Author Archives: LINK Medical Center

About LINK Medical Center

Dr. Amstutz is a classically-trained Chiropractor since 2006, with a foundation in performance and rehabilitation. He began studying in the Complexity Model with Guy Voyer in June 2011. He has recently completed the SomaTherapy program for the 2nd time and is in the process of completing the SomaTraining program for the 2nd time. He works with many professional athletes in various sports and continues his role as student in an 8-year European/Canadian Osteopath program through Sutherland University in Montreal, QC with Dr. Voyer. He is one of only two approved SomaTherapy teachers in the U.S. and will also be leading SomaTherapy courses for the SomaEducationalGroup.com in NYC.

Umbilical Hernia?

So… I began a new chapter in my career.  One that involves another 8 years of study. When I first began this journey I attended a “knee course” in LA with Guy Voyer MD, DO.  I spent 27 hours that weekend re-learning knee biomechanics and knee anatomy.  There are structures that he described that are not in the medical anatomy textbooks in the US!   Needless to say, I was a little surprised, confused and bewildered at the same time.  That was June of 2010.   Since then, the level of insight and applicable anatomy/ biomechanics gets more and more insightful.  Here is but another example!

The level of anatomy and biomechanics far exceeds what I’ve been taught thus far.  By simply applying anatomy at its highest level, I have been able to assist patients with hernias, that I never understood before to be possible.

Patient:  Reports to my office complaining of an umbilical hernia that she got 14 years prior, from carrying twin girls.  She also has a more recently found inguinal hernia on the R, but that’s not for this blog!  Below is the picture of the size of her umbilical hernia.

After prescribing one abdominal exercise to properly close the hole at her belly button.  This is the after picture that I took 3 weeks later!

The original size was palpable and not visible.  In the ‘after’ photo, the hernia was no longer palpable outside of the belly button ring.

photo.JPGBefore                                                                                                  photo.JPGAfter

Side Effects:  a tighter overall abdomen as we ‘tightened her corset’ around her abdominal wall.

Next up.  Her inguinal hernia!  Please check the testimonial section of the website for her testimonial.

If you know any women or men with umbilical hernias, diastasis recti or other issues with the abdominal wall, please refer them in for a consult.

Please email me with any questions that you may have!

In Health.

Dr. Jason Amstutz DC, RTP, CCSP, CSCS

DrAmstutz@LINKMedicalCenter.com


STRUCTURE DICTATES FUNCTION Function 3 of 3

The final of a 3 part series on Function.  I could write a 10 part series, but I will save you all the boredom!

So… we’ve discussed what Function isn’t.  So how do we create it?  What are the parts involved?

Without plunging deep in the proverbial ‘rabbit hole’ we will keep it simple.

I’m going to argue the following

Structure Dictates Function!  Most of us have heard and/or used this before.  Its been a mantra of mine since I first graduated Chiropractic school.  Not until recent did I truely understand what 10% of this means.

The Structure:  primarily starting with the Pelvis.  (Without making this into an anatomy lesson, I will attempt to make this brief and poignant)

  • Based upon Tensegrity = Force of Compression (using bones) combined with Tension (using ligaments and fascia)
    Human as a Tensegrity Model!

    Human as a Tensegrity Model!

                                                                    copyright  T. Flemons 2006  www.intensiondesigns.com

Therefore…  The pelvis is literally the ‘center’ of the balance of the entire Tension and Compression (tensegrity) system!

Specific Example.  Scapula is directly influenced by the Pelvis via 1 direct link!  How is that?  Simple.  Latissimus Dorsi (lat) is continuous with the thoracolumbar fascia which is connected directly to the pelvis (1).  Continuous with the Latissimus Dorsi is LeBlanc’s Fascia, which connects directly to the scapula.

What does that mean for a patient or athlete?  A pelvis that is not properly balanced will directly cause a shoulder issue (of many varieties;  labrum tears, tendonitis, impingement, scapula dyskinesis, etc)

The basic KINETIC CHAIN theory that we have all learned or heard about, needs some clarifications.  Mainly that the CHAIN is not the ‘shin bone connected to my thigh bone’ approach, but better explained…’the shin bone is held in relationship to my  thigh bone via a vast complicated network of fascia and ligaments and muscles’ AND the mechanics of the knee (joint between the shin and thigh bones!) is NOT ONLY determined by the bony interface, but also highly influenced by the tension in the system in the anterior, posterior, medial and lateral sides (to simplify)…

This explains many more complicated interactions of the body that Dr Guy Voyer has been introducing to many Therapists, Doctors and High Level Trainers in the US and Canada.  If the structure isn’t properly balanced and mobile, proper Function isn’t achievable.

