Return to Play Considerations in the Shoulder Injured Athlete: Part 1 Created by: Chip Hewgley, MPT...

Return to Play Considerations in Return to Play Considerations in the Shoulder Injured Athlete:the Shoulder Injured Athlete:

Part 1Part 1

Created by:Created by:

Chip Hewgley, MPTChip Hewgley, MPT

Emory Physical TherapyEmory Physical Therapy

Emory Sports MedicineEmory Sports Medicine

Throwers ParadoxThrowers Paradox

The shoulder must be loose enough The shoulder must be loose enough to allow excessive shoulder external to allow excessive shoulder external rotation but stable enough to prevent rotation but stable enough to prevent symptomatic humeral head symptomatic humeral head subluxation, thus requiring a delicate subluxation, thus requiring a delicate balance between mobility and balance between mobility and functional stability.functional stability.

The key to effective treatment is a The key to effective treatment is a complete and thorough exam with complete and thorough exam with differential diagnosis.differential diagnosis.

Throwing InjuriesThrowing Injuries

Typically the result of repetitive Typically the result of repetitive microtraumatic stresses put on the microtraumatic stresses put on the shoulder during the throwing motion.shoulder during the throwing motion.

Causes of InjuryCauses of Injury

Alterations in throwing mechanicsAlterations in throwing mechanics

Muscle fatigueMuscle fatigue

Muscle imbalance/ weaknessMuscle imbalance/ weakness

Excessive capsular laxityExcessive capsular laxity

Common sites of InjuryCommon sites of Injury

Glenohumeral capsuleGlenohumeral capsule

Glenoid labrumGlenoid labrum

Rotator cuff musculatureRotator cuff musculature

Evaluating the throwing athleteEvaluating the throwing athlete

Range of motionRange of motion

Muscle strengthMuscle strength

LaxityLaxity

ProprioceptionProprioception

Factors to ConsiderFactors to ConsiderThrowing a baseball requires transfer of Throwing a baseball requires transfer of energy from feet through the legs, pelvis energy from feet through the legs, pelvis and trunk out through the shoulder elbow and trunk out through the shoulder elbow and hand.and hand.Reduce the risk of re-injury by following a Reduce the risk of re-injury by following a GRADUAL progression of interval throwing.GRADUAL progression of interval throwing.Proper warm-up is crucialProper warm-up is crucialMost injuries occur as a result of fatigueMost injuries occur as a result of fatigueProper throwing mechanics lessen the Proper throwing mechanics lessen the incidence of re-injuryincidence of re-injury

Total Motion ConceptTotal Motion Concept

ER + IR = total motionER + IR = total motion

Sum of ER + IR = throwing vs. non Sum of ER + IR = throwing vs. non throwing shoulder (+/- 5)throwing shoulder (+/- 5)

Wilk, K.E. ASMI 2003.Wilk, K.E. ASMI 2003.Study looked at 372 professional Study looked at 372 professional baseball players.baseball players.Pitchers averaged 130 degrees of ER Pitchers averaged 130 degrees of ER and 63 degrees of IR at 90 degrees and 63 degrees of IR at 90 degrees of abduction.of abduction.ER was 7 degrees > in throwing ER was 7 degrees > in throwing shoulder.shoulder.IR was 7 degrees > in non throwing IR was 7 degrees > in non throwing shoulder.shoulder.

Throwers Laxity / Acquired LaxityThrowers Laxity / Acquired Laxity

Describes the anterior capsule and Describes the anterior capsule and inferior capsuleinferior capsule

Most likely is acquired over time.Most likely is acquired over time.

Wilk, K.E. ASMI 2003Wilk, K.E. ASMI 2003Isokinetic testing of ER strength of Isokinetic testing of ER strength of the throwing athlete is significantly the throwing athlete is significantly weaker (6%) vs. non throwing weaker (6%) vs. non throwing shoulder.shoulder.IR strength was significantly stronger IR strength was significantly stronger (3%) in throwing vs. non throwing (3%) in throwing vs. non throwing shoulder.shoulder.Optimal ER/IR strength ratio should Optimal ER/IR strength ratio should be between 66-75%.be between 66-75%.

