Aquatic Exercise. Rehabilitation after the SLAP lesion repair. I. Anatomy & Function SLAP 의가장흔한손상기전. Anatomy of the Shoulder (I)

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1 Aquatic Exercise Rehabilitation after the SLAP lesion repair Sports Medicine Clinic Sky 임승길 ATC 2 SLAP 의가장흔한손상기전 SLAP Superior Labrum Anterior to Posterior 1. Compression force Attempting to catch a heavy Falling object 2. Traction force Water skiing Throwing 종종 inferior instability & rotator cuff tear 관련 3 4 Anatomy of the Shoulder (I) I. Anatomy & Function 5 6 1

2 Anatomy of the Shoulder (II) Rotator Cuff primary function is a local stabilizers to keep the ball in the socket 7 8 Scapulohumeral force couple Glenoid labrum Glenoid Labrum 9 The long head of the biceps tendon has an attachment on 10 both the posterosuperior labrum & the supraglenoid tubercle Glenoid labrum Superior & Inferior labrums differ Inferior Labrum Firmly attached to the glenoid More inelastic Superior Labrum loosely attached to the glenoid Triangular in shape Fibrocartilagious consistency Resembles the meniscus in the knee

3 ROM 과용어 ROM 과용어 Horizontal adduction: 130 deg Horizontal abduction: 30 deg Introduction II. Biomechanics of the Shoulder During Throwing Motion Analysis of Baseball Pitching Force & Torque at the Shoulder Shoulder Injury Mechanisms Six Phases of Baseball Pitching Motion Wind-up 1. Wind-up 2. Stride 3. Arm cocking 4. Arm acceleration 5. Arm deceleration 6. Follow through

4 Stride Arm cocking Arm cocking Arm acceleration Arm deceleration Follow through

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6 저항성트레이닝에의한변화 36 6

7 SLAP Type A. Type I Degeneration Fray Firmly attached to the glenoid No avulsion of the biceps tendon B. Type II Degeneration Fray Complete detachment of the labrum from the supurior glenoid rim Biceps unstable SLAP Type C. Type III Bucket-handle tear Free margin is displaced into the joint Labrum & biceps attachments are stable Catching & locking D. Type IV Superior portion of the labrum is displaced into the joint Biceps long head partially rupture

8 O Brien Test (Active compression Test) SLAP arthroscopic repair 1. The GH joint is 90deg flexed & horizontally adducted 15deg from the sagittal plane. 2. The humerous in full internal rotation and the forearm pronated 3. 통증과펑소리는 SLAP lesion/ AC joint pathology을의미 SLAP OP Tension on anterior band of inferior glenohumeral ligament SLAP Lesion Common avulsion injury Superior labrum tear Anterior posterior

9 Shoulder injury mechanism (SLAP Lesion) 1. Rapid elbow extension 2340 deg/sec 2. Eccentric contraction of biceps 3. Biceps long head tears the labrum away from the glenoid Shoulder injury mechanism (Grinding on labrum) Imbalanced muscles Humeral head anterior translation Impingement on the anterior labrum Movement of the humeral head cocking/acceleration Shoulder injury mechanism (Grinding on labrum) Extreme ROM A/P Laxity deceleration A/P Translation + internal rotation + compressive force 51 Grinding on labrum 52 Shoulder injury mechanism (Rotator cuff tension)

10 Summary Summary Shoulder force & torque during arm cocking Shoulder force & torque during arm deceleration Conclusions Pitching One of the fastest human movement. ER: 180 deg 7500 deg/sec Critical instants Arm cocking Arm deceleration Most overuse injuries to the shoulder occur at these two instants 57 기분좋은상상 Principles of Rehab in the Thrower III. Rehab Protocol (Type 2 SLAP Lesions) 1. Never overstress healing tissue 2. Prevent negative effects of immobilization 3. Emphasize external rotation muscular strength 4. Establish muscular balance 5. Emphasize scapular muscular strength 60 10