So if you’ve given up on your Shoulder, Lowback, Neck, Headache Pain OR you are desperately trying to get your 95mph fastball back, 4.1sec 40…or ….  Give us a call and find out exactly the disturbance in your Tensegrity system that is causing your pain!

In Health

Jason Amstutz DC, RTP, CCSP, CSCS

Somatherapy and Somatraining Student of Dr Guy Voyer.

DrAmstutz@LINKMedicalCenter.com


Before Movement is discussed, should you first assess for muscle recruitment and muscle quantity? Function Part 2 of 3

Before ‘movement’ is discussed, should you first assess for muscle recruitment and muscle quantity?

Some of the latest ‘hot topics’ in the rehab and training world, uses movement quality as a sign of DYSfunction or lack of function.  Take a moment and think about that…kinda makes sense but has some inherent holes.

#1 what about the structure itself?  If the structure is limiting the ‘movement’, you are not going to fix it via bettering the movement… a cyclical argument perhaps?

#2 Retraining the movement pattern in the absence of proper balance in the Tensegrity matrix of the body, makes it another bandage!

Now.  Ignoring movement patterns for this blog, lets look at proper recruitment and quantity of muscle.

Proper recruitment:  We are not talking about ‘recruitment patterns’.  We are talking about what percentage of the specific muscle needed for an action, are actually being recruited for the action.  The body and especially athletes are master compensators.  Therefore, they can get by with minimal recruitment and still ‘function’ at a high level and appear ‘strong’ in the process.  For example…can the athlete maintain a stable single leg stance (no contralateral hip drop) for all 4 quarters of the game, instead of using Trendelenburg as a 1 repetition test?

Quantity of muscle?  Too many times I have examined athletes, and patients alike, and noticed that the quantity of muscle is lacking in a specific area.  For example…a runner that has no ‘glutes’???  Let’s not argue about recruitment here, but simply that they have ‘no butt’… glute max, glute med and glute minimus!  Argument:  to stretch and/or recruit muscle fibers when they are overall lacking, seems to be another limiting concept of correction, training etc.   Doesn’t it?    Furthermore, to train those muscles (which are small and lacking) in a complex movement/exercise like the lunge or any squat variation, seems like a bad idea due to the reinforcement of the already existing compensation?  All quad? or quads and TFL?  which we have probably already found Tight and Sore…

The point:  All of the ‘new’ concepts out there don’t take the place of using sound clinical judgement in your approach to an athlete/patient.  Do they?

If your treatment or training seems to lack this type of analysis, please come in for an examination and find out what your true limiting factors are!

In Health,

Dr Jason Amstutz  DC, RTP, CCSP, CSCS

SomaTherapy and SomaTraining Student of Dr. Guy Voyer


What is function? Part 1 of 3

Sometimes its easier to describe what something ISN’T before you define what is is.

Function is an example.  What function isn’t!

Muscle mass ≠ Function

Speed ≠ Function

No pain ≠ Function

Only Function = Function!

In other words.  You can muscle mass, speed and no pain and still not be 100% functional.

Lack of function, is much easier to identify.  It comes in many, many forms.  From decreased speed on a fastball, volleyball spike  OR decreased times in the 100m or 1000m OR decreased vertical jump, to name a few.

The point is simple.  The lack of function doesn’t automatically lead you to the answer.

So the next time your shoulder, lowback or performance suffers, seek the proper Functional Assessment and don’t simply treat the pain or joint!

Call us at 949-722-7070!  We will identify the functional deficit and Correct it.

In Health and Performance.

Jason Amstutz DC, RTP, CCSP, CSCS


The Shoulder: Overkill on Rotator Cuff Exercises with Baseball Pitchers?

This is a quick shoulder blog…
Anatomy facts;
1. Scapula is the largest SESAMOID bone in the body.
2. Proper tension (i.e. strength, flexibility, tissue quality) must be maintained in the system (Kinetic Chain) for maximum function and performance.
3. Scapula is directly linked with the pelvis. Therefore, improper pelvic mechanics can significantly affect the Scapula and the shoulder.
4. 2 separate and important muscle groups: interscapular muscles and the rotator cuff muscles.

