Treating the competitive volleyball player series, Part 2: Shoulder Impingement Assessment

Congratulations to TEAM USA on their BRONZE medal and TEAM CHINA on their GOLD medal yesterday. Not the outcome that TEAM USA wanted, but it is still a medal and everyone played their hearts out. TEAM CHINA showed that they had the grit to grind it out against a very tough SERBIAN team.

While there can be a plethora of shoulder injury diagnoses in volleyball players, the most common would be overuse of the shoulder leading to impingement (of either form, subacromial or posterior/internal impingement). Front row attackers (hitters) have the highest risk of shoulder injuries due to the high number of repetitions (Top NCAA Division 1 hitters can reach up to 1,600 swings in a season, with an average of 40-50 swings  match*). *This number may not be accurate due to variability in number of sets and points in each set (3 vs. 4 vs. 5 set matches) – it also depends on if the team heavily relies on one athlete for offense or not.

The pathology of subacromial impingement is that the tendon of the supraspinatus muscle is “pinched” under the coracoacromial arch – the supraspinatus muscle passes inferior and anterior to this arch and when the shoulder is flexed in a neutral position, this muscle/tendon is jammed against the inferior portion of the coracoacromial arch. This can also irritate the subacromial bursa, leading to increased pain.

Posterior, or internal, impingement is when the posterior/superior aspect of the labrum is impinged on the underside of the supra and infraspinatus muscles; mostly secondary to laxity in the anterior capsule in overhead athletes.

In most literature, the pathology will focus on the glenohumeral joint and the immediate surrounding/involved structures. However, much of the pathology stems from elsewhere – thoracic spine, cervical spine, costovertebral joints, scapulothoracic “joint” etc… For example, if the client’s thoracic spine is hypomobile or “stuck” in extension, this will induce a relative “anterior tilt” of the scapula (posterior/inferior rotation of the costovertebral joint). If you were to only work on the glenohumeral joint, you’d get no where in your treatment because the CAUSE is NOT the GH joint, but the lack of mobility in the thoracic spine.

costovertebral extensionposture comparison

As you can see from the above image, a flattened T spine (middle image) can also predispose a client to forward head/rounded shoulder posture, thereby increasing the risk of shoulder impingement and muscle imbalances. In this situation, the client’s posture will increase pec minor and major compensation in an overhead athlete due to increased activation while trying to stabilize overhead and during follow through.

Lower traps and serratus anterior may be inhibited or dysfunctional in this posture. Lower trap inhibition reduces overall AROM in flexion – the lower traps are responsible for the final 10-15deg of flexion through inferior stabilization of the scapula, allowing room for GH joint to continue into flexion. If the scapula was not stabilized inferiorly, it would get in the way in the terminal degrees and cause pain and impingement. Lower traps would also act as a counterforce to the pec minor muscle in this situation. Serratus anterior is responsible for upward rotation of the scapula as well as improving congruency between the scapula and the rib cage. If inhibited, can lead to poor congruency and may lead to increased dominance of pec minor/major as well as winging of the scapula.

Another aspect that should be investigated is the SC/AC joint. Often neglected in shoulder rehab, but the SC joint is required to glide inferior and rotate posterior during shoulder elevation. The clavicle is the one bony connection of the scapula to the thorax. If the proximal end of the clavicle does not glide and rotate properly, it will negatively impact the AC joint at the distal end. This, ultimately, leads to poor gliding between the acromion and clavicle – decreasing overall shoulder flexion.

While subacromial impingement is the more talked about form of impingement, Internal/posterior impingement is quite common in the overhead athlete such as baseball pitchers and volleyball players. Any athlete that goes through a similar motion to the “throwing arc” is at risk for developing posterior impingement. This is when there is anterior laxity (or instability) and posterior shoulder pain due to pinching between the underside of the supra/infraspinatus and the posterior capsule/labrum.

Athletes will typically present with Glenohumeral Internal Rotation Deficit (GIRD), where they will have excessive external rotation and lack shoulder internal rotation. This is due to the requirements of their respective sport. In volleyball, if the setter sets the ball to the middle many aspects can go wrong and can lead to the middle hitter compensating to reach for the ball: 1. If the middle hitter’s approach and take off is in front of the hitter, often times the set will be behind the hitter and therefore, in order to hit the ball, they will be reaching way behind them, increasing anterior GH stress. 2. If the setter’s location is off and the set drifts off the net, the hitter will be in the same situation as #1. In both cases, there will be increased anterior capsule stress which can lead to laxity over time. However, only one of these situations is controllable by the hitter (#1).

In many cases, many therapists may give the “Sleeper Stretch”. This is because many believe that the posterior capsule is “tight” and that stretching it will help. In one study conducted by Borsa et al, it was shown that, in fact, the opposite it true – there isn’t “tightness”, but rather laxity in the posterior capsule in many cases. Therefore, the sleeper stretch is not a good idea. It also places the shoulder into further “impingement” if you think about it.

However, deficits in internal rotation can also be traced back to the thoracic spine – if you think about it, you need a bit of CONTRALATERAL thoracic spine rotation to reach up your back (L rotation for R IR up the back). In Treating the Overhead Athlete series, Part 4 I go over sidelying rib cage mobility. This exercise is a good one to give as a home program so that the athlete mobilizes their rib cage and T spine into contralateral rotation.

https://instagram.com/p/BG8nJlunq_O/
The above link is a video of Foluke Akinrawdewo, 2012 Olympic Silver Medalist/2016 Olympic Bronze Medalist/3x First Team All-American during her time at Stanford University. She is a great Middle Blocker and in the above video she is hitting a “slide” where the middle takes off one foot -like a lay up in basketball – behind the setter. It may appear that she is putting her shoulder into further impingement or hurting it.This is a common issue for volleyball hitters. Due to the dynamic nature of the sport and the high number of variables, there is never a black and white answer. As a MIDDLE hitter, Akinrawdewo has to commit to her approach and take off – it is very hard for her to adjust her approach speed and step length once she commits to a play. The setter (Alisha Glass in the above video – 3 time NCAA D1 Champion at Penn State, First Team All American) is taught to put up a hittable ball – in this case against 2 blockers, she cannot/should not put the ball too tight to the net. The ball also can drift off it’s trajectory mid set and the hitter will need to adjust their ARM to hit the ball (cannot adjust their approach very easily from the middle due to the speed of the game).

