Mapping Movement Tape me out to the ballgame

My Goal Don t be the Bird!

Be the Pig

tools RockTape Arsenal 5

Mob/Sta Kit

Major League Baseball

1. THE PROBLEM Epidemiology Expert Opinion 3 HOUR TOUR 2. THE SOLUTION Screening Mobility Motor Control Stability Scars/Topicals

Movement Pyramid corrective exercise - Used to normalize human movement before increasing training or exercise demands rock tape - A special kinesiology/sports tape that provides support while allowing full range of motion. Tape is used to decrease pain, unload tissue via decompression, and provide a novel stimulus that improves body awareness. iastm - Instrument - Assisted Soft Tissue Massage - A manual therapy technique designed to provide direct, mechanical manipulation of irregular tissue. rolling/balls/bands - A collection of tools used by athletes for manipulation of the myofascial system to normalize muscle tone. assessment- The act of making a judgment about the quality of human movement screening- The act of examining people to decide if they are suitable for a particular movement or exercise 9

The Problem

It s Complicated Consensus

Jason L. Zaremski, M.D., CAQSM Assistant Professor, Department of Orthopaedics & Rehabilitation Divisions of PM&R, Sports Medicine, & Research, University of Florida AAPMR Annual Meeting Boston, MA October 3 rd, 2015

Epidemiology-Baseball >10,000 baseball players in NCAA Division I baseball 500,000 HS aged baseball players in the US Shoulder and/or elbow pain ranges from 17% to 45% in one season. Adams JE. Injury to the throwing arm: a study of traumatic changes in the elbow joints of boy baseball players. Calif Med. 1965;102:127-132. Lyman S, et al. Longitudinal study of elbow and shoulder pain in youth baseball pitchers. Med Sci Sports Exerc. 2001 Nov;33(11):1803-10. National Collegiate Athletic Association Sports Sponsorship and Participation Reports. 2014.

50% of 9-14 yr old players have experienced elbow &/or shoulder pain during play Lyman et al: AJSM 12 Surgeries appear to be increasing in young baseball players Fleisig et al: J Sports Health 12, Erickson AJSM 15 Incidence of UCL injury in 15-19 year olds > 9% between 2007 and 2011.

Risk Factors Overuse Throwing Fatigue from Overuse Fleisig 2011 AJSM, Dale N Am J Sports Phys Ther 2007, Olsen AJSM 2006, more.. Guidelines: MLB Pitch Smart Specialization: Specialization Position Statement DiFiori AMSSM Or is it due to Biomechanics Throwing v Pitching ROM, TROM, GIRD (glenohumeral internal rotation deficit): Wilk et al, AJSM 2014; Hurd JAT 2012 Pitch Type: Controversial (specifically Curve Ball)

The elbow is the most claustrophobic joint in the body Eric Cressey

Tommy John, the ACL of the Elbow Dr. James Andrews

Tommy John Epidemic? http://jasoncollette.com/wp-content/uploads/2014/05/surgeries.png

Ulnar Collateral Ligament Injuries Chronic valgus stress places ligament at risk for laxity or tearing Pitchers at highest risk

UCL Injuries - Evaluation Medial pain during late cocking, acceleration or deceleration is hallmark Pain with valgus testing more reliable than laxity Laxity on valgus testing at 30 minimal unless tear is complete MRI with contrast fluid leakage outside of joint represents complete tear

Valgus/Extension Overload It always leads back to the valgus and extension forces (termed valgus-extension overload by many) that combine to wreak havoc on an elbow during throwing Valgus force of 64Nm on the elbow (Fleisig, et al.)

Tissue Failure Rate As Morrey et al. determined, the ulnar collateral ligament (UCL) takes on approximately 54% of this valgus force meaning that it s assuming about 35Nm of force on each pitch. This is all well and good until you realize that in cadaveric models, the UCL fails at 32Nm

UCL Injuries - Treatment Rest Physical therapy NSAIDs Return to throwing when pain-free Surgery autologous tendon secured in tunnels in humerus and ulna in figure-of-eight fashion, ulnar nerve transposed

Popular Opinion? Survey of people in the New York City area, asking high school pitchers, college baseball players, parents, and coaches, What do you think the success rate of Tommy John surgery is? They think two-thirds of people have a successful surgery. Now get this: One-third to half of them think they ll have better velocity after the surgery. Even scarier: Twenty-five to 50 percent of them think you could you have surgery sometimes without even having the injury, just to make your elbow stronger.

