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Nov 02, 2022

Assessing the Pitcher's Shoulder

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Dr. Yoni Rosenblatt: Welcome to the True Sports Physical Therapy Podcast. I'm joined again by Alex Gett, Dr. Alex Gett, who has just an outstanding background with elite throwers. Let's just sum up kind of how you got to here. For those out there who maybe have not heard from you yet. How you got to where you are today career-wise. And then we're gonna dive right into shoulders and talk about some of the myths, some of the facts, how you diagnose and how you take them all the way through back onto the mound. We'll make it specific to pitchers. So, Alex Gett, tell us about your career.

Dr. Alex Gett: Yeah, so originally I was a strength coach. That was pretty much the bread and butter of what I was doing and I had stints at the division one level and then in professional baseball with the Kansas City Royals. And it was during my time with Kansas City when I was just around some really, really smart people on a sports medicine staff that are really good at what they do. I really wanted to just take my knowledge and take what I was able to do with athletes on the sports med side, just take it to another level. Some personal situations went into that, my decision to walk away from that job and pursue PT. But I grinded through PT school and I knew that I was either A, gonna go back to baseball, or B, take a job like this. The athletes and ortho and there was no question that that was gonna be the career path I would choose.

Dr. Yoni Rosenblatt: Well, speaking as the owner of True Sports PT, I am thrilled you did that 'cause you've been unbelievable working here in Frederick one-on-one with athletes every single time, 45 minutes. And you have really developed a serious following, understandably, in the baseball world. So I want to get some quick hitters to really put together some advice and some really guiding outlook to sports PTs, how they should address the shoulder in the high level pitcher. So high level pitcher comes in to see his shoulder has been bothering him. What are the first few questions you're asking him upon evaluation?

Dr. Alex Gett: So, again, it really depends on their age, their level. So we're gonna go high level for the sake of this case. I wanna know, when did it start? I want you to tell me where, literally point where. Is it a pinpoint with one finger or Is it like a broad based area, so we got, when, where, how long has this been going on? What your workload been since, I really dive into their subjective. I need to know as much as I possibly can because I've learned that the more information I get there especially with somebody that's high level and in tune with their body, the less time I have to spend getting all my objective stuff. Now, I still make sure I rule out some other things. Obviously you have to make sure you're covering your bases, but if I can really dive into the subjective and they can get up and kind of show me like, hey, show me the phase of throwing, Where is this getting you? Is it when you're in layback? Is it when the ball leaves your hand? Show me. That gives me a lot of information and I just kind of dive in. 'Cause then at that point you've seen enough of 'em, you have some differentials in your head and then you just start working backwards.

Dr. Yoni Rosenblatt: I love that, I love that. So why do you care whether it's pinpoint, whether it's diffuse?

Dr. Alex Gett: Yeah, for me, if there's a pinpoint issue, they can put one finger on it. Something structural in my mind so there's something structural that may be potentially causing that pain. I also need to know the quality of pain, but if they can usually put one finger on it, there's something usually under that finger that's causing the issue. If that's more broad based diffuse stuff, I'm not leaning as much towards like, hey, this is a specific structure. It could be just general muscle pain or it could be something else. But it's just gonna kind of like dictate the train or where I put most of my stock to start at least.

Dr. Yoni Rosenblatt: Yeah, absolutely. I loved what you said about, and you're gonna hear this on the pod so much, you want a list of what could this possibly be. And so when you look at a joint, you look at a shoulder, what are the things that could possibly be causing that pain? And now let's start crossing them off with every single question that comes outta your mouth. Where does it hurt? That can absolutely be a differential. How does it hurt? Can absolutely color. What could possibly be wrong with the shoulder? We know it's cuff, we know it's labrum, we know maybe it's neck. Maybe, you're gonna tease out weakness, tightness, and just keep it simple, but you gotta walk in with that list and just don't waste the time with, What? What do you think is a big waste of time?

