#24 - Shoulder Injuries and the Throwing Athlete, Pt. 1

FAKTR, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents. Serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to consume. to digest with actionable information that you can implement into practice right away. Let's get started. Hi guys, welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thank you for listening. Today we kick off a new training titled Shoulder Injuries and the Throwing Athlete with Dr. Ross Keys. When it comes to treating any athletic injury, it's vital that you as a clinician understand the sport-specific biomechanics and the physical demands of the most common movements of the sport. This is especially true when it comes to movements that require a great deal of repetition coupled with velocity or heavy load. In this 2-part training, we will focus on shoulder injuries that are common in throwing athletes, and then break down the assessment of sagittal, frontal, and transverse plane movement to develop effective treatment plans. Dr. Ross Keys has an elevated level of experience with athletics and the stress that comes with training and competing at a high level. During his time playing college football, Dr. Ross sustained a variety of soft tissue injuries that include 3 shoulder labral tears with reconstructions, knee meniscal tear, and MCL tear. Having to work through these injuries has helped him develop a level of empathy that provides a solid foundation for working with athletes and helping them to continue and prolong their athletic journey. Dr. Keys has completed advanced training in evaluation and treatment of athletic injury and is a certified chiropractic sports physician. Dr. Ross is also a certified strength and conditioning specialist with experience coaching high school, collegiate, and professional athletes. So today's training is chock-full of a ton of great clinical pearls and wonderful information that you guys can use with your patients starting right away. So with all that being said, let's not delay any longer. Cue the intro music. Let's dive in.

Thank you so much. Welcome everybody. All right. So yes, as Jessica said, we're going to be diving into shoulder injuries and I wanted to direct it more towards the throwing athlete because a lot of clinicians I know have issues with that. Just kind of managing them, what kind of stresses they're putting themselves through, and then how to evaluate the shoulder because it's certainly far more than just banded internal external rotations. Here's a little bit about me. Not too much into bragging or talking about myself. So we'll go through this quick. Biggest thing I'd like to point out is, yes, I've had a lot of shoulder injuries. Those are all sustained during football, all on the same shoulder. First surgery was unsuccessful. The rehab on that, a lot of banded movements, and then the subsequent injuries there and reconstructions, we did a little bit different approach. And at this point, so those were about 13 years ago, and at this point I can hardly tell the difference between the two sides. So that's great. Bucket handle tear, meniscus. Grade 2 MCL sprain in the knee, all from football, and then rupture of the scapholunate ligament, which has been all right. Even though I'm a chiropractor, so use my hands a lot, I have to be aware of keeping that protected. I list those things just to show, like, empathy goes a long way when you're working with patients. I put this stuff on my bio in my website because we all generally have the same credentials and education, speaking more about chiropractors specifically, but When people can see like, man, he's had injuries, so he knows like what that feels like, psychology behind having an injury and then being told you can't do something. When I had my first labral tear, the physician told me that there wasn't going to be any issues, we can fix it up, it'll be fine. And then 2 years later, then I had the second 2, and that physician told me that basically my dreams of going to the NFL were gone. In which my brother had got to the NFL, so was definitely something that was within sights for me, but Living through that, it definitely helps me be empathetic towards the athletes that come through my doors to make sure I word things well and try to support them as much as possible because you just don't know. You can't just look at it like, oh, you tore this, you're not going to be able to continue. It's like we can always do more, we can always do better. And so diving into, I got my CSCS, so I've had a decent amount of experience coaching high school, collegiate, and professional athletes, sports physician. And right now I have a sports injury clinic inside of a performance gym. If I wasn't tethered down by a charging cable, I'd bring the camera out so you can see the facility. It's very beautiful. I don't own the facility. I'm just with inside of it. But my main focus and main niche right now is high school athletes. I have a pretty good handle of talking with athletic trainers and high school coaches just because that's the people I've been dealing with for the last, I don't know, 20 years through my experience. And I just find it pretty easy to talk with them and get those athletes in and get them where they need to go. So we'll dive into the actual stuff. You can help these athletes. So don't get discouraged when a shoulder comes in because there's a lot of moving parts. The shoulder, I like to say, is beautifully complicated. There's so many moving