Shoulder Pain in Overhead Athletes and Hip Tightness

Although my main focus is injury prevention for runners, I want to address an area of concern I see in the clinic with overhead athletes (athletes who have to bring their arm above their head). Shoulder and elbow injuries are very common in overhead athletes such as baseball players and volleyball players. Rehab typically focuses on the injured shoulder or elbow. However, for a complete recovery, assessment of the whole body must be performed. Otherwise, the injury will linger or affect another body region.

Example 1

Patient presented difficulty lifting his left arm to his ear after a work injury. We focused on his shoulder but the last bit of motion remained painful and limited. I noticed his right leg position rested outward when he was lying on his back. As a result, I decided to take action on his hip mobility. I stretched and mobilized his hip to allow for more neutral position. After 5 minutes of stretching and mobilizing, he had full pain free shoulder motion.

Shows foot pointed outward
as a result of tight hips

Picture shows fascial connections between the
 hip/pelvis and the shoulder girdle
Picture from Born to Walk: Myofascial
Efficiency and the Body in Movement
by James Earls

Why?

Our body is held together by connective tissue which connects our muscles so our body can work together as a system. Tight hip flexors will stiffen the anterior aspect of the trunk and turn the leg outward. This tightness will increase the tension when lifting the arm overhead.

Try This: Raise your right arm overhead and take notice of how your shoulder feels. Now, with the left hand grab and hold the bottom corner of your shirt in your hand. How does it feel? It should feel harder to lift your arm.

Hip Flexor Stretch

Adding arm movements to your stretches allows you to capture the 3 planes of motion, target different angles of the muscles, and ultimately provides a more comprehensive stretch. After the stretch, I recommend performing high knee marches at different angles to activate the newly stretched muscle tissue.

Example 2

A baseball player has shoulder pain only when he pitches. Standard treatment would address his tendonitis. After checking his hip rotation in a standing position, he has limited external rotation of his right hip. Performing joint mobilizations to provide more external rotation eliminates his shoulder pain while throwing.

Pitching Mechanics 

The top video shows pitching mechanics with a throwing warm up but before hip flexor stretching. The bottom video shows pitching mechanics with a throwing warm up and hip flexor stretching. Notice the difference in mechanics. The bottom video shows improved hip opening, shoulder position upon release, and improve knee flexion during the follow through.

Why?

Proper throwing mechanics require the right hip to rotate throughout the movement. When this motion is limited,  the trunk stops rotating and the shoulder has to absorb the energy.

To loosen the hips to prepare for pitching, I recommend hip flexor stretches in all 3 planes. As a follow up, perform a lunge matrix focusing on the rotational lunge.

Bottom Line

These examples demonstrate how the hip can affect the shoulder in everyday tasks and in overhead athletes. The body is connected and works as a system. We need to find the source of the problem and not just treat symptom.

Knee Pain: The Adductors Role

It's the last several weeks before the big marathon. You're out for your 20 mile run and feel great. BAM at mile 11, an ache develops at the side of the knee. You try to ignore it. You try to run it off. But it gets worse. You have to do the walk of shame home.
A basic Google search brings up ITB tendonitis. You foam roll your ITB, you ICE and you do glute strengthening. Your knee pain is slightly better but is still nagging. What is causing this continue?

A running analysis reveals something unexpected.



The left leg lands under the center of the body. However, the injured leg drifts towards OVER the center of the body when it hits the ground. Each time the foot lands the ITB is getting injured.

What can cause this?

Adductor mobility

Adductor muscle group. Thieme: Atlas of Anatomy General Anatomy and Musculoskeletal System

Left: normal running position Right: Tightness of the left adductor
bringing the right leg closer to midline as it lands.

A closer look at her adductors revealed the UNINJURED leg lacks 15 degrees of mobility. The trail leg extends behind the body AND is stretched sideways from the body. Lack of mobility of the adductors of the trail leg pulls the front leg laterally. When the leg hits the ground it lands under the center of the body. This will put a stretch stress to the lateral side of the leg. The connective tissue of the out side of the leg gets over stretched causing ITB tendonitis.

Adductor Stretch

Place one foot up onto bench with foot turned away with the knee bent. Shift body weight towards the bent knee to feel stretch on the inner thigh. Drive hip forward and backwards, side to side and twist. 

                        

Follow up the stretch with a tri-plane lunge. This will help keep the adductors strong and mobile.  http://3drunner.blogspot.com/2015/07/basics-of-3d-exercises.html

The next time your ITB flares up, take a look at your adductor mobility. 

