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“You have your Uvulus Muscle & It Connects to the Upper Dorsimus:”Functional Anatomy of
the Shoulder
Dan Lorenz, DPT, PT, ATC/L, CSCS
April 12-13, 2017
WPTA Spring Conference
Thank you!!
• Mark Lydecker, Erik Gregersen, Erin Bellin, Janet Palmatier
• Froedert Medical Center
• My family
• My mentors
• YOU!
“Allow myself to introduce…myself”
• Originally from Chicago area
• B.S and M.S. PT from GVSU
• DPT Univ of St. Augustine
• Chicago White Sox MLB AT intern, 1997
• Duke University Sports PT Fellowship, 2004-2005
• Director of Rehab/Assistant AT, Kansas City Chiefs
• Current practice owner, SSOR
• Chair, SPTS Sports Performance Enhancement SIG
Disclaimer…
In an effort to avoid this…
Cliff’s Notes on Shoulder Anatomy/Function
Scapula/Scapulothoracic Anatomy Culham & Peat, JOSPT 1993
• Lies at the level of the 2nd thoracic vertebrae to the 7th vertebrae
• Rests about 5-6cm from the spinous processes
• Glenoid has a downward inclination in normal shoulders
• Postulated that resting position of the scapula is altered in subjects with abnormal thoracic and
cervical spine sagittal alignment
Scapular Muscles
Posture/Scapular Position
• “Upper Crossed Syndrome” Janda
• “SICK” Scapula Burkhart and Morgan
SICK Scapula
• Type I
• Inferior medial border prominence
• Tight: pec major/minor
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Tight: pec major/minor
• Weak: Low trap, serratus
SICK Scapula
• Type II
• Medial border prominence
• Weak: Upper and lower trap, rhomboids
SICK Scapula
• Type III
• Superiormedial border prominence
• Tight: Levator scapulae
• Weak: Rhomboids
Role of the Scapula
• Stable part of GH articulation
• Dynamically positions glenoid
• Base for muscle attachment
• Need to maintain length tension relationship
• Posture
• Improper training methods
Orientation
• 30-35° in anterior to the frontal plane
• Why we need to do rotator cuff exercises in the scapular plane!!!!
Orientation
• Upwardly rotated 5-10° in frontal plane
• Forward tilt in scapular plane
• Worsened by posture, improper training methods, sport demands
• 2-3 inches from spine
• Inferior angle at T7
• Spine at T3
Stabilizers
• Trapezii
• Rhomboids
• Levator scapulae
• Serratus Anterior
Extrinsics
• Deltoid
• Bicep
• Triceps
Intrinsics
• Rotator Cuff
•
•
• Do you remember the force couples in the shoulder? Why are these so important??
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Do you remember the force couples in the shoulder? Why are these so important??
Force Couples
• Elevation
• Rotator cuff
• Deltoid
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• Elevation
• Upper Trap
• Serratus
• Lower trap
• Depression
• Lower trap
• Infraspinatus
• Teres Major
• Rhomboids
• Posterior deltoid
Faulty Mechanics: Anterior Tilt
• Ludewig & Cook, JOSPT 2000
• Increased tilt between 90-120° elevation in subjects w/ impingement
• Lukasiewicz et al, 1999, Warner et al, 1992
• Decreased subacromial space
Faulty Mechanics
• Borich et al, 2006
• Correlation of limited IR and scapular anterior tilt
• Eccentric overload to posterior cuff
• HH retroversion
• Thickening of posterior capsule
• Anterior shoulder tightness
Faulty Mechanics
• Ludewig et al, 1996
• Superior translation of HH
• RC weakness
• RC fatigue
• Secondary impingement
Faulty Mechanics
• McQuade et al, 1998
• Fatigue affected SH rhythm
• Cools et al, 2003
• 39 OH athletes w/ impingement
• 30 normal OH athletes
• EMG muscle latency of traps
• Delay in middle and lower trap activation in injured group
Faulty Mechanics
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• Thoracic Spine
• Excessive protraction
• Excessive anterior tilt
• If flat, excessive winging
• Janda’s Upper Crossed Syndrome
Slouched Posture Reduces Motion Uhl
• Shoulder abduction ROM
• Erect: 157.5°(+10.8)
• Slouched: 133.9(+13.7)
•Abduction strength @ 90°
Erect: 10.4kg (+4.5)
Slouched: 8.7kg (+3.5)
•Scapular Kinematics
•Upward rotation
Erect: 43.1(+7.5)
Slouched: 37.9°(+6.5)
•Posterior tilt
Erect: 44.7°(+6.8)
Slouched: 40.6°(+6.9)
Kebaetse et al. Arch Phy Med Rehab 1999
•
Can We Measure it Clincally? Uhl
• Short pectoralis minor group at 90°elevation
• 7° < External Rotation
• 6° < Upward Rotation
• 7° < Posterior Tilting Borstad & Ludewig JOSPT 2004
• Measure pectoralis minor length from 4th rib tocoracoid
• High reliability ICC=.82
• Based on the sample of 26 subjects typical lengths were 16 +.3 cm Borstad JOSPT 2008
SH Rhythm
2:1, but found to be highly variable
Scapular Retraction
• Provides stable base and starting point for proper mechanics
• Cocking phase (elevation and ER)
• Rhomboids and middle traps
• Associated w/ thoracic rotation and extension
• Why we’ve got to make sure the thoracic spine moves!!
Scapular Protraction
• Shoulder transitions from cocked position to throwing position
• Serratus anterior
• Pec minor
Glenohumeral Joint
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• Surface of fossa is only ¼ to 1/3rd of the humeral head
• Labrum deepens the cavity and makes up 50% of the depth and is important in joint stability
• Capsuloligamentous Mechanisms
• SGHL – prevents inf displacement of HH in the adducted, dependent arm
• MGHL – lies under subscap, attaches on lesser tuberosity; limits ER between 0-90°
• IGHL – “Hammock effect”; limits inf translation during elevation
Shoulder Ligaments
Musculotendinous Cuff
• Rotator cuff functions to COMPRESS and DEPRESS the humeral head
• Supraspinatus and deltoid are prime movers for abduction
• Infraspinatus, subscap, and teres minor compress AND downwardly translate
• Inman has reported that the infraspinatus is at peak activity at 120° of elevation, teres minor at
180° to “seat” the humerus JBJS 1944
Rotator Cuff
Posterior Shoulder/Rotator Cuff
Shoulder Neurovascular Anatomy
Suprascapular Nerve Entrapment & Quadrilateral Space Syndrome
Thoracic Outlet Syndrome
Paget-Schroetter Syndrome (“Effort Thrombosis”)
Core Anatomy – “Serape Effect”
THANK YOU!!!
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Examination and Treatment of the Upper Extremity Pathologies in the Athletic
Patient
Dan Lorenz, DPT, PT, LAT, CSCS
Director of Clinical Operations/Owner, SSOR Physical Therapy
WPTA Spring Conference
April 12-13, 2018
Objectives
• Discuss various shoulder and elbow pathologies in the athlete and regular Joe/Jane
• Highlight relevant examination procedures
• Discuss evidence-based approach to rehabilitation of post-operative conditions
Evidence-Based Medicine
“Evidence-based practice is the integration of (1) clinical experience and expertise, (2)
patient values, and (3) the best evidence (research) into the decision making
process for patient care.”
Sackett DL, Straus SE, Richardson WS, et al. Evidence-based medicine. Churchill
Livingstone: New York. 2004.
Medical Screening
• Pain that does not vary and is present at rest, especially if at night
• Pain that doesn’t vary with position
• Symptoms that fluctuate with organ function, related to eating or defecation
• Changes in general health
– Fever, chills, malaise
– Unexplained weight loss
– Nausea > 2 weeks duration
Good rule of thumb…
We should be able to provoke the pain through the exam and/or affect it by treatment
• If not, it is likely not a musculoskeletal problem!!!
Shoulder Paradox
• “Intrinsically unstable”
– “Seal balancing a ball” Rowe, Zarins JBJS 1981
• Must be loose enough to perform sport movements, but stable enough so as to
not have injury
Key components of Exam
• History
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History
• Palpation
• ROM
• Laxity Assessment
• Muscle strength testing
• Special Tests
• Cuff
• Instability
• SLAP tests
Excellent Reference for the Shoulder Exam IJSPT 2013
History
• Age
• Years throwing
• Other sports?
• Hand dominance
• Level of competition
• Innings pitched
• Pain scale
• Tenderness
• “PQRST” Boissonault
Chief Complaints
• Why are you here?
– Pain? Velocity decrease?
• When and how did it start?
• Onset?
– Insidious or traumatic
• Worse/better?
• When during motion is pain present?
Shoulder Complaints
• Symptoms
– Also need to check for entrapments, brachial plexus injury etc
• Characteristics
– Location
– Severity
– Provocation
– Duration
– Paraesthesias?
• Injury pattern
– Sudden or traumatic
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Sudden or traumatic
– Traumatic blow or fall
– Recurrence
Physical Exam of the Shoulder
• Hegedus et al, BJSM 2008
– Poor sensitivity and specificity for Neer and Hawkins signs
– SLAP tests: Speeds Test fair results
– High sensitivity and specificity
• ER Lag Sign
• Biceps Load II
• Apprehension Sign
• Relocation/Release Test
Physical Exam of the Shoulder Hegedus et al, BJSM 2012
• “Based on the review…use of any single test to make a pathognomonic diagnosis
cannot be recommended”
• “Combinations provide better accuracy, but marginally so”
Stability Tests
• Sulcus at 0° abd, 45° abd (optional), 90° abd (optional) O’Brien et al, AJSM 1990
• Load and Shift Sillman & Hawkins 2009
• Apprehension and Relocation Jobe, 1990
• Hyperabduction Test
•
Labrum Tests
• Speeds
• Grind Test Snyder 1990
• Clunk Test Andrews, 1985
• Dynamic Labral Shear
• Active Compression Test O’Brien AJSM 1998
• Biceps Load I and II Kim AJSM 1999, Arthroscopy 2001
• ER Supination Test Myers AJSM 2003
• Pronated Bicep Load
Rotator Cuff
• Neer Neer JBJS 1972
– Passive elevation w/ IR
• Hawkins-Kennedy Hawkins AJSM 1980
– Elevation in scapular plane, IR at 90° abd
• Full Can
• Lag Signs Hertel JSES 1996
• Napoleon Test Takeda et al, Arthroscopy 2016
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Napoleon Test Takeda et al, Arthroscopy 2016
– Subscap tears; Sens 65% for detecting partial tears, 85% for full thickness
– Supine, hand on belly, try and lift elbow
• Lift off Gerber JBJS 1991
•
Resisted Movements
• ER at side
• IR at side
• Shoulder abd at 90°
• Full can
• ER/IR at 90° abd
• Biceps
• Retraction, protraction
• Lower trap
Strength Testing
• Using HHD at 90° abduction in supine is a reliable method to determine strength of
the RC Michener et al, Phys Ther 2005; Turner et al, J Sport Rehab 2009; Tyler et al
JSES 2005
Strength Testing
• McLaine et al, J Sport Rehabil 2015
– Isometric tests of the shoulder w/ HHD in sitting, supine, and prone
• Flex/Ext at 140° in scapular plane, IR/ER at 90° abd
– Good to excellent intra-rater reliability
– Intra-rater reliability not affected by position
–
• Cools et al, JSES 2014
– Acceptable reliability using HHD
• Cools et al, KSSTA 2015
– Normative data established for 18-50 y.o for HHD RC testing
Palpations
• Supraspinatus
• Biceps tendon
• Bursae
• Posterior cuff
• Pec minor
• Latissimus dorsi tendon in the shoulder
• Cervical?
NV Assessment
• Skin color
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• Temperature
• Pulse
• Sensation
• TOS Tests
– Adson’s Manuever
– Halstead’s Test
– Roos Test
– Allen Test
Upper Limb Tension Testing
Upper Limb Tension Testing
Upper Limb Tension Testing
Examination
• Posture
• Inspection for asymmetries
• C-spine screen
• AROM
• PROM
– Quantity
– End feel
– Six motions: scapular plane elevation, ER at 90° abd, IR at 90° abd, ER in scapular
plane, Horiz add at 90° abd, horiz abd w/ ER
Anterior Shoulder Instability Manske
• HISTORY
– Sensation of subluxation with abducted and externally rotated position
– Discomfort due to chronic instability
– Pain in anterior and inferior shoulder
– Difficulty with overhead functional activities
Laxity v. Instability
• Laxity – ability to translate the humeral head on the glenoid
• Instability – clinical condition in which unwanted translation of the humerus
compromises the comfort and/or function of the patients shoulder
Continuum of Stability
• Static stability
– Ligaments, capsules, labrum
– Special tests
• Dynamic stability
– Musculotendinous
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Musculotendinous
– Muscle testing
• Neuromuscular stability
– Proprioception
– Kinesthesia
– Functional testing
Mechanoreceptors Vangsness et al
• Have adaptability
– Pacinian corpuscles – FAST adapting
• Not as abundant in shoulder
• Compression AND tension
– Ruffini endings – SLOW adapting
• Responds to changes in tension (Continuous)
• Most abundant receptor in shoulder
Dynamic Stability
• Muscles provide dynamic stability in the middle ranges where ligaments are lax
• Rotator cuff functions to:
– Depress humeral head during elevation
– Compress head into glenoid to promote stability
Saha, Acta Orthop Scand 1971; Itoi et al, JBJS 1994; Cain et al, AJSM 1987
Classification
• Onset
• Degree of laxity
• Frequency
• Lesion presence?
• Volition?
