Month: March 2017

Movement of the Week: Landmine Variations for Baseballers

 

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If you are training or rehabbing baseball players I’m sure the Landmine Press and its multiple modifications are staples of your strength program.  Since you’ve already got your athletes familiar with the Landmine and it’s benefits, here are a few variations that will be ideal for your baseball and softballers.

Landmine Floor Press

The Floor Press is a great supine pressing exercise for throwers because it prevents excessive anterior shoulder stress as the humerus contacts the floor prior to traveling behind the frontal plane of the body.  It works well for training small groups or teams because it does not require a spotter and can be part of a circuit.

Landmine Pitching Deceleration

Decelerating the forward, downward and rotational forces of the pitching motion is essential for arm health.  This drill will train the stride leg, core and posterior shoulder muscles necessary for efficient full body pitching deceleration.

Landmine Renegade Row

The Renegade Row is one of the toughest plank variations you’ll ever do.  This is a fantastic way to train scapular and core stability while effectively loading the row for strength gains.

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Dynamic Scapular Stability

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By Meggie Morley, DPT Student

A solid foundation of scapular stability is not only important for optimizing shoulder mechanics, but also the motions of the elbow, wrist, and hand. There are traditional methods of assessing and treating scapular stability, but several articles and studies are exploring new ideas and approaches.  In an article by McQuade et al, scapular stability was defined as “’normal’ scapula movement on the thorax during upper extremity motions.”

One of the core principles of scapular motion is the concept of scapulohumeral rhythm. The idea is that for every two degrees of humeral elevation there is a corresponding one degree of motion of the scapula.   For example, 180 degrees of shoulder abduction is comprised of 120 degrees of arm elevation and 60 degrees of scapular upward rotation. However, recent studies have shown that scapulohumeral rhythm can actually vary from anywhere between a 1:1 to a 6:1 ratio. Several factors such as external load, speed, fatigue, pain, and plain of elevation of the arm where all shown to affect scapulohumeral rhythm.

Traditional treatment methods have also tended to focus on identifying postural “abnormalities” in the scapula and correcting them through strengthening and stretching. However, a systematic review by Ratcliffe et al. studied patterns in subacromial impingement, and found that no ideal scapula position exists and deviations in scapula motion do not cause or contribute to subacromial impingement.  They found that there was evidence for scapula kinematic alterations in people with impingement, but the type and prevalence of those alterations were inconsistent. In other words, one person could present with the same kind of movement pattern and static scapular posture as the next person, but one could have impingement and the other could show no symptoms at all.

After taking these new studies into account there are several ways to optimize scapular mobility and stability for each individual patient. Regardless of the individual’s scapular posture or movement patterns, it is critical that the scapular stabilizers and upward rotators are properly firing before moving the upper extremity, specifically the trapezius and serratus anterior muscles.  Warming up the scapular stabilizers before a shoulder workout is important in order to ensure that the scapula will be optimally supporting the upper extremity.  Single Arm Plank variations are activities that require the scapular muscles of the stabilizing arm to activate in order to keep the rest of the body steady.


It is also important to train the muscles in the range of motion that is weak or required for certain sports and activities. This is demonstrated in the Isometric Band Hold + Rhythmic Stabilization drill. Demand is put on the stabilizing muscles of the scapula and core by holding the band steady as the practitioner attempts to move the arm out of position.

The concept of dynamic scapular stability is continuing to evolve as more studies are published. A focus on optimal scapular stability and mobility with an attention to each patient’s individuals needs is one way to incorporate both new and traditional treatment methods in order to achieve the patient’s goals.

