 Aloha and welcome back to Movement Matters on Think Tech Hawaii. I'm Christine Linders, your host and physical therapy orthopedic clinical specialist. We're wrapping up Sports and Fitness Injury Prevention Month today and are speaking with Dr. Daphne Scott from the Hospital for Special Surgery in New York City to learn how to prevent shoulder and elbow injuries in Little League and adult baseball players. We can prevent these injuries from occurring and the key is identifying and addressing imbalances in range of motion and strength early on before pain occurs. Dr. Scott and I will be discussing what athletes, coaches and parents need to know to keep these athletes healthy and on the field. Let me welcome Dr. Daphne Scott, the assistant attending physician at Hospital for Special Surgery in the Primary Sports Medicine Department, team physician for the West Chester Knicks, consultant for UFC and team physician for USA Track and Field at the 2017 IAAF World Championships in London, England. Dr. Scott, Aloha and Mahalo for joining us on Movement Matters today to talk about keeping these young athletes healthy and enjoying their sport. Aloha, thank you so much for having me. It's great to have you. So what do you find puts a young athlete at risk? The biggest thing that we're seeing right now is overuse. With kids playing one sport all year round or maybe two sports all year round with no break, we're really seeing that that's just putting a lot of stress on the body. So it's really the overuse injuries that we're seeing. Yeah, that's what I had suspected that being around sports, being in sports and also working with a lot of young athletes and old athletes as well, old meaning anything over 20. We'll group us all together in that, right? But the specialization that's happening now where youth are tending to play one sport year round, I'm seeing idices as well as adults, I should say, runners and athletes that are maybe in their 30s and 40s and they're playing year round now living in Hawaii. You can actually play those outside year round and I'm seeing things that are occurring as well. So in the baseball player, I know Little League is very big in Hawaii with the world champions and all that. So what kind of injuries have you seen specifically in maybe some baseball players, youth, adults? Yeah, I mean, the biggest things that we see primarily kind of middle of the season in the end of the season, shoulder and elbow injuries, those are huge. Again, going back to that whole overuse component of throwing and things like that, it's rare. Occasionally we'll see an ankle injury if someone hits the back wrong, but really the big things are in the elbow injuries. Okay, that's what I've noticed and I noticed I've seen a couple when I was working with you in Connecticut that were a shoulder injury and an elbow injury. And I know with one of the athletes that I saw, I think he was about somewhere between 13 and 15, he had one weak hip on one side I found in the exam and he was a pitcher, he was a young pitcher, and he was throwing the standard amount of pitches. His dad and his coach were on them about making sure they don't overthrow, making sure they're not throwing curveballs, making sure they're not trying to throw for absolute speed with the gun and everything when they're too young. I found a weak hip in this young kid and so like when you see this youth in your office, how do you know whether you're going to be referring to physical therapy or doing some diagnostics, how do you determine that? Yeah, so generally if anyone's under the age of 18, I don't just get x-rays, I actually will see them versus a little bit different with my adult patients where sometimes I'll just get the x-rays first and then see them, but for a lot of our young athletes that like to see them first, get the history, find out what's bothering them, where does it hurt, how long has it been hurting, what have they tried to make it better, try to get as much information from them as I can, and then we do an exam and if someone comes in with shoulder pain, my exam is not just of their shoulder, I'm having them stand up for me, I'm looking at their feet look like, do they have really flat feet, do they have really hard arches, I'm having them do some squats with me and see does it look like they have weak hip muscles, weak core, weak pelvic stabilizers, because all of that goes into how they're playing and a lot of the times it has to do with their injury, especially with the upper arm, I think one of the big things for kids that are throwing or throwing, most of the weight is generated from the lower side of the body, you have a weakness down, then you're going to mess that chain, and then you're kind of overusing the shoulder and the elbow to really try and pitch ass, which is where we'll see a lot of the injuries in our young people. That is so well explained, thank you for that. So if we look at this brief image of throwing mechanics, this shows someone making a pitch, and so it looks pretty complex, they're wind up cocking, they're throwing, they release it and they follow through, and so that hip needs to have such stability, I think it's something that a lot of people don't talk about when you have a baseball player, parents, players, health