• Direction
• Arm dominance
• Age
• Timing
• Desired activity level
Mechanism
• Generalized laxity
• Previous history of subluxation/slipping
• Chronic instability may be symptomatic
Mechanism
• Posterior blow to the arm
• Posterior force on anterior aspect of ABD/ER shoulder
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• Active patients <20 yrs old have extremely high recurrence rates, exceeding 90%
– Arciero et al, JBJS 1998
– Matsen FA et al, CJSM 1984
– Postacchini et al, JSES 2000
– Rowe CR, Surg Clin North Am 1963
– te Slaa et al, JBJS Br 2004
Evaluation
• Assess motion and strength
• Apprehension and relocation +
• Sulcus sign +
• Upper quarter screen
– May have cervical complaints or referred scapular pain
• Might check for systemic hypermobility
– Beighton scale
Load & Shift
Bankart lesion
• Anterior shoulder dislocation causes avulsion of labrum from glenoid as well as
avulsion of the AGHL
• Results in ant and possibly inf shoulder instability
• Main lesion repaired during shoulder stabilization procedures
LHB Importance
• LHB is a depressor of the humeral head
– Itoi et al, JSES 1996
• Becomes more important as a stabilizer once RC fatigue surfaces
• With bicep loading, there is significantly decreased A/P translation, particularly w/
ER Itoi et al, JSES 1994
• With an artificial Bankart lesion, the biceps is more important than any other RC
muscle in stabilizing the GH joint against anterior translation Itoi et al, JBJS 1994
SLAP Lesions
• First described in 1985 by Andrews et al, AJSM
• Labral injuries in throwers
• They postulated that tensile failure at the biceps attachment was the MOI
• Biceps contracted eccentrically to decelerate the extending elbow during follow-
through phase of pitching
SLAP Lesions
• Term coined by Snyder et al, Arthroscopy 1990
• “Disruption of the superior labrum-biceps complex involving tearing, separation, or
both of the superior labrum, beginning posterior to the biceps tendon insertion
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both of the superior labrum, beginning posterior to the biceps tendon insertion
and extending anteriorly”
External Rotation-Supination Test
Dynamic Labral Shear
O’Brien’s Test/Active Compression
“Dead Arm Syndrome”
• Pathologic condition in which the thrower is unable to throw with pre-injury
velocity and control because of a combination of pain and subjective unease in the
shoulder
• Usually pain or discomfort occurs in the late cocking phase of the throw as the arm
begins to move forward
SLAP Lesions
• Classic description of a patient w/ a labral tear is one whose shoulder has pain w/
palpable clicking
– Liu et al, AJSM 1996
• Rarely are labral tears seen without the presence of instability
– Hurley, AJSM 1990
– Rames, Orthop Clin North Am 1992
– Timan, Radiology 1993
Mechanism
• Shoulder is forcefully ABD and ER
• Posterior force to humerus w/ shoulder in 90° of forward flexion
• Superior labrum w/ biceps tendon traction
• FOOSH w/ ABD and forward flexed arm
In Throwers…
• Tensile Overload
– Superior labrum
– Rotator Cuff
– Posterior capsule
• Compressive/Shear Overload
– Internal impingement and SA Impingement
• Torsional Overload
– Labrum (Peel Back)
– Rotator Cuff
SLAP Symptoms
• Pain
• Pain greater w/ overhead activity
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Pain greater w/ overhead activity
• Painful catching and popping
• “It feels deep in there”
• Classic description of patient w/ labral tear is one whose shoulder has pain with
throwing activities and palpable clicking Liu
“Peel Back Mechanism”
• Torsional force “peels back” the biceps and posterior labrum as the shoulder goes
into extreme ABD/ER during the cocking phase
• Peel back repeated every time the arm is brought into the cocked position causing
progressive failure over time, with gradual enlargement of the lesion Burkhart and
Morgan, Arthroscopy 1998
Normal
Pathologic
Good Read on SLAP’s IJSPT 2013
Biceps Tendinopathy
• HISTORY
– Tenderness over anterior upper arm
– Pain with supination of forearm
– Pain with overhead or throwing motion
– Snapping sensations in upper anterior arm
Mechanism
• Chronic repetitive overhead activities
• May be secondary to other issues
Evaluation
• Motion rarely limited
• Tenderness to palpate biceps tendon/bicipital groove
• May have decreased strength
• Speeds, Yergason’s and Biceps load tests +
• All imaging may becompletely normal
• Rotator cuff status? Might be the culprit!!
Bicep Load I and II
Primary Impingement
• HISTORY
– Ages 35-55
– If younger think secondary vs primary
– Anterior or anterolateral shoulder pain
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Anterior or anterolateral shoulder pain
– Painful arc
– Night pain
– Pain with OH activities
Mechanism
• Chronic Repetitive overhead activities
• Poor posture and scapular control
• Acromion abnormalities
Evaluation
• Decreased rotator cuff and scapular strength
• Tendons tender to palpate
• Limited glenohumeral motion
• Evaluate scapular mechanics
• Posture
• Neer’s impingement, coracoid impingement, and Hawkins-Kennedy +
• Plain films canexclude spur or DJD
• MRI excludes RTC tears
Neer’s
Hawkins-Kennedy
Coracoid Impingement Sign
Secondary Impingement Syndrome
• HISTORY
– Younger athlete ages 15-35 years of age
– Anterior or anterolateral shoulder pain
– Painful arc
– Night pain
– Pain with overhead activities
Mechanism
• Chronic
• Repetitive overhead activities
• Poor posture and scapular control
• Acromion abnormalities
• Usually underlying laxity or instability
Evaluation
• Decreased rotator cuff and scapular strength
• Tendons tender to palpate
• Excessive glenohumeral motion
• Evaluate scapular mechanics
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Evaluate scapular mechanics
• Neer’s impingement, coracoid impingement,and Hawkins-Kennedy +
• Sulcus sign and load and shift +
Thoracic Outlet Syndrome
• HISTORY
– Neurologic symptoms, vascular symptoms or both
– Discoloration of skin
– Numbness and tingling with overhead activities
– “Heavy” feeling in arm
– Paget-Schroetter Syndrome??
Mechanism
• Chronic
• Repetitive motions
• Breathing?
• Tightness of scalene’s, pectoralis minor, limited mobility under first rib
• Table to posterior edge of acromion should be 1” Sahrmann
Evaluation
• Rule out cervical spine
• Decreased scapular and rotator cuff strength
• Chest breather? Diaphragmatic?
• Assess shoulder ROM and muscle flexibility
• Adson’s test, Roo’s test, Allen’s test and military brace test may be positive
Allen Test
Roos Test
“Military Brace” Test
Did you Know??
• Wisconsin is the only state to offer a Master Cheesemaker program
• Takes 3 years to complete and you need at least 10 years of cheesemaking
experience to be a candidate
Posterior Shoulder Pathologies
Internal Impingement
• HISTORY
– Chronic
– Usually OH athlete
– Posterior shoulder pain w/ activities
– Pain more with OH activities in 90/90 position, late cocking
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Pain more with OH activities in 90/90 position, late cocking
– Limited IR ROM
• GIRD
• Horizontal adduction
Internal Impingement Walch et al JSES 1992
• An intra-articular impingement that occurs in the ABD/ER position
• Undersurface of the post/sup RTC contacts the post/sup glenoid labrum and may
become pinched between labrum and GT
• May progressively worsen due to repetitive stretching of the ant
capsuloligamentous structures
Internal Impingement
• Most important pathologic process is loss of IR in abduction, not the gain in ER
• Acquired IR caused by post/inf capsule contracture is the essential lesion that
results in increased ER
• Can occur w/o ant capsular laxity
Examination
• Clearly identify location of pain
• Assess ROM
– May have GIRD
– May have excessive motion
• Assess manual muscle tests
• Passive joint play
• Jobe’s subluxation relocation test
•
Posterior Shoulder Instability
• HISTORY
– Sliding out of the back
– Cross body movements
• Swinging a baseball bat
• Follow through on golf swing
– Blocking
– Swimming strokes
– Repetitive or single event
Mechanism
• Acute or chronic
• Specific motions may create symptoms
• Fall on flexed shoulder or cross body movement
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Fall on flexed shoulder or cross body movement
Examination
• Assess passive and active ROM
• Assess manual muscle test
• Posterior instability tests
– Jerk Test
– Posterior apprehension test
• Passive joint play assessments
Scapular Winging/Tipping/Tilting
• HISTORY
– Pain
– Gradual onset
– OH activities
– Many causes
– Abnormal scapular positions
– May affect all shoulder motions
– Is this a normal anatomical variant?? Plummer et al, JOSPT 2017
Mechanism
• Poor posture
• Chronic
• Repetitive OH activities
• Often seen with impingement
Examination
• Posture
• Manual muscle tests
– Scapular stabilizers
– Rotator cuff muscles
• AROM and PROM
• Assess scapulohumeral rhythm
Dyskinesis Hickey et al, BJSM 2018
Scapular Dyskinesis Uhl
• Recent 3-D kinematic analysis suggest that asymmetry is very common
• The dominant side scapula appears to be more internally rotated and anteriorly
tilted in healthy college athletes Oyama JAT 2009
• 76% of 56 participants had at least one plane of scapular asymmetry Uhl
Arthroscopy 2009
• Observation of dyskinesis does not indicate injury but in the presence of symptoms
should be a trigger to further investigate causes
•
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Exam of Tests Used for Scap Dyskinesis in Subj w/ Shoulder Pain Lange et al,
Phys Ther Sport 2017
• Systematic review
• Over 3200 articles, only 15 met inclusion criteria
• Conclusions:
– Lack of high quality inter and intra-rater reliability
– Manual correction only used in 1 study, but yet, we use it to guide treatment
– Strong need for more research
– Level III evidence
Quadrilateral Space Syndrome
• HISTORY
– Axillary nerve entrapment
– Baseball, softball, volleyball and tennis
• High index of suspicion
– Vague nondescript posterior shoulder pain often with symptoms down the
posterior aspect of the arm
Mechanism
• Acute or chronic
• Insidious onset
• During OH athletic events
Examination
• Loss of motion
• Pain at end range of motion ER
• GIRD
• Pain to palpation in QS
• Radicular symptoms into forearm
• Thickened band posteriorly
Suprascapular Nerve Entrapment
• HISTORY
– Usually chronic condition
– Vague posterior pain
– Strength sometimes spared
– ROM may be limited and painful
– Cyst from labral pathology
– Might report weakness or fatigue w/ activity
Mechanism
• Repetitive OH motion
• Forceful internal rotation motion
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Forceful internal rotation motion
Examination
• May be relatively painless pathology
• RTC strength testing
• Visual inspection for atrophy
• Assessment of ROM
• Heaviness in arm
• Pain intoneck and upper back
• Check dural tension
What is “normal” for throwers?
• Wilk et al, CORR 2012
– ER 132 +/- 9
– IR 52 +/- 9
– Pitchers greater ROM that position players
– TROM DOM 184°, Non-DOM 190°
Total Motion Concept
• ER + IR = Total Motion
– Wilk et al, AJSM 2002
– Wilk et al, JOSPT 2009
• Check IR total and isolated IR
• Humeral head retroversion will change this
– HH Retroversion Assessment
– Can we measure it clinically?
TROM and GIRD
GIRD Manske et al, IJSPT 2013
• Anatomical GIRD: normal in OH athletes characterized by loss of IR <18-20°
• Pathological GIRD: loss of 18-20° of IR coupled with corresponding loss of TROM
>5°
• Problems occur if GIRD:ER Gain ratio >1
Post cuff/Eccentric Overload/GIRD
ROM Deficits
• Camp et al, Arthroscopy 2017
– Level III retrospective review of preseason ROM measures and possible
relationship to shoulder and elbow injury over 6 seasons in one MLB team
– 53 injuries in 132 pitcher seasons
– Most significant risk factor for elbow injury was >5° loss of ER
– Risk of elbow injury increased 7% for each degree of ER loss and 9% w/ each
degree of flexion deficit
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– None correlated to shoulder injury
Hmm…may be on to something
• Noonan et al, AJSM 2016 showed:
• Increased humeral retrotorsion lead to more ELBOW injuries
• Less retrotorsion leads to more SHOULDER injuries
Posterior Shoulder Tightness Assessment Kolber & Hanney, NAJSPT 2010
• Normal horizontal adduction in supine w/ scapula fixed is 20°
• Sidelying assessment w/ inclinometer is reliable
Scapular Assistance Test
• Pt elevates indep
• Clinician fixes scapula and assists w/ upward rotation
• Interpretation -scapular motion deficiency may be a factor in producing symptoms
Kibler & McMullen JAAOS 2003
• Reliability ranged from .53 -.92 (kappa) Rabin et al., JOSPT 2006
•
“Flip” Sign
• Resist ER and watch for the scapula to reposition or the medial border become
more prominent
• Indicative of scapular weakness
Retraction Test
• Pt seated, elevates indep
• Clinician retracts scapula and then repeats
Retraction Test
• Increase in strength in retracted position
– 24% in injured
– 13% in controls
• No change in pain
• Apparent cuff weakness may be arising from poor scapular control Kibler et al,
AJSM 2006
Did You Know?
Wisconsin was the 1st state to institute a statewide income tax
Rehabilitation of the Athletic Shoulder Noyes
• Posterior cuff and capsule length
• Scapular retraining
• NM re-training of rotator cuff
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• GH dynamic compression stabilization
• Total body coordination/synergy
Regardless of age/level for PERFORMANCE…
• The Athletic Shoulder needs:
– Cooperation with the thoracic spine and scapula
– Fitness base/work capacity
– Hip mobility and stability
• We say the same thing about the shoulder, yes??
– Single leg stability/balance
– Strength
• Deceleration/braking
• Starting strength
– Power/explosiveness
• Linear and rotational
Non-Operative Rehab: Instability
• Early controlled motion
– To tolerance
– Motion not stretching!
– Do not stretch!
