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1/26/2015
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ROBERT MCCABE , PT., OCS,
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COMMON INJURIES Little Leaguer’s Shoulder
Medial Elbow Injuries (Little League Elbow)1. UCL Injuries2. Medial epicondyle apophysitis
Shoulder Microinstability Posterior / Internal Impingement
SLAP Tears Lateral Elbow - Compression Injuries
- osteochondritis dissecans
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Epiphysitis of humeral head Traction injury to
growth plate
Occurs during deceleration of throwing / follow through↑ distraction force
with eccentric IR
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Traction injury to UCL (anterior band) ligament
Occurs during cocking phase of throwing and early acceleration
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Apophysitis of medial epicondyle
Traction injury to growth plate
Occurs during cocking phase of throwing ↑ valgus force with
excessive ER
OsteochondritisDissecans
Compression of radial head / capitellum
Occurs during cocking phase of throwing and early acceleration
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COMMON FINDINGS Scapular Dyskinesia
Tight Post-InferiorGH Capsule
Poor PitchingMechanics
Overload/overuse
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Impairment in the normal resting position of the scapula or alteration in normal dynamic scapular motion.
Type I-III ClassificationType I – Prominence of infero-medial borderType II – Prom. of entire medial borderType III – Prom. of entire scapula
& superior translation of entire scapula
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Classifications• Type I
• Type II
• Type III
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TYPE I and IIAssociated with:
SLAP tears (type II)
Dysfunction of lower trapezius
Dysfunction of serratus anterior
Tightness of UT, post GH capsule or PM
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SCAPULAR DYSKINESIACommon Pattern
Post tilt, UR ,ER Impingement (64%) Instability (100%)
Ludewig Physical Therapy 2000,Into JSES 92’. Ogston,AJSM2007. Matias. Clin.Biomech 2006
Causes- Impaired:1. Posture- ↑Kyphosis2. Muscle Performance Endurance
(Acute effect)3. ROM/FlexibilityTight Posterior GH capsule Pectoralis Minor Upper trapezius
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EVALUATION- SCAPULA
Dynamic/Objective Tests
1. Lateral scapula glide test2. Scapular Assistance test3. Scapular Retraction Test
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EVALUATION- SCAPULA Lateral Scapular Glide Test• Horizontal Measurement (cm) from
inferior angle to spinous process in 3 positions:
- arms @ side - hands on hip- 90˚ GH abduction (IR)
• “Semi-dynamic”
SCAPULA SLIDE TEST + Test => 1.5 cm side to side
difference.
Test-retest reliability = .43 -.92 (inter and intra)
Validity = .90
Position 1 and 2 more reliable
Screening ToolKibler 88, 90. Odom, PT, 01, Curtis, NAJSPT,06
Purpose- Determine if scapula dyskinesis is contributing to sp. weakness in pts. w/ shoulder pathology
Technique- Empty can test manually produce scapular retraction. repeat empty can test
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SCAPULAR RETRACTION TEST
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SCAPULAR RETRACTION TEST
(+) test = strength w/ scapula retracted
Limitation:Threshold value for change not determined
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Kibler. AJSM 2006
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SCAPULAR ASSISTANCE TEST
• Purpose – Contribution of scap. dyskinesis to pain/weakness in pts with shoulder pathology
• Technique- Active elevation in sagittal or scapular plane repeat with manual assistance to promote upward rot. & post. tilt
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SCAPULAR ASSISTANCE TEST
+ Test =1. ↓pain of ≥ 2
points on 10 point scale
2. ↓Weakness
Rabin. JOSPT 2006
Greenfield AJSM 1990
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IGHL (posterior band)Teres Minor
Infraspinatus
Teres Major
» ↑ superior labrum strain via ↑ peel back forces
» ↑ Compression on posterior labrum
» ↓ ER compensate w/ ↑ abd. ant capsule stress (tension) micro-instability
» Entrapment of undersurface of posterior RC ( Posterior/ Internal impingement ) Burkhart. Arthroscopy 2003
Clabbers J Sport Rehabil. 2007
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Burkhart. Arthroscopy 2003
Clabbers J Sport Rehabil. 2007
» Late Cocking Phase - Bicep vector’s to more posterior position↑ torsion of biceps anchor/labral attachment medial/lateral gapping of labrum off glenoid
» Normal response» Accentuated by Post GH
tightness!!!Sup view (left)
Burkhart, Arthroscopy 2003
Repetitive Abd/ER » Posterior-inferior
capsule tightnessImpingement of
undersurface of post-sup. RC between posterior labrum and greater tuberosity ↑Ant capsule laxity
Superior view- left shoulder
Walch. JSES 92’
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» HORIZONTAL ADDUCTION
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Meyers Post GH Test
• Technique- Pt. retracts scapula clinician stabilizes scapula passive horizontal adduct. (in neutral rot). Measure > formed between axis of humerus and horizontal plane from superior aspect of shld.
• Inter tester reliability = .94
• Construct Validity p= .004
Myers. AJSM 2007
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MYERS. – SUPINE POST GH TEST
Shoulder Baseball
Players
Tennis
players
Normal Subjects
Dom 105 103 107
Non-Dom 114 111 107
Look for symmetry
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IR ROM :CAUSED BY RETROVERSION + GH TIGHTNESS !!
LIMITATIONOF Measuring IR ROM!
