ER + IR = Total Motion
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1 Treating the Thrower s Shoulder Michael M. Reinold, PT, DPT, ATC, CSCS Introduction Common site of injury» Repetitive forces / stresses Tremendous joint forces» Anterior shear forces X BW» Distraction forces % X BW High velocities (7,265 0 /sec) Tremendous mobility» Repetition & fatigue» Arm fatigue & injury patterns» Number of pitches Introduction To treat the athlete you must understand:» The shoulder» The unique characteristics of the overhead athlete» The specific pathology Common findings» Excessive ER» Limited IR Anterior laxity Posterior tightness Motion and Laxity Wilk,Reinold,Crenshaw,et al: Examined ROM in professional baseball players 90 deg abduction:» Dominant: deg» Non-Dom: deg. 90 abduction:» Dominant: deg» Non-Dom deg Total Motion: Total Motion Equal Bilateral!!!
2 Total Motion Concept Wilk et al AJSM 2002 Causes of Loss of IR Motion Humeral Retroversion Several studies have shown retroversion of the humerus» Crocket AJSM 2002» Reagan AJSM 2002 ER + IR = Total Motion Causes of Loss of IR Motion Posterior Capsule Contracture Borsa, Wilk, Reinold: AJSM 2005 Examined GH translation in 43 professional baseball pitchers» Anterior: 2.81 mm» Posterior: 5.38 mm Significantly greater posterior translation No differences between D and ND» No correlation between IR ROM and posterior translation
3 Causes of Loss of IR Motion Posterior Muscular Contracture Reinold: AJSM 08 ROM Before & After Throwing Measure PROM before and after pitching in 117 professional baseball players Significant decrease in:»ir: -8.5»TM: -9.5» elbow extension: -2.4 Changes still present at 24 hours Tomiya: AJSM 04 Tomiya: AJSM 04 Range of Motion After Throwing Course of a Season Reinold & Gill: 06-08» Studied ROM characteristics over course of a season» Cumulative decrease in ROM over season Players GAIN ER by ~5-10 degrees Players that do not stretch loss IR and elbow extension» Efficacy of our stretching programs» Still analyzing but interesting!! I am not sure that the posterior capsule is the cause of the changes in IR in overhead athletes» I have not seen this to be common in the healthy or the injured athlete IR is supposed to be less in the throwing arm, amount depends on retroversion» Throwing causes acute loss of IR, can become cumulative Assess, DON T ASSUME! Principles of Shoulder Care Stretching Strengthening Dynamic Stability
4 Stretching the Thrower s Shoulder Principles Prevent cumulative loss of motion Maintain total motion Pitching with loss of total motion results in greater chance of injury» Ruotolo: JSES 06» Myers: AJSM 06 Unique Characteristics Not all pitchers are the same! Assess each player individually» Range of motion» Shoulder laxity» Collagen deficiency Unique Characteristics Collagen deficiency loose shoulders» Large total motion» Laxity exam Maintain motion» Avoid aggressive stretching» Insufficient static stability» Worried about dynamic stability» Injuries occur when tired Unique Characteristics Shoulder s with normal motion are more likely to get tight» Eccentric muscle damage» Cumulative effects are more visible Stretching the Thrower s Shoulder Principles If performed routinely, motion should not be a problem Shouldn t have to resort to aggressive stretching Player s want to feel it on their spot
5 Stretching the Thrower s Shoulder Principles Goal is to avoid aggressive stretching while maintaining total motion» Perform stretching frequently» Feel player assess motion & end feel» Assess response to workload» Nourish joint, cartilage, tendon» Pump out eccentric damage Shoulder Exercises Introduction Recent advances in the knowledge of shoulder function Evolution of shoulder treatment» Development of rehabilitation programs Less theory, more scientific proof What s the Best Exercise for ER? Reinold et al: JOSPT 04 What s the Best Exercise for ER? Reinold et al: JOSPT 04 Side 62-67% 67% ER Scapular Plane 53-55% 55% ER@ % What about the empty can exercise?
6 Full Can Vs. Empty Can Reinold et al: J Athl Train 07 EMG 64% supraspinatus» FC, EC, P. HABD Significantly less deltoid with full can» 84% FC» 119% Prone» 124% EC Scapular Position Static resting position of scapula is protracted and anterior tilted» Reinold, Wilk, Bastan: APTA 06» 71 Professional baseball pitchers These positions have strong correlation with decreased serratus and lower trapezius strength» Thigpen, Reinold, Gill: APTA 08» 50 Professional baseball pitchers Static Shoulder Stabilization Baseball pitchers inherently have poor static stability» Require precise interaction of the dynamic stabilizers The KEY to treating the overhead athlete Train the rotator cuff to be strong & SMART Understand:» Shoulder Pitcher - Pathology Principles of Treatment»Stretching» Strength / dynamic stability Specific pathology» Settle down inflammation» Regain total motion / dynamical stability Key Points
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