MECHANICS OF OVERHEAD SPORT ACTIVITIES

1. MECHANICS OF OVERHEAD SPORT ACTIVITIES Overhead motions, place particular types of stresses on the shoulder and other upper-extremity segments. An appreciation of these stresses and of the biomechanics in overhead sports, can help you develop suitable rehabilitation programs .

2. PITCHING Pitching is a smooth, continuous motion that occurs during a relatively brief period of time. Kinetic chain from foot to fingers Lower extremity provides the power Trunk rotation allows transfer of energy to shoulder and elbow

3. Phases of a Pitch 1.Wind-up- Earliest phase Ends with hand separation Requires good balance and pelvic/trunk strength 2. Early Cocking Starts with hand separation Ends with foot plant Early Cocking - Shoulder Deltoid and supraspinatus function together to elevate humerus to greater than 90 degrees of abduction Low elbow and ‘out-of-plane’-problems may begin here.

4. Phases of a Pitch Early Cocking - Shoulder Peri-scapular muscles work in coordinated fashion to tilt glenoid superiorly to match humeral abduction Serratus anterior is primary rotator Poor peri-scapular strength may lead to internal impingement problems Late Cocking Starts with foot plant Ends with maximal external rotation of shoulder.

5. Phases of a Pitch Late Cocking - Shoulder Infraspinatus and teres minor External rotation Help restrain anterior humeral head translation Serratus anterior Allows maximal superior tilt of glenoid to allow maximal external rotation Subscapularis, pectoralis major and latissimus dorsi Provide anterior capsular support Subscapularis Rotates to superior position

6. Phases of a Pitch Anterior capsular laxity can lead to humeral head translation and internal impingement problems. Laxity problems reduced with proper scapular positioning and subscapularis strength. 3. Acceleration Starts with maximal external rotation of the shoulder. Ends with ball release. High angular velocities occur about both shoulder and elbow. Shoulder internal rotation up to 7600 deg/sec, elbow around 2500 deg/sec. Both joints also see significant joint compressive loads.

7. Phases of a Pitch Acceleration - Shoulder Pectoralis major and teres minor High electrical activity Work cooperatively to control internal rotation of the shoulder Posterior deltoid and supraspinatus Work to reduce posterior humeral translation 4. Deceleration Starts with ball release Ends after one third of time till the end of arm motion.

8. Phases of a Pitch Deceleration - Shoulder Teres minor Most active of all glenohumeral muscles. Controls deceleration. Other posterior muscles also assist. 5. Follow Through Starts after one third of terminal arm motion following ball release. Ends with the end of arm motion.

9. TENNIS serve 1. Wind-up Stars when the athlete prepares for the motion. The shoulder is in slight abduction, extension, and external rotation. The trunk is slightly laterally flexed and rotated, the legs are rotated. 2. Cocking Cocking begins with ball release from the opposite arm . The scapula is upwardly rotated and adducted, the shoulder is abducted and externally rotated, and the elbow is flexed. Supraspinatus, infraspinatus, subscapularis Stabilizing the humerus in the glenoid ,positioning the shoulder.

10. TENNIS serve Serratus anterior is active to stabilize the scapula on the thoracic wall, rotating the scapula into the correct position. Posterior deltoid and trunk lean are responsible for shoulder abduction. Biceps activity is moderately high during this phase. 3. Acceleration Begins with internal rotation movement of the shoulder and ends with ball contact. Subscapularis is very active to produce internal rotation. Pectoralis major and latissimus dorsi work to adduct the arm .

11. TENNIS serve 4.Follow- Through Occurs from ball impact to the end of the motion. Latissimus dorsi and pectoralis major decelerate forward shoulder motion Rotator cuff work eccentrically to provide deceleration of the forward momentum and distraction pull on the humerus in the glenoid; The serratus anterior is active eccentrically; and the biceps continues its eccentric control of the elbow.

12. Forehand Ground Stroke 1. Racket Preparation Begins with the shoulder turn and ends with the initiation of weight transfer onto the front foot . Little muscle activity occurs in the shoulder. 2. Acceleration Begins with weight transfer onto the front foot and ends at ball impact. 3. Follow- Through Follow-through occurs from ball contact to the end of the motion

13. Backhand Ground Stroke 1. Racket Preparation This phase begins with shoulder turn to place the racket shoulder to the net and ends with weight-transfer initiation to the front foot. 2. Acceleration Acceleration begins with weight transfer to the front foot and ends with ball contact. 3. Follow- Through Follow-through takes place from ball contact to the end of the stroke.