That was a lot of volleyball jargon. I am in no way criticizing Alisha Glass or Foluke Akinrawdewo – they understand the mechanics of their game as well. This is a snapshot into some of the problems of treating an athlete.  The main point and take away is that when/if you’re treating a volleyball player, DON’T JUMP TO CONCLUSIONS! This is actually very important when treating any athlete. You can try to correct their approach and arm swing, but realize that a lot of it is out of the athlete’s control due to the speed of the game and the number of variables involved. It is out job as sports physical therapists to make sure that out athletes can adapt to any situation during a game.

References:

Escamilla, R. F. et al. Optimal Management of Shoulder Impingement Syndrome. J Sports Med. 2014; 5: 13–24.

Paine, R. et al. The Role of the Scapula. Int J Sports Phys Ther. 2013 Oct; 8(5): 617–629.

Manske, R. C. et al. Shoulder Posterior Internal Impingement in the Overhead Athlete. Int J Sports Phys Ther. 2013 Apr; 8(2): 194–204.

Borsa, P. A. et al. Mobility and Stability Adaptations in the Shoulder of the Overhead Athlete. Sports Medicine. 2008 Jan; 38(1): 17-36

Biomechanics of the Thorax

 

Treating the competitive volleyball player series, Part 1: An Introduction

Who’s been hyped up for the Olympics this year? I live for every 4 years (well, really every 2 because of the winter Olympics). Finally, other sports other than American Football, Basketball, Baseball, and Hockey will be featured for 2 weeks, and we get to see history being made.

This will be the first series of many to address athletes of specific sports. For those who don’t know me, I played volleyball in college and have coaching experience at the high school and collegiate levels – currently coaching at a local private school in Boston. USA volleyball is on the hunt for the ever elusive Olympic Gold, as they’ve finished with a silver medal at each of the last two Olympics, falling to 2 time defending champion and this year’s host, Brazil. So naturally, I am biased and picked volleyball as the first sport to address. However, having treated major league and collegiate baseball players and played soccer and ran track and field, you can expect these sports to be represented in the near future as well.

Volleyball players fall under the umbrella of “Overhead Athlete”, so if you would like more background on that, please refer to my 4 part series of “Treating the overhead athlete“. Naturally, volleyball players will present with shoulder injuries including but not limited to impingement, rotator cuff tear, labral tear, and scapular dyskinesia. However, due to the dynamic nature of the sport, lower body injuries also occur at a high rate including, but not limited to, ACL tears, ankle sprains, patellar tendinitis (jumper’s knee), ankle sprains, and patellofemoral pain syndrome (PFPS).

There are 6 basic skills involved in volleyball: serve receive forearm passing (bump, off of a serve), overhead passing (setting), hitting (spike), blocking, digging (a forearm pass that happens when you pass a hit), and serving. There are several positions in volleyball, and the athlete’s risk of injury is correlated to their position; setter, outside/right side hitter, middle blocker, and libero (back row specialist in the different color jersey).

Libero
Libero Dive
middle hitter slide
Middle Hitter – Slide
outside hitter
Outside Hitter
setter
Setter jump setting

Front row players (hitters/middles/setters) have the highest rate of injuries. Middle and outside hitters not only put their shoulders at risk due to high repetitions, but upon landing, the impact on their joints (femoralacetabular, tibiofemoral, talocrural/subtalar) are at risk for injury. Setters may not have the high incidence of shoulder injuries as hitters, but they certainly can develop impingement and scapular dyskinesia due to their overhead arm position. And since setters on many teams play all the way around, they will be required to block at the net and are at risk for developing lower extremity pain/injuries.

Defensive players don’t usually develop upper extremity injuries, but can develop overuse injuries and tendinitis in their knees due to being constantly in a squat position. Hip injuries can also develop such as acetabular impingement, PFPS, and jumper’s knee. Not to mention, diving on the ground can lead to knee and hip bruises.

In the following 2 posts, I will divide the injuries into upper and lower extremity as well as dissect the injuries that develop, including WHY, and how you can assess your athlete.

Featured Professional: Ramez Antoun, PT, DPT, SFMA,PNF

ramez headshot

A few weeks ago I had the opportunity to connect with a fellow physical therapist in the Boston area, Dr. Ramez Antoun, PT, DPT, SFMA, PNF. Dr. Antoun is a graduate of UMASS Lowell’s DPT program as well as Kaiser Permanente’s Proprioceptive Neuromuscular Facilitation (PNF) fellowship in Vallejo, CA. He is SFMA and Dry Needling certified and is currently pursuing his COMT for manual therapy through the Institute of Orthopedic Manual Therapy (IOMT). He is the founder of NEUROPEDICS, a cash based physical therapy service – currently based in Somerville, MA: http://www.neuropedicspt.com/

Below is a highlight of the interview I had with Dr. Antoun:

JC: I know you’ve written on the PNF philosophies in your blog, which can be found here: http://www.neuropedicspt.com/professional-blog. But could you highlight some of these PNF philosophies?

RA: If you’ve read the book “Start with WHY” by Simon Sinek, he talks about the golden circle and how the core is the WHY statement (the why we do what we do), the outer ring is the HOW (how we do what we do), and the outermost ring is the WHAT (what products we will use, dumbbells, kettlebells etc…). As residents of PNF, we are introduced to philosophies.