Dr. Alex Gett: That has been the biggest thing I've changed. And again, you don't know any better when you come outta school, but it's just like I'm doing all my active range of motion, all my passive range of motion. Then I get out to gony, and then I do my strength test, and then I do my special test and it's like, they're great, you're gonna get a pile of information, but you got 45 minutes and you may have just wasted 20 of them, if nothing was pertinent that you did. So again, that's why I dive in, I really dive into their subjective, because now I am going... My questions are very specific, my objectives even gonna be more specific because now I have a pretty good idea of what's probably going on. And if something's off with my objective stuff, then I back up and I ask them more questions. Alright, did you say this started hurting or whatever it may be. But the more information I get from them, then that just kind of helps me and I can just start getting pretty specific with some things. So the biggest thing is getting rid of a lot of fluff. And getting extreme right away. And then that's only gonna help me with my diagnosis, prognosis, whatever, home exercise stuff. It just makes things much easier.

Dr. Yoni Rosenblatt: Yeah, great point. It also develops that rapport with your pitcher, with your athlete. They know you care because you are grilling them with questions. If I had a nickel for every time I heard an athlete tell me that they've walked into a surgeon's examination room and he is like, "Hey, move here, move here, move here. Here's what's wrong with you. Take this or go get this... " Because they don't take the time to develop that relationship, that's another thing that you're doing. Everything that comes outta your mouth, it should be a reason for it. And I think that's exactly what you're describing. At what point would you tell the listening audience to say, you have to include this in your evaluation that's not shoulder specific? I guess to ask it better, what else are you looking at outside of their shoulder once you get into the objective?

Dr. Alex Gett: Definitely I'm gonna clear above and below neck, T spine's a big one. I'll even break out an SFMA, just like a tier 1. Hey, like what are your... I mean, and I take 'em through like all the neck stuff and then their shoulder quadrants and everything. Their squat, their single leg stance. So if I'm looking for more broad things to treat, maybe the shoulder, maybe the pain's presenting himself at the shoulder, but the shoulder kind of checks out, then I'm just gonna start looking at bigger picture stuff.

Dr. Yoni Rosenblatt: I love that because as sports PTs we love the idea of treating this entire athlete. I would say, correct me if I'm wrong, don't look at their hip until you look at their shoulder. They're there for their shoulder. It's crazy to me when I see athletes come in and they're like, "Yeah, I was told my shoulder's bothering me because my contralateral hip." Okay. I mean, listen, maybe, but you also might have a SLAP tear. So like, let's figure that out.

Dr. Alex Gett: Exactly, to the shoulder until like Eric Mayer says the quad until it's not the quad, it's your shoulder until I think it's not your shoulder.

Dr. Yoni Rosenblatt: I love it. Yeah. Yeah. And that's a great idea. Okay. So within that evaluation, 45 minutes I think is a luxury. Some places give you an hour. So let's say you had an hour, you have an awesome subjective. Where does it hurt? How does it hurt? When does it hurt? What does it feel like? Then you move in, you said you're gonna ask about the neck. You're gonna clear the neck, you're gonna look at the T spine, then maybe you're looking through the hip SFMA. Then what do you do?

Dr. Alex Gett: So now I'm trying to find your pain, like your pain. Whatever, something I may do, it may hurt. I want the pain that brought you through the door. I'm trying to find it. If I can find it, then we're like, we're cooking a little bit. And again, they show me that or they tell me that through their subjective and they show me kinda like, get up and show me. Where does this bother you? I'll say a lot of times there's a lot of anterior shoulder pain, if it's in the shoulder. So how much, in my mind I'm like alright, well, there's maybe a laxity issue. If there's a laxity issue, what structure could be involved? Probably gonna be a labrum. Probably. Start doing my tests to get specific with the labrum. If that checks out, I'm like, "Okay, what else could it be?" As they're on the table, I'm asking them questions. They don't know it, but I'm like diving deeper as I'm playing with their arm. But that anterior instability, we know that a high level guy, especially those guys that are 90-plus, they're layback and the amount of external rotation is ridiculous.

Dr. Yoni Rosenblatt: Yes, that's awesome. Okay. So what are your go-to tests? 'Cause there are a lot of trash tests. So what are your go-to tests when you're looking at a labrum?

