Shoulder and Core presentation 2016 (1)cme.uthscsa.edu/Courses/SportsMedicine/2016...This presentation is the intellectual property of the author. Contact them for permission to reprint

This presentation is the intellectual property of the author.Contact them for permission to reprint and/or distribute.

Addressing Core and Balance Deficits to Maximize Return to Sport in Overhead Athletes

Meg Jacobs P.T.

Momentum Physical Therapy and Sports Rehab

“Hands‐on care for faster results”www.WeGetYouHealthy.com

Through research, it has been shown that both elbow and

shoulder injuries among athletes performing overhead activities is associated with shoulder and hip ROM deficits as well as with poor

core strength and balance.

• ROM deficits have been shown to place additional demands on other joints throughout the body.

• Core stab is the “ability to control position and movement of the trunk for optimal production, transfer and control of forces to and from the UE and LE during functional/sport activities”.

• Balance is the “dynamics of the body posture to prevent falling and is affected by inertial forces acting on the body”.

• Pitching motion is complex and involves extreme transfer of energy through the entire body.

• Scapular and trunk control are a necessity for optimal overhead activities.

• Forces at the shoulder can escalate with an athlete that is compensating for injuries and or ROM deficits in other body joints…low back, hip, knee, ankle…

S Scher et al.

• Hypothesized that limited ROM of the hip is associated with altered shoulder ROM and development of shoulder injuries.

– “Poor extension of the dominant hip during acceleration phase of pitching motion, could cause pitcher to increase the amount of shoulder ER in attempt to achieve desired throwing motion”. This “flying open” could increase stress to anterior shoulder structures, leading to chance for injury.

Scher et al.

• Similar hypoth‐

– “Restricted hip IR of the non dominant hip during follow through phase of throwing, may limit LE ability to absorb or dissipate energy generated during the acceleration phase, placing greater demands on the RC to act as a decelerator of arm at follow through, leading to posterior shoulder dysfunction”.


Scher et al.

• Concluded that “hip ext and shoulder ER ROM are related to BB players with history of shoulder injury”.

• They demonstrated an “association between shoulder and hip motion and the development of shoulder injuries”.

J.Craig Garrison et al.

• Hypothesized that “BB players with ulnarcollateral ligament (UCL) tears would have a greater glenohumeral IR deficit (GIRD) and deficit in overall total range of motion (TRM) in the throwing shoulder compared to the non throwing shoulder”.

• BB players frequently demonstrate increased shoulder ER and decreased IR while maintaining normal TRM of the throwing shoulder

• Studies have shown that shoulder deficits of IR >25 and TRM >5, have tendency for higher risk of injury.

• Burkhart et al.‐ developed the term GIRD and defined it as a deficit of shoulder IR > 20 in the throwing shoulder.

– GIRD has been documented in the dominant/throwing shoulder and is suggested to be pathological and assoc with shoulder and elbow injuries.

Dinesetal et al.‐ found a correlation with increased GRID in BB players with UCL injuries.

J Craig Garrison et al.

• Concluded: there is a “statistically significant difference in shoulder TRM in the UCL injured BB players compared to non UCL injured players”.

• They were able to recognize that TRM deficits could play an important role in identifying players with UCL injuries or potential for injury.

J Craig Garrison et al.

• Study‐ “BB players diagnosed with UCL tears demonstrate decreased balance compared to healthy controls”.

– Objective: to compare LE balance and shoulder ROM in BB players with UCL tears to healthy BB players without UCL tears.

– Conclusion: BB players with UCL tears demonstrated decreased performance for their stance and lead LE during a “Y” balance test.


Kibler and Sciascia

• Proposed: “inadequate ROM and poor balance may significantly affect athletes ability to transfer energy along the kinetic chain, resulting in dysfunctional movement and stresses at various segments to include the elbow”.– Impaired control at the LE and trunk may alter position of shoulder and elbow through the throwing motion potentially leading to increased stress placed across those joints.

• In BB players, muscle activation patterns and transfer of energy begins in the Les and transfers up through their trunk, into the UE in order to achieve max throwing velocity.

