Tag: Low Back Pain
Latissimus Tears: The Newest Injury for Throwing Athletes (Part II)
Just when you thought rehabbing pitchers was hard enough, a new injury has emerged in the throwing population
If you haven’t read Part I of our series, please check it out now. In part I we discussed anatomy, how the lats are in involved with pitching, reasons for the increase in lat injury frequency, and a brief surgical review.
For Part II, we are discussing common compensations we see in the “lat dominant” population and demonstrate a few examples of our favorite functional exercises to retrain this dominance with video demonstration by OSSPT patient and San Francisco Giants prospect, Caleb Simpson.
As previously mentioned, the lats have multiple attachment sites, spanning across several joints in the body, including the thoracic and lumbar spine, pelvis, ribs, scapula, and humerus. Because of all these various attachment sites, the lats have a major influence on posture, breathing, pelvic control, scapular mobility, and glenohumeral positioning. When the lats are working properly, they are crucial in power development with throwing; however, when the lats become too dominant, they are at risk of injury.
Although we are big believers of implementing deadlifting, horizontal/vertical pulling, and carrying into an athletes plan of care, we need to make sure the lats do not become the dominant muscle with all lifts for the throwing athlete. When presented with a task that is too demanding for the throwing athlete, he/she will revert to over-utilizing the dominant muscles. Our job as physical therapists is to, first identify these compensations, then educate and correct the athlete of proper movement patterning. We must prescribe the athlete with exercises that are challenging, but also achievable.
To assist with better identifying when the lats may have become too dominant, we have listed some common compensation patterns to look for.
Common “Lat Dominant” Compensations
1. Excessive lumbar extension/anterior pelvic tilt: with attachments to the thoracolumbar fascia, spine, and pelvis, overly dominant lats will often lead to excessive lumbar extension and an anteriorly pelvic tilted position. Overly-dominant muscles often lead to shortened muscles so we need to incorporate exercises that force the lats to work in an eccentric, lengthened position while maintaining a neutral spine.
2. Faulty breathing mechanics: most of our patients, particularly our athletes, have poor diaphragmatic breathing and often over recruit the accessory respiratory muscles, including the lats. Many of the accessory respiratory muscles further pull the body into a lumbar extended, anteriorly pelvic tilted position. At rest, we breathe approx. 15,000-20,000x/day. If we are constantly breathing improperly, the lats are living in faulty, shortened positions. We spend a lot of time teaching proper diaphragmatic breathing to our throwing athletes and incorporate diaphragmatic breathing into our exercises when possible.
3. Rib flaring: the first two compensations we discussed will often lead to rib flaring, so if we correct the excessive lumbar lordosis/anterior pelvic tilt and faulty breathing mechanics, the rib flare may resolve; however, a rib flare can also develop due to weakness of the anterior core. With our throwing athletes, we must incorporate anterior core control exercises while in an overhead position. This will ensure our pitchers can successfully control the rib cage, which is vital to ensure proper scapular position as well.
4. Shoulders falling into IR and/or adducted positions: the most common technique used to identify this compensation pattern is the prone horizontal abduction exercise. Instead of the shoulder remaining at 90 deg. during the arm raise, the overly dominant lat will pull the arm down toward the hip (as you can see in the picture below). In early stages of rehab, teaching and performing this exercise correctly can be an appropriate intervention to reduce the lat dominance and improve mid trap and rhomboid activation with this movement.
5. Insufficient scapular elevation/upward rotation: due to the lats attachment to the inferior aspect of the scapula, “dominant lats” can lead to depressed scapula, or at the minimum, dominant lats can prevent proper scapular elevation/upward rotation with overhead movements. For the throwing athlete, a lack of proper scapular control and movement will lead to impaired glenohumeral joint congruency and contribute to rotator cuff/labral pathology.
