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.

Concussion in Sports 

Concussions are common in athletes.  They commonly occur in contact sports, such as football, and non-contact sports, such as soccer. BSR Physical Therapy and our doctors of physical therapy can help evaluate, manage and treat patients with concussion.  This article helps to answer some common questions you may have.

What is a Concussion?

“Sport-related concussion is a traumatic brain injury induced by biomechanical forces … This may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.”

Does it Show up in MRI, CT Scans or X-Rays?

Acute concussion injuries do not show up on imaging.  Emergency room departments will commonly perform CT scans for the brain and skull to ensure that there are no fractures, brain bleeds or serious injuries.  MRI will commonly not find any acute injuries as well, but new research has shown chronic changes in the brain long after the time of injury.

What are the signs and symptoms of a Concussion?

Some common symptoms include neck pain, dizziness, blurred vision, difficulty concentrating, sensitivity to light, sounds, and motion sickness.  Some people can also experience changes in mood or behavior.  It is common to have symptoms immediately but some can develop in hours or over the next couple of days.  In most cases, symptoms resolve on their own with relative rest, however, there are some cases that last a little longer than usual (more than a week or two).

When should I seek professional help?

High school athletes should have an athletic trainer as part of the sports medicine team to evaluate the athlete for a suspected concussion.  Athletic trainers are qualified healthcare professionals to manage suspected head injuries and refer out when appropriate. In cases where symptoms do not resolve with time and relative rest, appropriate referral to a healthcare professional is indicated.

How can physical therapists help?

Physical therapists may be asked to help manage and treat those who still have lingering symptoms from a concussion.  The physical therapist should take a good history of the injury and progression of the symptoms. A comprehensive physical examination should be performed to assess neck motions, balance, concentration and eye movements to see if there are impairments causing symptoms and limiting functional ability.  An individualized plan of care and treatment is then provided to decrease concussion symptoms and progressively return to activity.

When can I go back and play?

Each case is unique in presentation, so no two concussions are alike no matter how “bad” they initially looked.  So the answer really is, it depends. The physical therapist will put you through a thorough return to activity protocol to simulate the demands of your sport to help gauge the readiness to return to sport.  In the end, in the State of New Jersey, a physician has the power to medically clear an athlete to return to sport, but a collaborative effort between the physical therapist, athletic trainer and physician should be made to ensure a safe return at a high level.

Conclusion

In summary, sports-related concussions are common in athletic endeavors in both contact and non-contact sports.  Symptoms from concussions usually resolve on their own with time and relative rest.  When symptoms linger for longer than usual, a qualified healthcare professional should be consulted.  Physical therapists are able to help assist in treating patients who have post-concussive symptoms and help return an athlete to play at a high level.   Give us a call if you would like some help getting back in the game after a concussion.

by Dr. Mark Daitol, PT, DPT, CSCS

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.

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.

 

 

Early Sport Specialization and Long-Term Athletic Success

Sport specialization is defined as year-round (≥8 months per year) intensive training in a single sport at the exclusion of other sports.   Early sport specialization refers to those who focus on a single sport before entering high school.  Advocates for early specialization propose that athletic performance in that sport will be better than the performance of those who play multiple sports.  These beliefs became popularized after several recently published best-selling books proposed a “10,000 hour rule” of practice for developing expertise in any given skill or sport.

The effectiveness of increasing the amount of early exposure to a single sport on athletic performance is questionable.  In fact recent research suggests those youth athletes who participate in multiple sports and delay specialization are at an advantage over those who specialize.  The long-term athletic development (LTAD) model provides a structured framework where youth athletes participate in multiple sports in order to maximize their full athletic potential over the lifespan.  Emerging research supports multiple sports participation and the LTAD model as methods to reduce injury risk and maximize athletic potential through high school, college, and beyond.

