With many neck pain disorders, a common culprit is poor motor control of the deep neck musculature. One of our special tests can be used to teach muscle recruitment of the cervical spine: the Craniocervical Flexion Test. Teaching the patient an upper cervical head nod is crucial to preventing overuse of the superficial neck flexors. Protrusion of the head is seen with superficial muscle use. Once the head nod is mastered, flexion of the lower cervical spine in supine can be utilized (while maintaining head nod). To improve control of the deep neck extensors, use eccentric exercises for the lower cervical spine while maintaining the upper cervical spine in neutral (try performing in quadruped or prone on elbows). Of course, theraband can be used as well to improve motor control for a muscle group. An important consideration is to keep the intensity low, so as to take advantage of the pain-mediating effects. Higher levels of contraction may aggravate the patient's symptoms initially.
When considering cervical muscle strength and endurance, remember to use exercises that are low load for endurance and high load for strength. The choice of focus between endurance and strength can be influenced by the sport of the patient (football - stength, swimming - endurance). With any cervical patient, we must also consider the shoulder and thoracic spine due to their proximity. Poor endurance/strength/motor control of the scapular musculature can lead to poor posturing and influence the positioning of the cervical spine, eventually producing pain. Therefore, it is important to focus part of the treatment on these muscles. Interestingly, this review found some studies that stated there was no difference between having the patient perform 1 set to exhaustion compared to performing 1 or 2 sets of 8-12 reps. Another study found no difference between 1 and 5 sets of repetitions. The American College of Sports Medicine supports the claim that 1 set of an exercise can be performed to exhaustion.
Repositioning Acuity, Oculomotor Control, or Postural Stability
As with any other joint, proprioception and kinesthesia can be impaired with pathology, but is more likely with traumatic pain. One method of treating this involves placing a light on the patient's head. A target is placed on the wall. The therapist passively places the patient's head in a specific position and the patient notes the position. The therapist then moves the patient's head around in various positions (with the eyes closed) and asks the patient to reposition his/her head to the starting position. The patient must rely on the mechanoreceptors to return to the starting position. Check out Table 2 for oculomotor control exercises and Table 3 for postural stability exercises in the review. All the exercises can be progressed by altering the stability of the surface the patient is standing on. It is especially important to adapt the exercises to being sport-specific to train the athlete for the forces their cervical spine will endure, when competing and practicing.
Children participate in sports on a regular basis as a means of activity, whether it be for fun or competition. The more children play any sport, the more likely they are to get injured. There are many factors that lead to injury, beginning with differences in anatomy & physiology compared to adults. Youth pitchers are throwing at a time when the epiphyseal plates are not close in the humerus and clavicle. Additionally, it has been shown that the tendons and ligaments in a child have a significantly greater amount of collagen type III compared to adults, contributing to capsular and ligamentous laxity. The combination of shoulder laxity and non-closed epiphyseal plates predisposes youth pitchers to shoulder injury.
There are many contributing factors that can lead to shoulder injury in youth pitchers. The pitching mechanics have been studied extensively and are broken down into 6 phases. The extreme ranges and torques placed on the shoulder joint during the pitching motion excessively stress the tissues of the shoulder. It is debatable whether alterations in the mechanics of the lower body during a pitch can affect the shoulder joint. For a more in depth look at pitching mechanics, the reader is referred to The Athlete's Shoulder. Injury has been shown to be linked to altered throwing mechanics, fatigue, number of pitches (>75), and number of innings pitched. It is interesting to note that pitch type does not have an effect on injury.
Some early signs of a shoulder injury to a pitcher involve pain with throwing, decreased pitch velocity, and decreased ability to locate pitches. When examining a pitches for injury, there are many items to take into consideration: shoulder motion, flexibility, strength, shoulder laxity, and additional parts of the kinetic chain.