1.Plank –> Downward Dog: an excellent upper extremity closed chain movement that promotes proper scapular upward rotation and requires anterior core control, while putting the lat in a lengthened position. We cue the athlete to drive thru the palms, maintain a neutral spine, and bring the hips to the sky. We will use this exercise as a primer before introducing higher level overhead movements.
2. MedBall Lat Pullovers: this exercise forces the athlete to maintain a neutral spine, not allow rib flaring while controlling the medball overhead, and teaches proper eccentric lat control. We will often incorporate diaphragmatic breathing techniques while in the overhead position as well. Just like our previous exercise, this can be another primer movement.
3. Wall Angels: this exercise is an excellent choice for the general population to address common postural dysfunctions including excessive lumbar lordosis, anterior pelvic tilt, increased thoracic kyphosis, rounded shoulders, and forward head positioning. To perform correctly, the athlete cannot allow rib flaring either.
4. Half Kneeling S.A. 90-90 Row-ER-Press: as we progress through our exercise examples, we are gradually increasing loads as well. With this exercise, we continue to demand proper core control, emphasized by adding an unstable surface via the Dynadisc for the R knee. This exercise also demands proper posterior rotator cuff activation as we cue the athlete to drive his fist straight to the sky during the press movement. To better replicate the pitching demands and mimic a glove side pulling that many pitching coaches instruct with an isometric glove side row.
5. Unilateral Overhead KB Marches: this exercise is a great stability based exercise in multiple planes of movement, particularly when we add the band resistance as well. The big thing to watch for is excessive lumbar extension, rib flare, pelvic drop, or the athlete not keeping the KB shoulder in full flexion with slight shoulder ER. We cue them to drive the KB to the sky w/o allowing the shoulder to shrug. As we can see in the video below, Caleb is having some difficulty with maintaining extended elbow position and he is allowing the shoulder to rotate internally.
6. Tall Kneeling Halos: our last exercise may look easy from the surface, but halos will reveal compensations really quickly. This exercise demands excellent core stability and a combination of excellent shoulder stability and mobility.
The lats are important muscles for the throwing athlete and it’s vital that we identify and correct common movement dysfunctions and implement appropriate exercises to re-train these faulty movement patterns.
I hope you enjoyed our 2 part blog post. I wanted to provide a quick shout out to Mike Reinold and Eric Cressey. I was introduced to these two guys eight years ago while working with the Atlanta Braves and I have attempted to read everything they have produced since that time and they are two of the biggest influences in my professional career. Both guys put out great material on a daily basis and so much of how I treat our baseball players is either directly or indirectly influenced by them, including this blog post. I want to say a big thank you to Mike and Eric for how much they have helped, not only me, but the medical and performance profession as a whole.
Enjoy The Tiger Woods Show While You Can, Because it May Be Over Sooner Than You Think
Tiger’s golf game may be peaking, but his movement suggests the end may be near
Unless you were on another planet this weekend, you could not have missed the Tiger Woods show in full effect. It felt like a throwback to Tiger’s earlier years, with crowd sizes already in the thousands from the first tee box and growing with every hole and the eruptions getting louder with every made birdie putt, everything in the golf world felt right. After seven top 12 finishes in 14 starts and a 2nd place finish this weekend at the PGA Championship, the buzz around the sports media world and general public has been unanimous… he is officially back. On the newest issue of Golf magazine, the headline simply states “This tiger is for real”.
I myself am an admitted Tiger Woods fanboy. You would be hard pressed to find someone else who follows Tiger Woods more closely than I do. The idea of him hoisting another major championship trophy gives me butterflies. I started playing the game of golf because of Tiger. As my friends and family can attest, I am a Nike loyalist because of Tiger. I even started buying Bridgestone golf balls this year because of Tiger. With all that being said, I am truly worried about Tiger and it has nothing to do with his golf career or whether he ever wins again. What I am ultimately worried about is his health in everyday life. I am worried that if someone does not get Tiger basic functional movement patterns corrected soon that it could be the last straw for not only his career, but could permanently alter his day to day life for the worse.
