Blog Article: Concussion in Sports

Concussions in Sports


Concussion has been a hot topic over the past few years. More so than ever with the big outcry over the NFL and player concussions, and now with the new Concussion movie starring Will Smith coming out this week. The awareness of the seriousness and possible implications of this injury are much more known to the general public.  While the public has a better understanding of what a concussion is and what some of the symptoms are, I feel the majority do not have a grasp on the complexity of this injury.

You can see your favorite NFL star get knocked out on a Sunday and be able to play next week’s game. While this is the case most of the time (80-90% recover within 7 days), there is a smaller percentage where this injury can be completely debilitating for weeks, months or even years. I currently work with individuals who are dealing with “post-concussion” symptoms anywhere from 2 weeks to 3 years after their injury.

What is a concussion?

According to the American Association of Neurological Surgeons the definition is “a clinical syndrome characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma.”

In many cases, concussions result in a coup and contrecoup force in which the brain forcibly contacts one portion of the skull, rebounds and contacts another area of the skull.  This leads to diffuse axonal injury in which the structures that transmit messages to and from the brain are stretched and twisted. This results in an immediate chemical inflammatory response due to the trauma. Many believe that this mechanism of injury is what leads to the initial “dazed and confused” appearance. Injuries to axons can take an extremely long time to heal and in some cases can result in permanent damage.



Many people relate concussions with a loss of consciousness. While it can be pretty much guaranteed that you have a concussion if  you lose consciousness after a blow to the head;  you can also have a concussion without losing consciousness.

Concussions are considered a “functional injury” in that many times there are no clear-cut medical indicators. A MRI or CT scan will not diagnose concussion. MRI’s are used to rule out a more serious injury such as intracranial bleeding. Diagnoses are usually made on symptom presentation.


As stated earlier, a smaller percentage of individuals who get a concussion struggle with symptoms for months or years afterwards. From working with many people that are dealing with chronic symptoms, I tend to see that the following are the most common and significant symptoms:

Headache, Dizziness, Neck Pain, Fatigue, Anxiety and Depression

The psychosocial symptoms seem to spur from post traumatic stress, mental stress and mental fatigue from dealing with prolonged headaches, dizziness, physical fatigue and lack of sleep for months. Many times people end up being taken out of their work or even losing their job because of the inability to perform their work duties. This significantly increases psychological stress and tends to exacerbate all of their physical symptoms.


From my personal clinical experience, the individuals who tend to have more prolonged symptoms are those who have multiple concussions. Research has shown that receiving multiple concussions tend to cause more severe symptom presentation in the successive events. One of the big issues being discovered is Chronic Traumatic Encephalopathy (CTE) as a result of repeated sub-concussive blows to the head. CTE has been found on the autopsies in some of the high-profile NFL players such as Junior Seau.  CTE has been linked to memory loss, mood swings such as rage, depression and other severe psychological disorders.


Physical symptoms that I have seen and worked on are headache caused from either mechanical of muscular neck trauma, dizziness due to visual and/or vestibular (inner ear) deficits, poor balance due to vestibular or multi-system deficits.

Current research is finding that one of the primary acute symptoms that may lead to prolonged recovery time is dizziness at time of injury or shortly thereafter.  Dizziness is being considered as a possible greater risk factor over loss of consciousness, headache and seizures. This is likely due to the fact that dizziness in many cases is an indicator of vestibular system dysfunction. The vestibular system plays an important role in oculo-motor (quality of eye movement) function and postural stability (balance). Deficits in oculo-motor function tend require a longer process of rehabilitation, in some cases require evaluation by a neuro-ophthalmologist and even vision therapy.

It is extremely important to recognize a concussion when it occurs on the field of play to avoid a phenomenon called Second Impact Syndrome (SIS). SIS is when an individual receives a second concussion before recovering from their initial injury. This results in diffuse swelling of the brain and can cause death. SIS resulting in death has been seen in football players who, for whatever reason, have been allowed to continue playing in the same game where they receive an initial head injury.



Again, most concussions resolve within 7-10 days, the ones that don’t can require treatment. Physical therapy can be effective in reducing the “post-concussion” symptoms. Sessions are based on the individual’s symptom presentation but usually involve neck soft tissue mobilization, neck mobilization and stabilization exercises. Balance or proprioception training is commonly worked on.

Vestibular based interventions are effective at reducing dizziness. These include adaptation and habituation exercises in which the individual repeatedly performs eye and/or head movements that reproduce symptoms. Repetition of these tasks strengthen the connection between the inner ear and the brain, and ultimately can significantly reduce or abolish dizziness.