Principles of Rehabilitation in the ThrowerPrinciples of Rehabilitation in the Thrower

1. Never overstress healing tissue.1. Never overstress healing tissue.2. Prevent negative effects of immobilization2. Prevent negative effects of immobilization3. Emphasize ER muscle strength.3. Emphasize ER muscle strength.4. Establish muscular balance.4. Establish muscular balance.5. Emphasize scapular muscle strength.5. Emphasize scapular muscle strength.6. Improve posterior shoulder flexibility.6. Improve posterior shoulder flexibility.7. Enhance proprioception and neuromuscular 7. Enhance proprioception and neuromuscular control.control.8. Establish biomechanically efficient throwing.8. Establish biomechanically efficient throwing.9. Gradually return to throwing activities.9. Gradually return to throwing activities.10. Use established criteria to progress.10. Use established criteria to progress.

4 Parts of Treatment Program4 Parts of Treatment Program

Activity modificationActivity modification

Flexibility exercises Flexibility exercises

Strengthening exercisesStrengthening exercises

Gradual return to throwingGradual return to throwing

Rehabilitation Program for the Rehabilitation Program for the Overhead ThrowerOverhead Thrower

Phase 1 (Acute Phase)Phase 1 (Acute Phase)

Goals:Goals:

1. Decrease inflammation and pain1. Decrease inflammation and pain

2. Increase flexibility and normalize ROM2. Increase flexibility and normalize ROM

3. Reestablish dynamic stability (muscle 3. Reestablish dynamic stability (muscle balance)balance)

4. Retard muscle atrophy4. Retard muscle atrophy

5. Restore Proprioception5. Restore Proprioception

Phase 1 TreatmentPhase 1 Treatment1. Modalities: Cryotherapy, ultrasound, electric 1. Modalities: Cryotherapy, ultrasound, electric stimulation.stimulation.2. Exercise: flexibility/stretching for IR and 2. Exercise: flexibility/stretching for IR and horizontal adductionhorizontal adductionRotator cuff strengthening with emphasis on ERRotator cuff strengthening with emphasis on ERScapular muscle strengthening with emphasis on Scapular muscle strengthening with emphasis on retractor, protractor and deep depressorsretractor, protractor and deep depressorsDynamic stabilization (rhythmic stabilization)Dynamic stabilization (rhythmic stabilization)Closed kinetic chain and Proprioceptive trainingClosed kinetic chain and Proprioceptive trainingNo Throwing!!!!No Throwing!!!!

Phase 1Phase 1

Phase 2- Intermediate PhasePhase 2- Intermediate Phase

Goals:Goals:

Progress strengthening exerciseProgress strengthening exercise

Restore muscle balanceRestore muscle balance

Enhance dynamic stabilityEnhance dynamic stability

Phase 2Phase 2

Continue stretching and flexibilityContinue stretching and flexibility

Primarily IR and horizontal adductionPrimarily IR and horizontal adduction

Progress strengthening programProgress strengthening program

Throwers Ten programThrowers Ten program

Core strengtheningCore strengthening

LE strengtheningLE strengthening

Phase 2Phase 2

Strengthening ExercisesStrengthening Exercises

Sidelying ER and Prone Rowing with Sidelying ER and Prone Rowing with ER have been shown to elicit the ER have been shown to elicit the highest EMG activity of post. Cuff highest EMG activity of post. Cuff muscles (Fleisig).muscles (Fleisig).

Scapula provides proximal stability to Scapula provides proximal stability to allow for distal mobility.allow for distal mobility.

Supraspinatus StrengtheningSupraspinatus StrengtheningEmpty can exercise originally highlighted Empty can exercise originally highlighted by Jobe for high EMG levels.by Jobe for high EMG levels.Townsend reported highest EMG activity in Townsend reported highest EMG activity in the military press but this exercise is not the military press but this exercise is not recommended for throwers.recommended for throwers.Blackburn noted prone lying with arm Blackburn noted prone lying with arm abducted to 100 degrees and full ER had abducted to 100 degrees and full ER had the highest EMG activity.the highest EMG activity.We recommend the use of the “full can” We recommend the use of the “full can” exercise to avoid superior humeral head exercise to avoid superior humeral head migration secondary to ER weakness.migration secondary to ER weakness.

