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Gary Sanchez and Bicep Injuries

Gary Sanchez, right-handed New York Yankees catcher, and a relied upon contributor at the plate, evidently sustained what has been called a right biceps strain when fouling off a 97-mph fastball in Saturday’s fifth inning 5-4 road-loss to Baltimore. He exited the field after a painful practice swing, and has yet to undergo a complete diagnostic work-up to determine the extent of the injury. reported Sanchez claimed “it felt kind of like when you pull a hamstring.” By Sunday, it was noted that he was feeling somewhat better, a great sign. Sanchez was placed on the 10 day DL pending further assessment.

We’ll know more about Sanchez’ injury after an MRI, but what we do know is that it is his elbow – the distal (lowermost) end of the tendon – that is painful, rather than the uppermost portion at the shoulder.

A little about the biceps muscle

The biceps derives its name because it has two heads, each of which has a different attachment at its origin in the shoulder region. The long head of the biceps attaches in the shoulder joint (at the supraglenoid tubercle), while the shorter head originates at the coracoid, a bony process that juts forward from the scapula (shoulder blade) and lies under the clavicle (collar bone). The muscle provides a degree of stability at the shoulder by depressing the head of the humerus, preventing it from riding upward, which would cause impingement on the structures in that region.

Both heads of the biceps converge to attach at their distal (lowermost) end, to two sites at the upper portion of the radius (one of the two bones at the forearm). So, in other words, there are two proximal bicep tendons in the shoulder region and only one at the distal end near the elbow.

The primary functions of the biceps are to flex the elbow and to supinate the forearm (rotate it to turn the palm forward/upward, as if turning a doorknob). It also contributes (secondarily) to flexing the shoulder.

Muscle Strain

Sanchez was diagnosed with a strain and, like ligament sprains, these are graded from 1 to 3 with a Grade I being a tweak to the muscle/tendon and a Grade 3 being a complete rupture. It would have likely been apparent had Sanchez completely ruptured the tendon, so the questions that remain are how much damage was done, and how long will it take him to respond to treatment and be back on the field. 

Distal biceps injury at the elbow region

These are less common than those to the proximal biceps at the shoulder. Ruptures to the distal tendon, which occur primarily on the dominant side, cause elbow flexion and supination weakness to a greater extent than proximal injury because the entire muscle complex is disrupted. Thus there is a greater functional deficit. However, there are other muscles that contribute to elbow flexion and supination so some function is maintained. In the event of a complete rupture, treatment can be either conservative – which will likely result in long term or chronic pain and weakness – or surgical.

It is also possible to have a partial rupture (Grade 2), after which the sufferer is predisposed to biceps tendinitis and compression of the median nerve.

Proximal biceps injury

Biceps tendonitis often occurs in the presence of rotator cuff inflammation and tears, and about half of all biceps ruptures occur in the long head, usually in the shoulder joint or in a groove (intertubercular groove) that houses the tendon in the front of the shoulder area. Since one of the bicep heads generally remains intact with this injury, function is only minimally impacted in the event of rupture, and treatment is most often non-surgical. When surgical intervention is indicated – largely due to pain – the tendon is either detached from the glenoid labrum in the shoulder joint and reattached elsewhere at the upper humerus (tenodesis) or the attachment to the humerus is simply severed (tenotomy).

Hoping for the best for Gary Sanchez – a very mild Grade 1 strain. In all likelihood though, ten days off will not be enough.

Your Body, Your Swing


For years golf professionals have been working with their clients on how to “fix” their swing.  In a recent post on, Jerry King discusses some great Tips & Tricks on how to avoid 4 common swing faults.  These tips and tricks can certainly be helpful, but in order to reduce the root cause of the swing faults, we must analyze our own bodies; there is more to the golf swing than just technique.  

Every golfer is unique and comes to the course with a different history.  Loss of mobility, strength and control has a large effect on the swing, and studies have shown that improving these factors through a structured exercise program can increase club and ball velocity and driving distance. 1  It is the accumulation of your entire physical history that is put to test when you step up and address each and every ball.  Avid golfers often spend years trying multiple techniques, clubs and products to get rid of their slice or improve their power, all the while never analyzing the most important equipment they own…themselves.  Many golfers know they should exercise, believing it will help their game, however they feel they need direction in order to know which exercises they will benefit from the most. Knowing this will prevent wasting time working on things that don’t need improvement.

We have spent years living in our bodies and watching them change as we age.  Why do we spend so much time and money on products, training videos and equipment and overlook the idea of improving ourselves? In a recent study, 36 male and female golfers were put through the Titleist Performance Institute Physical Screen with the goal of determining if there was a correlation between limitations found in their screen and some of the most common faults found in the golf swing.  At the conclusion of the study researchers found “when a golfer could not overhead deep squat or single leg balance on the left side, they were 2-3 times more likely to exhibit an early hip extension, loss of posture, or slide during the golf swing.”2

This is just one example of how poor mobility and control of our bodies can affect our golf swing.  The RPT golf improvement program, utilizing the TPI physical screen and swing analysis, was designed to address exactly this!  Our 6-week program achieves results! This program has helped many golfers obtain their goals, and in its 4th year running we are excited to offer it now in both our Upper West Side and Millburn locations!


