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

Return to Play Considerations in the Shoulder Injured Athlete: Part 1. Created by: Chip Hewgley, MPT Emory Physical Therapy Emory Sports Medicine. Throwers Paradox.

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

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  1. Return to Play Considerations in the Shoulder Injured Athlete:Part 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 > in throwing shoulder. • IR was 7 degrees > 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. 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!!!! Phase 1 Treatment

  17. Phase 1

  18. Phase 1

  19. Phase 2- Intermediate Phase • Goals: • Progress strengthening exercise • Restore muscle balance • Enhance dynamic stability

  20. Phase 2 • Continue stretching and flexibility • Primarily IR and horizontal adduction • Progress strengthening program • Throwers Ten program • Core strengthening • LE strengthening

  21. Phase 2

  22. Phase 2

  23. Phase 2

  24. 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.

  25. 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.

  26. Phase 3- Advanced Strengthening Phase • Goals: begin aggressive strengthening • Increase power and endurance • Begin more functional drills • Initiate throwing activities as tolerated

  27. Exercises: Phase 3 • Throwers Ten Program • Manual Rhythmic Stabilization • Plyometric drills • Dynamic stabilization

  28. Phase 3

  29. Phase 3

  30. Plyometric Program • Two handed drills: • Chest Pass • Overhead soccer throw • Side to side throw • Side throw

  31. Phase 3

  32. Phase 3

  33. Plyometric Program cont’d • One handed drills • standing throw (feet fixed) • wall dribbling • Plyometric step and throw

  34. Phase4Throwing Program Initiation • Begin with shadow / mirror throwing to work on proper mechanics.

  35. Phase 4

  36. Criteria to begin Throwing • Satisfactory clinical exam • Painfree ROM • Satisfactory isokinetic test results • Appropriate rehab progress

  37. Unilateral Muscle Ratios

  38. Interval Throwing Program • Designed to gradually increase quantity, distance and intensity.

  39. Throwing Program(2 Phases) • Phase 1: long toss program • Phase 2: off the mound • Initiate @ 45 feet and progress to 60 feet.

  40. Sample long toss program • 25 throws @ 45 feet, rest 5 min. 25 throws @45 feet. • 35 throws @ 45 feet, rest 5 minutes, 35 throws @45 feet. • 25 throws @ 60 feet, rest 5 minutes, 25 throws @ 60 feet. • 35 throws @60 feet, rest 5 minutes, 35 throws @60 feet. • 25 throws @ 90 feet, rest 5 minutes, 25 throws @90 feet. • 35 throws @90 feet, rest 5 minutes, 35 throws @ 90 feet. • 25 throws @ 120 feet, rest 5 minutes, 25 throws @ 120 feet. • 35 throws @ 120 feet, rest 5 minutes, 35 throws @ 120 feet.

  41. Sample mound program • 25 throws @ 50% • 35 throws @ 50% • 50 throws @ 50% • 25 throws @ 75% • 35 throws @ 75% • 50 throws @ 75% • 25 throws @ 90% • 35 throws @ 90% • 50 throws @ 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

  42. 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.

  43. 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.

  44. 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

  45. Sample Softball Throwing Program 10 throws @30’, rest 8 min., 10 throws @ 30’ 10 throws @45’, rest 8 min, 10 throws @ 45’ 10 throws @ 60’, rest 8 min, 10 throws @ 60’ 10 throws @ 75’, rest 8 min, 10 throws @ 75’ 10 throws @ 90’, rest 8 min, 10 throws @ 90’ 10 throws @ 105’, rest 8 min, 10 throws @ 105’

  46. Softball ITP Cont’d • 10 throws @ 60’,10 pitches @ 20’, rest 8 min, 10 throws @ 60’, 5 pitches @ 20’ • 10 throws @ 60’, 10 pitches @ 35’, rest 8 min, 10 throws @ 60’, 10 pitches @35’. • 10 throws @ 60’, 10 pitches @ 46’, rest 8 min, 10 throws @ 60’, 10 pitches @ 46’. • 10 throws @ 60’, 10 pitches @ 46’, rest 8 min, 10 pitches @ 46’, rest 8 min, 10 throws @ 60’, 10 pitches @46’.

  47. 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.

  48. Softball ITP Cont’d • 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 @ 75%, 15 @ 75%, 15 @ 75%, 15 @ 75%, 1 throw to each base, 15 @ 75%. • 1 throw to each base, 15 @ 100%, 20 @ 75%, 15 @ 100%, 20 @ 75%, 1 throw to each base, 20 @ 75%. • 1 throw to each base, 15 @ 100%, 20 @ 75%, 15 @ 100%, 15 @ 100%,20 @ 75%, 1 throw to each base, 15 @ 75%.

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