Return to Play Considerations in the Shoulder Injured Athlete: Part 1

1
Return to Play Considerations in the Shoulder
Injured AthletePart 1

• Created by
• Chip Hewgley, MPT
• Emory Physical Therapy
• Emory Sports Medicine

2
Throwers Paradox

• The shoulder must be loose enough to allow
  excessive shoulder external rotation but stable
  enough to prevent symptomatic humeral head
  subluxation, thus requiring a delicate balance
  between mobility and functional stability.

3

• The key to effective treatment is a complete and
  thorough exam with differential diagnosis.

4
Throwing Injuries

• Typically the result of repetitive microtraumatic
  stresses put on the shoulder during the throwing
  motion.

5
Causes of Injury

• Alterations in throwing mechanics
• Muscle fatigue
• Muscle imbalance/ weakness
• Excessive capsular laxity

6
Common sites of Injury

• Glenohumeral capsule
• Glenoid labrum
• Rotator cuff musculature

7
Evaluating the throwing athlete

• Range of motion
• Muscle strength
• Laxity
• Proprioception

8
Factors to Consider

• Throwing a baseball requires transfer of energy
  from feet through the legs, pelvis and trunk out
  through the shoulder elbow and hand.
• Reduce the risk of re-injury by following a
  GRADUAL progression of interval throwing.
• Proper warm-up is crucial
• Most injuries occur as a result of fatigue
• Proper throwing mechanics lessen the incidence of
  re-injury

9
Total Motion Concept

• ER IR total motion
• Sum of ER IR throwing vs. non throwing
  shoulder (/- 5)

10
Wilk, K.E. ASMI 2003.

• Study looked at 372 professional baseball
  players.
• Pitchers averaged 130 degrees of ER and 63
  degrees of IR at 90 degrees of abduction.
• ER was 7 degrees gt in throwing shoulder.
• IR was 7 degrees gt in non throwing shoulder.

11
Throwers Laxity / Acquired Laxity

• Describes the anterior capsule and inferior
  capsule
• Most likely is acquired over time.

12
Wilk, K.E. ASMI 2003

• Isokinetic testing of ER strength of the throwing
  athlete is significantly weaker (6) vs. non
  throwing shoulder.
• IR strength was significantly stronger (3) in
  throwing vs. non throwing shoulder.
• Optimal ER/IR strength ratio should be between
  66-75.

13
Principles of Rehabilitation in the Thrower

• 1. Never overstress healing tissue.
• 2. Prevent negative effects of immobilization
• 3. Emphasize ER muscle strength.
• 4. Establish muscular balance.
• 5. Emphasize scapular muscle strength.
• 6. Improve posterior shoulder flexibility.
• 7. Enhance proprioception and neuromuscular
  control.
• 8. Establish biomechanically efficient throwing.
• 9. Gradually return to throwing activities.
• 10. Use established criteria to progress.

14
4 Parts of Treatment Program

• Activity modification
• Flexibility exercises
• Strengthening exercises
• Gradual return to throwing

15
Rehabilitation Program for the Overhead Thrower

• Phase 1 (Acute Phase)
• Goals
• 1. Decrease inflammation and pain
• 2. Increase flexibility and normalize ROM
• 3. Reestablish dynamic stability (muscle balance)
• 4. Retard muscle atrophy
• 5. Restore Proprioception

16
Phase 1 Treatment

• 1. Modalities Cryotherapy, ultrasound, electric
  stimulation.
• 2. Exercise flexibility/stretching for IR and
  horizontal adduction
• Rotator cuff strengthening with emphasis on ER
• Scapular muscle strengthening with emphasis on
  retractor, protractor and deep depressors
• Dynamic stabilization (rhythmic stabilization)
• Closed kinetic chain and Proprioceptive training
• No Throwing!!!!

17
(No Transcript)
18
Phase 1
19
Phase 1
20
Phase 2- Intermediate Phase

• Goals
• Progress strengthening exercise
• Restore muscle balance
• Enhance dynamic stability

21
Phase 2

• Continue stretching and flexibility
• Primarily IR and horizontal adduction
• Progress strengthening program
• Throwers Ten program
• Core strengthening
• LE strengthening

22
Phase 2
23
Phase 2
24
Phase 2
25
Strengthening Exercises

• Sidelying ER and Prone Rowing with ER have been
  shown to elicit the highest EMG activity of post.
  Cuff muscles (Fleisig).
• Scapula provides proximal stability to allow for
  distal mobility.

26
Supraspinatus Strengthening

• Empty can exercise originally highlighted by Jobe
  for high EMG levels.
• Townsend reported highest EMG activity in the
  military press but this exercise is not
  recommended for throwers.
• Blackburn noted prone lying with arm abducted to
  100 degrees and full ER had the highest EMG
  activity.
• We recommend the use of the full can exercise
  to avoid superior humeral head migration
  secondary to ER weakness.