Dr. Alex Gett: I almost always start with apprehension, relocation tests, because they're almost, almost always gonna have some laxity anteriorly. And as far as labrum, it can be as simple as like a speeds. I do like a crank, to like a grind, like a load and shift type thing. I'm trying to jam that humeral head into the faucet and I'm like grinding on, it's almost like a scours. I kind of break into a scours. The shoulder, I'm usually gonna catch it there, with the amount of pressure I'm driving into the faucet as well as now I'm playing, I got my other hand and I'm just like driving that thing like posteriorly. I'm driving in all directions to try and stress that thing as much as I can. That's usually gonna catch it.

Dr. Yoni Rosenblatt: So I love that. I think it's also, we talk a lot about the difference between treating gen pop, and treating high level sports. One of the things that I always say is like, when I go to the weight rack and I'm grabbing something for my pro NFL guys, even baseball guys, I'm always gonna grab like 20 pounds heavier than I think. That's one thing. The other thing is level of force and manipulation. These guys' shoulders are used to going through insane ranges of motion. You better stress it with your big boy muscles to see if you can reproduce that pain. So I think that's a good point.

Dr. Alex Gett: Yeah. If you can't find it, then you're just kind of like, you don't know what to tell 'em. What are you gonna tell 'em? Like, what's wrong with my shoulder?

Dr. Yoni Rosenblatt: Go back to doctor.

Dr. Alex Gett: Yeah. Right. You gotta find a way. If for some reason I don't find it on the table, then I'm taking you out to the floor. I'm telling you I'm gonna find it.

Dr. Yoni Rosenblatt: Love it.

Dr. Alex Gett: I'm gonna stress... And that goes back to the strength.

Dr. Yoni Rosenblatt: Okay. What are you doing out there?

Dr. Alex Gett: It depends. If I don't find it, it goes back to the position they showed me, that bothers it. So I'm gonna stick you in that position and I'm gonna stress it either manually or I'll hook up bands. That goes back to being, having that strength piece. I can kind of put you in positions and apply vector, multi-vector, whatever it may be, to get you in a position where I'm probably gonna find it.

Dr. Yoni Rosenblatt: Do you ever put a baseball in their hand?

Dr. Alex Gett: All the time. Weighted ball, baseball, all the time. And if I can kind of find it, okay, then I'm like, it's constant. I'm just diving deeper than you're subjective. It's like, well, how severe is this? How much has this really limited you? And just like, well, I kind of feel it when I throw, but it's not too bad. It's like, okay, well, maybe we caught something before it actually started. But in my mind, if I can stress you to a certain level and I can't reproduce it, then I'm wondering like, well, how severe is this to you? And then there I am again diving into your subjective with even more stuff. And if I find it, then bang, then I know exactly what to go at.

Dr. Yoni Rosenblatt: It's easy. Okay. So, quick clinical pearl there would be a lot of these guys don't feel it till inning six, seven, or pitch 85, 90. So how are you gonna mimic their fatigue? They walk in, they're fresh. Let's see what happens when we fatigue 'em out with a band. So I think that's one thing that is worthwhile that I've learned kind of over the years. The other thing would be how do they do if it's not labrum and we're thinking cuff or self tissue? Well, let me leave it to you. How do you get to that? What makes you start thinking, "Nah, this is cuff?"

Dr. Alex Gett: Yeah. If you're strong, right? If I'm tugging on your joint and grind, literally scouring your joint and there's really no pain there, I'm like, okay, labrum probably checks out. If you're painful with just active motion, and if I'm doing like my manual ISOs on you and there's pain there, then I'm kind of leaning more towards cuff. Because something, anytime you contract the muscle, it hurts. Yeah. So now I'm like, okay, something. Now, it's just like, well, where is it? Is it more back side, a front side? If I close down your joint, if I stretch you, if I close it down, front versus back, does that bother? Now, I'm trying to, is it contractile or not, really what I'm going at.

Dr. Yoni Rosenblatt: Okay. So that makes a lot of sense. Do you care whether it's their labrum or their cuff?

Dr. Alex Gett: As far as prognosis, yes. As far as what I'm gonna do for treatment, yeah. 'Cause I'll put more stock in certain things if it's one versus the other, but definitely for primary.

Dr. Yoni Rosenblatt: What are those?

