What is Meniscus Tear?!

Sports news world is busy with the news of the basketball player having a meniscus repair surgery. But what is meniscus?! Meniscus is a fibrocartilage that exists in the knee. Its roles are to absorb shocks and to make the knee joint more stable by deepening the concave part of the joint (tibia). There are 2 menisci in the knee; one located laterally and the other located medially. Medial meniscus is more commonly injured. Degenerative meniscus injury is common as people age. But it also happens in sports especially in sports that involve a lot of cutting, changing directions, and twisting such as soccer and basketball. It also happens with anterior cruciate ligament injury. Depending on where the injury is and how severe it is, it can be repaired. The center of meniscus does not have sufficient blood supply and does not heal well. The outside of it, on the other hand, is more vascularized and has more chance to heal. Meniscus repair seems to do better in younger athletes and in those who are having an ACL reconstructive surgery at the same time. Older knees have less chance of successful meniscus repair surgery. Athletes with meniscus tear may complain of dull aches and pain, sharp pain with motion, swelling, loss of motion, loss of function, joint line tenderness, etc. It may cause clicking sounds and it may feel like knee is locking up. The picture below is an arthroscopic view of torn meniscus. Whether a torn meniscus can be repaired depends on the location of the injury and the severity of it. Also, the age is a factor. If it is shaved off, it usually takes about 4 to 10 weeks to rehab. It is repaired it will take a lot longer. Rehabilitation of repaired meniscus usually involves non-weight bearing for 4-6 weeks and start partial weight-bearing and rehab may take as long as 4-6 months.

 



Lateral Posterior Hip Muscle Exercise for Baseball Pitchers

It is well known the importance of hip muscles, especially gluteal muscles and external rotators. They play an important role in not only stabilizing the hips but also the knees and lower legs. Every baseball pitcher has to be on one foot during stride phase of the pitching motion. If he is not able to maintain the stability of his lower leg, hip, and trunk, he will not be able to effectively transmit a ground reaction force through trunk, upper body, and to his arm and to the ball. Doing hip exercise on a table is a good way to start but he will need to train the muscles in standing as well. Here is one easy way to work on his hip muscle strength.

 

This is an isometric hip muscle (gluteal) strengthening exercise. He is pushing the physio ball into the wall with his left knee while trying to maintain his upright posture with his right leg. With this exercise, he should be able to maintain the upright posture without moving any part of the body. This works on his bilateral hip muscles, especially gluteus medius. If he brings his left knee up to the level of his hips, he now is working on his external rotators of his left hip as well as his right gluteus medius. Also he needs to use his core muscles to stabilize his pelvis.

Modified Sleeper Stretch

Major league baseball season is already half way through and summer baseball league is in a full swing for college and high school baseball players. We have already talked about how important it is to prevent injuries rather than treating injuries that have already happened. For baseball players especially pitchers, it is important to maintain sufficient shoulder range of motion(ROM) to prevent injuries. A loss of internal rotation and total arch of motion compared to the non-throwing arm of more than 5 degrees may put pitchers in increased risk of injury according to past studies. Several stretching techniques to increase or maintain shoulder internal rotation ROM have been described. One way to stretch is sleeper stretch. However, for high school and little league baseball level, there may not be a table available to lay on and do sleeper stretch. So, here is another way to do sleeper stretch. Instead of laying down on a table, a wall can be used to do the same stretching(pictures). Also, horizontal adduction(cross arm) stretching is an effective way to regain or maintain internal rotation motion. Stretching the shoulder on a daily basis especially after pitching is an important part of injury prevention for baseball pitchers.

Modified sleeper stretch (start)

Modified sleeper stretch (end)

Knee: In a Triangle Relationship?!

Knee injuries are very common among athletes. There are many different types of injuries that can happen to the knee joint. Common injuries include Osgood-Schlatter disease, Larsen-Johansson disease, ACL tear, meniscus tear, runner's knee, OCD, etc. But why knee injuries are so common?! When I explain to athletes, coaches, and parents, I usually use this analogy "because the knee is in a triangle relationship with the hip and ankle". The knee joint is between the hip and ankle. The hip is important because the posterolateral muscles of the hip controls the knee motion in athletic movements such as jumping, cutting, etc. Past studies have shown that poor control of the knee in those movements may put athletes in more risk of injuries such as ACL tear. Also, it has shown that weak hip muscles are related to lower extremity injuries. The ankle/foot is also important because whatever ankle and foot do will affect what the rest of the body does. If they do not function well, it will affect your balance ability, your ability to absorb ground reaction force, and where the knee goes. Tight Achilles and calf muscles will affect how you do things such as squat. The mid-foot needs some stability. Low and high arch will affect the rest of your lower leg. Foot and ankle are very complex and there are a lot of things that can go wrong. Thus, if you want to keep the knee healthy, you will need the ankle/foot and hip to function in ways they are supposed to. But if you can keep the hips and ankles/feet happy, the knees will be more than likely happy (injury free).

