Soft Tissue/Bony Adaptation in Throwing Elbow

It is known that our body has an ability to adapt in response to stress placed on it. Muscles get bigger and stronger after weight lifting. Endurance improves after prolonged exercise. In similar way, properties of joints and soft tissues changes as a result of stress placed on them. For example, in overhead athletes, they will lose the amount of internal rotation range of motion (ROM) and gain external rotation ROM, commonly known as GIRD (glenohumeral internal rotation deficits). In throwing elbow, as a result of repetitive throwing motion, soft tissue and bony adaptation about the elbow joint occurs. During throwing motion, distractive force is placed on the medial side (inside) of the elbow, where ulnar collateral ligament is. Compressive force exists on the lateral side (outside) of the joint. Also, stress is placed between trochlea and olecranon on the back of the elbow joint. After repetitive stress placed on the joint, it is shown that properties of UCL may change without any symptoms. In a study conducted on non-injured high school-aged baseball pitchers, MRI's were taken on their throwing elbows and non-throwing elbows and those images were compared. They found out that more than 60% of pitchers had thickening of the ligament in throwing elbow. Also, they found sclerosis in ulnar-throchlea joint without symptoms. Sclerosis means hardening of a bone mainly as a result of repetitive direct contact between two bones. We do not know it this will be a risk factor for future injuries or this may indicate anything significant. However, even in healthy pitchers, these changes do occur. When evaluating throwing athletes, it is important to know that these changes in MRI may not indicate an actual injuries if it is not consistent with objective and subjective evaluation. Other findings in the study was edema around UCL attachment, bone spur, etc. Further studies will be needed to investigate whether this soft tissue and bony adaptation may indicate risks of future injuries.  

MRI image of UCL tear

What We Don't Know about ACLR: Graft Maturation

       We have talked about rehabilitation after ACL surgery. However, there are many things that are not clear to us. What we know is based on clinical trials and studies done in the past and their results are consistent. When it comes to how ACL grafts go through maturation process, it is not that clear. Once ACL graft is in place, it goes through a process of vascularization and maturation. We do not know at what point the graft is strong and mature enough to do what. All we know is that we have been successful rehabilitating those patients following protocols (to note, there are a bunch of different protocols). And time to return to sport has shortened. But we do not know whether it is safe and healthy to a graft.

       A study took a look at when ACL grafts finish their vascularization process based on MRI. It showed that it might take up to a year for the grafts to vascularize. Once again, we do not know if it is safe to return the athletes to sport before the vascularization process is finished. One thing to note is that studies done in Indianapolis using accelerated rehabilitation protocol showed that up to 20% of athletes younger than 18 years of age re-injured or tore ALC after returning to sport.

      There have been so many studies done on ACL tears and rehabilitation. However, this stays as a hot topic in sports medicine. One reason probably is that there are so many things we do not know yet.  

Rehabilitation after ACL Tear: 16 Week Post-Op and Return to Play

By week 16, agility and plyometric exercise can be initiated if the injured athlete has good proprioception, postural stability, and strength. However, those exercises should not cause any pain or other complications like swelling. Balance and proprioception are hard to measure objectively. Some may use how long they can balance on one leg and other may use BEST as a measurement. Strength may be hard to measure also if isokinetic machine or hand-held dynamometer are not available. However, before plyometric training is initiated, the athlete should have about 80% of the strength back when compared to the uninjured side.

Then, the athlete can gradually progress to sport-specific training and back to practice. The return to play criteria should include 1) full ROM, 2) no pain, 3) no swelling, 4) optimal strength (at least 85% compared to the uninjured side), especially quads, 5) good proprioception and postural stability, 6) good mechanics (risky movements such as jump-landing, cutting motion, etc.), 7) no instability. It is also important to ready the athlete psychologically.

Rehab program should also include injury prevention program for both of the knees since some studies show that athletes with history of ACL injury may be more at risk of reinjurying the same knee or the other knee. It usually takes about 6 months plus minus one month until return to sport.   

