By: Eric Cressey

As you’ve probably already surmised by now, I’m always looking to meet new physical therapists who are effective at bridging the gap between healthy and injured athletes. The sad truth is that just as there aren’t many trainers/coaches who really understand musculoskeletal dysfunction and the resulting pathology, there aren’t many PTs who really understand what an athlete puts his/her body through on a daily basis. Let’s just say that I’m lucky to have found Mike Stare, and it’s just my luck that he’s right up the road from me here in Massachusetts. Mike is a brilliant PT and trainer from whom you can expect to hear a lot more in the months and years to come; we’re already brainstorming on some projects together. Here’s a small sample of the great information Mike has to offer; as I told Mike, I think it’s some of the best information we’ve had in any interview at EricCressey.com thus far.

EC: Hi Mike, thanks for taking the time to join us today. Before we get cracking with the interview, could you tell us a bit about who you are, where you’ve been, where you are, and where you’re going?

MS: I’m a Physical Therapist and a CSCS, practicing with Orthopaedics Plus in Beverly, MA, as well as Director of Spectrum Fitness Consulting, also in Beverly.

My early years as an oft injured and undersized athlete landed me in the orthopedists’ office far too often. After a serious neck injury from football, I found myself in Physical Therapy for several weeks. That experience really opened up my eyes and I decided that I wanted to pursue a career as a PT.

I studied kinesiology at the University of Illinois, and began working as a personal trainer for the division of campus recreation. I also worked with the spinal cord athletes there, and had an opportunity to travel to the 1996 Paralympic games to work with spinal cord injured athletes. I moved East to pursue a Masters of Science in Physical Therapy at Boston University. I continued to work as a personal trainer with the Boston Sports Clubs and obtained the CSCS while I was in grad school. I also had the opportunity to help develop and teach a training curriculum for the trainers at BSC.

After graduation, I worked in an outpatient rehab hospital where I saw the full spectrum of conditions. I treated a C5 quadriplegic who was more athletic the most people I know, a lady who had both legs amputated from her pelvis (best pair of arms on a 60 year old I ever saw and a heart of gold), bodybuilders with overuse injuries, chronic low back pain – you name it – I saw it. It was a phenomenal learning experience, but I knew that I needed to focus in order to hone my expertise. So I choose to concentrate on orthopedics, and jumped on board with Orthopaedics Plus.

I returned to graduate school part-time while working full time as a clinician to finish my Doctorate in Physical Therapy, and then completed a two-year fellowship in orthopaedic manual therapy. That was an invaluable experience; I learned from what I truly believe to be the greatest minds in Physical Therapy.

I had moved away from personal training while pursuing my post-graduate studies, and I really missed it. As a clinician, I grew frustrated with the fact that many of my patients were seeing me for injuries or conditions that could have been prevented if they had received the proper training or education. I thought I was going to lose my mind if I saw another 16-year-old girl with excessive genu valgum and the glute strength of a mosquito limping in after ACL reconstruction waiting to get back to her three soccer leagues.

I decided that I needed to provide a service that would not only help people recover from their injury, but also reduce their injury risk and enhance their performance and health. As a result, in partnership with Orthopaedics Plus, I formed Spectrum Fitness Consulting this past January. We focus on providing personal training services, as well as sports conditioning for young athletes. Our studio is located adjacent to the PT clinic, which facilitates me working as both a clinician and a trainer.

We are rapidly growing and have some excellent new programs coming soon. I’m looking forward to finding some quality trainers to help us grow, as well as expanding our reach throughout the North Shore region, developing more of a web presence, and hopefully perform some research in the near future For now, I’m trying to stay focused on getting things done right, keep my head from spinning off, and enjoy hanging out with my new baby and my wife as often as possible.

EC: The first chapter of your memoirs is now officially complete; congratulations! Moving on…you’ve done quite a bit of research on preventing elbow injuries in young pitchers; what have you got for us?

