![[Case Studies] Managing ulnar collateral ligament injuries in baseball: a case study with Mike Reinold](https://cdn-images-3.listennotes.com/podcasts/physio-network/case-studies-managing-ulnar-6F-BY_jLZ9g-27iStX6kIJG.1400x1400.jpg "[Case Studies] Managing ulnar collateral ligament injuries in baseball: a case study with Mike Reinold")
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In today's episode of Case Studies, we're joined by Mike Reynolds, a world-renowned physical therapist, athletic trainer, and strength and conditioning coach.
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Mike is founder of Champion Physical Therapy and Performance in Boston and former head of athletic training and physical therapist for the Boston Red Sox, and also former senior medical advisor for the Chicago White Sox.
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He's widely recognised for his expertise in shoulder and elbow rehab, especially in overhead and throwing athletes.
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In this episode, Mike talks us through a real case study involving a baseball pitcher who presented with gradually worsening medial elbow pain early on in the season.
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Initially still able to play, the athlete symptoms progressed to the point where pitching was no longer possible.
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Mike unpacks how he approached this case, from taking a detailed subjective history, narrowing down his differential diagnosis, performing key objective tests and arriving at a clear diagnosis.
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He then shares how he built the rehab plan, what went well, what didn't, and key lessons every clinician can take away when working with throwing athletes.
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So whether you're working in sport or just want to refine your clinical reasoning, this is a brilliant example of expert level thinking in action.
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As you can imagine, this is just a brief coverage of this case, and you can dive way more detail with our case studies.
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You can find more information in the link in the show notes.
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But for now, grab a pen and a paper and open those ears, and sausages are never made a be.
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Mike, welcome to Case Studies.
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It's great to have you on and really looking forward to talking through this case with you today.
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Yeah, James, thanks so much for having me.
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Always an honor to be involved, and I'm a big listener to the other podcasts.
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So when you reached out to try to start this new case series, it sounded really exciting.
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I'm honored to be on, but I'm also excited to hear from the other people that you're gonna have in future episodes too, because this seems like a really neat format for future podcasts.
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So thanks for having me.
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Thanks for thinking of me.
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Brilliant.
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Well, let's get straight into it, shall we?
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So we're gonna go into your case study, Mike.
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Do you want to kickstart us with a bit of background on this one, including the subjective history for us?
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Absolutely, yeah.
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This specific one was a sophomore in college, he's a 20-year-old college baseball player, and I saw him at pretty much the beginning of their competitive season in the late winter.
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So I'm up in the northeast of the United States, up in Boston.
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So they start to play some games in February to go down south for warmer weather.
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It's usually right around late February, early March, where you start to see these injuries come in at the beginning of the season.
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So again, we had this player, it was the beginning of the season.
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They started to report having medial elbow pain.
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Very common if you work with overhead athletes and lots of sports, especially baseball, medial elbow pain.
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And didn't really feel anything over the winter in the offseason.
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But for the last three, four weeks, when they started ramping up their bullpen and they started throwing more off the mound, it was slowly getting worse.
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And their big complaint now is obviously they have no velocity, they're struggling with command, and it's just too uncomfortable to pitch effectively.
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So they technically cannot compete at their sport with the symptoms they're having.
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So we have that.
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I like to ask them specifics of the pain.
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So medial elbow pain, like nobody comes to you and says, I have medial elbow pain.
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They'll point at their elbow, they'll say something.
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You have to try to figure it out.
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But I like to ask things like specifically, can you point with one finger?
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Right.
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We can make sure that we're getting it right on that spot.
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And with baseball players, the inside of the elbow is such a small part of the body, right?
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It's very specific.
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It's almost like the size of like a dime or a nickel that you can just point to and you can see that pain on there.
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So typical medial pain.
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I like to ask when it happens during the throwing motion as well.
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Does it happen during ladyback?
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Does it happen as you start to accelerate the arm forward?
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Does it this happen at ball release or the follow-through?
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And for this particular person, and most people with zombie jaw injuries, they have pain with laid back.
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So full external rotation of the shoulder.
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So I think I have a decent understanding of where I'm probably going to go from here, but I also like to ask questions about their history.
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So, have you had pain in the past, right?
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Did anything wrong with your shoulder, right?
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We're looking specifically at your elbow, but if you had a past shoulder injury.
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And this particular kid who was pretty good, he said never really had any shoulder problems.
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He did say when he was really young that he had some inside of his elbow pain when he was young, that they shut him down for a couple months when he was like late little league age.
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I wouldn't say that's an irrelevant finding, right?
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Because that was probably the beginning of this year, but that was about five, six years ago.
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Again, he hasn't really had symptoms for a while.
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But he did add this, and I always do like to ask him, I say, Well, anything changed this year?
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What did you do something different?
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And I asked things like, Did you grow?
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I know he's 20, but believe it or not, we still see 20-year-olds go through growth, but did you grow three, four inches this year?
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And he said, No.
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He said, But I did start a velocity program this year, and that's something that we're finding quite a bit in our sport now, is that we're pushing the envelope of their physiological norms pretty much and trying to gain throwing velocity because velocity is what works, it gets batters out.
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So you succeed at your sport, you can get college scholarships, you can potentially get drafted and play at the professional level.
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So everybody's chasing velocity.
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So he and his pitching coach got on a velocity program this offseason and started doing a lot more.
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So started throwing with weighted balls, so different weights of balls, so underload and overload balls, started doing some extreme long toss where he's trying to throw it as far as he could.
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But then more importantly, really just up the frequency and volume of his throwing because he was doing these things.
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So that's a really clear history then.
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As you said, Mike, you're kind of getting into some specifics that you need to.
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We're gonna talk in a minute why you're gonna be doing that, because uh straight away running around your head, I'm sure, is a list of differential diagnoses.
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Some of the listeners may well have picked up on probably where we're gonna end up, but I think there probably will be many, many listening who aren't picking up that.
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And I just added on this note, picking up the term they're using there, the Tommy John injury.
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And I think there probably will be listeners who've never heard that before.
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So just talk us through, Mike, your differentials.
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What are the things outside of where we know we're going, but what are the other things you were thinking?
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I need to knock these off my radar or start ruling things out.
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Right.
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I like how you you've led to this though, because this isn't like a one of those true crime podcasts, right?
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Where you're you have a suspensive mystery that oftentimes the subjective leads us to where we're probably gonna go and where we're probably gonna end up, right?
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That's a good subjective.
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But yeah, differential diagnosis for the medial elbow to me, in a throwing athlete, it's one of four things.
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And I actually shouldn't say one of four things because oftentimes it could be several of these, it could be all of these, right?
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But it's the bone, the nerve, the muscle, and the ligament.
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And the ligament on the medial elbow that we're talking about is the ulnar collateral ligament.
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And the reason why these are called Tommy John injuries is there was a baseball pitcher back in the 80s, the 1980s.
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I have to say that now, that 1980s.
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It's it sounds weird saying it that way.
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But several decades ago, that was the first person to have this surgery, and his name was Tommy John.
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They named the surgery after him, just being the first person, and everybody now, like every kid knows what it is, right?
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Baseball coaches, parents know what it is.
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It's a Tommy John injury.
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So, yeah, diagnosis for me is usually gonna be one of those four things.
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And I never go into it assuming it's gonna be the Tommy John ligament, your ulnar collateral ligament.
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I don't assume that.
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Sometimes it isn't, but we're gonna look at those four things.
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The interesting thing between these four, though, and again, bone, nerve, muscle, ligament, is that they all get injured with the same mechanism, right?
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Baseball pitching and extreme layback as they get into external rotation of their shoulder during the pitching motion.
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So that's why you could almost argue that all these injuries to them are brothers and sisters, because if you stress one, you tend to stress the others.
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But for bone, we tend to get what's often called little lead elbow, but essentially that's like a growth plate injury, right?
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Where you have a growth plate injury to the medial side of the elbow there.
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And that's usually in youth where their growth plates are still open and they haven't matured, right?
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And that's a potential bony injury that you could have with that.
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This person's 20 years old.
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I guess it's still possible to get a stress reaction in your growth plate there, but it's pretty rare the older you get.
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We start to see that usually that's in the 12, 13, 14, maybe 15-year-olds that we see that those growth plate injuries, but that is definitely something we're gonna look for.
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That one's easy to rule out, obviously, just because it's a different spa.
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The second thing is the nerve, and that's the ulnar nerve.
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So the ulnar nerve that goes to the medial side goes through essentially the same area that the ligament, the flexor pronator mass, and these types of injuries happen with these athletes, right?
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But the ulnar nerve can get affected as well because, again, extreme external rotation, you can have various degrees of elbow flexion and extension as you're going through the pitching motion.
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It's very similar to a nerve glide for the ulnar nerve.
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And a lot of people almost throw with almost a nerve glide type motion.
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So we see some people that have ulnar, excuse me, ulnar nerve uh subluxation, and you can actually see it sublux in and out of the groove, and you can certainly have some of that.
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That's nerve.
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The way we differentially diagnose that is obviously do we have anything neurological?
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So oftentimes you'll see some numbness and the tingling and the fifth finger.
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In extreme rare cases, you'll see some like hypothenoreminence, atrophy, and some decreased in strength.