• Restore dynamic stability
– Hold static
– Dynamic – move through space then stabilize
– Closed chain
• Restoration of proprioception
– Awareness of position
• Stable base of support
– Proximal stability
Non-Operative
• Perturbation Training
– End range stability
– Postural/positional disturbance
• Improve endurance/tolerance
– 1) High Load, 2) Reps to fatigue 3) Isometric holds + reps
– Fatigue affects strength
– Fatigue affects proprioception, 45-78% decline Voight JOSPT
• Functional Drills
– Plyometric drills
– Sport drills
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Sport drills
Bottom Line…
• Dynamic stabilization and NM control
• Strengthen cuff muscles, especially ER muscles
• Dynamic stability comes from co-contraction
• CLOSED CHAIN
• Rhythmic stabilization, perturbations, sustained holds/endurance
POST-OPERATIVE
• Rotator Cuff Repair
• Bankart Repair
• SLAP Tears
Did You Know?
• The 21st Amendment which repealed Prohibition nationwide, was authored by
Wisconsin Senator John Blaine
Rotator Cuff Repair
• Inflammatory Phase 0-3 days
• Proliferative phase initiates week 1 with increased fibroblasts till week 4
• Maturation Phase
– Collagen maturing by 2 months
– 4 months maturation of repair site
• Sharpey’s fibers START AT MONTH 3!
– Sonabend, JBJS 2010
– False safety at 6 weeks!
Are you really immobilized?
• Smith et al, JBJS 2004
– Pulling open a door activated rotator cuff 10-20% MVIC
– Pushing open a door quickly activated infraspinatus 45-60%
– Reaching with contralateral limb faciliates scapular mm action in the involved
limb 20-60%
– Don’t drink a beverage w/ the involved side! High RC activity Long et al, JOSPT
2010
What about Ball Squeezes??
• Max squeeze activated cuff but not >20%
• Careful if bicep tendon repaired or tenodesis>>>increased activity
– Alenabi et al, JSES 2013
What about Pendulums?
• Lowest EMG of the cuff w/ small circles (20 cm)
– Long et al, JOSPT 2010
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Pool/Aquatic Therapy
Kelly BT et al., JOSPT 2000
• Shoulder elevation in the water at slower speeds resulted in a significantly lower
activation of the rotator cuff and synergistic muscles
• Allows for earlier active motion in the post-operative period without compromising
patient safety
Early v. Delayed ROM
• Why DELAY??
– Evidence of high RC failure rate
– Healing (Sharpey’s fibers) take 3 months or so >>watch excessive tension!
– Immobilization doesn’t weaken tissue
– Immobilization/”stiffness” may help long-term
Early v. Delayed
• 3-6 weeks of immobilization has shown:
– Increased healing in rats Gimbel 2007, Thomopoulus 2003
– Increased heaing without stiffness Sarver 2008
– Parsons, JSES 2010
• Retrospective review
• Immob 6 weeks
• Grouped into stiff v. non-stiff
• No differences at a year out
Early v. Delayed
• Think longer immobilization if poor healing potential:
– Multiple tendon repair
– Large tear repair
– Poor tissue quality
– Significant fatty degeneration/atrophy
• Not likely in young athletes
– Older patients
HALFWAY POINT!!
• Let’s get off our asses…
• Hip mobility circuit time
Early v. Delayed
• Think PROM early if:
– Single tendon repair
– Small size tear
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Small size tear
– Good tissue quality
– Partial thickness
– <50 yo
– Adhesive capsulitis
Research
• Shurong et al, AJSM 2013
– Rabbits (30) compared:
• No immobilization in cage
• Immobilization – casted 6 weeks
• Immob w/ PROM (cast removed for part of the day)
– Non-immobilized: significantly worse healing via MRI, histological, biomechanical
studies
– Immob and immob w/ PROM – no differences
– Early PROM harmless in this study
–
Early v. Delayed
• Saltzman et al, JSES 2017
– Systematic review comparing early v. delayed motion to evaluate for higher
failure rate or more successful outcome
– Comparable functional outcomes and retear rates at 1 year in each group
– Early group had better motion up to a year
– Re-tear rates larger in early motion and large tears
Well, what if we don’t fix ‘em?
• Piper et al, JSES 2018
– Systematic review/meta-analysis of Op v. nonop treatment for full thickness RCT
– Only 3 studies qualified, 269 patients, 59-65 yo
– Statistically significant improvement in outcomes in operative group in Constant
and VAS scores but not clinically significant
Rehabilitation
• Begin in supine position with passive and active assisted exercises
– These show <20% MVC of the rotator cuff muscles
• McCann et al, CORR 1993
• Uhl, Am Acad Phys Med Rehabil, 2010
Active v. Upright-Assisted v. Gravity Minimized Exercises Gaunt et al, Sports
Health 2010
• Evalutation of anterior deltoid, supraspinatus and infraspinatus EMG
• Upright active elevation showed highest activity level for all muscles
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Upright active elevation showed highest activity level for all muscles
• Gravity-minimized exercises generated lowest EMG activity for IS and SS
EMG of the Cuff
• Gaunt et al, Sports Health 2010
– Gravity-minimized and upright-assisted elevation exercises similar in strain to
supraspinatus and infraspinatus
• Base progression on other factors
– “Wall walk found to generate more EMG activity of cuff than all exercises for ant
deltoid and supraspinatus”
EMG of Shoulder Exercises McCann et al
• Measured EMG of common passive, active, and active assisted exercises
• Supine exercises (passive, AA) should be considered in early p/o period to achieve
max motion w/ least amt of muscle activity
• Caution isometrics due to high levels of EMG activity
EMG of Shoulder Exercises Uhl et al
• EMG of common p/o passive, active-assisted, and active exercises
• Previously recommended that p/o exercises cause <20% MVC of rotator cuff
muscles
• Passive and active assisted exercises are safe in supine
– “Forward bow” the best one
• Active elevation in upright posture showed highest activation of rotator cuff
Post-Operative ROM: “Forward Bow”
AAROM
Gravity-Eliminated AROM
Flexion in Sidelying
“Safe” Exercise
“Safe” Exercise
Progression of Exercises
• AAROM in supine
• AROM in supine
• “Beach Chair”/Recliner scaption
• Standing punch/”Wash cloth Press Up”
• Active elevation against gravity
– 90° is goal w/o UT compensation
• Progress to 120° Inman VT et al, J Bone Joint Surg, 1944
– Teres minor peaks at 120°
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• Progress to 180°
– Infraspinatus peaks at 180°
•
Rehab Guidelines McMullen et al
• Appropriate scapular motion requires muscular flexibility
– Pec Minor
• Best stretch is unilateral self-stretch in doorway
–Borstad et al, JSES 2006
–Recent study showed 90° and 150° best, Borstad 2006 just had 90°
– Upper trapezius
– External rotators
Pec Minor Techniques
Pec Minor
Rehab Guidelines
• CLOSED CHAIN exercises are key, even for the overhead athlete
– Provides co-contraction of the rotator cuff at submaximal levels Dillman et al, J
Sport Rehabil 1994; Kibler et al, Adv Oper Orthop 1995
– Decreases GH translation Warner et al, JSES 1999
– Increased UMN activation in those w/ spinal cord injury Gefen et al Spinal Cord
1997
–
Rehabilitation of the Shoulder
• What is the optimal plane for elevation??
– SCAPTION W/ ER
• Minimal capsular stress Doody, 1970
• Optimal length-tension relationship Lucas 1973
• Optimal SA clearance
–> in scapular plane Muraki, 2012
–> in ER Flatow, 1994
• Better scapular mechanics (than empty can) Thigpen, 2006
• When strengthening, equal cuff activation to other standing exercises Reinold,
2007
RCR Summary
• First 6-9 weeks loading across tendon must be minimal
• Protected loads through 12 weeks
– Tendon 50% of tensile strength
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• Too much movement (cyclic loading) = stress at repair site
• No stress = not ideal either
Summary of RCR Treatment Timeline
• Target full AROM by weeks 12-16
• Strength likely to increase up to a year
• Plyometrics around week 16
• Usually ISP start around 6 months
• Functional testing algorithm passed prior to DC
•
Another good resource…Reinold et al, JOSPT 2009
Did You Know?
Barbie comes from the fictional town of Willows, Wisconsin
Rehab Guidelines Schollmeier et al, CORR 1994
• Effect of immobilization
– Progressive restriction in range of motion with increases in intraarticular pressure
– Capsule and subscapular bursa showed focal adhesions
– These values not affected up to 4 weeks
• Protected mobilization is imperative for optimum healing
Keys to Post-Op Rehab
• Protect healing tissue
– Recover and establish strength of surgery
• Restore PROM
– Loss of motion is “kiss of death” in OH athlete
• Restore strength and stability
– Surgery did STATIC, we do DYNAMIC
• Restore imbalances/enhance deficits
– Hips, spine, pelvis
• Gradual criteria-based return
Rehabilitation
• Usually sling for 3-6 weeks
• Depends on:
– Amount of redundancy
– Extent of damage to labrum
– Degree of pre-op sulcus
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Degree of pre-op sulcus
– Uni vs MDI
– Security of fixation
– Concomitant procedures
– Surgeon preference
–
Rehabilitation – 6-16 weeks
• Wean from immobilizer
• Gradual progression to terminal ROM allowed
• Should have full ROM around week 12
• ER progressed from initial 30-45° gradually to full ER
• Ultimate progression is full ER at 90° abduction
– Contract-Relax
– Contract-Relax/Agonist Contract
Return to Activity Phase
• Usually 16+ weeks
• Varies from 4-6 months based on sport and physician preference
• Objective benchmarks:
– ROM
– Muscular strength and endurance
– Shoulder rating systems/outcomes
SLAP Tear/Repair
Type of SLAP Snyder et al, Arthroscopy 1990
• Type I
– Degenerative fraying
– Periphery attached and biceps firmly attached
Types of SLAP
• Type II
– Degenerated and fraying
– Superior labrum and LHB tendon stripped off underlying glenoid
– Unstable labral-bicep anchor
•
Types of SLAP
• Type III
– Bucket handle tear
– Central portion displaced into the joint while periphery firmly attached to the
glenoid
•
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Types of SLAP
• Type IV SLAP
– Bicep anchor and labrum avulsed from glenoid rim
Occurrence Snyder et al Arthroscopy 1990
• Type I 11%
• Type II 41%
• Type III 33%
• Type IV 15%
Post-Operative Rehab
• Depends on the type of repair
• Usually ER is limited for at least 4-6 weeks
• Brace for 6 weeks, sleep too!!
• Limit extension beyond neutral
• No active bicep contraction w/ resistance for up to 12 weeks
• Throwing programs can begin anywhere from 4-6 months
Impingement
• Primary
– Steuri et al, BJSM 2017 – exercise seems best for pain, ROM, and function while
tape, laser, MT, and ECSWT may be added
• Secondary
– Underlying stability issue
• Internal
– Don’t crank into IR, but ensure GIRD doesn’t exist
– Mechanics!
– Thoracic rotation and extension
Good resource! IJSPT 2013
Best Exercises: Serratus Ekstrom et al, JOSPT 2003
• Dynamic Hug
• Push-up plus
• Shoulder abduction, plane of scapula, above 120°
• Serratus punch
• Scaption
• Wall slide
Serratus Progression Decker, AJSM 1999
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Serratus Progression Decker, AJSM 1999
• Least to most challenging based on average amplitude of MVIC
– Shoulder Extension (5+3)
– Press-up (32+28)
– Forward Punch (34+15)
– Scaption(38+10)
– Knee Push-up Plus(40+15)
– Serratus anterior Punch (44+12)
– Dynamic Hug (50+15)
– Push-up Plus (58+17)
One more comment on Serratus…
• Protraction focuses on upper fibers
• Elevation above 120° is needed to address lower fibers of Serratus
– Diagonal Flexion / Adduction / Ext. Rot.
Best Exercises: Upper trapezius
• Rowing
• Military press
• Horizontal abduction w/ ER
Best Exercises: Middle Trap
• Horizontal abduction (Neutral)
• Overhead arm raise in line w/ lower trap
• Horizontal abduction w/ ER
• Prone extension
• Wide-grip rowing
Best Exercises: Lower trapezius
• Abduction
• Rowing
• Horizontal abduction w/ ER
• Prone external rotation
• BIL ER w/ tubing
• Wall swims
• “Robbery” exercise
• Shoulder depression into ball
• Press ups
Bilateral ER
Best exercises: Rhomboids Moseley et al, AJSM 1992
• Horiz abduction (neutral)
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Horiz abduction (neutral)
• Scaption
• Rowing
Prone Retraction Exercises
Prone Retraction Series #2
Best Exercises: Rotator Cuff Reinold & Wilk, JOSPT 2004
• Supraspinatus
– Prone horizontal abduction at 100° w/ full ER
– Prone ER at 90° abduction
– Standing scaption to 90°
• Teres Minor/Infraspinatus
– SLER, 0° abduction
– Standing ER at 45° of abduction
– Prone ER at 90° abduction
–
Some other favorites
Exercise Ideas
Exercise Ideas
Exercise Ideas
Core and Shoulder Link Brummit & Dale, North Am J Sports Phys Ther 2009
• “Exercise that addresses shoulder weakness and core dysfunction simultaneously
may serve as transition between shoulder rehab program and the terminal, sport-
specific functional exercises.”
• Exercises should include:
– Side plank w/ ER
– 3 point plank w/ horiz abd/ER
– 3 point plank w/ row OR extension
– 3 point plank w/ diagonal arm raise
Review of Exercise in Athletes w/ Shoulder Pathology Wright et al, BJSM 2017
• Meta-analysis of Level I-IV RCT’s using exercise for athletes w/ shoulder pathology
• 33 exercises in 6 studies that met the inclusion criteria, 102 in 33 level V studies
• Strongest evidence supports single plane, OKC exercises performed below 90° and
CKC UE exercises
• Sadly, a majority was expert opinion
Core and Shoulder
Core and Shoulder
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Core and Shoulder
Not just the shoulder!