Phase 3- Advanced Strengthening Phase 3- Advanced Strengthening PhasePhase

Goals: begin aggressive Goals: begin aggressive strengtheningstrengthening

Increase power and enduranceIncrease power and endurance

Begin more functional drills Begin more functional drills

Initiate throwing activities as Initiate throwing activities as toleratedtolerated

Exercises: Phase 3Exercises: Phase 3

Throwers Ten ProgramThrowers Ten Program

Manual Rhythmic StabilizationManual Rhythmic Stabilization

Plyometric drillsPlyometric drills

Dynamic stabilizationDynamic stabilization

Phase 3Phase 3

Plyometric ProgramPlyometric Program

Two handed drills:Two handed drills:

Chest PassChest Pass

Overhead soccer throwOverhead soccer throw

Side to side throwSide to side throw

Side throwSide throw

Phase 3Phase 3

Plyometric Program cont’dPlyometric Program cont’d

One handed drillsOne handed drills

standing throw (feet fixed)standing throw (feet fixed)

wall dribblingwall dribbling

Plyometric step and throwPlyometric step and throw

Phase4Phase4Throwing Program InitiationThrowing Program Initiation

Begin with shadow / mirror throwing Begin with shadow / mirror throwing to work on proper mechanics.to work on proper mechanics.

Phase 4Phase 4

Criteria to begin ThrowingCriteria to begin Throwing

Satisfactory clinical examSatisfactory clinical exam

Painfree ROMPainfree ROM

Satisfactory isokinetic test resultsSatisfactory isokinetic test results

Appropriate rehab progressAppropriate rehab progress

Unilateral Muscle RatiosUnilateral Muscle RatiosVelocityVelocity ER/IRER/IR ABD/ADDABD/ADD

180 deg/sec180 deg/sec 65-75%65-75% 78-85%78-85%

300 deg/sec300 deg/sec 61-71%61-71% 88-94%88-94%

Interval Throwing ProgramInterval Throwing Program

Designed to gradually increase Designed to gradually increase quantity, distance and intensity.quantity, distance and intensity.

Throwing ProgramThrowing Program(2 Phases)(2 Phases)

Phase 1: long toss programPhase 1: long toss program

Phase 2: off the moundPhase 2: off the mound

Initiate @ 45 feet and progress to 60 Initiate @ 45 feet and progress to 60 feet.feet.

Sample long toss programSample long toss program25 throws @ 45 feet, rest 5 min. 25 throws @45 feet.25 throws @ 45 feet, rest 5 min. 25 throws @45 feet.35 throws @ 45 feet, rest 5 minutes, 35 throws @45 feet.35 throws @ 45 feet, rest 5 minutes, 35 throws @45 feet.25 throws @ 60 feet, rest 5 minutes, 25 throws @ 60 feet.25 throws @ 60 feet, rest 5 minutes, 25 throws @ 60 feet.35 throws @60 feet, rest 5 minutes, 35 throws @60 feet.35 throws @60 feet, rest 5 minutes, 35 throws @60 feet.25 throws @ 90 feet, rest 5 minutes, 25 throws @90 feet.25 throws @ 90 feet, rest 5 minutes, 25 throws @90 feet.35 throws @90 feet, rest 5 minutes, 35 throws @ 90 feet.35 throws @90 feet, rest 5 minutes, 35 throws @ 90 feet.25 throws @ 120 feet, rest 5 minutes, 25 throws @ 120 25 throws @ 120 feet, rest 5 minutes, 25 throws @ 120 feet.feet.35 throws @ 120 feet, rest 5 minutes, 35 throws @ 120 35 throws @ 120 feet, rest 5 minutes, 35 throws @ 120 feet.feet.

