Dr. Mike Marshall's Pitching Coach Services
----------------------------------------------------------------------------------------------- For Tendon Pain, Think Beyond the Needle
February 28, 2011

Two time-honored remedies for injured tendons seem to be falling on their faces in well-designed clinical trials.

The first, corticosteroid injections into the injured tendon, has been shown to provide only short-term relief, sometimes with poorer long-term results than doing nothing at all.


     In an earlier discussion of what corticosteroid shots do, I provided a research paper that found this result over fifty years ago.  In my Special Reports file, please read, 'Cortison Shots Make Injuries Worse.'

     The fact that orthopedic surgeons and physical therapists choose to ignor that research speaks to their not having the right answer and their money-grubbing laziness.


The second, resting the injured joint, is supposed to prevent matters from getting worse.  But it may also fail to make them any better.


     That orthopedic surgeons and physical therapists do not understand the simple basis physiological function of atrophy speaks to their academic ignorance.

     Rest decreases fitness.


Rather, working the joint in a way that doesn’t aggravate the injury, but strengthens supporting tissues and stimulates blood flow to the painful area may promote healing faster than “a tincture of time.”


     To recover from injuries, athletes have to start below the intensity that injured them and gradually increase their intensity to levels that stimulate the body to make a physiological adjustment.

     But, as the emailer wrote, for over forty years, I have explained this in great detail.


And researchers (supported by my own experience with an injured tendon, as well as that of a friend) suggest that some counterintuitive remedies may work just as well or better.

A review of 41 “high-quality” studies involving 2,672 patients, published in November in The Lancet, revealed only short-lived benefit from corticosteroid injections.  For the very common problem of tennis elbow, injections of platelet-rich plasma derived from patients’ own blood had better long-term results.


     Well, that is the answer.  For everybody that injures a tendon, doctors only need to inject platelet-rich plasma that they derived from the patient's own blood.  NOT!

     That sounds like an excuse for blood doping aerobic athletes.  Who knows whether the plasma injection also contained steroids?


Still, the authors, from the University of Queensland and Griffith University in Australia, emphasized the need for more and better clinical research to determine which among the many suggested remedies works best for treating different tendons.

My own problem was precipitated one autumn by eight days of pulling a heavy suitcase through six airports.  My shoulder hurt nearly all the time (not a happy circumstance for a daily swimmer), and trying to retrieve something even slightly behind me produced a stabbing pain.

Diagnosis: tendinitis and arthritis. Treatment: rest and physical therapy.

Two months of physical therapy did help somewhat, as did avoiding motions that caused acute pain.  The therapist had some useful tips on adjusting my swimming stroke to minimize stress on the tendon while the injury gradually began to heal.

The following spring, although I still had some pain and feared a relapse, I attacked my garden with a vengeance.  Much to my surprise, I was able to do heavy-duty digging and lugging without shoulder pain.

Could the intense workout and perhaps the increased blood flow to my shoulder have enhanced my recovery?  A friend, Richard Erde, had an instructive experience.


     The author said, "The therapist had some useful tips on adjusting my swimming stroke on the tendon whiel the injury gradually began to heal."

     Then, the author said, "The following spring, although I still had some pain... ."

     That does not sound as though the physical therapist helped.

     The author said, "Could the intense workout and perhaps the increased blood flow to my shoulder have enhanced recovery."


     If athletes injure themselves and rest, then, when they try to do whatever injured them, they will still feel the pain.  The only way to eliminate the pain is to judiciously train at gradually increasing intensities through the pain until the involved tissues can withstand the stress.

     Of course, if inappropriate force application techniques contributed to the injury, then, while they are judiciously training at gradually increasing intensities, the athletes must adjust their force application technique.


An avid tennis player at 70, he began having twinges in his right shoulder while playing.  Soon, simple motions like slipping out of a shirt sleeve caused serious pain.

The diagnosis, based on a physical exam, was injury of the tendon that attaches the biceps muscle of his upper arm to the bones of the shoulder’s rotator cuff.

He was advised to see a rheumatologist, who declined to do a corticosteroid injection and instead recommended physical therapy and rest.

“I stopped playing tennis for a month, and it didn’t help at all,” Mr. Erde told me.  “The physical therapist found I had very poor range of motion and had me do a variety of exercises, which improved my flexibility and reduced the pain somewhat.”