Tiger has already undergone an L5-S1 fusion approximately 1 year ago to help alleviate his pain and shooting symptoms into his legs. The reason for his fusion is simple: he lacked the ability to control his spine at that L5-S1 segment leading to excessive shear on the vertebrae and disc, leading to breakdown and nerve damage. Because Tiger could not stabilize that joint effectively on his own, the solution is to provide artificial stability via the surgical procedure. To be clear, the disc breakdown was not the problem, it was the symptom. No different than if we have a hole in the roof and every time it rains, it ruins the carpet on the floor. The carpet getting ruined is not the problem; it is a symptom of having a hole in the roof. No sane person would ever recommend just replacing the carpet after every rainstorm. They would quickly identify the hole in the roof and fix that before ever replacing the carpet. Tiger’s actual underlying problem was the inability to control the spine; therefore, if Tiger, or anyone else who undergoes spinal surgery, does not learn to control the spine postoperatively, then it’s only a matter of time before they break down again. The only difference is that the next time they break down, it most likely won’t be at the fused segment; but rather, it will be at a segment above or below the previous surgery. Want proof? In a 2018 study looking into reoperation rates following spinal fusion, researchers found that over 12% of patients required a reoperation within 2 years of the initial surgery, and almost 20% required reoperations within 4 years of initial surgery. The number one reason why they required re-operation was adjacent segment pathology, meaning the segment above or below the surgical site breakdown (1).
The common misconception is that a fusion can and/or will fix all your pain and complaints. As we stated above, a spinal fusion treats the symptoms, NOT the underlying movement dysfunctions that led to needing the surgery in the first place. To better understand, we will use the example of a patient experiencing a heart attack. When excessive blockage of blood flow to the heart happens, it can trigger a heart attack. When this happens, a cardiothoracic surgeon will often perform angioplasties by inserting balloons and/or stents to open up the restricted blood vessels, or may perform a bypass procedure whereby blood flow is redirected from blocked vessels to healthy vessels. Even though the surgery was necessary, the cardiothoracic surgeon realizes that a combination of factors led to the patient needing the surgery and will attempt to address all those factors post-operatively to ensure the patient is better, including diet, weight loss, stress, sleep, exercise, smoking, etc. The cardiothoracic surgeon does not perform the heart procedure and then just give the patient a pat on the back and send them on their way. Too often, post-surgical spinal patients believe that the spinal surgery fixed the underlying problem and that they now just need to let time take place for healing. Furthermore, over half (55%) of surgeons do not send their patients to physical therapy following spinal surgery (2). I was shocked when I first read this statistic because we work with so many great spine specialists on a regular basis that appreciate what we can offer patients, but it made me realize that even with all the spine patients we treat postoperatively, that there is another half of the population who are never referred to physical therapy postoperatively.
So back to Tiger and why I am so concerned… As I mentioned previously, Tiger revealed a significant movement dysfunction this weekend. So what movement dysfunction am I talking about?
After Tiger completed his round and walked off the course, he began climbing stairs on the walkway. While stepping up, Tiger displayed a major asymmetry when climbing the steps. As you can see in the picture and video (starting at the 21 second mark) below,.
Tiger displays a major asymmetry in posture when standing on one leg and lifting the other up to the next step. On the left picture, Tiger is standing on his right leg only and lifting his left leg up toward the next step. He does an excellent job of stabilizing his R leg while in single leg stance, he keeps his spine neutral and unloaded, and keeps his pelvis in line. This movement will lead to a happy and healthy back. For the picture on the right side, he is now standing on his L leg while lifting his R right toward the next step. In this picture, Tiger displays the classic lumbar extension rotation movement impairment syndrome, with his spine rotating and falling into excessive extension (look at the difference in shirt wrinkles on the left verses nothing on the right) resulting his buttocks falling out to the right, all resulting in excessive compression and shearing on the lower lumbar spine.