A Technique to Increase Internal Rotation Range of Motion in Baseball Players

This baseball season is in full swing including high school, college, and professional baseball. Only a few weeks into Major League season, there are quite a few players put on DL. Shoulder and elbow are among the most injured joints in baseball players especially pitchers. Many of those injuries are chronic in nature and, thanks to many research studies, we know more about what happens to throwing shoulders from repetitive stress and what risk factors may be. Many of baseball pitchers develop a loss of internal rotation (IR) range of motion (ROM) as a result of repetitive throwing. Studies suggest that GIRD (glenohumeral internal rotation deficit) of more than 5 degrees may put baseball pitchers in more risk of shoulder injury. GIRD is a loss of total shoulder ROM (IR + ER) compared to the non-throwing shoulder. What this tells us is that it is important to keep ROM in both shoulders relatively close and, in order to do so, it is necessary to keep stretching the external rotators and posterior capsule. There are some techniques to stretch. Sleeper stretch and passive internal rotation stretch are shown to be effective. Also cross arm stretch is another way to stretch posterior capsule. A study published in 2011 suggests that not only passive stretching the muscle energy technique may be effective in gaining shoulder IR and horizontal adduction ROM. According to this study, the muscle energy technique into horizontal abduction increases both shoulder IR and horizontal adduction ROM immediately. This does not mean that other stretching methods such as sleeper stretch and passive stretching are not good. However, the muscle energy technique can provide effective way to relieve a loss of ROM in baseball pitchers.  

Importance of Hip Strengthening When Treating Athletes with PFPS

The importance of hip strength in athletes' ability to control their knee alignment, especially gluteus medius and external rotators, are well documented. Hip muscle weakness has been liked to injuries such as ankle sprain, ACL sprain, etc. Patellofemoral pain syndrome (PFPS) is another injury suffered by many athletes often leading to loss of practice time and competition. PFPS, however, can be caused by many causes including patella maltracking, patella instability, quad muscle weakness, hip muscle weakness, etc. And this condition is more prevalent in female athletes than in male athletes. It is very important when treating athletes with this condition to identify underlying causes and treating them instead of treating the symptoms, whether it is in the ankles, knees, or in the hips. One thing that we focus when rehabilitating athletes with PFPS is to make sure they have good hip strength and good control of their lower extremities. A study published a few years ago verifies this. In this study, they put athletes with PFPS into 2 groups with one being quad strengthening group and the other being hip strengthening group. After 4 weeks of exercises, the hip strengthening group improved in pain level significantly more than the quad strengthening group. This tells us how important it is to include hip strengthening in a rehab process. This does not mean that it is not important to do quad strengthening exercises because, in this study, the quad strengthening group also got better in pain level and in function. It is important to do both of quad and hip strengthening when treating athletes with PFPS. Some of the hip exercises that can be done easily are side-lying hip abduction, monster walk, clam shell, etc. And again, it is very important to find out what is causing PFPS and treating the causes instead of just treating the symptoms.

Monster walk exercise

Core Stabilization Exercise: Dead Bug

Even though it is every important to know draw-in exercise (pelvic tilt) is the most basic core exercise and the fundamental to any other core exercises, at some point, athletes will need to advance to more difficult core exercises. We have already discussed a few different ways to make it harder. One of more advanced core exercises is dead-bug exercise and this is often used to evaluate athletes' core strength as well. However, to many athletes, it is very difficult to do this exercise correctly. According to our data, about 50% of 300 elite junior tennis players failed to correctly perform dead-bug exercise. The picture below shows a starting position of dead-bug exercise. Then, athletes will lower one arm and an opposite leg towards the table while maintaining neutral spine and pelvis (without arching the back). As we mentioned, even for elite athletes, this is not an easy exercise to do. But there are variations of this exercise, which are easier to do.

 

1) From starting position, they can just lower their arm and alternate.

2) They can also lower a leg only but with their knees bent at 90 degrees. 

3) They can slide a physio ball under their legs and roll the ball out instead of lowering a leg on their own power. Or they can put both legs on the ball.

 

These are some of examples to make it a little easier. As they get stronger, they can advance to full dead-bug exercise. Dead-bug exercise is just one of many core exercises and just one of many advanced forms of draw-in (pelvic tilt) exercise. Most sports are played in their feet, so eventually, they need to advance to core exercises in upright position and their feet. But again, the fundamental of any core exercises is maintaining neutral spine and pelvic positions and maintaining stable 'core' during those exercises.

