The View from Sports Center

The End of Prolotherapy

Day #58  Post-Prolo
Friday, May 14, 2010

"Oh, my God! Kelsey! Is that your bad shoulder!" exclaimed Heidi.

Heidi had walked by the open door of the consult room where Christine was testing my shoulder and caught a glimpse of the action so she stopped.

And apparently stared.

Christine was using a hand held digital muscle tester to test how much force I could produce for certain motions of the shoulder: flexion, abduction, external rotation, internal rotation, and then one that stresses the supraspinatus muscle.

I pushed as hard as I could against the resistance supplied by Christine. I think it must have been at this point that Heidi walked by the door. My face was probably scrunched up like a true strong man.

I met or exceeded four out of six goals and was 90% of the remaining two. Nothing hurt. The shoulder felt strong. Solid.

The next day, today, I had a follow up visit with Dr. Fullerton.

I explained the results of the test but that I still had some pain with a certain motion. And that if I treated the infraspinatus trigger point, that motion became pain free.

He suggested that an injection of the trigger points might be all I needed right now.

I was all for that. Another series of prolo shots means another six weeks of rehab and I don't mind that if that's what I need but if not, I'm ready to move on to the next round of training.

I sort of wish I hadn't agreed to the trigger point injections. When the needle hits the point, the muscle grabs it like it an intruder and it doesn't want to let go. Hurt? Uh, yeah. Sure does. The upside is that I can move my arm better. And that the discomfort passes quickly.

So, it looks like the end of prolotherapy.

At least for my shoulder. And I'm thrilled with my outcome and where I am right now.

I have another ultrasound in about six weeks to look at the tendon but I seriously doubt I'll need any more prolo.

As I was leaving, Dr. Fullerton asked,"So, I'm seeing you next week for your knee? What's up?"

"I think I tore the medial mensicus. Pretty sure I did. Showing a client a drill. Got caught in an odd position getting up. A couple of clunks and thuds and a few days later it was hard to walk." I showed where the symptoms typically show up.

"Yeah, sounds like a degenerative tear. We'll look at it then," he replied.

Good news is I can concentrate on the knee injury and close the chapter on the shoulder.

I stopped the Low Intensity Pulsed Ultrasound on my knee after about a month. Not sure if it helped or not since I was also doing several other things but overall my knee feels better. I have some low grade symptoms from time to time but I can't fully flex it, it doesn't feel stable, and I know I can't load it much without provoking some symptoms (tightness, cramping, pain). And if I try something like a Child's Pose, I have a sharp pain on the medial part of my knee right where the meniscus is located. Classic symptoms of a tear.

I know that surgery is a possibility and if I need to go that route, I will. But, I still have some other non-surgical options and as long as I don't continue to aggravate it, I'll be ok.

In the meantime, a typical rehab day is:

• 15-20 minutes of low load bilateral squats (I use a Total Gym).
• 20-30 minutes of tailgaters or leg sliders.
• 100 quad sets.
• 45 minutes of resistance intervals on an elliptical machine. Resistance intervals are two things: one is the machine has a program that automatically adjusts the resistance every few minutes. The other is that I carry a 15 lb dumb bell in one hand for five minutes then the other hand for five minutes. I then wait five minutes and repeat the process.

I'll do this three or four days per week. I missed most of last week since it was birthday week and my brother was in town.

I see Dr. Fullerton on Friday, May 21st. I'll let you know what happens. Tear? Where? How big? Prolo? PRP? Surgery?

Lots of questions. No answers yet.

Just have to get comfortable with the unknown and the transitional nature of life. You never really know what will happen so for now, stay in the present.

DK

Question from a Reader About Prolotherapy

Hey Doug

Well I just had confirmation of a torn supraspinatus - back to my sports doc tomorrow to discuss prolotherapy.  I had a gnarly bike crash 2 months ago, and my shoulder never came right, so broke down and went to the physio last week who referred me to the doc.  I have been lifting heavy since the accident, some sessions better than others with over the head presses and incline presses.  but like you said, conditioning stuff is OK, burpees, chins, pushups etc all OK.

