Check out our newest video on some simple strategies to help control your breathing and it’s effects on the body!
Check out our newest video on some simple strategies to help control your breathing and it’s effects on the body!
Today’s blog post is from our Women’s Health Specialist and OSSPT physical therapist, Jenna Jarvis. We hope you enjoy and share with your friends.
When I started physical therapy school, I suspected I would likely work in an orthopedic and sports setting; however, I never suspected I would become a Women’s Health Specialist and treat pelvic floor dysfunctions. In fact, prior to physical therapy school, I did not even know women’s health or pelvic floor therapy existed. People often ask me what led me down this path and why I chose this specialty. In reality, I didn’t choose to become a Women’s Health Specialist as much as it chose me.
Beginning in my first year of physical therapy school, I started developing a constant, aching pain in the back of my right hip and thigh when sitting for long periods of time while studying or riding in the car while commuting to school. Not long after, I began experiencing pain with running, my main outlet from the stress of school. After a few weeks of continued pain, with no help from any of the exercises I “Googled” online and knew from PT school already, I decided to schedule an appointment with a physical therapist for further evaluation. After a few weeks of treatment, I still noticed only a minimal difference in my symptoms and became quite frustrated with my situation. I continued consulting with other physical therapists and an orthopedic surgeon, but never found any answers or treatment that relieved my pain. I started to feel a little crazy, and question whether it was all in my head. My pain was so intense, I could hardly sit in the car without a cushion and I had to stand in the back of the classroom during lectures. Most frustratingly, I could no longer run due to the pain being so severe.
Nine months of continued, unrelenting pain later, we had a guest lecturer present about women’s health physical therapy. As I stood in the back of the room (remember the pain was too intense to sit), she presented a case study of a 20 year old female who had pain with running and sitting. As she continued discussing the case, all the symptoms matched mine entirely. I knew I needed to explore this treatment more. After class, I talked with the Women’s Health Specialist and she confirmed that, in fact, a lot of my symptoms were common with pelvic floor dysfunctions and that she felt confident she could help me. To this day, I can still not explain the amount of relief I felt to know that my symptoms, not only made sense, but that a solution was also available as well. Within the first few weeks of treatment, I already noticed a reduction in pain, returned to some light running, and I could finally sit in class again. Within a few months of treatment, I was at least 95% better and ran my first marathon, qualifying for the Boston Marathon. I finally had my normal life back!
Following my personal experience and success with pelvic floor therapy, I knew I wanted to offer these same services to my future patients. Knowing that these advanced women’s health treatments were not taught in PT school, I found and attended some of the most advanced and respected pelvic floor and women’s health courses and completed a long term clinical rotation with one of the premiere women’s health specialists in the country treatments women with pelvic floor dysfunctions on a daily basis. Additionally, I am constantly learning more about this specialty every day. In my experiences, I am always astonished with how many of patients have lived through years of pelvic and low back pain with no answers before they discovered pelvic floor therapy. Pelvic floor physical therapy is truly my passion and my professional mission is to educate the medical field and the public about pelvic floor therapy and its benefits.
Pelvic floor physical therapy is a common term for a thorough examination, assessment, and treatment of the thoracic, lumbar, and sacral spine, pelvis, and lower extremities and various related physiological systems that could be causing pain or dysfunction. Pelvic floor therapy is also known as women’s health physical therapy, pelvic floor physical therapy, pelvic rehab, or urogynecological physical therapy. In addition to the pelvic realm, women’s health therapy can also be beneficial for women following breast cancer and radiation treatment to address pain, decreased upper extremity mobility, and other dysfunction related to treatment of cancer.
Pelvic and women’s health therapy can be beneficial for patients experiencing the following:
In your first visit, you can expect a thorough examination of your past medical history, eating, drinking, voiding, and sexual habits and how they may relate to your pain or dysfunction. In addition, an examination of the thoracic and lumbar spine, pelvic, and lower extremities will be done to assess any orthopedic dysfunction that could be contributing. Finally, an examination of strength and control of the surrounding musculature will be assessed, which will include an external and possibly an internal examination. Patient comfort and safety is always my top priority. I understand that every patient will have differing levels of comfort and we can always modify the examination and treatment to the patient’s preference.