Early Sport Specialization & High School Athletics

Present day athletes are specializing in a single sport earlier than previous generations.  One recent study showed current high school athletes specialize at an average age of 13 years old.  Current collegiate athletes specialized at an average age of 15 years old.  High school athletes who specialize in one sport for more than 8 months of the year are 2 to 3 times more likely to suffer a lower body overuse injury.  Athletes who engage in baseball for more than 8 months per year are more likely to develop overuse arm injuries.  The repetitive nature of engaging in a single sport predisposes youth athletes to chronic injuries which will likely impact their career beyond high school.  Also, there is currently no evidence which suggests athletes who specialize in a single high school sport are more successful performers than multisport athletes.

Early Sport Specialization & Collegiate Athletics

A survey of Division I college athletes showed 16% specialized in 9th grade and 41% specialized in 12th grade.  This suggests the majority of NCAA Division I athletes were late to specialize in their chosen sport.  Therefore, early specialization does not appear to be necessary in order to succeed at the collegiate level.   Other research found college basketball players who specialized late in their playing career developed their skills and performance to a greater level than those who specialized early.    Several Division I college coaches have gone on record to state their preference for recruiting multisport college athletes.  Athletes who participate in multiple sports possess superior fundamental movement skills and are generally more “coachable” than single sport athletes.

Early Sport Specialization & Professional Sports

Professional athletes are now advocating for multiple sport participation in today’s youth.  Sixty-three percent of surveyed professional baseball players believe early sport specialization is not required to play professionally.  Only twenty-two percent of professional athletes from multiple sports would want their own child to specialize in 1 sport during childhood

NBA players who played multiple sports in high school participate in more professional basketball games throughout their career compared to those who specialized early.  These same NBA players who played in more games were less likely to suffer an injury compared to those who specialized early.  Also, those NBA players who specialize late demonstrate greater longevity in the league.

Approximately half of present day MLB players specialized prior to high school.  Those who specialized early sustain more serious injuries during their professional career compared to those who specialize late.   Youth baseball players should be encouraged not to participate in a single sport given the increased incidence of serious injuries later in their careers. To date no research suggests that early specialization is needed to reach the professional level of any team sport.

Closing Thoughts

Parents and coaches should encourage youth athletes to delay sport specialization as late as possible.  Athletes who specialize late are at least as likely to compete at high levels (college and professionally) as those who specialize early.  Also, those  who delay specialization are less likely to sustain injuries and more likely to achieve long-term success at the professional level.   Most importantly, encouraging multiple sports participation promotes long-term enjoyment of sport which will build health and fitness habits for a lifetime.

References

  1. Bell DR, Post EG, Trigsted SM, Hetzel S, Mcguine TA, Brooks MA. Prevalence of sport specialization in high school athletics: A 1-year observational study. Am J Sports Med. 2016;44(6):1469-1474. doi:10.1177/0363546516629943.
  2. Buckley PS, Bishop M, Kane P, et al. Early single-sport specialization and professional athletes. Orthop J Sport Med. 2017;5(7):1-7. doi:10.1177/2325967117703944.
  3. Post EG, Thein-Nissenbaum JM, Stiffler MR, Brooks MA, Bell DR. High school sport specialization patterns of current division I athletes. Sport Heal A Multidiscip Approach. 2016;XX(x):1-6. doi:10.1177/1941738116675455.
  4. Santos S, Mateus N, Sampaio J, et al. Do previous sports experiences influence the effect of an enrichment programme in basketball skills? J Sports Sci. 2017;35(17):1759-1767. doi:10.1080/02640414.2016.1236206.
  5. Wilhelm A, Choi C, Deitch J. Early sport specialization effectiveness and risk of injury in professional baseball players. Orthop J Sport Med. 2017;9:1-5. doi:10.1177/2325967117728922.

 

Little League Elbow: 5 Things Parents and Coaches Should Know

Little League elbow is an overuse injury affecting the inside part of the overhead athlete’s elbow.  The injury occurs in youth athletes 8 to 13 years old with open growth plates.  In these youth baseball players, the growth plate is much weaker than the ligaments and muscles surrounding it.  Once the growth plates fuse, athletes are more likely to injure soft tissues such as the ulnar collateral ligament (UCL).  Little League elbow is most common in baseball pitchers but can also occur in any position player, softball players, or tennis players.