14. SWIMMINGfreestyle stroke 1. Pull-Through Is the propulsive phase of the freestyle stroke and is similar to the acceleration phase in throwing. Early pull-through Upper trapezius to upwardly rotate the scapula. Rhomboids to retract the scapula. Supraspinatus, anterior, middle deltoids stabilize the humerus. Later pull-through Pectoralis major and latissimus dorsi act as the propulsive muscles Deltoids lift and place the arm in preparation for hand exit from the water serratus anterior stabilizes the scapula.

15. SWIMMINGfreestyle stroke Teres minor, subscapularis stabilize the humerus as well as performing their movement activities. Serratus anterior,rhomboids downwardly rotate the scapula as the shoulder moves into extension. Teres minor assists with shoulder extension, and the subscapularis internally rotates the humerus. 2. Recovery Recovery phase begins when the arm leaves the water and continues until hand entry. Early recovery Is initiated by abducting and rotating the humerus and rotating the scapula, the supraspinatus and middle deltoid.

16. SWIMMINGfreestyle stroke As recovery progresses,rhomboids retract the scapula, subscapularis internally rotates the shoulder from a maximally externally rotated position at middle recovery and assists the infraspinatus in depression of the humerus in the glenoid before hand entry. The subscapularis and the serratus anterior work consistently throughout the entire swimming stroke.

17. GOLF SWING 1. Take-Away Begins when the golfer addresses the ball, and it ends at the top of the backswing. 2. Forward Swing This phase begins at the end of backswing and continues until the club becomes horizontal. 3. Acceleration Acceleration occurs from the time the club becomes horizontal to the time of ball contact. 4. Follow-Through Follow-through begins with ball contact and continues to the end of the stroke .

18. GENERAL REHABILITATION CONSIDERATIONS STABILITY Static stability - joint capsule, ligaments, and glenoid labrum. Dynamic stability - nerves and muscles, including ppropriate  input from the afferent receptors to the central nervous system. SCAPULAR MUSCLES Control scapular motion. Their strength and control are crucial to the shoulder. An unstable scapula leads to impingement and biceps or  rotator cuff tendinitis.

19. GENERAL REHABILITATION CONSIDERATIONS Biofeedback technique Used to either facilitate rotator cuff activity or reduce upper trapezius activity during shoulder elevation exercises. Scapular taping Used in cases of secondary impingement in which faulty positioning of the scapula during overhead movements causes impingement of the rotator cuff tendons. FORCE COUPLES Infraspinatus and teres minor form a force couple with subscapularis, and the rotator cuff forms a force couple with the deltoid(glenohumeral joint ). Upper and lower trapezius and serratus anterior work together to upwardly rotate scapula, and the pectoralis minor, levator scapulae, and rhomboids working together to downwardly rotate scapula.

20. GENERAL REHABILITATION CONSIDERATIONS RELATIONSHIP BETWEEN TRUNK/HIP AND SHOULDER The legs and trunk provide 51% to 55% of the total kinetic energy and total force for overhead activities. The shoulder contributes 13% to the total energy production and 21% of the total force. exercises for hip rotators, extensors, and abductors, as well as for abdominals, obliques, and trunk extensors, should be included in a shoulder rehabilitation program. POSTURE Correct posture is crucial to shoulder balance and function. Posture must be corrected if the rehabilitation program is to be successful.

21. GENERAL REHABILITATION CONSIDERATIONS CERVICAL AND THORACIC INFLUENCES If shoulder symptoms increase with movement, palpation, or joint mobilization of the spine, cervical spine may be the source of shoulder pain. Reproducing the patient's pain is a key component of the rehabilitation assessment for determining the origin of the patient's complaints. Restricted costothoracic and thoracic spine mobility can restrict the shoulder's movement. SCAPULAR PLANE Placing the arm in a scapular plane reduces impingement of its tendons and is generally more comfortable for the patient .