 

FullSizeRender 9Blog Post written by Meggie Morley, DPT Student at Columbia University.  Meggie is currently in her final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources

  1. McQuade KJ, Borstad J, Siriani de Oliveira, A. Critical and Theoretical Perspective on Scapular Stabilization: What Does It Really Mean, and Are We on the Right Track? Phys Ther. 2016. 96:1162-1169.
  2. Inman VT, Saunders JB, Abbott LC. Observations of the function of the shoulder joint. 1944. Clin Orthop Relat Res. 1996; 330:3-12.
  3. McQuade KJ, Smidt GL. Dynamic scapulohumeral rhythm: the effects of external resistance during elevation of the arm in the scapular plane. J Orthop Sports Phys Ther. 1998 Feb; 27(2): 125-33.
  4. Mottram, SL. Dynamic stability of the scapula. Manual Therapy. 1997 Aug 31; 2(3): 123-131.
  5. Ratcliffe E, Pickering S, McLean S, Lewis J. Is there a relationship between subacromial impingement syndrome and scapular orientation: a systematic review [erratum in: Br J Sports Med. 2014;48:1396]. Br J Sports Med. 2014; 48: 1251-1256.

Movement of the Week: Dynamic DB Squat/Swing Variations

Once your patient/client/athlete can squat efficiently and can perform a DB or KB swing safely, it is time to train multi planes.  These 3 variations of DB swings translate well into throwing and swinging sports and can be biased for mobility,  rotational speed or strength, depending on the load.  They can also give you feedback about an athlete’s rotational coordination, timing and range of motion limitations. Lastly, they can easily be integrated into a metabolic conditioning circuit for athletes that participate in rotational sports.

Golf Squat 

Cues: Starting position is a squat with the elbows extended and forearms against the inner thighs.  Start the upward swing from the hips followed by the DB.  At the top diagonal position, the hips should be fully rotated and extended with the spine in neutral.  Watch the feet for inversion rolling or leg external rotation to make up for limited hip internal rotation.

Reverse Golf Squat:

Cues:  Starting position is a squat with the DB tucked against the lateral hip pocket, elbows flexed and body weight shifted slightly to the loaded side.  The opposite shoulder should be rotated towards the opposite hip.  Thrust the loaded hip and let the DB elevate upward and outwards with the elbows extended at chest height.

Square Stance X-Chop:

Cues:  Starting position is a squat with the DB tucked against the lateral hip pocket, elbows flexed and body weight shifted slightly to the loaded side.  The opposite shoulder should be rotated towards the opposite hip.  Start the upward motion by thrusting the loaded hip into extension and opposite side rotation.  The DB will follow and finish over the opposite shoulder with both hips rotated and the spine in neutral.  Watch the feet for inversion rolling or leg external rotation to make up for limited hip internal rotation.

Synovial Plica Syndrome: Symptoms & Treatment for Anterior Knee Pain

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By Tom Sutton, DPT Student

Introduction and Anatomy

In a study by Lee et al, synovial plica syndrome (SPS) of the knee is said to be a cluster of symptoms and not one specific presentation or cause. Some of these problems may consist of pain in the anterior region of the knee, clicking, clunking and popping sounds that can occur during functional activities such as squatting or negotiating stairs.  SPS can affect males and females alike, most commonly between the ages of 10-30. Plica is actually the name of a structure in most peoples’ knees, many are non-symptomatic,”inward folds of the synovial lining,”(1) that can be impinged between the quadriceps tendon and femoral trochlea when the knee flexes between 70-100 degrees.   The plica is attached to the articularis genus muscle and runs into the synovial lining of the knee, located on the medial side of the retropatellar fat pad.  Figure 1 Image-2presents an image of the plica in the knee. The study performed by Lee et al investigated what synovial plica syndrome is, how it can affect people and how to properly treat this type of knee pain.