During the late cocking and acceleration phases of throwing, the shoulder and elbow are subjected to very high forces.  The repetitive stress of throwing can lead to pain, swelling, and tenderness in this area.  The youth baseball player may also show signs of decreased throwing velocity and accuracy.   If untreated, there is a small chance for early growth plate closure or fracture, which could require surgery.  Little League elbow will often heal completely with 2 to 4 months of rest and an individualized physical therapy program.  Below are 5 things parents and coaches should know to prevent Little League elbow in youth baseball players.

#1: Elbow injuries are more common in those who play year-round

 The repetitive stress of throwing a baseball subjects the growing elbow to excessive forces.  The growing bones of youth athletes need time away from throwing.  Youth baseball players should take 3 to 4 months off from throwing each year.  This period should be devoted to playing other sports in order to develop overall athleticism.  This is also the ideal time to perform resistance exercise to build strength in the lower body, core, and arm.  Players who throw year-round or in multiple leagues are often plagued by arm fatigue.  Throwing with fatigue is the number one risk factor for shoulder and elbow injury in youth baseball players.

 #2: Little League elbow is common in both pitchers and catchers

 A 2004 study in the American Journal of Bone and Joint Surgery found 70% of youth catchers demonstrate signs of Little League elbow on x-rays.  In comparison, 63% of pitchers demonstrated these findings. Approximately half of these pitchers and catchers complained of elbow pain.  The other half were not experiencing pain.  However, catchers complained of elbow soreness more often than pitchers. During a game, catchers and pitchers may perform an almost equal number of throws.  Also, catchers often throw from a squat or semi-squat position.  Without the ability to generate force from the lower body, this position may place additional stress on the catchers elbow.  It may be advantageous for catchers to throw from a standing position whenever possible.  In any case, parents and coaches should closely monitor catchers and pitchers during the course of a season.  Any signs of altered throwing or complaints of pain by the athlete should prompt a medical evaluation.

#3: Taller players are more likely to develop Little League elbow

Overall height and a recent increase in growth have been shown to be risk factors for developing Little League elbow.  During the growth spurt it is believed that the rate of bone length growth exceeds the rate of bone strength development.  Therefore, the growing bone and growth plate may be more susceptible to those who are experiencing rapid changes in height.   Taller players are also more likely to throw at greater velocities which subject the elbow to greater stress.  Therefore, the stress associated with these developmental factors, along with throwing excessively at increased velocities, may predispose the taller baseball player to elbow injury.  Parents and coaches should keep a close eye on these taller players and be on the lookout for any early warning signs of arm pain or fatigue.

#4:  Little League elbow is more common in players working with private coaches

A recent study investigating Little League players in the United States found two factors associated with positive elbow MRI findings.  These two factors were year-round play and working with a private coach.   Additionally, a history of arm pain was also associated with year-round play and working with a private coach.  This is not to say that youth baseball players should not work with private coaches.  Private coaches can be instrumental in improving throwing mechanics thus potentially improving performance and reducing injury risk.  However, working with pitching coaches can contribute to throwing excessively or even year-round.   Baseball players should be encouraged to work with coaches to improve their skills and love for the game.  However, it is extremely important that these players get ample rest from throwing so they do not jeopardize their long-term playing career.

#5: Strengthening and stretching exercise can reduce the risk for developing elbow injuries

Muscle imbalances and poor movement patterns during and following growth spurts predispose youth athletes to overuse injuries such as Little League elbow. Modifiable risk factors for injury relate to improving shoulder flexibility and total arm strength.  A recent study in the American Journal of Sports Medicine showed youth baseball players can significantly reduce their risk for elbow injury by engaging in a regular stretching and strengthening program.  These exercises should target the trunk and arm musculature to address factors shown to be associated with injury risk.  Strengthening the shoulder blade and rotator cuff muscles us often emphasized in overhead athletes.  Athletes should be instructed in individualized programs based on their own unique needs.  There is no one size fits all program for baseball players.   Below are a few exercises which are useful for some overhead athletes.

