Evaluating and Treating Shoulder Injuries in Overhead Athletes Sieara Bishop, SPT
Learning Objectives
Appreciate the differences in an overhead thrower’s shoulder
Identify common shoulder injuries that affect overhead athletes
Identify key components of an evaluation for an overhead athlete
Knowledgeable about the principles of a rehabilitation for an overhead athlete
Understand proper overhand throwing mechanics
Knowledgeable about the 4 phases of a rehabilitation program for overhead athletes
Recognize the criteria for return to play for an overhead athlete
Knowledgeable about how to promote and implement a shoulder care prevention program
Outline
Characteristics of overhead throwers
Common injuries
Biomechanics of throwing
6 phases of throwing
Important areas to assess Rehabilitation program
Treatment
10 principles of Rehabilitation
4 phases of a Rehabilitation Program
Discharge
By classification system and tissue
Evaluation
Risk factors for injury
Criteria for return to play
Prevention program
Tips for preventing injury
Pitch count recommendations
Additional resources
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Characteristics of Overhead Throwers
Characteristics of Overhead Throwers
Range of motion1:
An obvious shift of more ER and less IR on throwing arm compared to the non-throwing arm
Total ER/IR from 90/90 position should be within 5 degrees though
Pitchers more likely to have more ER than position players
Laxity1,2:
Most throwers exhibit significant laxity, often from the anterior and inferior capsule
Debate on whether the laxity is acquired, congenital
Bigliani et al. studied MLB players and found evidence for congenital laxity
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Typical Characteristics of Overhead Throwers
Strength1:
ERs are significantly weaker than the non-throwing side
IR was significantly stronger than non-throwing side
Adductors significantly stronger than non-throwing side
Supraspinatus significantly weaker than non-throwing side
Optimal strength ratio: ERs at least 65-75% the strength of the IRs
Proprioception1,3:
Diminished in the throwing arm compared to the non-throwing
Improvements were seen at end-range ER
Risk Factors for Shoulder Injuries
GIRD4
Total rotational motion more than 5 degree difference from nondominant shoulder4
Scapular dyskinesis1
Muscular imbalance5
Instability/laxity1
Muscle fatigue as it decreases proprioception and alters biomechanics6
Poor mechanics1
Common Injuries
Categorizing Common Injuries7 ➢ Primary Disease ➢ Primary Instability ➢ Secondary to microtrauma ➢ Secondary to generalized ligamentous laxity ➢ Acute traumatic instability ➢ Posterosuperior Glenohumeral Impingement
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Common Injuries by Tissue1
Posterosuperior glenoid impingement
Subacromial impingement
Tendinitis
Posterior RC muscles, biceps
SLAP lesions
Bennett’s lesion
Primary instability
Acute traumatic instability http://stemcellprofessionals.com/wp-content/uploads/2016/07/Shoulder-Pain-in-bel-air-Maryland-4.png
Evaluation
Biomechanics of Throwing 6 phases of overhand throwing7 1.
Wind-up
2.
Early cocking
3.
Late cocking
4.
Acceleration
5.
Deceleration
6.
Follow-through
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6 Phases of Overhand Throwing
Key Aspects of an Evaluation
History8:
Timing of pain (how many throws, what velocity, what point in 6 phases)
Physical Exam8:
Stability: sulcus sign, apprehension/relocation, ant/post drawer tests, anterior release test
Labrum: clunk test, anterior slide test, O’Brien (active compression test) http://b.vimeocdn.com/ts/349/342/349342644_640.jpg
Key Aspects of an Evaluation
Evaluate throwing mechanics1,9 Video from multiple angles Take a top down or bottom up approach
Lateral view: Balanced as stride leg reaches highest point Knee slightly flexed as stride leg contacts the ground Stride length ~ height of the athlete Arm abducted ~90-100 degrees at full ER Full follow-through with arm ending outside lead leg Posterior view: Arm path smoothly down, back, and up Avoid arm moving too far behind the body Ball should face away in late cocking (RH pitcher to ~ ss, LH pitcher to ~ 2 nd) Anterior view: Stride foot pointed towards target Avoid toes pointing left of target for a RH pitcher Minimal elbow flexion at release
Treatment
10 Principles of Rehabilitation1 1. Never overstress healing tissue 2. Prevent negative effects of immobilization 3. Emphasize external rotation muscular strength 4. Establish muscular balance
5. Emphasize scapular muscle strength 6. Improve posterior shoulder flexibility (internal rotation range of motion) 7. Enhance proprioception and neuromuscular control 8. Establish biomechanically efficient throwing 9. Gradually return to throwing activities 10. Use established criteria to progress
4 Phases of Rehabilitation Program6 1.
Acute Phase
2.
Intermediate Phase
3.
Advanced Strengthening Phase
4.