The first philosophy of PNF is that every living thing has potential – this is rooted in neuroplasticity research. The brain is constantly able to make new connections, new patterns, new associations, which is one of the things we have to truly believe in when rehabbing [clients], because from a neurological standpoint, we have very debilitated [clients] (strokes/TBI) who are paralyzed and believing they can’t walk again, and that innate belief that you can create changes based, on neuro plasticity, that they can walk again, is the first stepping stone of PNF – going into treatment with a positive attitude. This leads me to philosophy number 2, which is treating the whole person. The whole human being encompasses the emotional (i.e. using positive language), the physical (i.e. biomechanical interventions), and the intellectual (i.e. educating the client). The third philosophy is always start with what the person can do – so a positive approach. We’re trained as therapists and trainers to look for weaknesses or impairments and highlight those when we’re talking through an evaluation process, but in PNF, first comment on what you see what’s good. For example: I see that your right shoulder moves really well, especially into upward rotation. The left side, not as good, but we can work with that. Rather than “Oh, that L side is tight, what’s going on there?” To me, the client is already coming to us broken down; a piece of their identity was already taken away from them. So one of the things I can do for them on initial contact is to be positive. The fourth philosophy is movement always needs to be purposeful and leading towards a functional goal. So our exercise program/progression should show a sense of progression back to functional. So I think 4×4 matrix (SFMA): supine/prone à quadruped à kneeling à standing.

JC: I completely agree with everything you’ve touched upon. Being positive. I don’t think that is something talked about enough in PT school. What was it like to go through the PNF residency in Vallejo, CA and how was this philosophy (#2) integrated?

RA: So the residency is 9 months, and it is split into 3 phases: 3month resident, 6month resident, 9month resident. You know how in PT school you always had a strength and problem list when evaluating/treating patients? When ever we did patient demos or working with a patient, they would force to always write down the positives, even within a treatment. In PT school, when a client doesn’t move the way you want them to, you say “No, not like that”. One time I was co-treating with my mentor, and she said, “That’s assuming that that movement is bad”. But when dealing with a neurological population, every movement needs to be considered beautiful, because if they couldn’t do that, then that would be paralysis. Instead of saying no, articulate what movement they did. For example, if you wanted them to reach up over 90 and they reached down below 90 articulate it “Good, you were able to reach down at this angle, now lets try to reach upward overhead”. That was huge, just being able to change my vocabulary and trying to not say “NO”.

JC: That’s a great philosophy, and along the lines of “any movement is better than no movement”.

RA: The only time to say no (and this can be applied to all populations) is when the movement is deemed unsafe and it was going to harm them. This brings us to the principle of “Protect before you correct” from Functional Movement Systems. For example, if someone is doing a lift, and his or her lumbar spine goes into flexion at the bottom, then “No, that is not how we load the spine”. There still is a framework of right and wrong, we still have to respect biomechanical movement. But nonetheless, we shouldn’t be quick to jump into giving negative feedback.

JC: I don’t like the segregation in the PT world. We have distinct settings that we practice in (acute care, inpatient rehab, ortho, sports etc…), but at the end of the day, our goal is to get the client in front of us to move better in the safest way possible. However, I feel that many therapists don’t see it that way, and think, “I’m an ortho therapist I don’t know what to do with a stroke patient”. I don’t like this separation.

RA: There is definitely overlap. There is a whole renaissance of where neuro and ortho are starting to blend together. And there’s a blend of the concepts in the sports world; neuro muscular control, neuro developmental postures, actually can make people move better than in isolation. But it hasn’t been like that. If you go back in history – guys like Maitland, Kaltenborn, Mulligan, Maggie Knott etc…. – They all hung out. They all influenced each other. I don’t know what made that message lost, that the neuro and ortho aspects need to be separated. But I think that they are starting to be marketed again, together.

JC: I completely agree, again. I’m not sure how the curriculum was at Umass Lowell, but at Emory, we were introduced to acute care, ortho, neuro, all separately and in isolation from each other.

RA: I think that it needs to be that way, initially. But by third year, maybe introducing the concept through a course like “Neuro for the orthopedic therapist” might be helpful. I don’t know if we can do ortho for the neuro therapist, but in the PNF residency in Vallejo, there were many therapists who had completed orthopedic training – if we had a patient who couldn’t get into a certain position due to tone or joint restrictions, then they would perform joint mobs. Then we’d follow it up with more neuro-based techniques, rolling etc…

JC: I felt very fortunate that while I was at Emory I had a professor (Dr. Baudo) – who has influenced my clinical reasoning and treatment philosophies a lot – whose big principle was segmental innervation. She would say, “If I have an athlete with an ankle sprain, why am I mobilizing L4/L5/S1? Because what do you think innervates the ankle? L4-5/S1.” So for me, a lot of diagnoses come back to the spine. If I can get one facet joint to move a little better, it could free up any tension on the underlying nerve.

RA: From a biomechanical aspect I might explain it like that. From a sensorimotor perspective I might explain it as stimulating the mechanoreceptors at that particular level, which can send feedback into the central nervous system to get an improved output from the brain for the dermatomal distribution. For patients, I explain it with the following visual explanation: Think about watering a plant. The pump is the spine, the hose is the nerve, the water is the electrical signal, and the plant is the muscle. If the pump isn’t working right, the plant isn’t going to get great water (poor water pressure). If we keep obsessing about why the end of the hose isn’t spitting out water and never look at or check out the pump to see if it’s working, how are we going to expect to help the plant grow? Go to the source of the problem.

Hope you guys enjoyed this interview. Please check out more of Dr. Antoun’s work on Facebook/Instagram at Neuropedics Physical Therapy and Sports Medicine Consulting.

Lateral Ankle Sprain series, Part 2: No Such Thing As A Minor Ankle Sprain

With all of the hype surrounding the upcoming Olympics, I felt like this was a great time to bring in some real life examples. This past week wrapped up the US Gymnastics and Track & Field trials – and what an exciting week it’s been. So far between Gymnastics, Track & Field, and Swimming it seems like in order to make the US Olympic team you have to start breaking some records.