professionals, they're not talking about thinking about what you just said, which is from below, the stability from below that can leave the shoulder and elbow out there to just try to really overthrow or launch if they don't have the stability from below, or as I've seen, I had a 21, I think it's 21 years old player who throughout his rotator cuff, he had a labral tear in the front of the shoulder, the cartilage that's in the front of the shoulder for those that don't know what a labrum is, it surrounds the ball in the socket, and so he was hurting his shoulder because he had an old ankle sprain, so when he was in that early phase, standing on one leg, getting ready to wind up to throw the pitch, he was wobbly, and so he didn't have the stability, so his arm kind of got left back a little too hard, which put a huge amount of strain on the front of the shoulder. Yeah, so I mean, I'm sure you must see, I mean, I don't know, do you see any throwers with hip injuries as well? Yeah, absolutely do. I actually had a picture who came in because he just wasn't able to generate enough force, and it actually had nothing to do with his shoulder, he ended up having, and we have this on whatever he gets again, and you had mentioned phases of throwing, but the windup phase, I mean, really the major stabilizers are at that point for the legs, the hip abductors, your hip flexors, the quadriceps are all involved in that first phase, that windup phase, and so if you have weakness there, there, again, we're already starting off from a bad point, so I just always tell people we have to get a good look of what's going on, a good look at the whole picture, and then kind of back up and go from there. No, that's great. So that's a great introduction for us to look at some images. So the image number one, I show a picture that just is, and not allowing your hip to have the adequate range of motion, and that I call the knee to opposite shoulder stretch. So you're basically hugging your knee up towards your opposite shoulder with one hand high, one hand low to increase the external rotation of your hip that you're going to need, mostly when you follow through, when you're traveling over that front standing leg and you're throwing that ball out, you need those muscles and that hip to have a lot of internal and external range of motion for both of those. And in image number two, I show these are very basic images. There's very sophisticated stretching to get hip range of motion, but for the purpose of the talk, this is allowing both hip and external and internal range of motion, but I use this more for internal range of motion, which is when your knee is crossing your body, because that's what you're going to need in those phases of throwing. And so the stability, one of the things I like to do, if we look at image number three, I do this on my back, on my side, side stepping, there's a million ways to do this, but you're working your gluteus medius in that deep hip rotator group, the abductors, the external rotators, and then you put it all into practice in image number four, by being able to stand on an unstable surface and maintain the stability of your leg with your pelvis aligned without your trunk leaning. And that is your single leg initial start where the pitchers winding up on that one leg and getting ready their coiling energy from the kinetic chain and getting ready to unleash it. So in image number five, now we're doing a single leg squat. So now you're making it more dynamic, you've got an unstable surface, you're bending the knee, you want to make sure that if you're doing this in the clinic that you keep the pelvis level. Those are just a few of the ideas of things that I think if a, if a player was in the clinic and someone found such as you found hip weakness, hip instability, shoulder elbow pain or hip pain that those things need to be added as well as a barrage of others. So now what about the shoulder? Let's talk a little bit about the shoulder. I know that I had talked to you in Connecticut about one youngster, I think he was 13. I was looking back who had some sore shoulder pain or no, maybe he wasn't and you found that the little league shoulder where the growth plate had started to get irritated from that, that year round that repetitive overuse. So what is the standard? How do you approach healing that? Yeah, that's a hard one. Little league shoulder is one, you know, that we see it not to and there's an injury to the growth plate. It is so important that we really take good care of it because that can affect how the arm goes on to grow and just how that person's shoulder will continue to progress. So one of the things that we do is absolutely have to shut down throwing, okay, which is a hard thing to do. If I can try to keep someone active and doing the things that they want, then great. But when it comes to a growth plate injury where we see wide mean on x-rays, I really need to shut them down to allow that to heal. When I say shut them down, that's no throwing, no pitching and and really go from there. Now, one thing that I have learned is that I will allow them to start in some physical therapy early on so that we can work on all of their panics. So like you said, I most of the time I can find something