22. REHABILITATION TECHNIQUES SOFT-TISSUE MOBILIZATION Supraspinatus Referred pain pattern occurs around the shoulder in the middle deltoid area down to the deltoid insertion and elbow's lateral epicondyle. Subscapularis Refers pain to the posterior shoulder and around the wrist, into the scapula and down the posterior arm to the elbow. Teres Minor Refers pain to the posterior deltoid, proximal to the deltoid attachment and about 5 cm (2.0 in.) in diameter.

23. REHABILITATION TECHNIQUES Infraspinatus Refers pain most often to the anterior shoulder, to the anterior arm, to the wrist, and to the radial fingers. On occasion, vertebral border scapular pain or pain at the base of the skull can also occur. Serratus Anterior Refers pain laterally to the midchest area or to the inferior angle of the scapula. Rhomboids The pain referral pattern is along the vertebral border of the scapula, with some pain possible into the supraspinatus area

24. REHABILITATION TECHNIQUES Pectoralis Minor Refers pain over the anterior deltoid with some spillover into the subclavicular area, pectoral area, and ulnar aspect  of the arm, forearm, palmar hand, and fingers. Latissimus Dorsi A constant aching in the inferior angle of the scapula and midthoracic area is typical of a pain referral with this  muscle. Spillover pain referral can also occur in the posterior shoulder, down the medial arm and medial forearm, and to  the hand and ulnar fingers.

25. REHABILITATION TECHNIQUES Teres Major Refers pain over the posterior deltoid, over the triceps long head, and occasionally into the posterior forearm. Pectoralis Major Refers pain to the anterior chest, anterior deltoid, medial epicondyle, sternum, and breast. Overspill referral pain can also occur in the medial arm and ulnar digits. Deltoid Anterior and posterior deltoid portions can refer pain over the anterior, posterior, and middle deltoid locations with some spillover into adjacent areas of the arm.

26. REHABILITATION TECHNIQUES Supraspinatus Friction Massage Massage technique is used to treat supraspinatus tendinitis. Cross-friction pressure is applied to the tendon for 1 to 2 min or until the tenderness subsides. Arm Pull This technique is a general myofascial stretching technique for stretching or mobilizing soft tissue. A longitudinal traction is applied to the patient's arm.

27. JOINT MOBILIZATION Glenohumeral Joint The techniques are usually named according to the direction of the mobilization force. Distraction With Oscillation Is a relaxation technique, is a good way to begin and end mobilization treatment; it relaxes the joint before and after treatment. Longitudinal Distraction This is a good beginning technique for improving inferior capsule mobility. Inferior Glide This technique is used to improve inferior capsular mobility by stretching the inferior capsular pouch.

28. JOINT MOBILIZATION Lateral Glide This technique is used to increase all motions of the glenohumeral joint. Posterior Glide This technique is used to improve flexion and internal rotation motions by improving posterior capsule mobility. Anterior Glide This technique is used to increase anterior capsule mobility for improving extension and external rotation . External Rotation This technique is used to improve external rotation motion.

29. JOINT MOBILIZATION Scapular Distraction This technique is used to improve subscapularis mobility . Scapular Inferior Glide This technique is used to improve downward mobility of the  scapula. Acromioclavicular Glides Anterior glides Posterior glides Sternoclavicular Glides Inferior glides Posterior glides

30. FLEXIBILITY EXERCISES PENDULUM EXERCISES Called Codman's exercises. Can be performed in the early rehabilitation phase. Distract the glenohumeral joint. Relax the muscles around the shoulder . Provide pain modulation. Passive flexion-extension motion of the shoulder. Horizontal flexion-extension motion of the shoulder. Circular motion of the shoulder.

31. REHABILITATION TECHNIQUES ACTIVE STRETCHES Inferior Capsule Stretch - incrises inferior capsular mobility to improve shoulder elevation. Posterior Capsule Stretch - is used to gain internal rotation, and horizontal flexion, is for the posterior rotator cuff. Anterior Capsule Stretch - is used to gain horizontal extension and external rotation. It stretches the anterior capsule and pectoralis major. Superior Capsule Stretch - increases superior capsule mobility. Internal Rotation Stretch - increases internal rotation and stretches the posterior capsule.