Sample mound programSample mound program25 throws @ 50%25 throws @ 50%35 throws @ 50%35 throws @ 50%50 throws @ 50%50 throws @ 50%25 throws @ 75%25 throws @ 75%35 throws @ 75%35 throws @ 75%50 throws @ 75%50 throws @ 75%25 throws @ 90%25 throws @ 90%35 throws @ 90%35 throws @ 90%50 throws @ 90%50 throws @ 90%25 throws live BP25 throws live BP50 throws live BP50 throws live BP1 inning game1 inning game2 inning game2 inning game3 inning game3 inning game1 inning game on back to back days1 inning game on back to back days

Phase 4: Return to ThrowingPhase 4: Return to Throwing

Progression of long toss program to Progression of long toss program to 120 feet.120 feet.

When the pitcher can throw from 120 When the pitcher can throw from 120 feet pain free he may begin throwing feet pain free he may begin throwing from the windup on flat ground and from the windup on flat ground and progress to the mound.progress to the mound.

Biomechanics of PitchingBiomechanics of Pitching

1. Windup: begins with foot drop and ends with 1. Windup: begins with foot drop and ends with hand separation.hand separation.2. Stride: front foot moves towards home plate.2. Stride: front foot moves towards home plate.3. Arm cocking: pelvis and upper trunk face 3. Arm cocking: pelvis and upper trunk face home plate and ER occurs.home plate and ER occurs.4. Arm acceleration: from maximum ER to ball 4. Arm acceleration: from maximum ER to ball release.release.5. Arm deceleration: from ball release to end 5. Arm deceleration: from ball release to end range IRrange IR6. Follow through: from maximal IR until pitcher 6. Follow through: from maximal IR until pitcher regains balanced position. regains balanced position.

Softball vs. Baseball PitchSoftball vs. Baseball Pitch

Fast Pitch softball (windmill style)Fast Pitch softball (windmill style)

Humerus in plane of scapulaHumerus in plane of scapula

Adduction of humerus- power Adduction of humerus- power generator is pec majorgenerator is pec major

Forearm strikes lateral thigh at ball Forearm strikes lateral thigh at ball release to decelerate arm vs. ER in release to decelerate arm vs. ER in baseball for decelerationbaseball for deceleration

Sample Softball Throwing ProgramSample Softball Throwing Program10 throws @30’, rest 8 min., 10 throws @ 30’10 throws @30’, rest 8 min., 10 throws @ 30’

10 throws @45’, rest 8 min, 10 throws @ 45’10 throws @45’, rest 8 min, 10 throws @ 45’

10 throws @ 60’, rest 8 min, 10 throws @ 60’10 throws @ 60’, rest 8 min, 10 throws @ 60’




Softball ITP Cont’dSoftball ITP Cont’d10 throws @ 60’,10 pitches @ 20’, rest 8 min, 10 throws @ 60’, 5 10 throws @ 60’,10 pitches @ 20’, rest 8 min, 10 throws @ 60’, 5 pitches @ 20’pitches @ 20’

10 throws @ 60’, 10 pitches @ 35’, rest 8 min, 10 throws @ 60’, 10 throws @ 60’, 10 pitches @ 35’, rest 8 min, 10 throws @ 60’, 10 pitches @35’.10 pitches @35’.

10 throws @ 60’, 10 pitches @ 46’, rest 8 min, 10 throws @ 60’, 10 throws @ 60’, 10 pitches @ 46’, rest 8 min, 10 throws @ 60’, 10 pitches @ 46’.10 pitches @ 46’.

10 throws @ 60’, 10 pitches @ 46’, rest 8 min, 10 pitches @ 46’, 10 throws @ 60’, 10 pitches @ 46’, rest 8 min, 10 pitches @ 46’, rest 8 min, 10 throws @ 60’, 10 pitches @46’.rest 8 min, 10 throws @ 60’, 10 pitches @46’.

If no soreness, advance 1 step every throwing If no soreness, advance 1 step every throwing day.day.If sore during warm-up but soreness is gone If sore during warm-up but soreness is gone within the first 15 throws, repeat previous within the first 15 throws, repeat previous workout. If shoulder becomes sore during this workout. If shoulder becomes sore during this workout, stop and take 2 days off. Upon return to workout, stop and take 2 days off. Upon return to throwing drop down 1 step.throwing drop down 1 step.If sore more than 1 hour after throwing on the If sore more than 1 hour after throwing on the next day, take 1 day off and repeat the most next day, take 1 day off and repeat the most recent throwing program workout.recent throwing program workout.If sore during the warmup and soreness continues If sore during the warmup and soreness continues through the first 15 throws, stop and take 2 days through the first 15 throws, stop and take 2 days off. Upon return to throwing, drop down 1 step.off. Upon return to throwing, drop down 1 step.

