Stephanie D. Moore-Reed, PhD, ATC California State University, Fresno California State University, Fresno S E S A P IX Lead/Stride leg

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1 OBJECTIVES Corrective Exercise to Address Common Biomechanical Alterations throughout Each Phase of the Throwing Motion Stephanie D. Moore-Reed, PhD, ATC California State University, Fresno Six phases of the throwing motion Key breakdowns in the kinetic chain Assessment Techniques Corrective Exercises California State University, Fresno Department of Kinesiology SIX PHASES 1.Windup 2.Early Cocking (Stride) 3.Late Cocking 4.Acceleration 5.Deceleration 6.Follow Through Meister, AJSM 2000 Terminology Lead/Stride leg: contralateral to throwing arm Trail/Stance leg: ipsilateral to throwing arm, used to balance body during cocking phase Importance of the Kinetic Chain Pitching motion is not an upper extremity action (requires entire body) Reduced stresses on shoulder reduced injury risk increased durability and health of shoulder (career) (Seroyer, Sports Health 2010) Improved velocity (Matsuo et al, J Appl Biomech 2001; Stodden et al, J Appl Biomech 2005; Werner et al, JSES 2008) 1

2 1.Windup 2.Early Cocking (Stride) 3.Late Cocking 4.Acceleration 5.Deceleration 6.Follow Through Wind-up Start: weight shift from stride leg to trail leg End: maximum knee lift of stride leg Preparation phase establishes rhythm (Meister, AJSM 2000; Dillman et al, JOSPT 1993) Seroyer et al, Sports Health 2010 Wind Up Considerations Maintain COG over stance leg Keep Center of Gravity over trail leg Premature movement forward KC disruption more stress on UE (Burkhart et al, Arthroscopy 2003) Trail leg characteristics Balance/postural control Hip abduction strength Good peak hip abductor activity proper throwing mechanics and reduced risk of injury (Yamanouchi, Kurume Med J 1998) Seroyer et al, Sports Health 2010 Hip ABD strength 1.Windup 2.Early Cocking (Stride) 3.Late Cocking 4.Acceleration 5.Deceleration 6.Follow Through Early Cocking (Stride) Start: Maximum knee lift of stride leg & ball removed from glove End: Stride foot contact Generate & transfer momentum up through the kinetic chain (Stodden et al, J Appl Biomech 2005) 2

3 Early Cocking Considerations Foot position at stride foot contact Foot should point toward home plate (slightly inward) Necessary for optimal rotation of hips, pelvis & trunk (Dillman et al, JOSPT 1993) Deviation may lead to problems Stride foot lands in closed position Must throw across body Slows down rotation of the torso, reducing body s momentum throw delivered entirely by arm Stride foot lands in open position Arm lags behind body Pelvic rotation occurs too early increased stress to anterior shoulder and elbow Seroyer et al, Sports Health 2010 Early Cocking Considerations Quality of stride foot contact Hyperextension of knee while planting the stride foot OR landing on the heel sudden deceleration of the body (Meister, AJSM 2000) Proper pelvic orientation at stride foot contact requires sufficient hip: ER ROM of lead leg IR ROM of trail leg Decreased hip ROM associated with decreased velocity and poor throwing mechanics (Robb et al AJSM 2010) Early Cocking Considerations Timing of trunk rotation Initiation of trunk rotation before stride foot contact higher elbow valgus torques (Aguinaldo & Chambers, AJSM 2009) Proper timing of pelvis rotation followed by upper trunk rotation maximizes KC Improper stride foot angle or position early rotation of pelvis additional force on shoulder and medial elbow (Fortenbaugh et al, Sports Health 2009) 1.Windup 2.Early cocking (Stride) 3.Late Cocking 4.Acceleration 5.Deceleration 6.Follow Through 3