32. REHABILITATION TECHNIQUES Rhomboid Stretch - stretches the rhomboids and posterior capsule. Supraspinatus Stretch - increases supraspinatus flexibility and superior capsular mobility. ASSISTIVE STRETCHES Supraspinatus Stretch - increases supraspinatus motion and superior capsular mobility. Infraspinatus Stretch - increases infraspinatus flexibility and posterior capsular mobility. Subscapularis Stretch - increases subscapularis flexibility and improves inferior capsular mobility.

33. REHABILITATION TECHNIQUES Teres Minor Stretch - increases teres minor flexibility and stretches the inferior capsule. Teres Major Stretch – increases teres major flexibility. Latissimus Dorsi Stretch - increases latissimus dorsi flexibility. WAND EXERCISES Use the aninvolved contralateral arm to provide the stretch force needed to increase motion. Holds the end position 5 to 10 s and repeats each motion several times. Can perform independently several times throughout the day.

34. REHABILITATION TECHNIQUES Wand Flexion - increases flexion motion. Wand Abduction- increases shoulder abduction. Wand External Rotation - increases external rotation. Internal Rotation - increases shoulder internal rotation. Horizontal FlexionExtension - increases horizontal movements. PULLEY EXERCISES Can be performed with a pulley, rope, or stretch strap. Can be incorporate into a home exercise program. The patient can perform them independently. Shoulder Flexion Shoulder Abduction

35. STRENGTHENING EXERCISES Begin with isometric activities and straight-plane isotonic exercises. Progress to multiplane and diagonal exercises. ISOMETRICS Begin early in a rehabilitation program. May be performed at multiple angles of a motion, in a pain-free position. Isometric contraction is gradually increased to a maximum, held at a maximum, and then decreased gradually until the muscle is relaxed. Each isometric is held for 5 to 10 s and repeated 10 times.

36. STRENGTHENING EXERCISES Shoulder Flexion - strengthens the shoulder flexors. Shoulder Extension - this exercise strengthens the shoulder extensors. Shoulder Abduction - strengthens the shoulder abductors. Shoulder Internal Rotation - this exercise strengthens the internal rotators. Shoulder External Rotation - strengthens the shoulder external rotators.

37. STRENGTHENING EXERCISES ISOLATED-PLANE ISOTONIC EXERCISES Scapulothoracic Exercises Manual Resistance to Scapula Can do this exercise early in the rehabilitation program for glenohumeral injuries. It does not stress the glenohumeral joint and assists in minimizing atrophy of scapular rotators. Scapular Protraction Serratus anterior is the primary muscle providing this motion. Serratus anterior can also be strengthened using a push-up plus. Serratus anterior can also be strengthened using rubber tubing or pulleys.

38. STRENGTHENING EXERCISES Scapular Retraction Is produced by the rhomboids and middle trapezius. An early-phase exercise for strengthening these muscles is a scapular squeeze. Prone flys and rows strengthen these muscles. A row exercise can be performed in prone or sitting. Scapular Depression This motion is performed by the lower trapezius and pectoralis minor. These muscles can also be strengthened with the use of a pulley or rubber tubing or with the resistance device anchored to the shoulder.

39. STRENGTHENING EXERCISES Bouhler Exercises Strengthen the lower trapezius as it functions in upward rotation of the scapula. Can be performe in different position. At a more advanced level, the patient is prone, either on a table or on a Swiss ball. Weights can be added to the hands for additional resistance. Scapular Elevation Is performed by the upper trapezius and levator scapulae. Initial strengthening include shoulder shrugs and manual resistance to shrugs. A more advanced exercise uses weight during shrugs.

40. STRENGTHENING EXERCISES Scapular Rotation Upward rotation is performed by the serratus anterior and trapezius muscles. Downward rotation is performed by the levator scapulae, rhomboids, and pectoralis minor and occurs during shoulder extension . Full range-of-motion exercise for scapular rotation also includes glenohumeral motion. Glenohumeral Exercises External Rotation Is performed by the infraspinatus, teres minor, and posterior deltoid. The exercises should be performed in the scapular plane.

41. STRENGTHENING EXERCISES Internal Rotation The subscapularis is the primary muscle responsible for internal rotation. It receives assistance from other muscles including the teres major, latissimus dorsi, anterior deltoid, and pectoralis major. Abduction This motion is produced by force-couple activity of the deltoid with the supraspinatus. The other rotator cuff muscles also play an important role during shoulder abduction and flexion. Horizontal Abduction Performed in the prone position with the arm in external rotation, demands output from the teres minor and infraspinatus.