Training/Rehab Common Protocols;
1. improve posture of the cervical spine… decrease forward head carriage (FHPosture is related to the Gravity Line and we should be strengthening the lower abdominals with most athletes with FHP).  A proper gravity line assessment and proper examination of the Sacral, lumbar, thoracic and cervical curves will provide the proper info.
2. Improve rounded forward posture of the throwing arm (especially)

3. Strengthen the rotator cuff musculature

4. Strengthen the interscapular muscles…rhomboids, middle and lower traps, levator scap, upper trap.

This is where I would like to spend some time and more detail.   Classic strengthening includes Y’s, I’s, W’s, T’s,  and rows of all types.  There is potentially a flaw in the methodology!

  1. #1 flaw.  What is the strongest and most powerful scapula adductor?  Middle and lower trap?  Nope.   Rhomboids.
  2. Any of the aforementioned exercises that are performed below the scapulohumeral angle do not maximize the stress to the interscapular portion of the chain, mainly the rhomboids.  That potentially eliminates any exercise below the T’s.  Those exercises that are performed at greater than 100 degrees of ABD are still in.
  3. Now.  How do we perform the exercise?  With dumbbells?  bands? balls? None of the above…  How about with just performing scapula protraction and retraction while leaving out the RTC (rotator cuff) and only using isometrically for now.
  4. Training volume and goals… i would argue (based upon my studies with Guy Voyer DO,MD) that we need to consciously shorten the rhomboids to retract the scapula AND with this kind of isolation, we need to perform hundreds of reps.

Next time you are spending countless hours strengthening the RTC.  See how you could better strengthen the chain via some proper rhomboid exercises and see how throwing velocity improves!

Find a qualified SomaTrainer to properly learn this protocol or come in for an assessment!

In Health,

Dr Amstutz DC, RTP, CCSP, CSCS


Do you have shoulder pain that is not getting better with rest, ice, ultrasound, e-stim, adjustments or physical therapy?

Do you have shoulder pain that is not getting better with rest, ice, ultrasound, estim, adjustments or physical therapy?
Precision is paramount to how to treat shoulder pain or weakness.

If you have pain raising your arm above your head and your doctor/therapist thinks that strengthening your shoulder is the answer, it may be time for another opinion.
If you have received countless numbers of the same ‘adjustment’ for your condition and its not resolving, it may be time for another opinion.

Precision in determining the CAUSAL tight structure (often not the muscle that appears tight) CAUSING your pain or dysfunction is the tricky part of shoulder treatment and diagnosis.  IF the ‘tight structure(s)’ is/are not firstly loosened via treatment (myofascial stretching, some type of manual therapy, etc) then all other exercises, stretches, adjustments are futile.

Shoulder Case from today:  55 yr old female with history of R shoulder pain for two years.  Pain with reaching behind her, pain with raising arm to the side, inability to put her arm up her back, put her shirt on, etc.  MRI showed only a little bursitis, X-rays negative.  Treatment consisted of 3 months of physical therapy (ultrasound, e-stim, mobilization, stretches and exercises) with no relief.  1.5 years of chiropractic with no relief.  Ultrasound guided subacromial bursae injection, w/ no relief.

After examine today… TIGHTEST STRUCTURE = capsule of the shoulder!  Until the shoulder capsule is pliable, elastic and lengthened properly, that shoulder will never get better.  No matter how strong her rotator cuff is… no matter how many adjustments to the ‘shoulder’ are performed.  No matter how long she ‘stretches her pec minor’ (as she described to me).  After one treatment today, she could raise her arm above her head without pain!  Other tight structures that were treated… falciform ligament (of the shoulder), conoid and trapezoid ligaments.

If you are or anyone you know is struggling with  a chronic or acute shoulder pain, please have them call the office.

Restoring proper movement to the shoulder is our expertise.  And your body’s job is to heal it, once the structure is properly balanced.

Call the office and get back in the Game!!  949-722-7070

Dr. Amstutz  DC, RTP, CCSP, CSCS


GIRD and Scapula Dyskinesis??? Shoulder Pain in Throwing Athletes

I must get this question/ previous diagnosis on young athletes weekly!!
I think every MD, DC, DO, PT etc is now aware of the paper written in 2003 regarding this ‘breakthrough’ on shoulder mechanics. The brief synopsis: GIRD (glenohumeral internal rotation deficit) was found in throwing athletes who had poor mechanics. SICK scapula/ Scapula Dyskinesis was also found in many athletes with shoulder pain, which is simply defined as…”a scapula that doesn’t move correctly”…

My Issue: These findings… rotational deficit of the throwing shoulder into internal rotation (tight external rotators) and a malpositioned scapula DO NOT describe what the actual problem is. Its merely an observation!