4 Late Cocking Start: stride foot contact End: shoulder in max ER ( º) Scapula retracts to assist with achieving this position & forms a stable base Late Cocking Considerations Loss of Scapular Muscle Control Scapula: base for muscle attachment and link to transfer forces from trunk to arm (Kibler, AJSM 1998) Increased protraction Hyperangulation in cocking and follow through (Kibler, AJSM 1998) SubAC Impingement risk increases Disrupts Kinetic Chain 20% decrease in energy delivered from trunk arm requires 33% increase in rotational velocity at the shoulder to deliver same amount of resultant force (Kibler, AJSM 1998) Internal Impingement Consequence of increased protraction Complain of pain at late cocking and early acceleration Posterior inferior supraspinatus tendon impinged 1.Windup 2.Early cocking (Stride) 3.Late Cocking 4.Acceleration 5.Deceleration 6.Follow Through Acceleration Start: maximum ER End: ball release Scapula begins to protract (controlled!) Arm internally rotates deg/sec (Dillman et al, JOSPT 1993; Pappas et al, AJSM 1985) Stride leg stabilizing 4

5 Shoulder Abduction & Lateral Trunk Tilt º Altered shoulder abduction Decreased ball velocity (MacWilliams AJSM 1998) Increased varus torque at elbow (Matsuo, J Appl Biomech 2001; Aguinaldo & Chambers, AJSM 2009) Arm Slot Variations Sidearm delivery higher elbow valgus torques compared to overhand arm slot (Matsuo et al 2000; Aguinaldo & Chambers, AJSM 2009) Submarine Aguinaldo & Chambers, AJSM 2009 Sidearm 3/4 Increased ball velocity associated with Greater knee extension motion & velocity (Matsuo et al, 2001; Escamilla et al, Sports Biomech 2002; Werner et al, JSES 2008) Greater forward trunk tilt (Stodden, J Appl Biomech 2005; Escamilla et al, Sports Biomech 2002) at ball release Seroyer et al, Sports Health Windup 2.Early cocking (Stride) 3.Late Cocking 4.Acceleration 5.Deceleration 6.Follow Through Deceleration Start: Ball release End: Max IR Reversal of earlier phases Most violent phase greatest joint loads Deceleration Characteristics Velocity -500,000 deg/sec 2 (Pappas et al, 1985; Dillman et al, 1993) Distraction forces as high as 81% BW (Werner et al, JSES 2007) Compressive force >1000 N-m (Fleisig et al, 1995; Dillman et, JOSPT 1993) Posterior musculature working eccentrically to slow down arm Hip abductors of stride leg maintain balance 5

6 Deceleration Considerations Tightness of posterior shoulder musculature Decreased Internal Rotation Decreased Horizontal Adduction Infraspinatus Teres minor Posterior deltoid Deceleration Considerations Posterior Capsule Tightness Decreased internal rotation Decreased horizontal adduction Decreased flexion Decreased abduction (Tyler et al, AJSM 2000; Burkhart et al, Arthroscopy 2003) Posterior Deltoid 1.Windup 2.Early cocking (Stride) 3.Late Cocking 4.Acceleration 5.Deceleration 6.Follow Through Follow Through Body moves forward with the arm Rebalancing phase Culminates in pitcher in fielding position (Fleisig, AJSM 1995) 6

7 SIX PHASES 1.Windup 2.Early Cocking (Stride) 3.Late Cocking 4.Acceleration 5.Deceleration 6.Follow Through KEY POINTS OF BREAKDOWN IN THE KINETIC CHAIN Key Breakdowns Lower Extremity 1. Trail leg hip abductor weakness 2. Premature forward motion 3. Stride leg foot placement & quality 4. Limited hip ER/IR ROM 5. Too much knee ball release Key Breakdowns Trunk 1. Timing of pelvis and trunk rotation 2. Decreased forward trunk tilt 3. Weakness in core strength Key Breakdowns Upper Extremity Shoulder Abduction varies from º Scapular Muscle Imbalance/Scapular Dyskinesis Increased scapular protraction Diminished max ER ROM Tightness of posterior capsule & musculature ASSESSMENT 7

