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

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.

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

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

Causes of Injury Alterations in throwing mechanics Muscle fatigue Muscle imbalance/ weakness Excessive capsular laxity

Common sites of Injury Glenohumeral capsule Glenoid labrum Rotator cuff musculature

Evaluating the throwing athlete Range of motion Muscle strength Laxity Proprioception

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

Total Motion Concept ER + IR = total motion Sum of ER + IR = throwing vs. non throwing shoulder (+/- 5)

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.

Throwers Laxity / Acquired Laxity Describes the anterior capsule and inferior capsule Most likely is acquired over time.

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%.

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.

4 Parts of Treatment Program Activity modification Flexibility exercises Strengthening exercises Gradual return to throwing

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

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!!!!

Phase 1

Phase 1

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

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

Phase 2

Phase 2

Phase 2

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.

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.

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

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

Phase 3

Phase 3

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

Phase 3

Phase 3

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

Phase4 Throwing Program Initiation Begin with shadow / mirror throwing to work on proper mechanics.

Phase 4

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

Unilateral Muscle Ratios Velocity ER/IR ABD/ADD 180 deg/sec 65-75% 78-85% 300 deg/sec 61-71% 88-94%

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

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

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.

Sample mound program 25 throws @ 50% 35 throws @ 50% 50 throws @ 50% 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

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.

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.

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

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’

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’.

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.

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%.

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

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. Mobility<> stability

USA Baseball Recommendations 9-10 year olds 50 pitches per game 75 pitches per week 1000 pitches per season 2000 pitches per year

USA Baseball Recommendations 11-12 year old pitchers: 75 pitches per game 100 pitches per week 1000 pitches per season 3000 pitches per year

USA Baseball Recommendations 13-14 year old pitchers 75 pitches per game 125 pitches per week 1000 pitches per season 3000 pitches per year

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, 2000;35(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. 2002;37(2):194-203.

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