Injury Prevention through Dynamic Stretching and Warm-up

By: Kira Davies, DPT, SCS

     A warm-up is the act of preparing an athlete both mentally and physically for exercise or sporting event.  Athletes tend to each have their own pre-participation regimen that they have settled into and find useful in developing an individual sense of readiness for the activity at hand.  The benefits of incorporating a dynamic stretching warm-up approach will be discussed below and may be an integral addition promoting injury prevention and performance improvement.

WU 1     Dynamic stretching involves active movements of a muscle that bring forth a stretch, but are not held in the end position.  Dynamic stretching uses speed of movement, momentum and active muscular effort to bring about a stretch.  By stretching muscles through movements similar to ones that occur during athletic competition, the joints and muscles may become more accustomed to the movements and less likely to become injured.  Incorporation of dynamic stretching into a training regimen may serve to prepare the body for the optimal athletic performance.  Other types of stretching include static and ballistic, and will be discussed later.

Injury Prevention

By stretching muscles through movements similar to ones that occur during athletic competition, the joints and muscles may become more accustomed to the movements and less likely to become injured.  Incorporation of dynamic stretching into a training regimen may also serve to prepare the body for the optimal athletic performance.

These warm-up programs have a more dynamic approach…

  • Focus more on the neuromuscular system of the muscle complex
  • Movement specific activities aide in short term flexibility gains
  • Active stretching has potential to reduce injury though decreasing reflexive muscle contractions

     When appropriately performed, dynamic stretching has been found to balance muscle tension throughout the body to prepare the joints and muscle for activity.  In doing so, stretching and active warm-up can help reduce the likelihood of certain types of injuries, specifically muscle strains.  This stretching technique can be useful before aerobic exercise, sports participation, and competition, and has been shown to reduce muscle tightness. The most recent scientific studies seem to suggest that dynamic stretches before competition are preferable to static stretches. This may be particularly true for strength and power athletes.

WU 2

Not only is there a role in injury prevention, but research suggests dynamic stretching may improve performance in the following activities…

  • Acceleration
  • Sprint performance
  • Agility Drills
  • Dribbling
  • Penalty Kick Speed
  • Jump Performance

Performance

Dynamic Warm-up should:

  • Be performed for 10-20 minutes
  • Be performed for 60 seconds/dynamic stretch with 1 stretch cycle every 2 seconds
  • Include preparation of all joints and major muscle groups (shoulders, elbows, torso/trunk, hips, knees, ankles
  • Include motions specific to the sport or activityWU 4
    • Ex) tennis: lateral motion of the legs, anterior/posterior of the upper body, rotation of the torso/trunk
    • Ex) baseball: consider the different needs of the catcher vs. pitcher
  • Include tri-planar motions
    • medial/lateral
    • anterior/posterior
    • transverse/rotational

Technique may be dependent on the age of the athlete, current physical condition, prior exercise experience, and gender.

     Static Stretching refers to traditional techniques where stretches are performed with a prolonged hold and used to increase the length of soft tissue and the flexibility of a specific muscle. This type of stretch has the most profound effect on a specific tissue known as collagen. WU 5Collagen is the cellular framework found in our muscles, tendons, and ligaments. Recent research suggests that static stretches have a neuromuscular effect on the muscle’s performance and may slightly decrease strength in the stretched muscle group for up to one hour.  Static stretching still absolutely has its place, and is an important aspect of an athlete’s overall health.  Static stretches help to reduce injury by maximizing flexibility and improving biomechanics.  Static stretching may be most useful and beneficial after activity and should be performed consistently (every day!) to increase and maintain muscle length and flexibility.

     Ballistic Stretching involves rapid stretches that are often associated with bouncing motions. These stretches should be used with caution as muscle strains can occur due to activation of the stretch reflex- causing the muscle being stretched to contract. This type of stretching is not recommended in youth athletics/sports and is also not recommended for injury rehabilitation.

WU 6

There are many ways that athletes prepare for their sport or competition. Consider incorporating a dynamic warm-up approach into your pre-participation regimen. Your body will thank you!