Question for you - what have you been told the prolotherapy actually does?  Just to encourage repair? Have you been told to curtail any activities?  How many sessions of injections are you going to have to have?  Does it deal to the inflammation as well?

Would be great to hear back from you, thanks in advance. 

Cheers,

Susan

********

Hi Susan -

I'm sorry to hear of your injury. But, the good news is that you have a good chance of recovery and getting back to doing the things you enjoy. The bad news is that the journey back to the land of fun stuff is often long and bumpy.

Prolotherapy causes an inflammatory reaction in the tissue which stimulates the production of new collagen - the basic building block of tendon. After the injection, which by the way is more like ten or twelve injections per session, you should not exercise the area for about three days. Then I use active-assisted motion for another ten days as the tissue moves through the first inflammatory phase. You can read more about the drills I use here (go to March 13 entry for a video of some of the drills). You then slowly progress the loading and demand on the involved area until the next series of injections.

The injections can hurt. Sometimes a little; sometimes a lot. And, the post-injection phase can also be painful. My first series was tough. Really interfered with sleep, hurt a lot during the day. But, the second round was better. A friend and client of mine just went through her second round of injections and she felt it was worse than the first. Point is, the reaction is highly variable.

You can't take any anti-inflammatory medication for at least ten days since the whole point of the injections is to inflame your tissue. You can take pain medication if needed though.

As for how many appointments you'll need, I don't know. So far, I've had two and have another one scheduled. I may need one or two more. It depends on how much healing has taken place and how symptomatic you are following the injections. An ultrasound will show the degree of healing.

And, although you didn't ask, but I'll weigh in on this anyway, bench press or incline press and overhead press are two drills I would take off your list. If you want to do an overhead press, do one arm at a time - dumb bell or kettle bell. This gives your thoracic spine some room to side bend and extend and help your shoulder. When you use both hands on a fixed bar, you have to have excellent thoracic extension and scapular stability to not overload your rotator cuff. Most people just don't have that kind of flexibility.

There's very little information on what to do following prolotherapy in terms of rehab or exercise. I'm working on ways to get that information out to people. I've been invited to speak at the American Academy of Orthopedic Medicine meeting next year on that very topic so between now and then I'll be developing the content and when I have something to share, you'll hear about it here.

Thanks for sending in your questions and I hope this was helpful to you. Best of luck in your recovery.

Shoulder Update - Day 30 Post-Prolo

Day #30

Friday, April 8, 2010

"Hey - you can feed your self this time! You seem to be doing a lot better!" Ellen said as we ate dinner.

"Really...you know I had forgotten about that but, yeah, you're right. My shoulder isn't as beat up this time around as last time," I replied.

About five hours earlier, I had finished the second round of prolotherapy administered by Brad Fullerton, MD. The process was still painful. He hit some real zingers but overall, I had fewer injections and when I left, I noticed I could move my arm without much pain. Of course, I knew that wouldn't last as the lidocaine wore off but it meant that he hit the right structures this time.

Last time, Dr. Fullerton spent quite a while trying to track down the source of the pain I was having with rotation and flexion of the shoulder. He couldn't find it but this time he seemed to have a renewed level of resolve. "We've got to zap that thing this time," he said in between bars of humming to Warren Zevon's "Lawyers, Guns, and Money".

He found two trigger points in my shoulder that were really sore and painful and when he punched on them, pain galloped up into my head and down the front of my arm. As my body sort of twisted around like Gumby, he said something like, "Freddenbocker schmoker socker" to help me not turn into Steve Carell in the scene from "40 Year Old Virgin" when he gets hair ripped off his body. I appreciated that - made me laugh.