Lastly, Vision assessment and treatment is very important. Convergence insufficiency is a common deficit found after head injury and can cause dizziness and headaches due to one or both eyes not moving correctly. Popular exercises for this deficit include thumb pushups and “String and bead” exercises.



Once the individual is at the point where symptoms are significantly reduced or abolished, then they start the return to play protocol. The return to play protocol consists of gradual increases in physical exertion tasks with at least 24 hours rest in-between each task. If the athlete can pass through each phase without reproduction of symptoms, then they likely can safely return to playing sports.


Baseline Testing

Baseline concussion testing is becoming more and more popular. This consists of a preseason screen of the athlete’s cognitive performance and balance. Some baseline testing can be very in-depth and include fancy equipment such as force plates to measure balance. However, research is finding that this is not necessary and that you can get good objective results testing an athlete on a Wii balance board or even just a piece of foam padding.  A standardized, acute post-concussion tool that is used on the sidelines has also been found to be effective to use as a baseline testing tool.  This is the Sport Concussion Assessment Tool-3 (SCAT-3). We created our baseline testing off of this standardized tool. Baseline testing is a quick and easy way to gather an athlete’s “normal” functioning and the results can be used to compare re-test scores in the unfortunate event that the athlete was to receive a concussion.


Baseline test comparisons are just one tool that should be used in the return to play decision making and should not be the sole factor in deciding whether an athlete returns to the field or not. It is recommended that any athlete who plays a sport with any risk of head injury receive baseline tests on a yearly basis to have the most accurate data.

SPI Fitness is comprised of two physical therapists with years of experience assessing and treating athletes with concussions. Ryan Monaco DPT, ATC has been one of the area’s leaders in raising concussion awareness along with the importance of baseline testing. He also has experience working with athletes from the sideline as an athletic trainer to the clinic as a physical therapist. Michael Jarmak DPT, CSCS has worked with athletes with concussions for the past 3 years. He currently works as a physical therapist at Syracuse’s CNY Sports Concussion Center, considered by many as the area’s top concussion management program. He has experience working with individuals anywhere from 2 weeks to 3 years post-concussion. Both Ryan and Michael are certified Vestibular Rehabilitation Therapists.

If you would like to learn more on about concussions, have baseline testing performed on your child or your team please contact us at or call 315-527-8383.

Blog article: The Shoulder and Elbow in the Overhead Athlete Part II: Common Shoulder and Elbow Injuries and How To Avoid Them

The Shoulder and Elbow in the Overhead Athlete

Part II: Common Shoulder and Elbow Injuries and How To Avoid Them

In part 1, the biomechanics of each phase of the baseball pitch were reviewed along with forces placed on the shoulder and elbow. It is clear that throwing a baseball is an extremely aggressive and violent act in which extreme forces and ranges of motion are placed on the shoulder and elbow. In part 2 I will review the characteristics of a pitcher, common injuries in these athletes and how you can avoid them.

Physical Characteristics of a pitcher’s dominant arm vs non-dominant arm:

Range of motion disparity

  • dominant shoulder has excessive external rotation and limited internal rotation



  • excessive glenohumeral capsule laxity, which is an acquired laxity from repetitive strain


Osseous adaptations

  • Increase shoulder retroversion (rotated backwards)



  • weak external rotators, strong internal rotators
  • strong scapular protractors and elevators



  • scapula protracted, anteriorly rotated at rest
  • increased scapular upward rotation during abduction of the shoulder


Glenohumeral Internal Rotation Deficit (GIRD)



This develops throughout a season or over years of repeated throwing and is characterized by a significant loss of internal rotation of the shoulder. Many pitchers have a natural loss of internal rotation which is usually off-set by an increase in external rotation range of motion. GIRD becomes an issue when there is a larger loss of internal rotation than there is a gain in external rotation. If not addressed, this puts the athlete at increased risk of developing some of the shoulder injuries that will be discussed below. Also, most pitchers maintain a very similar total range of motion in the dominant and non-dominant shoulders but at times an uncompensated GIRD can lead to differences of 10-15 degrees or more.

As discussed in the previous article, most injuries occur during the late cocking, acceleration and the deceleration phases of the pitch.  To get a better understanding of why these injuries occur during specific phases, review part I to get an idea of the stresses at the shoulder and elbow during each phase.