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That's pretty rare because if you've had that that long, you probably would have already addressed it.
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And again, we ruled that out.
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So tonel sign was negative on them, going through all the neurological things, nothing was of interest in there.
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So bone and nerve, we kind of moved on from.
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Next to is muscle ligament.
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So the flex for pronator mass and then the ulnar collateral ligament, if you really think about them, they both are working together to stabilize the medial side of the elbow.
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So we have the dynamic stabilizers and the muscles, and then the static stabilizers in the ligament.
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And again, they're both gonna get stressed with this motion because we have this varistoric and that valgus stress on the medial side of the elbow that's gonna cause both of those areas to potentially be symptomatic.
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So on this particular person, he did have discomfort with muscle contractions.
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So for us, that does mean that the flexor protonators involve could just be inflamed.
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It doesn't always necessarily have to be a tear, but it could be.
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Could just be inflamed.
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Some people don't have any discomfort with the muscle and it's just the ligament, but for him, he was a little uncomfortable in the muscle.
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And then we get to the big one, the ligament, the ulnar collateral ligament.
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So, you know, valgus stress testing is really the key to this.
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I particularly like to do this in the prone position and almost perform it almost like you would an MCL of the knee off the edge of the table with the elbow.
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And I've got a bunch of videos of that on my website and social media that you can probably dig up with me, me testing the UCL.
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But I really want to stabilize the shoulder, make sure that we're not getting any contributing motions of the shoulder to confuse things.
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On most of the testing, we did a Milkingstein, we did a moving valgus, and we did valgus stress testing in the prone position.
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And he had discomfort in all of those.
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So we're curious of the ligament, right?
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Without an MRI, we're still not sure if the ligament is completely involved.
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There are times that just having a flexor pronator strain could also hurt those motions, but it seemed to me like he probably had a little bit of those two.
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We did send him out, he did get an MRI, and it did show a partial tear of his UCL, right?
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So he had a little bit of inflammation in his flexor pronator mass and a partial tear of his UCL with the MRI.
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And that's common, right?
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Like the UCL in the elbow is not like your UCL on the knee, where you go skiing and it pops, it tears in half, right?
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Oftentimes what happens is you almost start to see some partial tearing, right?
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So he had a partial tear and something that considering his age, considering his duration of symptoms and the severity of the MRI, we were hoping that we would be able to get by with some non-operative rehabilitation for him.
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That was kind of like our differential diagnosis.
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And then based on that, I have a good understanding.
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We talked about a little about the objective testing to help me with his differential diagnosis.
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But to me, I still don't know what I need to do with him yet, right?
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All I know is he hurts and he has some special tests that are positive.
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But I haven't yet created my checklist of things that are suboptimal for me to actually start working on.
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So that's where my brain goes to next is what do we need to look at objectively to see now not only what's the differential diagnosis, but what is our treatment plan going to be for this person.
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Definitely.
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So you're starting to go into the realms of a problem list, aren't you?
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Really?
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We're starting to say, okay, well, we we can start seeing some structural issues.
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We're seeing ruling out other things, starting to rule in some things, but what are we going to do is more about the individual and what you're actually going to find in terms of restrictions and reductions in strength and um things like that.
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So where do we go next, then?
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I guess we we know what tree we're barking up, right, with our structural examination.
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Now it's looking at the functional stuff.
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And for us, what we did is we jumped in objectively and we like to get a good thorough assessment of them.
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And a couple of things stuck out to me.
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One, they had a loss of overhead elevation, quite a bit.
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They had about 145 degrees of shoulder flexion versus 175 on the other arm.
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And that's a big deal.
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We see that a lot in our baseball players.
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I almost call shoulder flexion the barometer of the shoulder, meaning if that is super tight, it often means your workload is super high and you're not recovering well.
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There are so much cumulative eccentric trauma in the lat, the Terry's major, the subscap from being into this layback external rotation position and then having to transition and come forward with velocity.
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It's a very stressful thing.
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And what we often find is that gets tight just in the normal act of throwing.
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But then when that gets tight and you lose shoulder flexion, then your biomechanics change when you pitch and your arm slot drops, and then you start putting more stress on your elbow.
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Chicken or the egg, I'm not sure, but you start to see that sometimes in people that have medial elbow pain, is that they also have limited elevation of the shoulder.
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So we found that great.
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That's something we can clean up.
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And I've actually had people just in a couple of weeks, if you clean up that range of motion and then bring them back through their throwing motion, their pain is much better, sometimes even gone.
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00:14:54.480 --> 00:15:06.559
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00:15:16.159 --> 00:15:20.960
You you mentioned a really good point there in terms of using that shoulder elevation as a barometer.
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Would you ever in a a kind of a team environment measure that routinely and see any changes?
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So uh on our professional teams that I work with, we measure those daily.
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Every day they come in, and we call it a pre-throw stretch just because you know you want the player to think you're stretching them versus staffing them, right?
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Measure measuring them.
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And if that we bring them through, it could take two minutes.
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And if things look great, we pat them on the shoulder, we say, Good look, go, good job, go get them today, have fun.
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If they look tight one day, we're like, Oh, you know what?
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You threw in the game yesterday, you had an upper body lift, you're a little strike.
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Then we're gonna apply treatments because one of my philosophies with working with baseball players is very simple, right?
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Let's say you're one of my pitchers, James.
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Every time you pick up a ball, I want you to look like James.
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And we know that throwing a baseball is technically bad for you, right?
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It's stressful, and you can get hurt doing it, right?
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So there's a lot of stress that happens.
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So when you go pitch, I know that after the game, your range of motion is going to be decreased.
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And if we don't address that cumulatively over the course of the season, that is gonna continue to decrease.
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So that's why it becomes that barometer.
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So we want everybody to look like themselves and to get some manual therapy wherever they may need each day to restore their motion to get them back before they throw again.
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Because baseball is one of those weird sports we play every day, it's not once a week like a lot of other sports.
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There's games every day.
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You know, in Major League Baseball in the States, we have 162 games in 180 days.
00:16:52.799 --> 00:16:55.759
But so that's their shoulder flexion.
00:16:55.840 --> 00:17:01.440
The other thing with him that we noted was that he had too much external rotation of his shoulder.
00:17:01.759 --> 00:17:16.799
And a lot of people think that that is a good thing, and it often is because the more external rotation you have, it correlates to an increase in pitching velocity, but it also correlates to an increase in stress, which is physics, right?
00:17:16.960 --> 00:17:21.279
Like we know that we're the medical professionals onto this, we understand that.
00:17:21.519 --> 00:17:24.559
But we see this oftentimes in our baseball players.
00:17:24.799 --> 00:17:36.559
20 years ago, and there's still some people that perpetuate this a little bit, but this concept of GERD and GERD with an eye, not the one where we have an upset stomach, but glenohumeral internal rotation deficit.
00:17:36.799 --> 00:17:54.799
And essentially what we were over-diagnosing 20 years ago was a normal adaptation that we found, where again, the bony changes of the humerus when you're going through a gross burnt and your growth plates are open and you throw, allow the throwing arm to get more external rotation, and then there's subsequently less internal rotation.
00:17:54.960 --> 00:17:59.519
But if you add up ER and IR on both sides, the number should be exactly the same.
00:17:59.759 --> 00:18:01.680
So let's make the numbers easy.
00:18:01.839 --> 00:18:06.799
Throwing side should have 120 degrees external rotation, 60 degrees of IR.
00:18:06.960 --> 00:18:09.920
On your non-throwing side, that's probably going to be off a little bit.
00:18:10.079 --> 00:18:17.359
Maybe that's 110 degrees ER, but 70 degrees of IR, but you add them both up, it's 180 degrees on the dot.
00:18:17.519 --> 00:18:24.960
And we find that with the hip too, but like for the shoulder, those are those bony changes from throwing when your growth plates are open.
00:18:25.200 --> 00:18:36.640
So when we see somebody like this person, they actually had 185 degrees of total rotational motion on their non-throwing side, the other arm, and they had 195 degrees on their throwing side.
00:18:36.720 --> 00:18:38.640
So 10 degrees too much.
00:18:39.039 --> 00:18:46.079
That we often see with somebody that just did those velocity programs that we talked about in the subjective.
00:18:46.319 --> 00:18:57.759
So weighted balls, long toss programs, they increase your amount of external rotation of your shoulder, which does help with velocity, but then puts more stress on the medial elbow, right?
00:18:57.920 --> 00:19:01.279
And again, you see the downward spiral happen quite a bit.
00:19:01.519 --> 00:19:04.799
So those are our two big areas of focus for his motion.
00:19:04.880 --> 00:19:06.960
Well, one was his external rotation was too much.
00:19:07.039 --> 00:19:08.720
So that's often harder to deal with.
00:19:08.880 --> 00:19:11.599
But usually the solution of that is we abstain from throwing, right?
00:19:11.680 --> 00:19:12.720
We just take the ball away.
00:19:12.880 --> 00:19:16.000
We don't do the aggressive throwing, and that hopefully helps a little bit.
00:19:16.160 --> 00:19:20.559
But for overhead elevation, that was a large focus of our manual therapy was to get that back.