8 Assessment LE & Trunk Hip IR/ER ROM Hip abductor strength Single-leg stance & squat Three plane core assessment UE Glenohumeral ER/IR ROM Horizontal Adduction ROM Humeral Retroversion Scapular Dyskinesis Hip IR/ER ROM Laudner et al, AJSM 2010 Hip Abduction MMT Correct Trunk Pelvis & Hip Hip & Knee SINGLE LEG SQUAT Crossley et al, AJSM 2011 Laudner et al, AJSM repetitions Three Plane Core Assessment Sagittal Plane Testing Evaluates eccentric strength of abdominals, quads, and hip flexors Concentric strength of hip and spine extensors Frontal Plane Testing Evaluates eccentric strength of QL, hip abductors Transverse Plane Testing Evaluates abdominals, hip rotators, spine extensors Kibler et al, Sports Med 2006 Consequences of repetitive Typical Motion Alterations in throwing Overhead Athletes Decreased internal rotation (IR) with concomitant external rotation (ER) gain (Bigliani AJSM 1997; Ellenbecker JOSPT 1996) Total arc of motion (IR+ER) similar bilaterally (Borsa MSSE 2006; Ellenbecker MSSE 2002) Seroyer et al, Sports Health

9 Bony Contribution Humeral retroversion: angle of the axis of the humeral head in a medial and posterior direction relative to the axis of the elbow joint (Reagan et al, AJSM 2002; Kronberg et al, CORR 1990, Gordon et al, JSES 2000) At birth = MORE retroverted, diminishes over time (Gordon et al, JSES 2000) Bony Contribution Larger angle of retroversion associated with greater ER motion (Kronberg CORR 1990) May be advantageous for achieving max ER and ball velocity More humeral retroversion Less humeral retroversion Pieper AJSM 1998 Glenohumeral Internal Rotation Deficit (GIRD) 15 loss of IR compared to non-dominant arm and 10 loss of total arc of motion compared to non-dominant arm Association of Limited ROM with Injury Secondary subacromial impingement (Tyler et al, AJSM 2000; Warner et al, AJSM 1990) Superior labral lesions (Burkhart et al, Arthroscopy 2003; Huffman et al, AJSM 2006) Internal impingement (Myers et al, AJSM 2006; Tyler et al, AJSM 2010) Ulnar Collateral Ligament tears (Garrison et al, AJSM 2012) Passive Rotational ROM Passive Horizontal Adduction Internal and External Rotation Total Arc of Motion Supine 0º Internal Rotation ROM 90 shoulder abduction 90 elbow flexion Humerus supported to maintain alignment Scapula stabilized at coracoid (Wilk, Sports Health 2009) Angle created by the end position of the humerus with respect to 0 horizontal adduction (vertical dotted line). (+) 0º (-) Laudner, JAT 2006 Supine Begin in 90 shoulder abduction and neutral rotation Stabilize scapula at lateral border with downward force Move humerus toward midline of body 9

10 Internal Rotation ROM True Glenohumeral Motion Scapula unstabilized Scapula stabilized Clinical Assessment of Humeral Retroversion Horizontal Adduction ROM Scapula unstabilized Scapula stabilized Non-Dominant (left) arm Dominant (right) arm More resting ER Normal Scapular Kinematics During humeral elevation: Upward rotation External rotation Posterior tilt Normal Scapular Kinematics During humeral elevation: Elevation Retraction (adduction + ER) UPWARD ROTATION EXTERNAL ROTATION POSTERIOR TILT Force Couples at Scapulothoracic Joint SICK Scapula Upper trapezius lower trapezius Serratus anterior trapezius Scapular malposition Inferior medial border prominence Coracoid pain & malposition dyskinesis of scapular movement Burkhart et al, Arthroscopy

11 Scapular Examination: Observation Static resting position: Elevation/depression ABD/ADD Up/downward rot Winging Med border Inferior angle Atrophy Dynamic movement: Scapulohumeral rhythm Concentric & eccentric phases Repetition With load Scapular Testing/Strengthening Trapezius Upper Middle Lower Serratus anterior Rhomboids Latissimus dorsi/teres major Levator scapulae Scapular Assistance Test Force Couples at Scapulothoracic Joint Positive test issue with muscular balance during scapular upward rotation 1. Unassisted active humeral elevation Rate pain 2. Assist scapular upward rotation during active humeral elevation Rate pain Positive test = pain Implications? Upper trapezius lower trapezius Serratus anterior trapezius Scapular Retraction Test 1. Resisted elevation (isometric) in scaption Note strength & pain 2. Add manual scapular retraction Note strength & pain Positive test = strength or pain Implications? Posterior Shoulder Endurance Test (PSET) Metronome with verbal cues 2% of body weight 90 degree arc of motion Repetitions to fatigue 11