Late Cocking Phase Injuries

Anterior Glenohumeral Instability. This is an umbrella diagnosis that can include the following:


SLAP Lesions:  Injury to the upper labrum of the shoulder. There are 4 common types. Types II and IV involve the origin of the long head of the biceps. When the biceps anchor is involved there tends to be an increase in shoulder instability. Type II is most commonly seen in the overhead athlete in which the “peel back” forces on the biceps tear the labrum and the biceps anchor.




Bankart Lesion: Injury to the anterior-inferior (front-bottom) part of the labrum. The head of the humerus will translate forward in the shoulder socket due to this injury.



Biceps Long Head Instability: When the shoulder is in the cocked position (90 degrees of abduction and external rotation) the long head of the biceps is placed anteriorly to the head of the humerus. With repetition of this movement and if the athlete has GIRD or a labrum lesion, the biceps tendon takes one excessive strain due to anterior movement of the humeral head. This leads to further instability. It can initially present as tendonitis and develop into tears, ruptures.




Internal Impingement, Subacromial Impingement: Anterior instability leads to compression of the posterior and/or superior rotator cuff tendons. It can also include compression of the superior labrum.




Acceleration Phase Injuries

UCL Injury: Sprain or tear of the ulnar collateral ligament of the elbow due to violent extension, valgus force, pronation and a traction force on the elbow. Athletes usually feel a pop followed by immediate intense pain.




Valgus Extension Overload:  This injury is exclusive to overhead athletes and is caused by repeated forceful hyperextension and valgus stress of the elbow. There is compression of the lateral part and distraction of the medial elbow. This injury is characterized by soft tissue swelling, development of osteophytes (bony overgrowth) in the elbow and at times fractures of the elbow can occur.




Little League Elbow:  This is characterized by the same forces on the elbow seen in valgus extension overload but occurs in preadolescents. It can lead to changes in the growth of the medial epicondyle of the humerus, tears of the wrist flexor tendons or even stress fractures of the humerus growth plates.




Deceleration Phase Injuries: These include all of the acceleration phase injuries along with rotator cuff tendonitis and tears.


So now you know all of the bad things that can happen to your shoulder or elbow with repeated pitching. Did it make you want to do everything that you can to prevent these from happening?…. I hope so.

I am going to go over some things that I do with my patients in therapy, along with our clients at SPI to help decrease their risk of developing one of these shoulder or elbow injuries.


Posterior Shoulder Mobility

As described above, anterior instability leads to many shoulder injuries. That’s why it is extremely important to maintain good mobility and soft tissue quality of the posterior shoulder to prevent excessive anterior movement of the humeral head.


Modified Sleeper Stretch

This works on improving internal rotation and stretching the posterior cuff muscles. The traditional sleeper stretch involves the body and arm being at a 90 degree angle, this however reinforces the compression of the tendons in the shoulder. The modified stretch has the body rotated back at 20-30 degrees to avoid this.


Modified Cross Body Stretch: The athlete stabilizes the scapula on their side and restricts external rotation at the elbow.


Posterior Cuff Mobilization: Using a lacrosse ball the athlete mobilizes the posterior rotator cuff. They can perform circles using their trunk to move while maintaining pressure, they can also perform active shoulder movements.



Thrower’s Ten / Advanced Thrower’s Ten: We utilize these shoulder strengthening programs developed by Kevin Wilk; a sports physical therapist who works with Dr. James Andrews and many MLB players to develop shoulder strength, stability and prevent injury. These exercises strengthen the shoulder while challenging the core by performing most on a stability ball.

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These are just a few examples of what we do. There’s a lot of ways we work on the shoulder and elbow using techniques proven through sports medicine research. I can’t give away all of the goods. I can give you an idea of what else we work on….. CORE AND POSTERIOR CHAIN.

Some tips for decreasing injury risk while training:

1. don’t do overhead presses – they reinforce the shoulder impingement mechanism

2. limit back squats – or if you do back squats, use a safety bar to prevent anterior shoulder strain. I prefer front squats or hip thrusts.

3. limit bench pressing – it “locks down” your shoulder blades. Do pushups instead, there’s a ton of ways to progress pushups to make them more challenging.


What else can you do to help prevent injury?….. don’t throw year round. Nowadays we see athletes playing in leagues for almost the entire year!  This continues to be the number one risk factor for developing injuries.

If you would like to learn more on how you can prevent shoulder and elbow injuries, properly strengthen and stabilize your shoulders and train like the pros then contact

Blog Post – Has Human Performance Passed Human Evolution?