Treatment for pelvic floor therapy may include, but is not limited to the following:
Kegel exercises are specific exercises that focus on strengthening the pelvic floor. Although these exercises can be beneficial in the right situation, Kegel exercises do not fix all pelvic floor dysfunctions. In fact, often times Kegel exercises magnify a patient’s symptoms. Pelvic floor dysfunctions are not caused purely by weakness; they are due to an inability to properly engage the pelvic floor musculature, which can be either over-active or under-active musculature. This is one of the biggest reasons why a patient cannot simply “Google” their problem and why they need to be individually evaluated by a specialist to determine the true cause of their pelvic floor dysfunction and to create an individualized plan to properly retrain the pelvic floor musculature.
When a patient is experiencing a significant pelvic floor dysfunction it can be debilitating and life altering. To make matters worse, resources to address these issues are often limited; patients are often initially misdiagnosed and improperly treated. If you are someone who has been suffering from a possible pelvic floor dysfunction, please do not give up. I have been in your shoes and I can help. If you have any additional questions or would like to schedule an evaluation, please call us at (405) 735-8777.
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.
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.
With Spring Training underway, baseball is officially back! As a fan, I am more than excited. As a medical professional and a PT who spends a lot of time treating the baseball population, I know my schedule is about to ramp up. As Posner, et al (2011) found, April is the month with the highest injury rates for MLB players, with pitchers having a 34% higher injury than position players. One of the injuries we are seeing more often than in years past in our professional pitchers are latissimus injuries. For a lot of reasons, we will discuss below, it seems that latissimus injuries are being diagnosed more frequently than they were in decades past. It was not until 2010 that the first lat repair surgery was performed on a professional baseball player, when Jake Peavy went under the knife. Since then, many of the game’s biggest stars, including Stephen Strasburg, Fernando Rodriguez, Clayton Kershaw, Noah Syndergaard, and Cardinals top prospect Alex Reyes have sustained lat injuries. In a systematic review of 30 professional baseball pitchers, Mehdi, Frangiamore, & Schickendantz (2016) found that the average time required to return to pitching was 99.8 days for the non-operative group and 140 days for the surgically treated group. As you can see, once you sustain a lat injury, the recovery is slow.
Because so few PT’s in the traditional clinic setting treat professional athletes on a regular basis, we created a massive two part blog for our audience to serve as an additional resource to develop a better understanding of the injury and implications for pitchers. We hope you will enjoy!
In Part I, we will review latissimus anatomy and it’s involvement with pitching, theories for the increase in lat injuries for professional pitchers, and a brief review of the surgery.
In Part II, we will discuss common compensations for “lat dominant” athletes and demonstrate a few of our favorite functional exercises that specifically focus on addressing the common compensation patterns.
The latissimus dorsi is the largest and most powerful muscle in our backs, originating from the T7-L5 vertebrae (basically our bra straps to our belt line), the thoracolumbar fascia, iliac crest, the bottom 3-4 ribs, and the inferior aspect of our scapula. The lats then insert on the intertubercular groove of the humerus. THAT’S A LOT OF ATTACHMENTS, LEADING TO A LOT OF MOVEMENT INFLUENCES. To make matters more complicated, the lats have a lot of variability in respect to its specific attachment sites.
The general functions of the lats include extension, adduction, cross body adduction, and internal rotation of the shoulder. For many recreational lifters, the lats become the dominant muscle with all vertical and horizontal pulling movements such as rows, pull ups, and pull downs.
For baseball pitchers, the lats are one of the most important muscles in developing arm speed, and therefore, increasing throwing velocity. As Eric Cressey (2016) has previously stated, the lat “connects the lower body to the upper body to allow for force transfer that ultimately leads to arm speed and ball velocity”. The lats have several very specific and important functions in the pitching motion, including the following:
The further the lay back phase, the more the elastic potential energy created by the lats, thereby providing more opportunities for increased velocity. If you look at the picture below of Billy Wagner, one of the hardest throwing pitchers in the history of the game, you can appreciate the considerable amount of layback in his throwing shoulder, and it quickly makes sense how he became of the games hardest throwers. He generated vast amounts of elastic potential energy via the lats.
If the idea of elastic potential energy is still confusing, then check out this short video below which provides additional information.
