On Sunday, the 76ers released an update on guard Markelle Fultz’s right shoulder injury. They stated that after a visit with Dr. Ben Kibler in Lexington, KY, it was confirmed that Fultz did not have any structural impairment but he would be out indefinitely with soreness and scapular muscle imbalance.
Scapular muscle imbalance, also known as scapular dyskinesis, is an asymmetry of the shoulder blades characterized by an abnormal movement pattern of the overused side. This is often seen in baseball pitchers and tennis players due to the repetitive overuse of the throwing or hitting arm. Although typically in basketball, shoulder injuries occur when the arm is blocked during a shot or hits the rim after a dunk.
Media reports stated that Fultz had a cortisone injection earlier in October. These are typically used to reduce inflammation and pain but with Fultz’s continued symptoms, we can assume that the injection didn’t have significant benefit. This supports the scapular dyskinesis diagnosis as injections generally don’t offer relief for this problem.
Return to play can be very difficult to predict, especially with the diagnosis of scapular dyskinesis. Some athletes respond to rehab in a few weeks whereas others require months of work. Rehab focuses on improving scapular stability and movement patters, but also addressing any kinetic chain dysfunctions that may be contributing to the shoulder issue. Sometimes another injury, such as Fultz’s previous ankle sprain, can cause certain muscle groups to overcompensate, resulting in dysfunction elsewhere in the body, like Fultz’s shoulder injury. Think of it as your car’s alignment being off.
The good news in all of this is that the injury appears to be non-surgical. The Sixers will be on top of Fultz’s rehab and will have him back on the court once the scapular dyskinesis and any other movement dysfunctions are addressed. Correcting these dysfunctions will allow Fultz to return to his previous level of performance while minimizing his risk of re-injury.
Philly.com Sports Doc
Posted: Monday, August 25, 2014, 5:30 AM
Achilles tendon rupture, the fear of every middle age man on the basketball and tennis court. Now that I am in my 40s I fall into that category. And unfortunately for me, I recently felt the dreaded “pop” while playing doubles tennis. At first, I thought the ball came from the next court and hit me on the back of the leg. Then I came to my senses and realized I had torn my Achilles. The people who stopped playing on the courts next to us must have thought I was in a lot of pain the way I was yelling while lying on the baseline. In truth, I didn’t really have much pain. I was yelling because I knew what was to come: Surgery, weeks of non-weight bearing and partial weight bearing, and the huge inconvenience this would be for work and life in general. My father-in-law, who was my partner in this ill-fated doubles match pointed out, “Hey, at least you won the point.” Not much consolation. My summer fun was over.
So what happened? How did I tear my Achilles? As I am known to do, I reviewed all the research hoping to figure out the cause. Maybe I was fatigued which may have contributed to the injury. More likely I’m predisposed as I tore the other side over a decade ago playing soccer. Neither time did I have any Achilles pain leading up to the injury.
There are some studies showing possible relationships with risk factors and Achilles ruptures. In the June 2014 edition of the journal Sports Medicine, Claessen et al categorized these potential risk factors into two categories: non-modifiable and modifiable. Non-modifiable factors include age, race, sex, medical issues, pre-existing musculoskeletal disease/tendon changes, ankle/foot alignment and genetic factors. Modifiable risk factors include obesity, sports activity, medication and smoking. From a specific sport perspective, Achilles tendon ruptures are found more frequently in athletes who participate in sports involving explosive acceleration such as basketball, tennis, baseball, and softball. Of the above factors, medications, especially Quinolones (specific antibiotics) and Corticosteroids, have shown to have the greatest risk for Achilles rupture.
There are multiple potential risk factors for Achilles tendon ruptures but none have been proven to be key factors. One risk factor that I definitely have is O blood type. A study from 1989 in the American Journal of Sports Medicine stated “In cases of multiple ruptures and re-ruptures, the frequency of blood group O was 71%.” However, the O blood type correlation is still up for debate.
Although the mechanism is still up for debate, what you’ll see if you slow down a video of the injury is the player taking a back step to push off and the knee forcibly extending at the same time. The combined force of foot plantar flexion and knee extension is likely too much stress for the tendon to handle. Watch the video of David Beckham tearing his Achilles for the prototypical mechanism of injury.
Strauss et al reported the following statistics in 2007 in the International Journal of the Care of the Injured. The incidence of Achilles tendon rupture is approximately 18 per 100,000 people. Ruptures typically occur in males between 30 and 50 years old and account for approximately 40% of all operative tendon repairs. Approximately 75-80% of cases can be attributed to participation in athletic activities, including ball and racquet sports.