Asymmetries as massive as the one displayed above is a major issue and something we seek to identify and correct in all our patients. How can we expect our high level athletes to move correctly during a high velocity movement such as a golf swing, if they cannot simply stand on one leg while flexing the other hip and be incapable of maintaining a stable spine position? The answer is simple, we cannot and should not. One might think I am over exaggerating the seriousness of matter, but the reality is that for most people repeated small abnormal stresses, known as repetitive microtrauma, are placed on the body leading to breakdown, not singular traumatic events. Even for Tiger, he did not damage his spine from a car wreck, fall, or one traumatic swing. His low back has been breaking down for years due to the accumulative effects of repetitive microtrauma from not only his swing, but also the day-to-day movement dysfunctions while walking, climbing stairs, squatting, lunging, etc. Because his L5-S1 are now fused together and he has still not corrected the underlying movement dysfunction that led to his initial breakdown, the next time he gets injured it will either be at the hips (below segment) or at the L4-L5 region. The irony of the situation is that the way he moves off the golf course may play a bigger role in his future breakdown than how he moves on the course itself. World renowned physical therapist, Shirley Sahrmann, says it so simply “we must undo in our day to day life what the sport does to us.” Every sport has very different demands. With golf, the biggest demand is rotation. The problem is not that Tiger is rotating while playing golf; the problem is that he continues to rotate through his spine through all his other day to day movements, thereby putting fuel on a fire, instead of undoing those faulty movements.
To be clear, I am not critiquing any of Tiger’s current or previous medical providers. We have no idea what has been discussed or attempted with Tiger. Based on multiple reports, Tiger has been known to be stubborn and it’s very possible, his health providers have attempted to fix these movement dysfunctions, and Tiger might see the fixes as unimportant and unnecessary. What I can tell you is that no one can move with those flaws and expect to stay healthy long term, much less the game of golf’s greatest player ever who has a history of knee issues, 4 previous spinal surgeries, and a swing speed over 125+ mph. The good news is it’s never too late to improve movement quality. For the millions of Tiger fans and more importantly, for Tiger himself, I hope he addresses these issues sooner rather than later, so he can not only keep playing the game he loves, but also enjoy his life with his children down the road.
- Irmola, TM, Häkkinen, A, Järvenpää, S, et al. Reoperation rates following instrumented lumbar spine fusion. Spine. 2018; 43:4. Doi: 10.1097/BRS.0000000000002291
- McGregor AH, Dicken B, Jamrozik K. National audit of post-operative management in spinal surgery. BMC Musculoskeletal Disorders. 2006;7:47. doi:10.1186/1471-2474-7-47.
Is My Post-Marathon Pain Normal & What Now?
Congratulations! For all those who completed the full marathon, you have accomplished a feat that less than half of 1% of people in the United States accomplishes in his/her lifetime (1). For those who completed the half marathon, less than 1% of people complete this feat yearly. Immediately after the race, the sense of accomplishment and pride quickly morph into some notable soreness (at least for us).
To help combat your post-run aches and pains, we have several tips:
- Re-hydrate: during the race, we sweat out fluid to keep our body temperature regulated and we must replenish those fluids after the race to reduce cramping, dehydration, and potential heat exhaustion. The average adult should consume approx. 3 liters of water daily (2); however, less than 25% of adults drink enough water on a daily basis. For the next few days after the race, re-hydrating is vital and we encourage people to at least intake the normal recommendations of 3 liters.
- Perform Light Exercise: exercising may seem counter-intuitive after a long run to reduce soreness, but the literature strongly recommends performing light low load exercise to reduce muscle soreness after a strenuous run. This can be as simple as a 15-20 minute walk, riding a bike, or a light swim. All of these activities will promote increased blood flow which can help expedite the inflammatory process and promote lymphatic drainage, which are all contributing factors to the muscle soreness/stiffness.