whether tight tight tight ring, deep glute medius, which is our major pelvic stabilizer. So the very least while I'm letting them rest their arm, I will allow them to start working on their lower leg, the lower biomechanics of things. Yet once they are pain free, then we can stop some things back. But it takes a while literally shoulder. I mean, for some kids, it can take up to six months to really get them back to doing things. Yeah, I think those are great things that you mentioned and it is important to work on the mechanics and rest it because that's important. These these these youths are they're growing and you want to have that growth plate solidify normally. I mean, some of the some of the complications I've seen them in adults were that they ended up with a little bit of a shorter arm length if it didn't heal properly. And sometimes kids fell when they were younger and they damaged the growth plate and you would see, you know, a little bit of a smaller humorous and asked them about it. Oh, I broke my arm when I was a kid and it damaged my growth plate. So it kind of halted that growth. Have you seen any of that with a little leg arm or it's too late? You know, I actually I haven't seen it when it's too late. Thank goodness. But I think that brings up another point is so much of when all of this is happening is when kids are hitting these big growth spurts. And one of the things that I also talk about is the fact that when when a kid's growing, you know, two inches and just a few months, they're typically not doing the stretching that they need to keep up with that. So if you imagine, your bones are growing really quickly, but the muscles in the tendons aren't able to do that. So then really tight muscles around the shoulder, you have the tight hamstrings, you have tight heel cord Achilles tendon, all of this goes to play into things and where now we're busy because kids are running from school to practice and, you know, maybe doing the very minimal amount of stretching. This is where, you know, I say we can look at things and aim to improve them working on the stretching, working on strengthening those small supportive structures such as the bloot medias, propellic stabilization, all of that. Just so important. That's so important. That's so great. So Dr. Scott, we're going to go to a brief break. I'm Christine Linders. This is Movement Matters on Think Tech Hawaii and we're speaking with Dr. Daphne Scott talking about how to prevent these injuries in Little League and adult baseball players. Stay tuned. We'll be right back for more. Aloha, I'm Kili Ikeena, the host of Hawaii Together on the Think Tech Hawaii Broadcast Network. Hawaii Together deals with the problems we face in Paradise and looks for solutions, whether it's with the economy, the government, or society. We're streamed live on Think Tech biweekly at 2 p.m. on Mondays. I want to thank you so much for watching. We look forward to seeing you. Again, I'm Kili Ikeena. Aloha. Welcome back. I'm Christine Linders. This is Movement Matters on Think Tech Hawaii and we are talking to Dr. Daphne Scott from New York about the things that we need to know to prevent injuries in young and adult baseball players. So Dr. Scott, we were just talking about it being so incredibly important to have the stability from below, working on the gluteus medius, the pelvic stability, so that you don't have excess strain on the shoulder and elbow when you are throwing, whether you're a catcher, pitcher, outfielder. And so now let's talk a little bit about the shoulder. I know I've had five shoulder operations. I have a great rotator cuff. All of my MRIs or arthograms always said well developed rotator cuff, but I did grow. We were talking about the bone growth. I did grow eight inches in about one and a half years. And so the doctors when I was 12 and I got to high school at 13, I was spraying in my ankles, my kneecaps were subluxating, my shoulders were dislocating. They said don't worry by the time she's 21, all of the muscles and everything will in the ligaments will have gotten their proprioception back and stabilize the joints. But of course I played D1 volleyball and all these other things. So I had five shoulder surgeries to tighten up my joint capsule by the time I was well four by the time I was done with my sophomore year. And I'm great. I'm playing beach volleyball today. I'm surfing. I just grew too long and was bendy-wendy. You know the instability factor I was the bait and scale perfectly. So let's talk about the shoulder and what can we do to prevent or what do you see like more biomechanics wise? What do you see like in your exam on the shoulder? You mentioned a little bit about scapular weakness in an athlete like that that's coming in with shoulder or elbow pain. Yeah, so scapular weakness is one of those things. So our scapula or shoulder blade what I always remember is that's the half of the shoulder joint. So if the muscles that support that aren't working well and it's moving symmetrically then that can definitely throw things off as well. The other thing that I see is people have a really tight what we call posterior capsule. Their motion on their throwing side is not necessarily the same as their motion on the other side. And so with that