Recommended Rest Guidelines Watch and respond to signs of fatigue. No overhead throwing of any kind for at least 2-3 months/year (4 months is preferred). No competitive baseball pitching for at least 4 months/year. Limits for pitch counts and days rest. Avoid pitching on multiple teams. Good throwing mechanics. ASMI Position Paper

The Solution

Injury Prevention Tactic for Throwing Athlete Volume and Mechanics

Volume

"I want parents and coaches to realize the implications of putting a 12- or 13-year-old through the type of athletic work done by a 25-year-old," says Dr. James Andrews.

Give them time off to recover. Please. Give them time to recover. Dr. James Andrews

Don't play year-round Dr. James Andrews

Stay away from radar gun Dr. James Andrews

Be careful around showcases Dr. James Andrews

Pitch Limit American Sports Medicine Institute (ASMI) recommends pitches per week: 1. Ages 8-10: 52 pitches 2. Ages 11-12: 68 pitches 3. Ages 13-14: 76 pitches 4. Ages 15-16: 91 pitches 5. Ages 17-18: 106 pitches Practice and recreational pitching add to this strain

Pitch Types Pitch type should also be limited to reduce injury Before age 10, only fast ball and change-up should be permitted Curveball, slider, knuckleball and screwball may be introduced with increasing age ASMI

Mechanics

Proper Mechanics Dr. James Andrews

Roundtable Discussion Orthopeadics Today (March 2015) late shoulder external rotation, low shoulder abduction and excessive elbow flexion during pitching are some motions that may lead to increased elbow torque Andrews, Ciccotti, Fleisig, Donohue, and more

Pitching Mechanics Curveball and slider related to joint pain in young pitchers These pitches place high loads on shoulder and elbow Curveball requires new set of mechanics Adolescents more susceptible to injury because growth plates still open

Youth Baseball Recommendations No curveball or slider between 9 and 14 Fastball and change-ups only Age-appropriate pitch limit per game By adhering to the above recommendations, we can expect the occurrence of shoulder and elbow pain in young throwers to decrease. Ref: ASMI

Dr. Andrews/Fleisig Optimize pitching mechanics to ensure using the whole body in a coordinated sequence (kinetic chain). A biomechanical analysis is recommended, as it provides objective data to the pitching coach, strength coach, and pitcher.

1. PITCH LIMIT! The Solution 2. PITCH MECHANICS! Throwing is not dangerous to a pitcher s arm. Throwing while tired is dangerous to a pitcher s arm. Rany Jazayerli (baseball writer).

What makes up good movement?

motor stability control mobility 47

mo bil i ty mōˈbilədē/ the ability to move or be moved freely and easily. sta bil i ty stəˈbilədē/ the state of being stable. motor control the systematic transmission of nerve impulses from the motor cortex to motor units, resulting in coordinated contractions of muscles. 48

soft tissue neurological joint 49

criteria for optimal efficiency spring compliance 50

+ Elastic Spring 51

Adjo Zorn fascial elasticity pre-push 52

Daniel Leiberman Barefoot Prof 53

compliant + spring = efficiency mobility MOBILITY motor control MOTOR CONTROL 54

fascia as our roadmap 55

it s all connected

connected both mechanically and neurologically Via the ectoderm 57

human GPS system fascial anatomy 58

Nervous System Fascia Muscle Pain/Performance Movement Joint 59

Review of the research

Strolling Under the Skin

Fascial Research Review Feldenkrais nervous system most important target for influencing posture and movement Rolf - fascia is most important tissue for posture and movement It's both!

innervation Fascia is innervated by: 1. Unmyelinated fibers terminating in the fascia 2. 17% motor 3. 43% sensory 4. Most myelinated fibers are particularly sensitive to stretch loading Dr. Robert Schleip

Dr. Geoffrey Bove D.C. It s all about the interfaces Interfaces are essentially the fascial planes between muscles, nerves, fascia, etc.. Lack of gliding is the enemy Positive treatment effects are at the loose connective tissue and not in the fascia Early intervention is the key Bove GM, Chapelle SL. Visceral mobilization can lyse and prevent post-surgical adhesions. Journal of Bodywork and Movement Therapies, 16, 76-82, 2012 doi: 10.1016/j.jbmt.2011.02.004

muscles act in synergy not in isolation muscular strain is applied along traceable myofascial lines Vleeming/Lee 68

fascial chains back chain front chain lateral chain functional chain core chain extremity chains spiral chain 70

performance front chain sagittal plane 72

taping sections of the chain 74

performance functional chain transverse plane 75

taping the chain 79

performance arm chains 80

taping the chain performance front arm chain performance back arm chain 81

Stecco Model - Helical Myers Model - Spirals 82

ref: Stecco 83

Screening

subconscious dysfunction conscious dysfunction conscious function subconscious function 88