• Hannon et al, IJSPT 2014
– Athletes w/ UCL tears in the elbow had altered balance prior to surgery w/ the
YBT
– Improved over time w/ rehab
– MUST incorporate core and balance training!
CKC
CKC
CKC
CKC
CKC
CKC
CKC
Pearl…
• Smith et al, Arch Phys Med Rehabil 2007
– EMG study of shoulder muscles in immobilized shoulder w/ kinetic chain
exercises
– Cross body rotation increased serratus activity while decreasing supraspinatus,
deltoid, and upper trap activity
– All below 20% MVIC
Example
Reactive NM Training
Keep in mind…
• Isolated training has been positively correlated to functional performance
– Ellenbecker et al, AJSM 1988
– Mont et al, AJSM 1994
– Treiber et al, AJSM 1998
– Davies et al, JSES 2011
• Be careful w/ just “functional training”
Kinetic Chain
• Shoulder “Dumps”
• Step up w/ ER
• Robbery
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• Lawnmower
• Fencing
• Elevation w/ step
Outcome Scales
• UEFI
• Kerlan-Jobe (KJOC) for throwers
• DASH
• UCLA Score
• Constant Score
• Penn Shoulder Score
Did You Know?
• The Cheesehead Hat debuted at a Brewers game, not a Packers game.
• OF Rick Manning wore it in the dugout
The Athlete’s Elbow – UCL Reconstruction
UCL Injuries
• Elbow extends at an avg angular velocity that can exceed 5000° per second
O’Driscoll et al, Clin Orthop 1992; Pappas AM et al, AJSM 1985
• Baseball – 2200° per sec Feltner et al, Int J Sport Biomech 1986
• Softball underhand – 680° per sec Barrentine SW. 12th Annual Injuries in Baseball
course
• Tennis serve – 1700° per sec Dillman CJ, USTA National Meeting
Stages of Ligament Pathology
• Stage I – Edema
• Stage II – Scarring/dissociation of ligament fibers
• Stage III – Calcification
• Stage IV – Ossification
Anatomy
• 3 individual joints in the elbow
• All three enclosed in one capsule
• UCL has three bundles
– Anterior
– Posterior
– Transverse ligament
•
Anterior Band
• Controls valgus forces
– Provides 55% of resistance to valgus stress at 90° of flexion
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• Primary stabilizer of elbow from 20-120° of flexion
• Inserts into ant/med portion of the coronoid of the ulna
Posterior Band
• Becomes taut at 60-90° of flexion
• Originates post/inf to axis of rotation and inserts into the medial aspect of the prox
ulna
UCL
Mechanism
• Result of repetitive valgus overload leading to recurrent microtrauma, attenuation,
and eventual rupture
• 50% of throwing athletes rupture it in a sudden, catastrophic event
• Almost always have pain/tenderness for years associated w/ throwing
Physical Examination
• History of FOOSH causing valgus thrust
• Pitcher may experience a “pop”
• Tenderness around the medial elbow
• Ulnar paresis
• Instability with valgus stress
• Usually + Tinel’s Sign over cubital tunnel
Special Tests
• Valgus Stress test
– Should do in pronation and 20° flexion
• “Good Hands” test
• “Moving Valgus” test
• “Milking” test
• Bounce test
– For osteophytes
Milking Test
Moving Valgus Stress Test
Valgus Extension Overload Syndrome
• Caused from medial laxity leading to radiocapitellar compression
• Posterior pain during acceleration and tenderness along the medial joint line
• Posterior/medial osteophyte develops
Differential Diagnosis
• Arthritis
• Cervical Radiculopathy
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Cervical Radiculopathy
• Chondromalacia
• Cubital tunnel syndrome
• Fibrosis
• Loose bodies
Valgus Extension Overload
Laboratory Studies
• X-rays to rule out other causes of elbow pain
• “Valgus stress radiograph to document joint opening
• “Gravity stress radiograph” – patient supine and shoulder in max ER
• Gold standard is MRI w/ contrast
Post-Operative Rehabilitation
• Emphasize early controlled ROM to avoid excessive stretch of reconstruction
• Encourage use of post-op brace to avoid accidental valgus stress being applied to
the elbow
• Avoid passive stretching
Phase I – Weeks 0-3
• Goals are to protect healing tissue, control pain, and retard muscle atrophy
• Week 1
– Posterior splint at 90 flexion
– Wrist ROM
– Elbow compressive dressing
– Cryotherapy
UCL Rehab
• Bernas et al, AJSM 2009
– Determine strain on UCL during rehab protocol
– ROM 0-50° showed minimal strain on UCL
– Forearm rotation didn’t affect strain
– Strain increased at 90° and above
– Isometrics safe <90°
– Valgus (IR) can increase strain
Phase I
• Exercises:
– Bicep isometrics
– Gripping
– Wrist ROM
– Shoulder isometrics – NO ER and IR!!
– Leg circuit
• Remember, these are athletes!!
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Phase I – Week 2
• Brace opened from 30-100°
• Wrist isometrics
• Elbow flex/ext isometrics
• Week 3, open brace from 15-110/120°
Phase II
• Goals are to increase ROM, regain/improve strength, promote healing of
reconstructed tissue
• Brace 10-120°
• Light resistance ex’s for arm
• Rotator cuff strengthening, but avoid IR/ER until week 6
• Scar desensitization and mobilization
Phase II – Week 6
• Functional brace 0-130°, AROM 0-145° without brace
• Initiate shoulder ER
• Progress all ex’s from before
• Cardiovascular and leg program
Phase III – Weeks 9-13
• Initiate eccentric elbow flex/ext
• Continue forearm/wrist strengthening
• Rotator Cuff strengthening
• Manual resistance/PNF patterns
• Plyometrics
• Good time to work on mechanics and “changing bad habits”
• Patient/family education, especially if a young athlete
Phase IV – Week 14-16
• Begin return to activity
• Phase I interval throwing program
• Emphasize elbow and wrist strengthening and flexibility
• USUALLY begin return to competitive throwing anywhere from 22-28 weeks
ITP’s – What’s the Stress???
• Slenker et al, OJSM 2014
– Compared stress off mound w/ flat ground
– Throwing off mound REDUCED stress compared to flat ground
– Shorter distances 60ft or less had similar strain as higher intensities off the
mound from stationary positions
– Longer throws (180 ft) showed less strain than short distances, likely from “crow
hop”
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• KINETIC CHAIN!!!!!
Interesting procedure…”Internal Brace”
Did You Know?
• The first-ever ice cream sundae was served (on a Sunday) in 1881 at Edward C.
Berner's soda fountain in Two Rivers, and it only cost a nickel.
Young Athlete Shoulder/Elbow
Considerations
• Diagnoses are different
• They heal faster
• They don’t understand “long-term” as well
– Day traders v. “long-view” investor
• Parent v. youngster goals
• Growth plate!!!
– Difficult to use protocols then
Don’t Forget – Beighton Scale!
Salter-Harris Fractures
Growth Plate Closure
• Time of closure varies w/ each growth center
– “Come Rub My Tree Of Love!!!”
• Open can vary from 8-18 y.o
• Females close about 18-24 mos after initiation of menses
• Begin distal extremities and move proximal
Growth Plate
• Physis – cartilage layer between primary and secondary ossification centers
• Location of axial and circumferential growth
• Growth in wave form helps resist shear forces
Growth Plate
• Epiphysis – layer of hyaline cartilage at end of bone, articulates w/ adjacent bone to
form joint
• Metaphysis – layer that leads to shaft
Immature Skeleton
• Apophysis – cartilaginous structure at end of long bones
– Attachment of musculotendinous structures
– Inflammation referred to as apophysitis
Properties of Immature Tissue
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• Ligaments are 2-4x stronger than bone in this population
• Bone is porous and more easily compressed
• Greater plasticity of tissues
Examination
• GH/scapulothoracic motion/strength
• Palpation
• Spine mobility
• Hip and core assessment
– Squat/SLS
– Plank/Side plank
– Double leg lowering
– A/P Tilt
• Flexibility
Little League Shoulder
• Little league shoulder is at the neck of the humerus at the growth plate caused by
repetitive throwing and likely improper mechanics
• Might lead to early closure
• Males, usually 11-13, up to 16 yo
Presentation
• Diffuse, chronic, or sudden localized pain over lateral shoulder from/while pitching
• Decreased performance
• Rest a few days doesn’t help
• Weakness in ER and ABD
Treatment Harada et al, JSES 2018
• REST!
• 6-8 weeks of healing
• Gentle stretching
• Core stability work
• After pain free ROM, can begin cuff strengthening
• Throwing mechanics
• Education on ITP!!!
Apophysitis
• During rapid periods of growth
• May remain symptomatic till closure
• Sports participation is acceptable if pain is mild and non-progressive
• Avulsion can occur w/ forceful muscular contraction causing osseous structure to
break away from bone
Apophysitis
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• Repetitive stress in late cocking and acceleration
• Attachment of UCL and flex/pronator mass
• Onset 8-14 yo
• Pain gradually or from one event
• Symptoms: medial elbow pain, stiffness, loss of motion, decreased performance
• Exam: Tender ME, pain w/ resisted flexion and pronation, weakness of cuff, loss of
up to 20° ext, valgus stress pain
Other injuries
• MDI
• Tendonitis
• Impingement
• Anterior/posterior instabilities or dislocations
•
**All treated similar to adults
The Growing Elbow
• Growth in 6 secondary ossification centers
• Ephiphyseal region 2-5x weaker than surrounding osseous tissues
• Last to close is lateral epicondyle (15-16 yrs), medial is 11-13 yo
• Repetitive stress = medial traction + lateral compression
“Little League Elbow”
• Medial epicondyle apophysitis
• Medial epicondyle avulsion fx
• Panner’s Disease
• UCL injury
• OCD to capitellum
• VEO
Avulsion Fx
• Valgus overload causes widening or separation
• Presents as sharp pain, often w/ a “pop” associated w/ a throw
• Exam: More painful and likely loss of ext
• Usually surgical if more than 2mm separation
Lateral Elbow
• OCD of capitellum
• Panner’s Disease
– More common in boys 4-10 yo
– Osteochondrosis of capitellum
– AVN and flattening of capitellum
– Loss of elbow motion
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Loss of elbow motion
– Surgery usually not indicated, rest and rehab work
– Key is early detection
OCD
• Usually capitellum, can be radial head
• From repeated lateral compression
• Presentation: 10-17yo, insidious lateral elbow pain w/ minimal swelling, may have
locking or mechanical symptoms if loose body present
Posteromedial impingement/VEO
• Stress reaction or osteophytes on posterior/medial olecranon w/ ext of elbow after
the throw
• Presentation: P/M elbow pain during deceleration of the throw
Rehab
• Control pain
• Regain lost motion
• Address the biomechanical problems
– Cuff and scapular weakness
– Post shoulder tightness
– Hip/core stability
– Spine mobility
– MECHANICS!
– Pitch counts, etc
Little League Elbow
• Same thing, just at the medial epicondyle
• Might be avulsion of the medial epicondyle
• Remember where adults v. children tear ligaments
• Key: REST!!!
THANK YOU!! Questions??
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Evaluation of Pitching Mechanics
Dan Lorenz, DPT, PT, ATC/L, CSCS, USAW
Classic…
Objectives
• Discuss the five phases of the pitch
• Discuss the various criteria that should be observed/performed in each stage
• Discuss the etiology of shoulder pathology in the pitcher
• Discuss common faults in each phase
• Briefly discuss rehabilitation of the pitcher’s shoulder
• Provide a framework for prevention of injuries
Principles of Pitching
• Balance
• Timing
• Direction
Phases of the Pitch
• Preparatory/Windup
• Stride
• Arm Cocking – early and late
• Arm Acceleration
• Arm Deceleration
• Follow-through
Preparatory/Wind-Up
• Sets timing
• Facilitates motion of the body parts towards home plate
• Initiates momentum that will release energy to the baseball during the throw
• Injury potential is low
Wind-Up
• Historical:
– Glove at chest height
– Shoulders between 2nd and home
– Lead leg hip/knee at 90°
• Signature Variables:
– Balance
– Athletic Position
– Posture
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Posture
Wind-Up
• Good balance
– head over trunk center, between balls of feet to start
– Athletic position
– Good posture – spine to hip angle that stabilizes head during delivery
“Balance Point” Errors
Balance Point
• Poor balance components
– Head position
– Rushed motion/Early hip drive
– Hand/Glove to high or low
– “Z” BP/ Collapsing trunk
– Spine to hip angle (tilt)
Balance Point
• Lead hip/knee at 90°
• Sets tone for pitch
Correct Balance Point
“Z” Position
Stride (Early Cocking)
• When hands break to when lead leg is planted
• Foot planted straight ahead, just off of midline
– If “open/outward” = more stress on shoulder
• Hips square toward target
• KEY is to keep trunk back as much as possible to maximize velocity Dillman
Stride (Late Cocking)
• Foot plant to max ER of shoulder
• Trunk rotates to bring shoulder square w/ plate
• As the body turns, the shoulder is the first to be “stressed”
• Stride distance is ideally about 80-90% of the pitchers height for pros
Stride Kinematics
• Biomechanics - Lower Quarter Requirements
– Lead leg hip ER/abduction
– Trail leg hip IR
– Trail leg to lead leg stride angle (>135°)
• Biomechanics – Upper Quarter Requirements
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– Stride trunk position must maintain proper scapular/body plane position between
30-40°
Stride Correction Pearls
• Weak musculature
– Drills to increase stance to lead leg transfer
– Takes more strength to slow down and stabilize
• Inefficient balance / stride pitching mechanics
– Drills to increase stance to lead leg transfer
– Its easier to change leg weight transfer than hip/shoulder/arm mechanics
Stride Direction
• Towards target or slightly closed
• “On Time, On Target”
“Open” vs. “Closed” Foot Position Blackburn
• Ideally, foot should be turned slightly inward at contact
• If too OPEN:
– Hips rotate and face the batter too early
– Trunk can’t help w/ rotation
• If too CLOSED:
– Hips can’t rotate
– “Throws across body”
Open v. Closed
• Too open = early hip rotation = hip rotation velocity (power) will be lost = stress on
the arm to create ball velocity.