Dr. Fullerton then took a needle and stuck it into the trigger points until he got a twitch from the muscle. Ok, so that hurts. Not like child birth or anything but still, it makes your toes curl. He had to hit the muscle a few times. When he was done, he re-tested my arm. Bingo. Full motion with almost no pain.

"So, this pain is not from the tear then, right?" I asked.

"Yep. Looks like it's trigger points. But, you have to wonder why you have some many of them though," he replied.

Trigger points. Some days I feel like somebody slipped into my brain and padlocked the file drawer that says, "What You Know About Pain and Movement".

The weird thing about trigger point pain is that where you hurt is not where the problem is and still, you can be really tender there. So, it's easy to get distracted. You think, for example, that the problem is in your neck. Your neck hurts, it's tender to touch, to stretch. But, the source could easily be a trigger point in the upper trapezius muscle belly several inches away from the pain.

For my shoulder, one of the trigger points was the infraspinatus muscle on the back side of the shoulder. It refers pain to the front. In the image, the "X" is the trigger point and the red area is where you feel the pain. Notice that it goes into the hand so you can misinterpret the issue. Because you hurt in the hand and arm, you might think, and logically so, that the source is the neck. I also had a lot of tenderness in the red zone. After the point was needled, most of the pain and tenderness was gone.

Next, I chill for a few days. I can do some general conditioning but I have to let my shoulder rest. Then, I start Phase I drills for about ten days and then move into Phase II. I'm headed back for a third prolotherapy session in the middle of May.

I'm optimistic about this whole process. I think in a few weeks, just based on how I feel and can move today, that I'm going to be a lot better. It takes a while for the tissue to heal, remodel, get stronger but when I'm done, I'll have a solid shoulder.

******

Follow my recovery from a rotator cuff tear here. I post new stuff every day or two generally.

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******

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And the Ultrasound Says....

"Yep, right there. You see that spot right there? That's a tear," said Dr. Fullerton. "So, when you move your arm out, when you rotate it, the motion tugs on that tear and that's probably why it hurts."

Dr. Fullerton had spent over an hour imaging my right shoulder with an ultrasound machine. That was after he had examined my shoulder and ended up scratching his head. The exam didn't fit the typical pattern of a rotator cuff tear. 

The tear is near the end of the supraspinatus tendon close to the bone. It's small. Not big enough for surgery.

"So, what's your suggestion about this?" I asked.

"Well, you can keep doing what you're doing since you're getting better. We could also inject the area with a mixture of dextrose and lidocaine to stimulate it. There's no rush here. So, if you want to wait a couple of months and keep working on it, you can," replied Dr. Fullerton. "But, I would like you to get an x-ray of the shoulder just to make sure you don't have a big spur or something there. I doubt that you do but it would be good to know."

So, with that information, I had to make the call to Christine to let her know that her suspicions were right. She was gracious as always and refrained from saying "I told you so."

I've been in rehab for my shoulder injury since the end of December 2009 and have made great progress. The reasons I went to see Dr. Fullerton were 1.) Christine told me to and 2.) I was still having trouble with a throwing motion. Knowing that I have a small tear and where the tear is explains why it still hurts with certain motions. 

What to do? Well, I'll get the x-ray and likely opt for prolotherapy in addition to the ongoing rehab. I'm curious about prolo so part of the reason is to satisfy my own sense of wonder about what it feels like, how it works, and to see how quickly I can heal the tear. Prolotherapy is not widely accepted within the medical community although it is less controversial than platelet rich plasma injections (PRP). Basically, what prolo does is irritate the tissue and stimulate it to heal. This is a similar process to what we use in an exercise based, tendon remodeling program so the combination should work well.

I've said before that accepting reality is one of the first things you have to do to start healing. For each of us, that process takes a different path and a different time frame and some of us get stuck in anger. We're angry at our pain, our injury, for what it has done to our lives. We can't do what we want to do and, well, it pisses us off. It doesn't help. You have to make peace with your self, your pain, your injury, then you can move forward. Until you do, you'll stay right where you are. It took me less time to make peace with my injury this time around than it did when I ruptured a disc in my back in 2008. I'm learning.