Surgery or not?
There is ongoing debate as to what is the best course of treatment: Surgical repair or non-operative treatment. Surgery involves bringing the two ends of the tear together and suturing them in place while the tendon heals. Non-surgical treatment involves casting the foot in plantarflexion (toes pointed down) and recasting weekly with gradual progression into dorsiflexion (toes up). Non-operative care has demonstrated a re-rupture rate from 10-30% where surgical re-rupture rates are around 3-4%. Surgical complications have been reported to occur in 7-42% of all cases and include difficulty with wound healing, skin necrosis, infection, and sensory loss. For me, it wasn’t a question. I elected to have surgery as I want the best chance at a full recovery.
This is the most frustrating part for me. For surgeries such as an ACL reconstruction, the harder you work the quicker you recover. It’s just the opposite with an Achilles repair. The tendon needs time to heel so for the first 2-4 weeks you can’t put any weight on the foot. Then, over the next 3-4 weeks you gradually increase weight bearing in a boot with a heel lift to take pressure off the tendon. Strengthening is started late in the rehab process which means it takes a long time to get your full strength back, and many people never regain full strength after this injury. I never regained full strength after my first surgery and definitely lost a step with sports (although that could just be me getting older but I’m going with the injury). It takes approximately 4-6 months to start back to running and to initiate sports activities with complete recovery taking close to a year. As you can guess, I’m in for a long and slow recovery following Achilles surgery.
Is there any way to prevent an Achilles injury? There isn’t much research on this topic. In younger, high level athletes, there probably isn’t a way to prevent it other than not playing as intensely. For someone older like me, there is the possibility that by improving flexibility and fitness you may be able to reduce the risk of injury, but it is still probably just bad luck.
For me, I’ll do my rehab and get back on the tennis court and the soccer field in the spring. Unless my surgeon and my wife force me to take up a sport with a lower risk of traumatic injuries, but with my luck, I’ll probably fall off the elliptical and break an arm.
Philly.com Sports Doc
Justin Shaginaw, MPT, ATC, Aria 3B Orthopaedic Institute, Athletic Trainer - US Soccer Federation
Robert Senior, Sports Doc blog Editor
POSTED: MONDAY, JANUARY 13, 2014, 6:00 AM
A 2008 study by Borowski et al in the American Journal of Sports Medicine looked at high school basketball injury rates using the online reporting from 100 high schools for the 2005-06 and 2006-07 seasons. They found that high school basketball players sustained 1.94 injuries per 1,000 athlete exposures (AE).
Injuries were more common in games versus practices (3.27 game injuries vs. 1.40 practice injuries).
Most Common Injuries (percentages are the respective portion of all injuries observed):
Girls sustained more injuries (2.08 per 1,000 AE) versus boys (1.83 per 1,000 AE). Girls accounted for more concussions and knee injuries, while boys sustained more fractures and contusions.
For college basketball, two articles published in the Journal of Athletic Training in 2007 (Agel et al and Dick et al) looked at the NCAA injury data from the 1988-89 through 2003-04 seasons. Lower extremity injuries accounted for more than half of all game and practice injuries with rates two times higher in games than practice.
Male injuries were 9.9 per 1000 AE during games and 4.3 per 1,000 AE during practice vs. 6.75 and 2.84 for females. Regarding ACL injuries in college basketball, women showed a 3.5 times greater incidence than men.
Common Game Injuries:
Philly.com Sports Doc
Justin Shaginaw, MPT, ATC, Aria 3B Orthopaedic Institute, Athletic Trainer - US Soccer Federation
Robert Senior, Sports Doc blog Editor
Posted: Monday, January 13, 2014, 6:00 AM
The winter sports season is in full swing. In gyms everywhere the squeak of basketball shoes on the court can be heard. Along with the layups and 3 pointers, there are common injuries that occur. Let’s talk about some of these common basketball injuries and the appropriate treatment.
This is the most common injury in basketball, accounting for 24.6 percent of women’s game injuries and 26.2 percent for men. It occurs when the foot rolls inward spraining the ligaments on the outside of the ankle. Swelling and bruising often occur with the severity of the injury dictating the athlete’s ability to return to play.