we really have to get into the stretching and that's more kind of a compensation type thing for just their mechanics and how their shoulders working with throwing over time. Yeah, that's right. You know it's funny when I am explaining to even people with bison tendonitis who are having it from having a new baby or they're on a computer desk job and they didn't have one before and their mouse clicking is when I see that shoulder blade winging or it's not moving symmetrically when I go through the motion test I always say you know your shoulder blade is the quarterback of your shoulder. Your rotator cuff muscles can they live in it on it? They reside on your shoulder blade and they reach out and they hold on to your humerus and they help stabilize it like this so if your shoulder blade the quarterback is not doing what it needs to do your shoulder and your rotator cuff muscles are put under strain and you also mentioned the range of motion that variance between the internal external rotation of the non-throwing side and the throwing side if we go to image number six this has been historically called the sleeper stretch. It has to be reformed. I don't know who sleeps like this but it has to be reformed very specifically because it is a capsular soda stretch it's not like you're just stretching your your muscles and your hamstrings and so that's what helps to make room in that post here a joint capsule so the humerus can sit right on the the glenoid which is the socket it's like a golf ball and a tee and it needs to sit centered there in order for your rotator cuff and everything to work optimally so if it's riding forward because there's that tightness in the post here the back of the joint capsule you need to do the sleeper stretch to make sure that the humerus the ball has room to move back on the socket and that's a one of the biggest things I see when I used to work with pro pitchers back in san diego is them needing that everybody's doing sleeper stretches because nobody had enough internal rotation motion to make it through follow-through and so the rotator cuff is just getting jerked they don't have the motion and the joint capsules like twisting absolutely absolutely what again you know going back to how you were talking about the golf ball sitting on a tee the other kind of analogy that I use is almost like a basketball sitting on a saucer plate for a lot of people it's not it's not stable all alone but when we add in everything else the labrum so the bumper that kind of surrounds that socket or that would run around that saucer plate helping to stabilize and then you add in all the other layers rotator cuff and everything else if that's not all working together then yeah the ball is being pulled in one one direction or the other and just put so much strain on that shoulder yeah that's right I like the uh I like the bumper and the saucer so I did a talk on swimmers a long time ago and I remember talking about the serratus muscle the serratus anterior that does that protraction and that's one of the things that helps to really stabilize the scapula the shoulder blade on your thorax on your upper back and also how like a pec minor the one in the front can be tight and it also attaches to the front of the shoulder blade so when it's tight the the pec minor has a huge role in keeping that quarterback that shoulder blade not in the right spot so if we go to image eight where I'm laying on my back and I've got a band around my hands this is something I came up with someone who did have a a humoral fracture they were stable and so I was trying to find a way to get them to work on their serratus and their posterior rotator cuff without pain that was going without pain so I just had them lay on their back and protract they get those shoulder blades off the rib cage and then oscillate out like that it's great for proprioception now there's a million ways there's the push-up plus there's the planking with a plus there's on the bozu there's push-ups against the wall do you have any favorite ones that you've learned over the years honestly I mean well I like what you just showed that's awesome but you're right I'm gonna push up with a plus or the planking with a plus that's kind of what we what we typically will utilize but you're so right again talking about the serratus and the pec that's really involved with that acceleration and ball release so again you know what I tell people is I don't just always content a little lower do you want things are better with the upper body that's when we can start working on all of those other must yeah very important time in throwing a cannon oh that's great and that led me perfectly into my next picture so we've done this sleeper stretch we've got the serratus now we're going to do image number seven which I like to call clocks because I will have people trace the clock now this is my left arm so this would be nine o'clock it's at shoulder height I am protracting I'm getting my shoulder blades off of my rib cage I'm holding a ball it's a left arm you do it the other way out if it's a right arm I will do ball circles I will raise it up and down from the ceiling to horizontal horizontal to vertical and I will just keep hitting the points of the of the clock with my guard arm