Dr. Alex Gett: So for labrum, it goes back to where are we at in the season? What's your workload been like? All those questions. But now I'm thinking more like, well, it's September right now, so let's say you have about three weeks left in the season. Alright. Are we just gonna buckle up and go? We're gonna do a pile of stability work, a pile of positional tolerance work, a lot of heavy manual isometrics to just get you through the season. And then, you really dive into this. Or is it February and you have eight, nine months to go now, and that changes things. So it's like, well, if I really think labrum's involved, then I'm probably like, "Well, we need to get an MRI and kind of figure things out."

Dr. Yoni Rosenblatt: Okay.

Dr. Alex Gett: Because if it changes the type of player you are, now we need to like dive into some imaging and really kind of figure out what's going on. Cuff, I'm starting with ISOs pretty much outside of your pain range. Again, heavy ISOs that they can tolerate outside of their painful range. And their prognosis is gonna be much better if that gets them kind of turning a corner quicker than a labrum, which if it's a cuff and not a labrum, they will turn that corner quicker. Now, I'm just diving into a pile of strength stuff, whatever mode I use.

Dr. Yoni Rosenblatt: Yeah. Yeah, okay. So I think that's great clarification. When do you say we gotta get imaging?

Dr. Alex Gett: Yeah, so for me, if I suspect something structurally, and it's like day one, anything I do is lighting you up on a table. The big one for me is if I see you've... I just had this happen. I was watching a kid throw a pen, never seen him throw before. He's frustrated. His slot is down, like he's dropping... He's just visibly... Like his slot, he has a low slot, but it doesn't look natural. Talking to dad on the side. His velo's down like eight miles an hour. I'm like, "Something's off here."

Dr. Yoni Rosenblatt: Yeah.

Dr. Alex Gett: Just literally broke into a shoulder screen.

Dr. Yoni Rosenblatt: Yeah.

Dr. Alex Gett: So I'm gonna get an MRI because everything I did lit him up. And he's young, and his volume's through the roof. It's just all the errors are pointing to like something structurally is kind of off here. And you get that clinical feeling, like that gut feeling when you see enough where you're kind of like, "I don't wanna really treat and wait for this. I wanna get you somewhere now, continue to treat, but you need to go somewhere now."

Dr. Yoni Rosenblatt: I mean that red flag you mentioned. You just watch that velo like fall off a cliff?

Dr. Alex Gett: That's the one, yeah.

Dr. Yoni Rosenblatt: Yeah. That's a great move that, "Hey, something's up, something big's up," probably MRI is worthwhile 'cause it happens like so acutely. So I think that's gold. Give me one, two, three things that, coming out of that evaluation, you want your athlete to know. What's that education piece?

Dr. Alex Gett: Yeah, I flat out tell them what I think may be going on.

Dr. Yoni Rosenblatt: Okay.

Dr. Alex Gett: Alright. I've made the mistake in the past, being young, I think it's this: Well, now they're gonna hold you to that.

Dr. Yoni Rosenblatt: Yeah.

Dr. Alex Gett: Now it's like, "I think it's potentially this structure that does this for your shoulder, potentially." And I say it again, "potentially. Some of the tests I've done, some of the manual things I've done on you, some of the things you're telling me, some of the things I'm seeing, are kind of pointing at this. I think if we get an MRI, it's either gonna tell us that's what it is or that's what it is not. And we just kinda wait and play that game. And in the meantime, we do some stuff that gets you hopefully feeling better, maybe turn a corner." But I want them to know, potentially, what I think it potentially could be, what I want you to do in the meantime, what I think you should do with your sport. 'Cause at the end of the day, you'll talk 'til you're blue in the face, give them the best instructions in the world. All they care about is, "So can I pitch this weekend?"

Dr. Yoni Rosenblatt: Exactly.

Dr. Alex Gett: Or, "Can I pitch tonight?" Like they don't know.

Dr. Yoni Rosenblatt: You cannot cover that.

Dr. Alex Gett: So I tell them like, "Hey, this is what I think you should do as far as your actual sport." Whether it's shut it down, give it a shot, whatever, image, no image, what you do for your sport, what are you gonna do at home? And then, potentially, how long this may or may not take if, one way or the other. If the MRI shows this, or if it shows this.

Dr. Yoni Rosenblatt: Spell it out, yeah. I love that.

Dr. Alex Gett: You just gotta hit them between the eyes because if you try and... People just want real, good or bad. So it's pretty easy for me to just kind of like, "Hey, here we go. This is what I think we've got going on."

