11/3/17
Philly.com
Health

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: 11/16/15

Add another player to the Eagles “out for the season” list. Jordan Hicks ruptured his left pectoralis major in the final minutes of this past Sunday’s game against Dallas. The injury occurred as Hicks reached his left arm out to tackle Cowboys receiver Cole Beasley. These injuries are usually the result of an eccentric overload on an outstretched arm. The injury occurs as the player is trying to move the arm forward (ie tackle) as the arm is forcefully pushed backwards (ie player running through the tackle). This sudden eccentric load causes the tendon to either rupture near its attachment on the humerus or to pull off of the humerus itself.

The pectoralis major muscle originates on the sternum and ribs and inserts on the proximal humerus at the bicipital grove. The main function of the pectoralis major is to elevate and internally rotate the arm and is the key muscle when performing activities that require power in these planes of motion. Most athletes are unable to return sports that require pushing and tackling, such as football and wrestling, without surgical repair.

A 2014 study by Tarity et al looked at pectoralis major ruptures in the NFL from 200-2010. They found 10 complete ruptures during this period. 5 of 10 were in defensive players and 9 of 10 occurred during games. All 10 occurred on the football field with none occurring in the weight room. The authors were able to obtain the mechanism of injury for 6 of 10, with all of the reported mechanisms involving either tackling or blocking. The incidence of pectoralis major ruptures during the 11-year study was 0.004 showing that it is a rare injury in professional football.  All 10 athletes returned to play in the NFL but the study was unable to obtain data to further investigate the long term effect the injury may or may not have had on their careers.  Previous studies have shown a much higher success rate with surgical repair versus non-operative treatment with 70% of athletes having excellent results.

The results of the NFL study are very promising for return to play after pectoralis major injuries. This is great news for Jordan Hicks. I’m sure we’ll see him back on the practice field sometime this summer and in the starting lineup come August.

Philly.com Sports Doc
POSTED: TUESDAY, NOVEMBER 25, 2014

If you’re a power lifter or body builder, please stop reading. If you’re a high level athlete, please read with an open mind. Now for the rest of us… My patients ask me all of the time, “What can I do in the gym?” For me, it’s not what you can and can’t do but what you should or shouldn't do.

Why do I say that? Here are just a few of the injuries we've seen in the office from doing the wrong things in the gym: a middle aged women who tore her ACL doing jumping jacks onto a plyometric box, a 60 year old who tore his meniscus when he was forced into deep knee flexion during yoga, and a broken tibia from the bar hitting her leg during Olympic lifting. It’s not that some people can’t do these things; it’s just that most of us shouldn't be doing them.

Here are my top 5 things you should avoid at the gym.

1. Deep squats

I always have this debate with strength and conditioning coaches. Why do they have their athletes squat past 90 with resistance?  It’s not functional except for maybe wrestlers and football lineman, and even with them, is it worth the risk of injury? For the rest of us who are just trying to stay in shape it is a recipe for knee pain and meniscus tears. Deep squats put significant strain on the knee ligaments, significant pressure on your patellofemoral joint (knee cap), and it puts your meniscus at significant risk for tearing.

Let’s talk about the meniscus tear more specifically. As we squat down, the knee not only flexes but the femur glides posteriorly on the tibia. From about 90 degrees and beyond, we are putting almost all of the pressure on the posterior horn of the meniscus. Now just add a little rotation and pop, there goes your meniscus. And we know that our menisci start to degenerate over time (starting at about 35-40) placing us at even greater risk for a meniscus tear. Do the theoretical benefits of deep squatting out weigh the risks, absolutely not!  So let’s please stop at 90 degrees.

2. Dead lifts

This is another exercise where I also debate people on the risk/benefit of the exercise. Yes, it’s a great exercise to strengthen your hip extensors (glutes and hamstrings) but it’s an even better way to injure your back. Repetitive flexion activities have been shown to be a significant factor in back injuries, specifically bulging and herniated disks. Even if you perform the exercise with perfect mechanics, which none of us do all the time, you’re still setting yourself up for a problem. Just like the meniscus in the knee, the discs in the spine start to degenerate with age. Combine this with an exercise that puts significant strain on the posterior annulus of the disc and you’re in for a lifetime of intermittent back pain. Instead of dead lifts, let’s focus on exercises that will still strengthen your hip extensors with less risk of injury. Lunges, step ups, bridging, and squats above 90 can all accomplish this while limiting the risk of low back injury.

3. Overhead presses

Overhead military press, dumbbell shoulder press, etc., all put your rotator cuff at risk for injury. Every time we lift our arms over head we have the potential for some impingement of our rotator cuff under our acromion. Now add weight and we’re just tempting fate. There is also a common theme with all these problematic exercises I’m writing about: our tissue starts to wear down and degenerate with age.