– Poor UE timing sequence with increased anterior shoulder strain at max ER and
ball release.
• Too closed = Front hip lock = inability to release hips for power = stress on the arm
to create ball velocity.
– Posterior shoulder eccentric overload
Stride Angle
• Max angle between lead and trailing leg at foot contact
•General indication of flexibility of the hips.
•Short SA are common in abdominal strain since they have to overuse the abdominals
to compensate for the lack of power generated from their legs and hips
•
Stride Angle Differences
“T Position”
“Critical Aspect of the Throw” Dillman
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• As the hand breaks from the glove, it should follow a “down, back, up” motion
• Ensures the throwing arm is properly synchronized w/ the body
• Ideally, arm is semi-cocked when the stride foot hits the ground
Forces in Stride Phase
• Compression force of GH joint to counteract distraction of “whipping motion”
• Due to extreme horiz abd, increased stress on anterior capsule
• As the trunk turns towards the plate, horiz add torque increases
Cocking Phase
• Body alignment occurs to allow acceleration of the baseball to the release point
• Energy is transferred from the LE’s to the trunk and eventually the UE
• In late cocking, the arm is abducted approximately 90-95° and horiz abducted
approx 30°
“Cocked Position”
Stride Foot Contact
• Heel/toe or flat/ball of foot
• Important in pitching to initiate the movement towards the plate….but then foot
contact will abruptly stop the forward motion and then allow the upper body to
“whip” toward the plate
• Lead Knee Angle
– Greater than 130°
– Stride angle
Key “Landmark”
• At foot contact, ball should be behind the head!
Elbow Flexion at Foot Contact ASMI
• Throwing elbow flexed about 90° as lead foot contacts the mound
– Faults
• Flexed too much towards pitcher’s head
–May cause the arm to “fly open” and cause injury as the elbow rotates
• Throwing elbow too straight
–Elbow can’t generate velocity
How far to stride?? Calabrese, IJSPT 2013
• Debatable (77-95% height)
• Younger (65 - 80% height)
• Recent review found youth baseball to average 66-85% of height Thompson et al,
Sports Health 2018
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Stride – UE Equal and Opposite Movement
• Mirror image of glove and ball hand in late cocking phase of stride
• Same image in early cocking phase
• Arm Path – smooth “down and up”
•
Arm Acceleration
• Max ER to ball release
• IR and horiz add force at 7000°/sec
– “Fastest human motion recorded” Wilk
• Elbow ext torque at 2300°/sec
• Varus torque to resist valgus
– 54% from UCL Wilk, Meister
Max Shoulder ER
• Forearm parallel w/ the ground as the trunk faces the hitter
• FAULTS
– Throwing arm does not rotate back far enough
– Throwing arm reaches max before or after the trunk faces the hitter
Shoulder Abduction at Ball Release
• Elbow is at or slightly above the line of the shoulders (94-100°)
• FAULTS
– Elbow too far below or above
– May damage shoulder
Knee Flexion at Ball Release
• Stride knee is straighter at ball release than at foot contact, knee about 120-145°
• FAULTS
– Too straight or too bent
• Straight = may be rushing or using short stride, trunk flexes early
• Flexed = trunk collapsing forward at ball release
Lateral Trunk Tilt at Ball Release
• Trunk tilted about 20° toward the non-pitching side
• FAULTS
– Too upright
– Too far tilt, chin not aligned over the stride knee
Trunk Flexion at Ball Release
• Should be flexed forward about 60°
• FAULTS
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FAULTS
– Too upright
• Increases arm stress as trunk is not transferring energy
– Too flexed
• Leaves arm behind
Timing of Hip/Shoulder Rotation
• Pelvis rotates shortly AFTER the foot is grounded and rotates toward the hitter
BEFORE the shoulders
– Greater energy stored = greater angular velocity
• FAULTS
– Pelvis rotates AFTER shoulders
– Pelvis/shoulders rotate TOGETHER
Trunk Arch/Drive
• At foot contact, the trunk is held back/hyperextended as they shoulders rotate
toward the hitter
– Allows max energy to transfer from hips to shoulder
– “Pre-stretches” the abdomen
• FAULTS
– Trunk remains neutral
– Weight moves forward too early
Arm Deceleration
• Ball release to arm across chest
• Forces: Humerus must be slowed from 7000°/sec = posterior shear force to stop
• Significant stress on posterior rotator cuff and capsule
Follow Through: ARM
• Arm moves toward target and crosses body toward outside of stride knee
• FAULTS
– Arm recoils into body prohibiting crossing
– Arm finishes between legs
LE Faults
• Rushing the Motion – “Pushing”
– Initiates stride by pushing w/ pivot leg and rushes towards home plate
– Lead foot planted too early, causing “low-cocked position” throw
– Causes over-striding
• Lowers center of mass
– Leads to excessive medial elbow and ant shoulder stress
LE Faults
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• Sitting and Leg Swinging
– Knee of pivot leg breaks out over toes, instead of rotating towards HP
– Lead leg tends to swing open like a gate, causing an open stride angle and
premature hip rotation
LE Faults
• Landing on a Stiff Leg
– Poor shock absorption
– Magnifies deceleration forces at arm and trunk
– More stress placed on posterior shoulder
Upper Extremity Faults
• Late Breaking
– Hands don’t break at midline
– Pitcher drifts hands posteriorly during initiation of stride
– Delays arm path and causes pitcher to throw from low-cocked position
UE Faults
• Breaking w/ Fingers under Ball
– Hands separate at break with thumb on top and fingers underneath ball
– Forearm never fully pronates during cocking phase
– Pitcher must push the ball or “pie throw”
– Tremendous loss of power and increased stress on the anterior shoulder
UE Faults
• Stiff Arming
• Pitcher breaks hand from glove, pushing ball and arm straight down into a locked
position
• Delays arm action
• Pitcher throws from a low cocked position
UE Faults
• Hooking the Baseball
– Wrist flexes w/ baseball after hands break from glove
– Causes improper arm path posteriorly and away from coronal plane
– Can cause wishbone effect
– Can delay arm action
“Inverted W”
Inverted “W”
Is the “Inverted W” that bad?
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• Douoguih et al, OJSM 2015
– Retrospectively evaluated “Inverted W” position and early trunk rotation
correlation to need for surgery
– Inverted W not associated w/ injury risk, but early trunk rotation was
• Typically occur together in Inverted W
“Inverted L”
Other Variations
Stride Hip and Shoulder Separation
• Optimal angle difference between lead hip and back shoulder 40 – 60˚
– < 40˚ look for tissue restriction
– > 40˚ hypermobile
Stride Hip/Shoulder Separation Faults
• Lack of Horizontal trunk flexion
• Early trunk rotation
• Arm late through acceleration
• Low pelvis rotation velocity
UE Faults
• Improper Follow-through
– Standing too upright – decreases load absorbed by trunk and legs
– Arm does not pass behind lead leg
• Abbreviated arm path loads post shoulder
– Recoil of throwing arm
• Tremendous force on post shoulder
Ball Release Faults
• Low shoulder rotation velocity
• Momentum direction altered
Follow Through
• From Max. Shoulder IR to the end of motion
– Does the trunk get to horizontal
– Does lead knee straighten after release?
– Can you see the back of your shoulder?
– Are they balanced?
Correcting and Changing Habits
• Most effective age group to change is 13-15 Andrews, Fleisig, Dun
• Most difficult ones to change are the ones that have been successful
• Use a mirror!
• Game time is not the time to change mechanics!!
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Game time is not the time to change mechanics!!
Signs of Fatigue in the Pitcher
• Rushing/pushing towards plate
• Standing too upright during follow-through
• Dropping of arm angle
• Pitches riding high
• Greater time between pitches
• Loss of control, velocity, or timing
• Pitches getting hit in the air
Million Dollar Question…
If an athlete has a “fault” but isn’t having issues, should you correct/fix it??
My personal take…
• Address the impairments that puts them at risk
• Inform, but don’t lecture
– “For what it’s worth…”
– “From lots of research on healthy pitchers, we know that X is a better way to do it”
• Make it clear you are not a pitching coach
“Prehab”/Rehab for the Pitcher
• Strengthening of the posterior shoulder
– “Posteriorly dominant”
• Restoration of rotational deficits in the shoulder
– “GIRD” – GH IR Deficit
• Strengthening of the legs
• Cardiovascular conditioning
• Flexibility of the hips, groin, hamstrings
• Spine mobility
“Take Home”
• Work on balance point
• Coordinate hips and shoulders
• Arm path
– “Down, back, and up”
• Stride Length
• “Get LONG!!”
How to Film a Pitcher
• Anterior View
– 10’ behind batter’s box
• Lateral View
– 90° to pitching rubber
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90° to pitching rubber
• Posterior View
– Halfway between 2nd base and pitching rubber
• Record at least three trials per view
The Evaluation
• Can perform indoor or outdoor
• Should be from a mound, 60’6” from home plate
• Analyze from the front, side, and back
• Evaluate from the ground up
• “Word to the wise:” Correct the slower LE faults before the faster UE faults
Recommendations
• Maximum pitches per game:
– Ages 8-10: 50
– Ages 11-14: 75
– Ages 15-18: 90-100
• Maximum innings per week:
– Age 14 and under – 6
– Through high school – 10
Resources
• www.pitchsmart.org
• www.elitebaseballperformance.com
• Little League Baseball/ASMI/USA Baseball
– www.littleleague.org
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Screening, Testing, Injury Prevention and Performance Enhancement in the UE
Athlete
Dan Lorenz, DPT, PT, ATC/L, CSCS
Director of Clinical Operations, SSOR Physical Therapy
Chair, SPTS Performance Enhancement SIG
WPTA Spring Conference
April 12-13, 2018
Performance Enhancing Products
An Homage to KC BBQ…
For what it’s worth, if you’re interested…
Objectives
• Identify common impairments in the upper extremity athlete that have been linked
to injury.
• Discuss screening and testing measures that can be done clinically to screen for
athlete appropriateness for performance training
• Understand the role of the kinetic chain in the UE athlete.
Can’t we do better??
• RTP for SLAP tears 35-88%
• RTP as low as 25% in athletes, as high as 77% in recreational athletes after RCR
• RTP after UCL reconstruction 65-97%
In order to “earn” the right to begin performance training, rehab should be done
(or darn close)
Functional Testing Algorithm – UE Davies 1998, 2011
• Visual Analog Scale
• Basic measurements <10% BIL
• Kinesthetic/Proprioceptive Testing
• Isokinetic testing
• Y – Balance Test
• Closed Kinetic Chain Upper Extremity Stability Test
– Males 23 touches, Females 21 touches
• 1-Arm Seated Shot Put
• Functional Throwers Performance Index
– Males 17-41%, Females 33-60%
• Underkoeffer Overhand Softball Throw
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Underkoeffer Overhand Softball Throw
• One Arm Hop Test Falsone et al, JOSPT 2002
• Sport Specific Testing
• Outcome scales
Development of the Physical Qualities of Athletic Performance
• Strength
• Power
• Elastic/Reactive Strength
• Speed
Regardless of age/level…
• The Athletic Shoulder needs:
– Cooperation with the thoracic spine and scapula
– Fitness base/work capacity
– Hip mobility
– Single leg stability/balance
– Strength
• Deceleration/braking
• Starting strength
– Power/explosiveness
Needs Analysis
• STEP 1:
– Injury history of the athlete
– Specific needs of the sport
• Repetitive symmetrical
–Example/s?
• Repetitive asymmetrical
–Example/s?
• Joints/movements involved?
– Metabolic systems involved
Needs Analysis
• Step 2:
– Athlete’s Strengths/Weaknesses
– Athlete Self-Assessment
– Functional Performance Testing
Needs Analysis
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• Step 3:
– Training program design principles
• Multi-sport athlete?
– Training of specific program parameter
• Strength, power, speed, etc
Needs Analysis
• Step 4:
– Assessment of Athlete and Training Program
• Self-assessment
• Observation and Examination
• Functional testing
Are they MENTALLY ready?
• Psychological Readiness to Return to Sport Scale Glazer, J Ath Train 2010
• ACL-RSI Webster et al, Phys Ther Sport 2008
• 20% fear re-injury after ACL Ardern et al, BJSM 2015
• UE data lacking
•
Currently tough to measure…
• Complex interplay of physical measures + psychosocial aspects, weather, field
conditions, nutrition, training, locker room chemistry, coaching…
• Despite our best intentions, no screen or test is perfect
Case in Point… Timpka et al BJSM
Why Screen or Pretest?
“A training program that focuses on the least developed factor contributing to maximal
POWER will prompt the greatest neuromuscular adaptations and therefore result in
superior performance improvements.”
Cormie, et al, Sports Med, 2011
Preparing the Athlete for Performance Training
Do they have appropriate…
– Mobility ?
– Exercise technique ?
– Performance Qualities ?
• Strength, Power, Elastic/Reactive Strength, Speed
– Work Capacity ?
Athletic Performance Panariello
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• The fastest and most powerful athletes in the world are those that place the
greatest amount of force into the ground surface area in the shortest period of time.
• “The fastest athletes spend the least amount of time on the ground (.07-.09 sec
sprinting speed)”
• “Main determinant of achieving maximum sprint speed was reducing the contact
time during the stance phase” Mann 1998
•
–
Important concept…
We develop ATHLETICISM, NOT skill!
