All Posts tagged Pain

Baseball Injuries: How to prevent.

Baseball Injuries: How to prevent.

Crucial Tips for Parents of Little League Players

–Angela Gordon, PT, DSc, MPT, COMT, OCS, ATC, FMS Lead physical therapist for the Washington Nationals Baseball team & NAIOMT Guest Faculty Member

As the little league season is upon us, there is quite a buzz these days on injury prevention and year round throwing in the youth baseball player. Over the last couple of years, I have seen quite an increase in youth injuries in the 10 to 13-year-old range from kids playing baseball either year round, playing in two leagues at the same time or both.

At this age injuries manifest in the elbow mostly due to overuse, improper throwing mechanics and also because of skeletal immaturity. Injuries such as medical epicondyle avulsion fractures and UCL strains are amongst the most common for this age range. The severity of these injuries are on the rise and what most parents and kids do not understand is that while we as a medical community have evolved and are great at helping to correctly these injuries, it still does not negate the fact that if these kids continue to play year round and in multiple leagues at the same time, their chances of making it beyond high school in baseball decrease to a generous 10%. I am a huge advocate for the STOP program that Dr. Andrews has begun to spread awareness of the potential hazards associated with overuse in youth sports. There is also a program started by MLB called Pitch Smart and an app developed by Dr. Andrews and Kevin Wilk out of ASMI called Throw Like a Pro, all to help promote following pitch counts and smart baseball habits. I make sure parents and athletes that I am treating are well versed in the pitch count and throwing regulations for youth baseball. I want parents and kids to understand that until they have a skeletally mature system, there are several things they should and should not be doing:

Do not play year round. I advocate 4-6 months off from baseball for 10-12 year olds and 4 months on for 13-14 yr old, and 3 month off for 15-18 yr olds. However with all the camps and showcases for high school athletes this can be nearly impossible.

Do not play on multiple teams. One team per season, do not cross over end of one season and beginning of another. If you have a break in between seasons (1 week to 4 weeks) take the time and proper steps to progress back into throwing and hitting.

Do not play pitcher and catcher in the same game or same day if playing multiple games. Be an advocate for your child, do not let coaches over utilize the kids during games and tournaments even if they are short on players. Nothing good ever comes out of this tactic for the athlete.

Avoid the training programs that require exercises and weighted ball activities that their system is not strong enough to handle. Volume, distances, weights, and exercises all need to be modified and reduced for the 10 to 13-year-old group.

Develop basic scapular stability. Most 10 to 13-year-olds have some baseline scapular dyskinesis due to skeletal immaturity and you can not develop full stability until you age. Focus on basic stability and only perform what bodies can handle until they mature.

The Thrower’s Ten program is a great program for this age range with no weights and light resistance bands. It is easy to perform with little to no equipment, compliance is high and it is not overtaxing on their system.
There are also some good basic throwing mechanics as described by Davis JT et al* that I review with this age group. Davis describes, for the youth these basic checkpoints are useful to help develop more efficient throwing until they achieve proper sequence of motion as they age:

Leading with the hips

Hand on top position

Arm in throwing position: elbow max height when lead foot contacts

Closed shoulder position

Stride foot towards home plate

This study by Davis et al concluded that hand on top and closed shoulder position are 2 parameters the pitcher should achieve to reduce humeral internal rotation torque and elbow valgus loads. A basic arm prevention program, volume control and basic mechanics instruction can have a positive impact in reducing the injury epidemic in the young baseball player.

*Davis JT, Lumpisvasti O et al. The Effect of Pitching Biomechanics on the Upper Exremity in Youth and Adolescent Baseball Pitchers. Am J Sports Med. 2009:37:1484-1489.


Acetaminophen no benefit for Back Pain

Acetaminophen no benefit for Back Pain


The commonly-prescribed drug acetaminophen or tylenol does nothing to help low back pain, and may affect the liver when used regularly, a large new international study has confirmed.

Reporting in today’s issue of the British Medical Journal researchers also say the benefits of the drug are unlikely to be worth the risks when it comes to treating osteoarthritis in the hip or knee.

“Acetaminophen has been widely recommended as being a safe medication, but what we are saying now is acetaminophen doesn’t bring any benefit for patients with back pain, and it brings only trivial benefits to those with osteoarthritis,” Gustavo Machado of The George Institute for Global Health and the University of Sydney, tells the Australian Broadcasting Corporation.

Most international clinical guidelines recommend acetaminophen as the “first choice” of treatment for low back pain and osteoarthritis of the hip and knee.

However, despite a trial last year questioning the use of acetaminophen to treat low back pain, there has never been a systematic review of the evidence for this.

Machado and colleagues analyzed three clinical trials and confirmed that acetaminophen is no better than placebo at treating low back pain.

An analysis of 10 other clinical trials by the researchers quantified for the first time the effect acetaminophen has on reducing pain from osteoarthritis in the knee and hip.