27
(No Transcript)
28
Phase 3- Advanced Strengthening Phase

• Goals begin aggressive strengthening
• Increase power and endurance
• Begin more functional drills
• Initiate throwing activities as tolerated

29
Exercises Phase 3

• Throwers Ten Program
• Manual Rhythmic Stabilization
• Plyometric drills
• Dynamic stabilization

30
Phase 3
31
Phase 3
32
Plyometric Program

• Two handed drills
• Chest Pass
• Overhead soccer throw
• Side to side throw
• Side throw

33
Phase 3
34
Phase 3
35
Plyometric Program contd

• One handed drills
• standing throw (feet fixed)
• wall dribbling
• Plyometric step and throw

36
Phase4Throwing Program Initiation

• Begin with shadow / mirror throwing to work on
  proper mechanics.

37
Phase 4
38
Criteria to begin Throwing

• Satisfactory clinical exam
• Painfree ROM
• Satisfactory isokinetic test results
• Appropriate rehab progress

39
Unilateral Muscle Ratios
Velocity ER/IR ABD/ADD
180 deg/sec 65-75 78-85
300 deg/sec 61-71 88-94
40
Interval Throwing Program

• Designed to gradually increase quantity, distance
  and intensity.

41
Throwing Program(2 Phases)

• Phase 1 long toss program
• Phase 2 off the mound
• Initiate _at_ 45 feet and progress to 60 feet.

42
Sample long toss program

• 25 throws _at_ 45 feet, rest 5 min. 25 throws _at_45
  feet.
• 35 throws _at_ 45 feet, rest 5 minutes, 35 throws
  _at_45 feet.
• 25 throws _at_ 60 feet, rest 5 minutes, 25 throws _at_
  60 feet.
• 35 throws _at_60 feet, rest 5 minutes, 35 throws _at_60
  feet.
• 25 throws _at_ 90 feet, rest 5 minutes, 25 throws
  _at_90 feet.
• 35 throws _at_90 feet, rest 5 minutes, 35 throws _at_
  90 feet.
• 25 throws _at_ 120 feet, rest 5 minutes, 25 throws _at_
  120 feet.
• 35 throws _at_ 120 feet, rest 5 minutes, 35 throws _at_
  120 feet.

43
Sample mound program

• 25 throws _at_ 50
• 35 throws _at_ 50
• 50 throws _at_ 50
• 25 throws _at_ 75
• 35 throws _at_ 75
• 50 throws _at_ 75
• 25 throws _at_ 90
• 35 throws _at_ 90
• 50 throws _at_ 90
• 25 throws live BP
• 50 throws live BP
• 1 inning game
• 2 inning game
• 3 inning game
• 1 inning game on back to back days

44
Phase 4 Return to Throwing

• Progression of long toss program to 120 feet.
• When the pitcher can throw from 120 feet pain
  free he may begin throwing from the windup on
  flat ground and progress to the mound.

45
Biomechanics of Pitching

• 1. Windup begins with foot drop and ends with
  hand separation.
• 2. Stride front foot moves towards home plate.
• 3. Arm cocking pelvis and upper trunk face
  home plate and ER occurs.
• 4. Arm acceleration from maximum ER to ball
  release.
• 5. Arm deceleration from ball release to end
  range IR
• 6. Follow through from maximal IR until
  pitcher regains balanced position.

46
Softball vs. Baseball Pitch

• Fast Pitch softball (windmill style)
• Humerus in plane of scapula
• Adduction of humerus- power generator is pec
  major
• Forearm strikes lateral thigh at ball release to
  decelerate arm vs. ER in baseball for deceleration

47
Sample Softball Throwing Program

• 10 throws _at_30, rest 8 min., 10 throws _at_ 30
• 10 throws _at_45, rest 8 min, 10 throws _at_ 45
• 10 throws _at_ 60, rest 8 min, 10 throws _at_ 60
• 10 throws _at_ 75, rest 8 min, 10 throws _at_ 75
• 10 throws _at_ 90, rest 8 min, 10 throws _at_ 90
• 10 throws _at_ 105, rest 8 min, 10 throws _at_ 105

48
Softball ITP Contd

• 10 throws _at_ 60,10 pitches _at_ 20, rest 8 min, 10
  throws _at_ 60, 5 pitches _at_ 20
• 10 throws _at_ 60, 10 pitches _at_ 35, rest 8 min, 10
  throws _at_ 60, 10 pitches _at_35.
• 10 throws _at_ 60, 10 pitches _at_ 46, rest 8 min, 10
  throws _at_ 60, 10 pitches _at_ 46.
• 10 throws _at_ 60, 10 pitches _at_ 46, rest 8 min, 10
  pitches _at_ 46, rest 8 min, 10 throws _at_ 60, 10
  pitches _at_46.

49
Soreness Rules for ITP (Axe, Windley,
Snyder-Mackler)

• If no soreness, advance 1 step every throwing
  day.
• If sore during warm-up but soreness is gone
  within the first 15 throws, repeat previous
  workout. If shoulder becomes sore during this
  workout, stop and take 2 days off. Upon return
  to throwing drop down 1 step.
• If sore more than 1 hour after throwing on the
  next day, take 1 day off and repeat the most
  recent throwing program workout.
• If sore during the warmup and soreness continues
  through the first 15 throws, stop and take 2 days
  off. Upon return to throwing, drop down 1 step.