I'm looking forward to the next few months as I help my shoulder heal, learn some new things, and get better - in more ways than one. I'll let you know how it plays out.

Onward....

Two Things Golfers Must Have - Part 2

Last week I told you about one of two things golfers must have to solve a painful shoulder. The first thing was to find out the strength of your shoulder. I explained that golfers need to generate about 14 lbs. of force up to 100 times in the course of a typical 18 hole round. And, that 14lbs., represented about 40% of normal strength.

The second thing to know is your shoulder ratio.

The rotation motions of the shoulder are referred to as internal and external rotation. To best understand these two motions, try this:

1. Lie down on the floor on your back. Slide your right arm away from your body until it forms a 90 degree angle with your trunk.
2. In this position, bend your elbow until it forms a 90 degree angle with the hand pointing up. You are now in what we call "neutral".
3. From neutral, drop your hand back towards the ground. This motion is external rotation. When your hand hits the floor, you have moved through 90 degrees of motion.
4. From neutral, drop your hand towards the ground. At some point in the motion, your shoulder will come up off the ground. This is the end of your internal rotation (see figure for example). Normal motion of internal rotation, from the neutral position, is 70-80 degrees. This gives your shoulder about 160 degrees of rotation movement (90 of external plus 70 of internal rotation).

The shoulder ratio is the amount of external rotation to internal rotation: 90 degrees of external rotation to 70 degrees of internal rotation giving you an ideal shoulder ratio of 1.3. Most golfers with shoulder pain have a shoulder ratio greater than 1.8 and often over 2.0 (a higher ratio means you have less internal rotation motion). I know - a lot of numbers - but hang in there. Here's why it matters. The golf swing takes less than 2 seconds - start to finish. In less than 2 seconds, your shoulder muscles have to figure out how when to contract, how hard, and for how long and this is influenced by how much motion you have in your shoulder.  So, if you have a high shoulder ratio (or too little internal rotation motion), your muscles have less time to react. They have to work harder in a shorter period of time and your chance of injury then goes up.

To solve shoulder pain in golfers, you have to know at least shoulder strength and the shoulder ratio. These two numbers will help you understand why you hurt and what needs to change for you to play safely and pain-free.

Hit'em straight.

Doug Kelsey

Two Things Golfers Must Have

"So, how's the golf game?" I asked.

"Uhh..well..not so good. My left shoulder hurts every time I swing a little bit too hard and really hurts when I hit the ball but I'm on a new anti-inflammatory that seems to be helping some," replied my friend.

"Yeah? Well, you know, we could help you with that shoulder. We could look at your arm and tell you how much strength you have and how much you need to play." I said.

"I know. I know. But, the meds are ok and I just don't have the time to mess with it right now. I'll just swing easy for a while. Besides, I know those muscle tests - you know 'good, fair, poor' - those aren't helpful really at all, " my friend explained.

"Agreed. But, that's not how we test your strength," I said as he started walking away.

About eighteen months later, we had nearly the same discussion.

So much for the meds.

And, he's a physician. And, he knows about shoulders. He operates on them.

Too bad for him because he could solve his shoulder pain and play without worrying. But, he needs to know two things. Here's the first one:

What is his shoulder strength?

To play golf, you need to generate 14 lbs. of pain-free force, about 40% of normal strength, up to 100 times in a typical 18 hole round (of course, the lower your score the fewer swings you take). Normal strength for males is about 35 lbs (this will be a little lower in males over the age of 60). So, chances are, that my friend's shoulder strength was less than 14 lbs. since swinging the club and hitting the ball both hurt. Nearly all musculoskeletal symptoms are the result of a physical demand that is greater than the physical capacity. If you need to generate 14 lbs. of force and can generate 10lbs., there's a good chance that before very long, your shoulder will hurt.  If my friend had discovered that his shoulder strength was, say, 10 lbs (which by the way is the typical top end force production for someone with shoulder pain), he would at least understand why his shoulder hurt and have some idea of how much stronger he needs to be.