The FIX! the proper combination of tension and flexibility to the scapula (b/c its the largest sesamoid bone in the body…) via proprioception, specific strengthening, myofascial stretching, joint pumping and joint manipulation to the proper constituents. If ALL of these are not part of your current or previous treatment plan, you need to give us the opportunity to teach you how to permanently correct your shoulder mechanics.

Any questions? Please call for a proper shoulder assessment and find out how treating the falciform ligament (of the shoulder complex), the conoid ligament and the trapezoid ligament will improve the scapula function in just one treatment!

In Health.

Dr Amstutz


NON TRAUMATIC SHOULDER PAIN! WHAT TO DO?

How to prevent rotator cuff injury, biceps tendonitis and other Shoulder Pain!

Ask 10 different types of therapist/physicians the number one cause of most shoulder pain and you are likely to get 10 different answers.
We can all agree on a couple of main causes of shoulder pain:

  1. Overuse is a common cause of rotator cuff strain, tearing and pain.
  2. The ‘core unit’ is important for decreasing the amount of strain on a throwing/overhead athlete’s accelerating and decelerating muscles.
  3. Bad biomechanics has an overall effect on shoulder pain (specifically biceps tendonitis, Rotator Cuff pain and shoulder bursitis.

How we fix or correct the Shoulder Pain patient is open to debate and usually depends upon what the Physician/Therapist expertise is.

The typical treatment protocol:

  1. Ice, rest, Ultrasound and massage to the areas of pain and associated musculature. Combined w/ some over the counter or prescriptions to help accelerate the decrease in pain
  2. Once the pain is gone, then it’s usually band exercises for the Rotator Cuff muscles and then a slow reintroduction to the sport or other activities.

The question in my mind when someone presents with shoulder pain is, “what is the exact biomechanical fault which is responsible for structures A, B and/or C to be in pain? (this obviously is thrown out the door if someone has fallen on it or has had an accident of some type!)

The result of bad biomechanics is PAIN! Plain and simple. Its our body’s way of letting us know that something isn’t working right!


When an “ankle sprain” is not just an ankle sprain…

Were you told you have just an “ankle sprain” but it is not getting better?  Read more to see if you may have one of the other injuries that can occur when you roll your ankle.

Intro and basic ankle anatomy:  Ankle sprains (aka a rolled ankle, inversion ankle injuries) usually implies rolling of the ankle so the foot turns in compared to the leg and this injures tissues on the outer side of the ankle.  This injury is very common in almost any sport and even occurs in non-sporting activities when walking on uneven terrain.  When this happens the person usually falls, feels immediate pain on the outside part of the ankle (lateral) and may or may not be able to put weight back on the leg.  Over the next few hours, swelling and bruising develops and they may still not be able to put weight on their injured ankle.  Over the next few days most people employ protection, rest, ice, compression, elevation (the PRICE principles) and the pain and swelling may improve.  The bruising usually changes to all sorts of pretty colors and the actual bruising (just blood under the skin) may follow gravity and settle down closer to the bottom of the foot away from where it hurts.  Below is a diagram of ankle/foot bones and ankle ligaments for reference so you can see where they are when I speak about each boney injury later in the blog.  The main bones to focus on are the lateral malleolus (bottom of the fibula bone on the outside of the ankle), medial malleolus (inside of the ankle, bottom of the tibia bone), talus (foot portion of the ankle joint), calcaneus (heel bone, connects to talus and rest of foot bones), base of the fifth metatarsal (where peroneus brevis muscle attaches, boney spot on outside part of the foot touching the ground).

Picture A is looking at the outside (lateral part) of the ankle, picture B is looking at the ankle from the back.   The main lateral (outside of ankle) ligaments involved in ankle sprains are named for the two bones they connect and are involved in ankle sprains usually in the following order 1) Anterior talofibular ligament (ATFL) (L1 in figure), 2) Calcaneofibular ligament (CFL) (L2 in figure), and rarely 3) Posterior talofibular ligament (PTFL) (L3 in figure).

Initial evaluation:  The Ottawa ankle rules were developed to help doctors decide which ankle sprains need to have an x-ray and which ankle sprains do not need an x-ray.  X-rays may catch a bone fracture but most ankle sprains do not have bone injury.  They state that anyone with pain in the malleolar zones (purple area in diagram below), pain at points A, B, C or D, or inability to bear weight immediately following injury and when seen in ER/Urgent Care/Clinic should get an x-ray.  If you can bear weight after the injury, don’t have boney pain at the spots noted in the diagram then you don’t need x-rays since you have had just a mild sprain and there is pretty much 0% chance of a fracture using the Ottawa ankle guidelines.


