessive forces through the lead side oblique musculature.  Finally, the large forces generated by lower body muscles (quadriceps and hamstrings) may overpower the weaker core musculature leading to injury during explosive sports movements.

The incidence of Abdominal Oblique Injuries in Baseball

A 2010 study in the American Journal of Sports Medicine investigated the incidence and trends of abdominal injuries in professional baseball players.  From 1991 through 2010, abdominal strains accounted for approximately 5% of all injuries in Major League Baseball.   Nearly half of these injuries occurred in pitchers.  Injuries occurred most often during the early part of the season.

In both pitchers and position players, the majority of injuries occurred on the side opposite to their throwing arm.  Pitchers missed, on average 35 days on the disabled list, while position players missed 26 days on average.  Players who receive steroid or PRP injections have been shown to miss more time from injury.   More than 1 out of every 10 sustained a re-injury during their career.  Most of these re-injuries occurred during the same or the following season.   As a result of these injury trends, many MLB teams have increased their focus on preemptive core and trunk strengthening exercises for all players.

Closing Thoughts on Oblique Injuries

The incidence of abdominal oblique injuries is on the rise in rotational sports such as baseball and golf.   These injuries can result in substantial loss of playing time.  Proper training and exercise can prevent abdominal oblique injuries from occurring.  These exercises can also be part of a comprehensive rehabilitation program to safely return an injured athlete back to sport.

References

  1. Camp CL, Conte S, Cohen SB, et al. Epidemiology and impact of abdominal oblique injuries in major and minor league baseball. Orthop J Sport Med. 2015;5(3):1-8. doi:10.1177/2325967117694025.
  2. Conte SA, Thompson MM, Marks MA, Dines JS. Abdominal muscle strains in professional baseball. Am J Sports Med. 2010;40(3):650-656. doi:10.1177/0363546511433030.
  3. Nealon AR, Kountouris A, Cook JL. Side strain in sport: A narrative review of pathomechanics, diagnosis, imaging and management for the clinician. J Sci Med Sport. 2017;20:261-266.

Baseball Stretching Drill to Restore Range of Motion between Innings

Baseball players will lose range of motion in their throwing shoulder and elbow following a pitching session.  This loss of range of motion becomes cumulative over the course of a season.   Range of motion deficits have been shown to increase the risk of arm injury in baseball players.  Baseball stretching routines performed over the course of a season can help reduce this risk.  Also, stretching drills during baseball games, or between innings, is another method to combat muscle tightness and loss of range of motion in baseball pitchers.

The two-out drill has been developed by researchers from the California State University in Sacramento, and world-renowned orthopaedic surgeon Dr. James Andrews.   These seven baseball stretching exercises can be performed in approximately one minute between innings.  During game situations, the drill is initiated after two outs have been recorded and prior to the pitcher taking the mound each inning.   Performing this drill has been shown to restore professional baseball pitchers shoulder range of motion back to pre-pitching levels.   The seven baseball stretching exercises are described below with a video to follow.

Baseball Stretching: The Two-Out Drill

  1. Internal rotation stretch. Place the non-throwing hand on top of the throwing elbow with the non- throwing forearm resting on top of the throwing forearm. The non-throwing arm is then used to produce an internal rotation stretch in the throwing shoulder by rotating the forearms down towards the ground. This stretch is held for 3 seconds and is repeated twice with approximately 1 to 2 seconds of rest between stretches.  Be sure to stay tall during the stretch and avoid holding your breath.
  2. Elbow extension stretch. Extend the throwing elbow with the forearm tuned up. With the opposite hand, pull the throwing hand so that the wrist is extended back. This stretch is held for 3 seconds and is repeated twice with approximately 1 to 2 seconds of rest between stretches.  Be sure to stay tall during the stretch and avoid holding your breath.
  3. Big arm circles. Perform big arm circles clockwise and counterclockwise for 5 repetitions each way.  Make the circles as big and fast but comfortable, with an emphasis on increasing range of motion.  Be sure to stay tall during the exercise.
  4. Small arm circles. Perform small, tight arm circles clockwise and counterclockwise. Movement is fast but at a comfortable pace.  Perform 5 circles forward, and 5 circles in reverse.
  5. Forearm touch. With the arms up out to the side and elbows bent, move the elbows in so the elbows and forearms touch.  Next, move the arms in the opposite direction until a mild stretch is felt in the front of the shoulders or chest.  Repeat 5 times continuously.
  6. 90/90 IR and ER. Begin with the arms up out to the side and elbows bent. Internally and externally rotate the shoulders as far as possible at a fast but comfortable pace. Repeat 5 times continuously.  Be sure to stay tall and breathe during the exercise.
  7. Trunk Rotation. Begin with the arms fully extended and out to the side.  Rotate your arms and trunk from side to side, through a full range of motion, to the left and then back to the right. Movement is fast but at a comfortable pace.  Repeat 5 times continuously.

Closing Thoughts

Performing the two-out drill with two outs will allow adequate time to prepare the throwing shoulder for the subsequent inning.  This may be a practical and effective means to preserve shoulder range of motion throughout the course of a baseball game.  Rest and avoiding excessive throwing is undoubtedly the most important factor related to reducing risk for arm injuries in baseball players.  However, the two-out drill may help maintain shoulder flexibility during a game, and perhaps over the course of a season.  Maintaining shoulder range of motion is just one small piece to minimizing risk for injury in baseball players.

References

  1. Escamilla RF, Yamashiro K, Mikla T, Collins J, Lieppman K, Andrews JR. Effects of a short-duration stretching drill after pitching on elbow and shoulder range of motion in professional baseball pitchers. Am J Sports Med. 2016;45(3):692-700. doi:10.1177/0363546516671943.
  2. Reinold MM, Wilk KE, Macrina LC, et al. Changes in shoulder and elbow passive range of motion after pitching in professional baseball players. Am J Sports Med. 2008;36(3):523-527. doi:10.1177/0363546507308935.
  3. Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med. 2011;39(2):329-335. doi:10.1177/0363546510384223.
  4. Wilk KE, Macrina LC, Fleisig GS, et al. Deficits in glenohumeral passive range of motion increase risk of elbow injury in professional baseball pitchers: A prospective study. Am J Sports Med. 2014;42(9):2075-2081. doi:10.1177/0363546514538