Mild ankle sprains can return fairly quickly, sometimes even in the same game with taping or a brace. More serve injuries can take weeks to months to recover. Immediate treatment involves immobilization and ice followed by range of motion, strengthening, and balance/proprioceptive exercises. For athletes that cannot bear weight on their foot, they should be put on crutches and see a physician to rule out a fracture as well as assess the extent of the injury. For prevention, taping and bracing has been shown to reduce the rate of ankle injuries in sports.
Stress injuries (shin splints, stress fracture, etc) are another common basketball injury, usually seen during preseason as athletes transition from softer outdoor fields in fall sports to the hard indoor courts. Initially, symptoms are only with activity. As the problem worsens, pain can occur with walking and even at rest. If not addressed early, it can lead to a stress fracture requiring the patient to stop sports for a prolonged period of time.
The common locations of these injuries are the tibia, medial malleolus, fifth metatarsal, and navicular. Initial treatment involves decreasing impact activities until symptoms resolve and assessing the athlete’s feet for appropriate shoes and possibly supportive inserts. It’s also a good idea to progress practice intensity gradually to allow players to acclimate to the new playing surface. Players that do not respond to conservative measures should be seen by a sports medicine physician for further evaluation.
Knee injuries are the second most common injury in basketball, with ACL injuries being more common in female players. Both meniscal tears and ACL injuries are caused by deceleration and pivoting on a planted foot. The common signs of an internal knee injury include swelling and a feeling of a “pop” or “catching and locking.” Immediate treatment should include ice and crutches if the athlete cannot walk normally followed by a referral to a sports medicine doctor to diagnose the injury.
Research has shown that ACL prevention programs have been effective in reducing the incidence of injury. Some well-known programs are the PEP program (http://smsmf.org/smsf-programs/pep-program), Sportsmetrics (http://sportsmetrics.org/), and the FIFA 11+ program (http://f-marc.com/11plus/home/) . Although some of these are sports specific, they can be easily modified for basketball.
Commonly known as patellar tendonitis or jumper’s knee, this injury presents as pain and tenderness of the patellar tendon. The mechanism of injury is believed to be due to repetitive strain to the tendon from jumping, cutting, and deceleration activities involved in basketball. Treatment includes limiting activity until symptoms improve, as well as ice, quad stretching, eccentric quadriceps exercises, and soft tissue treatments. Patellar tendon straps can also be beneficial. In more chronic cases, medications, injection therapies, and surgery are other options.
In younger patients whose growth plates are not closed, usually under 15, Osgood-Schlatter syndrome is more common. This is an injury to the attachment of the patellar tendon to the tibia. The tendon actually pulls away from the bone causing a boney protuberance that can become painful and tender. The treatment for Osgood-Schlatter syndrome is rest and ice as it is almost always self-limiting.
Finger injuries are fairly common in basketball and occur when players “jam” their fingers on the ball. The injuries are usually simple sprains that can be treated symptomatically with ice and buddy taping. Occasionally these injuries can be more serious such a fracture and tendon rupture. If the player’s finger looks deformed or if they are unable to move it, they should be evaluated by a sports medicine physician to accurately diagnose the injury.
Shoulder injuries are relatively rare in basketball with the most common being dislocations and labral tears. These injuries usually occur when a player is blocked during a shot forcing the arm backwards. For a dislocation, urgent treatment should be sought from the team’s athletic trainer and a physician if necessary. Labral tears should be considered for players with chronic shoulder pain with overhead activities such as shooting, and an appointment with a sports medicine physician should be schedule to accurately diagnose the injury.
The other upper extremity injury seen in basketball is a fracture. These usually occur from falling on an outstretched arm. As with dislocations, the player should be evaluated by the team’s athletic trainer and referred to a physician for urgent care.
As you can see, lower extremity injuries account for the majority of basketball injuries. Many of these are minor and can be managed conservatively with a quick return to sports. With more serious injuries such as ligament/tendon ruptures and fractures, urgent care by a sports medicine physician is advised. The above treatment recommendations are just a guideline and any injury should be evaluated by your team’s athletic trainer or a sports medicine physician to accurately diagnose the injury and provide appropriate care.
Philly.com Sports Doc
POSTED: Tuesday, May 14, 2013, 6:00 AM
Justin Shaginaw MPT, ATC
Baltimore Ravens linebacker Ray Lewis speaks during an NFL Super Bowl XLVII football news conference on Wednesday, Jan. 30, 2013, in New Orleans. Lewis denied a report linking him to a company that purports to make performance-enhancers. The Ravens face the San Francisco 49ers in the Super Bowl on Sunday. (AP Photo/Patrick Semansky)
We all marvel in the extraordinary recovery of athletes following injury.