Given that we are on the ankle sprain series, I wanted to draw everyone’s attention to the 200m Finals of the Track and Field Trials on July 10. Below is a video of the finals heat, many top contenders in the field vying for 1 of 3 spots on the Olympic roster. In lane 5, is Allyson Felix, the reining 200m Olympic champion from 2012. Prior to the 200m qualifiers, Felix had already qualified for Rio in the 400m, winning the 2016 trials a few days ago. Coming into the trials this year, Felix has been dealing with an ankle injury to her R leg after a misstep in a training session back in late April – forcing her to pull out of a couple meets in May and June. In an interview with her coach following the injury, he said “(The injury) is 80 percent better in less than a week”. I’m not sure that a grade 2 ankle sprain is 80% better in less than 7 days (some public education may be needed for this coach). Felix, herself, said “The speed wasn’t there” for her in the 200m trials.

If you’ve been keeping up with the news, you’ll know that Felix missed making the Olympic team for the 200m by .01s (what a photo finish), still running a blistering 22.50s. Take a look at the video below (excuse the woman yelling in the background):

The slow-motion play back begins at about 4:35. If you pay attention to Felix (in all blue, lane 5) as she’s pushing towards the finish line, you’ll notice that she does not get the same push with her R leg as she does with her L leg, she has asymmetrical strides bilaterally, and her hamstring prematurely contracts on her R side reducing her quad contraction that she needs for her push (leading to less hip extension as well).

Following an ankle injury, there is a change in neuromuscular activation and firing due to the body’s mechanism of protection. Peroneal activation is delayed, glute med activation is impaired, increased MTrPs develop in the  lateral gastrocs, increased activation of hamstrings. I’m assuming that with Felix being a high profile athlete, she’s getting/gotten some of the best rehab since her injury, but this just goes to show that even 2 months out, she is STILL dealing with the residual effects of an ankle sprain – grade 2.

Friel et al. found that not only is ipsilateral hip abductor weakness noted following an inversion ankle sprain, but that plantarflexion ROM is also limited on the involved side. This also means that the force that can be generated from the involved side is significantly less. As you can tell from the above video, that is exactly what happened to Allyson Felix in the 200m finals.

How many of you are reading this thinking: “She missed it because the other girls were faster” or “it was just bad luck”? Just a week ago, she blew away the competition in the 400m with a time of 49.68s. She had the speed for the 400m, however after 3 rounds in the 400m and 2 rounds in the 200m trials, by the time the 200m finals came around, she could no longer compensate and hide her ankle injury and it’s residual impairments.

On the flip side, she has been dealing with injuries (like most athletes) for a good part of her career, may also have chronic ankle instability. In 2010 she had to pull out of a meet due an ankle injury. She tore her hamstring in 2013 during the 200m event. Who’s to say that these past injuries did not contribute to her “misstep” 2 months ago?

Felix missed Rio in the 200m by .01s not simply because she didn’t have the speed. She didn’t have the most efficient movement pattern down the stretch. From the start, she was placing a lot of pressure on her R ankle – it’s her first “pull” step out of the blocks (she pushes off with her L). Down the stretch, she was not able to make the final push with her glutes and quads/gastroc-soleus, and the asymmetry of her stride decreased the amount of force she could generate.

For those who think ankle sprains don’t affect your performance, even months/years down the line: Allyson Felix missed the Olympic roster by .01s …. all because of an ankle sprain.

References:

Hertel, J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle sprains. Journal of Athletic training. 2002;37(4):364–375

Friel, K et al. Ipsilateral hip abductor weakness after inversion ankle sprain. J Athl Train. 2006; 41(1): 74–78.

http://www.globetrottingbyphiliphersh.com/home/2016/4/28/news-of-allyson-felix-misstep-sends-coach-into-brief-thankfully-despair

 

 

 

 

Lateral Ankle Sprain series, Part 1: An Introduction to Anatomy of the Ankle

It might seem odd to jump from the shoulder/overhead athlete in one topic series to lateral ankle sprains at the other end of the body in the very next, but I promise there is a connection – there always is. Many overhead athletes rely on the hip opposite their dominant side for power generation and stability – L hip (stance hip) for R handed pitchers, L hip adduction in R handed javelin throwers etc… Therefore, if the opposite hip is important, then so too is the opposite ankle. After all, the contralateral hip relies on the ankle to remain upright. 

Lateral ankle sprains are among the most common in sports injury. The ankle joint is comprised of three separate articular surfaces: the talocrural, subtalar, and distal tibiofibular joints. The talocrural joint is the articulation between the dome of the talus and the distal ends of the tibia and fibula, while the subtalar joint comprises of the anterior and posterior articulations of the talus and calcaneus, and distal ends of the tibia and fibula join together to form the final piece of the ankle in a syndesmotic joint.

The talocrural joint sits on an oblique axis and is the hinge joint that is responsible for dorsiflexion. This joint is crucial during weight bearing, as it allows any torque in the lower leg (internal/external rotation) to be transmitted to the foot (supination/pronation). The subtalar joint, an articulation between the calcaneus and talus is responsible for rear foot eversion/inversion and also participates in this force transfer. The subtalar joint is made up of two separate joint cavities and therefore, 2 separate joints, the anterior subtalar joint (talocalaneonavicular) and the posterior subtalar joint. The sinus tarsi and canalis tarsi separate the anterior and posterior components. Due to the location of the sinus tarsi, it is vulnerable to overuse injuries and ankle sprains, resulting in sinus tarsi syndrome – impingement of fatty tissue.

The distal tibiofibular joint makes up the last piece of the ankle joint. The tibia and fibula have two articulations, one distally and one proximally, and are connected along their shafts by a syndesmosis. Due to two points of contact between the tibia and fibula, as therapists, we need to address both in an ankle sprain. In normal dorsiflexion ROM, the fibula should glide superiorly and a little posteriorly. Most commonly, the distal tibiofibular joint can be anterolaterally shifted in chronic ankle injuries, reducing overall ROM in dorsiflexion – this is also due to reduced ligamentous stability from the anterior talofibular ligament (ATFL). Therefore, assessment of symmetry bilaterally of the fibula position following a lateral ankle sprain is paramount.