Proximal humeral epiphysiolysis has a common point of maximal tenderness over the lateral aspect of the proximal humerus. Radiographic findings consist of a widening of the proximal epiphysis of the humerus. Patients are advised to rest (one study recommended 6 weeks of no throwing with complete rests, followed by 6 weeks of no throwing during strengthening rehabilitation - totalling 3 months without throwing), be educated on proper pitching mechanics, and a strengthening program focused on the rotator cuff, periscapular muscles, and core musculature. A normal capsular pattern is also addressed during rehab.
Due to the excessive mobility of the throwing shoulder, pitchers are predisposed to rotator cuff injuries, secondary shoulder impingement syndrome, and SLAP lesions. Rotator cuff injuries display pain during the release, deceleration, and follow-through phases of throwing. Patients typically report pain and weakness, especially decreased ROM during abduction with ER or IR. Pitchers may also display decreased velocity and precision. Additionally, these pitchers often show poor scapulohumeral control during pitching motions. When the patient is identified as having a rotator cuff injury, cessation of throwing activities is advised until symptoms disappear. As expected, rehabilitation includes strengthening of the rotator cuff and scapular stabilizer muscles, while addressing scapulohumeral control and ROM. Once the patient's strength and ROM are normal and pain-free, the patient can then commence a throwing program with reeducation of proper pitching mechanics.
Secondary impingement shoulder, caused by weakness in the rotator cuff muscles and ligamentous laxity, displays pain in the anterior or anterolateral aspect of the shoulder, especially during overhead activities. Pain is especially profound during arm cocking and acceleration phases of pitching. These individuals are treated conservatively normally with strengthening the rotator cuff and scapular stabilizers.
Symptoms associated with SLAP lesions include a dull aching sensation within the joint, pain and a catching feeling when throwing, trouble sleeping due to shoulder discomfort, and decreased pitch velocity. The pitcher will usually complain of pain during the cocking phase of the throw. (Remember with labral pathology to utilize the Active Compression test (O'Brien), Biceps Load II test, and the Anterior Slide test). While these tests are useful, imaging can raise positivity in correct identification. However, MRIs should only be used once conservative treatment has failed. In adolescents, conservative treatment and rest is attempted before surgery and includes rest and physical therapy. Patients are limited from return to play until full ROM and strength are achieved without pain.
Some general limitations recommended for injury prevention in adolescent pitchers include: avoiding pitching when arm fatigue or pain is present, refraining from throwing activities at least 3 months a year, not playing catcher and pitcher in the same game, not pitching 3 days in a row, and pitching for >1 team. For specific limits on the number of pitches thrown per game, mandated days of rest based on # of pitches thrown, and pitch limits, check out table 1 in the article.
Pitchers are continuously doing something to prepare for their next game, even during the off season. During the off season, it is essential that the pitcher includes stretching, cryotherapy, and a global kinetic conditioning program in their training. Strength training is obviously included as well, especially due to the findings of weak ER and supraspinatus strength found in many pitchers. Rehab of the pitchers shoulder includes activities in 4 phases:Acute: cryotherapy, iontophoresis, ultrasound, e-stim, flexibility and stretching the posterior shoulder muscles, rotator cuff and scapular stabilization stretngthening, and dynamic stabilization exercises. No throwing.
Intermediate: stretching (especially IR and horizontal adduction of the shoulder), progressive isotonic strengthening and initiation of core lumbopelvic region and lower extremity strengthening.
Advanced Strengthening: previous components are continued, plyometric program, endurance drills, short distance throwing.
Return to Activity: exercises and modalities from prior stages, progressive interval throwing program to transition back to competitive throwing. During this phase a data-interval throwing program is utilized for the transition back to competitive throwing. Check out Table 2 in the article for the detailed steps. An alternate throwing program frequently used is a long-toss program. This is adequate as well, so long as maximal distance is not used due to the strain is places on the throwing mechanics.
Zaremski, J., & Krabak, B. (2012). "Shoulder injuries in the skeletally immature baseball pitcher and recommendations for the prevention of injury." PM&R: The Journal of Injury, Function, and Rehabilitation, 4(7), 509-515.