Has Human Performance Passed Human Evolution?


This past weekend I had the opportunity to work along side an Orthopedic Surgeon who specializes in Sports Medicine with more years of experience than he would like me to mention in this blog post. I always look forward to these times as he is a great teacher and I get 3+ hours to pick his brain.

One topic that we spoke of was the rise in shoulder and elbow injuries for baseball players, specifically pitchers. I told him my hypothesis (and not mine alone) that the increase in the velocity of the fast-ball over the past decade and the rise in injuries is a correlation that cannot be ignored. Even with the advancement in injury prevention and pitch count etc. we usually will not see a significant change until the younger generations become of age to sustain a possible injury.

With the emergence of concussions being a significant problem in the media and the rise in shoulder and elbow injuries for major league baseball, one injury that has taken a back seat in recent years are ACL tears.

ACL tears have become a common theme in athletics and specifically female athletics. Female athletes have a 4-6x greater chance of tearing an ACL then their male counterparts and about 1 in 20 female collegiate athletes will undergo an ACL injury.

So why is there not a huge out-cry to stop female athletics like there is to institute pitch count rules or remove hitting in football? Surely these numbers are indicative of an epidemic. One thing is that we have gotten really good at fixing ACL’s and they are not career ending like they were 20 years ago.

fig-3What do we know?

  1. We know that like the ulnar collateral ligament of the elbow there has been a rise in ACL injuries over the past ten years.
  2. We have many theories as to why there is an increase in ACL injury in the male and female athlete but not one thing is certain.
  3. 70% of ACL injuries are non-contact.

Lets take a look at that last statistic. 70% of the injuries are non-contact. Doesn’t that seem a little funny? 30% of the injuries are relatively unpreventable with contact sports being the way they are but 70% come from performing normal athletic activities such as running, cutting and jumping.


So this leads us to the title of this article: Has Human Performance Passed Human Evolution. If a possible reason for the increase in UCL injuries of the elbow is due to the increase in velocity of throwing, is it reasonable to assume that in sports such as football, basketball and soccer where the athletes are getting bigger, faster and stronger has our muscular strength increased so much that our ligaments cannot withstand the stress put on them with athletic activity? And I’m not speaking of a muscular imbalance here. I have some highly skilled and significantly strong athletes who still manage to tear their ACL.

Where do we go from here? Fortunately there is a significant amount of research out there on what works and what doesn’t as far as ACL injury prevention. Our goal at SPI is to implement these specific exercises and training techniques into our programming for our male and female athletes. To find out more information about our ACL injury prevention programs contact us at for us to speak to your organization and show you how to implement these exercises to reduce risk of injury.

Blog Article – The Shoulder and Elbow in the Overhead Athlete: Part I

The Shoulder and Elbow in the Overhead Athlete

Part I: Basic Anatomy and Biomechanics of Throwing

The world series might be coming to an end but now is the time where high school and college baseball players can make big impacts on their upcoming season. Doing the right things now for your shoulder, arm and body can help make or break your season. As they say, “championships are won in the off-season”. But that is something I will talk about in my next post “Part II: Common shoulder and elbow injuries and how to avoid them”.

In part 1, I want to talk about the biomechanics of the throwing motion, most specifically in the pitcher. Throwing a baseball has been described as “one of the most violent maneuvers to which any joint in the body is subjected”. Throwing a baseball requires flexibility, muscular strength, coordination, synchronicity and neuromuscular control.

Here’s examples of the incredible stress and forces that are placed on your shoulder and elbow while pitching.

Angular velocity:                  Forces:
Shoulder – up to 7250º/s              Shoulder – 1/2 to 1-1/2 body weight
Elbow – up to 2300º/s                   Elbow – 300 N to 900 N


Before we go into the biomechanics of throwing let’s briefly review the shoulder or as us fancy medical people call it, the glenohumeral joint:



The shoulder is the most mobile joint in the body and therefore is inherently unstable. It has static and active stabilizers. Static Stabilizers – ligaments, labrum, capsule. Active stabilizers – rotator cuff, large muscles (deltoid, serratus anterior, biceps, pectorals).



UnknownStabilizers throughout the pitching cycle:

Mid range – rotator cuff

End range – large muscles, ligaments and capsule

Extreme ranges – ligaments, capsule




The elbow:

Made upd1d21e74605b7e0a2e2c9e26e0cce941 of bony, ligamentous and muscular stabilizers. The most famous ligament stabilizer is the ulnar collateral ligament or the UCL. This is the ligament that we are seeing more injuries in, resulting in Tommy John surgery. Some muscular stabilizers are the triceps and wrist flexors.