The main ligaments involved in stabilizing the ankle include the ATFL, posterior talofibular ligament (PTFL), calcaneofibular ligament (CFL) – all responsible for lateral stability – and the deltoid ligament – for medial stabilbity. The former three are more commonly injured due to their role in lateral stability and the prevalence of lateral ankle sprains, however the deltoid ligament can be pinched during grade 3 lateral ankle sprains.

Aside from rehabilitating the site of pain and addressing joint mobility/strength/proprioception deficits locally, it is vital to search up the chain for impairments – namely, the glutes/hip (including adductors) and anywhere along the lateral – including the peroneals and TFL – and functional lines. We are all familiar with the functional relationship between the glutes-lumbosacral fascia-lats (aka. Hip to contralateral shoulder relationship), however that is only on the posterior side, but there exists a similar relationship anteriorly. This relationship links the adductors and the contralateral lateral sheath of the rectus abdominis and pectoralis major.

When treating an athlete with an ankle sprain it is important to note not only the site of pain but to also address the core and hips higher up in the chain. This is due to the alterations in motor recruitment during gait following an ankle injury – antalgic gait often leads to mild Trendelenburg gait pattern and reduced activation of hip stabilizers in single limb stance secondary to pain. In the previous topic series, I’ve discussed how important it is for overhead athletes, and the demands of their sport, to have functional glute and core strength – it generally is a good idea to assess in any athlete. In one study it was also shown that any individual with a history of ankle sprains have reduced glute function. In the following segments I will address some manual interventions including taping and neuromuscular interventions, and return to sport testing.

References:

Hertel, J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle sprains. Journal of Athletic training. 2002;37(4):364–375

Kobayashi, T. Fibular Malalignment in individuals with Chronic Ankle Instability. JOSPT. 2014; 44(11): 872-878

 

Featured Professional: Nicole Canning, PT, DPT

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Dr. Nicole Canning, PT, DPT is our first featured professional on #NotYourAveragePhysio. She was a classmate of mine while at Emory University and is also the author of the blog: inthegamept.wordpress.com. Check it out! Dr. Canning is also a former NCAA D1 soccer player at St. Johns University in Queens, NY, and is also a soccer coach with experience in strength and conditioning as well. Recently I’ve had the opportunity to catch up with her and pick her brain a little:
JC: Where do you currently work and what population do you treat?
NC: I currently work at Competitive Athlete Training Zone (CATZ) Physical Therapy Institute in Pasadena. Since we are also attached to a Sports Performance Center, I see mostly youth, high school, and collegiate athletes, as well as active adults. I also see a small mix of general orthopedic cases.
JC:What are your top treatment philosophies when treating athletes?
NC: My main priority is getting the athletes I treat back onto their respective field/court as safely and quickly as possible, making them a better athlete in the process, and preventing future injury. My two biggest philosophies are promoting efficient movement, and education.
At CATZ, we draw primarily from the Gray Institute and the philosophy of Applied Functional Science. Essentially in this philosophy, movement in all three planes (sagittal, frontal, and transverse) is addressed, with respect to ground reaction forces, center of mass, gravity, momentum, reaction, and relevance, in order to enhance functional movement. For example, when I am working with an athlete, I need to know what movements are specific to his/her sport, what internal and external drivers of movement are utilized, what types of movement do they need to be able to react to, etc. I then look at how they are currently moving and performing these tasks, figure out where the dysfunction is occurring, and then address those impairments in a sport-specific, movement-based, and meaningful way for each individual.
I also like to draw from the Strength and Conditioning world when prescribing exercises for my athletes. Since many of these athletes are currently working, have worked, or will eventually work with a Strength and Conditioning Coach, I believe it is helpful to incorporate those principles as well, and tie it in with whatever pathology or impairments a given individual presents with. I also think it’s important to understand periodization when working with athletes, especially with college athletes. It’s imperative to understand how you need to challenge them differently based on what point of their season (or off-season) they’re in. The Strength and Conditioning world has also helped me in my prescription of exercise dosage. There are different rep and set variables to work with based on what you are trying to achieve. I don’t think I can truly do my job to the best of my ability unless I incorporate essential Strength and Conditioning principles.
Another philosophy I tend to get on my soap box about is the mental/emotional aspect of treating athletes. Competitive athletes possess a very different mentality than the general population. They will over train, play through pain, and do whatever they feel they need to do in order to stay at the top of their game. It’s crucial to understand that in order to help it work for the patient and their rehabilitation rather than working against them.
Finally, the most important thing I do for my patients is education! My goal is to never see my patients again (as a patient) once they have returned to their sport. I educate them on how to maintain ideal movement, how to prevent future injuries, and how to listen to and respect their bodies when they need rest.
JC: What are your clinical interests?
NC: Although I love treating any and all athletes, my main clinical interest is in treating conditions of the lower extremity. I particularly enjoy treating patients with ACL injury because I can take the athlete and basically build them back up from scratch. Aside from gaining range of motion and improving strength and neuromuscular control, I can also take a look at what impairments may have put them at risk of that ACL tear in the first place, and then address those risk factors to decrease the risk of re-injury, or injury to the contralateral side. With patients with ACL injury, you get to literally teach them how to walk, climb stairs, squat, run, jump again. What better way to address dysfunctional movement and inefficient movement patterns and teach the athlete ideal movement instead?
JC: How has your background as an NCAA D1 soccer player helped you in treating athletes?
NC: The ways in which my background as an NCAA D1 soccer player helps me treat athletes are countless! Probably the biggest aspect it helps me with is the mental/emotional facet of treating athletes. Not only do I have insight into the mental and emotional roller coaster that goes along with being a competitive athlete (especially one sidelined with an injury), but I feel that it also helps my patients to connect with me and feel more comfortable when they learn that I was once in their shoes and, to some extent, can understand what they’re going through. This helps me understand when I can push them a little harder, and when I need to back off a bit and allow them to experience success. I think generally, there’s a high level of mutual respect and understanding between my patients and me, and when a patient truly believes that you’re the Physical Therapist who’s going to get them better, and help them become a better athlete, then you’ve already won half the battle.
JC: I know you conducted research, and presented a platform talk at CSM 2015, on implementation of ACL injury prevention programs, can you tell me a little more about that project?
NC: Yes, as a female soccer player, I have always been interested in ACL Injuries. Also, aside from being a Physical Therapist, I have been coaching youth soccer for nearly 10 years now. While I was in PT school, I noticed that many of the research articles I read had great ways of helping to identify and reduce risk factors for ACL tears. Actually, considering how common ACL tears are among female soccer players, I was surprised at how much research I was finding on the topic, especially in the past 5-10 years. This made me wonder how there could be so much research on preventing ACL injuries, and yet the number of ACL injuries per year kept increasing. I realized that there is a huge gap between clinical research and its actual implementation into the population it addresses. I also realized that Physical Therapists, Orthopedic Surgeons, Professional and Collegiate Strength and Conditioning Coaches and ATC’s all have access to this information, but by the time an athlete gets to any of these people, it is often too late. This information is staying at the collegiate and professional levels and has no way of being accessed by youth athletes. I find this to be extremely surprising and important because nearly every researcher, MD, PT, ATC, Coach, S&C Coach will tell you that this stuff needs to be introduced and implemented while the athlete is still developing and growing. I decided to delve a little more deeply into where this breakdown of information was occurring, why it wasn’t being implemented, and how to bridge that gap between clinician/researcher and youth soccer player so that the research can be utilized in a meaningful way.
Thank you to Dr. Nicole Canning PT, DPT for taking the time to chat. Hope you all enjoyed this new segment!