Osseous adaptations in response to tensile stress on posterior capsule( humeral + glenoid retroversion)
Humeral Retroversion
~ Posterior torsion/rotation of humerus in horizontal plane
Humeral / Glenoid Retroversion IR ↑˚17 in pitchers
Irreversible
Beneficial ? - ↑↑ in asymptomatic throwers
Crockett AJSM 02’ , Whitely, JOSPT 2009
≮=30
Generalized Ligamentous Laxity
• Elbow recurvatum = >10˚
• Thumb to forearm opposition = < 1cm
• MCP hyperext. = > 60˚
• DIP hyperext = > 30˚
* Remember: Laxity ≠ Instability
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» Anterior Apprehension Test
• 90/90 position• Passive overpressure at end-
range of ER • If (+) apprehension apply
posterior glide to humerus• (+) Test = Elimination of
instability/apprehension
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Test (+) Sens. Spec PPV/LR+
NPV/
LR -
Accur.
Apprehension
↑ Pain 50 56 14 88 55
↑Apprehension 72 96 75/20 96/.29 93
Appre-Reloc.
↓Pain 30 90 19 94 86
↓Apprehension 81 92 53/6.5 98/.18 91
Ant. Release
↑ Pain/Instab. 64 99 __/58 __/.37 65
Farber, JBJS 2006, Hegedus, BJSM. 2008 Luime JAMA 2004
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» JOBE RELOCATION TEST
• 90/90 position• Passive overpressure at end-
range of ER • If (+) Posterior shoulder
pain apply posterior glide to humerus
• (+) Test = Elimination of posterior shoulder pain
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Biceps Anchor
Associated Pathologies/Conditions• Partial supraspinatus tear (45 %)• RCT (11%)• Bankart (11%• Partial biceps tear (20%)
• Ganglion cyst- spinoglenoid• AC arthrosis
• HAGL lesion (SLAP II)• Internal impingement (SLAPII)• Scapular Dyskinesis (SLAP II)
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SPECIAL TESTS- SLAP
• Clunk Test• Anterior Slide Test• Active Compression Test • Dynamic Speed’s TestBiceps Load test I and IIResisted Supination –ER
Test• Pronated Load Test
Strong Evidence
Clunk Test- With the arm abducted to varying degrees overhead, clinician applies anterior force to humeral head while passively rotating humerus (IR/ER).
(+) test = “clunk”. Andrews AJSM 85
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Anterior Slide With pts. Hand on hip, clinician applies antero-superior force while manually stabilizing scapula. (+) test = pop/crack and pain Kibler. Arhroscopy 95’
CLUNK TEST
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ANTERIOR SLIDE TEST
Active Compression Test -With the humerus in IR & flexed @ 90 and horiz adducted 30˚ , clinician applies downward force repeat w/ humerus in ER
(+) test = Pain “inside” shoulder on 1st
test and no pain on 2nd test.
*AC pathology = pain @AC jointO’Brien AJSM 98’
Dynamic Speed’s – Clinician applies resistance to simultaneous shoulder elevation and elbow flexion. (+) test = Deep shoulder pain > 90˚
Wilk JOSPT 2005
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Biceps Load I• Shoulder @ 90˚ abduction
and max ER,(elbow flexed @ 90, supinated forearm)
• Resisted elbow flexion in order to recreate “peel back” mechanism.
(+) test = Deep shoulder pain.
Biceps Load II – shoulder ispositioned @120˚ abductionKim. Arthroscopy 2001
Kim. AJSM 95’
Resisted Supination External-Rotation Test
Test position : @ 90˚ abduction and max ER, (elbow flexed @ 65-70˚, neutral forearm)
resisted supination/simultaneous passive ER in order to recreate “peel back” mechanism.
(+) test = Deep shoulder pain.
Myers AJSM
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Pronated Load Test Shoulder abducted
90˚ w/ full pronation passive ER to end-range contract biceps to provoke “peelback” force on labrum
(+) test = painWilk JOSPT 2005
SLAP- SPECIAL TESTS Most Accurate Tests
1. Biceps Load I2. Biceps Load II3. Resisted Supination- External Rotation
Hegedus, BJSM 2008. Dessaur, JOSPT 2008
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REFERENCE SLIDE (NO AUDIO)
Biceps Load I
91 97 29.1 .1
Biceps Load II
90 97 30.0 .1
Supination-ER
83 82 4.6 .2
Specificity Sensitivity LR+ LR-
» Factors ↑GH Kinetic Force
• Dropping of trail shoulder• No “hand on top” position• ↑ Sh ER > 56˚@ stride foot
contact
• ↑Toe out ( >10˚)• ↑ Lateral placement( > 10 cm vs plant foot)
Stride
Foot
Flesig 94’
Elbow Flexion < 90 degrees at glove separation ( hand closer to head)
Excessive shoulder horizontal adduction
Arm slot position < ¾ position ( 120º )
Arm slot determined by:
Shoulder abduction angle (90-100º)
Lateral trunk tilt angle (20-30º)
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INJURY RISK FACTORS
↑Pitch count/gameThrowing sliders (↑risk +86%)Throwing curveballs ( ↑ risk + 56%)Fatigue• ↓Velocity• ↑Upright trunk @ follow thru
Throwing change-ups ↓ risk by 12%
Flesig AJSM 2002, 2006. Escambilla AJSM 2007
BIOMECHANICAL COUNSELING Parameters for Safe Pitching
• Stride length = 73-86% of height• Max Sh ER = 155˚• Avoid toe out/ lateral placement of
lead foot• Keep hand on top of ball thru early
cocking phase• “Pitch downhill”
EDUCATION
Patient/Parent/Coach
Follow UBMSAGuidelines
• Pitch counts
Follow Interval Throwing program
Monitor signs/ symptoms of fatigue
STOPSPORTS INJURIES.ORG
END OF AUDIO – REFERENCE SLIDES FOLLOW
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I
56
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If any pain , Stop throwing for 1 week
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