This test is very easy to perform, is non-invasive and takes less than one minute. It will tell you exactly how much more strength you need to play safely and pain-free.

Most people assume that if they don't hurt, all is well. But, medications can't change your strength. So, you may feel better after the anti-inflammatory (Motrin, Aleve, etc.), but if your shoulder strength is still too low, you'll end up with a sore shoulder all over again.

Adequate shoulder strength is one of the keys to playing golf without worrying about hurting yourself. There's one more thing to know and I'll tell you about it next week.

Doug Kelsey

Shoulder Pain: The Problem is Dem Bones

During his first season in the big leagues in 1998, the strong, young kid with the monster fastball noticed a nagging pain in his right elbow. He thought it would go away but it didn't. He played in pain through the remainder of the season. In the spring of 1999, he tore a ligament in his right elbow and had a Tommy John surgery. He missed the entire 1999 season spending much of it in rehab for his elbow.

After playing the first part of 2000 in the minor leagues, the Chicago Cubs added him to the roster in May. His debut with Cubs was promising but a new warning sign appeared: right shoulder pain. He was out for a month with a diagnosis of tendinitis and followed this with a triceps strain. He was on and off the disabled list about as often as Paris Hilton buys a new purse. In August 2005, he was headed for yet another surgery, this time on his right shoulder. He then spent several months in rehab.

Following the surgery, Kerry Wood spent four months in rehab for his shoulder to prepare for the 2006 season.  Then, in March of 2006, he had a "minor" arthroscopic procedure - a "cleaning up of his meniscus" -  on his right knee. He made it back to the mound May 18, 2006.

By early July 2006, it appeared that Kerry Wood's career as a professional baseball pitcher might be over. The Chicago Cub's once promising star pitcher tore the infraspinatus muscle, one of the rotator cuff muscles in the right shoulder. According to an article in the Chicago Tribune, Wood will go through more rehab and is debating about surgery. Again.

Do you see a trend? Is there somthing missing in his repeated bouts of rehab or is Kerry just an extremely unlucky guy?

If Kerry attempts a come back, he has a lot of work ahead of him. The obvious problems are in his shoulder but slinking around in the shadows is his right knee. His "minor" surgery in March was on one of the primary stabilizers of the knee - the meniscus - a crescent-moon shaped piece of cartilage tacked onto the top of your shin bone, the tibia.  The meniscus helps absorb shock in the knee and keeps the thigh bone (femur) and shin bone (tibia) from moving too much especially during a twisting action like baseball pitching.

Baseball pitchers need rock solid legs. It's where all the power comes from and when you don't have it in the legs, you steal it from the shoulder. Small changes in stability of the knee, like what happens when a portion of the meniscus is removed, rarely cause problems at low speeds and forces like tossing a baseball to your son in the back yard or even a slow jog around the neighborhood. But, pitching requires a lot of force over a short period of time. You need all you can get from your legs.

On the outer rim of the meniscus is a small bed of nerves. These nerves are now thought to play an important role in telling your brain how to coordinate muscles during complex tasks like pitching. Signals from the ankle, knee, and hip converge in the brain influencing how and when the various muscles contract. Think of a conference call with people giving their opinion of what you should do and imagine that you could actually listen and analyze everyone at once. This is what your brain does. It's listening to the advice from the joints. When a part of the meniscus is removed, some of the nerves may be damaged or removed as well. It's like someone hung up on your conference call. You don't have all the advice you need so, your brain does the best that it can. In most cases, the shoulder or elbow works harder to generate more force. The harder you try to throw with your arm, the easier it is to hurt your arm. This leads to periodic shoulder or elbow injuries. Anytime you have a repeated injury of the shoulder, you will usually find an unresolved problem in the hip, knee or ankle.