Closing Thoughts

Little League elbow is becoming increasingly more common as youth baseball players are throwing more often and at greater velocities.  It is more important than ever for parents and coaches to closely monitor all youth baseball players for excessive amounts of throwing and the early signs of arm fatigue.  Also, pitchers, catchers, taller players, and those with private coaches may be at an increased risk for injury thus requiring close observation.  Youth baseball players who adhere to regular stretching and strengthening exercise can reduce their risk for injury.  Therefore, preventing Little League elbow requires a team approach involving the player, parents, coaches, trainers, and the medical staff.

 References

  1. Hang DW, Chao CM, Hang Y. A clinical and roentgenographic study of Little League elbow. Am J Sports Med. 2004;32(1):79-84. doi:10.1177/0095399703258674.
  2. doi:10.1177/2325967114566788.
  3. Pennock AT, Pytiak A, Stearns P, et al. Preseason assessment of radiographic abnormalities in elbows of Little League baseball players. J Bone Jt Surg. 2016;98:761-767.
  4. Sakata J, Nakamura E, Suzuki T, et al. Efficacy of a prevention program for medial elbow injuries in youth baseball players. Am J Sports Med. 2017; Published:1-10. doi:10.1177/0363546517738003.
  5. Yukutake T, Kuwata M, Yamada M. A preseason checklist for predicting elbow injury in Little League baseball players. Orthop J Sports Med. 2015;3(1):1-7.

Little League Shoulder: 5 Things Coaches and Parents Should Know

Little League shoulder is an overuse condition that affects the upper arm growth plate in the throwing arm of skeletally immature baseball players.  The image above (A) shows the widening of the upper arm growth plate in a young athlete diagnosed with Little League shoulder.  The condition is characterized by generalized shoulder or upper arm pain during throwing.  In more severe cases, Little League shoulder may cause pain with activities of daily living or at rest.

Little League shoulder and Little League elbow are treated with a period of rest, physical therapy, and programs to improve strength and throwing mechanics.  Premature closure and fractures of the growth plate have been reported in association with Little League shoulder but these are extremely rare complications.  Most will eventually ‘‘outgrow’’ the condition spontaneously with normal growth plate closure.  However, some continue to experience pain during the preadolescent or adolescent years which may considerably limit participation.

Little League shoulder most commonly occurs in youth overhead athletes between the ages of 11 and 16 years.  Thirteen years is the most common age at which players move out of Little League and to a larger diamond.  This requires a longer distance for pitches to cross home plate.  Therefore this is the period where coaches and parents should most closely monitor youth athletes for early signs of pain.  Below are five key considerations for returning injured youth baseball players back to play safely.

#1 Little League Shoulder is Occurring with Increasing Frequency

The increasing frequency of Little League shoulder is due to overuse and throwing with arm fatigue.  This trend is likely due to greater numbers of pitchers participating in competitive leagues and doing so at increasingly younger ages.   Increased velocity of pitches thrown, as compared with previous decades, is also a likely contributor.  Year-round participation, participation on multiple teams in a season, the influence of private pitching coaches, and ‘‘showcase’’ events all contribute to increased stress to the skeletally immature athlete.  It is imperative that coaches and parents monitor players in accordance with Little League pitch count recommendations.  It is also strongly recommended that players take at least 3 to 4 months per year off from throwing.

#2 Little League Shoulder Treatment Always Includes Rest from Throwing

Baseball Phases of Throwing

During the late portion of the arm-cocking phase of throwing, there are considerable rotational forces acting on the shoulder. These forces can deform the cartilage of the growth plate and play a role in the development of Little League shoulder.  The only way to remove the stress and allow the injury to heal is to stop throwing.  The longer players throw with arm pain, the longer resolution of symptoms will take.  Therefore, the initial treatment plan for Little League shoulder always consists of cessation of throwing.  This period typically lasts 2 to 4 months.  The pain usually resolves within the first 1 to 2 months of rest.  However, premature return to throwing often leads to recurrence of symptoms.  It has been estimated that approximately 25% of injured players will experience a recurrence of pain within 6 months of resuming throwing.