Ray Lewis returned to play less than 3 months following tricep repair surgery. Adrian Peterson nearly broke the single season NFL rushing record less than a year after ACL reconstruction. Kyle Lowry played point guard for Villanova less than 4 months following his own ACL reconstruction.
How is this possible? Do these gifted athletes just work harder during rehab? Do their bodies heal faster than the rest of us?
Or could it be the fear of most sports fans in the 21st century? Could these be using performance enhancing agents to speed up their recovery? Let’s discuss the factors and controversies that contribute to a speedy recovery in more detail.
Ray Lewis and his tricep. Ray injured his tricep on October 14th, 2012. He had surgery three days later and played in his first game on January 6th, 2013. That’s less than 3 months after injury—an unheard of turnaround time. There are many factors contributing to his extraordinary recovery.
First and foremost, Ray took a great risk at returning that soon. His chance of re-tear was very high as the surgical repair takes at least 3-4 months to be even close to being strong enough to withstand the forces involved in football. I’m sure that his rehab was rigorous in regaining the strength needed to block and tackle in the NFL. One would think his age would be a detriment to a speedy recovery, but it doesn’t seem to have been a factor.
The big question: did the deer antler spray help? There is little scientific evidence that IGF-1 (insulin-like growth factor) has any performance enhancing or injury recovery benefit. And IGF-1 is not affected when delivered through a spray. In Ray Lewis’ case, he probably beat the odds of re-injury by playing as early as he did vs. having an amazing recovery aided by performance enhancing supplements.
Adrian Peterson. He is still the talk of the town when it comes to returning from ACL surgery. In his first season back, he nearly sets the NFL rushing record.
Adrian’s first game back was 9 months after his ACL surgery. Although his level of play was astonishing— many players never quite get back to their pre-injury level—the time frame that he returned to play in is within the normal range of 9-12 months. Was there anything more than hard work and determination that contributed to his recovery? A good surgeon and rehab staff helps. But probably more than anything is what makes him such an amazing athlete is the same thing that gave him such a remarkable recovery… great DNA. There are no rumors or whispers about deer spray or any other performance enhancing substances with Peterson, just old fashioned hard work.
When we look for an unbelievably quick recovery from ACL rehabilitation, we don’t need to look any further than the Main Line and former Villanova basketball star Kyle Lowry. Kyle tore his ACL the summer before his freshman year at Villanova. He had surgery on September 17th and played in his first collegiate game on December 31st. That’s just 3 ½ months after ACL reconstruction! Not only did he return to play so quickly, but he had a great season and was named to the Big East All-Rookie team as well as being tabbed Philadelphia Big Five Rookie of the Year. Kyle has gone on to have a successful NBA career without any inkling of a previous ACL injury.
In Lowry’s case, his recovery can be based almost exclusively on his genetics as even performance enhancing substances couldn’t have produced such as a rapid return to basketball.
Genetics, hard work, or performance enhancement? How do these athletes return so quickly? Even though in Ray Lewis’ case there are questions regarding hormone usage, all the deer antler spray in the world won’t get players back on the court and field as quickly as these players returned. These players get back to sports on the accelerated track due to their genetic makeup, excellent surgeons and rehab staff, hard work, and willingness to play in a time frame that puts them at higher risk for re-injury.
I'm sure everyone is curious of this experimental treatment that pro athletes are flying to Germany to have done. It is a Similar treatment to PRP (platelet rich plasma) that is done here in the states. PRP is used to stimulate healing of tissue where Bynum's therapy, Regenokine or Orthokine treatment, is in theory blocking inflammation through the infanti-inflammatory cytokine IL-1 receptor antagonist (IL-1Ra). The hope is that it can alter the inflammatory response and limit cartilage erosion present in osteoarthritis. To date, there only a few studies that support this claim, and no longer term trials supporting its use. Insurance does not pay for either PRP or Regenokine/Orthokine treatments which cost hundreds (PRP) to thousands of dollars (Regenokine). There are other treatment options that are covered by insurance and have research to support their use, such as viscosupplementation. It's important to discuss your options with an orthopedic or sports medicine specialist as newer isn't always better and potential downsides do exist for some treatments, the least of which is the money you've spent for a treatment that didn't work.