- Soft Tissue Work: After a marathon, blood flow and other fluids become stagnant in the muscles and other surrounding tissues. Through a variety of techniques, such as foam rolling, we can help “squeeze” out those stagnant fluids, which the body will then replace with new fluids/nutrients reducing soreness and aid in overall recovery of the soft tissues. Too often, patients believe foam rolling should be a “no pain, no gain” situation; however, we should avoid excruciating pain. We instruct patients to stay in an “it hurts so good” zone where you are experiencing only a little discomfort while foam rolling and no worse afterwards. Another excellent recovery strategy is receiving a soft tissue massage from a licensed and skilled massage therapist. This should be a lighter intensity massage, focusing more on “flushing” strategies. The muscles are already traumatized from the run. We do not want to add additional trauma to the tissues or this can slow recovery.
- Take Time Off Running: For all of our high level runners, do not freak out. We are only asking you to take a short break. For half marathoners, we recommend taking a week off. For our full marathoners, at least two weeks off of running is our recommended time off. Some people may choose to perform light runs as a recovery strategy, but we encourage utilizing cross training strategies mentioned above.
We know there are a lot of snake oil salesmen pushing all kinds of expensive recovery products on the market. Many of these are unnecessary and have not shown any evidence of being beneficial. Following these simple strategies, you should be back to pounding the pavement in no time.
For those runners who experienced specific pain during or after the race, such as hip pinching, knee grinding, low back pain, foot pain, etc, this may be a WARNING of an underlying issue that warrants more specific and skilled treatment from a physical therapist. Up to 68% of runners experience an annual injury (2). Many of these injuries go untreated and lead to a snowball of issues down the road, often resulting in runners shortening distances or eliminating running all together. In a previous blog post, The Straw That Broke the Camel’s Back, which details how repetitive, overuse injuries occur and are often due to underlying movement impairment syndromes. Running is no different. Running, in itself, is not a bad or harmful activity; however, running without the prerequisite movement patterns, flexibility, mobility, stability/motor control, etc. will lead to injury over time.
Do not stress, soreness is normal and expected after any high level workout, much less a 26.2 mile run; however, if you notice that one particular area is not recovering like the rest of the body, then we can help. No referral is needed. Call us at 405-735-8777.
We Must Build a Foundation Before We Can Build Walls
A few nights ago, I couldn’t sleep and ended up watching a show about the construction of the Burj Khalifa, the tallest building in the world. In the show, they mentioned that the design used approx. 50% the amount of steel used in the construction of the Empire State Building, which is half the height of the Burj Khalifa. That fact initially surprised me, before realizing it was a simply matter of improved design efficiency and building a better foundation which could tolerate higher loads. That concept brought me back to one of our principal philosophies we apply at OSSPT, which is to ensure we build a better foundation of movement quality, before we ever increase movement quantity. The foundation of physical therapy should be about correcting faulty movement patterns.
“Tarzan, to me, is the epitome of fitness. The guy is strong, agile and quick. He can run, jump, climb and swing through trees. If we take a person who moves well and put them on a Crossfit type of training program, we turn them into Tarzan. If we take that same program and give it to the majority of people in society who move poorly, we turn them into a patient.”
– Gray Cook
Faulty movement patterns are the underlying reason behind ALL chronic conditions and many acute injuries. Without fixing the foundation, we are fighting a losing battle and eventually the walls will come crashing down, whether that be a recurrence of previous injury, worsening of current symptoms, or simply developing a new injury complaint. The number one risk for musculoskeletal injury is a previous injury, clearly indicating that something we are doing in the rehabilitation process is wrong and insufficient.