This is once again true for the rotator cuff. So why do an exercise to strengthen our shoulders that puts our rotator cuff at significant risk for injury? If you want to strengthen your deltoid you just need to do some pushing and pulling exercises. Overhead exercises aren't functional and the risk of injury just isn't worth it. Don’t try to “isolate” your shoulders and instead strengthen them functionally with pushing and pulling exercises such as push-ups and incline pull-ups on the smith press or TRX.

4. Bench press to your chest

I don’t like the bench press because it’s not a functional exercise, but that’s another discussion. The risk with bench press is that when your elbows break the plane of your chest, you’re putting significant strain on the stabilizing structures of the shoulder, specifically the labrum and capsule. Now add heavy weight and it’s a labral tear waiting to happen. And like everything else, the labrum degenerates over time. Clicking in your shoulder? It’s probably a labral tear. If you have to bench, keep the weight reasonable and don’t let your elbows break the plane of your chest. Better yet, do a standing cable column press as it is a much more functional position; just don’t go too deep and your shoulders will thank you.

5. Anything with heavy weights

I’ll be the first to admit that I loved lifting heavy weights when I wrestled in college. It was always a competition of who could bench and squat more.  Looking back, bench pressing did nothing for me as a wrestler as I should have been doing more pulling exercises. After two shoulder surgeries, a hip labral tear which has likely progressed to arthritis (no MRI as I don’t want to know), focal arthritis in my knee as well numerous other chronic injuries, my joints wish I had focused on functional training and not weight lifting.

There is starting to be a paradigm shift in the strength and conditioning world. People are turning away from weight lifting and focusing on functional training and injury prevention. Stanford University’s director of football sports performance Shannon Turley is on the forefront of this movement. Instead of having freshman players hit the weight room when they get to school, they focus on regaining flexibility, improving core stability, and relearning correct movement patterns. He has had to write letters to NFL scouts about his program and why his players don’t have a record setting combine bench press but excel on the field and are injury free.

EXOS, formerly Athlete’s Performance, is the provider for strength and conditioning for the Men’s U.S. National Soccer team. Their approach to sports performance is to fix an athlete’s problems/weaknesses.  There is little return in trying to improve quad strength in soccer players who already have super strong quads. Instead, you’ll see more gains by focusing on correcting their weaknesses such as limited hip mobility and glute med weakness. Even though we’re not professional athletes, let’s take a page out of their training programs and try to fix our deficits such as flexibility, core strength, and movement patterns and leave the heavy weights on the rack.

As I’m writing this, I’m envisioning the comments that I’ll be getting. But as I always tell my patients, “Is it better to look good or to feel good?” Let’s move away from working out the way we always have and start thinking about our long term health, as many of the exercises we do are counterproductive to our overall goal of living a healthy, happy, and pain free life.

Philly.com Sports Doc
Posted: Monday, May 12, 2014, 9:37 AM

Unlike other collegiate sports, there have been no studies published on track and field injuries using the NCAA injury surveillance system. Therefore, we will look at the few studies that analyze injury prevalence in track and field.

A 2005 article published by Zemper in the journal Medicine and Sports Science suggested that 70-80 percent of all track and field injuries are the result of running events. 75 percent of all injuries are to the lower extremity and the overwhelming majority of injuries occur during practice. A 2011 article by Jacobsson et al in the American Journal of Sports Medicine showed a strong dominance of overuse-related conditions such as tendinopathies and stress fractures in track and field athletes.

These overuse injuries account from 60-90 percent of injuries in various published papers. An article by Alonso et al in 2012’s British Journal of Sports Medicine looked at track and field injuries during the period of the Daegu 2011 IAAF World Championships. Sprint events accounted for 27.7% of all injuries followed by long distance at 17.3%, and jump events at 14.1%.

Let’s look at the some of the different events and the injuries that go along with them.

Sprints and Relays

The most common injury in sprint events is muscle strain, specifically hamstring strain. The mechanism of hamstring injuries is still being debated.  These include neuromuscular inhibition, eccentric overload, over-striding, and decreased muscular endurance to name a few. To simplify hamstring injuries, these can be broken down into acute and chronic injuries.

Acute hamstring injuries are the result of a distinct injury such as a sprinter pulling out of a race. These usually involved a tear of the hamstring muscle. These can be minor or more serve where bruising, swelling, and a defect are noted. Hamstring injuries can result in significant time away from training and competition, and early return frequently results in re-injury. Treatment involves management of pain in the acute phase of injury followed by rehabilitation to regain ROM, strength, and eccentric control prior to initiating a running program.