Muscles and tendons, throughout the body, are most vulnerable to injury during the eccentric phase of movement (being lengthened). When you add large loads to the eccentric phase, as seen when throwing a baseball, and then ask the muscle-tendon complex to transition from being maximally lengthened to concentrically contracted at high speeds , we are asking for trouble. As you can see, the demands on the lats are very high during the throwing phase.
To provide a better visualization of what happens when you overload a muscle/tendon during the eccentric phase, check out this video below (beware of language). At the 30 second mark, you will see a lady (wearing the ironic “Today is the Day” shirt) take a quick step back with her left leg, leading to an eccentric stretch to the Achilles, followed by an attempt to quickly concentrically contract and shorten her Achilles. Unfortunately for her, she overloads the tissue, rupturing her Achilles (if you don’t mind the language, you can literally hear the pop happen).
Clearly, pitching places a lot of demands and stresses on the body, particularly the lats, but the question remains, why such sudden increases in lat specific injury risk? The answer appears to be multi-factorial. Below, I have listed some of the probable causes.
While most lat injuries are Grade I or II strains (partial tears), occasionally a throwing athlete will sustain a tear large enough that requires surgical intervention. Dr. Anthony Romeo performed the first lat repair surgery on a MLB player and has become the pioneer of the lat repair surgery. According to Dr. Romeo’s website,
“The latissimus dorsi repair is done by making an incision in the back of arm, near the armpit. The ruptured tendon is then located, and sutures are placed in the end of the torn tendon. Those sutures are then used to pull the tendon back up to the arm bone where the tendon ruptured. Small metallic anchors, called buttons, are then used to fix the tendon to the bone.” (https://www.romeoorthopaedics.com/surgeries/latissimus-dorsi-repair).
In the picture below, you can see OSSPT patient and San Francisco Giants prospect Caleb Simpson’s incision following his lat repair surgery.
Clair, M. (2018, August 29). Are pitchers really throwing harder than ever? Retrieved from https://www.mlb.com/cut4/are-pitchers-really-throwing-harder-than-ever/c-292153594
Cressey, E. (2016, May 4). Pitching injuries: should lat strains even be happening? Retrieved from https://ericcressey.com/pitching-injuries-lat-strains
Cressey, E. (2018, July 9). 5 reasons for the increase in lat strains in baseball pitchers. Retrieved from https://ericcressey.com/5-reasons-lat-strains-baseball-pitchers
Fleisig, G. S., Andrews, J. R., Dillman, C. J., & Escamilla, R. F. (1995). Kinetics of baseball pitching with implications about injury mechanisms. The American Journal of Sports Medicine, 23(2), 233–239. https://doi.org/10.1177/036354659502300218
Gowan, I. D., Jobe, F. W., Tibone, J. E., Perry, J., & Moynes D. R. (1987). A Comparative Electromyographic Analysis of the Shoulder During Pitching. Professionals versus Amateur Pitchers. The American Journal of Sports Medicine, 15(6), 586-590.
Mehdi, S.K., Frangiamore, S.J., & Schickendantz, M.S. (2016). Latissimus dorsi and teres major injuries in major league baseball pitchers: a systematic review. American journal of orthopedics, 45(3), 163-167 .
Posner, M., Cameron, K., Wolf, J., Belmont, P., & Owens, B. (2011). Epidemiology of major league baseball injuries. The American Journal of Sports Medicine, 39(8), 1676-1680.
Reinold, M.M., Macrina, L. C., Fleisig, G. S., Aune, K., & Andrews, J. R. (2018). Effect of a 6-week weighted baseball throwing program on pitch velocity, pitching arm biomechanics, passive range of motion, and injury rates. Sports Health, 10(4), 327-333.
Reinold, M.M., Wilk, K.E., Macrina, L.C., Sheheane, C., Dun, S., Fleisig, G.S., Crenshaw, K., & Andrews, J.R. (2008). Changes in shoulder elbow passive range of motion after pitching in professional baseball players. American Journal of Sports Medicine, 36(3), 523-527.
Zeppieri, G., Lentz, T., Moser, M., & Farmer, K. (2015). Changes in hip range of motion and strength in collegiate baseball pitchers over the course of a competitive season: A pilot study. International Journal of Sports Physical Therapy. 10, 505-513.
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.
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.
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.
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.