Basic Treatment for ankle ligament sprain:  If there is no fracture seen on initial x-rays you likely just have sprained or torn the ligaments, although it is possible that another injury was missed on the initial x-ray.  Grade I sprain is a stretch of the ATFL and maybe the CFL, Grade II sprains are partial tears of the ATFL and maybe the CFL, Grade III sprain is complete tear of at least the ATFL, CFL and possibly the PTFL.  The severity of the injury affects the length of time before you can put weight on the ankle, the instability that may be present after you heal and the length of time it will take to get you back playing your sport.

After being evaluated by a sports medicine physician, you can continue to use the PRICE principles for a few days +/- limiting weight-bearing (crutches) if needed.  It is important to begin physical therapy soon after injury to work on reducing swelling, receive pain relieving treatments, maintain range of motion (alphabet exercises) and work on muscle strengthening to help stabilize your ankle for the future.  As you begin to place more weight on your ankle you can begin to work on balance (aka proprioception) because this is crucial in your ability to return to your sport and prevent future ankle sprains.  The balance training is usually what is forgotten in the rehab process because at this stage the pain is better or gone, however leaving balance training out leads to chronic ankle instability and repeat ankle sprain injuries.  There is a gradual progression of activity in your rehab program before you can return to full unrestricted play in your sport.  You may be advised to use an ankle sports brace or special taping for games to prevent re-injuring of that ankle.

If there is only a ligament injury and there is chronic ankle instability for longer than 12 months a surgery could be considered, but this scenario is rare.  Prior to considering surgery for chronic ankle instability, you should also consider trying platelet rich plasma (PRP, see separate blog on this topic) injection to allow your body to heal itself without going under the knife.

What is a “high ankle sprain”?

Occasionally, the talus bone twists and pushes the tibia and fibula (lower leg bones) apart causing a tear of the connective tissue between the tibia and fibula in the calf area.  This is called a “high ankle sprain” (aka a syndesmosis injury).  This injury may occur along with other injuries to the ankle but is important to diagnosis this since the syndesmosis usually needs a longer time to heal, around 6-8 weeks.  There are certain findings on exam and on x-ray that will show that you have injured the syndesmosis.

So you did your PT, can walk without a limp but still have some pain 6-12 weeks after your injury.  What might be going on?

If all you have injured is your ligaments, then most people improve with conservative treatment over a period of 3-6 weeks.  If you had a Grade II-III tear without bone fracture you may be having symptoms of chronic ankle instability and could be a candidate for platelet rich plasma (PRP) treatment, see separate blog on the topic.  Briefly, PRP involves drawing some of your own blood, removing everything but the growth factors in the platelets, concentrating them and injecting them back into your torn ligament.  This attracts stem cells that begin healing damaged tissue and could stabilize your ankle and resolve your pain.

Other things that may cause chronic ankle pain after an ankle injury include things like sinus tarsi syndrome, anterior or posterior ankle impingement, arthritis or a fracture that was not seen on the original x-rays.

Sinus Tarsi Syndrome:  There is a small cave like opening (aka sinus) on the outside of your foot between the talus and calcaneus bones.  If pain is produced when this is pushed on, as well as when the ankle is turned in (inverted), a cortisone injection that relieves the pain is both diagnostic and therapeutic.

Anterior impingement: Usually seen in soccer, high jump, running, basketball, volleyball or ballet dancers because they repeated plantar flex (toes pointed down) the ankle and cause soft tissue or boney growth in the front of the ankle.  They may also have a history of repeated ankle sprains.  Pain is in the front of the ankle and reproduced with dorsiflexion (toes pointed up) with limited movement.

Posterior impingement: Can be from overuse (such as ballet dancers and running) or from trauma of forcing the ankle into a plantar flexed (toes pointing down) position.  Trauma may cause injury or fracture to the back part of the talus.  Some people have an extra bone back there, called an os trigonum, and this bone can be irritated or torn away from the talus.  Posterior impingement causes pain just in front and on either side of the Achilles tendon, and pain is increased with forced plantar flexion.

Ankle Arthritis: This can be seen on x-ray and usually only develops if there is chronic instability of the ankle over a long period of time.  Stiffness in the morning, decreased range of motion, pain after exercise or walking all day are some of the symptoms.