“You get better hitting home runs by going to the batting cage”
What Performance Characteristics Determine Elite Performance? Lorenz et al,
Sports Health
• In the anaerobic athlete: POWER
Performance Variables and Baseball Ability
• Lower body field tests correlated to throwing velocity Lehman et al, JSCR 2013
• The only variable that mattered in BOTH pitched ball velocity and bat velocity was
the standing long jump Nakata et al, JSCR 2013
Performance in Throwers
• Push off force and ball speed correlation Oyama & Meyers, JSCR 2017; McNally,
JSCR 2015
• Relationship between trunk rotation, dynamic stability and pitch velocity Bullock et
al, JSCR 2017
•
Performance in Throwers
• Excessive contralateral trunk tilt reveals compensations Oyama et al, Clin J Sports
Med 2017
• In youth and adolescent pitchers: Sgroi et al, JSES 2015
– Each yr older, 1.5 mph
– Each inch in ht, 1.2 mph
– Separation of hips/shoulders, 2.6 mph
– Increasing stride length 10%, 1.9 mph
–
Performance in Elite Pitchers Fleisig et al, AJSM 2018
• Followed youth pitchers ages 9-15 and compared to elite pitchers
• Main findings:
– Youth pitchers had a shorter stride than elite pitchers
– Youth pitchers landed in a more “open” landing than elite pitchers
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– Youth pitchers land with too much ER at foot contact
– Youth pitchers have less hip/shoulder separation than elite pitchers
Total Motion Concept
• ER + IR = Total Motion
• Wilk et al, AJSM 2002
• Wilk et al, JOSPT 2009
• Loss of ER linked to increased risk of shoulder injury Wilk et al, AJSM 2015
TROM and GIRD
Thoracic Spine Rotation and Extension
• Regional interdependence Wainner et al, JOSPT 2007
– Loss in thoracic spine rotation may lead to increased compensatory thoracic ER
– Increased kyphosis linked to medial elbow injury Sakata et al, AJSM 2017
• Rotary sports involve thoracic rotation
– Lumbar locked and seated rotation, bar in front, most accurate Johnson et al, J
Ath Train 2012
Thoracic Spine & Scapula
• Dyskinesis, coordination, SICK scapula change the position of the GHJ in Max ER
Konda et al, AJSM 2015
• GHJ, scapular, and thoracic movements make major contributions to Max ER
Miyashita et al, AJSM 2010
Seated Thoracic Rotation
Quadruped Thoracic Rotation
BIL Shoulder Flexion
BIL Flexion – ROM restricted
BIL 90/90 Abduction
BIL 90/90 Abduction - Restricted
KC BBQ
Beighton Scale
Beighton Scale
Basic Measurements
• Time/Soft tissue healing
• VAS
• Anthropometric measures
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• AROM <10% difference
• PROM
• Core testing?
Balance/Proprioceptive Testing
• Davies et al, JOSPT 1993
– Measure angular joint replication
Strength Testing
• McLaine et al, J Sport Rehabil 2015
– Isometric tests of the shoulder w/ HHD in sitting, supine, and prone
• Flex/Ext at 140° in scapular plane, IR/ER at 90° abd
– Good to excellent intra-rater reliability
– Intra-rater reliability not affected by position
–
• Cools et al, JSES 2014
– Acceptable reliability using HHD
• Cools et al, KSSTA 2015
– Normative data established for 18-50 y.o for HHD RC testing
Strength Testing
• Using HHD at 90° abduction in supine is a reliable method to determine strength of
the RC Michener et al, Phys Ther 2005; Turner et al, J Sport Rehab 2009; Tyler et al
JSES 2005
UE Functional Tests
• Y Balance Test Westrick et al, IJSPT 2012
– Reliable test of UE closed chain function and core strength
– Fair to moderate correlation to other core stability and UE functional tests
–
Million dollar question: Relevant for OH athletes??
UE YBT
• Butler et al, IJSPT 2014
– UE YBT revealed no difference between dominant and non-dominant arms in
healthy softball and baseball pitchers
– Soooo….
• There shouldn’t be asymmetries side-to-side!!!
Seated shot put test
• Has become the “1 leg hop test of the UE”
• Minimum Detectable Change (MDC)
– DOM 17 inches, NDOM 18 inches
• Reliable and valid
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Reliable and valid
– Gillespie et al, J Human Mvmt Studies 1987
– Negrete et al, JSCR 2010
– Good for older adults too! Harris et al, JSCR 2011
–
CKC UE Stability Test Goldbeck & Davies, J Sport Rehab 2000
• Line 3 feet apart
• Males – push up position; Females – on knees
• Touch both hands to each line as many times as possible in 15 seconds
• 3 tests, average score
• Norms: Females 21, Males 23
– Collegiate males 26, females 21 Pontillo et al, JOSPT 2011
– Football/wrestlers 29
• Correlates w/ HHD strength of elevation and IR Pontillo et al, JOSPT 2010
• Clinically useful test for UE function
– Rousch et al, IJSPT 2007
CKC UE Stability Test
Functional Thrower’s Performance Index (FTPI) Davies et al, JOSPT 1993
• Line on floor 15’ from wall, 1’x1’ square, 4’ from floor
• 4 submax controlled warmups
• Controlled max number of accurate throws in 30 seconds
• 3 sets
• Divide total number/accurate throws x 100%
FTPI Davies et al, JOSPT 1993
• Norms Males Females
• Throws 15 13
• Accuracy 7 4
• FTPI 47% 29%
• Range 33-60% 17-41%
UE Performance Tests
– Medicine ball chest pass
• Davis et al, J Strength Cond Res 2008
– Backward medicine ball throw
• Clemons et al, J Strength Cond Res 2010
Upper Extremity/Trunk Strength/Power Ellenbecker & Roetert, MSSE 2004; Ikeda
et al, Eur J Appl Physiol 2007
• Overhand, Backward, and Rotational medicine ball throws using 6 lb ball
• Normative values established for males and females
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Normative values established for males and females
One Arm Hop Test Falsone et al, JOSPT 2002
KC BBQ
Total Body Screen
• Overhead Squat
– Indication of ankle, knee, hip, and spine mobility and stability
Closed Chain Ankle DF ROM
Is it Valid? You bet!!
• WB DF measures have good inter and intrarater reliability in healthy and those w/
fractures Hoch & McKeon, Man Ther 2011; O’Shea & Grafton Man Ther 2013
• Each cm from wall indicates 3.6° of DF
• Side-to-side asymmetry of more than 1.5 cm may be relevant for pathology Hoch
& McKeon
• Normative values show that mean toe-to-wall distance should be 10 cm (about 4”)
Which method?
• Konor et al, North Am J Sports Phys Ther 2012
– Tape measure distance to wall vs. goniometer vs. inclinometer
– Tape measure and inclinometer showed higher reliability than gonimeter
The Ankle MATTERS!!!
• Robertson & Fleming, Can J Sport Sci 1987
– The ANKLE was 50% of the extension for the broad jump and 40% for the vertical!
• Needs to be MOBILE, STRONG, and ELASTIC!!!
LE Screening
Hip Rotation ROM
– Hip rotation deficits have been found in overhead athletes McCulloch et al, OJSM
2014; Ellenbecker et al, AJSM 2007
– Have been correlated to injury Young et al, AJSM 2014; Li et al, Orthop Rev 2015;
Saito et al, OJSM 2015
Single Leg Squat/Step Down
• Relationship between unilateral squat and single leg balance McCurdy et al, J Sport
Sci Med 2006
• Strong indicator of hip abductor muscle function Crossley et al, AJSM 2011
Y-Balance Test/SEBT
• Recent review found it was ONLY test associated with increased injury risk
compared to 13 other tests Hegedus et al, BJSM 2015
• Deficits linked to injury in D1 athletes Wright et al, Physiotherapy 2016
• Link between poor performance & UCL tear Garrison et al, JOSPT 2013
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• Reliable test of balance and strength in the LE Plisky et al, JOSPT 2006; Dobija et al
APMR 2016; Plisky et al, NAJSPT 2009
Balance and Hip/Shoulder Connection
• Lower extremity balance is altered in baseball players prior to UCL reconstruction
Hannon et al, IJSPT 2014
• Balance deficits found in athletes w/ shoulder dysfunction Radwan et al, IJSPT 2014
• Training and rehabilitation programs should consider focusing on lumbopelvic-hip
and scapular muscle strengthening as well as coordinated strengthening of the
pelvic and scapular stabilizers, in baseball pitchers Oliver et al, JSCR 2015
•
Balance
Hip Mobility
Fatigue
• Fatigue alters pitching mechanics Grantham et al, OJSM 2014
• Dale et al, N Am J Sports Phys Ther 2007
– Greater IR fatigue after repeated throwing
– Implications for stability
• Escamilla et al, AJSM 2007
– Biomechanics of pitching as pitcher approached fatigue
– Found that the trunk was in a significantly more vertical position w/ fatigue
• Knee extensor fatigue inhibits forward trunk lean
• Decreased trunk tilt leads to decreased velocity because of decreased
momentum transfer
Fatigue and Cuff Strength
• 18% loss of RC strength after pitching a game
• Lose 3-4% loss of strength throughout season
• Fatigue of the cuff leads to 2x the amount of superior humeral head migration
Chopp JSES 2010
Building Work Capacity
• Javorek DB Complexes
– 6 exercises, 6 reps each, repeat 3x
• Example:
–DB Upright Row
–DB High Pull Snatch
–DB Squat Push Press
–DB Bent Over Row
–DB Hang Clean
•
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Work Capacity
• Combination lifts
– Hang high pull to front squat to press
– Light weights
– Core and hip stability ex’s for active recovery
• Interval Runs
– Keep work:rest ratios 1:3, progress to 1:1
– Encourage runs >40-50 yards distance
Core Stability/Strength
• No definitive test for core stability & relationship between core stability and UE
injury is questionable Silifies et al, Braz J Phys Ther 2015; Reed et al, Sports Med
2012
• Linked to performance testing, power in the extremities, positive effect on throwing
velocity in handball players Sharrock et al, IJSPT 2011; Shinkle et al JSCR 2012;
Saeterbakken et al, JSCR 2011
Link between Core Strength and Athletic Performance
• Zazulak et al, AJSM 2007
• Sato et al, JSCR 2009
• Devlin, Sports Med 2000
• Abt et al, JSCR 2007
• Cholewicki et al, Spine 2005
• Borghuis et al, MSSE 2011
• Thorpe & Ebersole, JSCR 2008
• Burnett et al, Man Ther 2004
• Saeterbakken et al, JSCR 2011
• Plisky et al, JOSPT 2006
• Behm et al, Appl Physiol Nutr Metab 2009
• Butcher et al, JOSPT 2007
• Wells et al, JSCR 2009
• Leetun et al, MSSE 2004
• Nesser et al, JSCR 2008
• Imai, IJSPT 2016
Don’t think it’s important?
Possible tests? (But still not good enough)
• Plank is basic measure of core strength and trunk endurance Schellenberg et al,
AJPMR 2007 & normative data has been established Chase et al 2014
• Kendall and Janda have proposed tests, no reliability established
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Kendall and Janda have proposed tests, no reliability established
• Bunkie test Brummit, Rehab Res Pract 2015
• Double leg lowering Lanning et al, J Ath Train 2006
– 50° normal in athletes Lanning; Sharrock et al
Core Testing
Janda
Double Leg Lowering
Please note…
• Weight Room Modifications for UE Pathologies
– Bench Press
• Wide v. “standard” grip
• Under v. Overhand grip
• Pad/Block on chest
• Flat ground
– Military Press
• Avoid the “high five”
• Caution dropping below 90° abduction
–
Return to Sport
• Core training for spine and pelvic support
• Lower extremity power and strength
• Explosive power and agility
• Isokinetic testing??
• Metabolic training
– Anaerobic v. aerobic
Return to Play: Decision-Based Model Creighton et al, CJSM 2010
• Step 1: Evaluation of health status
– Demographics
– Symptoms
– PMH
– Signs
– Labs
– Functional Testing
– Psychological
– Potential seriousness
RTP Model
• Step 2: Evaluation of Participation Risk
– Type of Sport
– Position played
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– Limb dominance
– Competition level
– Ability to protect
RTP Model
• Step 3: Decision Modification
– Timing and season
– Pressure from athlete
– External pressure
– Masking the injury
– Conflict of interest
– Fear of litigation
KC BBQ
Statistics STOP Sports Injuries
• Overuse injuries are responsible for nearly half of all sports injuries to middle and
high school students
• Although 62% of organized sports-related injuries occur during practice, one-third
of parents do not have their children take the same safety precautions at practice
that they would during a game.
•
Statistics
• 20% of children ages 8 to 12 and 45% of those ages 13 to 14 will have arm pain
during a single youth baseball season.
• Injuries associated with participation in sports and recreational activities account for
21% of all traumatic brain injuries among children in the United States.
Statistics
• According to the CDC, more than half of all sports injuries in children are
preventable.
• By age 13, 70% of kids drop out of youth sports. The top three reasons: adults,
coaches and parents.
• Since 2000 there has been a fivefold increase in the number of serious shoulder and
elbow injuries among youth baseball and softball players.
Contributing Factors to Injury Myer et al, ACSM HFJ 2013
• Previous injury
• Muscle imbalances
• Lack of corresponding NM adaptation to growth during maturation
– Abnormal/aberrant movement
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Abnormal/aberrant movement
• Nutritional deficiencies
• Improper footwear
• Poor physical fitness
– Secular trends
– Decreased strength
– Decreased movement skills
No question…
The single biggest risk factor for injury is previous injury!!!
Overuse Physeal Injuries: UE
• Gymnast wrist, Little League Elbow/Shoulder are main conditions
• RISK FACTORS:
– Consistent UE loading
– Timing of growth spurts
– Excessive game and season pitch counts
– Pitching while fatigued
– Pitch type and selection
Adolescent Throwing Athlete
• Shanley & Thigpen, IJSPT 2013
– Common impairments include alterations in shoulder ROM, muscle performance,
poor neuromuscular control of the core, scapula, and lower extremities
UE PREVENTION
• Monitor pitch counts
• Encourage 2-3 months of active rest
• Appropriate ROM and strength
• Flexibility, strength, and balance training
See themes here?