• Inefficient movement patterns that begin at the LE, involving poor balance, could alter the throwing mechanism and lead to UE injuries.

Integrating Shoulder and Core Ex with Rehab for Overhead Athletes

• Athletes involved in overhead activities are at risk for overuse and traumatic injuries

• Failure to identify and address all musculoskeletal dysfunctions may delay successful return to sport

• Proper use of kinetic chain allows for max force to be developed in the core which can be efficiently transferred to the UE

• Combining shoulder, core and balance ex can serve as a transitional program from general rehab to return to sport

General Rehab Guidelines

• MD protocol

• Basic: decrease pain, increase ROM and flexibility, manual therapy to address decreased ROM and joint mobility, strengthening

• Integrate core strength, muscle activation and balance

Establish Proper Motion

• Sleeper stretch‐ IR ROM

• Horizontal add‐ posterior capsular stretch

• Door/corner stretch‐ pec and ant capsular stretch


Initial Strength‐ address proximal dysfunction with emphasis on scapulo‐

thoracic dyskinesis

• Rotator Cuff

– Supraspin: scaption with IR

– infraspinatus: horiz abd @90 with ER

– Teres minor: sidelye ER at 0 ABD

– Subscap‐ scaption with shoulder IR

Facilitate Scapular Motion

• Incorporate trunk and hip for facilitating proximal and distal sequencing of muscle activity.

Facilitate Scapular Motion Scapular Stabilizers

• Upper trap: rowing

• Mid Trap: horizontal ABD neutral and with ER

• Lower Trap: Abduction and rowing

• Rhomboid: scaption and horizontal ABD neutral


As strength improves, progress to sport specific movement patterns that

address core and balance issues

• Identify core weakness

– Trendelenburg sign (during gait)

– Femoral add (lunge)

– Femoral IR (lunge)

– Knee valgus (lunge)

– Tibial IR (lunge)

Various levels of ex can address core weakness

• Isometric shoulder ex activate trunk muscles and can be started early rehab

• Small amplitude isotonic ther ex (body blade) activate various trunk muscles in addition to shoulder stabilizers

• Fast isotonic shoulder movements increase trunk muscle activation

• Movement speed can also greatly influence core activation

Advanced shoulder/core stab can be addressed when performed correctly

and symptom free

• Side plank with ER‐ obliques and transverse abdominals

• 3pt plank with shoulder horiz abd with ER‐supraspin, mid trap and rhomb

• 3pt plank with shoulder ext‐mid trap and post deltoid

• 3pt plank with shoulder row‐ trap, rhomboid and post deltoid

• 3pt plank with diagonal arm raise‐mid and low traps

Side Plank with ER 3 Pt Plank with Horiz ABD


3 Pt Plank with Ext 3 Pt Plank with Row

3 Pt Plank with Diagonal Sports Specific

• Integrating sports specific ex that encourages improved LE muscle endurance and strength to facilitate proper UE mechanics, muscle activation, proprioception and muscle sequencing

• High rep/low weight address power and endurance deficits

Power Position with Trunk Twist Step Back with Power Position


Step Back with Power Position Rebounder with Power Position

Primal 7

• “A system that works through suspension and resistance bands together which maximizes movement patterns

– Allows for graduated loading

– Allows for training in all planes

– 7 movement patterns that are building blocks for all activities

Pull Up

Assisted Pull Up Unassisted Pull Up


Assisted Push Up Assisted Push up on Rings

Unassisted Push up on Rings Assisted Flys

Assisted Roll Outs Push to Pike


Conclusion

• Don’t overlook core stab, balance and distal dysfunction (poor rear foot control, decreased ankle ROM, hip ext and abductor tightness/weakness, limited spine mobility, limited core strength, poor scapular control) as all are limitations to a successful rehabilitation and return to sport for our athletes.

• Create a “STABLE BASE” for proper development and transfer of energy to the shoulder and elbow of our overhead athletes.

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Shoulder and Core presentation 2016 (1)cme.uthscsa.edu/Courses/SportsMedicine/2016...This presentation is the intellectual property of the author. Contact them for permission to reprint