  1. Lephart, SM., Smoliga, JM., Myers, JB., Sell TC., Tsai, YS. “An eight-week golf-specific exercise program improves physical characteristics, swing mechanics, and golf performance in recreational golfers.” Journal of Strength and Conditioning Research (2007): 860-9. Web.


  1. Gulgin, H., Schulte, B, Crawley, A. “Correlation of Titleist Performance Institute (TPI) Level 1 Movement Screens and Golf Swing Faults.” Journal of Strength and Conditioning Research (2014): 534-39. Web.

Part Three: Fighting Inflammation With Nutrition – The Brain & Gut

Brain Foods: For General Health & Post Concussion Care

Following head injury, an anti-inflammatory diet (see Parts One & Two of this series) is recommended. Though drinking coffee has been shown to benefit brainpower and protect against dementia, in the immediate post-concussion period, caffeine should be avoided  However, in the event of post-concussion syndrome – when symptoms persist beyond the expected recovery time – the benefits of coffee may prove helpful in modulating symptoms such as headache and issues with alertness. There isn’t one magic answer here, but rather it might be advisable for the post-concussion sufferer to experiment and assess the outcome.Also related to headaches, checking Vitamin D levels in the blood can prove helpful in determining whether supplementation might prove beneficial (more on that below).

Nicotine is another substance contraindicated after concussion (not that it would be recommended at any other time). Likewise, avoiding alcohol is an important aspect of a brain healthy diet, particularly so in the event of head injury. Getting adequate sleep, adding exercise to one’s routine, as well as such things as mindfulness and meditation, also contributes to optimized brain function.

Some of the foods recommended for protecting cognitive function and memory include: avocados, beets, blueberries, bone broth, broccoli, celery, coconut oil, dark chocolate, egg yolks, green leafy veggies, rosemary, salmon, turmeric and walnutsSome of the best leafy greens are Swiss chard, kale, spinach, watercress and Romaine. Other fish besides salmon that are rich in good oils, like sardines, also make the cut.

Supplements for Cognitive and Neuroprotective Function

Fish oil supplements can provide another source of the omega-3 fatty acids our bodies need and which benefit brain function. It is recommended that consumers interested in these supplements buy only those from a quality source that controls for PCBs and oxidation. For more on the vital omega-3s EPA and DHA, which benefit us in myriad ways, here is a brief and wonderful synopsis of their neuroprotective properties.

Another supplement established in animal studies to have neuroprotective effects is Creatine. Nutrition conscious neurologists may recommend this agent for those who’ve suffered concussions and have persistent symptoms or are affected by neurodegenerative diseases. More studies are needed to verify the benefits of creatine for humans.

A third supplement often taken for its cognitive and neuroprotective benefits is MCT oil, which is a derivative of coconut oil, but it’s a little more complicated than that. Evidently not all MCT oils are created equal.

Bone Health Plus More

I always felt that with a proper diet, we get the necessary nutrients from food and so taking vitamins is not necessary. However, even I take a few vitamins these days. Vitamin D, important for bone health and likely a whole lot more, is found in very few foods. Though sun exposure helps in its natural production, conditions are not always optimal and sunscreen curtails this benefit. It is easy to become Vitamin D deficient, based on what has been established as the normative range. And since Vitamin D also aids in the absorption of calcium, it seems best to turn to a supplement when your levels are low. And that is the conclusion drawn from many studies on Vitamin D and Calcium for prevention of bone loss (osteopenia and osteoporosis) and fractures. However, the research is confusing. Some analyses do not support a benefit in increasing bone density in people over 50 or in preventing fracture in this population. It should be noted that many studies also point to an increased risk of kidney stones and a correlation with heart disease amongst those taking these supplements.

For a synopsis of outcomes from studies on Vitamin D and its impact on everything from colds to cancer, DocCheckNews most recent newsletter has a wonderful piece entitled Vitamin D-Religion: Amen. Some findings include:

  • Daily Vitamin D supplementation in those with low serum concentration resulted in a 12% decline in acute respiratory infections.  Universal supplementation was not recommended.
  • Men with low serum levels of Vitamin D suffered twice as often from chronic headaches. An ongoing Vitamin D study in Finland, with results due in 2018, is intended to answer remaining questions about the vitamin’s relationship with headache pain.
  • Though moderate supplemental doses are considered safe, in excess, Vitamin D may lead to increased falls and fracture in the elderly.
  • Vitamin D supplements taken during pregnancy may increase the risk of the child suffering food allergies later in life.

