With spring finally here, amateurs and professionals alike have returned to the baseball diamond. More than 40 million Americans participate in baseball and softball each year. According to the American Academy of Orthopedic Surgeons (AAOS), there are over 500,000 injuries per year related to baseball.
American children begin playing organized baseball at 5 or 6 and some people continue to play the sport past the age of 60 whether games are competitive or during a family picnic. As a result of this, different injury patterns present themselves. Most of us who have played can relate to some type of degree of injury associated with our baseball experience. Most of the injuries occur when sliding into the base, rounding the bases or colliding with another player or with the outfield fence. There are also a fair share of stress or overuse injuries, as well as injuries that occur from being hit by the ball.
Unfortunately, there is very little in the literature regarding baseball injuries at the present time. There are only a few selected general articles on baseball. The literature that does exist is typically all about pitchers’ shoulders and elbows as well as treatments associated with the Tommy John surgery. There are only a few citations on college baseball and softball.
Podiatrists who have a strong emphasis on sports medicine strive to make the game as safe as possible for players and protect athletes from further injury recurrence. There are four keys to injury management and these keys include: complete evaluation;
early recognition and treatment; caring for a definitive injury; and the timing of the return to play.
In preseason or spring training at any level, one needs to evaluate the players in order to assess their weaknesses, special injury risks and individual needs. At all levels, it is important to teach players body wellness and fitness. There is a distinct level of injuries that occur at different levels of play that include Little League and Babe Ruth leagues and the professional Minor Leagues and Major Leagues.
Inside Insights On Shoes And Playing Surfaces
At all levels, players should utilize running sneakers for fitness. Additional items in the player’s bag should include flat gum sole shoes for artificial surfaces, molded rubber spikes or metal cleats. Depending on the playing surface and weather conditions, players should select shoes for the majority of play. The proper selection of shoes is critical and is involved in the treatment and prevention of growth plate injuries.
Shoe selection is of great concern with all injuries. This can be a tricky issue at the Little League levels as a team may be sponsored by a local sports store or a particular parent may have a contact providing shoes and textiles for the team. (Also see “Pertinent Preventive Considerations With Adolescent Ballplayers” on page 60.) An injury may be tied to the actual shoe design or cleat placement.
The podiatrists should evaluate the shoes, including the flex point and those shoes with a very stiff plate in the arch. This has presented a unique set of circumstances with metatarsalgia, plantar fasciitis and Achilles tendonitis being secondary to inherently poor shoe design.
In regard to playing surfaces, more and more schools and leagues are going to an artificial turf or multipurpose surface type. It is not so much the “thickness of the carpet” and blade height but one has to be especially cognizant of the importance of the under surface or basement membrane that is present beneath the actual playing surface.
Depending on this type of membrane, it is very reasonable that athletes can use metal cleats without posing any extra issues with ground surface contact. If the basement membrane is too hard, then athletes may use a different type of shoe, including a flat or turf type shoe with multiple small cleats.
Pointers For Managing Common Injuries
Achilles tendonitis and bursitis with fasciitis and apophysitis occur among children as well as Major League Baseball (MLB) players. This may be related to using shoe gear, including spikes and cleats, for multiple seasons or getting hand-me-downs from another family member. It is always better for the children in early Little Leagues to use a shoe with a small heel as this helps prevent many of the aforementioned problems.
Forefoot injuries occur commonly at all levels. Indeed, baseball players often have digital deformities prior to breaking into the major leagues. Hallux limitus, hallux valgus and hammertoes with second metatarsophalangeal joint (MPJ) capsulitis are quite common. These injuries are again due to the playing surface, prolonged season, genetic predisposition to injury, shoe gear and the nature of the game. One can address many of the forefoot problems, including the aforementioned growth plate problems, with custom orthotics (see “Pertinent Preventive Considerations With Adolescent Ballplayers” on page 60).
When prescribing the orthotic device, it is important to send the player’s shoes to the lab. The lab can provide a direct evaluation of the shoe, matching up the specific type of orthotic with the specific individual biomechanical needs of the injured player. Typically, orthotic labs use polypropylene, subortholene and graphite material orthotics for basic plate design.