42. STABILIZATION EXERCISES Stabilization exercises help to restore the scapular stability crucial to shoulder motion. Advanced open chain exercises for shoulder stability include isokinetic exercises and open chain elastic-band exercises. SCAPULAR STABILIZATION Exercises should begin early in the rehabilitation program. The progression begins with isometric stabilization exercises and advances to stabilization during arm movement, in simple planes and then in diagonal planes. Swiss Ball Stabilization Various exercises using Swiss balls can facilitate scapular stabilization.

43. STABILIZATION EXERCISES Distal Movement Stabilization These activities involve movement of the distal extremity. Require movement control and strength and stabilization of the shoulder. It is necessary that the patient maintain correct scapular position. Rhythmic Stabilization These exercises assist in re-educating the proprioceptors and improve kinesthetic awareness. Proprioceptive Neuromuscular Facilitation Include isometrics, concentrics, eccentrics, and rhythmic stabilization. Uses the sport rehabilitation specialist's manual resistance. In the early rehabilitation stages, PNF can enhance neuromuscular control, and at later stages it can improve strength and coordination of muscle firing.

44. STABILIZATION EXERCISES In the early rehabilitation stages, PNF can enhance neuromuscular control, and at later stages it can improve strength and coordination of muscle firing. This form of exercise uses the sport rehabilitation specialist's manual resistance. In the early rehabilitation stages, PNF can enhance neuromuscular control, and at later stages improve strength and coordination of muscle firing. In the early rehabilitation stages, PNF is commonly used for rhythmic stabilization stabilization. In later rehabilitation stages,PNF increase coordination through use of eccentric resistance in functional planes .

45. PLYOMETRIC EXERCISES UNSTABLE SURFACES Exercises on unstable surfaces provide dynamic stabilization stress to the shoulder. Muscles must provide dynamic shoulder stability while simultaneously maintaining balance on a moving surface. PLYOMETRIC PUSH-UPS Plyometric push-ups begins with a wall push-up. Push-up can also be performed on a trampoline. The most difficult plyometric push-up is performed with boxes.

46. PLYOMETRIC EXERCISES RESISTED MOVEMENT IN WEIGHT BEARING These exercises require good strength, control, and endurance. A stair machine, a step machine, or a treadmill can be used. MEDlCINE- BALL EXERCISES These exercises begin with a lightweight ball-9 kg (2 lb). Can increase as the patient is able to maintain control. Rotation Progression Rotational Tosses

47. FUNCTIONAL ACTIVITIES Progress gradually in time, resistance, and/or distance. For overhead activities, the progression is from lower to higher movement. If one element is increased, another may be decreased to allow the body to adjust to new stresses.

48. SPECIAL REHABILITATION APPLICATION SHOULDER INSTABILITY After the first week The shoulder is taken out of the sling, to permit active assistive range of motion in straight-plane flexion. Gentle, passive motion to no more than 0º external rotation with the elbow at the side can also begin. Abduction to 30° , isometrics in non-stress positions, manual resistance to scapular stabilizers, avoiding stress to glenohumeral joint. By the sixth week Passive shoulder flexion range of motion should be normal, passive external rotation 50° to 60° with the elbow at the side. After the third week, gentle, active resistive isotonic exercises for internal rotation, external rotation to about 20° to 30° with the elbow near the side, and abduction to 20° can begin in a scapular plane .

49. SPECIAL REHABILITATION APPLICATION SHOULDER IMPINGEMENT Secondary and primary impingement both result in inflammation of the soft-tissue structures in the subacromial space. Rehabilitation emphasizes control of the inflammation, correction of the secondary cause, and restoration of normal shoulder function. Placing the shoulder in a loose-packed position with the arm slightly abducted and flexed. Early on, the program incorporate neuromuscular re-education for proprioception and improved kinesthetic awareness of the scapular rotators for correct scapular positioning during arm movement. Rotator cuff exercises in a pain-free range of motion are important at this time. Progression of exercises is based on the patient's pain and strength.

