Dr. David Sohn - Sports Medicine
In this episode of Prescribed Listening from The University of Toledo Medical Center, Chief of the Shoulder and Sports Medicine Division, Dr. David Sohn emphasizes the importance of stretching in preventing and treating pain.
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Transcript
Voiceover:
Welcome to Prescribed Listening from the University Of Toledo Medical Center. Today's
guest is Dr. David Sohn, chief of the shoulder and sports medicine division at UTMC
and head orthopedic physician for the University Of Toledo Football Team. For athletes
of all kinds, he emphasizes the importance of stretching in preventing and treating
pain.
Dr. David Sohn:
My name is David Sohn. I am a professor of orthopedic surgery and the chief of the
shoulder and sports medicine division here at the University Of Toledo Medical Center.
I have been a sports medicine physician for the past 12 years. I am a former athlete.
I really enjoy athletics and athletic competition. And so, the area of sports medicine,
which is basically trying to keep people in the game has always been very appealing
and interesting to me.
Dr. David Sohn:
One interesting thing about sports medicine is relative to other orthopedic disciplines,
we have relatively a lower percentage of surgeries that we see. Probably only about
one in five people who come and see me actually ended up needing to have a surgical
condition. So, one thing I have learned is that an aspect of physical fitness that
most people tend to neglect is that of stretching and flexibility.
Dr. David Sohn:
When we think of physical fitness... I encourage people to think of physical fitness
as a tripod. Three different legs. Everyone knows about strength and they will do
strength training. Everybody knows about cardiovascular, so they'll do things to improve
their cardiovascular fitness. But one thing almost everybody forgets is flexibility.
I would say that the greatest bang for the buck that people can do for their physical
fitness, at least in terms of avoiding pain, avoiding musculoskeletal pain, is stretching.
There are numerous conditions where people will come and see me and they'll have pain.
All I really need to do is encourage them to do the proper stretching and it will
get rid of it.
Dr. David Sohn:
Some examples: patellofemoral pain. Patellofemoral pain means that you have pain around
the knee cap, which is also called the patella. This is a joint that will see in certain
activities up to three times our body weight. So it's a joint that really can load
a lot, particularly with thigh-based strengthening. People who are doing a lot of
kicking, people who are doing a lot of jumping, people who are doing a lot of sprinting
or stair climbing. These things all use your quads and will overload your kneecap,
your patella, and they will have corresponding anterior knee pain. They'll have this
pain even if they're joints [inaudible] as perfect. You get an MRI and it's a perfect
looking knee.
Dr. David Sohn:
This person does not need any injections. They certainly don't need any kind of surgery.
What they need is to offload the kneecap. Almost invariable, people here will have
tightness at their hamstrings because the hamstrings are an antagonistic muscle to
the quadriceps. The hamstrings: when they pull, the knee bends. When the quadriceps
pull, the knee straightens. So they're kind of counterproductive.
Dr. David Sohn:
Someone who has tight hamstrings. The hamstrings are constantly pulling the knee into
flexion. To counter that, the quadriceps have to add even more force in order to get
it to straight. Now, you take an athlete who is doing a lot of quadriceps-based exercises.
They're already doing a lot of jumping or kicking or sprinting. If their hamstrings
are tight, their quadriceps have to account for that extra 15% or so of tightness.
They're going to develop pain and inflammation around their kneecap. You take that
same person and if you encourage them to make daily hamstring stretching apart of
their life, now they can do their activity without incurring that extra pain and they
can get back to what they love - without injections or without surgeries or anything.
Dr. David Sohn:
Another example is your iliotibial band. There's a condition called runner's knee,
where if you have a tight iliotibial band, that band actually rubs against the outside
of the knee - a bone called the lateral epicondyle. People who are running a lot,
it's actually just like two sticks rubbing against each other, making friction and
making a fire. Just rubbing, rubbing, rubbing, rubbing, rubbing, and it will cause
inflammation.
Dr. David Sohn:
The same person that... They love running though. So what should they do? Stretch
your IT band. If you stretch that IT band, now you don't have as much friction. Now
you can do what you love. You can run and you don't need surgery. An injection might
be necessary to calm down some of the inflammation, but the basic thing that you really,
really, really need to do is stretch that IT band.