Osteochondral injuries:  The “dome” or joint surface of the talar bone is covered in cartilage to help the ankle joint glide smoothly.  Sometimes, in about 10-20% of ankle sprains, a “bruise” can develop in the inner or outer sides of the talar dome.  These are called Osteochondral lesions because they involve the cartilage (chondral) and the bone (osteo) immediately beneath.  Depending on the grade of injury this may require prolonged time on crutches, and if severe, surgery to reattach a piece of the cartilage to restore a smooth joint surface and hopefully decrease the chances of arthritis later in life.

Occasionally in younger people (10-30yo) a similar problem may develop without any trauma or injury, called Osteochondritis dissecans (aka OCD lesion).  This is from a decrease in blood supply to the small area of bone and cartilage and we are not sure why this occurs.  OCD may also happen in the knee or elbow in some patients.

Other fractures that may have been missed:  These may include fractures of the lateral talar process, posterior talar process and anterior process of the calcaneus.  These are commonly missed because initially the x-rays may be normal and the pain may be where everyone with an ankle sprain hurts, over or near the stretched/torn ligaments.  So the x-rays and the physical exam may not be helpful initially.  After the rest of the ankle pain and swelling has resolved, it becomes easier to localize the exact area of remaining pain over one of these boney areas.  Repeat x-rays may show the fractures or an MRI might be needed to find them.  Treatment varies depending on many factors but generally having a fracture takes longer to heal than just ligament injuries.

Injuries to the 5thmetatarsal:  The most common injury to the 5th metatarsal (the bone in the foot that connects to the little toe) occurs with an ankle sprain when the peroneus brevis muscle pulls off a piece of the base (blue area in image).  These fractures typically heal with a cast or walking boot for 4-6 weeks.  It is important to make sure that the fracture seen on x-ray does not represent a “Jones Fracture” (green area in image).  A Jones fracture is in a particular spot where blood supply is poor and about 25% of the time a Jones fracture will not heal even when placed in a cast.  There are certain indications for these Jones fractures to be surgically fixed to prevent chronic pain from a non-union.

Tendon injuries:

Besides the bones, cartilage and ligaments the tendons may be injured with an ankle sprain.  Major tendons around the ankle include: the Achilles in the back, anterior tibialis (AT), extensor hallucis longus (EHL) and extensor digiti longus (EDL) in the front, peroneus longus (PL) and brevis (PB) on the outside and the posterior tibialis (PT), flexor digitorum longus (FDL) and flexor hallucis longus (FHL) on the inside of the ankle.  Most commonly the peroneus brevis is torn or inflamed at the lateral malleolus or pulls a piece of bone off the base of the 5th metatarsal (see above).  The peroneus longus can also be torn or inflamed at the lateral malleolus or as it goes under the cuboid bone.  Occasionally, the covering that holds the peroneus tendons behind the lateral malleolus (the retinaculum) can be loose or torn and the tendons can snap back and forth out of their normal grooves, this snapping sensation is felt by the patient and can causes further stress/friction on the tendons.  Although the other ankle tendons are commonly injured they are not related to ankle sprains.

Other possibilities:  Occasionally a nerve can be pinched or scar tissue pushes on a nerve and causes chronic pain, numbness/tingling in the foot/toes.  Also, the lining of the joint (the synovium) may become inflamed, synovitis, and may benefit from a cortisone injections if severe enough.  Rarely, things like gout, pseudogout or infection can cause ankle joint pain, swelling and redness but this is usually not associated with an ankle injury onset.

Work-up for chronic pain after ankle sprain?  You probably need to be seen by someone who specializes in sports medicine, not necessarily a surgeon but someone with extra training in musculoskeletal medicine.  After they examine you they might send you for repeat x-rays or special x-ray views, MRI or perform a diagnostic ultrasound to find out what is wrong.  Treatment may range from surgery, crutches, therapy, or injections depending on what might be wrong.  Sometimes these difficult cases take a long time to heal and may involve some trial and error even in experienced hands.

At Stark Sports Medicine we offer a complete range of non-surgical options for musculoskeletal injuries from highly trained therapists and sports chiropractic care to cutting-edge PRP injections and diagnostic musculoskeletal ultrasound.  So if you’ve injured yourself today, have been living with chronic musculoskeletal pain or want a non-surgical second opinion give us a call at Stark Sports Medicine to arrange your initial evaluation. 949-722-7070.