We are a society that likes to compartmentalize, reduce, isolate problems and then fix them. If you have shoulder pain, you see a shoulder specialist, maybe have shoulder surgery, go through shoulder rehab and move on. But, unfortunately, that's not how the body works. Your shoulder needs the "advice" of your hip, knee and ankle; your lower back depends on your butt muscles; your knee needs your ankle; your neck thrives from your upper back. You know the old song, Dem Dry Bones - "the ankle bone's connected to the knee bone, the knee bone's connected to the thigh bone...."? It's true. The body's joints and muscles work together. When it comes to rehab, joints and muscles that work together, win together.

If you're struggling with persistent shoulder pain and recurring injuries, like Kerry Wood is, make sure you have any nagging hip, knee or ankle problem addressed as part of your shoulder rehab. It could be the one thing that truly "fixes" your shoulder.

Make today count.

Doug Kelsey

PS - For those of you with shoulder pain, check out our next free seminar, Shoulder Pain: Why it Still Hurts to Throw, Swim, or Serve. Seating is limited - call 512-206-0433 to reserve your spot.

Why Dads Can't Play Catch

Playing catch is a sort of national pastime in the US. All you need is a baseball glove and a baseball. And, all you do is throw the ball, the other guy catches it and throws it back. Why all the fuss? Why do Dad's seem so set on playing catch with their sons?

Playing catch is like a rite of passage. It's something that fathers and sons have done for many years and it's a way Dads connect with their sons without the need for conversation (which as well all know is a must for most men). Dads become kids again, their sons grow up, and they both have a good time.

Until Dad can't throw anymore because his shoulder hurts.

We have seen a lot of Dads over the years who have shoulder pain ONLY when they throw and they feel a heavy pressure to get better quickly. Their sons are growing up and they know that playing catch will fade with age. Every other activity seems to be just fine but the pain from throwing is a stinker. It just won't go away.

Many Dads try things like creams, rub-downs, stretching, medication (Aleve, Motrin, Aspirin,etc.) to chase off the nasty pain pest. Sometimes it works; most of the time it doesn't. And there's a reason why these things fail. Actually, two reasons.

The first reason is that there are two motions in the shoulder that must be within a certain range and have a balance between them- a ratio. We call this the shoulder ratio (for more detail on the specific motions and how it effects the throwing motion, click here). It's similar to other motion ratios of the body (one of the reasons for back pain is an inadequate lower back ratio) and it's something you can restore with prescriptive exercise but never fix with creams, rub-downs or pills.

The second reason is your shoulder is weak. Dads often argue. "Look, I go to the gym, lift weights, and work out all the time. I hardly think I'm weak." But, when we test their strength in specific movements, they are often 50-80% less than normal. Numbers are a beautiful thing; very hard to argue with the facts. You may think you're strength training the right way and that your shoulder is tough and strong but the numbers don't lie. You're weak as a kitten.

If you're a Dad with a sore shoulder or a Mom who knows one, carve some time out of your day and come by Sports Center on May 16, 2006 to hear me talk about this issue. I'll explain the shoulder ratio, what having a strong shoulder really means and the two muscle groups critical for long term shoulder health (and they are not in your shoulder). It's a great talk (I know - I'm biased but it's true) and it's free. You'll get an inside look at how we tackle this issue and help Dads play catch again.

We're ready to play. Are you?

Make today count.
Doug Kelsey

The Curse of a Gift - A Must Read for Baseball Pitchers

As the ball flew from the hand of the young, agile baseball pitcher, he felt something odd in his right arm. It went numb; then it tingled. And, for a brief moment, his arm felt lifeless. It felt dead.

It had happened before. Normally, Jimmy could stall. He would walk around, call the catcher out to the mound and gently shake his arm. The feeling would come back and although his shoulder hurt, he usually could make it through the inning. Today, though, he knew he would not make it. His arm hung lifeless by his side. He was done.