Soreness Rules for ITP (Axe, Soreness Rules for ITP (Axe, Windley, Snyder-Mackler)Windley, Snyder-Mackler)

Softball ITP Cont’dSoftball ITP Cont’d2 throws to each base, 15 pitches (50%), rest 8 min, 15 pitches 2 throws to each base, 15 pitches (50%), rest 8 min, 15 pitches (50%), 1 throw to each base, 15 pitches (50%).(50%), 1 throw to each base, 15 pitches (50%).2 throws to each base, 15 pitches (50%) X 3 w/ 8 min rest, 1 throw 2 throws to each base, 15 pitches (50%) X 3 w/ 8 min rest, 1 throw to each base, 15 pitches 50%.to each base, 15 pitches 50%.2 throws to each base, 15 pitches (50%), 15 pitches (75%) X 2 w/ 2 throws to each base, 15 pitches (50%), 15 pitches (75%) X 2 w/ 8 min rest, 1 throw to each base, 15 pitches (50%).8 min rest, 1 throw to each base, 15 pitches (50%).2 throws to each base, 15 pitches(50%), 15 pitches (75%),15 2 throws to each base, 15 pitches(50%), 15 pitches (75%),15 pitches (75%), 20 pitches (50%), 1 throw to each base, 15 pitches pitches (75%), 20 pitches (50%), 1 throw to each base, 15 pitches (50%).(50%).2 throws to each base, 15 @ 75%, 15 @ 75%, 15 @ 75%, 15 @ 2 throws to each base, 15 @ 75%, 15 @ 75%, 15 @ 75%, 15 @ 75%, 1 throw to each base, 15 @ 75%.75%, 1 throw to each base, 15 @ 75%.1 throw to each base, 15 @ 100%, 20 @ 75%, 15 @ 100%, 20 @ 1 throw to each base, 15 @ 100%, 20 @ 75%, 15 @ 100%, 20 @ 75%, 1 throw to each base, 20 @ 75%.75%, 1 throw to each base, 20 @ 75%.1 throw to each base, 15 @ 100%, 20 @ 75%, 15 @ 100%, 15 @ 1 throw to each base, 15 @ 100%, 20 @ 75%, 15 @ 100%, 15 @ 100%,20 @ 75%, 1 throw to each base, 15 @ 75%.100%,20 @ 75%, 1 throw to each base, 15 @ 75%.

Softball ITP Cont’dSoftball ITP Cont’d1 throw to each base, 20 @ 100%, 15 @ 100, 20 @ 100%,15 @ 1 throw to each base, 20 @ 100%, 15 @ 100, 20 @ 100%,15 @ 100%, 20 @ 100%, 1 throw to each base, 15 @ 100%.100%, 20 @ 100%, 1 throw to each base, 15 @ 100%.

1 throw to each base, 20 @ 100%, 15 @ 100%, 20 @ 100%, 15 @ 1 throw to each base, 20 @ 100%, 15 @ 100%, 20 @ 100%, 15 @ 100%, 20 @ 100%, 15 @ 100%, 1 throw to each base, 15 @ 100%.100%, 20 @ 100%, 15 @ 100%, 1 throw to each base, 15 @ 100%.

BP 100-120 pitches total, 1 throw to each base per 25 pitches.BP 100-120 pitches total, 1 throw to each base per 25 pitches.

Simulated game, 7 innings, 18-20 pitches /inning, 8 min rest Simulated game, 7 innings, 18-20 pitches /inning, 8 min rest between innings.between innings.

The Overhead Throwing AthleteThe Overhead Throwing Athlete

Extreme stresses applied to the Extreme stresses applied to the shoulder.shoulder.

Tremendous angular velocities Tremendous angular velocities (greater than 7000o/s).(greater than 7000o/s).