11 Principles of Rehab in the Thrower Phase 1: Day 1~Week 6 Restrictive Motion 6. Improve posterior shoulder flexibility(internal rotation ROM) 7. Enhance proprioceptive & neuromuscular control 8. Establish biomechanically efficient throwing 9. Gradually return to throwing activities 10. Use established criteria to progress 61 Goal Protect the anatomic repair Prevent negative effects of immobilization Promote dynamic stability Diminish pain & inflammation 62 Biceps brachii action Weeks 0~2 1. Elbow, shoulder flexion 2. Supination of forearm 3. Long head assists abduction 4. Short head assists adduction 5. Helps stabilize humerus in glenoid fossa during heavy lifting or carring 63 Sling for 4wk. Sleep in immobilizer for 4wk. Elbow & Hand ROM Hand-gripping Ex. Contraction of the biceps actually lifts the superior labrum off the glenoid Submax pain free isometrics at 0 deg abduction(ir, ER, Ext, Abd) : No elbow or shoulder flexion No isolated biceps contractions(6주 ) Cryotherapy, modalities 64 Weeks 0~2 Weeks 0~2 Passive & gentle active-assisted ROM Ex. Flexion Week 1 : 60 deg Week 2 : 75 deg Week 3 : 90 deg Elevation in scapular plane to 60 deg Passive & gentle active-assisted ROM Ex. External & internal rotation with arm in scapular plane External rotation Week 1 : deg Week 2~3 : 30 deg Internal rotation to 45 deg *** No active external rotation, Extension, Abduction

12 Hand-gripping Ex. Passive & gentle active-assisted ROM Ex. Putty Exercise/ Rice Drill Passive & gentle active-assisted ROM Ex. Weeks 3~4 69 Discontinue use of sling at 4wk. Sleep in immobilizer until week 4 *** No active external rotation, extension, elevation Initiate rhythmic stabilization drills Initiate proprioception training Tubing external & internal rotation at 0 deg abduction Continue isometrics Continue crytherapy 70 Rhythmic stabilization drill Weeks 3~4 Continue gentle ROM Ex.(passive ROM & active-assisted ROM) Flexion to 90 deg Abduction to 75~85 deg External rotation in scapular plane to 25~30 deg Internal rotation in scapular plane to 55~60 deg *** Rate of progression based on evaluation of the patient

13 Weeks 5~6 Stretching Exercise Gradually improve ROM Flexion to 145 deg External rotation at 45 deg abduction: 45~50 deg Internal rotation at 45 deg abduction: 55~60 deg May initiate stretching Ex. May initiate light ROM at 90 deg abduction Continue tubing external & internal rotation (arm at side) Weeks 5~6 No Resistance Arm Ergometer PNF manual resistance Initiate active shoulder abduction(without resistance) Initiate active full can Ex.(weight of arm) Initiate prone rowing, prone horizontal abduction *** No biceps strengthening 75 Week 12 : High resistance, for endurance 76 Scapular Stabilization Ex. Phase 2: Weeks 7~14 Moderate protection phase Goal Gradually restore full ROM(week 10) Preserve the integrity of the surgical repair Restore muscular strength & balance

14 Weeks 7~9 Weeks 10~12 Gradually progress ROM Flexion to 180 deg External rotation at 90 deg abduction: 90~95 deg Internal rotation at 90 deg abduction: 70~75 deg Continue to progress isotonic strengthening program Continue PNF strengthening Initiate Thrower s Ten program 79 May initiate slightly more aggressive strengthening(up to 7Ibs) Progress external rotation to thrower s motion External rotation at 90 deg abduction: 110~115 in throwers(weeks 10~12) Progress isotonic strengthening Ex. Continue all stretching Ex. Progress ROM to functional demands Continue all strengthening Ex. 80 Isokinetic Exercise 180 deg/sec : Week 10 Modified neutral position progress to 90/90 position in scapular plane Exercise to reestablish Neuromuscular control Exercise to reestablish Neuromuscular control Large muscle Exercise(Week 12) Do not allow elbow to extension past plane of thorax