Overhead Athlete series, Part 3: Biomechanics and Movement Patterns of the Overhead Athlete

Understanding anatomy is very useful when treating any client population, however, when treating an athletic population, it is imperative to understand the sport in question, as well as the associated movement patterns. As mentioned previously, most studies are conducted on baseball athletes, but an overhead athlete can play a number of sports, and the mechanics of a baseball pitch/throw can be extrapolated to each of these sports with minor changes. To start, we will outline the mechanics of a baseball player’s pitch.

There are 5 distinct phases of a baseball pitch – wind-up, cocking/stride, acceleration, deceleration, and follow-through. The wind-up phase sets up the pitcher to transfer his weight from their hind leg to their front leg, and is essentially a single leg stance, with opposite knee march. In this phase the hands are together; when the hands break, we enter the cocking/stride phase. In the early cocking phase, the scapula is retracted, the humerus is abducted/externally rotated/horizontally extended – placing maximal stress on the anterior joint capsule. At the same time, the stride leg (contralateral to the throwing arm) begins to extend at the knee/hip and internally rotate. The body’s center of gravity also begins to lower due to the support knee and hip flexing and anteriorly rotating – this is accompanied by extension of the lumbar spine to assist in the shoulder’s external rotation. During this phase, the deltoid and RTC sequentially become active. Internal rotators activate during late cocking to decreased external rotation. Tensile forces are increased in the abdominals and spine to stabilize the trunk. This puts the body in the best position to transfer weight from the support leg to the stride leg as well as energy from the hips and core to the ball.

Acceleration takes place from maximal humeral external rotation/abduction/extension and scapular retraction to when the ball leaves the hand, at which point the scapular has protracted and the humeral position is in internal rotation/flexion along with elbow extension. This is also the point at which the energy stored from the cocking phase is transferred to the ball – therefore successful weight shift from support to stride leg as well as trunk rotation (i.e. thoracic rotation) are necessary for a successful pitch. The Lats and subscapularis muscles are highly active during this short period of time to allow for full internal rotation of the humerus. This ties into the final 2 phases of the pitch – deceleration and follow-through. During these phases, all muscles are active to either slow down the arm or bring it into increased internal rotation. The infraspinatus, teres minor, and posterior deltoid are all active eccentrically to slow down the humerus, while the lats and subscapularis continue to bring the humerus into internal rotation. Elbow flexors including the biceps brachii are active to prevent excessive extension of the ulnohumeral joint. To complete the motion, the trunk continues to rotate contralateral to the throwing arm and flexes. By now, the pitcher should have already transferred all of his weight from his support leg to his stride leg, ending in, again, single leg stance.

baseball pitching phases

Given the above phases of a pitch, the same can be applied to other sports. In volleyball the arm swing phase – when the hitter is in the air – is almost identical to a pitcher’s throw. However it is not as extreme in ROM and the weight shift occurs without rotation in preparation for jumping and can be combined with the hitter’s wind-up phase, while the trunk rotation occurs in the same phase as a pitch, acceleration-deceleration. The other distinction between a pitcher’s arm and an outside hitter’s arm is that the volleyball hitter will swing with decreased abduction and increased flexion through the acceleration phase – their hitting arm will attempt to pass over their head rather than to the side and contact the ball (equivalent to ball release in baseball) with full elbow extension.

In track and field, a javelin thrower’s arm goes through very similar motions as a volleyball hitter. There isn’t much of a wind-up, rather, when the thrower pulls the javelin back, they are already in their cocking phase. Due to the demands of the sport, these throwers also have their arm pass through an arc that is less abducted than a baseball pitcher – they need to achieve height on their throw. The key in this sport, however, is in their legs. The javelin thrower begins with the arm at 90-90, holding the javelin, and starts with a straightforward sprint. During the final steps (when the thrower enters the cocking phase), the thrower moves forward with cross over steps, requiring increased activation of the contralateral adductors followed by contralateral trunk rotation and flexion.

javelin throwing phases

During a tennis serve, again, there is a very similar sequence of movements. There is a windup phase that consists of knee flexion and the toss with scapular retraction of the racquet arm (cocking phase). In order to contact the ball, the athlete must generate power through their lower extremities and core and accompany it with trunk rotation. From here, the movement sequence is similar to the above sequences of acceleration, deceleration, and follow-through.

