Ask the Doctor!

This regular segment of ‘Ask the Doctor’ addresses questions sent in by Sports Medicine Weekly followers.

In this segment Dr. Cole answers questions about:

  • Recovery from a Broken Toe: Recommended Rehab Routine.
  • Fluid on the Knee: Description, causes and treatment.
  • Discussion with Steve Kashul on family workouts.

Click here to have your question addressed live by Dr. Brian Cole on an upcoming show.

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Youth Pitching Study: The Effect of a Strengthening Program

Image result for core strengthening exercises

WHAT IS THE STUDY?

This study is examining the effect of a 6-week hip and core strengthening program on shoulder and elbow motion during pitching. Participants are 13-18 years old who pitch in at least one game per week on average during the season. Players will either be assigned to the control group or the strengthening program group. In the strengthening group, players will be taught a hip and core strengthening program and will be expected to complete it daily for 6 weeks. In the control group, players will continue to train as they were before enrolling in the study.

WHY HIP AND CORE STRENGTHENING?

The forces generated by the hip muscles during throwing are vital to the initiation and transfer of power to the arm. Electromyography (EMG) has shown that the legs and trunk provide rotational momentum for the arm and create over 50% of the total force and kinetic energy in a tennis serve. Other studies have shown that as a game progresses, players first show fatigue in their hip and core muscles and then lose their correct pitching form. In order to keep the same speed of their pitch while tired, players often use poor form and place themselves at risk for injury. We hope that using this conditioning program will strengthen the hip and core muscles and allow pitchers to continue pitching with proper form, therefore decreasing injuries.

WHAT WILL THE PLAYER BE EXPECTED TO DO?

When the player and parents decide to participate, the player will have baseline measurements taken, including hip range of motion, hip strength and the single leg squat test. Next, players will pitch while there are 1-inch markers attached to their arms and legs, which help us track body movements. If assigned to the strengthening group, players will be instructed on the proper completion of 10 exercises and will be instructed to do these daily before their regular practice sessions for 6 weeks. The program takes 10-15 minutes to complete. Players will also fill out a weekly compliance log of how often they do the exercises. The same tests will be repeated after the player has finished the 6 week program and then again after 6 months.

WHERE WILL THE TESTING TAKE PLACE?

The testing will take place at the new Rush University Medical Center Sports Training Facility in Oak Brook, IL.  If you believe you or your patients might qualify for one of our clinical trials or wish to be evaluated, please contact our research administrator, Kavita Ahuja, MD at (312) 563-2214 or kavita.ahuja@rushortho.com.

WHAT ARE THE RISKS AND BENEFITS?

There is minimal risk associated with participating. Risks include injury from pitching, muscle soreness or discomfort associated with completing the hip and core strengthening program. Potential benefits include improvement in the players’ pitching mechanics and/or velocity. However, that result cannot be guaranteed.

Research Graphic

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Is Toe-Walking an Early Sign of a Health Condition?

By Brian Rog with Contributions by: Annie Kender, PT, DPT, C/NDT of the ATI Grand Blanc, Mich., Clinic

Is Toe-Walking an Early Sign of a Health Condition?

When a child learns to walk, instinctively, he or she will begin walking with their feet flat on the ground. But because this is a skill that takes much practice, it’s not uncommon for them to transition on and off their tip toes as their walking abilities develop.

Some children begin walking on their toes for stability, others walk on their toes for sensory reasons – these children sometimes have difficulty tolerating pressure through their heels or they prefer the sensations (or proprioceptive input) they received from their joints locking out. Children may also walk on their toes due to range of motion restrictions in their calf muscles (gastrocs).

As your child’s coordination and muscles develop, they will begin walking with a heel-toe pattern; on average around 18 months of age. However, should those heels remain ascended beyond age 2-3 as your child’s only means of getting around, this may be an early sign of a neurological condition (Cerebral Palsy, Spina Bifida, Tethered cord, etc.). Conversely research reports 7-24 percent of children who walk on their tip-toes are idiopathic toe walkers, meaning they do not have a correlated disgnosis such as Cerebral Palsy.

When to see a specialist

Research supports the idea that heel strike in children begins around 22 weeks following initial onset of walking independently. For the majority of children, this occurs around 18 months of age. Toe walking is not considered a normal part of this early independent gait. As we mentioned, if by age 2, your child hasn’t outgrown toe walking, this may be an indication of neurological immaturity or muscle weakness.