Mike Gruba, MD
Rehab Director
Stark Sports Medicine Group
17524 Von Karman Ave
Irvine, CA 92614
949-722-7070

DISCLAIMER: In no way should the content of this Website be considered as medical advice. The information here is provided for educational and informational purposes only and is NOT a substitute for the advice of an appropriately qualified medical practitioner or other health care provider. Please consult a physician if you suspect you are ill or injured.


Painful elbows in throwing athletes

Pitcher elbow

Second only to shoulder pain, elbow pain is one of the most common and dreaded injuries for throwing athletes.  This pain can represent a variety of injuries.  This blog will review some of the most common issues we see with elbow pain in throwers, brief anatomy lesson, and what might be the problem depending on where you hurt.

Basic Elbow Anatomy:

The elbow is a simple joint that allows for flexion, extension and rolling of the forearm (like when you are using a screwdriver).  The joint is made up of the upper arm bone, the humerus, and the radius and ulna forearm bones.  The radius is across from the capitellum (part of the humerus) and is on the outside (lateral) of the elbow and the ulna is across from the trochlea (part of the humerus) and makes up the inside (medial) and pointy back (posterior) parts of the elbow.  There are multiple muscles that cross the elbow, too many to discuss here.  There are also many ligaments that help support the elbow joint, the most important for this discussion is the ulnar collateral ligament (UCL) that supports the inside of the elbow joint.

From Journal of Shoulder and Elbow Surgery, 1996,5:349

Why is the elbow injured when throwing?

There are a lot of components to throwing a ball.  These are broken into several phases: the wind up, early cocking, late cocking, acceleration, deceleration and the follow thru phase (see diagram above).  The late cocking phase starts when the front leg lands and acceleration phase starts when the ball starts to come forward.  These two stages place the most stretch on the medial (inner) elbow tissues while also causing compression of the lateral (outer) elbow tissues.  All of the torque and energy from the pitchers legs is moved up thru the core muscles of the torso and transferred to the shoulder and then elbow.

DIFFERENTIAL DIAGNOSIS

There are two key ways to separate patients with elbow pain clinically, by the location of the pain and by their skeletal maturity (age).

ANTERIOR (FRONT) ELBOW SYMPTOMS

  • Biceps tendonitis, tear or bursitis
    • Pain may be worst during follow thru phase.
  • Flexor/pronator muscle injury
  • Nerve entrapment (Lateral antebrachial cutaneous, posterior interosseous or anterior interosseous nerves) and C5 radiculopathy (pinched nerve in neck)
    • Pain plus numbness/tingling or certain muscle weakness.  Need EMG/NCV test to diagnose the problem.

MEDIAL (INNER) ELBOW SYMPTOMS

  • Age <15yo then possibly Little Leaguer Elbow Syndrome (LLES) (aka medial epicondylar apophysitis or traction apophysitis and epicondylitis.
    • Symptoms of progressive pain with throwing, decrease accuracy/speed
    • Can lead to medial epicondyle avulsion fracture (see below), which requires surgery, if continued throwing despite pain.
    • Rehab- Stop throwing, restore motion and when appropriate begin strengthening dynamic stabilizers of medial elbow amongst other treatments.
  • Medial epicondyle avulsion fracture
    • Can result from continued throwing despite pain from LLES.
    • Symptoms of pain and swelling, usually unable to fully straighten elbow.
  • Age >15yo then possibly Ulnar Collateral Ligament (UCL) sprain or tear
  • C8-T1 radiculopathy (pinched nerve in neck) or ulnar nerve injury at elbow (aka cubital tunnel).
    • Need EMG/NCV test to diagnose.
  • Medial epicondylitis (aka golfer’s elbow) or epicondylalgia

LATERAL (OUTER) ELBOW SYMPTOMS

  • Age 7-12yo than possibly Panner’s Disease, (aka osteochondrosis of capitellum)
    • Symptoms: dull, achy activity related lateral pain.  Sometimes swelling, clicking and decreased range of motion.
    • Usually resolves on its own if complete rest (no weight bearing on arm and no throwing)
  • Age 13-17yo than possibly Osteochondritis Dissecans (OCD) lesion of the capitellum (part of the humerus bone that makes up the outer elbow joint)
    • Just below the joint surface a bone injury occurs from repeated compression during throwing.
    • Symptoms: dull pain worse with activity.  Unable to fully straighten elbow and perhaps catching/locking elbow symptoms.
    • If untreated it may lead to pieces of bone floating around in the joint, joint surface deformity and early elbow degenerative arthritis.
    • Needs MRI to detail severity of OCD lesion.
    • Type 1 = no displacement, no articular cartilage fracture.
    • Type 2 = partialy displaced, articular cartilage fracture.
    • Type 3 = completely displaced, boney loose body in joint.