Dr. Yoni Rosenblatt: What do you use to teach them? Are you showing them on posters? Are you showing them on skeletons? Are you showing them on your shoulder? What are you doing?

Dr. Alex Gett: Yeah, so I'll use my shoulder. I'll use their shoulder, their non-involved shoulder. I'll pull up a image on my phone, just like a skeleton on my phone. Here's what I'm talking about. Here's what it does. But yeah, I educate 'em as much as I can. But the big thing for me is, I want them to feel comfortable that I'm making the right decision for them. That's the big thing because it goes back to what we've talked about a little bit. It's like, for me, you meet so many different people, so many different personalities. You can't dive into that and kind of really understand what gets them ticking, day one. You just don't. But if you're just real, and you just kind of tell them what they need to hear, that starts it. And then, the more you're with them or whatnot, then it kind of builds that relationship, and then it just opens up everything.

Dr. Yoni Rosenblatt: Boom. That relationship piece, that's what it's about. Maybe you got it wrong on your diagnosis. If you have a relationship, it doesn't matter 'cause they know that you care about them and that you're gonna do whatever it takes to get them right. I think there's so much more there to peel apart. I think that is an awesome start to a subjective on a shoulder of how do you get that information, it's the beginnings of a really good objective. I would say that's a good objective. I can't remember the last time I used a gony. And it's not because, oh, I've been just doing this for so long. It's that does that matter? That education piece. How quickly can you come up with a theory as to what's going on with their shoulder? How can you prove that theory to them, or a hypothesis? How can you prove that hypothesis to them one way or another? And then how well can you get them to be eager to come back for visit two? Not because it helps the business but because that's what they're definitely going to need to get better, right?

Dr. Alex Gett: Yeah.

Dr. Yoni Rosenblatt: And I think you really did a great job of hitting on all those things. Young sports PTs, older sports PTs that want to get better at shoulder and cuff and labrum rehabilitation, differential diagnoses, where do they find Alex Gett?

Dr. Alex Gett: So I have a website, I actually wrote an arm care ebook.

Dr. Yoni Rosenblatt: Hell, yeah.

Dr. Alex Gett: There's another little project. That can be found on my website. It's called Periodized Arm Care for the Overhead Athlete. And that goes back to my strength stuff. It's like an actual periodized, progressed program 'cause, especially for pitchers, man, arm care is just so like, "What do you do?" "Oh, I got my J-Bands, and I do some of this." I'm like, "Okay dude." That's why I wrote it 'cause I'm just like, "This is garbage."

Dr. Yoni Rosenblatt: I love that.

Dr. Alex Gett: So across the board, anybody can... And it can be in season, out of season, whatever. It's just like a structured, safe program, but anyways.

Dr. Yoni Rosenblatt: On your website?

Dr. Alex Gett: On my website, yeah.

Dr. Yoni Rosenblatt: Love it.

Dr. Alex Gett: And then my Instagram is prst_pt. I have a Twitter that I'm not as active on, but I get on every once in a while, same handle prst_pt. But yeah, man, the shoulder, it's...

Dr. Yoni Rosenblatt: Where are you treating? Where do you want athletes to find you?

Dr. Alex Gett: Yeah, True Sports Physical Therapy. We're located in Frederick, Maryland at Mad Fitness. Also I work with Dustin Pease at Pease Baseball Professionals. That's also in Frederick. You can easily look up the addresses online.

Dr. Yoni Rosenblatt: And that's a beautiful symbiosis of strength and performance, and it just speaks to how well you're able to live in both realms. So yeah, Pease Baseball is really a must to check out.

Dr. Alex Gett: Yeah, absolutely, absolutely.

Dr. Yoni Rosenblatt: So it's awesome. Alex, thanks so much for your time. Thanks for the education. There's so much more that we're gonna get to. We want to hear from you. We want to hear what you want to hear, what you loved about this pod, what you didn't necessarily love about the pod. Totally fine with that. What you hated. You just wish I would sit up straight more, or whatever. Share it. We're here for you. We look forward to hearing from you. Thanks, Alex.

Dr. Alex Gett: Absolutely, man. Thank you.

Dr. Yoni Rosenblatt: Appreciate you.


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