Jimmy had "Dead Arm Syndrome".

Dead Arm Syndrome (DAS) is a pain induced paresis. The word paresis means "a partial or slight paralysis". DAS is a condition in which a pitcher throws so hard that he paralyzes his arm from pain. But, pain from what?

Have you ever noticed the extreme flexibility of a baseball pitcher's shoulder? At the start of the delivery phase of the pitch, the hand is well behind the head. Normal rotation of the shoulder in this direction is about 90 degrees or the hand pointing up to the sky (the position you use when being sworn in - like the President). It is not uncommon for a pitcher to possess 120 to 140 degrees of rotation.  This exceptional mobility is one of the attributes of great pitchers. It's a gift. A gift that sometimes comes with a curse.

The shoulder complex is very mobile by design. With four joints moving in three planes, you can place your hand in space through a very wide range of motion. Pitchers improve on the design partly from years of training (including stretching) and partly from their particular genetic profile. But, while this flexibility improves performance, it also increases the risk of a certain type of injury that typically occurs only in very flexible shoulders: a Bankart Lesion.

A Bankart Lesion is a tear of the cartilage (called the glenoid labrum) that forms the shoulder socket. In most cases of DAS, the pitcher has a Bankart Lesion. The pain comes from tearing the cartilage (although it has a meager blood supply, the upper margin does have small blood vessels and nerves), over stretching the attaching tendon (biceps), joint capsule and, in some cases, a mild stretch injury to the axillary nerve.  When the tear is large enough, surgery is required to repair it.

One of the secrets to reducing your risk of a Bankart Lesion or for other problems associated with pitching is in the balance between the two rotation motions of the shoulder.

I have to get technical for a few moments. No way around it. But, if you have had DAS or know someone who does, this information is critical. So, take your time as you read this.

The rotation motions of the shoulder are referred to as internal and external rotation. To best understand these two motions, try this:

1. Lie down on the floor on your back. Slide your right arm away from your body until it forms a 90 degree angle with your trunk.
2. In this position, bend your elbow until it forms a 90 degree angle with the hand pointing up. You are now in what we call "neutral".
3. From neutral, drop your hand back towards the ground. This motion is external rotation. When your hand hits the floor, you have moved through 90 degrees of motion.
4. From neutral, drop your hand towards the ground. At some point in the motion, your shoulder will come up off the ground. This is the end of your internal rotation (see figure for example). Normal motion of internal rotation, from the neutral position, is 70-80 degrees. This gives your shoulder about 160 degrees of rotation movement (90 of external plus 70 of internal rotation).

Baseball pitchers with DAS, in nearly every case, have less then 45 degrees of shoulder internal rotation but still have a combined motion of at least 160 degrees. They just have way too much motion in one direction and not enough in another. 

The speed of a fastball for most college level baseball pitchers is 35 meters / second. The force exerted on the back of the shoulder to slow the arm moving through a normal amount of internal rotation (at this point, the ball has left the hand) is approximately 90 lbs. But, when a pitcher has 45 degrees of internal rotation, the time to slow the arm is reduced by nearly 50%. So, he has to generate a lot of force in much less time (this principle of force applied over a period of time is why airbags work so well).  As a result, the force to slow the arm climbs to 162 lbs. Any wonder why injuries might occur?

If you or someone you know has DAS, be forewarned. This is, in nearly every case, secondary to tears to the glenoid labrum. Have your motion checked by a physical therapist or athletic trainer who works with sports related injuries. If you ignore it, you will very likely end up in surgery, a year of rehabilitation and may never throw a smoking fastball again.

Make today count.

Doug Kelsey
Author. Speaker. Therapist.