A variety of top covers can cushion and control hyperhidrosis. Sometimes one can use a medial flange based on the position of the player. Pitchers sometimes require a small piece of material in the area of the first MPJ that protects the first MPJ/ big toe when they go to push off and follow through when delivering the ball to home plate.
When it comes to Babe Ruth leagues, American Legion players and/or university/college baseball, podiatrists may have to contend with previous injuries sustained at an earlier level. Typically, we are all familiar with tendonitis, plantar fasciitis, shin splints and iliotibial band syndrome. Podiatrists should provide appropriate treatment based on the acute or chronic nature of these injuries.
Assessing Other Conservative Modalities
In our office, we have instituted a variety of new treatments, which include a variety of topicals and patches that have been present for many years in Europe and have recently emerged in the United States.
Players can use the new Flector Patch (Alphapharm) applied 12 hours at a time, especially on tendons. One may cut this patch to specifically address localized pain in a tendon, soft tissue or joint.
Homeopathic medications may include topical or oral Arnica or Traumeel (Heel, Inc.). Patients have often used Biofreeze (Hygenic Performance Health) topically with or without the use of ultrasound in the rehabiltation phase. Patients can use topical diclofenac sodium 3% (Solaraze Gel, Doak Dermatologics) b.i.d. or t.i.d. on affected areas of soft tissues and joints.
All of these treatments have provided success in addition to other modalities, which include prednisone, Medrol Dosepak and other typical oral anti-inflammatory agents. Podiatrists may also consider the use of local compounding pharmacies for topical anti-inflammatories.
Typically, one can treat a contusion, fasciitis and other common injuries with a Cam walker or a Royce Equalizer boot. Players can use these devices off the field and continue to play.
When Should Players Return To The Field?
In regard to the return to the playing field, this is always an extremely difficult issue.
One of our treatment goals is to keep athletes out of our office. With this in mind, one must ensure that athletes are: using proper equipment; setting reasonable training goals for sports and rehabilitating from injuries from that sport; and allowing enough time for training. If athletes adhere to these principles, they can significantly decrease the frequency of recurrence of their injuries. The biggest reason for recurrence is failure to completely rehabilitate from the first injury.
It is our experience that most baseball injuries typically take athletes out of competitive play for less than three weeks. Our office typically facilitates activity modification without complete stoppage of play, even if the patient has had some form of surgery or cast immobilization to treat an injury. It is rare to stop a patient from working out completely but the podiatrist will modify the exercises to work around the injury.
Although athletes at all levels have undergone surgery for acute injuries, elective surgeries are most common and players usually have these surgeries when it is best for all parties involved including the team, agents, coaches and the practicing physician. These elective surgeries are usually scheduled for the off-season.
Keys To Developing A Conditioning Program For Athletes
Modern athletes face many challenges as they reach for success and these challenges have become more severe as time has passed. Modern athletes face a longer competitive season, more demanding travel schedules and a deeper pool of talent against whom they must compete.
An extremely important step in overcoming these challenges is developing and executing a comprehensive conditioning program. Athletes have been engaged in “sports specific” training for years, many with limited success. However, with the extraordinary amount of information available and a growing number of highly qualified exercise professionals and strength coaches able to apply this information, every athlete is now able to reach the edge of his or her performance capabilities.
The outcomes of a conditioning program should be twofold: injury prevention and increased performance capability. A sound training program may be able to execute both objectives. In regard to developing effective conditioning programs, there are several important tenets.
• The program must be developed based on the individual characteristics of the athlete.
• The program must be progressive in nature.
• The program must account for all components of the kinetic chain.
The first step in developing the program is screening the athlete’s movement patterns. Research has shown that many injuries occur as a result of poor movement patterns. If the strength coach can identify and correct poor movement patterns, the athlete has a better chance of staying injury-free.
The Functional Movement Screen is a great tool for screening the athlete. Components of the Functional Movement Screen include the overhead deep squat, the in-line lunge and the hurdle step. Based on the results of the movement screens, the strength coach can develop a program based on the individual needs of the athlete. Here are some key questions to consider.
• Should the athlete be training for mobility or stability?
• Does the athlete have significant muscular imbalances?
• Should the athlete build a functional foundation or should he or she be developing a sport-specific skill?