#3 Early Physical Therapy Should be Prescribed

Physical therapy treatment is initiated early to normalize shoulder range of motion and to begin a progressive strengthening program. Differences in side-to-side shoulder rotation ROM is believed to contribute to shoulder pain in the youth baseball player.  These asymmetries have also been associated with a recurrence of Little League Shoulder.  Therefore, it is important that youth athletes with Little League Shoulder are evaluated and treated by a physical therapist in order to address these risk factors.  The cross body stretch targets posterior shoulder tightness which contributes to loss of motion in overhead athletes.

Posterior Shoulder Stretch
Cross Body Stretch

Strengthening the rotator cuff and shoulder blade muscles is important to build arm strength while resting from throwing.  Weakness of the rotator cuff muscles has been shown to be a risk factor for shoulder and elbow injury in adolescent pitchers.  Youth baseball players should demonstrate full pain-free strength of the rotator cuff muscles before throwing is resumed.  Sidelying external rotation and prone horizontal abduction exercises target the posterior rotator cuff muscles which are often weak in young throwers.  It is also important for athletes to strengthen the lower body and core musculature.  Weakness in these areas will result in increased stress transferred to the throwing arm.

#4 Throwing Programs Should be Undertaken after Arm Strength is Developed

Structured interval throwing programs allow for a safe transition back to play.  These programs are designed to replicate game conditions in a progressive and safe manner.  Because individual differences exist, these programs must be tailored to the injured athlete’s physical and emotional needs.  Omitting or rushing throwing programs often leads to recurrence of symptoms and delayed return to play.  Also, long toss throwing should be used judiciously due to increased rotational forces imposed on the healing growth plate.  Communication between the medical team and coaching staff is important to ensure the success of interval throwing programs.

#5 Flaws in Pitching Mechanics Should be Corrected Before Returning to Play

Before returning to unrestricted play, injured athletes should have their throwing mechanics assessed by a coach.  In particular, the rate of trunk and pelvis rotation during the acceleration phase of throwing has been linked to shoulder injuries in youth baseball players.  Hip-to-shoulder separation refers to the position of the hips relative to the shoulder just prior to the front foot contacting the ground.  Under ideal pitching mechanics, the hips are facing home plate and the shoulder continues to face towards third base in a right-handed pitcher.  This allows for the optimal transfer of force from the core to the throwing arm.  As fatigue increases, the hips and shoulder begin to rotate in unison resulting in an open hip-to-shoulder separation.  This loss of force transfer and power generation results in increased stress placed upon the shoulder and elbow.  This flaw should be corrected to reduce shoulder stress in the youth overhead athlete.

Closing Thoughts on Little League Shoulder

Little League Shoulder usually resolves with 3-4 months of rest but symptom recurrence may occur.  It is important to not rush youth athletes back to throwing before their range of motion and strength are normalized.  Correcting any pitching mechanic flaws and a progressive throwing program is also required before unrestricted return to play.  Even after returning to play, close monitoring of athletes for at least 1 year is recommended to ensure the prevention of recurrence. Finally, current guidelines regarding pitch counts, rest, and activity modification should continue to be emphasized for long-term health.

References

  1. Harada M, Takahara M, Maruyama M, et al. Outcome of conservative treatment for Little League shoulder in young baseball players: Factors related to incomplete return to baseball and recurrence of pain. J Shoulder Elbow Surg. 2018;27:1-9.
  2. Heyworth BE, Kramer DE, Martin DJ, Micheli LJ, Kocher MS, Bae DS. Trends in the presentation, management, and outcomes of little league shoulder. Am J Sports Med. 2016;44(6):8-11.
  3. Sabick MB, Kim Y, Torry MR, Keirns MA, Hawkins RJ, Frcs C. Biomechanics of the shoulder in youth baseball pitchers implications for the development of proximal humeral epiphysiolysis and humeral retroversion. Am J Sports Med. 2005;33(11):1716-1722.