“We concluded that it is too small to be clinically worthwhile,” says Machado.

He says the effects of acetaminophen on the human body are not well understood and just because it can stop headaches, it doesn’t mean the drug will work in all circumstances.

“There is probably a difference in the pain mechanisms in low back pain and osteoarthritis, compared to headache,” says Machado.

Liver effects

Importantly, the new study was the first to show that patients using acetaminophen for low back pain and osteoarthritis were nearly four times more likely than those taking placebo to have abnormal results on liver function tests.

Machado says it’s unclear whether this means acetaminophen could cause liver damage in the long term.

“But if you see elevation of enzymes in the short term, it’s a concern for the long term,” he says.

Machado and colleagues point to another recent study suggesting acetaminophen raises the risk of cardiovascular, gastrointestinal and renal disease. They argue doctors should reconsider their recommendation that patients use the drug for low back pain and osteoarthritis of the hip or knee.

Keep active advice

“It’s time the clinical guidelines are reviewed,” says co-author of the new study associate professor Manuela Ferreira. “Acetaminophen shouldn’t be included in the guidelines for back pain.”

When it comes to treating osteoarthritis, Machado and Ferreira call on doctors to explain the actual risks and benefits.

“If you ask me it’s not worthwhile,” says Ferreira.

Ferreira says anti-inflammatories are the second
choice of treatment for low back pain but they have greater side- effects.

The researchers say other non-drug treatments recommended in the clinical guidelines should be used instead.

These include reassuring patients that low back pain is generally benign and that the best remedy is to keep active. Exercise, strength training and weight management have been shown to be effective in treating osteoarthritis of the hip and knee,” says Machado.

Arthritis Research UK also said physical activity is probably a better and more effective way of keeping the pain of arthritis and joint pain at bay than taking painkillers.

The arthritis group said it’s been known for some time acetaminophen may not work for everyone with severe pain from their arthritis, but some people find it allows them to sleep and to exercise without discomfort.

Low back pain and other musculoskeletal conditions account for one-third of missed work time in Canada.

With files from CBC News

© Australian Broadcasting Corporation, 2015


Shin Splints

Shin Splints

‘Shin Splints’ is an outdated term which is now believed to cover many forms of anterior shin pain. What most people perceive to be ‘shin splints’ should actually be termed Medial Tibial Stress Syndrome (MTSS).

This condition typically presents with pain on the inside border of the Tibia which intensifies at the start of exercise but may ease as running continues in the early stages. Pain generally eases with rest and there are no neurological symptoms. MTSS accounts for approximately 13-17% of running injuries, with only Plantar Fasciitis occurring more frequently. MTSS is 10 times more common in females during basic running training than their male counterparts.

As the name suggests, MTSS is a condition caused by increased bone stress. Even healthy bone contains microcracks, but microcracks under continued overloading will develop into macrocracks, resulting in pain and the potential to develop into Tibial stress fractures if ignored.

How is the Tibia Overloaded?

Our bones are strongest at withstanding compression forces, weaker in tension forces and weakest of all in resisting shearing forces. When we run, all three directions of force are applied to the bone.

Tension Force

When running, the combination of the foot hitting the ground on the outside of the heel and the more medial compression loading force from the Femur onto the Tibia causes a bending force on the bone. The lateral Tibia is subjected to a compression force which as discussed is withstood well, but the medial Tibia undergoes a tension force which can result in bone stress.

There are two reasons why some people are more prone to this condition than others:
◾Those whose Tibia has a narrow diaphyseal width are more prone to bone bending forces
◾Those who overpronate

Overpronation places additional strain on the medial Tibia border due to increased tension in the facial and muscle attachments including the Tibialis Posterior, Soleus and Flexor Digitorum Longus. This ‘pulling force’ increases tensile bone stress on the medial aspect.

Shearing Force

Shearing forces are the hardest on the bone.  These are produced as overpronation at the foot causes an internal rotation force on the Tibia. An external force is placed on the Tibia from above due to external femoral rotation which is made worse by weak hip rotators. This causes a shearing, or twisting force on the Tibia bone.


This latest view on MTSS development has some impact on the way the condition should be treated. Treatment should be approached using the following four aims:
◾Strengthen the Tibial cortex and aid recovery
◾Reduce Tensile Tibial bone stress
◾Reduce Shearing Tibial bone stress
◾Reduce vertical loading rate

Strengthen the Tibial Cortex

Bones strengthen in response to stress. But it has to be the right kind of stress and in the right doses. As MTSS is down to too much of the wrong stresses it is vital that the causes which have predisposed the individual to tension and shearing stresses on the Tibial are corrected before commencing a graded running program. So, in the meantime, rest is recommended, from running and walking if this also causes pain.