Hamstring Strain

A nagging pain develops in the back of your thigh. Was it the added speed work? Maybe the increased milage? Could it be a strained hamstring?
Conventional thought is the hamstring bends the knee. When we want to flex the hamstring our knee bends. However, during function, our muscles work differently. In running, the hamstring slows down knee extension as your knee swings forward. The hamstring muscle elongates to control the knee's motion. This is called eccentric muscle action which puts more stress on the muscle. With increase mileage or speed the hamstring becomes overworked and leads to a strain.

Before we look at hamstring, we have to assess other body regions.

Rule Out These Body Regions...

Low Back

The first thing is to rule out referred pain from the lumbar spine. When the nerves of the low back are compressed, it can refer pain to the muscles it innervates. Typically compression of the S1 nerve (also L5 in a smaller population) will refer back to the back of the leg.  Even though the pain is in the hamstring, treating it will not affect the underlying cause. The compression can be caused by a herniated disc or by a condition called stenosis. Taking pressure off the nerve is the only way to treat the "hamstring pain".

Sacroiliac Joint

Next check to make sure the pelvis is level! The pelvis can become malaligned with a mis-step off a curb, long periods of poor posture or simply imbalance of muscles. The hamstring is attached to the ischial tuberosity on the pelvis.  A mis-alignment of the pelvis will have a different pull on the hamstring causing a strain. To perform a quick screen, stand in front of a mirror making sure your feet are aligned forward. Put your hands on your pelvis with the index fingers under the pelvic bone. Look in the mirror to make sure your hands are level.

Top picture: shows level position of pelvis. Bottom picture: shows
rotated position of pelvis

***If you have symptoms of low back or sacroiliac dysfunction please go see your physical therapist.

Hamstring vs Gluteals

When the low back and sacroilliac joint are cleared, we can truly treat the hamstring. OR can we? Conventional treatment is to stretch and strengthen a strained hamstring but research shows the muscle is flexible and strong. Assuming there wasn't a specific incident, a strain muscle signifies overuse. So we have to find out how the hamstring get strained in the first place.
When we look at the function of the hamstring it is similar function of the gluteals. If the gluteals are weak, the hamstrings are at a biomechanical advantage to take over. In addition to treating the hamstring we have to consider glute strength.

Gluteal strength Test 

A quick screen for gluteal strength: Perform 10 on each side. Is there one side that's harder then the other?

Gluteus Medius - Lay on your completely on your side. Leg should be in line with the trunk. Lift leg towards ceiling. ** Make sure to not let the leg drift forward

Gluteus Maximus - Stand in front of a desk and lean forward. Kick your leg back without twisting your hip.

Functional 

Single leg squat - Stand on one leg and perform a squat. Keep the knee aligned forward and pelvic level. 

Left shows good single leg squat form; R shows the knee rolling
inward and and the hip dropping

Basic Strengthening

Clam - Lay on your side with knees bent to about 90 degrees and heel lined with bottom. Keeping the feet together lift knee towards ceiling. The key to this exercise is to ensure the hips are stacked directly on top.

Side leg lift - On your side, hips stacked on top. The bottom leg can be bent for stability. Lift top leg up towards ceiling. Make sure the thigh is in line with the body. The tendency is to allow the leg to drift forward.

Bridges - Lay on your back with your knees bent. Flatten your back by tilting pelvis up. Lift the hips off the ground.

Tri-Plane Strengthening

Tri-planar Lunges with Arm Driver

Using lunges are the best way to strengthen the gluteals. Reaching our arms in different directions can isolate certain muscles. This sequence will help increase gluteal strength. Lunge forward while reaching your hands forward. Next lunge forward while reaching the arms sideways away from the front leg.  Lastly turn your arms towards the right leg. 

Lunge with reach towards foot 

Working the hamstring eccentrically is the best way to simulate it's function while running. Step back with one leg and squat back while keeping the front leg straight.

Treating the Hamstring

Hamstring Stretch 

The first couple days of the onset of hamstring pain, the focus is to decrease inflammation. Apply ice for 15 minutes 2-3 times a day to decrease inflammation and take a couple of days off from running.  After 3-5 days use a heat pack to help increase blood flow to the area. Gentle stretching of the hamstring can start.

Lacrosse Ball Massage

Using a lacrosse ball to massage the hamstrings will help restore mobility of the soft tissue. Providing compression and relaxation to the hamstring will allow improve fluid dynamics of the soft tissue allowing the muscle fibers to glide more efficiently. 

A hamstring strain can take up to several months to resolve. However, taking time off from running and performing the proper exercises can accelerate recovery. Be patient!

Stay tuned for the next post!

It's Plantar Fasciitis!

