Biceps and Shoulder Pain

People with shoulder pain often assume they’ve injured their rotator cuff, but sometimes that is not the only culprit. Shoulder specialist and orthopedic surgeon Dr. Marc Kowalsky of ONS notes that an injury to the tendon of the biceps, the prominent muscle in the upper arm that made Popeye and spinach famous, can cause shoulder pain and other uncomfortable symptoms such as clicking or popping.

“The biceps tendon is an often-misunderstood structure of the shoulder and arm,” said Dr. Kowalsky. “We now know that damage to that tendon is often the primary cause of shoulder pain in active people.”

Anatomically, the biceps muscle has two tendons, called heads, that attach it from the elbow to the shoulder. The tendon of the short head attaches to a bone on the shoulder blade outside of the joint. The long head, usually the source of the pain, takes a circuitous path into the shoulder joint. It then attaches to the top of the socket and the glenoid labrum.

As with any other tendon in the shoulder, the biceps can develop tendonitis and tears. It can be a result of repetitive, strenuous overhead activities. Pain from biceps tendonitis or partial tearing typically occurs over the front of the shoulder. It radiates toward the biceps muscle. If the biceps tendon fully tears or ruptures, patients may notice bruising and a cosmetic deformity as the muscle descends and becomes more prominent, in what is known as a “Popeye sign”. Lastly, you can affect the biceps tendon by instability, particularly in certain overhead athletes including swimmers. Biceps instability can also occur in association with a particular tear of the rotator cuff tendon in the front of the shoulder. When this happens, pain is caused because the biceps has slipped from its bony groove of the upper humerus (head of the arm bone).

Moreover, most patients with tendonitis, a partial, or complete rupture of the long head of biceps can be treated conservatively. You can use a combination of ice, anti-inflammatory medication, physical therapy, and corticosteroid injection, said Dr. Kowalsky. Although the cosmetic deformity from a complete rupture will persist, once the pain from the acute rupture improves, strength and overall function of the shoulder should return to normal. If conservative measures fail to relieve symptoms from biceps problems, surgery may be recommended.  If you experience shoulder pain, consult with a fellowship-trained shoulder  specialist at ONS. 

Shoulder and Elbow Throwing Injuries Rise for Young Athletes

SURGE IN ELBOW AND SHOULDER INJURIES FOR YOUTH INVOLVED IN THROWING ACTIVITIES. 

Young male baseball player

For youth involved in repetitive throwing activities, there is an epidemic of elbow and shoulder injuries, usually due to overuse, poor training, improper throwing mechanics, and fatigue, according to sports medicine physician, Demetris Delos, MD, who specializes in shoulder and knee conditions.

The dreaded injury to the ulnar collateral ligament (UCL)  is usually caused by excessive pitching. If the UCL is injured, it can sometimes be difficult to repair or rehabilitate and may require the so-called Tommy John procedure in order to return to competitive pitching. The surgery is named after Tommy John, the first baseball pitcher to undergo successful UCL reconstruction surgery in the 1970’s.

Other common throwing-related injuries include Little League shoulder, which occurs when the growth plate of the humerus (arm bone) becomes inflamed by the excessive forces produced by repetitive throwing. Similarly, Little League elbow involves injury to the growth plate along the inner portion of the elbow.

In addition to acute injuries, repetitive activities such as throwing can lead to physical changes in the development of growing bones and joints. Significant amounts of pitching during adolescence can change the rotation and shape of the shoulder which may leave the player vulnerable to shoulder injury and arthritis in adulthood.

Studies show that children and adolescents who pitch competitively for more than 8 months in a year are the most prone to injury. Throwing more than 80 pitches per game, a fastball that consistently exceeds 85 mph, or pitching while fatigued are also risk factors for injury.

According to one study, pitchers who pitched more than 100 innings in a calendar year were 3.5 times more likely to sustain serious injuries requiring elbow or shoulder surgery or retire due to the injury. This is why USA Baseball and Major League Baseball now recommend that youth pitchers of all ages and abilities take a minimum four month break from overhead throwing, with at least two months off consecutively.

However, athletes and their parents should be reassured that numerous studies have shown that kids who are exposed to a range of sports that utilize different muscle groups and mechanical skills have greater overall success in athletics than those who specialize early on. In addition, they are less prone to injury and burnout than those who focus on a single sport exclusively.

Who is Tommy John and why did he have surgery?

Putting On White GlovesWhat is Tommy John surgery? Dr. Sethi and Yu Darvish of the Texas Rangers know. It is when an individual undergoes the reconstruction of a torn ulnar collateral ligament. Dr. Paul Sethi of ONS is a disciple of Dr. Frank Jobe, the man who did an ulnar collateral graft in Tommy John’s elbow in ’74 and so created the most famous baseball-medical connection since Lou Gehrig’s disease (also known as, ALS).