Dr. David Sohn:
In the shoulder... The shoulder, there's a condition called impingement. What impingement
is, is where two bones in the shoulder pinch against each other when you raise your
arm. These two bones are the acromion and the greater tuberosity. When you raise your
arm or do reaching, these bones tend to move closer to each other. The unfortunate
thing though, is the rotator cuff lives in between these two bones and so does the
bursa. So if you're repetitively reaching, then you're repetitively pinching that
rotator cuff or the bursa. But there is an exercise that you can do to kind of stretch
and open up the capsule so that the starting position between those bones is further
apart. You have to begin with greater space between the acromion and the greater tuberosity.
You have to begin with more space for that rotator cuff in bursa to live.
Dr. David Sohn:
If you're diligent about doing certain stretches called posterior capsule stretching,
then you can, again... You can do those things you love. So let's say you're a tennis
player or you're a volleyball player or you're someone who does a lot of overhead
things, you don't have to stop doing those things if you are... Or a swimmer. If you're
diligent about stretching. There are numerous conditions which we treat in sports
medicine, which are almost entirely nonsurgical and can be helped with stretching.
Dr. David Sohn:
All of our joints are use-it-or-lose-it. If we don't take our joints through a certain
range of motion, then our joint capsules can tighten. Think of the joint capsule as
a loose bag around a joint. If that bag shrinks and tightens down, now that... It's
not a problem when the joint is in mid range, but at the end points of the range of
motion, if that capsule is tight, then you lose that ability.
Dr. David Sohn:
An example would be somebody who has, for example, a flexion contracture of their
knee, which is actually... It sounds like it's not much, but it is extremely painful.
The ability to fully straighten your knee is critical to being able to walk and stand
for long periods of time without pain. If you ever noticed that when you're standing
for long periods of time, just for your own kind of like fun, just tap your thighs
if you've been standing for a long time and you'll find that your muscles are actually
not engaged. The thighs are completely relaxed. That's because our knees have something
called the screw home mechanism, such that when it fully straightens, the knees actually
twist at the last second and kind of lock the knee into position. This allows us to
stand without engaging our thighs.
Dr. David Sohn:
People who lose the ability to fully straighten their knee, they lose that. That ability
to lock out their knees. Their thighs are constantly engaged all day. If you want
to know what it feels like to be that kind of person, walk for just 15 minutes with
your knees slightly bent and your thighs will be burning with pain because that's
not the way our knees are designed. So if we're not fully stretching, then we're going
to lose that.
Dr. David Sohn:
Another example is frozen shoulder. Frozen shoulder is a condition where the capsule
that the shoulder lives in shrinks and becomes inflamed and you lose your ability
to fully straighten and you will have pain at the end points of your range of motion.
This will disrupt your sleep pattern. Because you'll be sleeping and people tend to
move around, and then they'll hit the end point of their range of motion very early,
and then it'll wake them up. These are all examples where not doing daily stretching
can cause pain even with our normal activities of daily living.
Dr. David Sohn:
Another one is muscles. You have your muscles, which then transition to a musculotendinous
junction, and then the tendons attach to the bone. well, muscles really only have
one thing that they can do. They can contract. That's what muscles do. They contract.
And then when they stopped contracting, then they can relax and the counter antagonistic
muscle will help stretch them out. But if all you're ever doing is contracting, then
over time, those muscles and tendons are going to get tight. The bones and joints,
all of our muscles and musculocutaneous systems, they're all based off of collagen.
They're not static like wood or metal. They have... Time dependent and also length
dependent properties there. Their properties actually change on stress and strain
curves. And so if we don't stretch on a regular basis, then we will become tight.
Dr. David Sohn:
One thing I have noticed is that athletes tend to become tight in whatever they use.
For example, a baseball pitcher is going to be tight in the throwing shoulder, more
than in the non-throwing shoulder. A sprinter is going to be tight in their hamstrings,
much more so than non-athletes. We do have a very good habit of stretching before
practices and we stretch before athletic contests, but we don't always stretch afterwards.
So stretching before activity helps prevent injury. No question about it. But stretching
afterwards is going to help prevent long-term stiffness and whatever the thing that
the athlete tends to use a lot would be.
Dr. David Sohn:
Static stretching is you reach and you hold. Dynamic, there's bobbing, there's some
momentum that goes along with it. You can gain more with dynamic, but the problem
is you can also have some more injuries. One general rule for stretching is you don't
want to cause pain. You want to stretch to a point of discomfort because then that
way you're making gains, but you don't want to cause pain.