00:19:20.720 --> 00:19:30.720
And then lastly, we see this with most of our people that aren't on a formal program and haven't been injured before, but they had weakness of their rotator cuff, specifically the external rotators of the shoulder.
00:19:30.880 --> 00:19:36.640
So he's about 20% less than what I wanted for him, which I believe is enormous, right?
00:19:36.799 --> 00:19:37.839
That's a big deficit.
00:19:38.079 --> 00:19:45.839
We have a lot of testing that we do to look at that, but you know, in a nutshell, we could tell you about 20% off on a shoulder external rotation strength.
00:19:46.079 --> 00:19:47.680
We call that the moneymaker, right?
00:19:47.759 --> 00:19:51.759
Because that's the big muscle group that has to help stabilize and position the arm.
00:19:51.920 --> 00:19:54.799
And when that is off, we start to see lots of problems.
00:19:54.960 --> 00:19:59.200
And when we get that superhuman strong, they tend to do very well, right?
00:19:59.440 --> 00:20:04.160
Very typical presentation, subjective, objective, putting it all together.
00:20:04.240 --> 00:20:10.480
You know, it sure looks like he's got a bit of a flexor pronate or strain with an underlying partial UCL sprain.
00:20:10.720 --> 00:20:16.079
And we have now a checklist of suboptimal things to work on, and it's time to get started.
00:20:16.240 --> 00:20:16.640
Brilliant.
00:20:16.799 --> 00:20:18.240
Right, straight into it then.
00:20:18.319 --> 00:20:19.200
Where do you go next?
00:20:19.279 --> 00:20:20.240
And what do you do?
00:20:21.200 --> 00:20:29.200
So for us, you know, very typical, and it'll depend on the purse and the time of year, but Tommy John injury like this, we have a six-week shutdown.
00:20:29.279 --> 00:20:30.480
That's pretty much our standard.
00:20:30.720 --> 00:20:34.799
Six week shutdown period to get this to settle down and try to ramp back up.
00:20:35.119 --> 00:20:45.599
And what we routinely say, give or take, is for what when we stop throwing, however long we're down, is how long it's gonna take to come back, right?
00:20:45.759 --> 00:20:51.440
So if we're down six weeks from throwing, it's gonna take at least six weeks to get back to where they were, right?
00:20:51.519 --> 00:20:56.799
So we're looking at a three-month period with this kid, probably at best case scenario to see what happens.
00:20:57.119 --> 00:21:01.599
But here's how I like to do my Tommy John non-operative rehabs.
00:21:01.920 --> 00:21:05.920
I like to break those six weeks down into two-week chunks, three two-week chunks.
00:21:06.480 --> 00:21:13.759
At the end of each of those two weeks, I'll redo those valgus stress tests that we did on the initial exam to see how they look.
00:21:14.240 --> 00:21:16.160
And this is very anecdotal.
00:21:16.240 --> 00:21:18.720
This is just my limited experience with it.
00:21:19.200 --> 00:21:23.839
But if you're asymptomatic at the two-week mark, congrats.
00:21:24.000 --> 00:21:29.359
We're still gonna wait six weeks, but your prognosis is probably gonna be pretty good.
00:21:29.599 --> 00:21:33.200
If you're symptomatic at two weeks, but then at four weeks you're not, okay.
00:21:33.359 --> 00:21:36.160
I'm a little less excited, but still optimistic.
00:21:36.240 --> 00:21:36.960
Let's proceed.
00:21:37.200 --> 00:21:44.559
And if you get all the way to the six-week mark and you're still symptomatic on exam, to be honest with you, we're probably sending you for surgery at that point.
00:21:44.880 --> 00:21:49.680
We can certainly try to wait longer, but that's a ton of time to allow initial healing.
00:21:49.920 --> 00:21:54.480
If it's not healed by then, we don't want to just bang our head against the wall, right?
00:21:54.720 --> 00:21:57.440
Because these kids' careers are short, right?
00:21:57.519 --> 00:21:59.680
We want to get them back to where they need to be.
00:21:59.920 --> 00:22:01.200
So that's usually how we go.
00:22:01.599 --> 00:22:03.920
This particular kid was in the middle.
00:22:04.240 --> 00:22:08.160
So at the four-week mark is when he was first asymptomatic.
00:22:08.240 --> 00:22:11.440
Two week he was better, but still had some symptoms.
00:22:11.519 --> 00:22:13.119
But at the four-week mark, he was pretty good.
00:22:13.359 --> 00:22:15.759
So we'll break down the rehab in those two-week blocks.
00:22:15.920 --> 00:22:18.240
The first two weeks, it's a lot of facilitating healing.
00:22:18.480 --> 00:22:25.039
So we do things like laser, we do pulse ultrasound, some basic modalities for kitchen sink, right?
00:22:25.119 --> 00:22:30.640
We understand that there's limitations and modalities, but there are studies that show that they promote ligament healing.
00:22:30.799 --> 00:22:35.839
So if we're trying to do anything we can to help these athletes get back as fast, we're gonna do that.
00:22:36.000 --> 00:22:38.799
We're gonna work on restoring his range of motion, right?
00:22:38.880 --> 00:22:44.960
So his shoulder that we wanted to clean up, a little bit of his flexor mass, a little bit of tightness with that, a little bit of his irritation with it.
00:22:45.039 --> 00:22:48.079
We're gonna get that going and we're gonna start our baseline strengthening.
00:22:48.240 --> 00:22:50.960
The second two-each block is where we get more advanced.
00:22:51.119 --> 00:22:55.039
So I want to now start pushing his range of motion and get back to his thrower's motion.
00:22:55.119 --> 00:23:06.240
And I want to start doing some advanced strengthening exercises, manual exercises, dynamic stability, but really start to progress his strength because I want to get that external rotation strength up.
00:23:06.400 --> 00:23:10.000
And then that third two-eat block is where we start prepping for throwing.
00:23:10.079 --> 00:23:19.680
So we'll start to do plummetrics, we'll start two-hand, we'll progress to one-hand plummetrics, and just finally start to use the extremity with a little speed, with a little bit of load, right?
00:23:19.839 --> 00:23:23.920
Work on both producing and dissipating force a little bit in that in that extremity.
00:23:24.160 --> 00:23:25.759
So just try to put that together.
00:23:26.000 --> 00:23:29.119
So for him, he progressed pretty fairly normal.
00:23:29.279 --> 00:23:31.440
He was asymptomatic at the six-week mark.
00:23:31.519 --> 00:23:34.000
So we started an interval throwing program.
00:23:34.319 --> 00:23:36.319
So we follow an interval throwing program.
00:23:36.400 --> 00:23:49.519
We're actually about to publish our one specifically for this, but we just published earlier in 2024 in IJSPT, we published our interval throwing program for Tommy John injuries, uh, following workload progressions.
00:23:49.759 --> 00:23:51.680
So along the lines of Tim Gabbett's work.
00:23:51.759 --> 00:24:03.200
But what we did was we essentially looked at their chronic workload buildup and their acute chronic workload ratios going through a throwing progression because we want to make sure we're doing our interval throwing programs as precise as possible.
00:24:03.359 --> 00:24:05.440
So we got him on a six-week program.
00:24:05.680 --> 00:24:07.440
He got pretty far through it.
00:24:07.519 --> 00:24:12.400
He got past the catch phase, he started long tossing a little bit, he progressed to the mound.
00:24:12.480 --> 00:24:16.400
But unfortunately, when he was off the mound, he started to have symptoms again.
00:24:16.640 --> 00:24:17.519
And we see that.
00:24:17.599 --> 00:24:19.359
We see that a good amount, unfortunately.
00:24:19.440 --> 00:24:23.119
I wish these non-operatives worked better, but they don't always.
00:24:23.440 --> 00:24:29.039
So started working with the kid late February, March, going through a three-month progression.
00:24:29.200 --> 00:24:30.559
It's now early summer.
00:24:30.720 --> 00:24:32.000
He's still having symptoms.
00:24:32.160 --> 00:24:33.759
He's a sophomore in college.
00:24:34.079 --> 00:24:43.920
This is where experience comes into play, James, because what I don't want to do is shut him down for another month, try again, and then this kid's gonna miss next season, right?
00:24:44.079 --> 00:24:45.440
So if we don't do that.
00:24:45.599 --> 00:24:47.759
So he ended up seeing the surgeon again.
00:24:47.839 --> 00:24:54.880
They ended up doing a ulnar collateral ligament repair with an internal brace augmentation on top of it.
00:24:55.039 --> 00:25:00.160
And the timeline for those to return back to sports are somewhere in that six to eight month mark.
00:25:00.400 --> 00:25:05.759
So, you know, him getting that in June puts him on pace to try to be ready for next season.
00:25:06.000 --> 00:25:12.319
Unfortunately, we did that, but you know, he goes into surgery a lot better because his body's in much better condition than it was before.
00:25:12.559 --> 00:25:21.359
But more importantly, is you know, it's almost like giving him that advice at concierge that don't just keep shutting down, ramping back up, shutting down, and you know that roller coaster.
00:25:21.440 --> 00:25:23.519
Sometimes it's just time to move on.
00:25:23.599 --> 00:25:26.960
And if we do the surgery in June, you'll be back for next year.