50
Softball ITP Contd

• 2 throws to each base, 15 pitches (50), rest 8
  min, 15 pitches (50), 1 throw to each base, 15
  pitches (50).
• 2 throws to each base, 15 pitches (50) X 3 w/ 8
  min rest, 1 throw to each base, 15 pitches 50.
• 2 throws to each base, 15 pitches (50), 15
  pitches (75) X 2 w/ 8 min rest, 1 throw to each
  base, 15 pitches (50).
• 2 throws to each base, 15 pitches(50), 15
  pitches (75),15 pitches (75), 20 pitches (50),
  1 throw to each base, 15 pitches (50).
• 2 throws to each base, 15 _at_ 75, 15 _at_ 75, 15 _at_
  75, 15 _at_ 75, 1 throw to each base, 15 _at_ 75.
• 1 throw to each base, 15 _at_ 100, 20 _at_ 75, 15 _at_
  100, 20 _at_ 75, 1 throw to each base, 20 _at_ 75.
• 1 throw to each base, 15 _at_ 100, 20 _at_ 75, 15 _at_
  100, 15 _at_ 100,20 _at_ 75, 1 throw to each base,
  15 _at_ 75.

51
Softball ITP Contd

• 1 throw to each base, 20 _at_ 100, 15 _at_ 100, 20 _at_
  100,15 _at_ 100, 20 _at_ 100, 1 throw to each base,
  15 _at_ 100.
• 1 throw to each base, 20 _at_ 100, 15 _at_ 100, 20 _at_
  100, 15 _at_ 100, 20 _at_ 100, 15 _at_ 100, 1 throw to
  each base, 15 _at_ 100.
• BP 100-120 pitches total, 1 throw to each base
  per 25 pitches.
• Simulated game, 7 innings, 18-20 pitches /inning,
  8 min rest between innings.

52
The Overhead Throwing Athlete

• Extreme stresses applied to the shoulder.
• Tremendous angular velocities (greater
  than 7000o/s).
• Throwers Paradox loose enough to throw but
  stable enough to prevent symptoms. Mobilityltgt
  stability

53
USA Baseball Recommendations

• 9-10 year olds
• 50 pitches per game
• 75 pitches per week
• 1000 pitches per season
• 2000 pitches per year

54
USA Baseball Recommendations

• 11-12 year old pitchers
• 75 pitches per game
• 100 pitches per week
• 1000 pitches per season
• 3000 pitches per year

55
USA Baseball Recommendations

• 13-14 year old pitchers
• 75 pitches per game
• 125 pitches per week
• 1000 pitches per season
• 3000 pitches per year

56
References

• Wilk, K.E., Meister, K., Andrews, J.R. Current
  Concepts in the Rehabilitation of the Overhead
  Throwing Athlete. AJSM, vol30, No. 1 2002.
• Paine, Russell M. The Role of the Scapula in the
  Shoulder. The Athletes Shoulder.
• Wilk, K.E., Andrews, J.R. et al. Interval Sports
  Programs Guidelines for Baseball, Tennis and
  Golf. JOSPT, vol 32, June 2002.
• Davies, G.J. Proprioception in the Thrower.
  ASMI. 2002.
• Wilk, K.E. Rehabilitation Guidelines for the
  Thrower with Internal Impingement. ASMI
  2002-2003.
• Andrews JR, Chmielewski T, Escamilla RF, Fleisig
  GS, Wilk KE. Conditioning program for
  professional baseball pitchers. ASMI, Birmingham,
  AL 1997.
• Andrews JR, Fleisig GS. How many pitches should I
  allow my child to throw? USA Baseball News,
  April, 1996.
• Fleisig GS, Barrentine SW, Zheng N Escamilla RF,
  Andrews JR. Kinematic and kinetic comparison of
  baseball pitching among various levels of
  development. Journal of Biomechanics 32 (12)
  1371-1375, 1999.
• Lyman S, Fleisig GS, Andrews JR, Osinski ED.
  Effect of pitch type, pitch count, and pitching
  mechanics on risk of elbow and shoulder pain in
  youth baseball pitchers. AJSM 30(4)463-468,
  2002.
• Ellenbecker, T.S., Davies, G.J. The Application
  of Isokinetics in Testing and Rehabilitation of
  the Shoulder Complex. Journal of Athletic
  Training, 200035(3)338-350.
• Meister, K. Injuries to the Shoulder in the
  Throwing Athlete. Part Two Evaluation/Treatment.
  AJSM, vol. 28, No. 4. 2000.
• Axe, M.J., Windley, T.C., Snyder-Mackler, L.
  Data Based Interval Throwing Programs for
  Collegiate Softball Players. Journal of Athletic
  Training. 200237(2)194-203.

57
Thank You