MS: Last fall I had the opportunity to mentor a Doctoral Student from BU. We found some great info about elbow and shoulder injuries in young baseball pitchers. Among some of the most notable findings:

· Injuries in young pitchers most often involve the growth plates, as opposed to the rotator cuff, labrum, or ligaments commonly seen in adults

· The growth plates are the weakest link in the joint complex in young pitchers.

· Growth plates in the elbow are open until about 16 and until 19-22 in the shoulder.

· Injury to the growth plate is very difficult to detect, except in severe cases. Thus, early and appropriate response to pain is critical.

· Pitch counts and pitch types are associated with risk of elbow and shoulder injury. Researchers from the American Sports Medicine Institute (ASMI) have given specific recommendations for pitch type and count based on their findings. For example, a sample of 476 9-14 year olds who threw curve balls had a 56% increased risk for shoulder pain and those who threw sliders had an 86% increased risk for elbow pain. A sample of 330 9-12 year olds showed increased incidence of elbow and shoulder injury occurred with:

1) Those who threw >75 pitches/game or 600/season

2) Pitched in multiple leagues

3) Experienced arm pain during the season

4) Pitched less than 300 pitches per season.

EC: Very interesting; we often hear about throwing too much as being a problem, but some kids were actually having problems from not throwing enough pitches and then going out to “turn it loose?” In other words, is that 300-600 pitches/season number precedent for a “golden pitch count rule?”

MS: No, I don’t consider it as a golden rule. Rather, it should provide a basis from which coaches, clinicians, and researchers can begin to establish the boundaries between what is too much stimulus for a developing arm, and what is not enough stimulus to facilitate enhanced motor skill and optimal conditioning.

The research from ASMI and others is merely revealing initial data about factors that correlate with shoulder and elbow injury, not cause the injuries. Pitch counts are a convenient way to quantify arm stress, but they are far from perfect. The research regarding this topic is still very new and continues to evolve. Pitch counts are just one of the many factors related to increased risk. I think focusing on a firm pitch count for the season may be a problem in that it relieves the coaches, parents, etc., of responsibility of considering other variables that may also indicate increased risk, essentially, providing a false sense of security.

It still isn’t clear why pitching less than 300/season was associated with risk of arm injuries. Perhaps those who threw less had less skill, and thus imposed greater stress upon their arms. Maybe they were less conditioned. Or perhaps, as you mentioned, they progressed their volume of throwing too quickly. The higher risk with throwing greater than 600 seems more obvious – perhaps it was just too much?

Regardless, I think the problem is not simply about too many pitches or too few pitches in games over the season. There seems to be a trend towards kids playing in less informal settings, and more often in competitive settings. This has some significant implications. Less informal play means less opportunity for honing the motor skill of throwing. Motor learning is best developed by practicing frequently, in small chunks of time, at initially lower intensities. This is what is typically done through informal play.

There is a big difference between how you throw in a competitive game situation versus while practicing or playing catch with friends. Thus, kids are in more frequent situations that place higher stresses on the arm, while spending less time improving their motor skills. Given this trend, I think it becomes clear why the incidence of arm injuries is one the rise.

Improving their conditioning and responding to the early warning signs of injury would substantially offset this higher risk. Combined with coaches focusing more on teaching the skill of throwing, while gradually increasing the volume and intensity of throwing, the incidence of arm injuries could be greatly reduced. Rather than just focusing on the pitch count, I suggest coaches and parents also simply rate velocity and control each inning, as well as observe any other signs of a change in mechanics or taking more time between pitches. This will be more effective than just quantifying pitch count.

EC: Great stuff – sorry to interrupt. What else have you got?

MS:

· Certain flaws in pitching mechanics will predispose the shoulder or elbow to greater stress. For example, excessive shoulder rotation at initial contact of the stride leg, and a more cross body horizontal arm follow-through leads to increased torque on the elbow.