50. SPECIAL REHABILITATION APPLICATION TRAUMATIC ROTATOR CUFF CONDITIONS Following surgical repair, the starting point, duration, and progression of the rehabilitation process depends on the size of the tear, the extent of the surgical repair . A sling or abduction brace may be used immediately postoperatively and continued for about six weeks. After 7 to 10 days of immobilization, mild passive and active assistive range-of-motion exercises. Early exercises include passive and active assistive elevation and external rotation, extension, and internal rotation ,pendulum exercises,joint mobilization for pain relief (grades I and ll). Active external and internal rotation performed with the elbow at the side and extended,manual resistance to scapular rotators. At 10 to 12 weeks, the patient should have nearly full range of motion.

51. SPECIAL REHABILITATION APPLICATION ARTHROSCOPIC DECOMPRESSION Rehabilitation can begin immediately after surgery. The first week or two involves primarily pain and swelling modulation and range-of-motion exercises. Early motion exercises can include Codman's exercises and active assistive range-of-motion exercises with a wand, pulley. Internal and external rotation motion exercises start with the elbow near the side and progress to 45° and then 90° of abduction, capsular stretches and joint mobilization,submaximal isometric exercises initiated in the first two weeks,scapular stabilization exercises and biceps and triceps exercises, early neuromuscular control exercises such as proprioception drills for glenohumeral positioning with eyes closed can be started early. The entire rehabilitation process may average three to five months.

52. SPECIAL REHABILITATION APPLICATION GLENOID LABRAL TEARS Whether or not instability is present, the usual treatment choice is to try conservative rehabilitation first. If instability is present, open reduction to remove the avulsed segment and stabilize the joint may be necessary. If an open repair is necessary, the rehabilitation program must be delayed because of the required additional immobilization; the rehabilitation program proceeds more slowly and cautiously. In these cases, the process will more closely follow the time line outlined for the rotator cuff repair program.

53. SPECIAL REHABILITATION APPLICATION ADHESIVE CAPSULITIS When adhesive capsulitis is in stage I, shoulder pain, pain at end ranges of movement, difficulty sleeping on the shoulder and progressive loss of motion are hallmark signs. Active range-of- motion exercises maintain muscle length. Attempts at stretching the capsule at this time cause pain but little change in mobility. In stage II, adhesive capsulitis has become mature, glenohumeral joint has lost normal mobility, and shoulder is very stiff,pain is present at the end of available motion. Continued active stretches, strengthening exercises in the available ranges should be a part of the program,ultrasound before joint mobilization may permit more optimal results from the mobilization. In the third stage, the patient`s is evident before the end of capsular restriction is reached. Continued range-of-motion exercises and active stretches are used throughout the day, self- mobilizations techniques are taught to the patient,strength exercises for scapular rotators, rotator cuff, and large glenohumeral muscles should be provided in a progressive program.

54. SPECIAL REHABILITATION APPLICATION ELECTROTHERMALLV ASSISTED CAPSULAR SHIFT The shoulder is kept immobilized for 7 to 14 days, although wrist and elbow motions are permitted. Active abduction is initiated about 10 to 14 days postoperatively, external rotation is permitted to 45° with the elbow at the side and at 90° abduction after about two weeks,forward flexion is kept to 90°, and extension is limited to 20° hyperextension. Strengthening exercises can be performed, Resistance consists of high repetitions with low resistance,resisted elbow and wrist motions should also be a part of the program. After week 12, the patient should be able to tolerate plyometric exercises.

55. SPECIAL REHABILITATION APPLICATION ACROMIOCLAVICULAR SPRAIN Active and active assistive range of motion are initiated on day 1 or 2 following the injury,isometrics to tolerance can also begin immediately. Once full motion is restored, a progression of strengthening exercises is used until the patient has full function without pain and is able to return to full sport participation. In the type II and Ill injuries, the shoulder may be immobilized for one to three weeks. Active assistive range of motion of the glenohumeral joint may begin early. Types IV, V, and VI are often surgically repaired, because significant damage to both static and dynamic structures around the joint has occurred.

56. SPECIAL REHABILITATION APPLICATION BICEPS TENDON INJURIES The most common injury seen in the biceps tendon is tendinitis Rehabilitation treatment must include an assessment of the rotator cuff, because pathology in this location is often related to biceps pathology. Control of pain, swelling, and inflammation is an initial goal of treatment. Therapeutic exercises progress as tolerated to include a strengthening sequence similar to that listed for conditions discussed earlier. It should also obviously include supination and elbow flexion exercises.