Foods that most of us associate with containing Vitamin D are: fatty fish, organ meats (uggh), eggs, and particularly dairy products. In addition to the dairy foods that many avoid these days, there are a variety of non-dairy foods that contain calcium. Again, it should be stressed that a healthy individual with normative levels, who eats a diet that supplies these nutrients, does not require supplements. And as noted, in larger doses they may prove harmful.


Those with gut issues such as Irritable Bowel Syndrome (IBS) would do well to read up on this diet. The acronym stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols. These are short-chain carbohydrates that are incompletely absorbed in the gastrointestinal tract and can be easily fermented by the bacteria in the gut.

Onions and garlic top the no-no list, but that list is a long one, highlighting foods that can trigger gastrointestinal symptoms. Experimenting to determine one’s particular sensitivities may be the way to go here as well.

Reflux Diet

Acid reflux, also known as GERD (GastroEsophogeal Reflux Disease) is a condition that involves exposure of the soft tissues of the esophagus to stomach acid. It can result in heartburn, but even in the absence of indigestion, it can result in such symptoms as a chronic dry cough, a sore throat, difficulty swallowing or bloating.

It is important to get an accurate diagnosis and crucial to follow a Reflux Diet that restricts acid intake. Foods to avoid include: tomatoes and tomato sauce, carbonated beverages, alcohol, caffeine, chocolate and citrus. Propping your upper torso and head up at night and not eating for three hours before bedtime are also recommended.

If you take medication to control reflux in order to eat as you please without consequence, that isn’t the way to go. Eating correctly and exercising regularly can make all the difference in avoiding the adverse effects of long-term use of medications that are meant for short term use only and are often over-prescribed.

Eye Health

Lutein is one of four carotenoids and is found in green leafy vegetables, red peppers, red spices like cayenne or paprika, and other colorful veggies like tomatoes. Carotenoids (the four are: alpha and beta-carotene, lutein and lycopene) are antioxidants (see Part One of this servies), and lutein has been found to have a preventive impact on macular degeneration and cataracts. A strong family history of macular degeneration, causing degrees of blindness with aging, and/or a diet lacking in an abundance of the foods mentioned above may be good reasons to consider a daily supplement high in lutein.

One additional note on tomatoes (which contain all four carotenoids), is that when they are eaten in combination with broccoli, there is found to be a relationship with prostate cancer prevention.


Just as a diet rich in the right foods that also limits the evil ones (like sugar) provides protection from chronic illness, so does exercise. Weight training and weight-bearing exercise improves bone density, preventing fracture. It increases muscular strength, therefore improving function, balance, and reducing incidence of falls with aging. It is important for optimizing brain health and lessening incidence or severity of depression. Exercise also diminishes reflux. And, high intensity interval aerobic exercise slows the effect of aging; this benefit is likely related to the fact that exercise even helps to control inflammation, though knowing your limits and listening to your body is key

Part Two: Fighting Inflammation With Nutrition – What We Now Know About Eggs, Red Meat & More

Eggs – Good Bad or Indifferent?

The push to cut down on eggs, particularly yolks, has tapered, with eggs now shown not to have the impact on cholesterol as previously thought. Most of the cholesterol in our bodies is produced naturally and does not come from our food. Eggs (especially those that are pastured & local) are a great source of essential amino acids. These unique building blocks of proteins cannot be produced by the body and must come from food.

Two caveats on the benefits of eggs… Though some recommend yolks as part of a brain-healthy diet, when consumed more than moderately, eggs (particularly yolks) and poultry (with skin) have been shown to correlate with a higher incidence of prostate cancer recurrence or progression. Men, particularly those who fall in higher risk categories, beware.

In addition, some people have unknown food sensitivities. Sensitivity to eggs – which often exists below the pain threshold but can have adverse physiological and biological effects – is more common than many realize. Those with such a sensitivity who consume eggs (especially frequently or in greater volume) may see they adversely impact cognition, or exacerbate headaches, upset stomach, etc. If you notice persistent symptoms or those that fluctuate along with things you eat, it might be a good idea to be tested for food sensitivities.

Anti-inflammatory Diets

One of the more distinctive and restrictive anti-inflammatory diets is The Bulletproof Diet. It replaces sugars with healthy fats, incorporates a focus on organic food, is gluten free and does not allow beans. Eliminating all processed foods and grains limits sugars dramatically, as does moderating natural sugars by limiting fruit intakeGhee (pictured above), which is butter minus the milk solids and water, leaving only butterfat, is another healthy fat that is a staple of this program. Bulletproof Coffee, can keep you feeling full and focused. I’ve gotten first hand reports!

There is much advice out there regarding diet, some of it conflicting. However, there are some commonalities.