Additional resources and sport specific routines may be found below:

FIFA- 11: developed by FIFA’s medical research center (F-MARC)

http://f-marc.com/11plus/home/

The 6 Characteristics of a Good Dynamic Warm-up: Eric Cressey

http://www.ericcressey.com/6-characteristics-good-dynamic-warm-up

Ready to Play: The Dynamic Warm-Up

Available through Duke Sports Medicine, DUKEHealth.org

http://www.dukehealth.org/health_library/health_articles/dynamicwarmup

YouTube Video References:

1) Sample Dynamic Warm-Up: Football

http://www.youtube.com/watch?v=Lv-iQorSHw4&feature=player_detailpage

2) Sample Dynamic Warm-Up: Soccer

http://www.youtube.com/watch?feature=player_detailpage&v=Dn122YQzyd8Sample

3) Sample Dynamic Warm-Up: Track & Field

https://www.youtube.com/watch?feature=player_embedded&v=Lv-iQorSHw4

4) Sample Dynamic Warm-Up: Baseball

http://www.youtube.com/watch?feature=player_detailpage&v=OrmJuEclOz0

Aside | Posted on November 20, 2013 by | Tagged , , , , , , , , | Leave a comment

Curveball Controversy

By Chris Anninos, DPT

Curve 1As a pediatric physical therapist, the majority of baseball injuries are related to the growth plates of the shoulder and elbow; also known as Little Leaguers Elbow and Shoulder. When evaluating these kids a common question I receive from parents is “Should or can my kid be throwing a curve ball?”  I find this to be a common question coming from parents who know their kid is being taught or has already been throwing one at a young age (under 14).  Asking is a way for them to either justify it being thrown or find out why there is such a stink on throwing it at a young age.  So what’s the big deal about the pitch? Is it hurting our kids?

That being said, let’s start with the literature:

• 2001: Lyman et al. found through postgame telephone interviews with 298 youth pitchers that there was no significant association between pitching a curveball and shoulder or elbow pain.1

• 2002: Lyman et al. found that in 476 pitchers there was a 52% increase in shoulder pain when pitching a curveball. 2

• Petty et al. reported that sixteen of twenty-four Tommy John’s patients threw a curveball before the age of fourteen. 3

• 10 biomechanical studies examining the motion of pitching a curveball have not shown that the mechanical differences that separate it from a curveball increase the strain on a pitcher’s shoulder or elbow.  Of particular note, there is no indication that there is additional stress to the medial aspect of the elbow potentially injuring the ulnar collateral ligament.

• In fact, the studies involving youth level pitchers, the population of greatest concern for potential consequences, showed decrease forces about the shoulder and elbow when throwing a curveball. 2,4

Curve 2So what does this mean?  Basically, like most topics in science and medicine, there is a need for more research.  Based off of what is available, it seems the curveball is in fact a safer pitch than the fastball.  There seems to be some correlation of arm pain with throwing a curve ball, but correlation doesn’t always mean causation.  So why are there age guidelines for curveballs?  Why is there so much hype on throwing a pitch when in fact it is less stressful?  This is where we have to look at the pros and cons of throwing the pitch at an early age.

Let’s start with the pros:

  • Effectiveness.  This is an obvious fact.  When you start to change “eye level” (ie Curveball) in hitters that aren’t used to their “eye level” being change, it will be more difficult to hit.  The kids who throw curveballs earlier will be more successful than a kid with comparable velocity and control that doesn’t throw one.  Essentially, young hitters are not used to seeing the curveball yet.
  • Early development of a pitch can be considered a pro or a con, but for the sake of argument we will consider it a pro.  Having more pitches, that can be controlled, can make you more successful in the higher and lower levels of baseball.