· The humerus rotates up to 7000 degrees per second in from late cocking phase to acceleration phase, and the arm experiences a distraction force of up to 1.5 the athlete’s bodyweight during the deceleration phase

· Clinicians and surgeons are reporting a 5-6 fold increase in pitching related elbow and shoulder injuries in youth pitchers. I’ve seen too many kids devastated by realizing that their throwing careers are over at age 15, recovering from their second arm surgery. There’s too much information out there; we need to apply it.

EC: Agreed! So why aren’t more trainers and coaches putting this information into practice?

MS: Although we found some great info about kinematics, kinetics, and epidemiology, there was very little information about conditioning or training strategies. It was implied by almost every researcher, but never thoroughly discussed. That is were my “Young Guns” program comes in. Our program will be the only that I’m aware of that will emphasize not only the preventative strategies via pitch count, pitch type, and throwing mechanic alterations, but also implement specific conditioning strategies. As with so many other conditions, the ability to generate and translate force through out the entire kinetic chain, as well as efficiently decelerate, correlates with improved performance and reduced injury. I think this reasoning applies perfectly to throwing athletes, and they should be trained accordingly.

EC: Great stuff; I’m sure it’ll be fantastic. How about correcting injuries once they’re in place? Any rehab tips for those who already have bum elbows?

MS: The injured tissue must be identified first. This is especially important for young athletes, as growth plates are particularly vulnerable. Treating a growth plate injury will be much different than treating a lateral epicondylopathy. Seeing an orthopedist who specializes in elbows and shoulders – together with a PT with a manual therapy background – is your best bet.

Next, identify the cause of the problem. It’s always easier to investigate a crime closest to when it was committed. The irritating factors must be modified or avoided.

Look at the shoulder, thoracic spine, and hips for mobility deficits. Inadequate mobility at any of the joints along the kinetic chain can result in greater compensatory mobility demands upon the more vulnerable elbow joint, leading to excessive strain and ultimately injury.

If soft tissues of the elbow are involved, such as is the case with tendonopathy of the common extensor (lateral epicondylopathy) or common flexor (medial epicondylopathy) tendons, deep tissue massage is very effective. It doesn’t feel so good initially, but it works. Usually, you can do it yourself; just follow the tendons starting about ½ inch from the origin, and deeply massage with small amplitude parallel and perpendicular to the tendons.

Joint mobilization is also very effective at restoring normal mobility and promoting joint healing – but you’ll need a skilled therapist for that. For less acute injuries, very high repetition, low load exercise can be effective at improving tensile qualities and promoting healing.

The common practice of applying ice shouldn’t be overlooked. Ice massage is very easy and effective. Freeze water in a Dixie cup, peel back the edges, and rub the effected area for about 5-10 minutes.

EC: My favorite part is that you never recommended non-steroidal anti-inflammatory drugs (NSAIDs). We know we’re dealing with degenerative, not inflammatory conditions, so these interventions have little merit aside of pain relief, which is better accomplished with ice anyway. All those NSAIDs are just inhibiting the healing process and giving people a false sense of good health, leading them to throw the tissue back into the fire much too soon. Would you agree? (You’re not allowed to disagree, for the record; this is my newsletter!)

MS: I absolutely agree, and not just because I fear being chastised like your friend Hugo from a few newsletters ago! Soft tissue injuries have often been labeled as tendonitis, the –itis suffix inferring an inflammatory pathology. However, histological studies consistently fail to find markers indicative of inflammation with these conditions, leading to the increasing use of the appropriate term tendonopathy instead. This is more than a semantics issue. As you mention, taking an anti-inflammatory to treat something that does not have an inflammatory pathology may yield unnecessary risks and hinder healing. Recent research has demonstrated impaired bone healing in conjunction with NSAID usage. This is particularly important if bone pathology is suspected, as often is the case with young pitchers having a high incidence of growth plate injuries

EC: This has been fantastic stuff, Mike; thanks for taking the time. Where can our readers find out more about you?

MS: It’s my pleasure Eric, anytime. I can be reached at mike@spectrumfit.net, and your readers can learn more about Spectrum Fitness Consulting, the Young Guns program, and myself at www.spectrumfit.net.