Getting the most attention for what are often termed heart healthy diets are the Mediterranean and DASH diets. Each has been shown to be effective and personal preference may play a role in which to choose if you if you want a specific food program. A Mediterranean Diet is rich in vegetables, fruits, nuts, olive oil, beans, legumes and herbs and leans more toward fish for protein. In this diet, dairy, poultry and then lean meat are at the top of the food pyramid, to be eaten in measured amounts. It is a plan that has been shown to have anti-inflammatory properties.

The DASH diet (DASH stands for Dietary Approaches To Stop Hypertension) has some similarities but is less restrictive of low fat dairy. Here is a comparison between the two.


Both diet plans, like the generic anti-inflammatory and brain-healthy recommendations, include a lot of fiber from vegetables and fruits. All heart healthy food plans limit sugar and salt. Sodium, which can cause water retention, may result in an increase in blood pressure, placing greater strain on the heart and blood vessels. High blood pressure is one of the common cardiac risk factors.

Red Meat

Many of these diets limit intake of red meat, though pastured grass-fed meats are recommended as a staple of the Bulletproof Diet. Red meats (particularly processed meats) are often restricted in other diets because some research has tied larger consumption of it to increased risk for colon cancer. However, it has been shown that these studies were unable to control for other poor dietary or health habits that were confounding factors influencing outcomes.

One high fat, low carb diet is that recommended by Gary Taubes, who wrote The Case Against Sugar, Why We Get Fat. He and Fred Pescatore, MD, creator of The Hampton Diet, advocate low carb, higher fat eating plans that do not place as much restriction on red meat. I’m a fan of Dr. Mark Hyman, who wrote Eat Fat Get Thin (amongst other books) and whose recommendations make a lot of sense. Like all the authors mentioned here, he explains why prior studies led to inaccurate conclusions and points to newer research supporting the fact that a heart healthy diet can include grass fed beef without adverse consequence.

What They Said About Vegetable Oils (Like Canola)? Never Mind. All Oils Are Not Created Equal

Stick to extra virgin olive oil or coconut oil. Especially when cooking. Heating vegetable oils alters their structure causing oxidation and the formation of aldehydes. Oxidation results in free radicals (which were addressed in Part One), which then result in cell damage that causes a host of adverse effects on the body. High levels of aldehydes have been shown to correlate with an increased risk of heart disease and cancer.

Olive oil has the lowest oxidation rate of the cooking oils and has also been shown to raise HDL and lower LDL cholesterol, changes that are good for heart disease prevention.

Another healthy cooking note is to avoid charring foods (particularly meats/fleshy foods) because that too can have a carcinogenic effect.

Part Three, the final blog of this nutrition series, covers specific food recommendations and nutritional issues related to brain health and post concussion care, for those with gastric issues (Irritable Bowel Syndrome (IBS) and Gastric Reflux), as well as nutritional guidance for eye health.

Fighting Inflammation With Nutrition

Whether dealing with the aftermath of an injury or simply seeking to optimize one’s health and wellness, there is wisdom in following a diet rich in foods considered to have anti-inflammatory properties. Chronic inflammation is now recognized as a major contributor to a number of illnesses, including diabetes, metabolic syndrome, hypertension and atherosclerosis, which predispose to cardiovascular events. Also Alzheimers, Parkinson’s, and autoimmune disorders, such as Lupus and Multiple Sclerosis. Conditions affecting the musculoskeletal system (such as rheumatoid and osteoarthritis) also play into this dynamic. Even depression and cancer correlate strongly with levels of inflammation.

How we eat can play a role in protecting us from illness by minimizing chronic inflammation and boosting brain and heart health. Weight control is a secondary, but welcome, byproduct of this thoughtful way of eating. Armed with the knowledge we now have, nutritional guidance should be a part of care delivery in every medical discipline, including physical therapy and orthopedics.

The world of nutrition and health has been turned upside down in recent years.

The Skinny On Fats

The old school emphasis on reducing all fat intake – but especially saturated and trans fats – has been replaced with an emphasis on eating healthy fats (including some saturated fats, like that in coconut oil). Other healthy fats include those in olive oil, avocados and nuts. In fact, your body needs these fats to function optimally, fight inflammation, and even to lose excess pounds.

Several articles I’d recommend on the subject include this one on why we need fat in our diets, this one on Facts About Fats, and this one on why carbs and not fats cause fatty liver disease.

Sugar Is The Enemy

Sugar is now thought to be the evil ingredient and the most significant dietary contributor to inflammation. It seems that this line of thinking, supported by a great deal of research, is going to prevail for the long haul.

Sugar comes in many forms, whether from refined carbohydrates, or that added to beverages, or even the natural sugars in fruits or dairy. They might be listed on an ingredients label as sucrose, corn syrup, glucose, fructose and galactose, lactose or maltose. Once ingested, these other sugars become glucose. Though both are processed by the body into sugars, refined carbohydrates are more of an issue than whole grains in our diet because much of the fiber, nutrients and essential fatty acids are eliminated in the refining process.