• OVERUSE
• Training errors
• Inappropriate rest and recovery
The “Puzzle” of Sports Injuries
Problem
WHEN should you start training?
– Should be able to follow directions and handle attention demands
– Prefer before Peak Height Velocity
• Approx 12 y.o in girls, 14 y.o in boys
– Training early in life increases training age and sets table for greater gains during
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Training early in life increases training age and sets table for greater gains during
postpubertal years
Biological v. Training Age
• Biological v. Training Age
– Training age – initiation from regular fitness training till present time Myer et al
– Maturity related differences in body size and motor skill occur at 6-7 y.o Myer et
al
What should a youth program look like? Myer et al
Integrated Neuromuscular Training
Program incorporating general and specific (targeted motor deficits) activities
including resistance training, dynamic stability, core training, plyometric drills, and
agility drills to enhance physical fitness
What is best?
• Chaouachi et al, JSCR 2014
– Olympic lifting, plyometrics and traditional resistance training all provide benefits
in children
– Proper supervision and progression is key
Key Program Components Myer et al
• Lower body BIL/UNIL
• Upper body PUSH and PULL
• Accel/Deceleration/Re-Acceleration
• Jumping, Landing, Rebound Mechanics
• Anti-rotation and Core bracing
Position Statement NSCA
• Injuries related to high school athletes appear to involve aggressive progression of
training loads or improper technique
• Resistance training and weightlifting have lower injury rates than football, baseball,
and softball
NSCA Position Paper
• Only 3 studies have shown an injury after weight training, all due to lack of
supervision or improper progression
• Only 1 study showed significant injury after plyometrics
– Athlete did >250 depth jumps in one training session!!
•
NSCA Position Paper
There is an increased injury risk in children who use exercise equipment at home
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ACSM Position Statement
• Strength training for children with maximal weights is not recommended because
of the potential for possible injuries related to the long bones
• Emphasis should be on proper technique and safety – not how much weight can be
lifted
• No current scientific evidence to support that early weight training can “stunt” a
child’s growth
•
Problem
Specialization at younger ages
AAP Position Statement, 2000
– “Kids should be discouraged from specializing in a single sport before
adolescence. Young athletes should be encouraged to participate in a variety of
different activities and develop a wide range of skills."
“Sport Specialization Scale” Jayanthi, AMSSM Meeting 2011
• Trains more than 75% of the time in one sport.
• Trains to improve skill or misses time with friends.
• Has quit other sports to focus on one sport.
• Considers one sport more important than other sports.
• Regularly travels out of state.
• Trains more than eight months a year, or competes more than six months
• Score: Uninjured 2.75, Injured 3.49
Problem
Lack of free play
When’s the last time you saw unorganized play or kids play “kick the can”?
Free Play!
• Miyaguchi et al, JSCR 2013
– “Dynamic activities, such as tag and soccer, promote development of reaction
speed and agility in movements involving the whole body. Preschool teachers
and physical educators should re-examine the effect of tag and use it periodically
to prevent injuries”
Problem
Lack of screening by coaches
They have a whole team to train and don’t have time to give individualized programs
and don’t know how to screen
Problem
• “We don’t have time to do that stuff”
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• “We’re already doing it”
• “We have limited time with them as it is and we have to work on sport stuff”
PROBLEM
Kids aren’t conditioned for all the sports!
– Escamilla et al, AJSM 2007
• Biomechanics of pitching as pitcher approached fatigue
• Found that the trunk was in a significantly more vertical position w/ fatigue
• Knee extensor fatigue inhibits forward trunk lean
• Decreased trunk tilt leads to decreased velocity because of decreased
momentum transfer
PROBLEM
We need to talk about this!
– J Strength Cond Res study shows only 14% of high school PE and sports coaches
passed an exam on resistance training principles and methods!!
• McGladrey et al, JSCR 2014
Problem Fact Sheet, ACS, AHA, ADA
Dropping of P.E programs and kids being more sedentary
• Only 3.8% of elementary, 7.9% of middle, and 2.1% of high schools provide daily
physical education or its equivalent for the entire school year.
• 22% percent of schools do not require students to
take any physical education at all.
• Nationwide, only 51.8% of high school students
attend at least some physical education (PE)
classes and 31.5% of those students have daily
physical education
Problem
Lack of consensus on what should be included in a program
• Most successful programs have:
Strength, Flexibility, Balance, Plyometrics
Problem
“Fads” in training and various training methods that may be dangerous for kids
“Insanity” or CrossFit not the best choices for kids, yet they are doing them
Problem
No off-season anymore
“I mean, Johnny just has to pitch over the winter “
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“I mean, Johnny just has to pitch over the winter “
Problem
How do we convince parents that time off is critical??
Speaking of “time off”…
Problem
How do we define performance enhancement?
• While your program may increase strength, vertical jump, agility, etc – does it
translate to the court/field?
• We give them the tools (strength, power, speed) to be better at the sport
• “You get better at basketball by playing basketball”
Problems
Kids are not “mini-adults”
No, the kids can’t use “State University’s” strength and conditioning program
Problem
What to do with the multi-sport athlete?
• Example:
– Baseball player plays baseball all summer, but when is there time to train for
football?
• Some football training not necessarily appropriate for baseball
Hotter than sunburn!
Yep, hockey too…
Why Tommy John’s??
• OVERUSE!!!!!!!!!!!!!!!!!!!!
• Posture
• Cuff and scapular weakness
• Spine mobility
• Hip mobility
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Hip mobility
• Pitching Mechanics
• Caution! Showcases, multiple leagues, pitching with fatigue, pitching and catching
in same game
Scary stuff!!!
• Makhni et al, Am J Sports Med 2014
– Questionnaire to >200 baseball players, ages 8-18
– 47% were encouraged to keep pitching despite arm pain
– 80% had pain the day after throwing
– 75% said pain limited how hard they could throw
– Pitch counts not enough to help
Check this out…ASMI
Pitch Count Recommendations ASMI
10 Recommendations Elite Baseball Performance
• Watch for signs of fatigue
• No overhead throwing of any kind for 2-3 mos a yr
• Follow limits and rest days
• Avoid multiple teams w/ overlapping seasons
• Good mechanics ASAP
• Pitchers should not be catchers too
• Shoulder or elbow pain in pitchers should be evaluated
• Avoid radar guns
• Minimize showcases
• Inspire interest/play in other sports to increase athleticism
AOSSM Paper…
• Survey of 3,100 high school, college, and pro athletes
– 68% of college specialized, 50% of pros in high school
– 81% of high school and college athletes believed that specialization helps play at a
higher level
– Only 22% of pro athletes said they would want their own kids to specialize
American Academy of Pediatrics
• AAP Position Statement, 2000
– “Kids should be discouraged from specializing in a single sport before
adolescence. Young athletes should be encouraged to participate in a variety of
different activities and develop a wide range of skills."
“The Era of Specialization”
• Single v. multi-sport athletes
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Single v. multi-sport athletes
• Increased sports participation
• Specialize early, train year round, compete at “elite” levels
• WHY?
– Media coverage
– Scholarships
– “National” teams, “National” competition
– “Professional” coaches in kids sports
But why are we doing it?
• Post et al, Sports Health 2017
– Evaluated high school sport specialization patterns in D1 athletes
– Specialization increased throughout high school but only 41% specialized in 12th
grade
Last Super Bowl…
• 88.7% of football players in Super Bowl team rosters played another sport in high
school
– Trackingfootball.com
Is LANGUAGE to blame?
• “Elite”
• “Select”
• “Showcase”
• “Competitive” vs. “Recreational”
– Translation: Awesome kids vs. kids that suck
“Back in the day”…
Back in ‘87
The “Culture” of Youth Sports
Look what we’re spending! TurboTax
Motor Learning
• Deliberate, repeated practice is required to attain expert performance Ericsson
1998; Ericsson & Lehman 1996
• Most “talented” (chess) individuals need 10 years of practice before winning
international competitions Simon & Chase 1973
• In musicians, duration of practice activities predicted adult achievement, high
effort/concentration, more emphasis on performance rather than enjoyment
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Ericsson et al, 1993
In athletes…
• Figure skater performance improved as a function of active hours practicing and
years skating Starkes et al, 1996
• Martial artists showed steady increase in practice as they increased in karate belt
classifications Hodge & Deakins, 1998
• Higher level of achievement in field hockey and soccer w/ greater time training in
development Helsen et al, 1998
I dunno…
Maybe the ones to specialize are the ones that require precise attention to detail for
performance???
On the contrary…
• KC Royals All-Star and 2014 ALCS MVP Lorenzo Cain didn’t play an inning of
baseball till high school
• We all know about Michael Jordan getting cut from his high school basketball team
• Tim Duncan swam until high school – 5 NBA Titles
• Michael Oher
• Alex Morgan – didn’t play soccer till 13 y.o.
On the contrary…
• Dikembe Mutombo didn’t play basketball till college!!
• Jimmy Graham (Seahawks TE) played FB AFTER 4 years of playing basketball at
Miami
• Hakeen Olajuwon didn’t play basketball till 15
• Antonio Gates didn’t play a snap of college football!
•
What’s to blame??
• Malcolm Gladwell and the “10,000 hours?”
• Early childhood successes of athletes like Tiger Woods and Wayne Gretzky…and the
home movies that followed
•
“My little Johnny can be that too!!”
10,000 Hours is Bunk…
Maybe it’s genetic…
What’s the research say?
• Law et al, Int J Sport Exer Psych 2008
– Compared Olympic/elite to non-elite rhythmic gymnasts
• Olympic ones were less involved in other sports and activities
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Olympic ones were less involved in other sports and activities
• Substantially more time on the technical side
• Rated their health as lower
• Had less fun overall
AMSSM Position Statement
“Early sport specialization is no guarantee of athletic success and may actually increase
the risk of injury and burnout in young athletes.”
Some things to think about…
• Sport injury patterns
• Individual injury history
• “Peak” performance age
• Physical maturation
• Biological v. training age
• Type of sport
– Repetitive, asymmetrical v. repetitive symmetrical
What we currently know…Myer et al, Sports Health 2015
• Year-round training in one sport may result in burnout, overuse injuries, and
dropping out of sports AAP, 2000; DiFiori et al, BJSM 2014
• “Don’t train more than your age per week”
• Exceeding 16 hours per week of total sports participation seems to have greatest
risk for injuries Jayanthi et a, J Sports Sci Tennis 2011; Loud et al, Pediatrics 2005;
Rose & Emery, MSSE 2008
•
What we know…
• Scheduled, intense competitions that last longer than 6 hours w/o recovery has
been implicated in injury Brenner, Pediatrics 2007; Jayanthi et al, J Med Sci Tennis
2011
What we know…
• 2014 “Path to Excellence” Survey of U.S. Olympians from 2000-2012
– 88% of athletes said playing more sports made them better athletes
– Olympians, on average, were involved in 3 sports till age 14, two sports from 15-
18 before concentrating
What the experts are saying…
• The American Academy of Pediatrics, The American Medical Society for Sports
Medicine, and the American Orthopaedic Society for Sports Medicine have all cited
the short and long-term consequences for overuse injuries
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What we don’t know…
• Age-adjusted training volumes
• Age-adjusted competition volumes
• Is it age or hours training?
Why more risk v. multi-sport?
• Doesn’t allow for rest for repetitively stressed areas of the body
• Fails to develop lots of NM skills
• Year-round exposure to single sport
• Overscheduling and competitions
• Repetitive technical skills and high-risk mechanics
– “Kick serve” in tennis
– Wrists in gymasts
– Pitchers
Why more risk?
• Psychological burnout
– Increased pressure
– Intense, adult-driven specialized training and competition
– Professional, “adult-style” practices
– Retirement from sport
Bad Combination
Young athletes 2x more likely to get injured when “perfect storm” of increased
training load and intensity + decreased sleep occurs
Von Rosen et al, Scand J Med Sci Sports 2017
Why more risk?
• Injury and fear of re-injury
– Athletes drop out or quit after injury
– Reduction in physical activity can have negative health consequences
– Psychological readiness not always physical readiness too
– May need coping skills
So who might specialize?
• Gymnasts
• Figure skaters
– FYI – Johnny Weir didn’t start till he was 12!!
• Rhythmic gymnasts
• Swimming/Diving
– FYI – Karen Legg, 2000 British Olympian, didn’t swim till 13
• Golf
• Tennis
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•
These sports “peak” at younger ages, highly technical, specific motor patterns
Recommendations
• Expose to multiple sports
• Avoid playing a single sport competitively year-round
• Focus on skill development rather than structured competition
• At least one full day of rest from training
AAP Recommendations
• Allow kids to play a variety of sports
– Less likely to drop out, better development in lots of sports
• Wait until after 15 or 16 to specialize
• Think about why the child is specializing?
– Is it for college success?
• Keep an eye on your child’s health
– Need more calories; need more iron, Vit D, calcium
• Rest 1-2 days per week
• Take 3 months off a year
A possible model…
• Non-profit for youth injury prevention
• The ASPIRE (Athlete’s Sports Performance Injury Reduction and Education)
Foundation
• 3 visits
• Instruct athletes, coaches, parents on basic strengthening, warm-up activities, and
stretching as well as education on the “how’s and why’s”
Even I SPECIALIZED to raise money for ASPIRE
KC BBQ
Disclaimer…
I’m starting at the “beginning”…
Lower Extremity/Core
Core Muscle Activation Donatelli et al, JOSPT 2007
• Side bridge exercise best for glute med and EO
• Quadruped arm/leg lift may help strengthen Gmax
• Bridge, unilateral bridge, side bridge, prone bridge and quad arm/leg lift are best for
muscle activation w/o external loading for trunk muscle endurance
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Core Muscle Performance Escamilla et al, JOSPT 2010
• Swiss ball exercises in prone were as effective or more effective in generating core
mm activity compared to bent knee sit up and traditional crunch
• Roll-out and pike were most effective for activating the core compared to all other
exercises
Research
• Okubo et al, JOSPT 2010
– Exercises showing greatest TrA activation was plank w/ contralateral arm/leg lift
– Multifidus activity greatest during bridge
– Contralateral exercises resulted in side-to-side differences
What’s the data on labile surfaces?
