Evidence Based Approach to Returning Baseball Pitchers to Participation. Cage SA, Gallegos DM, Warner BJ

Transcription

1 Evidence Based Approach to Returning Baseball Pitchers to Participation Cage SA, Gallegos DM, Warner BJ

2 Thank you

3 Outline Quick reminder on evidence based practice PICO Question Phases of throwing Relevant anatomy of the shoulder complex Pitching injury epidemiology Best available evidence for return to throwing Anecdotal evidence for return to throwing Conclusions

4 Obligatory Evidence Based Practice Refresher

5 What is evidence based practice? This is the wrong question. We need to be asking, what EBP is NOT EBM is not a blueprint on how to practice athletic training. Decisions on how to care for athletes are not based solely on the available evidence. Factors such as personal experience, judgement, and patient preferences must be considered. Any clinician who feels restricted to behave only as the evidence dictates is missing the concept of EBM. (Steves and Hootman, 2004)

6 Professional Expertise What is evidence based practice? Incorporates Best Research Evidence EBP Clinical Expertise Patient Values and Preferences

7 PICO Question

8 PICO Question Patients Baseball pitchers undergoing rehabilitation following a shoulder or elbow injury Intervention Pitching off of a 10 mound at 60 6 Control Pitching off flat ground at 60 6 Outcome Increased stresses at the elbow and shoulder

9 Phases of Throwing

10 Phases of throwing Wind up Neutral GH position Varied elbow position Low GH joint stress Lower body/core muscle contraction

11 Phases of throwing Cocking 90 degree GH rotation Maximal ER Concentric external rotators Eccentric internal rotators Anterior/Inferior GH capsule stress 90 degrees elbow flexion* Valgus stress Varus torque

12 Phases of throwing

13 Phases of throwing

14 Phases of throwing

15 Phases of throwing Acceleration GH moving into IR to release Anterior GH capsule stress Concentric internal rotators Serratus anterior Upper trap Trunk Eccentric external rotators Rhomboids Middle/Lower trap Elbow moving into extension

16 Phases of throwing Deceleration GH moving into IR after release Poster GH capsule stress Concentric Internal Rotators Triceps Brachii Eccentric External Rotators Biceps Brachii Brachialis Elbow moving into extension

17 Phases of throwing Follow through GH horizontal adduction GH internal rotation GH adduction Posterior GH capsule stress Concentric internal rotators Eccentric external rotators Elbow extension

18 Relevant Shoulder Anatomy

19 Shoulder Complex 4 Articulations Glenohumeral Joint Acromioclavicular Joint Sternoclavicular Joint Scapulothoracic Articulation 16,000+ possible positions Mobility Stability

20 Relevant Elbow Anatomy

21 The Ulnar Collateral Ligament

22 The Ulnar Collateral Ligament Anterior bundle Primary restraint against valgus force Transverse bundle Little support Posterior bundle Taut beyond 60 degrees of flexion

23 The Ulnar Collateral Ligament

24 Shoulder & Elbow Epidemiology

25 Shoulder & Elbow Epidemiology Incidence of shoulder and elbow injuries in adolescent baseball players has increased over the past 20 years. Of all overhead athletes, baseball pitchers are uniquely susceptible to acute and chronic upper extremity pathologies Particularly ulnar collateral ligament sprains Generally require surgery and ~10 months of therapy

26 UCL Sprains Valgus load at the UCL experienced by professional pitchers when throwing is greater than what the body can produce with a maximal isometric contract This valgus stress must be countered by a varus moment distributed across: Muscles & tendons Osseous articulation UCL To support a varus moment, the UCL has to undertake an elevated amount of tension

27 UCL Sprains Tension at the UCL can be reduced through contraction of the wrist flexor and pronator muscles Generates joint compression Pitching motion imparts the largest valgus moments during the cocking and acceleration phases of throwing

28 What is being done? Baseball organizations are taking steps to limit the number of pitches thrown per game Required days of rest between pitching outings Age limits being placed on certain types of pitches

29 Why the rise injury incidence?

30 When the inevitable happens

31 Best available evidence Generally agreed upon that it is necessary to gradually increase throwing distance, volume and intensity after injury What do you progress first? How fast do you progress? When do you put them on the mound?