parts. We have the most range of motion in that glenohumeral joint out of every joint. So what we're going to try to do here is give you some of the tools that you can to evaluate the shoulder and then some movement-based strategies to try to improve them. Things we'll learn, basically we'll go through is throwing, what sports have throwing in them, and it's not just baseball and softball. There are many other sports that utilize throwing. Going into the planes and how we can use those as tools for evaluation as well as tools for rehabilitation. And then getting into effective treatment strategies. So soft tissue treatment, joint mobilization, Exercise prescription, and then often missed but very important stress modification. So nutrition, sleeping, work, school life, all that kinds of stuff. So we'll dive into patient presentations. Baseball, I think, will be the one I use the most examples of just because the mechanics of throwing are a little bit more easy to understand when you think of baseball and softball. Volleyball, we add that in there because as you swing the arm forward, Just like tennis, that is a throwing motion, and we'll get into what I define as throwing in the next slide, I think. Basketball with shooting, football mainly the quarterback, and mixed martial arts, and then also boxing. So like I said, baseball is easier to see just because the athlete's usually by themselves. Good to see the wind-up as they cock that leg up, the drive as we're pushing down towards where we're going to throw the ball, and then the follow-through. Which is also like the eccentric portion of the movement on the hip. And we'll dive into why that is important and often where many of the injuries happen in the thrower. Some definitions to go over just so we kind of have an even field here so you guys know what I'm talking about. Throwing, like I said, includes punching and striking objects with another object or your hands. So it's not just the act of throwing a ball, it's including as punching even though you're not throwing something, you are throwing your fist essentially. And then some of these definitions we don't have to fully go into, but mobility— how much range of motion do you have? Stability— how well can you resist the force that's exerted on you? Stiffness— the ability to resist applied stretch. So the planes of movement, like I said before, are where we're going to be diving into with these movements. And my evaluation may be a little bit different than what traditional schooling, at least what I experienced, uses as the way to evaluate shoulders using a lot of orthopedic tests and stuff like that. I like to look at what sport they are doing, what movements are they required to have, and then move them through those, see how they're doing, and then address it with that. Some more definitions. So let's go through some of the main presentations that I see with shoulder pain. So we got anterior glenohumeral pain, superficial and deep posterior Glenohumeral pain, superficial, deep, and lateral shoulder pain. And then also pain behind the scapula and AC and SC joint pain. Getting back to anterior glenohumeral pain and impingements, usually that's kind of go hand in hand, getting a shoulder impingement in the front of your shoulder. Superficially, I'm going to be thinking a lot more active structures. So thinking more biceps tendon long head typically. As it runs through that groove. And I'll get into a case that I had this week, a baseball player with that pain. On Wednesday, a couple days ago, I had an athlete call in that he had shoulder pain while he was pitching in the first inning of that game, which was the day before on Tuesday, and he felt the pain in the front of his shoulder. Now, his, his mother told me it was something with his scapula, and then he told me it was Pain in the front of his shoulder. So I really didn't know what I was getting myself into until I got him in the office and he pointed right towards where the biceps tendon goes through the groove up over the humeral head into the shoulder. And pretty quickly we could figure out that it was an impingement syndrome. So what I did is we just talked a little bit to figure out what his life was like the few days leading up to that. He had, mind you, so he's a high schooler, I think 16 or 17. His mom wasn't in the room at the beginning of the session when I was talking to him. And, if you have worked with high school athletes, when their parent is there paying attention, their answers are a little bit different or the parent is going to add a little bit more information. That can be pretty crucial. So, he came in and I asked him what was going on. He said, yeah, I was pitching, I couldn't get through the first inning and I felt this sharp pain. So then, Lead into, okay, what were you doing the day before? And he's like, well, I had an upper body workout. Wasn't anything different than I would normally do. He did a circuit of pushups, pullups, and bicep and triceps. And so I was like, okay, well, it's probably too much to do a day before you're pitching. But it wasn't until his mother came in and said, well, yeah, but we were pulling all these trees on their farm the day before his workout. So he's in A position that he's not used to doing very often. So he did that for a long period of time. It wasn't necessarily stressful that day, but he was filling up his cup. And then the next day he goes into doing his workout and his positioning, as I asked him to show me how