Transcript Rehabilitation of the Throwing Athlete

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
35 throws
25 throws
35 throws
25 throws
35 throws
25 throws
feet.
35 throws
feet.
@ 45 feet, rest 5 min. 25 throws @45 feet.
@ 45 feet, rest 5 minutes, 35 throws @45 feet.
@ 60 feet, rest 5 minutes, 25 throws @ 60 feet.
@60 feet, rest 5 minutes, 35 throws @60 feet.
@ 90 feet, rest 5 minutes, 25 throws @90 feet.
@90 feet, rest 5 minutes, 35 throws @ 90 feet.
@ 120 feet, rest 5 minutes, 25 throws @ 120
@ 120 feet, rest 5 minutes, 35 throws @ 120
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
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
10
10
10
10
10
throws
throws
throws
throws
throws
throws
@30’, rest 8 min., 10 throws @ 30’
@45’, rest 8 min, 10 throws @ 45’
@ 60’, rest 8 min, 10 throws @ 60’
@ 75’, rest 8 min, 10 throws @ 75’
@ 90’, rest 8 min, 10 throws @ 90’
@ 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): 13711375, 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.
Thank You