You get out of bed one morning and your foot hits the ground. "OUCH!" What's causing this pain? You walk around getting ready for work and the pain seems to be disappearing. "Phew", you have to go for your 10 miler after work. The next day the same thing happens. Eventually, you feel the pain every time you stand. AND even when you are running! Finally, after a week you decided to do a Google search - plantar faciitis.
You roll, you ice, you wear a sock thing at night, but nothing changes.

What is plantar fasciitis?

Plantar Fascitis is the inflammation of the fascia (connective tissue) on the bottom of your foot. It spans from the heel to the toes. At the beginning stages,  the tissue gets stretched with weight bearing however over time, with each step the tissue gets more inflamed.

What are the risk factors plantar fasciitis?

A systematic review of journal articles on plantar fasciitis was performed in 2008 and revised in 2014. The big risk factors for getting plantar fasciitis are being a runner, a person who stands for work and limited ankle dorsiflexion. We all all know you're not going to stop running or working, so let's focus on what we can change.

Limited ankle dorsiflexion
This means the ankle joint has a limited mobility to flex the foot towards the body. Ankle dorsiflexion is required to have proper mechanics while running. When ankle dorsiflexion is limited, the sequence of movement of the foot is changed, putting more stress onto the plantar fascia.
Tightness of the calf muscles ( gastrocnemius and soleus) can also contribute to limited dorsiflexion. Connective tissue from the calf spans down into the heel and blends into the plantar fascia. Limited mobility of the calf muscles can contribute to increase stress of the plantar fascia.

Treatment

Ball Roll on Calf 

Most people with plantar fasciitis know to roll the bottom of their foot on a tennis ball or golf ball. However, there is a myofascial pain referral zone at the base of the calf where the muscle becomes tendon. This zone is slightly to the outside of the center of the muscle tendon junction. In a long sit position, use a roller or a lacrosse ball to roll out the area for 2-5 minutes depending on tolerance.

'X' marks the spot

Ankle Mobilization

Lace Lock method

When you can't have a therapist to follow you around, you have to improvise. Using a running shoe is the perfect substitute to assist in self mobilizations. Tie shoes using the lace lock method. Thread the lace on the same side through the last hole. Pull the opposite lace through the hoop. Tie the shoes really tight across the front of the ankle. In standing, put one foot in front and rock forward allowing the knee to bend to mobilize the ankle. Angle the knee to go over the pinky toe. Then angle the one to go over the big toe.
5 times each direction
*** Only tie the shoes laces very tight when mobilizing!!

Calf Stretch with Tri- Plane Tweak

This is a tri-planar tweak on the standard calf stretch. Stand with one foot forward and use knee to drive the motion forward. Then twist left and right. Lastly sway your hips side to side.
Perform 10-15 repetitions

Out of the box

In normal mechanics, the hip and thoracic spine absorbs lateral and rotation motion respectively as the arms swing back and forth. However, if those regions are stiff, the motion is transferred to the ankle. The ankle is forced into an over supinated position. In the supinated position the foot is unable to absorb shock putting more stress on the plantar fascia. Improving mobility in the hips and thoracic spine will take the stress off the plantar fascia.
Please refer to earlier post on stretching the hip and thoracic spine.

http://3drunner.blogspot.com/2015/03/spine-stiffness.html
http://3drunner.blogspot.com/2014/06/ankle-sprain-how-thoracic-spine-and-hip.html

By addressing limitations locally in the ankle and globally at the hip and thoracic spine, you achieve a more comprehensive treatment plan.

3D Exercises - Rotational Opposite Arm Driver

In our 3 stances, squat, lunge and single leg, we can use our arms to create different movements. This changes the exercise by putting an emphasis on varying muscles.

The focus of this series is to use our arms to drive rotation at shoulder level.  These exercises develop the muscles of the upper back and rotator cuff. Not only are these exercises great for all athletes, they specifically strengthen the muscles responsible for controlling the follow-through phase of throwing and hitting.

3D EXERCISES

Discus Squat 

Hold a weight in one hand. As you squat, bring the arm out to the side with the thumb up. As you stand, swing arm across the body using the other hand to stop the weight. Repeat then switch sides.

Lunge Matrix 

Holding a dumb bell in each hand lunge forward and take opposite arm across the body toward the knee. Return to the start position. Repeat on the other side.
Side lunge as you bring the opposite arm towards the knee. Return to start position and repeat on the other side. Rotation lunge as you bring the opposite arm toward bent knee. Repeat to start position and repeat on the other side.