Cons:

  • Kids that are effective and win games are typically over utilized.  Most baseball injuries we see are related to some form of overuse, and in most cases can be avoided.
  • A curveball is an advanced pitch and requires good grip and hand size to cover the ball. Despite coaching, it is difficult to throw a proper curveball and a lot of kids are actually throwing sliders without realizing it.  There is limited research on the stresses of throwing a slider, but one study has shown it to be more stress on the elbow and shoulder.5  A properly thrown curveball has a 12-6 (on a clock) trajectory with minimal lateral movement.  As the ball moves laterally this is more typical of a slider or what is known as a “slurve” (slider-curve).  Sliders typically have the fingers on the outside of the ball, where with the curve ball the fingers are on top (see image).  Having the fingers on the outside of the ball effects forearm and elbow mechanics and in some cases adds more stress to the medial (inside) structures of the elbow.5  
Curve grip

Curve Grip

Slider grip

Slider Grip

  • Developing a curveball takes away from the development of the 2 most critical pitches; fastball and change-up.  As a player moves to the next level of baseball, change of speeds becomes more critical (change-up) than a change in planes (curveball).  Yes, a good curveball can be effective, but the ability to accurately control pitches and vary your speeds is necessary at the college level and above.  Good hitters will hit good curveballs, but the ability to disguise speeds can fool a good hitter.  Some of the most effective pitchers we’ve seen today are fastball-change-up pitchers.
  • Young catchers will have difficulty blocking the curveball due to the spin.  Blocking as a catcher is different for each pitch, but this is a skill catcher’s work on in high school and above.  Mastering the basic techniques is more important than factoring in the “kick” of a curveball.
  • Skeletally immature individuals are more apt to injure their growth plate due to overuse, increased stress, or throwing fatigued.  Throwing fatigued increases your chance of injury by 36 times!!6
  • The biomechanical research does not factor in fatigue related changes in mechanics and other issues that come with overuse or throwing later in games.  Only one of the studies was actually performed on adolescent athletes.

One can look at the above pros and cons and suggest that if throwing a curveball leads to improved effectiveness and winning, then by all means “master” the curve as young as possible.  Win as many games as possible! Go for it! WRONG! A coach that puts winning before development of adolescent athletes is missing the boat.  Developing our youth athletes and promoting sport participation is the purpose of youth sports, not building our trophy cases.  Studies have shown that by age 13, 70% of kids drop out of youth sports because of 3 reasons: Adults, Coaches, and Parents.  Yes, winning is a part of development and builds the competitive nature of our athletes, but if jeopardizing the well-being, participation, or development of our kids is the price…it’s not worth it.  Last time I checked, 11 year olds don’t get recruited to college or the MLB (no matter what the parent next to you says, it doesn’t happen), and winning youth championships does not put food on the table.

Curve 5So, if you are buying into my rant, what do you do? It’s pretty simple, stick to the guidelines put forth by people way more experienced than you and I.  The USA Baseball Medical/Safety Advisory Committee has used a substantial amount of literature, surveys, and anecdotal evidence to formulate the ages to learn specific pitches.  Yes, these are guidelines, but not throwing a curve until the age of 14 is not that unreasonable.  Kids develop at different rates and some will peak earlier than others, but as a guideline, kids under 14 are most likely skeletally immature in the elbow and shoulder (higher risk of growth plate injury). This is also right around when they start high school and can most benefit from the addition of a curveball.  Will there be some exceptions? Maybe, but find me a 13 year old or younger that can consistently spot a fastball and change-up and I’ll find you an umpire that is his father or a kid that is the next Greg Maddux.

Click Here for a great handout on other guidelines for baseball injury awareness and prevention through Dr. James Andrews’ American Sports Medicine Institute.

Curve 6

References

1. Lyman S, Fleisig GS, Waterbor JW, et al. Longitudinal study of elbow and shoulder pain in youth baseball pitchers. Medicine and science in sports and exercise. Nov 2001;33(11):1803-1810.

2. Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. The American journal of sports medicine. Jul-Aug 2002;30(4):463-468

3. Petty DH, Andrews JR, Fleisig GS, Cain EL. Ulnar collateral ligament reconstruction in high school baseball players: clinical results and injury risk factors. The American journal of sports medicine. Jul-Aug 2004;32(5):1158-1164.