A rise in blood glucose triggers a release of insulin and other substances that create an environment conducive to inflammation. More on this can be found here.

Carbs also produce more belly and liver fat than dietary fat itself. In addition, excess sugars contribute to cholesterol imbalances – elevated LDLs and lowered HDLs, contributing to heart attack risk.

Omega-3 Fatty Acids Rule

Found in fish (salmon is king – pun intended), nuts (particularly walnuts), certain oils, leafy greens and flax seeds, Omega-3s are an essential part of our diet. They serve a multitude of purposes and our bodies don’t produce them. They are in the cell membranes of all our cells and are integral to the production of certain hormones that do everything from assisting with regulation of blood clotting, blood vessel function and control of inflammation to impacting genetic function. Also integral to the findings is that Omega-3 Fatty Acids are an important nutrient for optimal brain health.

Here is one piece on Omega-3s. Here is another that describes their impact on many disease processes. Their antioxidant properties and the impact they have on inflammation have been explored in a significant amount of research, some of which is discussed here.


Chemicals in our bodies called free radicals can wreck havoc by damaging our cells, thus altering their structure and function. Antioxidants, extracted from foods that we eat, combat free radicals to limit that damage which, left unchecked, contributes to a host of chronic conditions. Other than for prevention of age-related macular degeneration, studies involving antioxidant supplements did not show them to be beneficial. However, evidence has shown that a diet rich in the naturally occurring antioxidants found in vegetables, fruits and whole grains does offer protection against cognitive decline and the diseases associated with aging.

More on specific foods (like eggs, red meat and oils), in Part Two of this series. Part three focuses on nutritional recommendations for brain health and post concussion, for those suffering from gastric issues (like IBS and reflux) and on foods for Eye Health.

MLB Injuries: Pitchers – vs – Position Players

An MLB team has a five man starting rotation but in the course of a season may start as many as 12 or 13 different pitchers due to injury. That requires great depth, and that players at the Triple A and maybe even Double A levels be ready for action. lists 70 player injuries as of this writing, and 45 of those – 64 percent – are to pitchers. Looking at that from another angle, at least at the moment, pitcher injuries overwhelm those to all the other position players combined.

One reason for this is that the pitching motion is extreme and the constant repetition required to prepare and to compete creates undue demand. This can cause tissues to break down, particularly

Those at the shoulder, elbow and forearm. Even hips and knees are vulnerable because of the generation of power from the lower extremity; and ankles can be prone to sprain.

With shoulder and elbow surgery to pitchers fairly commonplace, and because of the extensive rehab required thereafter (anywhere from 11-30 months), pitchers, on average, stay on the DL for longer periods. This also skews the statistics.

So what is it about pitching that creates vulnerability?

According to Dr. James Andrews, renowned orthopedic surgeon, the single most important factor resulting in elbow injuries to pitchers is overuse: daily, weekly and annually. He notes other primary factors as being insufficient rest, pitching while fatigued and poor mechanics. For younger athletes, playing on multiple teams or increasing demands by playing catcher when not pitching contributes to lack of rest and resultant overuse.

Though in Dr. Andrew’s interview he cites throwing curveballs and sliders as potentially increasing the likelihood of elbow injury, he is likely referring more to younger athletes who are not physically mature and whose mechanics may be faulty. It is generally understood that, in the pro ranks, fastball pitchers – who throw at an increased velocity – generate forces that place the greatest strain on the structures of the elbow and forearm. Thus there is danger in consistently throwing at maximum effort.

The doctor does point out an interesting conundrum however, in that “players with higher velocity have longer careers and also perform better. Therefore, it would be unrealistic to recommend that pitchers simply not throw as hard. However, varying speeds might improve a pitcher’s effectiveness and conceivably also reduce injury risk.”

While some never return to competition after Tommy John surgery (studies show anywhere from 7-17 percent), others go on to complete as well (which is the goal) or even better than they had pre-operatively. Performance improvements may be attributable to the strength and conditioning programs during rehab or to a player having played with mild or undiagnosed injury pre-operatively.

About half of the pitchers who have Tommy John surgery subsequently go on to have other arm injuries (many requiring surgery) – whether to the elbow or shoulder.

Surgeons are keeping an eye on an alternative procedure to repair the Ulnar Collateral Ligament (UCL) at the elbow. It is referred to as a “primary repair” and is still in an experimental phase for professional athletes. Dr. George Paletta, who performed the surgery on former Cardinals reliever Seth Maness last year, believes it could replace Tommy John surgery because of the shorter rehab time. In place of a graft reconstruction of the UCL, the injured ligament is preserved and repaired to the bone. So far, with a smaller sample of (mostly younger) patients, the doctor reports a high success rate. However, earlier studies demonstrate that the procedure may necessitate a selection process that excludes older athletes with ligament damage that is not limited to either end of the UCL.