1 2 3 Frontal Plane (coronal) a vertical plane running from side to side; divides the body or any of its parts into anterior and posterior portions. Sagittal Plane a vertical plane running from front to back; divides the body or any of its parts into right and left sides. Transverse Plane a horizontal plane; divides the body or any of its parts into upper and lower parts. 89

tech support 90

SCREEN 93

performance functional chain transverse plane 94

No Tape Tape

Mobility

stimulation of mechanoreceptors tissue manipulation hypothalamic tuning global muscle tone Autonomic Nervous System - Brain palpable tissue response intra-fascial smooth muscles 100

4 types of fascial receptors 4 1 golgi receptors (type Ib) pressure/force 2 interstitial (type Iii/iv) sustained/rapi d pressure pacinian corpuscles (type II) 3 rapid pressure/ vibration ruffini endings (type II) sustained pressure 101

when and how? pre workout moveme nt self myofascial release post workout 102

stimulatory receptors pacini mechanoreceptors: these receptors are primarily responsive to rapid pressure changes. Stimulating these receptors can result in improved proprioceptive feedback and controlled motor movement. pre activity 103

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inhibitory receptors ruffini mechanoreceptors: stimulation of ruffini corpuscles is assumed to result in a lowering of sympathetic nervous system activity (van den Berg & Capri 1999). slow deep tissue techniques tend to have a relaxing effect on local tissues as well as on the whole organism. It therefore appears that deep manual pressure specifically if it is slow or steady- stimulates interstitial and Ruffini resulting in global muscle relaxation, as well as a more peaceful mind and less emotional arousal. post activity 105

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Langevin study : thoraco-lumbar fascial movement 108

glide - pin and stretchgliding) 1. SCAN tissue that feel restricted or limiting movement quality (movement assessment) 2. IDENTIFY tissue quality during specific pre treatment movement = Target Tissue 3. HOLD above or below target tissue and begin to MOVE tissue thorough ROM for 30-60 seconds = FASCIAL MOVEMENT RELEASE (FMR) 4. Address tissue up/down stream to affect possible limiters in movement quality = RIPPLE SCAN + IDENTIFY + FMR + RIPPLE 109

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banded mobilizations 111

mobilization vectors + torque 112

3 mobilization vectors 1. glides - perpendicular to joint plane 2. traction - parallel to joint plane 3. torque - tissue torque applied with mob band 113

proximal stability allows for distal mobility 3 points of contact 114

anchor 3 points of contact 115

clock method 116

inferior vector (shoulder) S u p o o r t e d S u p o o r t e d 108

2 ways to affect motor control 1. tape on skin 2. corrective exercise 128

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how it works! pain decompression neuro-sensory X

largest organ in your body X

effected by: 1. Mechanical Deformation 2. Neurological Stimulation X

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Skin Drag also creating mechanical distortion of the neural sleeve.

neurological extension of the brain = X

Somatosensory fibers Afferent fibers carrying info of different modalities are of different sizes What property of large diameter axons allows for increased speed of conduction? 137

Cutaneous mechanoreceptors: (slow vibration, texture) (sustained touch, pressure) (rapid vibration) (rapid vibration) (deep pressure) (movement of hairs) 139

Somatosensory projections: tracts 1. Dorsal column-medial lemniscus pathway 2. Anterolateral pathway 141

2 nd $$Order$ Processing$ 1 st $Order$ Processing$ X

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Improve tactile acuity decrease pain improve body awareness X

Conclusion study shows convergent evidence that touch induces analgesia in a spatially dependent fashion.

shoulder 154

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fascial unloading 165

Pre-Tape Post-Tape X

In vivo MRI imaging

Findings Confirmed that convolutions in the superficial tissues are formed. Free nerve endings in this region are sensitive to stretch loads, and these convolutions may result in alterations of afferent input/pain inhibition. Local tissue (target tissue) demonstrated sizeable and mechanical effects shown The non target tissue also showed sizeable heterogenous deformations with inter-subject variability being notable. Additionally the researchers found in the local tissues, the deformations created were not related to the direction of taping, further debunking the myth that the direction of application of the tape is important