Graded running programs are designed to gradually overload the bone to strengthen it. Here is an example:
Reduce Bone Stresses

In order to reduce the stress on the Tibia, overpronation must be corrected. It is not simply enough to look at the patient’s feet and determine if they have a ‘good arch’ or not. Even those with a ‘high arch’ can be heavy overpronators! In order to address this properly, gait analysis should be performed using video technology to slow down the running cycle and highlight excess motion at the subtalar joint.

For those found to overpronate, both orthotics and footwear should be addressed. Either stability or motion control shoes should be worn and orthotics inserted in addition, when necessary. Placing orthotics into neutral shoes will be next to useless as the insert will simply ‘sink’ into the cushioning of the shoe.

Overpronation can be further reduced by increasing the range of dorsiflexion available at the ankle. The Gastrocnemius and Soleus muscles are responsible for plantarflexion and so if tight or shortened can reduce the range of dorsiflexion. In order to compensate for this, the foot overpronates further to bring the bodyweight over the stance foot. Stretching exercises and sports massage therapy are ideal for doing this.

Along the same rehabilitation exercise lines, strengthening the lateral rotators of the hip can also help reduce shearing forces on the Tibia. Exercises such as the Clam are ideal.

Whilst it may be a difficult conversation to have, patients who are overweight are more prone to MTSS as the pronation force = mass x acceleration. Higher body mass results in increased pronation.

Reduce Vertical Loading Rate

Finally, the runner, therapist and coaches etc should work together to try to reduce the Vertical Loading Rate (VLR) of the running pattern. What this means is how quickly vertical load is applied during impact. A higher loading rate has been linked to an increased injury risk in runners.

There are a few ways in which this can be achieved but a lot of research is still underway to determine the best ways of doing this. Some will argue for a change in technique to favour forefoot running and others would go as far as recommending barefoot running. Whilst landing on the forefoot rather than the heel does seem to reduce vertical loading rate, it is not clear at the moment the effect that this has on pronation. And so by trying to fix one problem, are we increasing another?

The most effective ways of reducing the VLR, without potentially causing other problems are to:
◾Reduce fatigue
Fatigue is responsible for a decrease in running efficiency and technique, as well as increases in lower limb muscle tension and so bone stress. Fatigue can be reduced using fitness training (cross-training) and correction of training errors.
◾Running form coaching
Working with a running coach can help to improve your running form and make it more efficient, thus reducing energy costs and fatigue.


Researchers and experts in the field of running injuries now believe true ‘shin splints’ to be a result of bone stress to the medial Tibia. With repeated running, the Tibia becomes overloaded, which over stresses the bone. These stresses are caused by excess tension and shearing forces on the Tibia.

Treatment should aim to reduce these forces with rest; footwear or orthotic changes; increases in ankle flexibility and hip rotator strength; weight loss; increased fitness; improved running form and a graded running program to increase cortical bone strength.


Low back Joint Manipulation…thoughts on research

Low back Joint Manipulation…thoughts on research

My personal opinion is that we should always put patient safety first, I do not want to do any treatment that can cause long term problems. The safety of lumbopelvic manipulation is clear to see- there are few risks to manipulation of the lumbar spine. This contrasts with the neck where more serious complications are possible. A study by Leaver, Jull et al has shown that patients with acute neck pain will get better faster with mobilization than manipulation.(43 days to 47). I have posted this article to drop box. Likewise the cochrane review by Gross et al has shown no significant benefits of manipulation over mobilization. So the question becomes why would someone manipulate rather than mobilize?

It is a far different equation when it comes to manipulation for the lumbar spine. We know it is safe and we know it is effective. There remains debate whether manipulation is superior to mobilization in terms of results. Studies by Cook and Hancock et al. have shown no significant difference between the two techniques, the latter also questioning the usefulness of the CPR. On the flip side the studies by Childs et al and Cleland et al have shown Manipulation to provide superior results at all reassessment points. Many other studies have shown lumbar manipulation to be an effective technique from both a patient improvement perspective (Childs et al, Flynn et al, Cleland et al, Aure et al, Cecchi et al), but also from a cost-efficiency perspective (BEAM) although the paper by Critchley suggested a back pain school approach might be more cost effective.

So basically we know that low back manipulation is a low risk technique that typically produces successful outcomes. Clearly there are semantic issues when comparing manipulative techniques to mobilization techniques as mentioned by Cook, I think it is fair to say that Manual Therapy is effective for lumbar spine treatment based on the CPR guidelines. It is costly to NOT give manual therapy to patients who fit the guidelines.

My personal opinion is that unlike the neck where I prefer to mobilize the joints- based on aforementioned research- I prefer to manipulate the lumbar spine if the guidelines are met. In my mind the benefit, cost-efficiency, and risk analysis make performing lumbar manipulations the treatment of choice for acute low back pain.

Gross AR, Hoving JL, Haines TA, et al. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine 2004;29:1541-8.

Leaver AM, Maher CG, Herbert RD et al. A randomized controlled trial comparing neck manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehabiltation 2010;91:1313-8.