Dr. David Sohn:
Why? Stiffness is primarily mediated by inflammation. If you are actually causing
inflammation, you're going to cause stiffness. It's going to be counterproductive.
So when you stretch, you want to stretch to the point of this. Conversely, you make
gains, but not to the point that you're actually having pain or else it's going to
end up being counterproductive. Dynamic stretching is as good as long as it's done
properly and you're not stretching to the point that you're actually causing pain.
Dr. David Sohn:
Of the things that I see in my clinic, the two things that I see the most are people
who have shoulder pain due to posterior capsule tightness and people who have anterior
knee pain from hamstring inflexibility. So we're not talking about having to do a
lot. A very popular stretch for posterior capsule stretching is the sleeper stretch.
You can just Google and you'll see. This is a tried and true stretch. If you do this
stretch 10 times every day... And by the stretch, I mean, you do the sleeper stretch
and you hold it for a 10 count and that's one. You hold the first hang on, that's
one. Do 10 of them for each shoulder. Do that every day. That will be the equivalent
of an apple a day keeps the doctor away.
Dr. David Sohn:
Same with the hamstring stretching. Do 10 seconds stretches. There's many different
hamstring stretching out there, just look them up. We all remember what it was like
in school. When you do your stretching of your hamstrings, there's... Reach out and
touch your toes, hold it for a 10 count. Same thing. Do that on a regular basis. That
will help out if you've got like Achilles pain or if you have plantar fasciitis. Stretching
out your heel cord. The calves and the Achilles tendon, same thing. Find a step, step
on it so that you're stretching the bottom of your foot, you're stretching the back
of your heel cord. 10 seconds, 10 times. That will, in the majority of times, get
rid of plantar fasciitis. So again, there's numerous things that we can help you with
just stretching and that don't need surgery or braces or injections or things like
that.
Dr. David Sohn:
Well, I'd say the big mistake is mixing stretching and strengthening. There's a rule
for strengthening. But strengthening is going to actually bring in some inflammation.
That makes sense, right? Particularly if someone's already tight or inflamed, that's
going to bring in more inflammation so that's going to be counterproductive. What
I would recommend is trying to think of things in stages. If your shoulders are tight,
if your hamstrings are tight, if you've got a frozen shoulder, if you've got knee
flexion contracture, if you've got plantar fasciitis with a tight heel cord, any of
these things. Focus on getting motion and flexibility first and just take a break.
Just take a pause from any type of strengthening during that time. Get your motion
first. And then once your motion comes, great. You can do any kind of lifting or strengthening
or things that you want.
Dr. David Sohn:
In my experience, stretching and flexibility. Flexibility will not come by itself.
For example, there are a lot of things that just come by this though. If you have
a scratch on your arm, you don't have to do anything about it. It's going to heal
by itself. There are even fractures. Like non-displaced hairline fractures, you just
protect that thing. It'll heal all by itself.
Dr. David Sohn:
Motion is not like that. If your shoulder is tight, if your heel cord is tight, if
your IT band is tight, hamstrings are... Whatever. It's not going away by itself.
It has to be earned. So if a patient comes in and their motion has improved significantly,
I know that they were working. It ain't coming no other way. You got to do it diligently.
Dr. David Sohn:
When you mix them, like a lot of times... Sometimes the most gung ho patient is the
patient who's going to get into trouble because they're so eager to get on with their
stretching. They're so eager to do things. They haven't gained their motion yet. And
then, they start to get setbacks. They start to bring inflammation in the system.
Inflammation causes stiffness, and then they start going backwards. It's not that
the stretches are right or wrong. I mean, there's a bajillion stretches. I mean, there
is true. Some stretches are better than like the sleeper stretches - a tried and true
stretch, but there's so many ways you can stretch your hamstrings. But if you stretch
your hamstrings and then you go out and you do a lot of squats or something like that,
it's going to be counterproductive.
Dr. David Sohn:
It's not that the stretches was done wrong, it's just that two things, which are antagonistic
are being mixed together. You're not going to get the best results. One thing to keep
in mind is I think there's a lot of times where people might be afraid of surgery
which I get. I mean, surgery can be scary. And so, I think there's sort of a perception
that if I see a surgeon... They're going to recommend surgeon, I don't want surgery
so I don't want to see a surgeon. I would challenge that notion. Overwhelming majority
of people who I see, for example, I do not recommend... Like 80% of the new patients
that I see, I don't do surgery on.