Another person to know in this field is Dr.Glenn Fleisig, a man who is well versed in this topic and has made a career out of arm injuries. He was recently interviewed in an article about the Tommy John surgery after a presentation at MIT Sloan Sports Analytics Conference about his collaborative study with Stan Conte of the Los Angeles Dodgers.

The research in the study noted that the Tommy John surgery is becoming more common, as more pitchers had the surgery in 2014 than in the 90’s combined. Although the success rate of the surgery is high, 20 percent of pitchers never regain a full level of performance even after PT. Other topics covered in the interview include:

  • What causes tears and the surgeries that follow

  • Whether it is the arm speed or the pitcher has his forearm cocked that far back

  • How long should we expect a pitcher to be out after TJ nowadays

  • Overuse of the ligament

  • Risk Factors and more

Read the Grantland article in order to enjoy the full interview about the Tommy John surgery.

“Maximizing Your Child’s Athletic Potential” Success

Delos_Houston_
Dr. Delos with Allan Houston

Last Thursday’s talk on “Maximizing Your Child’s Athletic Potential” was a success. A big thank you goes out to the Junior League of Greenwich for making it possible with their focus on improving the community and empowering others to further health and education! Ultimately they brought together the perfect combination of experts to inform the public about the youth and the sports they love.

Dr. Delos, of ONS and Greenwich Hospital, was a panel speaker at this event. He specializes in sports medicine and arthroscopic treatment of knee and shoulder disorders. Before ONS, Dr. Delos was the Assistant NFL Team Physician for the New York Giants and was team physician for a number of local high school and college athletes.

Other panel members consisted of Andy Barr, Director of Performance and Rehab for the New York Knicks, Mubarak “Bar” Malik, Head of Strength and Conditioning for the New York Knicks, and Allan Houston, one of NBA’s all-time greatest long range shooters and Olympic gold medalist, as the moderator. Each participant reinforced the importance of parents taking interest in the development of their young athlete and properly guiding them to the path of success. Parents attending this event were very attentive, and came prepared with questions.

Conversations covered the fundamental topics, like proper sleep habits and nutrition. For example, a young athlete’s nutrition should increase in relation to the amount of activity they experience daily. This may be common knowledge to an adult but for an adolescent, proper amounts of sleep and good nutrition that balances the amount of activity should be added to their routine.

Aside from the basic topics of discussion, there was a myth to be busted as well; to find out the details of the myth and for more information about the questions that were asked at the event, please read the article written by the Greenwich Freepress.

Delos_Group_2
Photography credit goes to the Delos family, thank you!

Overuse Injuries: Cause and Effect (Part I)

Cohen headshot for letterGloria Cohen, MD is a specialist in non-operative sports medicine who believes in taking an integrative approach to medical management by considering a patients’ bio-mechanics, cardio-vascular and pulmonary function as it relates to athletic performance. Aside from her impressive medical career, Dr. Cohen is a successful competitive runner who has qualified twice for the New York Marathon and is also an off-road and road cyclist. Her academic insights are a combination of both research and real-world experience, the following article is her most recent commentary on the topic of “overuse injuries”:

What is an “overuse injury”?
An “overuse injury” is an injury that results when excessive stress is applied over a period of time to bones, muscles, tendons, and other supporting soft tissue structures of a particular body part.  This differs from an acute injury which happens quickly and is traumatic in nature. Too much stress to a body part will cause the tissues to break down faster than healing can occur, thereby resulting in an injury. A good analogy would be to consider what happens to a credit card or a piece of metal when you bend it back and forth repetitively – first you see the stress reaction, and then with continued stress the item breaks in two.  As you can appreciate, we want to avoid the latter situation when it comes to the body.

What are some common examples of “overuse injuries”?
Every body part can be affected by an overuse injury.  Some common examples you might be familiar with are: rotator cuff injuries of the shoulder; epicondylitis or tennis elbow; patellofemoral pain syndrome of the knee; and tibial stress syndrome or “shin splints” for the lower leg.  Here are a few case examples of classic overuse syndromes:

Jogging injury.

  1. A 40 year old male has recently increased the intensity and frequency of his swimming activity over the summer months. He now complains of pain in the front of his shoulder with overhead and rotation motion. Diagnosis: Rotator cuff tendinitis
  2. A 30 year old female has been playing tennis daily, now competing in matches at a more difficult level. She complains of increasing soreness in the outside aspect of her elbow. She had tried to play through the pain, but had to stop. She says that she can barely lift a coffee cup now because of the elbow pain. Diagnosis: Tennis Elbow /Lateral epicondylitis
  3. A 20 year college student takes up running during her summer break from school. When she returns to school, she decides to train for a half marathon. As she increases her mileage, and adds speed work to her training program, she develops pain in the inside aspect of one shin. She now complains of pain with just walking. Diagnosis: Shin splints/Medial Tibial Stress Syndrome