32 Best available evidence Considerations Severity of injury Nature of surgery Time of year Patient s eligibility/contract status No universally accepted throwing program

33 Best available evidence Shoulder and elbow torque greater when throwing at distances of feet when compared to throwing from a mound at 60.5 feet Timing of mechanical events appears to be similar when throwing on flat ground compared to the mound Pitch cycle slightly shorter off a mound

34 Best available evidence Joint velocity similar when throwing from flat ground compared to off a mound GH and elbow joint moments significantly greater when throwing off a mound Maximum and average pitch velocities higher when throwing off a mound Another indication of increased force?

35 Best available evidence Ground reaction forces on the plant leg are greater when throwing off a mound There is still a measure of difficulty assessing these values in game situations

36 What we ve been working on

37 Motus Sleeve Acquires motion data through a 3d Motion sensor embedded in a device the size of a thumb drive Housed in a spandex sleeve Provides information such as: Arm speed Varus moment torque Elbow height Release point

38 Motus Sleeve

39 Motus Sleeve Previous used in study on arm torque at various elbow angles Analyzed 82,000 pitches by 81 professional pitchers Elbow torque increased significantly as pitchers increased their GH rotation during cocking phase Increased arm speed is directly related to increased in elbow torque

40 Is this the safest way to throw?

41 Cage, et al, (In Preparation) 11 collegiate pitchers Wore Motus Sleeve on medial joint line of elbow 5 max effort 4-seam fastballs 60 6 from 10 pitching mound 50 6 from 10 pitching mound 60 6 from flat ground 50 6 from flat ground

42 Motus Sleeve

43 Cage, et al, (In Preparation) Arm Speed in RPM 60 6 from 10 mound from 10 mound from flat ground from flat ground

44 Cage, et al, (In Preparation) Arm Speed No significant differences caused by throwing surface or distance

45 Cage, et al, (In Preparation) Torque in N m 60 6 from 10 mound from 10 mound from flat ground from flat ground 41.76

46 Cage, et al, (In Preparation) Torque Significant differences (p=0.021) were observed between mound and flat ground throws No significant effects (p=0.515) from distance

47 Until we have more information Rely on pitch velocity and location rather than pitch counts Injury rates have improved Is this practical for everyone?

48 Next Phases Evaluate arm speed and elbow torque at more distances Evaluate effect of arm slot on arm speed and elbow torque

49 PICO Question Patients Baseball pitchers undergoing rehabilitation following a shoulder or elbow injury Intervention Pitching off of a 10 mound at 60 6 Control Pitching off flat ground at 60 6 Outcome Increased stresses at the elbow and shoulder

50 Conclusions Researches and clinicians have yet to universally agree on a return to throwing protocol The diligent clinician must consider all aspects of their patient s injury when designing a protocol Severity Type of surgery Length of time post surgery Eligibility/contract status Phase in life

51 Conclusions Things we do know Increased elbow and shoulder torque when distance is increased ( vs ) Joint velocity is similar when throwing from a mound or flat ground Maximum and average pitch velocities are higher when throwing from a mound compared to flat ground The elbow and shoulder experience greater forces when throwing from a mound compared to flat ground at similar distances

52 Conclusions This information cannot be ignored Begin to incorporate pitching motion into throwing program prior to placing patient on mound Ensure adequate strength and endurance prior to increasing volume, distance, and intensity of throws

53 Conclusions Evaluation and re-evaluation of throwing program outcomes is crucial to advancing patients appropriately When the evidence is lacking, use what you have available Do not forget your clinical expertise

54 Quiz Time

55 Question 1 Which of the following is NOT a common site of upper extremity injury in baseball pitchers? Biceps brachii tendon Medial epicondyle/ulnar collateral ligament Rotator Cuff All of these are common sites of upper extremity injury in baseball pitchers.

56 Question 1 Which of the following is NOT a common site of upper extremity injury in baseball pitchers? Biceps brachii tendon Medial epicondyle/ulnar collateral ligament Rotator Cuff All of these are common sites of upper extremity injury in baseball pitchers.

57 Question 2 True/False: Distance thrown can play a factor in the forces exerted on the shoulder and elbow complexes during throwing.

58 Question 2 True/False: Distance thrown can play a factor in the forces exerted on the shoulder and elbow complexes during throwing.

59 Question 3 True/False: Traditionally, throwing off of a mound has been thought to exert the same forces on the elbow and the shoulder as throwing from flat ground from an equal distance.