Serratus Anterior: 3 Exercises to Improve Overhead Mobility

The serratus anterior is a key muscle involved with the performance of many overhead movements such as throwing a baseball, serving in tennis, and pressing a barbell overhead.   This muscle spans from the upper 8 ribs along the side of the trunk up to the inner border of the shoulder blade.  This muscle assists with rotating the shoulder blade (scapula) upwards and tilting it backward in order to position the arm for optimal overhead function.  Along with thoracic spine extension mobility, these scapular movements are often ignored as important components of overhead function.  The serratus anterior is also the primary muscle that protracts the scapula during upper extremity function.  This involves the scapula moving forward along the rib cage such as when punching in boxing.

The Serratus Anterior and Overhead Function in Athletes

Individuals with shoulder problems demonstrate decreased upward rotation of the scapula, decreased posterior tilt of the scapula, and increased activity of the upper trapezius muscle.  In particular, swimmers and baseball pitchers commonly present with a pattern of decreased serratus anterior activation and increased activation of the upper trapezius.  This alteration in muscle patterns leads to compensatory movements, decreased overhead range of motion, and increased stress to other structures such as the rotator cuff and elbow joint.

The serratus anterior functions to upwardly rotate and posteriorly tilt the scapula
Assessing strength of the serratus anterior

Exercises that combine scapular upward rotation, posterior tilt and protraction are ideal to activate the serratus anterior.  It is also helpful to include closed chain exercises where the hand is fixed to a surface through the floor or a wall.  Finally, exercises performed with the arm elevated above the shoulder or eye level elicit greater activation of the serratus compared to exercises performed at or below the shoulder level.  Wall slide and bear crawl variations fulfill these criteria which are optimal to train the serratus anterior in overhead function.

 Wall Slide with Foam Roll

Begin with your forearms resting on a foam roll against the wall placed at shoulder height.  Protract the shoulder blades by pushing the upper back away from the wall to activate the serratus anterior.  Next, “roll” the forearms up the wall in a controlled manner, making sure you don’t lose protraction.  Return back to the starting point in a controlled manner and repeat for the desired number of repetitions.

Serratus Anterior Wall Walks with Band

Begin by wrapping a resistance band around your wrists and pulling your wrists apart. Your forearms should remain parallel and take the form of the number “11” throughout the exercise.  Protract the shoulder blades by pushing the upper back away from the wall to activate the serratus anterior.  Then, “walk” the forearms up the wall in a controlled manner to approximately eye level or slightly higher, making sure you don’t lose protraction.  Return back to the starting point in a controlled manner and repeat for the desired number of repetitions.

Bear Crawl

Assume an all-4’s position with the hands in front, shoulder-width apart, feet behind the hips and up in the air.  The knees should remain elevated from the floor so you are stabilized by 4 points of contact.  Begin by pushing the back up towards the sky to protract the scapula and activate the serratus anterior.  Crawl forward starting with your right hand and your left foot following with the left hand and the right foot.  After each step, pause briefly to exhale. Take four steps or more depending on space, then turn around and bear crawl back.

Closing Thoughts on Serratus Anterior Exercise

Building a foundation of strength targeting the scapular muscles is crucial for overhead athletes.  This foundation should include movements that facilitate activation of the serratus anterior through scapular upward rotation, posterior tilt, and protraction.  These exercises can be included as part of a strength training session warm-up or part of a regular arm care program.   Overhead athletes, such as baseball players and swimmers, should particularly include exercises targeting the serratus anterior and lower trapezius as part of their year-round strength and conditioning program.

5 Thoracic Mobilization Drills to Improve Overhead Mobility

The position and mobility of the thoracic spine directly affects the amount of overhead shoulder movement available.   A more erect and mobile thoracic spine and rib cage will result in greater overhead range of motion.  A slouched posture or stiffness in the thoracic spine and rib cage will result in a loss of range of motion reaching overhead.   Excessive thoracic kyphosis, or a slouched posture, may alter the position of the shoulder blade and impair muscle activation patterns both of which contribute to limited overhead function and shoulder pain.