Throwers Paradox: loose enough to Throwers Paradox: loose enough to throw but stable enough to prevent throw but stable enough to prevent symptoms. Mobility<> stabilitysymptoms. Mobility<> stability

USA Baseball RecommendationsUSA Baseball Recommendations

9-10 year olds9-10 year olds

50 pitches per game50 pitches per game

75 pitches per week75 pitches per week

1000 pitches per season1000 pitches per season

2000 pitches per year2000 pitches per year


11-12 year old pitchers:11-12 year old pitchers:






13-14 year old pitchers13-14 year old pitchers





ReferencesReferencesWilk, K.E., Meister, K., Andrews, J.R. Current Concepts in the Rehabilitation of the Overhead Wilk, K.E., Meister, K., Andrews, J.R. Current Concepts in the Rehabilitation of the Overhead Throwing Athlete. AJSM, vol30, No. 1 2002.Throwing Athlete. AJSM, vol30, No. 1 2002.Paine, Russell M. The Role of the Scapula in the Shoulder. The Athletes Shoulder.Paine, Russell M. The Role of the Scapula in the Shoulder. The Athletes Shoulder.Wilk, K.E., Andrews, J.R. et al. Interval Sports Programs: Guidelines for Baseball, Tennis and Golf. Wilk, K.E., Andrews, J.R. et al. Interval Sports Programs: Guidelines for Baseball, Tennis and Golf. JOSPT, vol 32, June 2002.JOSPT, vol 32, June 2002.Davies, G.J. Proprioception in the Thrower. ASMI. 2002.Davies, G.J. Proprioception in the Thrower. ASMI. 2002.Wilk, K.E. Rehabilitation Guidelines for the Thrower with Internal Impingement. ASMI 2002-2003.Wilk, K.E. Rehabilitation Guidelines for the Thrower with Internal Impingement. ASMI 2002-2003.Andrews JR, Chmielewski T, Escamilla RF, Fleisig GS, Wilk KE. Conditioning program for professional Andrews JR, Chmielewski T, Escamilla RF, Fleisig GS, Wilk KE. Conditioning program for professional baseball pitchers. ASMI, Birmingham, AL 1997.baseball pitchers. ASMI, Birmingham, AL 1997.Andrews JR, Fleisig GS. How many pitches should I allow my child to throw? USA Baseball News, Andrews JR, Fleisig GS. How many pitches should I allow my child to throw? USA Baseball News, April, 1996.April, 1996.Fleisig GS, Barrentine SW, Zheng N Escamilla RF, Andrews JR. Kinematic and kinetic comparison of Fleisig GS, Barrentine SW, Zheng N Escamilla RF, Andrews JR. Kinematic and kinetic comparison of baseball pitching among various levels of development. Journal of Biomechanics 32 (12): 1371-baseball pitching among various levels of development. Journal of Biomechanics 32 (12): 1371-1375, 1999.1375, 1999.Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. AJSM 30(4):463-468, 2002.mechanics on risk of elbow and shoulder pain in youth baseball pitchers. AJSM 30(4):463-468, 2002.Ellenbecker, T.S., Davies, G.J. The Application of Isokinetics in Testing and Rehabilitation of the Ellenbecker, T.S., Davies, G.J. The Application of Isokinetics in Testing and Rehabilitation of the Shoulder Complex. Journal of Athletic Training, 2000;35(3):338-350.Shoulder Complex. Journal of Athletic Training, 2000;35(3):338-350.Meister, K. Injuries to the Shoulder in the Throwing Athlete. Part Two Evaluation/Treatment. AJSM, Meister, K. Injuries to the Shoulder in the Throwing Athlete. Part Two Evaluation/Treatment. AJSM, vol. 28, No. 4. 2000.vol. 28, No. 4. 2000.Axe, M.J., Windley, T.C., Snyder-Mackler, L. Data Based Interval Throwing Programs for Collegiate Axe, M.J., Windley, T.C., Snyder-Mackler, L. Data Based Interval Throwing Programs for Collegiate Softball Players. Journal of Athletic Training. 2002;37(2):194-203.Softball Players. Journal of Athletic Training. 2002;37(2):194-203.

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Return to Play Considerations in the Shoulder Injured Athlete: Part 1 Created by: Chip Hewgley, MPT...

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