he was doing them, very anterior and superior rotated shoulder complex. So all those structures are pretty compromised. So when you get into doing push-ups and things like that, And bicep curls, we already have smaller space in there, and now we're adding in a lot of stress through those tendons and muscles in that area. So he was just getting into too much stress. And then you think the next day you throw him into high velocity pitching. And so his athletic trainer at that point told him he needed to go do banded internal external rotations. And I have my opinions on those. And like I said at the beginning of the presentation, there's far more to shoulder rehab than that because With just jumping to that as your treatment, you're overlooking the reasons why his biceps tendon in this case was being overutilized. That totally— it doesn't look into how the shoulder blade is playing into it, how it's chronically superior and anterior. So we're already having a compromised joint space. And so all it's going to do is work on strengthening the rotator cuff muscles, as they would put it, but That doesn't really lead to improvement of what happened. While it will help him get out of pain, get back to throwing, we're much more likely to get back into having the same issue. And then at that point, each subsequent event like that, the tissue is going to get weaker and weaker. And usually that can end up in a worse injury like a biceps rupture or into the glenoid labrum issues. So deep pain on all of these in the shoulder, I find, is going to be far more related to Passive structures. So thinking of passive structures, we're thinking of bone, ligaments, cartilage, and cartilage-like stuff, basically like the labrum. Active pain, or we're— I'm going to be thinking more superficial, which is going to be muscles and tendons. The defect to passive structures is going to be because your active structures are not properly doing their job. The passive structures Can take on stress. They can take on extra stress in order to help you heal the active structures. But if you don't look at getting yourself to get out of those compensations, then those things get wore down quicker, and then that's where you get tearing and fracturing and stuff like that. So diving into, yeah, deep glenohumeral pain anteriorly, I'm going to be thinking more labrum where the biceps dives in. Posterior glenohumeral pain, superficial, thinking more rotator cuff.

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Deep, again, I'm thinking more labrum there. Lateral shoulder pain superficially, thinking deltoid strain. Deep, labrum, or even getting into bursal irritation, so bursitis. Getting into these other conditions, so pain behind the scapula, another very, very common— I guess it doesn't have to be behind the scapula, but in that area. So between the shoulder blade to the spine, very often very pinpoint. You're thinking, yeah, it's probably a rib. And so you'd ask them if they have increased discomfort or pain with deep inhalation or even inability to deep inhalation— inhale. If they say yes, then I'll be like, all right, well, rib subluxation is likely going to be my top diagnosis at that point. Even if they say no to that, I'm still going to be having rib issue. Up high in my diagnosis because your ability to expand and compress your rib cage is extremely important when we're talking about scapular movement. AC and SC joints, usually, I mean, just because they're very superficial ligaments, oftentimes you're going to see actual change in the structure. So you'll see a clavicle sitting higher or something like that, or it's going to be very evident when you have inflammation around a specific joint, redness around specific area, very, very point tenderness in that area. So those are usually pretty evident and often, well, they're going to be attributed to a contact injury, which these other ones aren't necessarily going to be because of contact. Overuse versus misuse, and that is kind of like what we talked about, passive and active. Overuse of muscles and joints is often going to lean more towards an active injury. So if I am just working myself too hard, Let's say like this athlete that I had come in with the biceps impingement, he was just doing a lot of stress in the area over a shorter period of time. Misuse is going to lead more into passive injury because we're not properly moving, which is then going to add that extra stress onto the passive tissue, which then can wear those down and then lead into more of those misuse injuries. So here are some of the main throwing sports: baseball and softball, football quarterback, Volleyball, field events in track, mixed martial arts, boxing, and hockey. When I have athletes coming in, it's always important to know what sport they are in because you need to do a little bit of background research on what they may be performing in the weight room, if they are at all. So, I'll just go through what I find commonly with these major sports in there. And, this is going to be more at high school based on my patient population, but these are the general trends on what their strength and conditioning programs are. So baseball and softball, there's typically a big emphasis on the glenohumeral joint movement itself. You'll see a lot of banded shoulder prehab type movements, but again, all they're doing is trying to quote unquote strengthen the rotator cuff muscles, which honestly are primarily stabilization muscles anyways. So If you don't address