P.S. If you are a PT or ATC and would like to learn more about how we use the Sports Center Training System to rebuild athletes with shoulder tendonitis, tendonosis, and rotator cuff tears, join us for our next professional education seminar on August 4th-5th at Sports Center. Only 12 clinicians get access to this seminar this year and there are only a few spots left. Take advantage of the early registration period ending June 29th and save. As always, graduates get 20% off any seminar. Call Angie Francis at 512-206-0433 or email her at [email protected] to register today.

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Shoulder Pain, Ice and Needles

Have you ever noticed how long the needle is when you get inoculated for something like tetanus? If you have even the slightest needle phobia, you might pass out. The needles are long - about 1.5 inches.

Injections delivered into your upper arm must penetrate into the muscle belly of the Deltoid muscle. There is a considerable amount of research on just how long a needle needs to be to penetrate most adults' Deltoid muscle. The average needle is between 1.0 and 1.5 inches long. Remember this. You will need it later.

I was watching a major league baseball game recently and happened to notice a pitcher sitting in the dugout with what looked like a small mountain of ice strapped to his shoulder. A few questions came to mind. Why do we use ice for a sore shoulder? How much ice do you really need? Is a thick pile of ice better than one of those gel ice packs you store in your freezer? How long should you use ice? And, how deeply does the cold penetrate? Does it get to the tissue that supposedly needs it?

Ice is probably the most commonly used physical agent in the sports injury world. When a baseball pitcher injures his shoulder, in most cases, the injured tissue is the rotator cuff muscle group. These small muscles (four in total - Supraspinatus, Infraspinatus, Teres Minor and Subscapularis), buried deep in the shoulder, control the finer motions of the shoulder. They blend together to form a large tendon that anchors to the top part of your arm. When you throw too hard, too long or too much, you strain the tendon and develop a deep, aching soreness. This can lead to rotator cuff tendonitis or tendonopathy (a weakness of the tendon).

Ice is often used as treatment for rotator cuff tendonitis. So, for the cold to work it must actually reach the tendon (how it helps or does not help tendonitis is for another time). Cold penetrates about 1 cm or slightly less than 1/2 inch. The rotator cuff is buried under your Deltoid muscle. Remember the needle length for injections? It was over 1 inch to get into the Deltoid. If the rotator cuff is under the Deltoid, and the cold of ice only penetrates 1/2 inch after a thirty minute exposure, how does the rotator cuff ever benefit from the ice? It doesn't. While the baseball pitcher sits with a pile of ice strapped to his shoulder, he is nicely cooling his Deltoid while his rotator cuff remains toasty warm.

Cold is cold. A pile of ice is not any better than a gel ice pack other than perhaps it will stay colder for a longer period of time. Ice helps reduce the pain of a sore shoulder, but if you think it helps prevent or treat rotator cuff tendonitis, you're wrong. The cold never gets there.

If your shoulder is sore, ice it if you want to temporarily reduce the pain. Perhaps a better choice is to figure out why you have a sore shoulder and what you can do to prevent it. Want to know more? Sign up for our June 14th free seminar on this very subject "Shoulder Pain: Why You Still Cannot Throw, Swim or Hit" and for all of the clinicians out there, reserve a spot in our upcoming professional seminar on August 4th-5th at Sports Center entitled "The Shoulder: Rehab for Rotator Cuff Tendonitis, Tendonosis, and Repair".

Ice is OK. Knowledge is better.

Make today count.

Doug Kelsey
Author. Speaker. Therapist.

P.S. I promised I would share with you some of the comments from our inaugural graduating class from Sports Center.  Click here to read their amazing comments.

References:
Chiodini J (2000) Vaccine administration. Nursing Standard. 14, 43, 38-42. April 2000.

Enwemeka, C. S., C. Allen, et al. (2002). "Soft tissue thermodynamics before, during, and after cold pack therapy." Med Sci Sports Exerc 34(1): 45-50.

Otte, J. W., M. A. Merrick, et al. (2002). "Subcutaneous adipose tissue thickness alters cooling time during cryotherapy." Arch Phys Med Rehabil 83(11): 1501-5.