return to play considerations in the shoulder injured athlete part 1 l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Return to Play Considerations in the Shoulder Injured Athlete: Part 1 PowerPoint Presentation
Download Presentation
Return to Play Considerations in the Shoulder Injured Athlete: Part 1

Loading in 2 Seconds...

play fullscreen
1 / 57

Return to Play Considerations in the Shoulder Injured Athlete: Part 1 - PowerPoint PPT Presentation


  • 184 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Return to Play Considerations in the Shoulder Injured Athlete: Part 1' - nitza


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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
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.
throwing injuries
Throwing Injuries
  • Typically the result of repetitive microtraumatic stresses put on the shoulder during the throwing motion.
causes of injury
Causes of Injury
  • Alterations in throwing mechanics
  • Muscle fatigue
  • Muscle imbalance/ weakness
  • Excessive capsular laxity
common sites of injury
Common sites of Injury
  • Glenohumeral capsule
  • Glenoid labrum
  • Rotator cuff musculature
evaluating the throwing athlete
Evaluating the throwing athlete
  • Range of motion
  • Muscle strength
  • Laxity
  • Proprioception
factors to consider
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
Total Motion Concept
  • ER + IR = total motion
  • Sum of ER + IR = throwing vs. non throwing shoulder (+/- 5)
wilk k e asmi 2003
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
Throwers Laxity / Acquired Laxity
  • Describes the anterior capsule and inferior capsule
  • Most likely is acquired over time.
wilk k e asmi 200312
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
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
4 Parts of Treatment Program
  • Activity modification
  • Flexibility exercises
  • Strengthening exercises
  • Gradual return to throwing
rehabilitation program for the overhead thrower
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 Treatment
phase 2 intermediate phase
Phase 2- Intermediate Phase
  • Goals:
  • Progress strengthening exercise
  • Restore muscle balance
  • Enhance dynamic stability
phase 2
Phase 2
  • Continue stretching and flexibility
  • Primarily IR and horizontal adduction
  • Progress strengthening program
  • Throwers Ten program
  • Core strengthening
  • LE strengthening
strengthening exercises
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
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
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
Exercises: Phase 3
  • Throwers Ten Program
  • Manual Rhythmic Stabilization
  • Plyometric drills
  • Dynamic stabilization
plyometric program
Plyometric Program
  • Two handed drills:
  • Chest Pass
  • Overhead soccer throw
  • Side to side throw
  • Side throw
plyometric program cont d
Plyometric Program cont’d
  • One handed drills
  • standing throw (feet fixed)
  • wall dribbling
  • Plyometric step and throw
phase4 throwing program initiation
Phase4Throwing Program Initiation
  • Begin with shadow / mirror throwing to work on proper mechanics.
criteria to begin throwing
Criteria to begin Throwing
  • Satisfactory clinical exam
  • Painfree ROM
  • Satisfactory isokinetic test results
  • Appropriate rehab progress
interval throwing program
Interval Throwing Program
  • Designed to gradually increase quantity, distance and intensity.
throwing program 2 phases
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
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
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
phase 4 return to throwing
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
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
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
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
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
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 d50
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 d51
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
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
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 recommendations54
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 recommendations55
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
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.