While a softball pitch presents with different mechanics, the throwing of a softball for positional players is the same. A more thorough breakdown of softball pitching mechanics will be addressed in the future.

By now, hopefully I’ve convinced you how important hip and core stability are in an overhead athlete – it is not enough to only address the shoulder, many times if you solve the deficits in the hips and core, their shoulder impairments will also resolve or reduce in severity. If you don’t believe me, here’s a good article that also discusses hip stability and it’s role in the pitching motion: http://lermagazine.com/cover_story/the-throw-from-below Understanding movement patterns inherent to the athlete’s sport can help direct your manual therapy and neuromuscular re-education, addressed in Part 4: Treatment interventions.

 

http://www.humankinetics.com/excerpts/excerpts/an-analysis-of-the-biomechanics-of-pitching-in-baseball

Overhead Athlete series, Part 2: Physical Characteristics of the Overhead Athlete

All athletes will develop special physical characteristics that are specific to their sport due to repetitive use of certain muscle groups as well as movement patterns required of that sport. Overhead athletes are no exception to this observation. Here are some of the physical characteristics to keep in mind of an overhead athlete upon initial evaluation – summarized from Wilk et al’s clinical commentary on shoulder injuries

Range of motion

In PT school, we’re all taught that normative values for external rotation and internal rotation (when measured in supine at 90° abduction) are 90° and 70°-90° respectively. That gives us a 160°-180° of TOTAL motion. It is important to keep the concept of total motion in mind, especially when dealing with overhead athletes. In baseball pitchers, there tends to be increased external rotation and decreased internal rotation. In a Wilk et al (2009) clinical commentary piece, Bigliani et al found that on average pitchers exhibited 118° of external rotation. Similarly, Reinold et al state that baseball pitchers ranged from 129°-137° of ER and 54°-61° of IR for a combined arc of 183°-198° of total motion. When looking at range of motion, I tend to stress the TOTAL arc of motion because the dominant/throwing arm will tend to have increased ER and decreased IR, but if the total arc of motion remains the same bilaterally then there isn’t a deficit; throwing tends to reduce IR. However in a baseball pitcher, if the total arc of motion is decreased when compared side to side, usually it will be due to a pathological loss of IR.

GIRD-glenohumeral-internal-rotation-deficit

Laxity and Osseous Adaptations

Most throwers will have some form of acquired laxity that can be noted through a physical assessment. Most of it is due to repetitive stress on the capsule – increased posterior capsular laxity when compared to anterior capsule.

In Wilk et al’s clinical commentary on shoulder injuries they bring up osseous changes in the humeral head that I found interesting. They stated that in most studies, there was on average a 17° of humeral retroversion in the throwing arm. This can have impacts on posture as well as the relationship between the humerus and scapula. This can also explain the differences in ER/IR ROM when measured R vs. L, though the total arc of motion may remain the same.

Muscular Imbalances

Due to repetitive motions, every athlete has muscle imbalances somewhere along the kinetic chain. With baseball pitchers, often times their internal rotators on their throwing side are stronger than their external rotators and tend to have strong adductors as well. Proper balance between antagonist and agonist is crucial to providing dynamic stability around any joint. There is a theory that proposes the external rotators should be at 65% of the internal rotators strength for optimal stabilization around the glenohumeral joint.

Posture

Due to the aforementioned muscular imbalances, overhead athletes often will have changes to the resting position of their scapula and thoracic spine. The two more common postural changes include an anteriorly tipped scapula when the shoulder is at rest and an upwardly rotated shoulder when the shoulder was abducted to 90° due to increased activity of the adductors (pec minor) and protractors/internal rotators (subscapularis, serratus anterior, latissimus dorsi).

 It is great to be able to identify these impairments and deficits, but if you are unable to treat them, then what’s the point? Treatment, including neuromuscular re-education and manual therapy tips, to follow in part 4. But first, we need to understand the biomechanics of an overhead athlete before we can treat. Continuing our assessment is Part 3: Biomechanics and Movement Patterns of the Overhead Athlete.

 

Reinold et al 2014 Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes, Part 2

Wilk et al 2009 Shoulder Injuries in the Overhead Athlete

Overhead Athlete series, Part 1: An Introduction to the Overhead Athlete

“Overhead athlete” is a broad term that encompasses many different sports including baseball, volleyball, tennis, javelin throwers, softball and more. While swimming could be grouped in this series because it is an overhead sport, it will have it’s own topic series in the future. Most research studies have been performed on baseball players, however, the mechanics of throwing, as well as the findings in the literature, can be extrapolated to the other aforementioned sports.

In order to effectively treat an overhead athlete, the therapist will need to understand the neural/mechanical relationships that exist in the shoulder joint and assess movement quality during an overhead throwing/hitting motion. I will not be listing treatments for specific diagnoses in this topic series – they will be addressed as separate topics in the future. Here I will outline the basics of the overhead athlete through anatomy and include clinical considerations that will be followed up with subsequent posts in much more detail.

The shoulder is a complicated joint due to its 3 degrees of freedom in ROM as well as its connections to the thorax and upper extremity. It is also the third most commonly injured joint. It plays an important role in stability and mobility. The glenohumeral joint is a ball and socket joint, a direct connection between the humerus and glenoid of the scapula. The scapula sits on the posterior aspect of the rib cage, and therefore is an indirect connection to the thoracic spine – indirect due to no true joint surface between the scapula and ribs/T-spine. The scapula is also connected to the clavicle, through the acromioclavicular joint. This connection as well as the thoracic spine’s relationship to the cervical spine warrants a deeper look into the shoulder’s mechanical relationship to the cervical spine – as well as its neurological relationship through the brachial plexus.

The above only lists the direct, bone-to-bone, articular connections. However, in order to produce movement, there are many, many muscular and ligamentous connections. The superficial back muscles including, but not limited to, the latissimius dorsi, all 3 aspects of the trapezius muscles, the rotator cuff muscle group and many more all control motion of the scapula and have a role in overhead movement.