POSTERIOR (BACK) ELBOW SYMPTOMS

  • Loose bodies in posterior elbow recess
    • Pain, clicking and lack of full elbow extension during follow-thru phase
  • Olecranon non-union, fracture or osteophyte formation
    • May require surgery
  • Triceps tendinopathy or tear

GENERAL WORKUP INFO

In younger throwers (<18 years old) it is important to know that there are multiple growth plates that fuse at fairly predictable times in our development.  Therefore, it is crucial to compare the painful elbow to the opposite elbow when looking at x-rays in young throwers.  The arrows in the x-rays below are pointing to normal looking growth plates, but these can look like fractures or may be appear too far apart.  So looking at the other side for comparison is cruicial.

-X-rays of both elbows is usually needed to evaluate bones/joints.

-Ultrasound can identify muscle trauma, tendonitis, tendinopathy, tendon tears, ligament tears.

Normal appearing Ulnar Collateral Ligament (UCL) with Ultrasound

-Nerve testing (aka NCV/EMG) can look into any nerve like symptoms (tingling, numbness, weakness).
-MRI is needed for OCD of capitellum (to know what Type it is and for surgical planning).

General treatment ideals

DISCLAIMER: In no way should the content of this Website or blog be considered as medical advice.  The information here is provided for educational and informational purposes only and is NOT a substitute for the advice of an appropriately qualified medical practitioner or other health care provider. Please consult a physician if you suspect you are ill or injured

1)      SEEK MEDICAL CARE FROM A QUALIFIED SPORTS MEDICAL PROFESSIONAL.  YOU NEED TO HAVE A PROPER WORK-UP COMPLETED BECAUSE TREATMENT IS DETERMINED BY FIRST GETTING A CORECT DIAGNOSIS!!!

a.      For more information about setting up an evaluation call Stark Sports Medicine at 949-722-7070.

2)      In the meantime, it is crucial that you stop throwing until you are evaluated!!!

3)      It is also fine to begin the “PRICE” principles (Protect, Rest, Ice, Compress, Elevate).

a.       Only immobilize the elbow if sore, however try to limit immobilization as much as possible so you don’t lose your range of motion.

4)      Depending on the diagnosis you may be referred for Physical Therapy, Surgical evaluation or be offered a pain relieving procedure (injection).

a.       SURGICAL INDICATIONS
-Medial epicondyle fracture or other fractures.
-Type 2 OCD lesion with locking/catching symptoms or all Type 3 OCD lesions

How do I prevent serious injury in my little leaguer?

If you want your little leaguer to be the next Nolan Ryan you have to take it upon yourself to keep them healthy.  There have been many good medical articles that looked into the risk factors for elbow pain in little leaguers.  Many leagues took this information and have implemented pitch counts and have limited the use of certain pitches that were known to increase the risk to the young athlete’s elbow.  Here are some general guidelines to follow.

1.      Make sure your athlete does a proper warm-up and stretch before each game and practice.

2.      It is recommended that you limit your athlete’s pitches by the following guidelines.   Studies have shown a significantly increased risk if an athlete pitches >9 months per year or more than 100 innings per year.  Also consider how much he/she is throwing in practice.

Athlete’s age

Pitches per game

Pitches per week

Pitches per season

Pitches per year

Pitches to be used/taught

<10

50

75

1000

2000

Fastballs only

11-12

75

100

1000

3000

Add changeup

13-14

75

125

1000

3000

Add curveball

15-16

90

Add slider, forkball, splitter, knuckleball

17-18

105

Add screwball

3.      Also, you may consider having a professional pitching coach evaluate the pitcher’s biomechanics.  This could be done if an athlete is pitching close to recommended limits above, has a history of injury and/or early in a little league career to educate and enforce good pitching mechanics from day one.  List of Instructors in California.

I hope you found this information helpful.  If you are having probems with elbow pain contact the medical experts at Stark Sports Medicine to schedule your thorough evaluation and depending on the problem we can offer you a broad range of non-surgical options to get you back to throwing pain free and better than ever.

Mike Gruba, MD
Rehab Director
Stark Sports Medicine
17524 Von Karman
Irvine, CA 92614
949-722-7070