00:25:27.039 --> 00:25:31.359
And we'll just have one year that you missed, and we'll get right back to your progression, hopefully.
00:25:31.440 --> 00:25:34.480
And that was part of the consultation that we had with him and his parents.
00:25:34.720 --> 00:25:35.680
Brilliant, really good.
00:25:35.920 --> 00:25:42.319
It's great to hear a case where you know it doesn't always go to plan, but most importantly, you have a plan of when it doesn't go to plan.
00:25:42.480 --> 00:25:45.759
And that plan was very individually athlete-centered.
00:25:46.000 --> 00:25:53.039
You know, you weren't dealing with uh someone who wasn't on a tight time frame, as you said, with a season or with a career that's short.
00:25:53.279 --> 00:25:54.559
Time matters, doesn't it?
00:25:54.799 --> 00:26:02.559
So, you know, having that plan for when it doesn't quite work out conservatively, it was really important for them as an athlete and you knowing that and having confidence in that.
00:26:02.880 --> 00:26:03.359
Absolutely.
00:26:03.519 --> 00:26:15.279
When you specialize and work with a specific population, especially that has unique injuries like this, that expertise that you have, that is something that's important to share with the athlete, the parents to help them, right?
00:26:15.359 --> 00:26:17.119
They because they need guidance.
00:26:17.200 --> 00:26:18.799
This isn't a normal injury.
00:26:19.039 --> 00:26:21.359
And my job is to help them succeed.
00:26:21.440 --> 00:26:24.960
And it's getting back on the field and doing that in the appropriate manner.
00:26:25.119 --> 00:26:26.880
So I think this kid's gonna do great.
00:26:26.960 --> 00:26:30.960
You know, he's in the middle of his rehabilitation progression right now, and things are going perfect.
00:26:31.119 --> 00:26:32.880
So I have full expectation.
00:26:33.119 --> 00:26:35.200
Outcomes of this procedure have been amazing.
00:26:35.359 --> 00:26:39.039
You know, we were skeptical of the wrong word for this new repair with internal brace.
00:26:39.119 --> 00:26:44.480
I don't want to say skeptical is the right word, but it's half the time of our traditional reconstruction that we did.
00:26:44.559 --> 00:26:53.519
So there's always a little hesitation that, you know, you want to make sure some of these kids aren't guinea pigs, but you know, they've done great and we've had really good success with them, and players have returned.
00:26:53.680 --> 00:27:00.240
We have some pitching and major league baseball with them, and it's been a great option for the right person if they're a candidate for it.
00:27:00.319 --> 00:27:01.599
So this kid got lucky.
00:27:01.839 --> 00:27:03.200
Mike, this has been fantastic.
00:27:03.359 --> 00:27:06.960
In the 30 seconds we've probably got left for this today.
00:27:07.200 --> 00:27:12.640
What would you say are your key takeaways for the listeners today, clinicians listening to this?
00:27:12.960 --> 00:27:20.079
The big takeaways here that people can learn from here is that a good subjective examination is going to lead your objective.
00:27:20.240 --> 00:27:25.519
And I think that's an important part here is to not rush through the subjective, let them tell their story.
00:27:25.599 --> 00:27:31.599
And I think what that will do is that will guide you on where you probably want to go for your differential diagnosis and your objective testing.
00:27:31.759 --> 00:27:34.400
I think that was a big takeaway with this kid.
00:27:34.559 --> 00:27:38.319
The second thing is that it's not just your structural examination, right?
00:27:38.480 --> 00:27:42.559
Just because you have a ligament sprain doesn't mean that I have a nice treatment plan built yet.
00:27:42.640 --> 00:27:45.839
I also need to do what we call that checklist of suboptimal.
00:27:46.000 --> 00:27:53.839
We put that together with the structural diagnosis, and now you can build a nice treatment program that centers around workload management, right?
00:27:53.920 --> 00:27:59.200
And essentially just slowly progressing the workload over time to return them back to their full activities.
00:27:59.440 --> 00:28:00.720
Yeah, absolutely, Mike.
00:28:00.960 --> 00:28:13.519
This has been really, really interesting, and I'm sure for many people who treat, even if it's on the audio, us throw our throwing athletes, this would be gonna be a really useful one to open our eyes up to this and some of the key treatment options they've got.
00:28:13.680 --> 00:28:17.440
So for those listening, do check out all the other stuff that Mike's done for Fizier Network.
00:28:17.519 --> 00:28:18.960
We've written some great blogs for us.
00:28:19.200 --> 00:28:21.519
So do search for Mike on the Fizier Network website.
00:28:21.599 --> 00:28:23.359
There's been some really interesting things on there.
00:28:23.440 --> 00:28:27.200
If you want to find out more, we'll put a link in the show notes to some of those as well.
00:28:27.359 --> 00:28:30.559
Mike, thanks again for your time and have a great rest of your day.
00:28:30.799 --> 00:28:32.640
Thanks so much for having me, that was fun.
00:00:02.799 --> 00:00:10.560
In today's episode of Case Studies, we're joined by Mike Reynolds, a world-renowned physical therapist, athletic trainer, and strength and conditioning coach.
00:00:10.800 --> 00:00:23.280
Mike is founder of Champion Physical Therapy and Performance in Boston and former head of athletic training and physical therapist for the Boston Red Sox, and also former senior medical advisor for the Chicago White Sox.
00:00:23.600 --> 00:00:29.760
He's widely recognised for his expertise in shoulder and elbow rehab, especially in overhead and throwing athletes.
00:00:29.920 --> 00:00:39.280
In this episode, Mike talks us through a real case study involving a baseball pitcher who presented with gradually worsening medial elbow pain early on in the season.
00:00:39.520 --> 00:00:44.719
Initially still able to play, the athlete symptoms progressed to the point where pitching was no longer possible.
00:00:44.960 --> 00:00:55.439
Mike unpacks how he approached this case, from taking a detailed subjective history, narrowing down his differential diagnosis, performing key objective tests and arriving at a clear diagnosis.
00:00:55.600 --> 00:01:04.159
He then shares how he built the rehab plan, what went well, what didn't, and key lessons every clinician can take away when working with throwing athletes.
00:01:04.319 --> 00:01:12.079
So whether you're working in sport or just want to refine your clinical reasoning, this is a brilliant example of expert level thinking in action.
00:01:12.239 --> 00:01:19.920
As you can imagine, this is just a brief coverage of this case, and you can dive way more detail with our case studies.
00:01:20.000 --> 00:01:23.120
You can find more information in the link in the show notes.
00:01:23.280 --> 00:01:28.719
But for now, grab a pen and a paper and open those ears, and sausages are never made a be.
00:01:30.239 --> 00:01:33.120
Mike, welcome to Case Studies.
00:01:33.200 --> 00:01:36.959
It's great to have you on and really looking forward to talking through this case with you today.
00:01:37.200 --> 00:01:38.959
Yeah, James, thanks so much for having me.
00:01:39.120 --> 00:01:43.359
Always an honor to be involved, and I'm a big listener to the other podcasts.
00:01:43.439 --> 00:01:48.239
So when you reached out to try to start this new case series, it sounded really exciting.
00:01:48.400 --> 00:01:56.319
I'm honored to be on, but I'm also excited to hear from the other people that you're gonna have in future episodes too, because this seems like a really neat format for future podcasts.
00:01:56.400 --> 00:01:57.359
So thanks for having me.
00:01:57.439 --> 00:01:58.239
Thanks for thinking of me.
00:01:58.400 --> 00:01:58.640
Brilliant.
00:01:58.719 --> 00:02:00.719
Well, let's get straight into it, shall we?
00:02:00.799 --> 00:02:03.680
So we're gonna go into your case study, Mike.
00:02:03.840 --> 00:02:09.360
Do you want to kickstart us with a bit of background on this one, including the subjective history for us?
00:02:09.759 --> 00:02:10.639
Absolutely, yeah.
00:02:10.879 --> 00:02:21.599
This specific one was a sophomore in college, he's a 20-year-old college baseball player, and I saw him at pretty much the beginning of their competitive season in the late winter.
00:02:21.759 --> 00:02:25.120
So I'm up in the northeast of the United States, up in Boston.
00:02:25.199 --> 00:02:29.280
So they start to play some games in February to go down south for warmer weather.
00:02:29.439 --> 00:02:35.360
It's usually right around late February, early March, where you start to see these injuries come in at the beginning of the season.
00:02:35.520 --> 00:02:38.479
So again, we had this player, it was the beginning of the season.
00:02:38.639 --> 00:02:41.520
They started to report having medial elbow pain.
00:02:41.680 --> 00:02:46.960
Very common if you work with overhead athletes and lots of sports, especially baseball, medial elbow pain.
00:02:47.120 --> 00:02:50.080
And didn't really feel anything over the winter in the offseason.
00:02:50.159 --> 00:02:57.039
But for the last three, four weeks, when they started ramping up their bullpen and they started throwing more off the mound, it was slowly getting worse.
00:02:57.199 --> 00:03:05.919
And their big complaint now is obviously they have no velocity, they're struggling with command, and it's just too uncomfortable to pitch effectively.
00:03:06.080 --> 00:03:10.960
So they technically cannot compete at their sport with the symptoms they're having.