Presentation

Given the fact that SPS may bring about a number of complaints and symptoms from patients, it is important to understand exactly what problems are present and how to diagnose SPS in order to demystify this type of knee pain. Lee et al reports is that SPS is most commonly without a mechanism of injury.(1) Plica-related problems in the knee can come about during knee flexion over time such as kneeling and sitting or repetitive exercises like running or biking.(4) The patient is going to complain mostly about pain and a “snapping” sound  on the medial side of the knee joint during flexion.(4) For a complete list by Lee et al, see Table 1 Image-1for signs and symptoms of knee SPS.(1) SPS can also mimic other pathologies such as meniscal problems, osteoarthritis of the knee and patellar tendinopathy.(1) According to Schindler, anterior knee pain is the “cardinal symptom” of plica syndrome (5). Since SPS can be caused by a traumatic mechanism of injury, overuse or associated with co-morbidities such as diabetes, (1) obtaining past medical history becomes more pertinent. Additionally, if the patient were to be younger and around the age of 13, it would be prudent to find out if they have been experiencing growth spurts, as symptoms of SPS can occur during this time.(1)

For more specific information on SPS, here is a printable booklet that is courtesy of Houston Methodist. (4)

Application & Closing Thoughts

Furthermore, if there is a stability or strength problem elsewhere in the body such as the back, hip or ankle, it is possible that this may cause problems in the knee that could explain the idiopathic nature of plica syndrome.(1) There are special tests that can be performed including Hughston’s Plica Test and the Stutter Test.(1) Although special tests do not hold diagnostic value, they can be helpful in ruling in and ruling out pathologies. Applying the knowledge from several SPS studies and sources, there are a number of ways to address a patient with SPS. Finding the cause of the problem should be the priority of the physical therapist as they begin to formulate a program for the patient. Treatment may consist of a wide variety of techniques such as soft tissue manipulation, stretching, functional exercise and postural education. Functional exercise and training will be very important because the patient can learn more efficient movements for everyday lifestyle as well as gain the strength needed in both lower extremities in a closed-kinetic chain (CKC) fashion. Below are a few examples of helpful CKC exercises. 

SPS has been shown to respond well to conservative treatment, (6) and most patients have demonstrated improvement and decreased pain.(1) An important takeaway from this is to understand why the patient is experiencing SPS and address the cause. Otherwise, it is possible the plica problem will linger and surgical methods may be weighed as an option. Although some studies have shown that most patients with failed conservative treatment have had success with surgery,(1) avoiding a resection procedure altogether would be a much better alternative.

img_7501Blog Post written by Tom Sutton, DPT Student at the University of St. Augustine. Tom is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

References

  1. Nixion A, Chandratreya A, Murray J, Lee P. Synovial Plica syndrome of the knee: A commonly overlooked cause of anterior knee pain. The Surgery Journal. 2017;03(01):e9–e16. doi:10.1055/s-0037-1598047.
  1. Griffith CJ, LaPrade RF. Medial plica irritation: diagnosis and treatment. Curr Rev Musculoskelet Med 2008;1(01):53–60
  1. Dandy DJ. Anatomy of the medial suprapatellar plica and medial synovial shelf. Arthroscopy 1990;6(02):79–85
  1. Houston Methodist. http://www.houstonmethodist.org/orthopedics/where-does-it-hurt/knee/plica-syndrome/. Accessed March 12, 2017.
  1. Schindler OS. ‘The Sneaky Plica’ revisited: morphology, pathophy- siology and treatment of synovial plicae of the knee. Knee Surg Sports Traumatol Arthrosc 2014;22(02):247–262
  1. Bellary SS, Lynch G, Housman B, et al. Medial plica syndrome: a review of the literature. Clin Anat 2012;25(04):423–428

Sports Hernia: Nomenclature, Examination and Rehabilitation

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By Tom Sutton, DPT Student

With every sport that athletes take part in including football, hockey and baseball, it is no surprise that many different types of injuries come about. One injury in particular, that is typically given a general diagnosis of “sports hernia,” involves groin and abdominal pain. According to a study carried out by Ellsworth et al in the International Journal of Sports Physical Therapy, sports hernia could encompass many symptoms and it is important for the practicing clinician to understand their patient’s presentation when treating them. This would of course include performing a thorough subjective examination as well as objective tests and measures. Although there is research in the current literature that discusses what rehabilitative measures should be taken in physical therapy for hernia-type injuries, Ellsworth examines more specific diagnoses beyond the catch-all term of sports hernia and compares conservative treatment vs. operative management.