As for the shoulder…

If you take a look at the list of MLB injuries at any given time, the majority of players dealing with shoulder issues are bound to be pitchers. Just as with the elbow, repetitive motion at high velocity can make surrounding tissues vulnerable. With extreme ranges of motion and rapid deceleration added to the equation, as they are with pitching, the shoulder is at risk. Less than ideal mechanics can also set the stage for breakdown. Whether impingement syndrome, rotator cuff strains / tears, a torn labrum, or tears of the joint capsule, all are unfortunately fairly commonplace.

The Pitching Motion

At the end of the cocking phase of pitching, the pitcher’s shoulder is at its maximum degree of external (outward) rotation. Though 90 degrees of outward rotation is considered normal for most of us, pitchers have a good deal more motion into this plane (consequently, many have more limited internal (inward) rotation than is classically “normal”).

For a thorough but basic understanding of pitching mechanics take a look here. If you’d like to scroll through a comprehensive medical review correlating mechanics during specific phases of pitching with injury, this article provides more detail.

During the movement of external rotation, the head of the humerus glides forward, putting stress on the front (anterior) of the joint capsule and the ligaments. These are the restraints that provide joint stability. When a pitcher moves forcefully to his end range of outward rotation with his elbow at shoulder height, these structures are stressed to their limits. This can cause injury.

A pitching shoulder that has anterior instability creates undue stresses on the rotator cuff tendons (and the bursa in that region). This creates inflammation or ultimately tears.

Weak rotators – lead to impingement, as they no longer serve to effectively position the humeral head and keep it from riding upward. Other muscle imbalances at the shoulder girdle also predispose to inflammatory conditions and impingement syndrome. Impingement then puts the cuff tendons at risk.

The labrum is a fibrocartilagenous structure that deepens the socket of the shoulder, providing additional stability while also enabling the motion this ball and socket joint requires for function. If the labrum is torn, the resulting instability can cause the shoulder to sublux or dislocate.



Protect Your Back! Avoid Injury When Shoveling Snow

Happy snow day to you! Are you stuck with the unwelcome task of shoveling snow? We’ve got your back! Snow can be pretty heavy, especially the really wet stuff. If you haven’t been hitting the gym regularly or training for snow shoveling as your sport of choice, you may be waking up with some aches and pains. Here are a few tips to dig yourself out a little more safely.

1. Avoid holding your breath
Optimize the function of your respiratory system and utilize the more efficient aerobic mechanism for supplying your muscles with energy. In addition, you may get lightheaded or feel a headache coming on if you hold your breath.

2. Bend from your hips and knees, NOT your back
Just as when you do a squat, ski, or even sit back into a chair, lean your upper body forward from your hips and knees while you balance your weight over your feet by leading and reaching back with your butt. Practice by doing squats to a chair without allowing your rear end to touch the chair.

3. Maintain a neutral spine
That means neither bending nor arching away from your midrange comfort zone. For some, neutral is a flattened low back, for others a very mild arch, but it is never the very rounded back you will see when you observe some people shoveling.

To maintain neutral you will have to engage your abdominal and low back muscles, working the low back extensors most as you bend, to stabilize your low back and keep it from rounding. Emphasize (contract) your abdominals as you reach and rise. The heavier the load you are shoveling, the harder your muscles should work to keep your spine in neutral.

4. Avoid reaching too far
Shovel the snow close to you – the more outstretched your arms are when you lift, the heavier the snow effectively becomes, placing a greater strain on your low back. To understand this better, imagine playing on a see-saw when you were a kid. The farther you sat from the center axis, the “heavier” you became, making it possible to keep your friend on the other end up high off the ground.

5. Lift from your legs
Just as when you lift a heavy box from the floor, rise from your knees and hips to avoid overdoing the effort on your arms and back.

6. Consider wearing an abdominal belt
Some studies have shown that wearing a belt for heavy lifting activities raises intra-muscular pressure of the back muscles (erector spinae) and in doing so helps to stabilize the low back (lumbar spine) during lifting exertions.

7. Pivot to avoid excess twisting of your trunk
Just as with a golf swing, allow your hips to move with your shoulders so that you require less rotation of your spine. For example, a right-handed golfer pivots over his right foot during his swing and follow-through while his left foot remains firmly in contact with the ground. When you are moving the snow from here to there, pivot over your back foot while turning your trunk toward the opposite side.

8. If the snowfall was a big one, lift and move it in layers to limit the weight
You don’t have to dig all the way down to the sidewalk with each maneuver.

9. Take rest breaks and be sure to stay hydrated
You may not realize how much you are actually exerting when you shovel snow. Drink before you get thirsty to avoid dehydration and rest to stay strong and refreshed.

10. Buy a snowblower, hire the kid next door or move to California!

11. A final caution: delegate the shoveling if you have a cardiac history, a significant history of low back problems or are suffering from a shoulder or knee injury.