• Snarr & Esco, JSCR 2014
– Labile surfaces increased EMG of RA, EO, and ES
– Increases challenge for those that need it
– HOWEVER, you should be careful in those w/ instability as it increases ES activity!
GLUTES!!!
Great References!
GMax
GMed
Clamshells
Clamshell 2/3
Bridges
Single Leg Bridge
Side Lying Leg Raise
Lateral Plank Bent Knee
Lateral Plank w/ Clamshell
Plank w/ Hip Ext
Side Plank Knee Extended
Side Plank w/ Hip Abduction
Reverse Straight Leg Raise
Start: Knee Straight, Toes Flexed
End Position
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End Position
Crabwalk
Step Down
“Assisted” Squats
Single Leg Deadlift
Single Leg Squat
Runner’s Squats
Retro Step Up
Lateral Step Ups
Anterior Lunge
Lateral Lunge
“Prevention Plyos”
• Single leg hops
• M/L hops
• Transverse hops
• “Ice skaters”
• Scissors
• Bounding
• Single leg “clean”
KC BBQ
Breathing w/ Abdominal Contraction
“Marching”
Level II Marching
Dying Bug
Dying Bug II
Bridge and Kick
Bird Dogs
“Ante-Rotation”
Rotation Control
• Planks w/ hip ext
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Planks w/ hip ext
• Planks w/ hip abduction
• “Push Up Planks”
• DB Row Planks
• Any of the above on BOSU, Physioball
•
***Can make these easier by changing plank angle
Balance/Proprioception Training
• Three key ways:
– Visual
– Vestibular
– Sensorimotor
KC BBQ
Upper Extremity
Quadruped Thoracic Rotation
Foam Roll Posture Exercises
“Open Books”
Start: Lay on side, hands together
End: Rotate other direction, return to start position
Quadruped Thoracic Rotation
Hamstring Stretch
Hip Flexor Stretch
Pectoral/Doorway Stretch
“Genie” Stretch
KC BBQ
“4 Buckets” Reinold
• Age/Maturity
– Age and Height BIG predictor of injury
– Throw w/ growth plates open, but lower intensity
• Mechanics
– We are in the velocity era!
• Arm Care
– Soft tissue work, strengthening, stretching/icing after
– “Pitching makes you tight and tired”
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“Pitching makes you tight and tired”
• Strength Training
– Linear and rotational power
– Hip and shoulder separation
– Whole body!
Regardless of age/level for PERFORMANCE…
• The Athletic Shoulder needs:
– Cooperation with the thoracic spine and scapula
– Fitness base/work capacity
– Hip mobility and stability
• We say the same thing about the shoulder, yes??
– Single leg stability/balance
– Strength
• Deceleration/braking
• Starting strength
– Power/explosiveness
Physical Qualities of Performance
• Strength
• Power
• Elastic/Reactive strength
• Speed
What Performance Characteristics Determine Elite Performance in the Same
Sport??
• Lorenz et al, Sports Health 2013
– Across all anaerobic sports, POWER was the variable that determined athletic
success among athletes in the same sport
Force-Velocity Curve
Strength
• Foundation for athletic performance:
– Starting strength
– Eccentric strength
• Deceleration/Cutting
Stiffness
• Greater “Stiffness” leads to:
– Greater RFD
• High force quickly more important than high force alone Angelozzi et al,
JOSPT 2012
– Greater overall force production
– Overrides GTO
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• Elastic strength
– Decreased ground contact times
Why appropriate strength base is required first!
•
“Starting” Strength
• Starts occur from a dead stop position
– No “preparatory” movement
– 2 foot contact to ground surface area
• High Concentric “Absolute” and “Explosive” Muscle Contraction Contribution
• Exercises – Squats, Hang Cleans, Lunges, Step ups
Box jumps, Med ball throw i.e. single maximal efforts
Eccentric Strength
• Strength increased with higher intensities (resistance)
• Force-Velocity Curve
– Greatest tension at high deceleration
• Needed for deceleration/cutting
4 Major Components of Deceleration Kovacs et al, Strength Cond J 2015
• Dynamic balance
– Ability to control high speeds
• Eccentric strength
– Ability to “put the brakes” on
• Power
• Reactive strength
– Stretch shortening cycle
Eccentric Hip/Shoulder
Deceleration in the Athletic Shoulder
• Arm deceleration during the pitch causes a posterior shear force of 50% BW to
reduce anterior subluxation Escamilla et al, AJSM 2007; Fleisig et al, AJSM 1995
•
Not just force PRODUCTION, but force ABSORPTION!!
Plyometrics
• “Ply” = measure, “Metric” = increase
• Stretch-Shortening Cycle
– Foundation of plyometrics
– Deceleration followed by rapid acceleration
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Plyometric Recommendations – Soccer Athletes Bedoya et al, JSCR 2015
• Systematic review of soccer players up to 17 y.o
• Program design recommendations:
– 2x/week for 8-10 weeks
– 72 hours between sessions
– Foot contacts 50-60 per session, no more than 8-120
– 3-4 exercises, 2-4 sets, for 6-15 reps
– Supervision is key!
Progression of Plyometrics
• Step 1:
– Jump TO box
– Develops technique
• Step 2:
– Jump FROM box
– Teaches muscle to override GTO
• Step 3:
– Reactive
Explosive Strength
• Jumps TO Box
• Countermovement Jumps
• Jump Squats
• “Scissors”/Split Jumps
• Stadium Steps
• Running Uphill
Elastic/Reactive Strength
• Leg stiffness is the ability of the leg musculature to resist lengthening when
subjected to a given force McMahonet et al, SCJ 2012
– Need baseline strength to maximize elastic components
• Achieved with plyometric training
• Jumps FROM Box
– Stretch Shortening Cycle
• Eccentric phase
• Amortization phase
• Concentric phase
–
•
What about UE Plyos??
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• Koch et al, JSCR 2012
– Compared GRF’s with different plyometric push-ups
– Clap push-up vs. drop push up from 3 different heights
– Clap had highest loading and propulsion rate
– Box height didn’t affect peak GRF
– Disparities shown in loading rate between dominant and non-dom
UE Plyos for Strength and Velocity
• Carter et al, JSCR 2007
– 8-week program, 2x/week
– “Ballistic Six”
– Plyos and Elastic Tubing
– Pre/post isokinetic testing
– Increases in CON IR and ECC ER strength and increases in throwing velocity
–
**Strength training and plyometric exercises are good for increasing throwing
velocity**
Is one method superior?
• Escamilla et al, J Strength Cond Res 2012
– 6-week program in baseball players consisting of either “Thrower’s Ten,” Kaiser
system, or plyometric activities for increasing throwing velocity
– No program superior
– Might this show that the lower body is more important????
Elastic/Reactive Strength
• Plyometric activities are the means to improve reactive strength
– Objective: Spend as little time on the ground with as much force into the ground
Agility Robbins & Goodale, Strength Cond J 2012
• Change of direction in response to a sport-specific situation or stimulus
– Physical component
• Increase force production into the ground
– Cognitive/”Technical” component
• Ability to react
• Ability to execute according to stimuli
• Decision-making affects agility Henry et al, JSCR 2013
Pediatric Athlete
To summarize…Pediatric Athlete
• Core Stability Training
– Developmentally based to more “functional”
• Emphasize body weight exercises
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– Volume based on training age
• Encourage free play
• MUST have strength base first!
• Postural control ex’s
Collegiate Athlete
• Likely improved training history
• Likely more injury history
• More bad habits
• Officially “specialized”
“Overreaching”
• Physical Factors
– Diet, sleep disturbances, other injuries, hormonal disturbances
• Psychological Factors
– Mood, motivation, fatigue, exams, confidence
• Social Factors
– Pressure from family, friends, coaches, media
Master Athlete
• Balance, strength, and mobility deficits as we age
• Increase in overall “stiffness”
• Postural considerations
• Increased fracture risk
• Cuff tear risk increases as we age
– Caution lots of overhead lifting
The Strength Reserve
• Collagen
– Protein (25% - 35% body’s protein content)
– Main component in connective tissue
– Found in fibrous tissue
– Tendon (SSC), ligament
– Accounts for 6% of the weight of strong tendinous muscles
• Collagen with age
– Changes occur +/- age 30
– Decreased quality and quantity
The Strength Reserve
• As the athlete ages the elastic/reactive capacity lost must be replaced by additional
contributions of maximal strength to maintain optimal levels of athletic performance
Training Considerations for the Master Athlete
• Lower impact plyos
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– Rope jumping
– Water!!
– Use agility ladder
• Total body exercises
• Mobility, flexibility emphasis
– Yoga, tai chi, etc
Resistance Training Guidelines ACSM 2009
• Multiple and single joint exercises, free weights or machines
• 1-3 sets per exercise, 60-80% of 1RM
• 1-3 mins rest between sets, 2-3days/week
• For power: single and multi-joint exercises, 1-3 sets per exercise, 30-60% of 1RM for
6-10 reps with high rep velocity
• For endurance: same as younger adults
Suggested Program Design
Assumptions
• Off-season program
• Untrained kids mostly, will touch on trained athletes
• Linear approach
– Periodization
• 12-week program
• Considerations:
– Days per week
– Training history
– Other sports?
– In vs. out-of-season
Weeks 1-2: Foundation
• M – Lift, Thrower’s Ten, Condition
• W – Lift, Core, Condition
• F – Lift, Thrower’s Ten, Core
Resistance Training
• 2 sets of each exercise, 10-12 reps, rest periods 45-60 secs
• Choose 2 exercises for each muscle group
• Back/Front squat, Lunges, Step ups, RDL’s, Split Squats, Deadlifts
• Rows, Supine Pull ups
• Push up w/ plus, DB bench/Incline DB
Bodyweight emphasis in kids!!!!
Thrower’s Ten
• 2 sets of each exercise, 12-15 reps, no rest between exercises in the circuit
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– Scaption
– SLER
– Tubing IR/ER
– D2 F/E patterns
– Rows
– Prone scaption
– Seated press ups
– Lateral raises
– Bicep curl/Tricep Ext
– Wrist curl/wrist ext
–
Conditioning – Weeks 1-2
• 60 yard sprints, 1:5 work:rest ratio
• 6x60 workout 1
• 6x60, 1x40 workout 2
• 5x60, 4x40 workout 3
• 4x60, 2x50, 4x40 workout 4
Core
• 2 sets of each, 20 reps, no rest between
• Bridges
• Sidelying leg raises
• Planks/side planks
• Bird dogs
• Dying Bugs
• Chops/Lifts
• Tube walks – lateral
• Clamshell series
• Side bridges
Weeks 3-4: Strength Building
• Increase 3-4 sets, 6-10 repetitions, rest 1-2 minutes between sets
• Consider submax reps to fatigue one workout, submax weight as fast as possible,
then one workout heavy in week 3
• Same resistance exercises
• Add explosive lunge/bound from ½ kneeling position
½ Kneel Lateral Bounding
Conditioning
• 60 yard sprints, 1:6 work:rest ratio
• 8x60 workout #1
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8x60 workout #1
• 10x60 workout #2
• 8x60, 4x40 workout #3
• 6x60, 4x40, 5x30, 3x20 workout #4
• Might do running uphill or resisted running if available
OR FREE PLAY!!!!!
Core
• Begin to add med ball work in week 3, higher load ball
• Could use as dynamic warm-up or part of core routine, 2x5 each
– Chest pass
– OH toss
– Backwards toss
– Squat thrust
– Slams
– Chops
– Lunge Toss
Advanced Core
Advanced Core
Week 5: Transition to Power
• 30-45% of 1RM for “Core” lifts
• 3-5 sets of core lifts, 2-4 reps, rest 3-5 minutes
• One strength day, 2 power resistance workouts
• Supplemental exercises 2-3 sets, 10-12 reps
– Knee extensions/hamstring curls
– Bent over row/supine pull ups
– Bicep/Tricep exercises
–
Plyometrics
• 2 sets of each, 5-6 reps, focus on double-leg movements
• CMJ
• Box Jumps (Jumps TO first)
• Broad Jump
• Power skips
• Lateral broad jump
• A/P and Lateral cone hops
Plyometrics
• Transition to more single leg/split movements weeks 7-8
– Split/scissors jumps
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Split/scissors jumps
– Step jumps
– Ice skaters
– Bounding
– “Walter Paytons”
NOTE!
• Box jumps, CMJ, Broad Jumps are all “starting strength” exercises
– Might consider using these in weeks 1-4 if older kids or if they have a training
base
Conditioning
• Increasing rest time to promote full recovery to develop explosive power (1:8-10)
• Distances decrease
• 5x30, 4x20 for example
Core
• Reduce developmental sequence exercises
• Decrease weight on the med ball exercises, increase speed of performance for
explosive power
Speed/Acceleration
• Assisted running
• “Get ups”
• Plyometrics – can begin jumps FROM box (reactive)
• Power skips, bounding to sprint, reactive jump to sprint
Weeks 9-12: Speed Phase
• Recommend doing one “strength” resistance workout, leave other two for power
and speed
• Speed/acceleration work performed FIRST in workout session
• Core med ball work should be performed as fast as possible
– Hips FIRST, THEN shoulders!!!!
Speed Phase
• Conditioning drills should be short distances (10-30 yards) and you can begin
“transition” movements (shuffle, then sprint = like stealing a base)
• Promote full recovery between sets to maximize speed development
THANK YOU!!!!
• @kcrehabexpert
• www.ssorkc.com
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