Athletic Pupalgia vs. Inguinal Disruption
Per Ellsworth, sports hernia is not solely limited to the athletic patient population and can be better described as either athletic pubalgia and inguinal disruption. Athletic pubalgia conveys “separation of the more medial common aponeurosis from the pubis,”(2) and can likely involve tendinopathy of the hip adductors. This term is reportedly the replacement term for sports hernia per Kachingwe.(3) Possible mechanisms of injury include agility type movements involving sharp cuts, turns and twists as well as high-intensity planting of the foot in the ground, “repetitive kicking and lateral motion.” (4) Kachingwe outlines the five signs that are indicative of athletic pubalgia that should be heeded in the clinical setting on Table 1.(3)table

Inguinal disruption is an umbrella term for pain syndromes that relate to an injury of soft tissue in the inguinal area. Sheen has suggested through his research that there are 5 possible signs of inguinal disruption and reports that 3 out of 5 increase the likelihood of an inguinal disruption diagnosis. The signs are as follows, per Sheen et al: (5)
1.  Pinpoint tenderness over the pubic tubercle at the point of insertion of the conjoint   tendon.”(5)
2.  Palpable tenderness over the deep inguinal ring.”(5)
3.  Pain and/or dilation of the external ring with no obvious hernia evident.”(5)
4.  Pain at the origin of the adductor longus tendon.”(5)
5.  Dull, diffuse pain in the groin, often radiating to the perineum and inner thigh or across the mid-line.”(5)

Screening & Diagnosis
Keep in mind, differential diagnosis is especially important for these types of injuries because sports hernia can mimic other conditions such as hip impingement, stress fracture and labral tears.(6) When screening for an inguinal disruption may consist of having the patient perform resisted sit ups and adductor squeezes which will likely show muscle weakness.(5) Gilmore reports that having the patient alternate between utilizing the Val Salva maneuver and breathing properly along with palpation of the transversalis fascia can reveal possible findings of inguinal disruption.(1) From an imaging standpoint, the standard appears to be magnetic resonance imaging (MRI) which is coming out with increased literature supporting its use in diagnosing core injuries.(1) The British Hernia Society in 2014 reported that there are two findings on an MRI that should be observed: bone marrow edema noted in the pubis and changes observed in the anterior capsule, adductor longus and rectus abdominis.(2) The MRI will show the degree of disruption present in the patient and may serve as a guide as to whether or not the patient will require surgery.

Treatment
The first line of defense for injuries typically involves conservative treatment before resorting to surgical procedures. According to Ellsworth, there is little evidence in the current literature that fully support conservative management for hernia-type injuries.(1) However there are reported studies that demonstrated patients showing improvement after a rehabilitative program following 6-8 weeks.(1) Like all injuries, there are guidelines and protocols that can be heeded and examined before initiating an exercise program, but the fabric and makeup of a patient’s program should ultimately be determined based on their presentation. Non-operative treatment would consist of essential pillars such as strength, balance and flexibility. It would include activation, strengthening and coordination of the core and hip musculature, soft tissue techniques and neuromuscular re-education.(1) Ellsworth provides a week-to-week protocol that can guide a clinician’s treatment of a patient with athletic pubalgia or inguinal disruption. The protocol for conservative treatment vs. operative rehabilitation differ for imperative reasons such as facilitating healing and controlling swelling. The protocols for conservative treatment and operative management can be accessed here.