00:03:11.120 --> 00:03:12.159
So we have that.
00:03:12.400 --> 00:03:15.280
I like to ask them specifics of the pain.
00:03:15.439 --> 00:03:19.439
So medial elbow pain, like nobody comes to you and says, I have medial elbow pain.
00:03:19.520 --> 00:03:21.280
They'll point at their elbow, they'll say something.
00:03:21.360 --> 00:03:22.479
You have to try to figure it out.
00:03:22.560 --> 00:03:26.000
But I like to ask things like specifically, can you point with one finger?
00:03:26.080 --> 00:03:26.240
Right.
00:03:26.479 --> 00:03:28.719
We can make sure that we're getting it right on that spot.
00:03:28.879 --> 00:03:33.280
And with baseball players, the inside of the elbow is such a small part of the body, right?
00:03:33.360 --> 00:03:34.240
It's very specific.
00:03:34.400 --> 00:03:39.039
It's almost like the size of like a dime or a nickel that you can just point to and you can see that pain on there.
00:03:39.120 --> 00:03:40.719
So typical medial pain.
00:03:40.879 --> 00:03:44.879
I like to ask when it happens during the throwing motion as well.
00:03:45.039 --> 00:03:46.719
Does it happen during ladyback?
00:03:46.800 --> 00:03:49.599
Does it happen as you start to accelerate the arm forward?
00:03:49.680 --> 00:03:52.479
Does it this happen at ball release or the follow-through?
00:03:52.719 --> 00:03:57.759
And for this particular person, and most people with zombie jaw injuries, they have pain with laid back.
00:03:57.919 --> 00:04:00.400
So full external rotation of the shoulder.
00:04:00.639 --> 00:04:07.439
So I think I have a decent understanding of where I'm probably going to go from here, but I also like to ask questions about their history.
00:04:07.520 --> 00:04:09.599
So, have you had pain in the past, right?
00:04:09.759 --> 00:04:11.280
Did anything wrong with your shoulder, right?
00:04:11.439 --> 00:04:14.639
We're looking specifically at your elbow, but if you had a past shoulder injury.
00:04:14.800 --> 00:04:18.800
And this particular kid who was pretty good, he said never really had any shoulder problems.
00:04:19.040 --> 00:04:27.600
He did say when he was really young that he had some inside of his elbow pain when he was young, that they shut him down for a couple months when he was like late little league age.
00:04:27.759 --> 00:04:30.160
I wouldn't say that's an irrelevant finding, right?
00:04:30.240 --> 00:04:34.160
Because that was probably the beginning of this year, but that was about five, six years ago.
00:04:34.399 --> 00:04:37.199
Again, he hasn't really had symptoms for a while.
00:04:37.439 --> 00:04:41.759
But he did add this, and I always do like to ask him, I say, Well, anything changed this year?
00:04:41.920 --> 00:04:43.120
What did you do something different?
00:04:43.360 --> 00:04:45.199
And I asked things like, Did you grow?
00:04:45.360 --> 00:04:51.360
I know he's 20, but believe it or not, we still see 20-year-olds go through growth, but did you grow three, four inches this year?
00:04:51.439 --> 00:04:52.319
And he said, No.
00:04:52.480 --> 00:05:09.360
He said, But I did start a velocity program this year, and that's something that we're finding quite a bit in our sport now, is that we're pushing the envelope of their physiological norms pretty much and trying to gain throwing velocity because velocity is what works, it gets batters out.
00:05:09.680 --> 00:05:15.600
So you succeed at your sport, you can get college scholarships, you can potentially get drafted and play at the professional level.
00:05:15.759 --> 00:05:17.279
So everybody's chasing velocity.
00:05:17.439 --> 00:05:23.199
So he and his pitching coach got on a velocity program this offseason and started doing a lot more.
00:05:23.360 --> 00:05:33.199
So started throwing with weighted balls, so different weights of balls, so underload and overload balls, started doing some extreme long toss where he's trying to throw it as far as he could.
00:05:33.360 --> 00:05:41.199
But then more importantly, really just up the frequency and volume of his throwing because he was doing these things.
00:05:41.519 --> 00:05:43.519
So that's a really clear history then.
00:05:43.680 --> 00:05:47.279
As you said, Mike, you're kind of getting into some specifics that you need to.
00:05:47.439 --> 00:05:56.399
We're gonna talk in a minute why you're gonna be doing that, because uh straight away running around your head, I'm sure, is a list of differential diagnoses.
00:05:56.879 --> 00:06:05.199
Some of the listeners may well have picked up on probably where we're gonna end up, but I think there probably will be many, many listening who aren't picking up that.
00:06:05.279 --> 00:06:10.319
And I just added on this note, picking up the term they're using there, the Tommy John injury.
00:06:10.480 --> 00:06:13.279
And I think there probably will be listeners who've never heard that before.
00:06:13.519 --> 00:06:17.120
So just talk us through, Mike, your differentials.
00:06:17.279 --> 00:06:21.680
What are the things outside of where we know we're going, but what are the other things you were thinking?
00:06:21.839 --> 00:06:26.079
I need to knock these off my radar or start ruling things out.
00:06:26.480 --> 00:06:26.800
Right.
00:06:26.879 --> 00:06:32.000
I like how you you've led to this though, because this isn't like a one of those true crime podcasts, right?
00:06:32.079 --> 00:06:39.839
Where you're you have a suspensive mystery that oftentimes the subjective leads us to where we're probably gonna go and where we're probably gonna end up, right?
00:06:39.920 --> 00:06:41.120
That's a good subjective.
00:06:41.360 --> 00:06:47.439
But yeah, differential diagnosis for the medial elbow to me, in a throwing athlete, it's one of four things.
00:06:47.600 --> 00:06:53.360
And I actually shouldn't say one of four things because oftentimes it could be several of these, it could be all of these, right?
00:06:53.519 --> 00:06:56.639
But it's the bone, the nerve, the muscle, and the ligament.
00:06:56.959 --> 00:07:00.720
And the ligament on the medial elbow that we're talking about is the ulnar collateral ligament.
00:07:00.800 --> 00:07:06.959
And the reason why these are called Tommy John injuries is there was a baseball pitcher back in the 80s, the 1980s.
00:07:07.120 --> 00:07:08.959
I have to say that now, that 1980s.
00:07:09.040 --> 00:07:10.639
It's it sounds weird saying it that way.
00:07:10.800 --> 00:07:15.839
But several decades ago, that was the first person to have this surgery, and his name was Tommy John.
00:07:16.160 --> 00:07:21.519
They named the surgery after him, just being the first person, and everybody now, like every kid knows what it is, right?
00:07:21.680 --> 00:07:23.360
Baseball coaches, parents know what it is.
00:07:23.439 --> 00:07:24.720
It's a Tommy John injury.
00:07:24.800 --> 00:07:28.639
So, yeah, diagnosis for me is usually gonna be one of those four things.
00:07:28.800 --> 00:07:34.319
And I never go into it assuming it's gonna be the Tommy John ligament, your ulnar collateral ligament.
00:07:34.480 --> 00:07:35.279
I don't assume that.
00:07:35.519 --> 00:07:38.480
Sometimes it isn't, but we're gonna look at those four things.
00:07:38.800 --> 00:07:48.560
The interesting thing between these four, though, and again, bone, nerve, muscle, ligament, is that they all get injured with the same mechanism, right?
00:07:48.800 --> 00:07:54.480
Baseball pitching and extreme layback as they get into external rotation of their shoulder during the pitching motion.
00:07:54.639 --> 00:08:02.240
So that's why you could almost argue that all these injuries to them are brothers and sisters, because if you stress one, you tend to stress the others.
00:08:02.399 --> 00:08:09.279
But for bone, we tend to get what's often called little lead elbow, but essentially that's like a growth plate injury, right?
00:08:09.439 --> 00:08:13.120
Where you have a growth plate injury to the medial side of the elbow there.
00:08:13.279 --> 00:08:18.399
And that's usually in youth where their growth plates are still open and they haven't matured, right?
00:08:18.480 --> 00:08:21.600
And that's a potential bony injury that you could have with that.
00:08:21.839 --> 00:08:23.439
This person's 20 years old.
00:08:23.600 --> 00:08:29.120
I guess it's still possible to get a stress reaction in your growth plate there, but it's pretty rare the older you get.
00:08:29.279 --> 00:08:38.159
We start to see that usually that's in the 12, 13, 14, maybe 15-year-olds that we see that those growth plate injuries, but that is definitely something we're gonna look for.
00:08:38.320 --> 00:08:42.080
That one's easy to rule out, obviously, just because it's a different spa.
00:08:42.320 --> 00:08:44.639
The second thing is the nerve, and that's the ulnar nerve.
00:08:44.720 --> 00:08:56.879
So the ulnar nerve that goes to the medial side goes through essentially the same area that the ligament, the flexor pronator mass, and these types of injuries happen with these athletes, right?
00:08:56.960 --> 00:09:06.799
But the ulnar nerve can get affected as well because, again, extreme external rotation, you can have various degrees of elbow flexion and extension as you're going through the pitching motion.
00:09:06.960 --> 00:09:10.799
It's very similar to a nerve glide for the ulnar nerve.