Not only should the overhead athlete’s shoulder be considered during treatment, we should also be looking at the client’s core and lower extremity strength as well. Through many sources including Tom Meyer’s “Anatomy Trains” book, we know that there is a connection between the shoulder and the opposite hip through fascial lines, both anterior and posterior. We also know, through video analysis and understanding of each of the above sports, that power and speed are generated through the hips and core. Therefore the core and both lower extremities cannot be neglected when rehabbing an overhead athlete back to their sport.

This is basic anatomy, however, the application of this basic information and formulating treatment can be tricky because there are many things to consider. When treating an overhead athlete, there are a few physical characteristics to consider; TOTAL arc of motion between external and internal rotation and comparing them Right to Left, quality of scapular motion, visual positioning of scapula, visual spinal postural assessment, and overall strength including hips, RTC, lower traps, and core muscles. Stay tuned for Part 2 in the Overhead Athlete series: Physical Characteristics of the Overhead Athlete.

Reinold et al 2014 Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes, Part 1

Breaking Down the Initial Evaluation, Part 4: Movement Assessment

 

The previous posts discussed static postural assessment. I never solely conduct a static postural assessment and establish my diagnosis. We, as physical therapists, are movement experts and therefore, while I can utilize a static postural assessment to guide my clinical evaluation, I am more interested in seeing how my client moves. More importantly, I am interested in how they move in weight bearing positions because we often are required to do so in our daily lives. I utilize the SFMA primarily and add in other movement patterns depending on the client’s sport (running assessment if there is a running component to their sport/activity, for example). A basic run-down of the SFMA is that it uses 7 top-tier movement patterns starting with the cervical spine to the overhead deep squat and single leg balance. Each top-tier pattern can be broken down into its component tests to determine whether the dysfunction is soft tissue, joint, or stability/motor control related.

I won’t be going over the entire SFMA top-tier screen in detail– if you want to know more, please attend a live SFMA weekend course – but I will be picking some of the clinical highlights from select movement patterns to help guide your clinical decision making and localizing the source of the pain more efficiently in an evaluation.

A big “principle” in the SFMA is if the client can’t perform the movement in standing, change the stability requirements and re-assess. If reducing the stability requirements for that particular movement increases ROM, then the primary deficit is in motor control/motor recruitment. For example, for cervical flexion, if the client is unable to touch their chin to their chest in standing, but is able to in supine, there can’t be a joint mobility problem because they can perform the movement when their cervical musculature is on slack – therefore, it must be over recruitment of cervical musculature when in weight bearing. Since utilizing the SFMA, I’ve begun to realize that I need to further test to distinguish what is causing a ROM deficit – is it a true joint hypomobility or is it more of a stability motor control deficit. Many patients may appear to have a lack of ROM, but if tested further, you may find that they just don’t know how to control their range. If you’ve further tested by eliminating body parts or reducing stability requirements and the client still has decreased range, then biomechanical assessment is warranted to determine the cause of joint hypomobility.

The first movement I’d like to review is the multi-segmental flexion. The client essentially locks out their knees (feet together, for consistency in every position besides single leg balance and overhead squat) and bends forward and tries to touch their toes. Most people who can’t reach their toes automatically assume they have tight hamstrings. However, this may not be the case. When I see someone perform this movement and they can’t touch their toes, I re-assess them after they have activated their core – I place a foam roller in between their legs and ask them to squeeze it hard and repeat the motion. If they gain more range with this modification, it tells me they have a weak core and their hamstrings are, more or less, “holding on for dear life” for stability. If they don’t gain more range, then it’s a possibility that they have tight hamstrings. **A neat trick in the clinic is you can differentiate which side is tight by unweighting each side and repeating the motion – unweight by flexing the knee on the side you are trying to put on slack.

The second movement pattern is multi-segmental extension. One of the criteria for this movement to be scored “functional” is that the ASIS have to translate anteriorly and clear the toes. I’ve found that when it doesn’t, there is an extension deficit at the hip. I further assess this with a “step up with opposite knee march to 90°”. With this follow-up test, I can determine if the client achieves hip extension through lumbar compensation. Either way, I would assess joint mobility of the hip in prone and sitting to conclude if it is a joint/soft tissue dysfunction or stability/motor control dysfunction.

Single leg balance is something I work on with a majority of my clients with low back and lower extremity diagnoses. One point that the SFMA makes about this pattern is that difficulty with single leg balance is not always a proprioception deficit – in fact they make a point to say that until you have ruled out all other possibilities (ankle ROM, vestibular, visual, core, hip stability etc…) you can’t be certain it’s a proprioception deficit. I tend to agree, as I have found that hip and core weakness are more common culprits (again, hips and core….). In the breakouts, one that I have tended to gravitate towards automatically is differentiating hip weakness and core weakness. Half kneeling on an airex pad loads both the hips and the spine while quadruped “bird dog” loads only the hips. By performing these two quick assessments, you will be able to tease out if the hips or the core require more neuromuscular re-education. **Side bar – I know that the core is still required to activate in quadruped, however the differentiation is that the spine is not loaded in this position, and therefore the stability requirements are different. Half kneeling is more demanding and loads the spine more than quadruped.**

With athletes, in addition to the SFMA top tier tests and their breakout components, I always like to add a jumping and/or running component to the evaluation. Most sports will have a jumping or running aspect and watching a client jump on and off a box to see how they land as well as how they run and how their body is moving during dynamic movements is vital. Golf will be a special topic discussed later in the future because it does not fit this rule, it is rather an exception, of having a jump or run aspect – it is mostly rotation and there are separate tests you can do for golfers.

This concludes the first topic series on the initial evaluation. Everything from here on out will build off of the information presented in these previous 4 posts as well as provide new, additional insight. The next planned topic series will discuss the Overhead Athlete. I hope you guys enjoyed this first topic series. Please comment below if you have any suggestions of topics to cover. Thanks, again.