4. Nissen CW, Westwell M, Ounpuu S, Patel M, Solomito M, Tate J. A biomechanical comparison of the fastball and curveball in adolescent baseball pitchers. The American journal of sports medicine. Aug 2009;37(8):1492-1498.

5. Fleisig GS, Kingsley DS, Loftice JW, et al. Kinetic comparison among the fastball, curveball, change-up, and slider in collegiate baseball pitchers. The American journal of sports medicine. Mar 2006;34(3):423-430

6. Fleisig GS, Andrews JR, Cutter GR, et al. Risk of serious injury for young baseball pitchers: a 10-year prospective study. The American journal of sports medicine. Feb 2011;39(2):253-257.

7. USA Baseball Medical/Safety Advisory Committee Recommendation

Aside | Posted on November 13, 2013 by | Tagged , , , , , , , | Leave a comment

Energy Drinks and Adolescents

Posted on October 31, 2013 by

By: Rebecca Berthold, ATC

More and more in today’s society energy drinks, such as Redbull and Monster, are being marketed to adolescents. We need to ask what nutritional benefits, if any, do these drink provide to our children? Most of the energy drinks contain caffeine and other herbs that are suppose to enhance your alertness. Frequently containing high and unregulated amounts of caffeine, these drinks have been reported in association with serious adverse effects.1 

Energy Drink 3

Some of these adverse effects can be increased heart rate, anxiety, dehydration due to increased urination, and difficulty sleeping. A child who consumes caffeine may also eat less; because caffeine reduces the appetite.2   This reduction is appetite can lead to children not getting the proper nutrition for bone and muscle growth. Therefore, we should try to limit the amount of caffeine our children are consuming for proper growth and development.

Energy Drink 4

 

References:

1.Seifert S, Schaecher J, Hershorin E, Lipshultz S. Health effects of energy drinks of children,adolescents and young adults. PEDIATRICS Vol. 127 No. 3 March 1, 2011 pp. 511 -528 (doi:10.1542/peds.2009-3592).

2.Caffine in diet. MedlinePlus Website for the National Institute of Health. http://www.nlm.nih.gov/medlineplus/ency/article/002445.htm. Publishes May5,2011. Accessed October 27, 2013.

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An Overview of Hypermobility and Ehlers-Danlos Syndrome

Posted on October 23, 2013 by

By: Sara Stites DPT, ATC

What is Hypermobility?

Hypermobility is when joints easily move beyond the normal range expected for a particular joint; it is considered a benign condition. Hypermobility is somewhat common in the pediatric population as it is estimated that 10%-15% of normal children have hypermobile joints.  A patient can be screened for joint hypermobility by using the Beighton Scale. Hypermobility is determined by having a score of 5 or higher on a 9 point scale. The Beighton Scale consists of the following tests:

  • Being able to bend your little finger back beyond 90 degrees (one point per finger)
  • Being able to push each thumb to the front of your forearm (one point per thumb)
  • Being able to hyperextend your elbows (one point per elbow)
  • Being able to hyperextend your knees (one point per knee)
  • Being able to place the palms of your hands on the floor while keeping your knees straight (one point)

Hypermobile 1

Hypermobility can occur in other joints such as the jaw, shoulders, and feet; it may or may not cause pain. Hypermobility may be used to an athlete’s advantage in sports such as dance and gymnastics, where excess mobility may be helpful.Hypermobile 2

What is Ehlers-Danlos Syndrome?

Ehlers-Danlos Syndrome, also known as EDS, is a group of inherited disorders that involves the connective tissues of the body.  Collagen is the connective tissue that is affected in patients with EDS. Collagen is like the glue our joints, muscles, ligaments, and skin need to stay together. Most people who have EDS usually have overly flexible joints and are sometimes referred to as “double jointed”. There are many different forms of EDS. Each form has specific symptoms and specific ways to test for it. For all types of EDS, a comprehensive evaluation that includes patient and family medical history and physical exam is very important to determine the proper diagnosis.  The three most common types of EDS that I am going to review are Hypermobile, Classic, and Vascular.