To that, ATI Physical Therapy experts suggest consulting with your pediatrician, because if left untreated, toe-walking can put your child at further risk for contractures, foot deformities and balance deficits. And in severe cases, your child may require surgical interventions if deformities or contractures are advanced. Fortunately, physical therapy interventions are an effective way to help your child overcome this.

Long-term effects of toe walking, if left untreated

As you can imagine, toe-walking places a great load on the muscles and tendons. Many children who consistently walk on their tip-toes since establishing independent ambulation, may develop foot deformities as early as the age of four. These children may demonstrate ankle range of motion restrictions, impaired balance and poor postural alignment.

Physical therapy for toe walking

Therapeutic treatment such as physical therapy can assist your child in achieving a heel-toe gait pattern as well as correcting any range of motion restrictions, muscle imbalances and postural deformities.  After identifying the child’s origin for toe-walking, a plan of care is established to address the child’s deficits. Treatment methods typically include stretching, strengthening of lower extremities and core, balance retraining, sensory integration techniques, serial casting, orthotic training and a home exercise program.

After completing physical therapy, what’s next?

Once your child has successfully completed their PT treatment, you will receive a home exercise program to further continue their treatment plan at home.

For children with an established heel-to-toe pattern, who no longer demonstrate weakness or range of motion restrictions, their home program is minimal. For children with neurological conditions as an underlying source of their toe-walking, they may require intermittent services over their lifetime to maintain gains, usually around growth spurts.

Is your child toe-walking? ATI may be able to help

If you are concerned about your child’s toe-walking tendencies, we first suggest connecting with your pediatrician to determine the next course of action. Should physical therapy be required, please don’t hesitate to contact your your nearest ATI physical therapy clinic to see what pediatric therapy options are available for your child.

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College Player Back in Action after Overuse Injury

By Midwest Orthopaedics at Rush

baseball player with baseball

Baseball is a huge part of life for Millikin University sophomore Ben Jacobs. And he doesn’t take his ability to play at the college level for granted.

Just a few years ago while playing in a high school summer travel league, Ben was afraid his plans for a college baseball career might be derailed. He felt a tingling sensation in his arm and pain with throwing. What he didn’t know was that he was developing a type of throwing overuse injury.

When the feeling in Ben’s arm changed from tingling to pain, he knew he had to see a specialist. Ben’s father had been a patient at Midwest Orthopaedics at Rush, so they sought help right away from that group. They were introduced to Dr. Gregory Nicholson, an expert in shoulder and elbow surgery.

Dr. Nicholson diagnosed Ben with ulnar neuritis (also known as cubital tunnel syndrome), an inflammation of the ulnar nerve, which passes behind the medial epicondyle of the elbow down through the forearm and into the hand. The ulnar nerve is more commonly thought of as the “funny bone” nerve and inflammation can cause numbness or weakness in the hand.

Because of the position of the nerve, it is stretched when the elbow is bent. Thus, with the throwing motion it can become inflamed. In some cases, a splint or brace that keeps the elbow straight can be enough to relieve the pressure on the ulnar nerve. In Ben’s case, Dr. Nicholson recommended surgery to decompress the nerve and relieve Ben’s symptoms.

“Ulnar nerve decompression and transposition (moving the nerve to the front of the bend of the elbow) is a low-risk, outpatient procedure with a relatively high success rate. If patients are diligent with their physical therapy and follow the course of treatment, most regain full function,” Dr. Nicholson explains.

Ben and his family agreed to the surgery and he completed it while still in high school. During the procedure, Dr. Nicholson made an incision along the inside of Ben’s elbow. Once the nerve was fully explored, decompressed and moved slightly, Ben’s connective tissue and skin were closed with small stitches.

The surgery was successful and Ben soared through his physical therapy. Now, a few years post-surgery, Ben says he “feels 100 percent,” and has had no pain recurrence.

However, in order to avoid another overuse injury, he has changed positions from pitcher to catcher.

“To err on the side of caution, I decided to primarily play catcher. That way, I’m not putting too much strain on my arm, but can still be involved in every pitch.”

To commemorate his positive outcome, Ben had a “smile” face tattooed over his surgery scar as a reminder to persevere and stay positive.


“At first my arm felt a bit strange after surgery and it took me awhile to adjust. But now I’m lifting weights and throwing with no problem and I feel stronger than ever.”


To schedule an appointment with Dr. Nicholson to discuss your shoulder or elbow pain or condition, call 877-MD-BONES.

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