Last week we did a segment on hip flexibility and this week we are going to build on that and discuss hip strengthening. Remember, the force it takes to throw a ball at high speeds requires energy to be transferred from the ground and lower body to the arm and hand. The strength of the hip is especially important for the throwing athlete as the body must be stable over the stance leg during this transmission of force. This stability comes from strength in the hip and hip stabilizers.

We’ve known hip strength is important as a study from 1986 by Steven Tippet broke down the phases of throwing and the strength required in both the arm and lower extremity. In this study, he found the strength in the stance leg was greater in college baseball players than strength in their lead leg. He also pointed out strength of the hip external rotators in the lead leg is necessary for proper placement of that limb upon release of the ball.

More recently, studies have linked weakness in the hip stabilizers (specifically the Gluteus Medius) to poor mechanics of the throwing arm leading to shoulder and elbow pain. In a study by Garrison et al, they found young baseball players with elbow pain from UCL involvement, demonstrated a significant deficit in single leg balance on both legs when compared to baseball players without elbow pain. They contribute this deficit to weakness in the stance limb including the hip and core.

Check out the video below to see some of our favorite exercises to strengthen the hip external rotators at home!

by: Meredith Kennedy, PT, DPT and Chris Goerlich, PT, COMT

Arnold A, Conway JE, Garrison JC, Macko MJ. Baseball players diagnosed with ulnar collateral ligament tears demonstrate decreased balance compared to healthy controls. J Orthop Sports Phys Ther 2013;43(10):752-758.

Tippett SR. Lower extremity strength and active range of motion in college baseball pitchers: a comparison between stance leg and kick leg. J Orthop Sports Phys Ther 1986;8(1):10-14.

With the start of baseball Spring Training fast approaching, we thought we would kick off a series on the throwing athlete, especially baseball players.  Pitchers will be highlighted as we most commonly see these players in our clinic.  We will discuss common injuries and some possible mechanical faults away from the site of pain that may lead to injury.  The throwing motion is quite complex, and rarely, if ever, is the problem isolated to the elbow or shoulder.  Remember, with throwing, force is transmitted from the

ground–>foot–>thigh/hip–>trunk–>shoulder–>elbow–>wrist/hand–>ball

and each of these components needs to be assessed and addressed.

So, we are kicking off this series talking about the potential for hip flexor tightness as one area to address in the throwing athlete.  Studies by Scher et al (2010) and Harding et al (2018) showed throwers with shoulder pain/injury had a greater prevalence of  decreased hip extension and external rotation motion on the stance leg (right leg if right-handed).  With limited hip extension,  strain on the front of the shoulder and inside of the elbow may increase.

One way to address hip flexor tightness is with a 1/2 kneeling hip flexor stretch.  The key is to rotate the hips rather than simply lunge forward.  Check out this short video…

by: Chris Goerlich, PT, COMT and Meredith Kennedy, PT, DPT

Post-run Recovery
by Meredith Kennedy, PT, DPT

Are you running in the Houston Marathon?  You’ve been training for a long time and you’re prepared for the race, but are you prepared for the next phase?  Do you know how to recover safely and effectively after the race?  Here are some tips!

First let’s understand what happens during the race.  Due to the repetitive action of running for 26.2 miles, your muscles take on a lot of stress and trauma.  This causes micro trauma at a cellular level to muscle fibers in the legs.  This micro trauma, if left alone, can cause localized swelling and toxin build up which can lead to pain and dysfunction.

The first step is to celebrate crossing that finish line!!  You have accomplished a great feat and deserve a big Congratulations!  Maybe indulge in a free beer or your favorite post-run refreshment.

Following the race it’s important to allow time for your muscles to heal and recover.  It is ideal to avoid running for about 2 weeks in order to prevent continued stress to the muscles.  Instead of running, try swimming, cycling, or even walking, but avoid being completely sedentary during this rest phase.  Another key is to continue to hydrate and maintain your nutrition.  As your body is healing, you need all your good nutrients to help.

Many people have questions in regards to deep tissue massages, foam rolling, cryotherapy, stretching, etc.  An important thing to remember is what you’re putting your muscles through.  Anything that will continue to stress or damage muscle tissue should be avoided.  Deep tissue massages and foam rolling both put compressive forces on the muscles and can cause further damage to the soft tissues; however, a gentle massage focusing on improving circulation can be beneficial.  Cryotherapy treatments including cold baths, cryochambers, and ice can be used to help flush the body of unwanted toxins. After a day or two of ice, consider hot-cold contrast baths to improve blood flow and lymphatic drainage.  Lastly, gentle stretching is great to continue, but be careful to avoid overstretching.

We are the 1st in the area to incorporate blood flow restriction training into our lower body rehab programs.

What is it?
Blood flow restriction (aka occlusion) training involves placing a pressure cuff around the thigh to decrease blood flow away from the leg; blood flow into the region continues.

Carpal tunnel syndrome is a common condition caused by irritation of the median nerve as it travels through a tight tunnel in the wrist.  There are many causative factors, but overuse is one of the most common issues, such as computer work and construction work.  Symptoms will occur in the thumb, index finger, and middle finger.

Symptoms include:

hand numbness 

sensation of pins and needles

hand clumsiness

hand pain at night

hand weakness

wrist weakness

Clinically, we assess neck motion as there is often an issue in the cervical spine that will need to be addressed.  We will check the mobility of the median nerve and often recommend nerve glides of the median nerve in addition to other manual techniques and education on activity modification.  Here is a short video demonstrating one way to glide the median nerve through its tunnel.