guide arm on the bottom and then the other arm on the top and then in the in the next image in number nine I show just another another clock it's like 1030 or something like that so now you're working them overhead and so it's a good thing to do once the arm is ready to go and you're going to be you've healed that stress reaction you're getting ready to getting them back to beginning to start to throw we want to make sure now that you're coordinating your serratus underneath your shoulder blade with your scapular muscles and your posterior cuff and then put it all into practice with image number 10 which is starting to work the cuff overhead so you need to have the concentric and eccentric of your external and your internal rotators this is showing external rotation you could do it fast you could do it slow you could do it at different ranges pulling for endurance pulling for strength pulling for speed and proprioception and I think that's a thing you know we started off this talk Dr. Scott talking about overuse and a lot of the injuries will happen if it is a big inning or a big season and these athletes are fatigued so now their hips are fatigued and they're strong and working fine but they're fatigued now the arm the rotator cuff is fatigued and you start seeing some maybe overuse injuries midseason that in a sound athlete exactly and the young ones usually midseason later season but we were even talking about our adults I mean how many weekend warriors do we know that'll go out and play in a softball or a baseball tournament and play three four five games all in a matter of a couple of days and just completely wreck their shoulder and come in with so much pain because of that so again all of its overuse it may be overuse over weeks or months or overused even just over a few days yeah that's spot on so I think one of the things too that I'm not sure if we talked about it earlier or not but in Hawaii you can play sports year round is there a recommendation of let's say you're playing little league baseball all year round how many months or how much time should that young athlete not do an overhead sport or throw a ball or potentially be surfing after he takes his break from baseball is there is there a magic number or a guideline you know everyone have a little bit of a different one I usually ask for about a month honestly I think that the puppy really can use that time now some people they say it's hard to take four weeks off at a time so maybe we break that up into two weeks you know two times a year but I really like for people to get about a month of rest from the throwing the other thing is we talk about sports specialization so for our really young people we know that the more sports that they're playing the more activities they're doing the better for their body with the exception of a couple of sports such as gymnastics or ice skating most kids do really well and their bodies do really well if they're participating in more sports that young kid who's just doing one sport year round for years and years and years they don't typically do as well and we know you know there's this interesting fact that in major league baseball there are no pitchers that actually pitched in little league so we just know that those those kids that are pitching in little league their shoulders their bodies can't paint it and so once they get to the pros that's they can't do it they can't get there I love that you said that and you know what I think I remember hearing that from you in the past that there's no major league ball pitchers that played little league they were the pitch the pitch sorry the pitch the pitch little league yeah that's a good point and that's I think that's a good point for all of us to be aware of too if you do have a youth pitching in little league if he's doing if he's doing it for fun or if he's doing it because he's aspiring to be a pro ball pitcher that might be something for parents and coaches to think about if they've got someone that looks like they've had talent to get them into a different sport or you play one season and that's it or you only pitch the last three innings once a month right there's got to be some way to vary it for these hopefuls and for some young leagues there are pitch counts which I think are great I also think that's a wonderful time for kids to go and play other positions and play outfield fetch you know get get to know all the other positions but you know if you absolutely baseball is the only thing that kids like that's fine but let's just get them moving around let's play let's play other positions but you know ultimately if they could play another sport a different sport work on a different set of muscle groups that's amazing well that is that is very wise advice thank you so much doctor Scott so we are out of time thank you so much doctor Scott and everyone for joining us today and thank you to think tecawaii and our sponsors and donors if your shoulders ever bother you during your day or during your sport or workout routine join us next month we'll be talking about shoulder injuries prevention and treatment from surfing and paddling to child care and working at your desk and as always life is better when you listen to your physical therapist see you in two weeks