Return to Activity Phase
Phase 1: Acute Phase
Goals:
Diminish pain and inflammation
Normalize motion
Retard muscular atrophy
Reestablish dynamic stability (muscular balance)
Control functional stress/strain
Treatment focus:
Cryotherapy, ultrasound, electrical stimulation
Flexibility and stretching for posterior shoulder muscles (improve internal rotation and horizontal adduction)
Rotator cuff strengthening (especially external rotator muscles)
Scapular muscles strengthening (especially retractor, protractor, depressor muscles)
Dynamic stabilization exercises (rhythmic stabilization)
Closed kinetic chain exercises
Proprioception training
Abstain from throwing
Phase 2: Intermediate Phase
Goals:
Progress strengthening exercise
Restore muscular balance (external/internal rotation)
Enhance dynamic stability
Control flexibility and stretches
Treatment focus:
Continue stretching and flexibility (especially internal rotation and horizontal adduction)
Progress isotonic strengthening
Thrower’s Ten program
Rhythmic stabilization drills
Initiate core strengthening program
Initiate leg program
Throwers 10 Program6 ď ľ
Used in phase 2 to progress isotonic strengthening and improve neuromuscular control
ď ľ
Performed in standing/prone and progressed to a stability ball
Phase 3: Advanced Strengthening
Goals:
Aggressive strengthening
Progress neuromuscular control
Improve strength, power, and endurance
Initiate light throwing activities
Treatment focus:
Flexibility and stretching
Rhythmic stabilization drills
Advanced Thrower’s Ten program
Initiate plyometric program
Initiate endurance drills
Initiate short-distance throwing program
Phase 4: Return to Activity
Goals:
Progress to throwing program
Return to competitive throwing
Continue strengthening and flexibility drills
Treatment focus:
Advanced Thrower’s Ten program
Plyometric program
Progress interval throwing program to competitive throwing
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Advanced Throwers 10 Program4 ď ľ
Used in Phase 4 to prepare athlete for return to sport
ď ľ
Emphasizes dynamic stabilization, co-activation, coordination, neuromuscular control, endurance training, proper posture, and core strengthening/endurance in thrower-specific positions
Discharge and Return to Play Considerations
Return to Play Criteria6
Full, pain-free sport-specific range of motion
Appropriate strength
Excellent stability
Proper throwing mechanics
Successful completion of rehabilitation program
Satisfactory subjective shoulder score (Kerlan-Jobe Subjective Score for Throwers >94)
Information on Prevention
Shoulder Care Program
Target population: healthy baseball and softball players aged ~13+ without shoulder pain or injury
Includes: stretching, strengthening, stabilization, plyometrics
When: in-season, pre-season, or off-season
Up to 3x a week, no game days, no consecutive days
Discontinue if shoulder becomes painful or injured
Why use a program like this?
Research suggests a year-round program like this be used to prevent injuries6
Can improve throwing velocity6,10
Tips for Athletes to Prevent Injury
Always warm-up before throwing
Adhere to pitch count guidelines
Play multiple sports
Avoid early sport specialization11
Set aside rest days during season and periods of no throwing during the offseason
Emphasize good mechanics, accuracy and control
Communicate with your coach/parent about how your shoulder is feeling
Pitch Count Recommendations ď ľ
Visit the Pitch Smart website created by MLB and USA Baseball for pitching guidelines for youth and adolescent baseball players
http://mlb.mlb.com/assets/images/8/6/8/209073868/cuts/750x422_pitch_smart_48oqijjy_o2br7htx.jpg
Additional Resources
Stop Sports Injuries by American Orthopedic Society for Sports Medicine
Preventing Sports-Related Injuries by Safe Kids Worldwide
https://www.stopsportsinjuries.org
https://www.safekids.org/preventing-sports-related-injuries
Parents Guide for Youth Sports Injuries by National Institutes of Health
https://www.niams.nih.gov/health-topics/sports-injuries-in-youth
Questions?
References 1. Wilk KE, Meister K, Andrews JR. Current concepts in the rehabilitation of the overhead throwing athlete. Am. J. Sports Med. 2002;30(1):136-151. doi:10.1177/03635465020300011201. 2. Bigliani LU, Codd TP, Connor PM, Levine WN, Littlefield MA, Hershon SJ. Shoulder motion and laxity in the professional baseball player. Am. J. Sports Med. 1997;25(5):609-613. doi:10.1177/036354659702500504.
3. Allegrucci M, Whitney SL, Lephart SM, Irrgang JJ, Fu FH. Shoulder kinesthesia in healthy unilateral athletes participating in upper extremity sports. J. Orthop. Sports Phys. Ther. 1995;21(4):220-226. doi:10.2519/jospt.1995.21.4.220. 4. Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am. J. Sports Med. 2011;39(2):329-335. doi:10.1177/0363546510384223. 5. Wilk KE, Andrews JR, Arrigo CA, Keirns MA, Erber DJ. The strength characteristics of internal and external rotator muscles in professional baseball pitchers. Am. J. Sports Med. 1993;21(1):61-66. doi:10.1177/036354659302100111. 6. Wilk KE, Arrigo CA, Hooks TR, Andrews JR. Rehabilitation of the overhead throwing athlete: there is more to it than just external rotation/internal rotation strengthening. PM R 2016;8(3 Suppl):S78-90. doi:10.1016/j.pmrj.2015.12.005. 7. Meister K. Injuries to the shoulder in the throwing athlete. Part one: Biomechanics/pathophysiology/classification of injury. Am. J. Sports Med. 2000;28(2):265-275. doi:10.1177/03635465000280022301. 8. Meister K. Injuries to the shoulder in the throwing athlete. Part two: evaluation/treatment. Am. J. Sports Med. 2000;28(4):587-601. doi:10.1177/03635465000280042701. 9. Whiteley R. Baseball throwing mechanics as they relate to pathology and performance - a review. J. Sports Sci. Med. 2007;6(1):1-20.
10. Escamilla RF, Ionno M, deMahy MS, et al. Comparison of three baseball-specific 6-week training programs on throwing velocity in high school baseball players. J. Strength Cond. Res. 2012;26(7):1767-1781. doi:10.1519/JSC.0b013e3182578301. 11. Pasulka J, Jayanthi N, McCann A, Dugas LR, LaBella C. Specialization patterns across various youth sports and relationship to injury risk. Phys. Sportsmed. 2017;45(3):344-352. doi:10.1080/00913847.2017.1313077.