Single Leg Balance ( tri-plane arm drive) 

Standing on one leg with weights in each hand, bring hands to shoulders. Reach arms up in front, back to shoulder. Reach behind your head, back to shoulder. Reach to overhead to the side, back to shoulder. Repeat on the side. Turn arms to one side, back to shoulder. Repeat to the other side.

For each exercise perform 10 repetitions and up to 3 sets

CORE EXERCISE

Bird Dog (aka quadruped arms and legs) 

Kneel in hands and knee position. While keeping a flat back, straighten opposite arm and leg. Keep the pelvis level as you hold the exercise. Maintain a flat back and level pelvis as you bring your arm and leg back into start position.

Hold for 10 seconds perform 10 times.

Basics of 3D Exercises

The inspiration for this 3D workout series comes from a patient and her physician. This patient was seeing me regularly for months with the goal of building general strength to ease chronic pain. Nearing the end of her therapy, we thought what can be better then videos to remind her of her exercise program? Before coming to physical therapy she felt sore and tired after simple daily tasks.  Now she is able to participate in gym classes and outdoor activities without increase in her symptoms. 

What is a tri-planar exercise program?
Our body moves through the 3 planes of motion - forward ( sagittal), sideways ( frontal) and rotation ( transverse). We also have 3 standing positions - squat stance, lunge stance and single leg stance. Implementing tri-planar motions in these stances will recruit more muscle fibers developing a more complete strength and mobility program.

These exercises are not only great for athletes but also the every day person to provide the most comprehensive strength and mobility program.

Exercises

1) Squats with triplane foot position

2) Triplane lunges

3) Balance with triplane foot reach

I recommend 5 to 10 repetitions of each exercise.

These exercises can be scaled up or down for any level of fitness or age. Perform a larger range of motion to make the exercise harder. Move in a small range to make the exercise easier. Hold weights to increase strength.

I included 2 traditional exercises as those are also important for a well rounded strength program. 

1) Side lying leg lift

2) Bridge 

I recommend 5 to 10 repetitions with a 10 second hold for each exercise.

For a variations on a tri-plane workout routine, follow me for the next 3D exercise.

Core Strength - Power of Proximal Acceleration

We all know core strength is important for running. It helps hold our body upright, regulates breathing and gives us explosive power. Planks and crunches are typically part of a runners strength routine. However, planks are a static exercise and crunches accentuates a flexed position. Do those exercises work the muscles specific to running? What other exercises load the core which most resembles running?

A closer look at the running form shows our pelvis rotates with each stride. While one leg is forward the other leg is behind. Meanwhile, our arms are moving the opposite direction of our legs. Our   abdominal muscles are being stretched with each stride.
Opposing motion between the arms and legs helps to stretch the connective tissue of the anterior core in a rotatory fashion. This is important because rotation provides the strongest load (think of the glide versus spin technique in field events).  The stretch of our anterior trunk loads our core, similar to the recoil of a slinky, which helps to accelerate our leg forward.

Note the stretch that occurs across our abdominals

A key component of spinal mobility is rotation occurs in the thoracic spine and the pelvis. The lumbar spine has very little to no rotational mobility. In order to effectively load the core, it is important to stretch the upper back and hips appropriately. Here are 2 links to upper back and hip stretches.
http://3drunner.blogspot.com/2015/03/spine-stiffness.html
http://3drunner.blogspot.com/2014/06/ankle-sprain-how-thoracic-spine-and-hip.html

EXERCISES
Planks with Pelvic Driver
Assume the normal plank position. Keep your arms straight rotate the pelvis towards the floor. To help load the frontal plane, move the pelvis side to side.

Resisted Pelvic Driver
Equipment needed - A belt and resistant band
This exercise requires a bit of creativity. Tie a resistant band to a belt. Then wear the belt. Attach the band with the belt around a post or fence. Place one leg forward with the band from behind. Adjust the belt so the band is coming from behind towards the side of the leg that is forward. Shift weight forward as you push the pelvis forward.

Stride Stance Ball Catches
Equipment needed - Ball or medicine ball
Stand with one foot in front. Use a ball and throw to a partner from the side. This exercise provides a stretch to the abdominals in a rotatory motion. A second throwing position can be throwing it overhead which provides a load in a different plane of motion. Try catching with one hand.
Throw and catch with the arm which is same side front leg.

Recommended 12 - 15 times of each exercise up to 3 sets

TRANSITION TO RUN
During strides or warm up, implement a pelvic drive while running. Visualize a rope in the front of your pelvis pulling your body forward with each step.

These exercises paired with a traditional strength routine will attack the core muscles in all dimensions.  Proximal acceleration is vital for the mechanics of numerous athletes such as golfers, throwers and even swimmers to produce force. So why not runners?!