After two months, he stopped the therapy.  Then several weeks ago, after watching the Australian Open, he thought he should do more to strengthen his arm and shoulder muscles and decided to try playing tennis more vigorously.

“The pain started to drop off dramatically,” he said, “and in just 10 days the pain had eased more than 90 percent.”


     As I have repeated said, anecdotal information does not satisfy research requirements.  While they can be interesting, without controlled research environments, other than to stimulate proper research, they are of little value.


A Frustrating Injury

Tendinopathies, as these injuries are called, are particularly vexing orthopedic problems that remain poorly understood despite their frequency.  “Tendinitis” is a misnomer: rarely are there signs of inflammation, which no doubt accounts for the lack of lasting improvement with steroid shots and anti-inflammatory drugs.  They may relieve pain temporarily, but don’t cure the problem.


     The article said, They may relieve pain temporarily, but don’t cure the problem.

     Nevertheless, doctors still prescribe them and people waste millions of dollars.  What part of money-grubbing laziness do they not understand?


The underlying pathology of tendinopathies is still a mystery.  Even when patients recover, their tendons may continue to look awful, say therapists who do imaging studies.  Without a better understanding of the actual causes of tendon pain, it’s hard to develop rational treatments, and even the best specialists may be reduced to trial and error.  What works best for one tendon, or one patient, may do little or nothing for another.

Most tendinopathies are precipitated by overuse and commonly afflict overzealous athletes, amateur and professional alike.  With or without treatment, they usually take a long time to heal, many months, even a year or more.  They can be frustrating and often costly, especially for professional athletes and physically active people like me and Mr. Erde.


     Athletes injure themselves as a result of lack of fitness or inappropriate techniques.  Therefore, when coaches teach force applications that eliminate injurious flaws and design interval-training programs that enable the involved bones, ligaments, tendons and muscles to withstand stresses greater than they could ever generate during competitions, they will never injure themselves.


In a commentary accompanying the Lancet report, Alexander Scott and Karim M. Khan of the University of British Columbia noted that although “corticosteroid injection does not impair recovery of shoulder tendinopathy, patients should be advised that evidence for even short-term benefits at the shoulder is limited.”  Like the Australian reviewers, the commentators concluded that “specific exercise therapy might produce more cures at 6 and 12 months than one or more corticosteroid injections.”


     The article said, "... specific exercise therapy might produce more cures at 6 and 12 months than one or more corticosteroid injections.”

     That sounds as though somebody is reading my stuff.

     The non-specific exercises that Physical Therapists recommend will never properly prepare athletes for competition.  All training must be specific.

     In my Special Reports file, I have included 'Specificity of Interval-Training by Professor William W. Heusner.

     Orthopedic surgeons and physical therapists might want to read what Professor Heusner has to say.

     If they still do not understand, then they can email me for clarifications.

     But, whatever they do, stop spreading your worthless rehabilitation nonsense.


Treatments to Try

Now the question is:  What kind of physical therapy gives the best results?

Most therapists prescribe eccentric exercises, which involve muscle contractions as the muscle fibers lengthen (for example, when a hand-held weight is lowered from the waist to the thigh).  Eccentric exercises must be performed in a controlled manner; uncontrolled eccentric contractions are a common cause of injuries like groin pulls or hamstring strains.

Marilyn Moffat, professor of physical therapy at New York University and president of the World Confederation for Physical Therapy, prefers “very protective” isometric exercises, at least at the outset of treatment until the tendon injury begins to heal.  These exercises involve no movement at all, allowing muscles to contract without producing pain.  For example, in treating shoulder tendinopathy, she said in an interview, the patient would push the fists against a wall with upper arms against the body and elbows bent at 90 degrees.

In another exercise, the patient sits holding one end of a dense elastic Thera-Band in each hand and, with thumbs up, upper arms at the sides and elbows bent at 90 degrees, tries to pull the hands apart.

“The stronger the shoulder muscles are when the tendinopathy calms down, the better shape the shoulder is in to take over movement without further injury,” Dr. Moffat said.  “You don’t want the muscles to weaken, which is what happens when you rest and do nothing.  That leaves you vulnerable to further injury.”


     At least, Dr. Moffat said, “You don’t want the muscles to weaken, which is what happens when you rest and do nothing.  That leaves you vulnerable to further injury.”

     Nevertheless, everything that she recommended is nonsense.


215.  Military press

Can you tell me if doing a military press (with a bar, not dumbbells) and coming down behind the neck instead of in front, is potentially hazardous to the shoulders?