Closing Thoughts and Applicability
To apply what has been discussed in a clinical setting, it is important to understand that a patient’s complaints of “groin pain” may be more serious. This is especially true if the patient does not respond well to conservative treatment. Of course, during the examination it is paramount to observe the area affected, perform inspection and palpation. As for exercise, there are numerous possibilities for the patient’s individual program, as long as it is proportionate to their progress. Achieving the goals of optimal strength, range of motion and coordination following a groin injury or post-surgical procedure are focuses of treatment. Being familiar with the protocols and knowing that they are to be guidelines only. Not every patient will fit the protocol perfectly. Once determined what specific diagnosis the patient has, it will be very important starting the patient on a great exercise program to instill changes moving forward, like any other injury.

img_7501Blog Post written by Tom Sutton, DPT Student at the University of St. Augustine. Tom is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

References

1.Ellsworth AA, Zoland MP, Tyler TF. Athletic pulbalgia and associated rehabilitation. Int J Sports Phys Ther. 2014;9(6):774–784. Accessed March 3, 2017.

2.Sheen AJ, Stephenson BM, Lloyd, DM, et al. Treatment of the Sportsman’s groin: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med. 2013. doi: 10.1136/bjsports-2013-092872.

3.Kachingwe AF, Grech S. Proposed algorithm for the management of athletes with athletic pubalgia (Sports Hernia): A case series. J Ortho Sports Phys Ther. 2008;38(12):768-781.

4.Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A, et al. Athletic pubalgia: Definition and surgical treatment. Ann Plast Surg. 2005;55(4):393-396.
Sheen AJ, Stephenson BM, Lloyd DM, Robinson P, Fevre D, Paajanen H, de Beaux A,

5. Kingsnorth A, Gilmore OJ, Bennett D, Maclennan I, O’Dwyer P, Sanders D, Kurzer M: ‘Treatment of the Sportsman’s groin’: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med. 2014, 48 (14): 1079-1087. 10.1136/bjsports-2013-092872.

6. Kaar, MD S. Sports Hernia. Sports MD. http://www.sportsmd.com/hip-thigh-injuries/sports-hernia-athletic-pubalgia/. Accessed March 3, 2017.

 

Movement of the Week: Tri-Planar Overhead Carry

This is an excerpt from a blog post I did for Daily Gaines:

The Overhead Carry is a well-known movement that can train overhead strength as well as shoulder and core stability. It can also be used as an assessment tool to help guide therapeutic and corrective interventions so that your athlete can continue to progress their overhead lifting safely. daily-gaines

Life and sport take place in 3 planes of motion, therefore training & mobility work should reflect that. Depending on the type of weighted modality, this movement can be biased for strength, stabilization or assessment. In the video below we use a med ball atop a flat hand and extended wrist to take a look at the athlete’s stability and mobility through all 3 planes. The ball is resting on the hand, so as form breaks down it will roll out of place or compensatory patterns will present themselves.

For the full blog post and more great sports performance content, check out DailyGaines.com

Visual Training: A Possible way to Enhance Baseball Performance

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By Tom Sutton, DPT Student

One important aspect of baseball, let alone sports is undoubtedly vision.  The input an athlete takes in while competing in a game or practice environment is paramount for peak performance. Having good hand-eye coordination and tracking skills to locate the ball as a batter or to accurately place the ball across the plate as a pitcher are just a few reasons why a baseball player needs good vision.

A recent study by Dimitrios Palidis and colleagues was conducted to evaluate the dynamic visual acuity (DVA) of 23 males on a high school baseball team in Vancouver, Canada. DVA is evaluated by two tests which are static-object (head rotation, with vision locked on a still object) and dynamic-object (head still with vision locked on moving target) fixation. This study was published in the Public Library of Science (PLOS) in February 2017.