Approximately 15 degrees of thoracic spine extension mobility is required for full overhead motion when lifting both arms such as when performing a barbell overhead press. Full 1-arm elevation requires approximately 9 degrees of thoracic extension.  Thoracic spine rotation is also crucial for rotational sports such as baseball where a large amount of power is transferred through the trunk.   A baseball pitcher who lacks thoracic spine rotation will compensate by increasing movement and stress through the shoulder and elbow joints.

Strength is foundational for optimal shoulder health but thoracic spine mobility is often a neglected area when athletes attempt to maximize their overhead shoulder function.  Therefore, exercises targeting thoracic spine extension and rotation mobility should be included in any rehabilitation or performance enhancement program seeking to optimize shoulder function.  Instead of jumping to restore shoulder mobility with bands and balls, try these thoracic spine mobility exercises first.

Bench T-Spine Mobilization

This is my favorite exercise for restoring thoracic spine extension.  It also provides a nice stretch to the lattisimus dorsi muscle which can also limit overhead mobility. The exercise begins by assuming a kneeling position facing a bench.  Place your elbows on the bench in front of you holding a PVC pipe or dowel with the palms facing up.  Sit back, pushing your buttocks towards your heels, keeping your spine relaxed, until you feel a stretch in your upper back.  For an added stretch you can bend your elbows further past your head.  Hold this position, and exhale fully.  Reverse the motion to return to the start and repeat the desired number of repetitions.

Thoracic Extension + Rotation (Reach Backs)

Begin this exercise by sitting back on your heels, face down, with one hand behind your head and the opposite forearm resting on the ground in front of you.  This position minimizes available movement in the low back and maximizes movement to the upper back.   From this position rotate your elbow up to the sky while exhaling.   The opposite forearm remains in contact with the ground.  Return to the starting position and repeat for the desired number of repetitions before switching to the opposite side.

Foam Roll Thoracic Extension Mobilization

This exercise can be a challenge to perform correctly.  Most end up extending through the lumbar spine and not the thoracic spine.  Begin in a lying position over a foam roll.  Place the hands behind the neck supporting, but not pulling on, the neck.  Raise the buttocks off the ground and roll the upper back up and down the foam roll.  Identify a sensitive, stiff, or tender area and then drop the buttocks down to the ground.  From this position perform small extension movements by lifting the elbows up towards the ceiling.  Be careful not to overextend at the lower back.

Thoracic Spine Windmill

This is my “go to” exercise to restore thoracic spine rotation.  Begin on your side with both arms outstretched in front of you.  Place a foam roll under your top leg with the knee and hip bent to 90 degrees.  The bottom knee and hip remain extended throughout the exercise.   Reach forward with your top hand and then complete a large circular windmill motion as you rotate your entire upper body.  Keep reaching as if you were attempting to lengthen your entire arm.  Follow your hand with your eyes to ensure proper thoracic spine and rib cage movement.  The top knee and leg should remain in contact with the foam roll throughout the exercise.  Perform the desired number of repetitions and then repeat on the opposite side.

Standing Thoracic Rotation Mobilization

The standing rotation exercise is ideal to incorporate into a pre-workout dynamic warm-up.  From a standing semi-squat position place one arm between your thighs just above the knees.  This position will block unwanted hip and pelvic movement.  Next, rotate the body upwards towards the sky by following your open hand with your eyes.  At the top of the movement, exhale before returning to the starting position.  Perform the desired number of reps and then repeat on the opposite side.

Closing Thoughts

After performing these mobility drills it is important to work on strength and endurance of the thoracic muscles.  Also, manual therapy to the thoracic spine and rib cage has been shown to accelerate recovery and reduce shoulder pain immediately and for up to 1 year.  Maintaining or improving thoracic spine mobility is imperative for any active individual who regularly functions overhead.  Manual therapy, mobility drills, and strength/endurance exercise targeting the thoracic spine can lead to significant gains in overhead function for athletes and the general population.  These 5 mobility drills can be easily integrated into any pre-workout warm-up routine or as part of a home exercise program.