Many athletes do not possess a functional foundation. A functional foundation is defined as having the appropriate balance of stability, mobility, strength and flexibility needed to execute the demands of a sport. Many athletes grow up doing a large amount of skill-specific training at the expense of movement pattern training such as squatting/lunging, pulling/pushing, rotation and single leg standing.
As a result, the demands of the game far exceed the performance capabilities of the athlete. In that environment, injuries are likely to occur. For example, baseball is a game of rotation. If the athlete’s hips do not have appropriate mobility, the knees, ankles and feet are forced to work harder and, in the case of the knees and feet, work differently than designed because that rotation must occur to meet the demands of the sport. Ultimately, keeping players healthy and at peak performance capability is a matter of training the joints for their intended uses as well as conditioning their bodies to the specific demands of the sport.
Eight Exercises That May Improve Conditioning For Ballplayers
Each athlete has his or her own movement profile and the strength coach should prescribe a conditioning program to address that profile. The following list of exercises is not meant to be a cookie-cutter workout. This is simply a sampling of drills we have used with great success to improve the performance capabilities of our athletes.
The bridge. The athlete lies on the floor with bent knees, squeezes the gluteals and pushes the hips up until there is a straight line through the knee and hip to the upper body. This exercise can fire up the gluteus maximus. We find many athletes with poor movement patterns and/or injury histories in the lower extremities are unable to use their glutes. The key is to fire up the glutes before lifting the hips. Repeat 10 times.
The plank. The athlete holds a straight body position, supported on elbows and toes, while bracing the abs and setting the low back in the neutral position. This exercise enhances pelvic stability. Again, we see a correlation between an unstable pelvis and injuries in the lower extremity. The most important element is to maintain “stiffness” between the knees and torso. Execute for one minute.
The side plank. The athlete lies on one side and then pushes up until there is a straight line through the feet, hips and head. This exercise can also enhance pelvic stability. The key is appropriate progression. Start on the knees and then work on the feet. Execute for one minute.
Standing pelvic tilts. This exercise is designed to restore mobility to the hips and to stimulate the core musculature. The keys are maintaining weight through the whole of the feet and keeping a neutral cervical spine. Execute 10 repetitions.
Kneeling hip flexors stretch. This exercise is designed to restore mobility in the hip flexors and stimulate the core musculature. The keys are to keep weight through the forward foot with minimal forward knee movement and the elbows extended. Execute 10 repetitions in each direction.
Standing gastroc/soleus stretch. While not necessary, we encourage the use of the Tri-Stretch device or a calf board. This exercise is prescribed to restore mobility to the ankle joint and stability to the knee joint. With the knee extended, the athlete should hold a static stretch for 15 seconds and then perform a lateral rocking motion with the ankle. Athletes should do 10 repetitions and then repeat with a bent knee.
Runner’s stretch. This exercise is designed to fire the lumbo-pelvic hip complex while putting a dynamic stretch on the hamstring group. Place the athlete in an offset position (one knee directly behind the forward foot) and then strengthen the forward leg. Have the athlete hold a static stretch for three seconds and return to the ground. Repeat 10 times. Repeat on the opposite leg.
Standing hip rotation. Prescribe this exercise to restore mobility (internal/external rotation) to the hips and stability to the knee. Place the athlete in a unilateral standing position and then rotate the posting hip through a complete range of motion. Keep a solid postural position and discourage lateral movement of the knee. Execute 15 repetitions in each hip.
As a sports medicine practitioner, you have to be flexible with time as being involved with sports teams at all levels often involves time spent after typical office hours. One also must be ready to deal with the politics of coaches and parents as the politics sometimes takes away from the overall treatment course.
Further, you must be a team player as there are a variety of specialists whom you will work with on a daily basis. Most commonly, an orthopedic surgeon is the point person who oversees the athlete’s overall treatment.
In our experience, baseball is a relatively safe sport at all levels although severe injuries can occur. When physicians and clinicians emphasize preventive measures such as appropriate footwear and conditioning, and aid baseball players in ensuring a smooth as possible rehabilitation from any injuries, they play instrumental roles within the healthcare team charged with keeping the baseball team on the field.