Distinct Eye Movement Patterns Enhance Dynamic Visual Acuity
Dimitrios J. Palidis1, Pearson A. Wyder-Hodge1, Jolande Fooken1,2, Miriam Spering

Background
In a study by Palidis et al, the investigators tested whether or not there is a relationship between a high school baseball player’s eye movement kinematics and DVA performance. With both static and dynamic methods of testing DVA, static-object is used in a variety of practice settings and requires the athlete to utilize the vestibulo-ocular reflex (VOR) to maintain fixation on the object.(2)eye-study

Methods
The study consisted of 23 males on the same high school baseball team with an average of 19.5 years. The study was performed at the University of British Columbia (UBC) in Vancouver, Canada. The researchers reported that the baseball players had either normal or corrected-to-normal visual acuity and those who did not have normal acuity wore contact lenses or glasses during the study. The study tested dynamic visual acuity by using black Landolt-C rings (see figure 1) and had the athletes track the “gap” in the letter “C” as it was spinning and moving horizontally on the screen from left to right. The athlete then had to decide with 4 arrow keys whether the “gap” in the letter “C” was located in the top right, top left, bottom right or bottom left corner. The “C” on the screen moved at a constant speed of either 50 or 70 degrees per second with random speeds and movements every trial.(1) Every time the athlete was correct in guessing which the corner the “gap” of the “C” was located, the width of the gap would decrease. The static acuity test (see figure 2) was performed with a visual acuity chart with numbers that the athletes were instructed to read from top to bottom while rotating their head.
Figure 1: The Landolt-C Ring test evaluating dynamic object acuity.(1)
Figure 2: The static acuity test,(1) utilizing VOR.(2) The top numbers signified a visual acuity of 20/800 vision and the bottom numbers were indicative of 20/20 vision. (1)

Results
The study showed that when athletes used smooth pursuit to track the object during the test as opposed to using anticipatory saccadic movements, their perceptual performance improved and translated to better DVA. As reported by Paladis et al, players who utilized anticipatory saccadic movements showed less accuracy and acuity during the dynamic object test.

Applicability and Conclusion
Have you ever noticed when watching a baseball game, the pitcher may squint as he is trying to see the signals given by the catcher? Sunlight is one thing, but when this happens during a night game, this may cause some viewers to wonder. In this case, the catcher may have highlighted marks on their hands and fingers to make it easier for the pitcher to see the calls made before he makes his pitch. If the pitcher is having trouble seeing the signs by the catcher, this may warrant a visit to the optometrist.

There are a few different ways to apply visual evaluation and training to a clinical setting before seeing an optometrist. A clinician or trainer can test an athlete’s vision with the static-object test using an acuity chart. Additionally, to further evaluate or enhance an athlete’s ability on the field, it may be prudent to find out what their dominant eye is. Although it is an older study from 2006, Shneor et al found that the dominant eye of given individual processes visual information better and faster and additionally takes over primary visual processing as seen in tests such as bionocular rivalry and hole-in-the-card.(3) Additional ways to test to see what the athlete’s dominant eye is, more can been seen here.

Utilizing computer-based tests to help facilitate better tracking skills and VOR training can be useful ways to assess an athlete’s visual ability and acuity to enhance their skill set and take their game to the next level. As suggested by Deveau et al, eye movement exercises can be a great intervention in an athlete’s training program. (4)

img_7501Blog Post written by Tom Sutton, DPT Student at the University of St. Augustine. Tom is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

References

Dimitrios J. Palidis DJ, Wyder-Hodge PA, Fooken J, Spering M. Distinct eye movement patterns enhance dynamic visual acuity. PLOS ONE. 2017;12(2):e0172061. doi:10.1371/journal.pone.0172061.
Demer JL, Crane BT, Tian JR, Wiest G. New tests of vestibular function. Ann N Y Acad Sci. 2001; 942: 428–445. PMID: 11710482
Shneor E, Hochstein S. Eye dominance effects in feature search. Vision Research. 2017;46(25):4258–4269. doi:10.1016/j.visres.2006.08.006
Deveau J, Ozer DJ, Seitz AR. Improved vision and on-field performance in baseball through perceptual learning. Curr Biol 2014; 24:R146–R147. doi: 10.1016/j.cub.2014.01.004

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