00:09:10.879 --> 00:09:14.639
And a lot of people almost throw with almost a nerve glide type motion.
00:09:14.879 --> 00:09:24.080
So we see some people that have ulnar, excuse me, ulnar nerve uh subluxation, and you can actually see it sublux in and out of the groove, and you can certainly have some of that.
00:09:24.399 --> 00:09:25.039
That's nerve.
00:09:25.200 --> 00:09:28.879
The way we differentially diagnose that is obviously do we have anything neurological?
00:09:28.960 --> 00:09:32.399
So oftentimes you'll see some numbness and the tingling and the fifth finger.
00:09:32.720 --> 00:09:38.480
In extreme rare cases, you'll see some like hypothenoreminence, atrophy, and some decreased in strength.
00:09:38.639 --> 00:09:42.639
That's pretty rare because if you've had that that long, you probably would have already addressed it.
00:09:42.799 --> 00:09:44.080
And again, we ruled that out.
00:09:44.159 --> 00:09:50.879
So tonel sign was negative on them, going through all the neurological things, nothing was of interest in there.
00:09:51.039 --> 00:09:53.759
So bone and nerve, we kind of moved on from.
00:09:53.919 --> 00:09:55.440
Next to is muscle ligament.
00:09:55.519 --> 00:10:04.799
So the flex for pronator mass and then the ulnar collateral ligament, if you really think about them, they both are working together to stabilize the medial side of the elbow.
00:10:04.960 --> 00:10:10.320
So we have the dynamic stabilizers and the muscles, and then the static stabilizers in the ligament.
00:10:10.720 --> 00:10:22.080
And again, they're both gonna get stressed with this motion because we have this varistoric and that valgus stress on the medial side of the elbow that's gonna cause both of those areas to potentially be symptomatic.
00:10:22.320 --> 00:10:26.960
So on this particular person, he did have discomfort with muscle contractions.
00:10:27.200 --> 00:10:31.440
So for us, that does mean that the flexor protonators involve could just be inflamed.
00:10:31.519 --> 00:10:33.919
It doesn't always necessarily have to be a tear, but it could be.
00:10:34.159 --> 00:10:35.120
Could just be inflamed.
00:10:35.200 --> 00:10:40.799
Some people don't have any discomfort with the muscle and it's just the ligament, but for him, he was a little uncomfortable in the muscle.
00:10:40.960 --> 00:10:43.840
And then we get to the big one, the ligament, the ulnar collateral ligament.
00:10:44.000 --> 00:10:47.360
So, you know, valgus stress testing is really the key to this.
00:10:47.600 --> 00:10:57.039
I particularly like to do this in the prone position and almost perform it almost like you would an MCL of the knee off the edge of the table with the elbow.
00:10:57.120 --> 00:11:03.200
And I've got a bunch of videos of that on my website and social media that you can probably dig up with me, me testing the UCL.
00:11:03.360 --> 00:11:09.919
But I really want to stabilize the shoulder, make sure that we're not getting any contributing motions of the shoulder to confuse things.
00:11:10.080 --> 00:11:16.639
On most of the testing, we did a Milkingstein, we did a moving valgus, and we did valgus stress testing in the prone position.
00:11:16.720 --> 00:11:19.120
And he had discomfort in all of those.
00:11:19.360 --> 00:11:21.919
So we're curious of the ligament, right?
00:11:22.000 --> 00:11:26.240
Without an MRI, we're still not sure if the ligament is completely involved.
00:11:26.480 --> 00:11:37.039
There are times that just having a flexor pronator strain could also hurt those motions, but it seemed to me like he probably had a little bit of those two.
00:11:37.360 --> 00:11:43.360
We did send him out, he did get an MRI, and it did show a partial tear of his UCL, right?
00:11:43.440 --> 00:11:49.919
So he had a little bit of inflammation in his flexor pronator mass and a partial tear of his UCL with the MRI.
00:11:50.159 --> 00:11:51.679
And that's common, right?
00:11:51.919 --> 00:11:58.399
Like the UCL in the elbow is not like your UCL on the knee, where you go skiing and it pops, it tears in half, right?
00:11:58.559 --> 00:12:02.000
Oftentimes what happens is you almost start to see some partial tearing, right?
00:12:02.080 --> 00:12:17.200
So he had a partial tear and something that considering his age, considering his duration of symptoms and the severity of the MRI, we were hoping that we would be able to get by with some non-operative rehabilitation for him.
00:12:17.360 --> 00:12:19.759
That was kind of like our differential diagnosis.
00:12:19.840 --> 00:12:22.720
And then based on that, I have a good understanding.
00:12:22.879 --> 00:12:27.840
We talked about a little about the objective testing to help me with his differential diagnosis.
00:12:28.000 --> 00:12:32.559
But to me, I still don't know what I need to do with him yet, right?
00:12:32.639 --> 00:12:37.120
All I know is he hurts and he has some special tests that are positive.
00:12:37.360 --> 00:12:43.919
But I haven't yet created my checklist of things that are suboptimal for me to actually start working on.
00:12:44.080 --> 00:12:56.320
So that's where my brain goes to next is what do we need to look at objectively to see now not only what's the differential diagnosis, but what is our treatment plan going to be for this person.
00:12:56.639 --> 00:12:57.039
Definitely.
00:12:57.120 --> 00:13:00.000
So you're starting to go into the realms of a problem list, aren't you?
00:13:00.080 --> 00:13:00.240
Really?
00:13:00.399 --> 00:13:04.480
We're starting to say, okay, well, we we can start seeing some structural issues.
00:13:04.720 --> 00:13:19.679
We're seeing ruling out other things, starting to rule in some things, but what are we going to do is more about the individual and what you're actually going to find in terms of restrictions and reductions in strength and um things like that.
00:13:19.840 --> 00:13:21.519
So where do we go next, then?
00:13:22.000 --> 00:13:26.720
I guess we we know what tree we're barking up, right, with our structural examination.
00:13:26.879 --> 00:13:29.039
Now it's looking at the functional stuff.
00:13:29.200 --> 00:13:34.399
And for us, what we did is we jumped in objectively and we like to get a good thorough assessment of them.
00:13:34.480 --> 00:13:36.080
And a couple of things stuck out to me.
00:13:36.240 --> 00:13:39.440
One, they had a loss of overhead elevation, quite a bit.
00:13:39.600 --> 00:13:44.960
They had about 145 degrees of shoulder flexion versus 175 on the other arm.
00:13:45.120 --> 00:13:46.159
And that's a big deal.
00:13:46.320 --> 00:13:48.480
We see that a lot in our baseball players.
00:13:48.639 --> 00:13:58.879
I almost call shoulder flexion the barometer of the shoulder, meaning if that is super tight, it often means your workload is super high and you're not recovering well.
00:13:59.120 --> 00:14:12.559
There are so much cumulative eccentric trauma in the lat, the Terry's major, the subscap from being into this layback external rotation position and then having to transition and come forward with velocity.
00:14:12.720 --> 00:14:14.480
It's a very stressful thing.
00:14:14.720 --> 00:14:18.480
And what we often find is that gets tight just in the normal act of throwing.
00:14:18.559 --> 00:14:27.200
But then when that gets tight and you lose shoulder flexion, then your biomechanics change when you pitch and your arm slot drops, and then you start putting more stress on your elbow.
00:14:27.440 --> 00:14:37.200
Chicken or the egg, I'm not sure, but you start to see that sometimes in people that have medial elbow pain, is that they also have limited elevation of the shoulder.
00:14:37.360 --> 00:14:38.799
So we found that great.
00:14:39.200 --> 00:14:40.399
That's something we can clean up.
00:14:40.480 --> 00:14:49.919
And I've actually had people just in a couple of weeks, if you clean up that range of motion and then bring them back through their throwing motion, their pain is much better, sometimes even gone.
00:14:50.399 --> 00:14:54.240
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00:14:54.480 --> 00:15:06.559
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00:15:06.960 --> 00:15:11.600
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00:15:16.159 --> 00:15:20.960
You you mentioned a really good point there in terms of using that shoulder elevation as a barometer.
00:15:21.120 --> 00:15:27.919
Would you ever in a a kind of a team environment measure that routinely and see any changes?
00:15:28.480 --> 00:15:33.440
So uh on our professional teams that I work with, we measure those daily.
00:15:33.840 --> 00:15:43.440
Every day they come in, and we call it a pre-throw stretch just because you know you want the player to think you're stretching them versus staffing them, right?
00:15:43.600 --> 00:15:44.720
Measure measuring them.
00:15:44.879 --> 00:15:47.759
And if that we bring them through, it could take two minutes.
00:15:47.840 --> 00:15:53.200
And if things look great, we pat them on the shoulder, we say, Good look, go, good job, go get them today, have fun.
00:15:53.360 --> 00:15:55.759
If they look tight one day, we're like, Oh, you know what?
00:15:55.840 --> 00:15:59.679
You threw in the game yesterday, you had an upper body lift, you're a little strike.
00:15:59.840 --> 00:16:05.120
Then we're gonna apply treatments because one of my philosophies with working with baseball players is very simple, right?
00:16:05.279 --> 00:16:07.279
Let's say you're one of my pitchers, James.
00:16:07.440 --> 00:16:10.480
Every time you pick up a ball, I want you to look like James.