Here is a great article we found from The Sports Physiotherapist. From our experiences in school, we learned about inguinal, femoral, and umbilical hernias, but did not receive much information on Sports Hernia. This article does a nice job discussing the pathogenesis, differential diagnosis, and clinical presentation of Sports Hernias.
Many dedicated athletes utilize an exhausting training program to enhance their skill level. Occasionally, athletes push their bodies beyond a healthy threshold that leads to under-performance and sickness. This study takes a look at the management of overtraining syndrome. There are three terms that, while similar, are quite different in describing the state of the athlete: functional overreaching, nonfunctional overreaching, and overtraining syndrome. Symptoms commonly seen in these disorders include:
-loss of motivation -weight loss
-insomnia -lack of mental concentration
-irritability -heavy, sore, stiff muscles
-tachycardia -awakening unrefreshed
Functional overreaching involves training at a higher intensity, so that performance decreases for a limited time and is improved following a rest period. This is commonly seen in training methods everywhere. Nonfunctional overreaching is similar to functional overreaching, except a longer period of rest is required for recovery. Sometimes there are psychologic and/or neuroendocrinologic symptoms experienced as well. Overtraining syndrome is differentiated from nonfunctional overreaching with an even longer period of time with decreased performance, usually greater than 2 months. It is associated with psychologic, neurologic, endocrinologic, and immunologic symptoms and another stressor that cannot be explained by another disease. The article examines many possibilities that could potentially explain these disorders: glycogen hypothesis, central fatigue hypothesis, glutamine hypothesis, oxidative stress hypothesis, autonomic nervous system hypothesis, hypothalamic hypothesis, and cytokine hypothesis.
Patients typically have a history that involves decreased performance even with a lengthy rest period, changes in mood, and no indication of another cause to the symptoms. Some people state that nonfunctional overreaching is diagnosed if symptoms disappear following less than 21 days of rest and overtraining syndrome is diagnosed if it has been longer than 21 days of rest with symptoms persistent. Since some pathologies can present similarly as overtraining syndome, it is important to listen for cues, such as lots of mood changes or having the ability to start a workout but missing the "finishing kick." There are many lab tests that can be performed to determine the likelihood of a contribution from a non-musculoskeletal source. According to Dr. Noakes, some early signs to keep an eye out for are progressive loss of weight, an increased fluid intake (especially in the evening), a progressively later bedtime each evening, a decreased number of hours of sleep, and a persistent increase of 5-10 beats per minutes in early morning pulse rate. Dr. Noakes references a study by Waitzthat states if a positive answer to 3+ of the questions below could indicate the need to decrease training:
-Does your normally comfortable pace leave you breathless?
-Do your legs feel heavy for far longer than usual after a hard workout or a race?
-Do you find it especially hard to climb steps?
-Do you dread the thought of training?
-Do you find it hard to get out of bed in the morning?
-Do you have a persistent lack of appetite?
-Are you more susceptible to colds, flu, headache, or infections?
-Is your resting heart rate 5-10 beats higher than usual?
-Is your heart rate during exercise higher than usual?
Treatment recommendations are quite varied with no proven findings as of yet. Some suggest relative rest, while others suggest complete rest from the sport (Dr. Noakes suggests 6-12 weeks of rest). It is important to take a look at the motivating factors of the athlete. With decreased performance, some athletes try to compensate with increased training levels, which can worsen the problem. Additionally, with the association of mood alterations a sports psychologist consultation should be considered. Others have recommended the use of selective serotonin reuptake inhibitors to alleviate some of the symptoms. The best course of managing overtraining syndrome is prevention. Athletes should increase their training load prior to increasing their intensity, giving their bodies ample time to adjust. One of the studies referenced in this article found a decrease in "burnout" for collegiate swimmers when training levels were adjusted based on mood (lower load with low mood state).