Hypermobile EDS

Hypermobile 3Hypermobile EDS is referred to as EDS-HT or EDS III. People with this type of EDS will typically present with very loose joints throughout their body and soft velvety skin. This is the most common type of EDS. There is no genetic test to test for EDS- HT, so diagnosis is based solely on history and physical exam. This may often go undiagnosed as generalized joint pain and may be passed off as “growing pains”. Some of the common signs and symptoms of EDS-HT are as follows:

  • Joints that dislocate or sublux with no to very mild trauma.
  • Pain that can be widespread and chronic. This pain is often caused by joint instability.
  • Wounds that take longer than normal to heal.

Classic EDS

Hypermobile 4Classic EDS is the second most common type of EDS. With Classic EDS patients typically have loose joints, fragile stretchy skin, and poor wound healing which is similar to the symptoms of EDS-HT. Some patients with Classic EDS may also have heart issues such as mitral valve prolapse or an enlarged aorta. Classic EDS can be diagnosed with genetic testing. Testing involves a blood test to determine if you have a particular collagen gene.

Vascular EDS

Hypermobile 5

Vascular EDS is more rare than Classic and Hypermobile EDS. Vascular EDS is also more serious and can be life threatening. Diagnosis of Vascular EDS is based on clinical exam, family history, and genetic testing which involves a blood test for the presence of a change in one copy of one particular gene. Patients with Vascular EDS typically present with the following:

  • Distinct facial appearance with a thin nose and lips along with hollow cheeks.
  • Thin skin that you can see through (can see blood vessels under the skin on areas of the body that typically cannot be seen such as on the chest and abdomen).
  • Very loose small joints such a fingers, but typically not large joints such as shoulders and knees.
  • Skin that bruises easily.
  • These patients are at high risk for life threatening rupture of the intestine, uterus during pregnancy, and arteries.

Hypermobile 6There is no cure for EDS. Treatment of EDS typically consists of management of the specific signs and symptoms, as well as lifestyle adjustments to prevent injury/complications.  Physical therapy is the main treatment for the joint related issues that accompanies EDS to improve muscular strength and increase joint stability. Physical therapy can also help with pain management, provide education in joint protection, and to help fit braces or splints when necessary.

Hypermobile 7

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Hydration: Year Round

Posted on October 16, 2013 by

By: Laura Clarke, MEd, ATC

Entering into mid October of football season athletic trainers might think that their athletes are well hydrated and taking care of their bodies in order to perform to their potential.  Flash back to last Friday night’s game where on three or more occasions we were running out onto the field to stretch out a cramping player.  Due to the change in weather in Virginia on a daily basis, hydration can sometimes seem less important on certain days.  If proper care is not taken in the days leading up to an athletic performance, performance can be lackluster.

Here are a few reminders for all athletes throughout the year:

  1. Stretching before and after activity with a proper warm-up and cooldown are important to prevent cramping from vigorous physical activity.
  2. Consume between 16 to 24 ounces of water two hours before a practice or competition.
  3. For activity lasting longer than one hour, a sports drink that contains between four to eight percent carbohydrate is recommended. The depletion of carbohydrates during activity will lead to muscle cramps.
  4. Eat a carbohydrate-rich meal or snack prior to endurance or intense exercise.
  5. Drink three to six ounces of water every 15 minutes during strenuous competition or practice.
  6. For chronic crampers, high sodium sports drinks can delay muscle cramping.
  7. Don’t forget to drink plenty of fluids after activity to replenish what you have lost during and prevent dehydration and cramping the following day.

Even with well conditioned athletes this far into the season, cramping is still a concern during Friday night lights.  Reminding and encouraging athletes to drink plenty of fluids throughout the week will help prevent muscle cramping during the game.

For more information, please visit:

http://www.nata.org/sites/default/files/FluidReplacementsForAthletes.pdf

http://www.chkd.org/documents/SportsMed/dehydrationbrochure.pdf

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