Also, my son almost broke my nose with a Maxline Fastball the other day.  His Maxline Fastball used to have a long slow bend, but not anymore.  This one started to my right, and broke so hard to my left at the last minute that I was only able to deflect it with my glove.  It would be an amazing out pitch against a lefty pull hitter.


     With the bar behind the neck, the Pectoralis Minor muscle is the only shoulder girdle muscle and the Subscapularis muscle is the only shoulder joint muscle that prevent the weight from falling backward.

     If your son loses his balance, then he would either fall backward or injure the attachment of his Pectoralis Minor muscle to the corocoid process of the Scapula bone and/or the attachment of his Subscapularis muscle to the lesser tuberosity of the head of the Humerus bone.

     Thank you for the question.  I should have thought of this scenario for the guy that said he tore his Subscapularis muscle attachment to the head of the Humerus bone.


216.  Causes of Pitching Injuries Part 1

You replied:  "02.  Despite not engaging their Latissimus Dorsi muscle, my baseball pitchers avoided pitching shoulder injuries because I taught them how to apply force in straight lines toward home plate and powerfully inwardly rotate (pronate) their pitching forearm before, during and after release."

I believe you have written that in the Kinetic Chain for your pitchers that the elbow joint conserves the momentum from the shoulder joint.  This means that the action of the shoulder joint precedes the action of the elbow joint.

Therefore, how does the action of the forearm joint now affect the shoulder joint?

For me, there is a disconnect here.


     You are correct.  The joint actions of the pitching arm move from proximal to distal.

01.  All pitching arm movements start with the Shoulder Girdle actions.
02.  Shoulder Joint actions build off the Shoulder Girdle actions.
03.  Elbow Joint actions build off the Shoulder Joint actions.
04.  Forearm Joint actions build off the Elbow Joint actions.
05.  Wrist Joint actions build off the Forearm Joint actions.
06.  The Hand Joints actions build off the Wrist Joint actions.
07.  The Finger Joints actions build off the Hand Joint actions.

     Therefore, it is not possible for the Forearm Joint action to come before or meaningly influence the Shoulder Joint actions.

     When I teach my baseball pitchers to drive the baseball toward home plate in straight lines, I am trying to minimize sideways forces.

     Because sideways forces injure the front and back of the pitching shoulder, by keeping the driveline straight toward home plate, the powerful pitching forearm pronation action prevents injuries to the pitching shoulder.

     When I teach my baseball pitchers to powerfully pronate their pitching forearm before, during and after they release their pitches, I am trying to keep their pitching arm moving in straight lines toward home plate.

     The position of the pitching upper arm that maximizes the power of the Latissimus Dorsi muscle is when the back of the pitching upper arm faces home plate with the pitching upper arm as vertically beside the head as possible.

     Nevertheless, although it introduces sideways forces, when the back of the pitching upper arm is not turned to face home plate and is not as vertical as I want, baseball pitchers can still drive their pitching arm in reasonably straight lines toward home plate.

     Therefore, to move from my Loaded Slingshot pitching arm position to my Slingshot pitching arm position, all baseball pitchers contract their Pectoralis Major muscle.

     However, if they do not take their pitching arm laterally behind their body, then all baseball pitchers can drive their pitching arm in relatively straight lines toward home plate.

     To get the extra inward rotation kick that the Latissimus Dorsi muscle provides, baseball pitchers have to turn the back of their pitching upper arm to face home plate and raise the pitching upper arm to vertically beside their head.

     This means that powerfully pronating the pitching forearm does not retroactively make the Shoulder Joint inwardly rotate.  Instead, powerfully pronating the pitching forearm enables baseball pitchers to drive their pitching arm in straight lines toward home plate through release.

     To satisfy the requirements for a Kinetic Chain, every joint action from the Shoulder Girdle to the Finger Joints have to provide force that accelerates the baseball.

     Because to prevent the bone in the back of the pitching elbow from slamming together, a spinal cord reflex contracts the Brachialis muscle, the elbow joint action does not provide force that accelerates the baseball.  Therefore, the 'traditional' baseball pitching motion is not a Kinetic Chain.

     Conversely, because, to extend the pitching elbow which accelerates the baseball, my baseball pitching motion contracts the Triceps Brachii muscle, my baseball pitching motion is a Kinetic Chain.


Good Luck Everybody
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