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Patellar taping effects Effects of Patellar Taping on Brain Activity during Knee Joint Proprioception Tests Using functional Magnetic Resonance Imaging Michael J.Callaghan, Shane McKie, Paul Richardson, Jacqueline A.Oldham 177

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Managing Fatigue

Pitching with Arm Fatigue Average > 80 pitches = 4x risk of surgery Pitch competitively > 8 months/year = 5x likelihood of injury Pitching regularly with fatigued arm = 36x as likely to have an injury and potentially need surgery! Olsen SJ, et al. AJSM. 2006

movement taping trends 1. Degraded Postural Performance after Muscle Fatigue Compensated by Skin Stimulation 2. Skin Strain Patterns Provide Kinesthetic Information to the Human CNS 3. Cutaneous Afferents Provide Information about Knee Joint Movements in Humans 4. Effects of taping on Scapular Kinematics and Muscle Performance in Baseball Players with Impingement Syndrome 182

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adhesive tape that is adequately placed on the skin can provide sensory information that compensate for the less accurate muscular proprioception after fatigue. The positive results could justify further investigations to better understand how cutaneous stimulation could allow us to enhance postural and dynamic movement control. 186

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taping with fatigued tissue 1. Improving dynamic postural control after a fatigue effort using Rocktape applied in the Performance Front Chain (Lent-Koop, USA, 2011) 2. The use of Kinesthetic taping to increase strength output in the lower limbs and enhance reaction times in soccer players (Goh, AUS, 2011) 188

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2 1 5 190 7

Taping for Movement Correction 191

Taping to mitigate AC/DC Stress Acceleration Deceleration

acceleration 193

UCL + Tommy Joh n 1. Leading with elbow too long 2. Arm/Hand too close to head (excessive flexion of elbow)

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deceleration 198

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Locking it in 201

less is more - mies van der rohe 203

isolation + integration 2 steps 204

isol ation exer cises 159

multi-planar approach 206

Pallof Brugger s integr ation exer cises 160

Brugger s Band Exercise - set up 161

integration 273

pallof rotation control 212

pallof frontal control 213

Scar Taping 214

scar taping goal: improving mobility and flexibility of post surgical incisions created via the biomechanical lifting effect (similar to skin rolling) and skin shear effect (micromassage mechanism). 215

Scar Types HYPERTROPHIC SCAR KELOID SCAR CONTRACTURE SCAR ATROPHIC SCAR 216

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early interventi on 219

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skin glide 221

stage 2: multi-directional manipulation 222

Pre-Tape Pre-Tape Post-Tape Post-Tape 223

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Topical agents perform ance 226

TRPM8 Receptors

Topicals Cold and pain signals are linked neurologically Pain and temp signals travel along same pathway Cold reduces pain through gate control theory Menthol TRP Cold Receptors Cold stimulates TRPM8 Cold receptors on nerves and blood vessels TRPM8 receptors may play a role in pain through central mechanism Glutamate system (Proudfoot et al, 2006) Opioid system (Galeotti et al, 2002)

Analgesia Mediated by the TRPM8 Cold Receptor in Chronic Neuropathic Pain Clare J. Proudfoot, Emer M. Garry, David F. Cottrell, Roberta Rosie, Heather Anderson, Darren C. Robertson, Susan M. Fleetwood-Walker, Rory Mitchell Current Biology Volume 16, Issue 16, Pages 1591-1605 (August 2006) DOI: 10.1016/j.cub.2006.07.061

Figure 1 Current Biology 2006 16, 1591-1605DOI: (10.1016/j.cub.2006.07.061)

Schematic Representation of a Possible Mechanistic Basis for TRPM8-Mediated Analgesia after CCI In this simplified hypothetical model, activation of TRPM8 in a subpopulation of afferents by icilin, menthol, or moderate cooling leads to central synaptic release of glutamate (Glu), which then acts through inhibitory Group II/III mglur receptors located either presynaptically on injury-activated nociceptive afferents or perhaps also postsynaptically on dorsal-horn neurons, thereby attenuating neuropathic sensitization.

Team Effort Between MDs, PT, DC, ATC, athlete coach, and family Dr. Craig Leibenson

FMT Certification Series Basic Performance Movability Special Populations Blades Canine Equine 2 3 4

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