Shoulder Impingement. David Wright’s Latest Injury?

Thirty-four year-old NY Mets third baseman David Wright has struggled these last few years, sidelined with a number of injuries and diagnoses. Wright’s latest ailment was reportedly diagnosed as a right shoulder impingement. However, accounts indicate that Wright is seeking a second opinion from orthopedists outside the Mets’ family. The result of this consult is not known as of this writing.

Wright’s most serious issue to date has been spinal stenosis, which can have significant implications for anyone, but particularly so for an athlete. He underwent a cervical discectomy and fusion last June to alleviate pressure on one or more spinal nerves as a result of a disc herniation as well as the stenosis. The fusion would have been performed to restrict mobility in order to limit stresses to the region and prevent instability that might otherwise lead to further nerve compression and irritation. However, stenosis is a narrowing of the spinal canal housing the spinal cord and is something that doesn’t resolve. It can lead to cord compression resulting in weakness, or in extreme cases, paralysis.

The presence of stenosis can also increase the incidence of less severe neurologic symptoms such as stingers, or cause episodes of neuropraxia. The latter is the complete block of nerve transmission though the nerve fibers remain intact. Though both are transient conditions, they are painful, with the latter generally taking a longer time to resolve. Cervical stenosis has ended the career of several football players, primarily due to the frequency and intensity of their symptoms. Interestingly though, sufferers are said by some not to be more at risk of serious spinal injury than their peers. Even when playing football.

David Wright is getting off to a halting start in his comeback from surgery. According to David Waldstein of the New York Times, Mets Manager Sandy Alderson noted that Wright had been experiencing shoulder soreness all spring. He reported that the Mets medical staff believes that resuming throwing after having not done so for so long during his recovery from the neck procedures was the catalyst.

Alderson also reportedly said that Wright had some instability in his right shoulder, which may have predisposed him to impingement. In addition, Mets’ doctors evidently pointed to an incomplete functional recovery of the surrounding musculature as a factor.

CBS reported that due to his prior injuries, Wright had altered his throwing mechanics, adopting more of a sidearm delivery. This too might have been part of what led to his current complaints.

Ed Coleman of WFAN reported that Wright’s throwing program has been suspended for at least two weeks and he was advised to focus on a strengthening program. It remains to be seen if any change to the plan will be effected once the newest diagnostic opinion is in play.

What is clear however, is that Wright is unlikely to be ready for opening day, may not be able to play every day when he does come back, and may have to consider a move to first to limit the need for him to throw longer distances with greater frequency. Wright is reportedly willing to do whatever is asked of him.

So what is impingement syndrome?

The word impingement tells you much of what you need to know – structures are being compressed or pinched. Pain occurs in the upper joint, especially when the arm is elevated and the shoulder rotated inwardly. Overhead and throwing athletes are prime targets. Rotator cuff tendon(s) and a bursa are generally what are impinged in the narrow space formed by the acromion (a portion of bone that appears like a hood over the shoulder), a prominence on the head of the humerus (the bone of the upper arm) and the ligament that connects the clavicle (collar bone) to the shoulder blade at the acromion.

Chronic impingement can lead to wear and tear of the rotator cuff tendons that pass through this (subacromial) space – not a great scenario. If rotator cuff tendons become inflamed, swelling will further compromise the joint space, creating more impingement. Degenerative rotator cuff tears can result in complete rupture and are often associated with biceps tendon rupture as well.

Ignoring symptoms of shoulder pain or soreness while remaining active generally exacerbates the problem. Though an injection can calm the acute inflammation and rest will allow it to do its job, rehab is paramount, and a two-week layoff (as has been suggested) isn’t likely to resolve the underlying causes of the condition.

Weakness of the outward (external) rotators also has an adverse impact on shoulder joint mechanics. Strong outward rotators stabilize and depress the humeral head, keeping it from gliding upward and narrowing the space the tendons and bursa require. Thus weakness can create impingement. So too can a forward head posture and shoulder blade (scapula) that is tilted forward (anteriorly) narrowing the joint space at the shoulder. It becomes a vicious cycle…

Rehab for shoulder impingement always entails working to reduce inflammation while normalizing joint mobility and addressing muscle strength and flexibility. If the rear portion of the joint capsule is tight, restricting internal rotation mobility, joint mobilization proves helpful. The presence of significant instability of the shoulder, generally in the front (anterior) compartment, complicates matters and may require surgery. Likewise, surgical intervention may be necessary if bone spurs or a hooked shaped acromion contribute to impingement. If there is something such as a spur in the way, strengthening alone isn’t likely to resolve symptoms.

What is the significance of a hyperextended knee?

Kevin Durant reportedly suffered a hyperextended knee less than a minute into last night’s contest against the Wizards in D.C. and exited the court shortly thereafter. An MRI is scheduled. The injury occurred when Washington Center, Marcin Gortat made contact with Golden State’s Zaza Pachulia who then stumbled, landing on Durant’s left leg.