00:16:10.639 --> 00:16:14.240
And we know that throwing a baseball is technically bad for you, right?
00:16:14.399 --> 00:16:16.960
It's stressful, and you can get hurt doing it, right?
00:16:17.039 --> 00:16:18.960
So there's a lot of stress that happens.
00:16:19.120 --> 00:16:23.600
So when you go pitch, I know that after the game, your range of motion is going to be decreased.
00:16:23.759 --> 00:16:28.159
And if we don't address that cumulatively over the course of the season, that is gonna continue to decrease.
00:16:28.320 --> 00:16:29.840
So that's why it becomes that barometer.
00:16:30.000 --> 00:16:38.799
So we want everybody to look like themselves and to get some manual therapy wherever they may need each day to restore their motion to get them back before they throw again.
00:16:38.960 --> 00:16:43.919
Because baseball is one of those weird sports we play every day, it's not once a week like a lot of other sports.
00:16:44.159 --> 00:16:45.120
There's games every day.
00:16:45.200 --> 00:16:50.720
You know, in Major League Baseball in the States, we have 162 games in 180 days.
00:16:52.799 --> 00:16:55.759
But so that's their shoulder flexion.
00:16:55.840 --> 00:17:01.440
The other thing with him that we noted was that he had too much external rotation of his shoulder.
00:17:01.759 --> 00:17:16.799
And a lot of people think that that is a good thing, and it often is because the more external rotation you have, it correlates to an increase in pitching velocity, but it also correlates to an increase in stress, which is physics, right?
00:17:16.960 --> 00:17:21.279
Like we know that we're the medical professionals onto this, we understand that.
00:17:21.519 --> 00:17:24.559
But we see this oftentimes in our baseball players.
00:17:24.799 --> 00:17:36.559
20 years ago, and there's still some people that perpetuate this a little bit, but this concept of GERD and GERD with an eye, not the one where we have an upset stomach, but glenohumeral internal rotation deficit.
00:17:36.799 --> 00:17:54.799
And essentially what we were over-diagnosing 20 years ago was a normal adaptation that we found, where again, the bony changes of the humerus when you're going through a gross burnt and your growth plates are open and you throw, allow the throwing arm to get more external rotation, and then there's subsequently less internal rotation.
00:17:54.960 --> 00:17:59.519
But if you add up ER and IR on both sides, the number should be exactly the same.
00:17:59.759 --> 00:18:01.680
So let's make the numbers easy.
00:18:01.839 --> 00:18:06.799
Throwing side should have 120 degrees external rotation, 60 degrees of IR.
00:18:06.960 --> 00:18:09.920
On your non-throwing side, that's probably going to be off a little bit.
00:18:10.079 --> 00:18:17.359
Maybe that's 110 degrees ER, but 70 degrees of IR, but you add them both up, it's 180 degrees on the dot.
00:18:17.519 --> 00:18:24.960
And we find that with the hip too, but like for the shoulder, those are those bony changes from throwing when your growth plates are open.
00:18:25.200 --> 00:18:36.640
So when we see somebody like this person, they actually had 185 degrees of total rotational motion on their non-throwing side, the other arm, and they had 195 degrees on their throwing side.
00:18:36.720 --> 00:18:38.640
So 10 degrees too much.
00:18:39.039 --> 00:18:46.079
That we often see with somebody that just did those velocity programs that we talked about in the subjective.
00:18:46.319 --> 00:18:57.759
So weighted balls, long toss programs, they increase your amount of external rotation of your shoulder, which does help with velocity, but then puts more stress on the medial elbow, right?
00:18:57.920 --> 00:19:01.279
And again, you see the downward spiral happen quite a bit.
00:19:01.519 --> 00:19:04.799
So those are our two big areas of focus for his motion.
00:19:04.880 --> 00:19:06.960
Well, one was his external rotation was too much.
00:19:07.039 --> 00:19:08.720
So that's often harder to deal with.
00:19:08.880 --> 00:19:11.599
But usually the solution of that is we abstain from throwing, right?
00:19:11.680 --> 00:19:12.720
We just take the ball away.
00:19:12.880 --> 00:19:16.000
We don't do the aggressive throwing, and that hopefully helps a little bit.
00:19:16.160 --> 00:19:20.559
But for overhead elevation, that was a large focus of our manual therapy was to get that back.
00:19:20.720 --> 00:19:30.720
And then lastly, we see this with most of our people that aren't on a formal program and haven't been injured before, but they had weakness of their rotator cuff, specifically the external rotators of the shoulder.
00:19:30.880 --> 00:19:36.640
So he's about 20% less than what I wanted for him, which I believe is enormous, right?
00:19:36.799 --> 00:19:37.839
That's a big deficit.
00:19:38.079 --> 00:19:45.839
We have a lot of testing that we do to look at that, but you know, in a nutshell, we could tell you about 20% off on a shoulder external rotation strength.
00:19:46.079 --> 00:19:47.680
We call that the moneymaker, right?
00:19:47.759 --> 00:19:51.759
Because that's the big muscle group that has to help stabilize and position the arm.
00:19:51.920 --> 00:19:54.799
And when that is off, we start to see lots of problems.
00:19:54.960 --> 00:19:59.200
And when we get that superhuman strong, they tend to do very well, right?
00:19:59.440 --> 00:20:04.160
Very typical presentation, subjective, objective, putting it all together.
00:20:04.240 --> 00:20:10.480
You know, it sure looks like he's got a bit of a flexor pronate or strain with an underlying partial UCL sprain.
00:20:10.720 --> 00:20:16.079
And we have now a checklist of suboptimal things to work on, and it's time to get started.
00:20:16.240 --> 00:20:16.640
Brilliant.
00:20:16.799 --> 00:20:18.240
Right, straight into it then.
00:20:18.319 --> 00:20:19.200
Where do you go next?
00:20:19.279 --> 00:20:20.240
And what do you do?
00:20:21.200 --> 00:20:29.200
So for us, you know, very typical, and it'll depend on the purse and the time of year, but Tommy John injury like this, we have a six-week shutdown.
00:20:29.279 --> 00:20:30.480
That's pretty much our standard.
00:20:30.720 --> 00:20:34.799
Six week shutdown period to get this to settle down and try to ramp back up.
00:20:35.119 --> 00:20:45.599
And what we routinely say, give or take, is for what when we stop throwing, however long we're down, is how long it's gonna take to come back, right?
00:20:45.759 --> 00:20:51.440
So if we're down six weeks from throwing, it's gonna take at least six weeks to get back to where they were, right?
00:20:51.519 --> 00:20:56.799
So we're looking at a three-month period with this kid, probably at best case scenario to see what happens.
00:20:57.119 --> 00:21:01.599
But here's how I like to do my Tommy John non-operative rehabs.
00:21:01.920 --> 00:21:05.920
I like to break those six weeks down into two-week chunks, three two-week chunks.
00:21:06.480 --> 00:21:13.759
At the end of each of those two weeks, I'll redo those valgus stress tests that we did on the initial exam to see how they look.
00:21:14.240 --> 00:21:16.160
And this is very anecdotal.
00:21:16.240 --> 00:21:18.720
This is just my limited experience with it.
00:21:19.200 --> 00:21:23.839
But if you're asymptomatic at the two-week mark, congrats.
00:21:24.000 --> 00:21:29.359
We're still gonna wait six weeks, but your prognosis is probably gonna be pretty good.
00:21:29.599 --> 00:21:33.200
If you're symptomatic at two weeks, but then at four weeks you're not, okay.
00:21:33.359 --> 00:21:36.160
I'm a little less excited, but still optimistic.
00:21:36.240 --> 00:21:36.960
Let's proceed.
00:21:37.200 --> 00:21:44.559
And if you get all the way to the six-week mark and you're still symptomatic on exam, to be honest with you, we're probably sending you for surgery at that point.
00:21:44.880 --> 00:21:49.680
We can certainly try to wait longer, but that's a ton of time to allow initial healing.
00:21:49.920 --> 00:21:54.480
If it's not healed by then, we don't want to just bang our head against the wall, right?
00:21:54.720 --> 00:21:57.440
Because these kids' careers are short, right?
00:21:57.519 --> 00:21:59.680
We want to get them back to where they need to be.
00:21:59.920 --> 00:22:01.200
So that's usually how we go.
00:22:01.599 --> 00:22:03.920
This particular kid was in the middle.
00:22:04.240 --> 00:22:08.160
So at the four-week mark is when he was first asymptomatic.
00:22:08.240 --> 00:22:11.440
Two week he was better, but still had some symptoms.
00:22:11.519 --> 00:22:13.119
But at the four-week mark, he was pretty good.
00:22:13.359 --> 00:22:15.759
So we'll break down the rehab in those two-week blocks.
00:22:15.920 --> 00:22:18.240
The first two weeks, it's a lot of facilitating healing.
00:22:18.480 --> 00:22:25.039
So we do things like laser, we do pulse ultrasound, some basic modalities for kitchen sink, right?
00:22:25.119 --> 00:22:30.640
We understand that there's limitations and modalities, but there are studies that show that they promote ligament healing.
00:22:30.799 --> 00:22:35.839
So if we're trying to do anything we can to help these athletes get back as fast, we're gonna do that.