stabilization, having a stronger complex doesn't really attribute to much improvement. Banded shoulder movements and med ball throws. I love med ball throws. So, this isn't put in here to say that they shouldn't be doing it. Med ball throws are fantastic. I will say that most people are doing medicine ball throws with too heavy of an implement. Usually, you can get probably the most out of med balls if you're sticking 6 pounds and under. Anything over that, then you're really going to be losing a lot of the high-intensity, high-velocity, short-duration movements that really benefit you out of medicine ball throws. Football, this is more specific for quarterback because quarterbacks always have a different workout than the rest of the team. So, they may not even be doing anything besides just keeping the arm fresh, just moving the arm around, doing lightweight here and there. The big 3, so bench, squat, and deadlift. Some bodybuilding to keep up muscle strength and get on a little mass. And very— I think I'd say infrequently Olympic lifts are incorporated, so snatching or cleaning, things like that. Volleyball, Olympic lifting, powerlifting with the big 3. Plyometrics is a big one, lots of jumping, box jumps, agility ladders, things like that. So again, not really doing much With the shoulder mechanics, specifically field events, lots of high-powered movements in Olympic lifting. And depending on those athletes, some of them could be doing multiple events. So, they could be adding a lot of sprint training into their programs and incorporating medicine ball throws, which this is going to be a very well-rounded program, especially if they're in the sprint training because they're very interested in That high power very quick, usually only a single movement. It's not multiple movements. So if you're doing shot put, you throw it once. It's not like pitching where you have to throw it over and over each inning. So they're very good at building that power, which usually means that they are addressing the eccentric motion of their lift, which is going to help stabilize and protect everything. Mixed martial arts and boxing, very high emphasis on endurance cardio stuff. Stuff like that, long steady-state movements, grinding workouts, and some bodybuilding. And then also a lot of abdominal work, lots of crunches, things like that to try to strengthen up the core. Hockey, usually pretty big on the bench squat, deadlift, some Olympic lifting, but then also again a lot of plyometric movements. What I talked about earlier, things to consider before you start is What kind of demands is their sport and position in that sport put them in or require of them to be successful in their sport? Do they have a current injury? Usually yes, if they're coming to see you. Or do they have a past injury? And we all know past injury is going to put them in a higher risk category based on past injury for another injury. And then very important, knowing the seasons of their sport. So you knowing when they're in season, when they're off season based Primarily with how you're going to approach your prescription of exercise or rehab, however you want to call it, because it's going to be different when they're not playing or practicing much than when they're in season. If they're off season, more quickly get into stressing them with more resistance. And then when they're in season, you have to be a little bit more careful of that. In there also, especially more specifically towards high school, there are Lots of events that they have to do year-round in order to get scouts to watch them play. So that's also something you need to be aware of with those athletes, just so you know you're not going to be giving them a good stressful workout and then they have a showcase that weekend. You just got to make sure those things are all aligned. And it also helps to know the general school schedule. If they're going to be going through finals a specific week, maybe not give them something really challenging to do or something new to have to like. focus on something that they haven't done before. Give them something that they have been working on and just let them work on that so they don't have to add more stress from testing and studying with having to learn new movements and perform those.

That's it for today's episode. Be sure to tune in for episode 25, where we wrap up part 2 of this training and discuss throwing in sports. What are the biomechanics involved, and where do things typically go wrong? We will also discuss effective treatment strategies to get your athletes back in the game, including soft tissue treatment, joint mobilization, and exercise prescription. You won't want to miss it. Episode 25 drops in 2 weeks, or 1 week for our Patreon subscribers. In the near future, we're also planning a few special Q&A episodes with past instructors, as well as those that have taken their FACTOR training to the next level. So please be sure to click on the Q&A link in our show notes and ask any burning questions that you may have. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Please give us a 5-star rating to help us grow the show. Every little bit helps. And last but certainly not least, be sure to visit the show notes for a link to download the PDF of today's full presentation, as well as learn about any special offers that we featured in today's episode. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future. So you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.