60 Question 3 True/False: Traditionally, throwing off of a mound has been thought to exert the same forces on the elbow and the shoulder as throwing from flat ground from an equal distance.

61 Question 4 True/False: Throwing programs should be done in conjunction with therapeutic exercise, not to replace a therapeutic exercise program.

62 Question 4 True/False: Throwing programs should be done in conjunction with therapeutic exercise, not to replace a therapeutic exercise program.

63 Question 5 True/False: Throwing program progression should only be re-evaluated at patient prompting.

64 Question 5 True/False: Throwing program progression should only be re-evaluated at patient prompting.

65 References 1. Anz AW, Bushnell BD, Griffin LP, Noonan TJ, Torry MR, Hawkins RJ. Correlation of torque and elbow injury in professional baseball pitchers. Am J Sports Med. 2010;38: Axe M. Recommendations for protecting youth baseball pitchers. Sports Med Arthrosc Rev. 2001;9: Buffi JH, Werner K, Kepple T, Murray W. Computing Muscle, Ligament, and Osseous Contributions to the Elbow Varus Moment During Baseball Pitching. Annals of Biomedical Engineering. 2015;43(2): Camp CL, Tubbs TG, Fleisig GS, Dines JS, Dines DM, Altchek DW, Dowling B. The Relationship of Throwing Arm Mechanics and Elbow Varus Toque: Within-Subject Variation for Professional Pitchers Across 82,000 Throws. Am J Sports Med. 2017;45(13): Dines J, Altchek D. Elbow Ulnar Collateral Ligament Injury: A Guide to Diagnosis and Treatment. New York, NY: Springer Science; Duggan JP, Osadebe UC, Alexander JW, Noble PC, Lintner DM. The impact of ulnar collateral ligament tear and reconstruction on contact pressures in the lateral compartment of the elbow. J Shoulder Elb Surg. 2011;20: Dun S, Loftice J, Fleisig GS, Kingsley D, Andrews JR. A biomechanical comparison of youth baseball pitchers: Is the curveball potentially harmful? Am J Sports Med. 2008;36: Fleisig GS, Andrews JR, Dillman CJ, Escamilla RF. Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med. 1995;23: Fornalski S, Gupta R, Lee TQ. Anatomy and biomechanics of the elbow joint. Sports Med Arthrosc. 2003;11: Hariri S, Safran MR. Ulnar collateral ligament injury in the overhead athlete. Clin Sports Med. 2010;29: Kageyama M, Suzuki C, Fujii M, Nakamoto H, Wada T, Maeda A. A biomechanical comparison of baseball pitching from the mound versus the flat ground focusing on ball velocity and motion of the lower limbs and trunk. Japan J Phys Educ Hlth Sport Sci. 2016;61: Lin FN, Kohli N, Perlmultter S, Lim D, Nuber G, Makhsous M. Muscle contribution to elbow joint valgus stability. J Shoulder Elb Surg. 2007;16: McGraw MA, Kremchek TE, Hooks TR, Papangelou C. Biomechanical evaluation of the docking plus ulnar collateral ligament reconstruction technique. Am J Sports Med. 2013;41: Motus Global: New Way to Keep Baseball Players in the Game: Motus Motion-Sensing Sleeve. Journal of Engineering. 2014: Nelson CW, Solomito M, Garibay E, Ounpuu S, Westwell M. A Biomechanical Comparison of Pitching From a Mound Versus Flat Ground in Adolescent Baseball Pitchers. Sports Health. 2013;(6): Nissen C, Westwell M, Ounpuu S, et al. Adolescent baseball pitching technique: a detailed three-dimensional biomechanical analysis. Med Sci Sports Exerc. 2007;39: Regular season pitching rules. Baseball. media/pitchingregulationchanges_bb_ pdf. 18. Seiber K, Gupta R, McGarry MH, Safran MR, Lee TQ. The role of elbow musculature, forearm rotation, and elbow flexion in elbow stability: an in vitro study. J Shoulder Elb Surg. 2009;18: Udall J, Fitzpatrick M, McGarry M, Leba T, Lee T. Effects of flexor-pronator muscle loading on valgus stability of the elbow with an intact, stretched, and resected medial ulnar collateral ligament. J Shoulder Elb Surg. 2009;18:

66 Questions