The UCL31216tn



Phases of Throwing a Baseball:




        Windup and Early Cocking:img_1247

  •    Ball leaves glove, arm moves into abduction/external rotation
  • Pre-loading for stretch-shortening cycle of shoulder internal rotators
  • Leg drive, trail leg loading, trunk rotation



Late Cocking Phase:wagner-300x199

  • Maximal external rotation, abduction
  • Initial trail leg hip extension
  • Extreme forces at shoulder
  • Minimal forces at elbow
  • Onset of large shoulder muscle activation
  • High rotator cuff activation attempting to stabilize the shoulder


Acceleration Phase:


  • Explosive forward motionimages
  • 0 – up to 100 mph in 0.03 seconds
  • Loading of lead leg
  • Abrupt, vigorous extension and pronation at elbow
  • High activation of rotator cuff and all scapular muscles
  • High activity of pectorals and lats for ball velocity
  • High forces at elbow
  • Low forces at shoulder



Deceleration Phase:

  • Release off ball, forward motion ceasespitching-arm-strength-drills-01
  • Most violent phase
  • High injury risk
  • Highest forces at shoulder, up to 1000N
  • High forces at elbow up to 900N
  • Very high muscle activity



As you now can see, throwing a baseball is a very aggressive action that can put you at high risk of injury if you don’t do the right things to care for your shoulder and body as a whole. In my next post I will cover some characteristics of the baseball pitcher, common injuries and how we help our athletes decrease their risk of injury during the season (hint: it’s not stretching your already hyper-mobile shoulder).

If you want to learn more about the shoulder, elbow, how to make them stronger and decrease your risk of injury email

Blog Article – Hip Pain in the Athlete

Hip Pain In The Athlete 

Football player most stressed joints

As a physical therapist and sports performance trainer I get to work with a good deal of athletes. One common issue that I have been coming across lately is hip pain.

Hip pain can have many different causes but most commonly there’s soft tissue (muscle, tendon, cartilage) involvement.  Lately I am seeing a major contributor to these patients and clients coming in the door with hip pain, and that is muscle imbalances. 

Too many athletes these days are “living in an anterior pelvic tilt”. I am seeing this issue in so many of my athletes. Anterior pelvic tilt can cause pain in the front, back or in both areas of the hip. Anterior pelvic tilt is caused by tight hip flexors and lower back along with weak abdominals and glutes. This presentation is called pelvic or lower crossed syndrome.


Anterior pelvic tilt puts the athlete at increased risk for common sports injuries such as groin strains, hip flexor tendonitis, hip impingement. It can also lead to issues above and below the hip such as low back pain, IT band syndrome and increase risk for knee injuries.

I always stress to all of my athletes that they need to have a strong core and posterior chain to become elite. This will help even out these “imbalances”. I work on these areas in every single session. I used to find it shocking that many of my athletes (even college level) can’t do a proper plank, squat or lunge without some sort of deviation. I now know to look for these deficits right away and to work on correcting before it becomes a big issue.

Here are some examples of what we have our clients do:


Glute-Bridge  Screen Shot 2015-10-18 at 11.29.12 AM


one of the best ways to strengthen your glutes and hamstrings, they have been found to activate your gluteus maximus more than traditional back squats


TRX Deep Squat Lat Stretch


Screen Shot 2015-10-18 at 11.31.30 AM



great way to work on hip mobility while stretching out the back, adding in     diaphragmatic breathing in the squat position will also engage your core





Half Kneeling Hip Flexor Stretch 


Screen Shot 2015-10-18 at 11.36.43 AM


an effective way of lengthening the hip flexors, make sure not too “over-stretch” or the muscle will increase in tone due to excessive strain.  Tighten up your glutes on the down leg and you’ll really feel it. As shown in the picture, adding an overhead kettle bell press hold will also engage the core and shoulder stabilizers



Dead Bug with Band Pull Down


Screen Shot 2015-10-18 at 11.45.02 AM

A great progression of the traditional dead bug exercise, really works the lower abdominals and adding in the band pull activates your lats and shoulders, key is maintaining the low back flat against the ground while kicking out, it’s harder than it looks


email if you are having sports related hip pain or if you think these exercises look cool and want to become a bad-ass athlete.