00:22:36.000 --> 00:22:38.799
We're gonna work on restoring his range of motion, right?
00:22:38.880 --> 00:22:44.960
So his shoulder that we wanted to clean up, a little bit of his flexor mass, a little bit of tightness with that, a little bit of his irritation with it.
00:22:45.039 --> 00:22:48.079
We're gonna get that going and we're gonna start our baseline strengthening.
00:22:48.240 --> 00:22:50.960
The second two-each block is where we get more advanced.
00:22:51.119 --> 00:22:55.039
So I want to now start pushing his range of motion and get back to his thrower's motion.
00:22:55.119 --> 00:23:06.240
And I want to start doing some advanced strengthening exercises, manual exercises, dynamic stability, but really start to progress his strength because I want to get that external rotation strength up.
00:23:06.400 --> 00:23:10.000
And then that third two-eat block is where we start prepping for throwing.
00:23:10.079 --> 00:23:19.680
So we'll start to do plummetrics, we'll start two-hand, we'll progress to one-hand plummetrics, and just finally start to use the extremity with a little speed, with a little bit of load, right?
00:23:19.839 --> 00:23:23.920
Work on both producing and dissipating force a little bit in that in that extremity.
00:23:24.160 --> 00:23:25.759
So just try to put that together.
00:23:26.000 --> 00:23:29.119
So for him, he progressed pretty fairly normal.
00:23:29.279 --> 00:23:31.440
He was asymptomatic at the six-week mark.
00:23:31.519 --> 00:23:34.000
So we started an interval throwing program.
00:23:34.319 --> 00:23:36.319
So we follow an interval throwing program.
00:23:36.400 --> 00:23:49.519
We're actually about to publish our one specifically for this, but we just published earlier in 2024 in IJSPT, we published our interval throwing program for Tommy John injuries, uh, following workload progressions.
00:23:49.759 --> 00:23:51.680
So along the lines of Tim Gabbett's work.
00:23:51.759 --> 00:24:03.200
But what we did was we essentially looked at their chronic workload buildup and their acute chronic workload ratios going through a throwing progression because we want to make sure we're doing our interval throwing programs as precise as possible.
00:24:03.359 --> 00:24:05.440
So we got him on a six-week program.
00:24:05.680 --> 00:24:07.440
He got pretty far through it.
00:24:07.519 --> 00:24:12.400
He got past the catch phase, he started long tossing a little bit, he progressed to the mound.
00:24:12.480 --> 00:24:16.400
But unfortunately, when he was off the mound, he started to have symptoms again.
00:24:16.640 --> 00:24:17.519
And we see that.
00:24:17.599 --> 00:24:19.359
We see that a good amount, unfortunately.
00:24:19.440 --> 00:24:23.119
I wish these non-operatives worked better, but they don't always.
00:24:23.440 --> 00:24:29.039
So started working with the kid late February, March, going through a three-month progression.
00:24:29.200 --> 00:24:30.559
It's now early summer.
00:24:30.720 --> 00:24:32.000
He's still having symptoms.
00:24:32.160 --> 00:24:33.759
He's a sophomore in college.
00:24:34.079 --> 00:24:43.920
This is where experience comes into play, James, because what I don't want to do is shut him down for another month, try again, and then this kid's gonna miss next season, right?
00:24:44.079 --> 00:24:45.440
So if we don't do that.
00:24:45.599 --> 00:24:47.759
So he ended up seeing the surgeon again.
00:24:47.839 --> 00:24:54.880
They ended up doing a ulnar collateral ligament repair with an internal brace augmentation on top of it.
00:24:55.039 --> 00:25:00.160
And the timeline for those to return back to sports are somewhere in that six to eight month mark.
00:25:00.400 --> 00:25:05.759
So, you know, him getting that in June puts him on pace to try to be ready for next season.
00:25:06.000 --> 00:25:12.319
Unfortunately, we did that, but you know, he goes into surgery a lot better because his body's in much better condition than it was before.
00:25:12.559 --> 00:25:21.359
But more importantly, is you know, it's almost like giving him that advice at concierge that don't just keep shutting down, ramping back up, shutting down, and you know that roller coaster.
00:25:21.440 --> 00:25:23.519
Sometimes it's just time to move on.
00:25:23.599 --> 00:25:26.960
And if we do the surgery in June, you'll be back for next year.
00:25:27.039 --> 00:25:31.359
And we'll just have one year that you missed, and we'll get right back to your progression, hopefully.
00:25:31.440 --> 00:25:34.480
And that was part of the consultation that we had with him and his parents.
00:25:34.720 --> 00:25:35.680
Brilliant, really good.
00:25:35.920 --> 00:25:42.319
It's great to hear a case where you know it doesn't always go to plan, but most importantly, you have a plan of when it doesn't go to plan.
00:25:42.480 --> 00:25:45.759
And that plan was very individually athlete-centered.
00:25:46.000 --> 00:25:53.039
You know, you weren't dealing with uh someone who wasn't on a tight time frame, as you said, with a season or with a career that's short.
00:25:53.279 --> 00:25:54.559
Time matters, doesn't it?
00:25:54.799 --> 00:26:02.559
So, you know, having that plan for when it doesn't quite work out conservatively, it was really important for them as an athlete and you knowing that and having confidence in that.
00:26:02.880 --> 00:26:03.359
Absolutely.
00:26:03.519 --> 00:26:15.279
When you specialize and work with a specific population, especially that has unique injuries like this, that expertise that you have, that is something that's important to share with the athlete, the parents to help them, right?
00:26:15.359 --> 00:26:17.119
They because they need guidance.
00:26:17.200 --> 00:26:18.799
This isn't a normal injury.
00:26:19.039 --> 00:26:21.359
And my job is to help them succeed.
00:26:21.440 --> 00:26:24.960
And it's getting back on the field and doing that in the appropriate manner.
00:26:25.119 --> 00:26:26.880
So I think this kid's gonna do great.
00:26:26.960 --> 00:26:30.960
You know, he's in the middle of his rehabilitation progression right now, and things are going perfect.
00:26:31.119 --> 00:26:32.880
So I have full expectation.
00:26:33.119 --> 00:26:35.200
Outcomes of this procedure have been amazing.
00:26:35.359 --> 00:26:39.039
You know, we were skeptical of the wrong word for this new repair with internal brace.
00:26:39.119 --> 00:26:44.480
I don't want to say skeptical is the right word, but it's half the time of our traditional reconstruction that we did.
00:26:44.559 --> 00:26:53.519
So there's always a little hesitation that, you know, you want to make sure some of these kids aren't guinea pigs, but you know, they've done great and we've had really good success with them, and players have returned.
00:26:53.680 --> 00:27:00.240
We have some pitching and major league baseball with them, and it's been a great option for the right person if they're a candidate for it.
00:27:00.319 --> 00:27:01.599
So this kid got lucky.
00:27:01.839 --> 00:27:03.200
Mike, this has been fantastic.
00:27:03.359 --> 00:27:06.960
In the 30 seconds we've probably got left for this today.
00:27:07.200 --> 00:27:12.640
What would you say are your key takeaways for the listeners today, clinicians listening to this?
00:27:12.960 --> 00:27:20.079
The big takeaways here that people can learn from here is that a good subjective examination is going to lead your objective.
00:27:20.240 --> 00:27:25.519
And I think that's an important part here is to not rush through the subjective, let them tell their story.
00:27:25.599 --> 00:27:31.599
And I think what that will do is that will guide you on where you probably want to go for your differential diagnosis and your objective testing.
00:27:31.759 --> 00:27:34.400
I think that was a big takeaway with this kid.
00:27:34.559 --> 00:27:38.319
The second thing is that it's not just your structural examination, right?
00:27:38.480 --> 00:27:42.559
Just because you have a ligament sprain doesn't mean that I have a nice treatment plan built yet.
00:27:42.640 --> 00:27:45.839
I also need to do what we call that checklist of suboptimal.
00:27:46.000 --> 00:27:53.839
We put that together with the structural diagnosis, and now you can build a nice treatment program that centers around workload management, right?
00:27:53.920 --> 00:27:59.200
And essentially just slowly progressing the workload over time to return them back to their full activities.
00:27:59.440 --> 00:28:00.720
Yeah, absolutely, Mike.
00:28:00.960 --> 00:28:13.519
This has been really, really interesting, and I'm sure for many people who treat, even if it's on the audio, us throw our throwing athletes, this would be gonna be a really useful one to open our eyes up to this and some of the key treatment options they've got.
00:28:13.680 --> 00:28:17.440
So for those listening, do check out all the other stuff that Mike's done for Fizier Network.
00:28:17.519 --> 00:28:18.960
We've written some great blogs for us.
00:28:19.200 --> 00:28:21.519
So do search for Mike on the Fizier Network website.
00:28:21.599 --> 00:28:23.359
There's been some really interesting things on there.
00:28:23.440 --> 00:28:27.200
If you want to find out more, we'll put a link in the show notes to some of those as well.
00:28:27.359 --> 00:28:30.559
Mike, thanks again for your time and have a great rest of your day.
00:28:30.799 --> 00:28:32.640
Thanks so much for having me, that was fun.