12 Lower Extremity CORRECTIVE EXERCISE TECHNIQUES Lateral Slide Supported SL Squats Trunk / Core Monster Walks Chop Lift Ellenbecker & Cools BJSM

13 Posterior Shoulder Stretching: Patient Applied Sleeper Stretch (Oyama AT and Sports Healthcare 2010; Laudner JAT 2008) Posterior Shoulder Stretching: Patient Applied Cross-Body Stretch (McClure, JOSPT 2007; Manske, Sports Health, 2010) Self-applied cross-body, scapula unstabilized Self-applied cross-body, scapula stabilized Posterior Shoulder Stretching: Clinician Applied Pectoralis Major Clinician-applied internal rotation, scapula stabilized Clinician-applied crossbody, scapula stabilized Pectoralis Minor Quadratus Lumborum 13

14 Latissimus Dorsi T-Spine Mobility Bow & Arrow Circle Stretches Self-mobilizations But what if static stretching isn t effective?! Other interventions to consider Hold-relax techniques Muscle Energy Techniques Soft tissue mobilization Massage Cross friction massage/instrument assisted mobilization Assess for altered arthrokinematics Joint mobilizations Muscle Energy Techniques Parameters of Application (Moore, JOSPT 2011) 5 second isometric contraction (Horiz Abd) 30 second active assistive stretch (Horiz Add) 3 repetitions total MET for the Horizontal Abductors Improved HA ROM 7±11º IR ROM 4±5º Muscle Energy Techniques MET for the External Rotators Improved HA ROM 5±9º Parameters of Application (Moore, JOSPT 2011) 5 second isometric contraction (ER) 30 second active assistive stretch (IR) 3 repetitions total Soft Tissue Mobilization Ischemic compression Transverse friction massage Focused myofascial stretch Instrument assisted (IASTM) Massage?? Reduces pain and sensitivity of trigger points (Chatchawan, J Bodywork and Mvmt Ther 2005; Hong, J Musculoskeletal Pain 1993) Improves function and ROM (McKechnie, J Sport Sci and Med 2007; Hunter, BJSM 2006; van den Dolder, Aust J Physio 2003) 14

15 Joint Mobilizations Posterior mobilizations directed at posterior capsule (Manske, Sports Health 2010; Muraki, JOSPT 2011) Parameters of Application Grades III and IV 10 minute treatment Strengthening / Neuromuscular Re-Education Arm fatigue while pitching is a risk factor for shoulder and elbow pain in youth baseball pitchers (Lyman et al, MSSE 2001) (Manske, Sports Health 2010) Serratus Anterior Punches Scapular Clock Mid Row Dynamic Low Row Serratus Anterior Push Up Plus Fencing Robbery 15

16 Lawnmower Shoulder Dump (Lawnmower Overhead) Sidelying ER Negatives Eccentrics & Plyometric Deceleration Sidelying Ball Drops Prone Ball Drops Standing ER Plyos 16

17 IWTYC: I Would Throw You a Curveball Throw Like A Pro App Intervention: Clinic (20 weeks) 14 HS baseball players Age 16 ± 2 years Height 182 ± 8 cm Mass 75 ± 11 kg No recent UE injury Compliant to protocol attended 2/3 of sessions Sports Health 2009 UBE warm up Theraband Rows ER & IR at Prone ER PHA ( T s) Sidelying ER neg Rebounder at Wrist curls Rice bucket 4 way hip Lateral step (80 ft) Hamstring curls (bilateral & single neg) Calf raises Intervention: Field (Weeks 1-10) Warm up run Theraband Rows ER & IR at Bicep curls Tricep extensions Chest press Twists Power cord Squats Lateral step Backward step Calf raises Abdominals 17

18 Intervention: Weight Room (Weeks 11-20) Warm up run Theraband Rows ER & IR at Bicep curls Tricep extensions Twists Supine chest press Seated rows Lat pulls Calf raises Hamstring curls Leg press Squats Knee extensions Abdominals Results Posterior shoulder endurance improved Baseline: 30 ± 14 reps 4 weeks: 66 ± 26 reps 20 weeks: 88 ± 36 reps Thank You! Questions? Stephanie Moore-Reed, PhD, ATC sdmreed@csufresno.edu fresnostate.box.com/fwata2015 California State University, Fresno Department of Kinesiology 18