Chronic hamstring pain can be due to a variety of underlying causes. These include incomplete rehabilitation from a previous hamstring injury, overuse injury, and referred pain from other areas such as the lumbar spine. A thorough evaluation from an athletic trainer or physical therapist is needed to determine the underlying cause and to develop an appropriate rehab program.

Middle Distance

Middle distance injuries are a combination of sprint injuries and distance injuries. The event distance and the training methods will dictate which type of injury is more likely to occur. As with any injury, the athlete should be evaluated by the team’s athletic trainer in order to develop an appropriate rehab program.

Long distance

Unlike sprints, long distance injuries are primarily overuse and repetitive stress injuries. These include sprains, strains, and tendinopathies as well as stress fractures, shin splints, and exertional compartment syndrome. Treatment should not only focus on resolving the symptoms but also include a thorough biomechanical evaluation to correct the underlying cause. This should include assessment of footwear, lower extremity alignment, and lower extremity flexibility and strength. This may also include modification of the athletes training program with decreases in frequency, intensity, and/or duration.

Hurdles and Steeple Chase

Hurdles and steeple chase have injuries similar to the above running events but also include more traumatic injuries. With hurdles, injuries can occur from hitting the hurdle or from catching a hurdle resulting in a fall or awkward landing. Steeple chase injuries can occur from stepping onto the obstacle, not clearing the obstacle, or landing from/over the obstacle.

Traumatic injuries can include contusions, ligament sprains, knee internal derangements (meniscus tear, ACL injury) and fractures. These injuries should be evaluated by the team’s athletic trainer and treated accordingly or referred to a sports medicine physician for more serious injuries. These more serious injuries usually require significant time away from training and competition.

Long jump and triple jump

Long jump and triple jump are horizontal jumping events with specific associated injuries. These injuries can be broken down into overuse and traumatic. Overuse injures include tendinopathies and repetitive stress injuries as seen in other events and should be treated as noted previously. Traumatic injuries occur either at takeoff or landing and can include fractures, acute muscle tears, dislocations, serious ligament sprains (such as ankle sprains), tendon ruptures, and knee internal derangements. These more serious injuries should be evaluated by your team’s athletic trainer and referred to a sports medicine physician for appropriate care. These more serious injuries usually require significant time away from training and competition.

High Jump and Pole Vault

High jump and pole vault are vertical jumping events with similar injuries to horizontal jumping events. These injuries can also be broken down into overuse and traumatic. Besides the traumatic injuries noted for long and triple jump, pole vault accounts for almost all of the catastrophic injuries (fatal, non-fatal but causing permanent severe functional disability) and serious (no permanent disability, but a severe injury). These more serious injuries should be evaluated by your athletic trainer and referred to a sports medicine physician for appropriate care. These injuries usually require significant time away from training and competition.

Javelin, shot put, hammer, and discus

Throwing events account for the vast majority of upper extremity injuries in track and field. These include injuries to the rotator cuff and shoulder labrum as well as abdominal injuries from the rotational throws, and lower extremity injuries from planting during a throw. One injury specific to the javelin is an ulnar collateral ligament tear (Tommy John injury).

UCL injuries in javelin are due to the throwing motion and the stress incurred at the elbow, similar to baseball. Throwing injuries need to be evaluated by the team’s athletic trainer and either treated conservatively through rest and rehabilitation or referred to a sports medicine physician when more a more serious injury occurs such as an ulnar collateral ligament tear.

Exertional heat illness

Lastly, environmental factors can cause heat related illness in track and field athletes. Athletes, coaches, and medical staff need to be aware of the environmental conditions (heat and humidity) and monitor athletes for any signs or symptoms of heat illness. Heat illness is an urgent and sometimes emergent issue and needs to be address by the event’s medical staff. Signs and symptoms can include finding it hard or impossible to keep playing, loss of coordination, dizziness or fainting, profuse sweating or pale skin, headache, nausea, vomiting or diarrhea, and stomach/intestinal cramps or persistent muscle cramps.

To truly evaluate an athlete for heat related injury, an accurate core body temperature needs to be assessed by a trained medical professional such as an athletic trainer. Cooling measures should be implemented with the best method being ice immersion. For those athletes with a core temperature over 104° and showing signs or symptoms of heat illness, immediate cooling should be implemented and emergency response should be initiated as heat stroke is likely.

The National Athletic Trainers Association has an excellent web page on How to recognize, prevent, & treat exertional heat illness: http://www.nata.org/nr072606

As you can see, not only do we see lower extremity injuries in track and field, we also see upper extremity injuries and environment injuries such as exertional heat illness. Although most of the injuries are minor, there are urgent and emergent injuries in track and field and these are best managed by the team’s athletic trainer and medical staff.