Bony Adaptation of the Shoulder in Baseball Pitchers

It is well known that the glenohumeral joint (shoulder joint) goes through changes in throwing shoulder of baseball pitchers. A change in its range of motion (ROM), know as glenohumeral internal rotation deficit (GIRD), is very common in baseball pitchers. GIRD is when pitchers lose internal rotation (IR) motion and gain external rotation (ER) motion and a total arch of motion (IR + ER) is considerably less than that of the non-throwing shoulder. According to a study, a loss of more than 5 degrees of total ROM increases a risk of shoulder injury in baseball pitchers. This change in ROM may be due to soft tissue adaptation or/and bony adaptation that shoulder goes through after repetitive stress placed on the joint. Known bony adaptations are humeral head retroversion where humeral head (the ball part of ball and socket shoulder joint, a part of upper arm bone), after repetitive torsional force from pitching, turns backwards compared to the other shoulder and glenoid retroversion where glenoid fossa (socket part of the shoulder joint, a part of scapula) shifts backwards. In most shoulders, the glenohumeral joint is aligned about 30 degrees anteriorly instead of facing straight to the side. However, in the throwing shoulders of baseball pitchers that have gone through this adaptation, the alignment of the joint is slightly shifted backwards. Importance of these adaptations, which likely happens before bones complete its growing process (physis closure), is that it may be a protective mechanism of the shoulder against repetitive stress and possible injury such as SLAP tear according to several studies. 

       Will baseball pitchers whose shoulder has gone through this bony adaptation be at less risk of SLAP tear in the future?! Is it better to start pitching when they are younger that later to prevent SLAP tear?! There are many more questions to be answered.   

 

 

Common Injuries in Elite Junior Figure Skaters

Figure skating may not attract a lot of attention except for the winter Olympics. However, it is a quit unique sport with plenty of technical skills and artistic aspect in it. As this figure skating season is coming close to an end this year, we thought to discuss common injuries in figure skating. According to a study published in 2003, which looked at singles, pairs, and ice dancing, about 70% of injuries in singles figure skating were chronic injuries. 60% of injuries in pairs were acute injuries. Of all the acute injuries suffered by elite junior figure skaters, ankle sprain was the most common. Common chronic injuries among those figure skaters were stress fracture, jumper's knee, Osgood-Schlatter disease, etc. Common injury sites for stress fracture were located in the foot and lower leg. Over all, more than 44% of all the injuries suffered was chronic in nature. This means that it is very possible to prevent such injuries.

 

It is very important to know that figure skaters wear rigid type boots which prevent them from moving their ankle. The importance of this is that......when athletes jump and land, they will bend the ankles, knees, and hips to absorb a force placed on the joints. The muscles around each joint play an important role in absorbing the force so that stress placed on the joints will be minimized. However, figure skaters do not have ankles and muscles around to dissipate the ground reaction force due to the boots that they wear. From a recent study, it is known that knee and hip angle on landing correlates with the amount of pressure felt by knee and hip joints. When figure skaters do not have the ankle and the muscles around it to absorb the ground reaction force, it is a disadvantage to them. They may need to work on the knee and hip muscle strength to 1) cancel out this disadvantage and 2) relieve a compensatory stress placed on those joints.  

Literature Update: Preventing ACL Injuries after Reconstruction

Anterior cruciate ligament (ACL) injuries are a hot topic again after RG III underwent reconstruction. And this is his 2nd reconstruction in the last 4 years. While some researchers suggest that a primary ACL reconstruction will not increase a risk of second injury, studies have suggested that there may be an increased risk of re-injuring the same knee or injuring the other knee  in up to 20% of those who have undergone a first reconstruction. This means that it is very important for athletes and health care providers to not only rehabilitate the reconstructed knee but also to minimize a risk of another ACL injury after returning to sports. We know from past studies that there are predisposing risk factors including muscle imbalance, poor biomechanics of high risk movement patterns, decreased neuromuscular control, etc. The same approach can be used to prevent a secondary ACL injury. However, a recent study suggests that asymmetries between a reconstructed knee and healthy knee are the key factors to prevent an ACL injury after reconstruction. Especially after a surgery, it is not rare that the athlete presents decreased muscle strength compared to the other healthy knee mostly in quads. Some athletes may have decreased range of motion. When returning to sports, it is very important that the athlete has optimal symmetries in muscle strength and balance, neuromuscular control, biomechanics of trunk and lower extremities, in addition to minimizing other risk factors.

Literature Undate: Preventing ACL Injuries

Anterior cruciate ligament injuries are a huge concern for athletes involved in high risk sports such as women's soccer and basketball, women's gymnastics, football, etc. Studies have shown that female athletes are 4-6 times more prone to an ACL injury. Researchers have done extensive studies on ACL injury risk factors and we now know more about the injury than in the past, even though there are still things that are not clear to health care providers and sports medicine personnel. One of the possible factors that make female athletes more prone to an ACL injury is a neuromuscular deficit that female athletes demonstrate. This neuromuscular deficit is shown to be developed after puberty in females. Also, it is shown that neuromuscular training can reduce the risk of ACL injuries in female athletes. A recent meta-analysis study shows that there may be a window where the neuromuscular training to prevent ACL injuries should be done. It collected study data from the literature published in the past and showed that preventative neuromuscular training may need to be done before female athletes develop the deficit. 

 

It may be difficult for parents and athletes to understand why. However, it is important to utilize injury prevention training/program earlier, especially if athletes are already demonstrating injury risk factors.