Your Injury Doesn’t Define You: Treating the Whole Person in Physical Therapy

Patient centered care is an essential piece of the physical therapy profession. Not only is it important to guide the patient in recovering from their injury or source of pain, but helping them become stronger, faster, and better than they were before is the key in sports rehab. This concept applies to every single patient: the teacher returning to CrossFit after shoulder pain, the soccer player recovering from ACL surgery, and the active older adult with chronic back pain.

Not only is treating the whole person important in recovering, but it could be what keeps athletes from subsequent injury. Improving quadriceps-to-hamstring ratio can decrease the risk of retearing the ACL. Improving hip mobility and lower body power can reduce stress on the UCL in pitchers decreasing return to sport complications after Tommy John.

Listed below are the essential categories to incorporate in rehabilitation of the throwing athlete, why they are important, and some exercise examples and suggestions (if applicable).

Hip Mobility –

The evidence within the literature reports decreased mobility in the hips, specifically internal rotation, is common in throwing athletes who have sustained an upper body injury. As the individual is rehabbing to return to their sport, it is crucial to incorporate this piece into their programming.

Retrospectively, it’s hard to know if limited hip mobility is the primary cause of upper body injuries. However, we can take steps within rehab to make sure that this does not become an influencing factor moving forward.

· 90/90 hip mobility exercise (pictured) to improve bilateral hip internal and external rotation.

· Ideally the individual has about 15 degrees of internal rotation of the lead leg in relation to the trail leg in order to optimize power from the trunk and avoid additional stress on the anterior shoulder.

Lower extremity power –

Power originating in the lower body is incredibly important when returning to throwing following an upper body injury. The “main force generators” within the throwing motion are the legs and trunk, so targeting these areas to aim for return of equal or better performance is crucial.

Studies have reported that a 20% loss in lower body power can lead to an increase of about 35% increase in stress and power requirement to achieve the same velocity and force with a throw or pitch. Similarly to other categories within this discussion, targeting lower extremity power can assist the individual in returning to sport stronger than they were before, in hopes that a subsequent injury can be avoided.

· Deadlifts, band pull throughs, and and other triple extension exercises are great to begin in initial phases of rehab if applicable, but should be continued and progressed throughout.

· During the initial phases of pitching, the stance leg glutes activate to maintain extension on the dominant side to provide stability and generation of force.

Shoulder stability –

Shoulder stability is incredibly important when working with athletes presenting with an upper extremity injury. Open kinetic chain and closed kinetic chain exercises can be added to the individual’s program to address the shoulder stabilizers. When considering return to sport, the throwing arm requires stability within the open chain. Periscapular (around the shoulder blade) and rotator cuff muscles may be strong but coordinating their activation to support the shoulder while transmitting force is essential to do in rehab to simulate game-like scenarios.

·  During the acceleration phase of throwing, the serratus anterior stabilizes the scapular so the humerus can move around a stable glenoid.

·   Pectoralis major and latissimus reach forces as great as 185% maximum muscle test strength during pitching.

Core –

With the translation of power and force through the lower body up to the trunk and into the arm, it is important to ensure that the core is strong. The core can often be a point of emphasis from day one of rehab. Core strength can still be addressed whether the patient has surgical limitations in the upper body or is in too much pain

·   In later phases of rehab, core can be integrated with other components as seen in the photo, shoulder stability, strength, and core in one exercise

· Evidence suggests that the non-dominant abdominals are highly active during the acceleration phase in order to facilitate trunk and pelvic rotation.

Closing Thoughts

Treating beyond the direct site of impairment is crucial in the realm of sports rehab. Not only can the individual return better than before, but hopefully with a reduced risk of further injury. From the therapist perspective, challenge yourself to understand the why, why did this patient end up in front of you with this injury? Incorporation of the individual’s sport into their rehab can not only make a change for their future, but make rehab fun!

References:

1 Swärd P, Kostogiannis I, Roos H. Risk factors for a contralateral anterior cruciate ligament injury. Knee Surg Sports Traumatol Arthrosc. 2010;18(3):277-291. doi:10.1007/s00167-009-1026-3

2 Seroyer ST, Nho SJ, Bach BR, Bush-Joseph CA, Nicholson GP, Romeo AA. The kinetic chain in overhand pitching: its potential role for performance enhancement and injury prevention. Sports Health. 2010;2(2):135-146. doi:10.1177/1941738110362656

https://5toolsportsscience.org/articles-1/2019/9/9/study-poor-hip-mobility-leads-to-higher-rate-of-throwing-injuries

By Dr. Kayla Parsons