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.   

Rehabilitation after UCLR: 12 Week Post-Op to Return to Play

During this phase of rehabilitation after Tommy John surgery, isokinetic exercise can be initiated if available and interval throwing program (ITP) can be initiated. In most protocols, isokinetic shoulder internal and external rotation, wrist flexion and extension, and forearm pronation and supination exercises can be initiated after 12 weeks after surgery. Shoulder internal and external rotation exercise may be initiated even earlier. However, these exercises should be done pain free or any ulnar nerve symptoms. Shoulder and wrist plyometric exercises after 12 weeks. Strengthening exercises should be advanced including shoulder exercises with shoulder in 90 degrees of abduction (closer to throwing motion). The athlete will start swinging a bat and start a batting program. Fielding the ball can also the initiated without throwing.  

 ITP is usually initiated after 16 weeks post-operatively. There are several ITP's available, each of which starts with short distance and gradually increases in distance and the number of throws (an example of ITP is listed below). Again, ITP must be done symptom free throughout. If any symptoms exist, it should be stopped until it resolves. After completion of ITP, the athlete will gradually return to play. For baseball pitchers, it usually takes about 10-12 months before they will start pitching in a game.

The goals of this phase are 1) to maintain full ROM, 2) to advance in strengthening program, 3) to initiate plyometric exercise for shoulder and wrist, 4) to start sport specific training such as ITP, swinging a bat, and fielding, and 5) to gradually return to play. 

Interval Throwing Program (ITP) (Phase 1: Soft Toss) 

Distance (ft)                   Warm-Up                  # of Throws

30                                                                      20 - 20
45                                    30                              20 - 20
60                                  30 - 45                         20 - 20
75                                  30-45-60                      20 - 20
90                                  45-60-75                      20 - 20
120                                45-60-90                      20 - 20
150                                45-60-90-120               20 - 20
180                                45-60-90-120-150        20 - 20

This is an example of ITP. The athlete will soft-toss 2-3 times at each distance before advancing to next and may throw 10-15 times at each distance for warm-ups. And ITP should be done every other day. The distance can go farther than 180 feet if athletes want to. 

Interval Throwing Program (ITP) Phase 2

In this phase of ITP, the athlete will start throwing with intensity gradually increasing. They will start at a shorter distance (around 60 feet) and less intensity (50%) and gradually increase in intensity and distance as needed.