Though the MRI may not reveal any significant injury beyond a mild sprain, there is a range of diagnoses possible in this situation.

What is the significance of a hyperextended knee?

Ligaments – which attach bone to bone – provide stability by restraining excessive movement in our joints. When a joint goes beyond its normal range of motion, the integrity of certain ligaments becomes compromised, resulting in a sprain. In the case of the knee, forceful or traumatic hyperextension into a bowed position stresses the anterior cruciate ligament (ACL) – which is the primary stabilizer of the joint – and may also impact other secondary stabilizers. Worst-case scenario for Durant would have been a Grade 3 sprain, otherwise known as an ACL tear. A Grade 3 sprain is actually a complete rupture. Best case would be a Grade 1 sprain, with only mild tweaking of the ligament.

When the knee hyperextends, the tibia (the larger bone in the lower leg) glides forward excessively on the femur (the thigh bone) at the knee joint. This abnormal movement, whether caused by trauma or a non-contact situation, can also result in a bone bruise, or contusion. As with a sprain, the extent of the contusion would be proportional to the degree of hyperextension that occurred and whether trauma played a role. Another factor is the athlete’s baseline – or normal – range of motion.

A prior history of ligament sprain that results in persistent joint laxity predisposes an athlete to excessive joint mobility. This may set the stage for a non-contact injury. Many people – particularly ballet dancers and gymnasts – have hypermobile knees, enabling extension beyond a level plane and into a hyperextended position. This expanded range of motion is their “normal”. For a hyperextension injury to occur in these populations, the tibia would have to glide that much further forward, still stressing its restraints.

It is important for an athlete or dancer to have exceptional muscle strength, particularly in those muscles surrounding a less than stable joint. It is also vital that strength is optimized at the end-ranges of motion. The hamstrings become particularly vital in the case of the knee, for in their role as knee flexors. In addition to bending the knee, the hamstrings also act to extend the hip. However, as knee flexors they provide a degree of dynamic restraint to limit hyperextension of the joint.

Concussion and How a PT Expert Can Help

In recent years it has become more apparent that any impact to the human body, whether a fall or a bicycle accident, can have more lasting effects than previously thought.  Concussions are among the many injuries resulting from trauma that are not physically apparent and are not easily recognized by victims and those around them. Concussion recognition during football, from the little leagues to the professional level, has gained media attention in the past decade. However concussions can also result from accidents, falls, and other types of impact sports. Soccer, hockey, volleyball, and basketball are just a few sports where aggressive play and bodily contact can lead to biomechanical brain injury. Coaches and health practitioners have the ability to help preserve athletic participation and future brain function by recognizing symptoms and by taking the appropriate action to help with healing.

Concussions are often difficult to diagnose without the proper tools and individuals may be reluctant to voice their symptoms. Competitive conditions make players fearful of being sidelined while workers or students may not want to delay projects at hand. Many others underreport or fail to report their symptoms because they lack the knowledge to recognize a true concussion. Players, coaches, and caregivers need to be educated in concussion symptom recognition and how to support these individuals.

Doctors of Physical Therapy are musculoskeletal specialists who can guide individuals and athletes recovering from concussion in a safe transition to daily activities, exercise, and sports.  Besides increased risk of a second more severe concussion, there exist other post-concussive risks that can be detrimental to a person’s well-being. Recent studies by Herman et al. (2016) and Gilbert et al (2016), have demonstrated a relationship between concussion history and lower extremity injuries in athletes. One concussion can disrupt a person’s balance and equilibrium as well as their strength and mobility. When this is paired with subsequent lower extremity injury, a repeating cycle is created where rest, muscle atrophy, and decreased mobility contribute to re-injury and further physical decline. Physical Therapy eliminates this cycle by targeting strength, endurance, and balance deficits in the core, hips, knees, and ankles that persist after concussion. With an individualized rehabilitation program provided by a trained Physical Therapist, a patient recovering from concussion can return to function and return to their sport with confidence and decreased risk of future injury.

Elizabeth Lamontagne PT, DPT, SCS, CKTP

Staff Physical Therapist at Recovery Physical Therapy



Herman, D.C. Jones, D. Harrison, A., Moser, M., Tillman, S., Farmer, K., …Chmielewski, T. L. (2016). Concussion May Increase the Risk of Subsequent Lower Extremity Musculoskeletal Injury in Collegiate Athletes. Sports Medicine. Doi: 10.1007/s40279-016-0607-9.

Gilbert, F.C., Burdette, G.T., Joyner, A.B., Llewellyn, T.A., Buckley, T.A. Association Between Concussion and Lower Extremity Injuries in Collegiate Athletes. Sports Health: A Multidisciplinary Approach. 2016;8(6):561-567. Doi: 10.1177/1941738116666509.