Adhesive capsulitis, commonly referred to as Frozen Shoulder, is a debilitating condition of the shoulder, marked by pain and progressive loss of motion. The shoulder joint is surrounded by a fibrous joint capsule, which in this condition, becomes inflamed and thickened, forming adhesions.

This condition is most prevalent in women from 40-60 years old, typically with no known cause, just a gradual loss of motion and increasing pain. A thorough history may reveal a rather insignificant act that precipitated this condition, something as simple as feeling a slight discomfort when taking down a box of Christmas ornaments. Periods of immobilization, such as using a sling after surgery, can also trigger a frozen shoulder. Xray and MRI imaging will usually be unremarkable, but arthroscopic evaluation will show a thickened, inflamed joint capsule. Studies have shown risk factors to include Diabetes and thyroid issues; prevalence in diabetics is 10-20% and thyroid (hyper- or hypo-) is 10-17.4%(http://www.ncbi.nlm.nih.gov/pubmed/12864792).

Adhesive capsulitis is a process that can last for 12-24 months. It typically goes through 3 phases: freezing, frozen, and thawing.
(1) Freezing stage: characterized by pain and progressive loss of motion; sleep is often disturbed in this stage.
(2) Frozen stage: pain will usually lessen considerably and there is no significant change in motion.
(3) Thawing stage: motion will begin to return and the ability to use the affected arm will improve.

So, what can be done? After seeing your physician and possibly receiving a cortisone injection, physical therapy is usually the next step. At your first visit, we will assess your range of motion and the mobility of the joints of the shoulder complex. Because of the inflammatory nature of this condition, aggressive stretching is NOT beneficial, as it only irritates an already irritated joint.

At Propel, we utilize joint mobilizations and gentle movements to decrease pain and improve motion. Dry needling, cupping, and taping techniques can also be used to help decrease muscular pain associated with this condition. We will provide a home exercise program consisting of various stretches to be performed several times per day; in my opinion, short bouts of frequent stretches throughout the day tend to be more beneficial than 2 30-min sessions/day.

Over the past 10 years, I have seen a large number of clients following rotator cuff repair.  The protocols from various surgeons are all over the place, and rightfully so, depend a great deal on what the surgeon saw during the procedure – size and location of tear, soft bone, tissue quality, tendon retraction, etc.  All of these things have an impact on post-op rehab.

Some surgeons want the client seen the day after surgery, while others wait 3-6 weeks.  Some recommend a sling for 1 week, while others recommend using a sling for 4-6 weeks.  As we can see there is no consensus on these matters, but the good news –  PEOPLE GET BETTER.

I recently came across this article in the American Journal of Sports Medicine  –

Early Versus Delayed Passive Range of Motion Exercise for Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trial

In a nutshell…

The authors of this study reviewed 6 randomized controlled trials consisting of 482 patients. They compared outcomes of those receiving early versus delayed range of motion (ROM) after rotator cuff repair. Those receiving early ROM had 3.5 degrees greater forward flexion (reaching overhead) ROM at 12 months post-op. However, the early group also had a higher incidence of re-tear, especially if they had a large tear.

In my experience, I haven’t seen much difference in outcomes of those with small to medium tears who start PT the day after surgery or 4 weeks after surgery; those starting the day after surgery are just less excited to see me:)   I do agree that large tears need a little more time to heal before beginning the rehab process.

Scher S et al.  Associations among hip and shoulder range of motion and shoulder injury in professional baseball players.  J Athl Train. 2010;45(2):19-197.

The Down Low:  According to this study, pitchers with a history of shoulder injury had decreased hip extension on the throwing side coupled with increased shoulder external rotation of the throwing shoulder.  In other words, if the dominant (throwing side) leg is lacking hip extension flexibility, the body will compensate by increasing the shoulder external rotation to create the “whiplike” effect.  This places more stress on the front of the shoulder (and elbow), potentially causing SLAP tears, rotator cuff tears, and ulnar collateral ligament tears in the elbow (Tommy John).

Take Home Message:   Train the entire body… throwing is not just about the shoulder.  Work on dominant side hip extension flexibility (ie. 1/2 kneeling stretch) and lead leg strength and hip stability.  Incorporating trunk control / core stabilization is equally important.

Early last month I got a text from the father of one of my former clients, a local high school football player.  He mentioned his son had some news he wanted to share with me and would stop by.  Well, football season carried on….all the way to the State Championship Game!!  A few weeks after the big game, Zack stopped by to share his big news – he had accepted a scholarship offer to play football for the Fresno State Bulldogs!  This young man is so humble about his accomplishments and I know he will do great things.

At his visit, Zack also brought in an article where he was honored by the Houston Touchdown Club.  As I read the article, I saw my name…what? my name?  I am so honored and blessed to have worked with this young man.  He is a testament to hard work, dedication, and focus.  We wish Zach success at the next level and beyond!!

In some cases after an ankle or foot injury, especially if it required a cast or walking boot, the ankle will become stiff and maybe even painful…going down stairs can be difficult.  You usually begin stretching and foam rolling the calf, but after several weeks or months, the ability to pull the top of the foot towards the shin (dorsiflexion) does not improve, and often you feel a “pinch” at the front of the ankle. One possible cause is tightness in the ankle joint, not the muscles around it.

Clinically, I assess the ankle joint capsule by gently moving the bones of the ankle, specifically moving the talus towards the back of the ankle; also performing a squat to see if the heel of the affected foot/ankle lifts off the grounds before the other one.

At Propel Physical Therapy, we use specific joint mobilizations to improve this ankle joint motion and then use the following exercise at home.