Ever wonder why your hip or knee become arthritic on one side and not the other? Ever wonder why your neck or low back are not getting better with years of adjustments, massages, etc? Ever wonder how you developed bone spurs in your your foot, heel, hip, shoulder, etc? The most likely answer is that you moved incorrectly, year after year, until finally, you developed structural changes, and then pain. As Gray Cook asks, are you moving poorly because you are in pain? Or are you in pain because you are moving poorly? We know that structural changes begin before we start experiencing pain, and we know that structural changes happen when we move improperly; therefore, we know that faulty movements lead to pain overtime. Here’s the great news… we can change how we move and if we change how we move we have an excellent opportunity to eliminate the pain cycle once and for all.
Try this quick test… perform a squat just like the kiddo in the picture to the right. If you can’t do it as well as that infant, then you are predisposed to injury. It’s as simple as that. We must squat, lunge, walk, climb stairs, push, pull, reach, etc. with proper mechanics, not because we are attempting to be elite level athletes, but simply because we are human beings and we must successfully build a solid movement foundation before we can build the walls of strength, flexibility, etc. around it.
“Success is doing the ordinary things extraordinarily well.”
– Jim Rohn
Not sure if you move correctly or not, schedule an evaluation with me and we will perform the Functional Movement Screen, a reliable and valid tool, to determine what weak links you may have that could eventually be the crack in your foundation, and then provide you with the proper tools to fix it before it becomes a bigger problem.
The Straw that Broke the Camel’s Back
We have all heard the common proverb “It’s the last straw that breaks the camel’s back“, referring to how something presumably minor can, overtime, cause a catastrophic and sudden reaction, due to the cumulative effects of the individual actions. Whether this refers to car tires wearing down overtime until the tire eventually blows a flat, a tree covered in ice during a snow storm that slowly bends more and more until it finally snaps, or continually “squeezing” into those tight jeans until finally one day you try squeezing into them and they rip at the seam, the overlying idea is that it was not one single event that led to the destruction; instead, it was gradual wear and tear over time. The same holds true for a large majority of injuries to the human body.
“It’s the little details that are vital. Little things make big things happen.”
– John Wooden
Many of the injuries we treat are not due to a single traumatic event, but are more often from chronic wear and tear, or as we describe it, repetitive microtrauma. Whether that be rotator cuff tears, carpal tunnel syndromes, lateral Epicondylagia/Tennis Elbow, Bulging/Herniated Discs, Arthritic related conditions, knee pain, tendonitis, etc., the underlying cause of the dysfunction is due to repetitive microtrauma leading to tissue breakdown and pain.
What causes repetitive microtrauma?
The simple answer is an underlying movement dysfunction and/or sustained postures, which results in muscle imbalances, soft tissue restrictions, joint dysfunctions, adverse neural symptoms, impaired stability/motor control, and eventually structural adaptations. Our job as physical therapists MUST be to not only treat the site of pain, but to identity and treat the underlying movement dysfunctions which led to pain and limitation in the first place. In other words, we must identify and treat the cause of the cause.
If my pain goes away, why does it matter?
When a patient comes into OSSPT with a rotator cuff tear, whether it be post-surgical or for conservative treatment, our first priority is to provide a proper environment to allow adequate healing to the damage tissue. Then we must identify and treat the underlying movement dysfunctions which led the rotator cuff to tearing in the first place, to prevent future recurrences. Simply giving generic range of motion and strengthening exercises is not enough and will result in short term improvements, at best. If we don’t fix the underlying cause of the cause, the likelihood of future re-injury is high.
Physical therapists wonder why so many of their patients return to the clinic weeks/months/years later complaining of the same symptoms they were previously treated for, often, blaming the patient for being non-compliant, a failed surgery, age, etc., without ever looking internally. We, as a profession, need to spend more time educating and proving to patients that we are more than just a profession of people who give out “stretches and stuff” as some claim, and prove to patients we are an invaluable member of the medical team, because right now, we are heading in the wrong direction as a profession, having become a bunch of overqualified exercise supervisors. If we keep heading this direction, doctors will continue to disregard our abilities, insurance companies will continue to cut reimbursement, and patients will continue to devalue the services we provide, until eventually, it will be the straw that broke the camel’s back for our profession.