2 leg box jump (start)

finish

Rehabilitation after ACL Tear: 12 Week Post-Op

Once all of the goals from the previous phase have been achieved, athletes can advance in their rehabilitation program per physician's protocol. Once 6 week mark has passed, most surgeons will allow the athlete to advance in strengthening program more aggressively. Closed and open kinetic chain exercises both should be used. Balance and proprioceptive/neuromuscular training also play an important role. However, all of these exercises should be done pain-free. Later in this phase, the athlete will be allowed to start jogging. Isokinetic knee extension/flexion exercise can be initiated around 12 weeks post-op if it is available. However, open kinetic chain knee extension should not be done past 30 degrees of extension since it is known that open kinetic knee extension will put stress on ACL past 30 degrees (between full extension to 30 degrees).  

Main goals of this phases will be 1) maintaining full ROM, 2) continue with strengthening program and to achieve optimal strength to begin plyometrics, 3) continue with balance and proprioceptive training, 4) begin slow jogging. Again, rehabilitation program should be based on physician's protocol. Some surgeons may allow to advance earlier than others. It should also based on tissue healing and athlete's tolerance and reaction to the program.

Core Stability Exercise II

We introduced one simple core stability exercise last time. This time, we will discuss how to make it more challenging. Once draw-in exercise gets too easy and once you get used to doing this correctly, you can make it harder. One way to do it is to pick up one foot about 5 inches off the table/floor and alternate feet from the draw-in position. But it is very important to keep the back flat against the floor keeping the ab tight throughout the leg movement. You can also add arm movement to the draw-in exercise. To do this, you bring your straight arms up above your shoulders, and lower one arm at a time toward the floor while maintaining the draw-in position. Athletes should be able to do these without too much trouble, if not, they need to work on these exercises so they can do them pretty easily. 

We well try to put up some pictures either on here or on our website.

Core Stability Exercise I

Core stability is very important not only for athletic performance but also for injury prevention. Research studies have shown a link between lower extremity injury and poor core/postural stability. Core muscles are the ones that attache to the pelvis, which include abdominal muscles, hip muscles, back muscles, etc. Each muscle play an important role in providing stability, however, the muscle called transverse abdominis seem to be very important when it comes to core stability. What this muscle does is that it compresses the trunk working almost like a girdle when it contracts. When doing core exercises, this muscle should be focused on not just other '6 pack muscel' and the ones that make you look better.

1) Draw-in

The easiest way to work this muscle is to do draw-in exercise. Sometimes, it is called pelvic tilt or ab set or iso abs. This is done by laying on the back with knees bent at around 90 degrees and trying to draw the belly button in towards the back. Or you can try to make the back flat against a table or floor. Sometimes, it is easier to do when you have a hand of someone's between the lower back and floor and try to press the hand down. You should not hold your breath or other body areas like neck and arms should be relaxed. Try to hold this position for 10 seconds and repeat 10 times to start. It may not as easy as it looks to do this exercise the right way.

Gymnast's Wrist

Gymnastics is a unique sport in that it requires weight-bearing on the hands. Because of that, injuries to the upper extremity is very common especially in elbow and wrist. Even though the most of the injuries are chronic in nature, acute injuries are also common such as ankle sprain. They start the sport really early and training can be extensive and long, which causes overuse.

Gymnast's wrist is an injury to the growth plate in the wrist. Radius is the main weight-bearing bone at the wrist and prone to injury from repetitive stress placed on it from tumbling and other weight bearing activities. Salter-Harris classification is often used to classify the severity of the injury with I being the least severe and V being the most serious. Athletes with this injury may complain of pain, swelling, loss of range of motion/strength, inability to weight-bear, etc. This condition should be treated with eliminating stress to the wrist, activity modification, rest, ice, NSAIDs, and sometimes physical therapy. She may return to sport when x-ray is normal and she is symptom-free. 

X-ray film of gymnast's wrist