Dr. David Sohn:
Surgery is just one of our tools in our toolbox. One nice thing about people who have
sports medicine training is we like to see people who we can get better with non-op.
That's part of our training. Our ultimate goal is really just to let you do the things
that you love. We do have, as part of our fellowship training, we work with physical
therapists. We work with brace manufacturers. We understand how to get people back
into the game, through conservative treatment. So I would encourage people to see
people sooner rather than later, if they're having pain. As a general rule, pain that
persists more than two weeks... Certainly, pain is more than six weeks, you should
probably see somebody. Just because not everything is something that is getting worse.
But there are some things that the longer you let it go, the worse it is. The treatment
would have been easier if you saw someone earlier.
Dr. David Sohn:
For example, rotator cuff tears. Not all rotator cuff tears are the same. The bigger
a rotator cuff tear, the more atrophy has gone on in the muscles and even the nerves.
Because of that, when you do a repair, generally speaking that the bigger the tear,
the longer the recovery. A small rotator cuff tear that gets torn, but it's less than
a centimeter. That's a pretty easy repair, not only to technically do, but also for
our patients to recover from. We're talking sling for six weeks. And then, there's
not that much rehab that has to happen because they don't have a whole lot of muscle
atrophy. So we're talking something like six to eight weeks.
Dr. David Sohn:
But then when you talk about a medium tear, one to three centimeters, now we're talking...
It's going to be more like three to four months. How about a large tear? A large tear
is defined as between three to five centimeters. Now, we're talking four to six months.
Well, what about a massive tear? A tear that's bigger than five centimeters. Now,
we're talking six to 12 months. So these are some very big differences. Since we know
that symptomatic rotator cuff tears on average change. They'll go from a small to
a medium to a large, so massive, every seven to eight months. That's something where
the sooner you treat that probably is the better.
Dr. David Sohn:
There are two things that you really want to see someone sooner rather than later.
One of them is, if you injure your knee and your knee can't straighten, then it could
be a displaced bucket handle meniscus tear. That's something you're going to want
early evaluation for because in that case, the torn meniscus is out of place. It's
away from its blood supply. The sooner we get that back into place and repair it,
so it's back to blood supply, the better chance we have to allow that thing to live.
I mean, not everybody who can't straighten their knee has that, but that's one that
you really want to see someone earlier, rather than later for.
Dr. David Sohn:
Another one is your elbow. The elbow joint does not tolerate immobilization for a
long time. Let's say you hurt your elbow, and then you go to the emergency room and
they put you in a sling or they put you in some type of immobilization. Sometimes
if you are immobilized for more than a week. In just something as simple like that,
you will lose the ability to fully straighten your elbow. It might not be necessary.
If you have something that is an inherently stable fracture, you want to get out of
your immobilization fast. That's not something that you want to hold and stick around.
I can imagine it's like someone hurt their elbow, they're in a sling. They figure
that the longer I stay in this sling, the better it's going to be. But then week after
week, it's getting worse and worse and worse because their elbows' getting stiffer
and stiffer and stiffer. You can lose the ability to fully straighten it. That's one
that you want to be evaluated early on. So then, you can be told, "Look. Get rid of
that sling." "At this point, the sling is the enemy."
Dr. David Sohn:
We have sports medicine that can cover from A to Z. We can care for the adolescent
athlete, we can care for the middle-aged athlete. We can treat anything from sprains
to overuse injuries or just weekend warrior injuries. Try not to be scared of the
orthopedic surgeon. We're not hammers that are always just looking for a nail. It's
not like that at all. When you come in and you're sitting in front of me, my only
goal is to get you better. If I can do that with a cream, I'll do it with a cream.
If I can do it showing you how to do some stretches, then that's what I'm going to
do. If you need formal physical therapy, we've got great physical therapists. Sports
medicine, trained physical therapists. They're used to working with athletes.
Dr. David Sohn:
If you need to see one of those guys, then we'll get you to go see them. If you need
surgery, it fits in my specialty and I feel like I can do that as well as anybody,
then I'll do the surgery. But if not, if there's someone who can do it better, I'm
going to refer you to that person. That's all I care about. If you're sitting in front
of me, then... No matter which path I have to go, I want you to get better. That's
my goal.
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