What are some of the specific causes of these “overuse injuries”?
As a primary care sports medicine physician I recognize that there are sport specific issues which may contribute to the resulting injury; but there are common “intrinsic” and “extrinsic” factors which play a major role in the development of these types of injuries. “Intrinsic” factors refer to the elements that we cannot control but that we can modify.  These include biomechanical alignment, such as knock knees, bowl legs, flat feet or high arched feet; leg length difference; muscle imbalance; muscle weakness; and lack of flexibility.  These factors can be modified to maximize the individual’s performance, and thereby treat or prevent injury.  An example would be a conditioning program and sport specific training. The “extrinsic factors” include training errors, such as doing “too much too soon”; training surfaces – running on too hard a surface, or playing on an uneven surface; shoes – it is important to wear the appropriate type of shoe for your foot mechanics and the sport; equipment; and environmental conditions. Paying attention to the “extrinsic factors” will help you modify the “intrinsic” ones.

… to be continued in the next segment, Overuse Injuries: Recovery (Part II)

Is the Screwball Pitch Hard on the Arm? ONS Orthopedic Surgeon Paul Sethi, MD Weighs In

BaseballWhen you think of baseball pitchers, what comes to mind? Fastball? Curveball?

These are common terms used to describe pitches thrown during Major League Baseball games. Professional pitchers that have perfected these two conventional styles may not have the special skill and expertise to pull off one of the most, if not the most difficult pitches in baseball history, the screwball.

New York Times article The Mystery of the Vanishing Screwball,” by Bruce Schoenfeld, describes the “screwball” as “erratic, irrational or illogical, unexpected.”

In his article, Schoenfeld writes about the screwball technique gleaning inside information from Hector Santiago of the Los Angeles Angels who says the secret to the pitch is “like driving with your right wheels going around a curve.”

Schoenfeld goes on to write that “Unlike the knuckleball, which is easy to throw but hard to master, the screwball requires special expertise just to get it to the plate. The successful screwball pitcher must overcome an awkward sensation that feels like tightening a pickle jar while simultaneously thrusting the wrist forward with extreme velocity.”

Chicago White Sox pitching coach Don Cooper is quoted in the article saying “the word on the street is that the screwball is hard on the arm.” Although there is no documentation of this, many experts continue to debate as to whether or not the intensity of such a throw is harmful to the arm.

According to the article, Schoenfeld found no existing research to help answer the screwball pitch question. That’s when he contacted ONS Orthopedic Surgeon and Sports Medicine Specialist Paul Sethi, MD.

Dr. Paul Sethi, a Connecticut orthopedist, was willing to help generate some new data. Sethi is a disciple of Dr. Frank Jobe, the man who did an ulnar collateral graft in Tommy John’s elbow in 1974 and so created the most famous baseball-medical connection since Lou Gehrig’s disease.

Dr. Paul Sethi
Paul Sethi, MD

I met Sethi at the Center for Motion Analysis in Farmington, Conn., in a 108-foot-long room as bright as an operating theater. A dozen cameras were mounted on the walls. A tattooed 26-year-old named Matt Bartolomei stood on a portable pitcher’s mound while technicians adhered sensors to his body.”

Dr. Sethi, along with a team of experts, were able to watch in slow motion and concluded that the force exerted on the elbow of the pitcher when he threw a screwball during the experiment was identical to that of a fastball or curveball.

“In fact, the screwball doesn’t exceed the fastball in any parameter.” The results were hardly definitive, especially given the data set of one. “But looking at the data compared to the normative data kind of makes me tingly,” Sethi said.

If he and Nissen could confirm the conclusions, Sethi believed they might rescue the screwball from near-extinction. While assisting Jobe in Los Angeles, he worked with Dodgers pitchers. He liked the idea of contributing to their cause. I was less certain, though, that a doctor could revive the flat lining screwball. For a pitch to be used regularly by major leaguers, or even Little Leaguers, it needed a stronger selling point than mere safety.”

Although the “screwball” has been somewhat “abandoned” by baseball, the research conducted by Dr. Sethi and the team he worked with could make for a comeback. In a phone message yesterday Dr. Sethi confirmed, “the “screwball” pitch isn’t a cause for higher risk of injury than that of a fastball or knuckleball. It puts the same amount of stress on the arm as the other pitches do.”

Paul Sethi, MD is a board-certified orthopedic surgeon who specializes in sports medicine, the shoulder and elbow. He served as an orthopedic consultant to the Los Angeles Dodgers baseball team. Sethi was also a former assistant team physician of the Los Angeles Lakers basketball team, Los Angeles Kings hockey team, Los Angeles Dodgers, and University of Southern California football team.

Orthopaedic and Neurosurgery Specialists PC (ONS) is an advanced multi-specialty orthopedic and neurosurgery practice in Greenwich, CT. ONS physicians provide expertise in sports medicine, minimally invasive orthopaedic, spine and brain surgery, joint replacement and trauma. For more information, please visit www.onsmd.com.

[Read Full New York Times Article]