15 Biodex Test(Week 12) Isokinetic performance evaluation of internal-external rotation 180, 300 deg/sec Goal(strength) 80% of unaffected side ER/IR ratio at 180 deg/sec Male 66 Female 71 Peak T/BW range ER at 180 deg/sec Male 11~15 Female 8~12 Peak T/BW range IR at 180 deg/sec Male 17~23 Female 13~ s s -1 ER IR ER IR Torque/Body weight % % Average Power Watts Watts Exceptional > 20 > 30 Exceptional > 85 > 150 Excellent 19~13 29~24 Excellent 84~70 150~120 Good 13~10 24~29 Good 70~55 120~90 Adequate 10~7 19~14 Adequate 55~40 90~60 Fair 7~4 14~9 Fair 40~25 60~30 Poor < 4 < 9 Poor < 25 < 30 Newsham K. R. et al(1998), Isokinetic profile of baseball pitchers internal/external rotation 180, 300, 450 s -1. Medicine & science 86 in sports & exercise. 1489~1495. Phase 3: Weeks 14~20 Minimal protection phase Phase 3: Weeks 14~20 Minimal protection phase *** Criteria for progression to phase 3 Full nonpainful ROM Satisfactory stability Muscular strength(good grade or better) No pain or tenderness Goals Establish & maintain full ROM Improve muscular strength, power, endurance Gradually initiate functional activities Weeks 14~16 PNF using a body blade/flexbar Continue all stretching Ex(capsular stretches) Maintain thrower s motion (especially external rotation) Continue strengthening Ex. Thrower s Ten program or fundamental Ex. PNF manual resistance Endurance training Initiate light plyometric program Restricted sport activities(light swimming, half golf swings)

16 Plyometric Exercise Chest Pass(Week 8) One arm overhead throw(week 12) Weeks 16~20 Continue all Ex. listed above Continue all stretching Continue Thrower s Ten program Continue plyometric program *** Initiate interval sport program (e.g., throwing): ITP Program Phase 4: Weeks 20~26 Advanced strengthening phase Phase 4: Weeks 20~26 Advanced strengthening phase *** Criteria for progression phase 4 Full nonpainful ROM Satisfactory static stability Muscular strength 75~80% of contralateral side No pain or tenderness Goals Enhanced muscular strength, power, endurance Progress functional activities Maintain shoulder mobility Weeks 20~26 Continue flexibility Ex. Continue isotonic strengthening program PNF manual resistance patterns Plyometric strengthening Progress interval sport programs Phase 5: Months 6~9 Return to activity phase *** Criteria for progression to phase 5 Full functional ROM Muscular performance isokinetic Satisfactory shoulder stability No pain or tenderness

17 Exercise Phase 5: Months 6~9 Return to activity phase Thrower Ten Program 1.Diagonal pattern D2 extension & flexion 2.External/internal rotation at 0 deg abduction Gradual progress sport activities to unrestrictive participation Continue stretching & strengthening program Thrower Ten Program Thrower Ten Program 3. Shoulder abduction(palm down) to 90 degrees 4. Scaption with internal rotation 5. Prone horizontal abduction 6. Press-ups Thrower Ten Program Thrower Ten Program 7. Prone rowing 8. Push-ups 9. Elbow flexion/extension

18 Thrower Ten Program Interval Throwing Program(ITP) 1 단계 - 거리별 구 (Long-toss 개념 ) 10.Wrist Flexion/Extension, Supination/Pronation 거리 (m)) 거리 (M) 단계 Interval Throwing Program(2 단계 ) ( 마운드에서던지기 ) 1) 직구던지기 1 단계 :50%-15 구 2 단계 :50%-30 구 3 단계 :50%-45 구 4 단계 :50%-60 구 5 단계 :50%-45 구 6 단계 :50%-45 구 75%-30 구 7 단계 :50%-15 구 75%-45 구 8 단계 :75%-60 구 2) 배팅볼던지기 ( 직구만던진다 ) 9 단계 :75%-45 구배팅볼 -15 구 10단계 :75%-45구배팅볼-30구 11단계 :75%-45구배팅볼-45구 3) 직구, 커브, 슬라이더, 체인지업 12단계 :75%-30구 50%-변화구15구 / 직구45구 13단계 :75%-30구 변화구30구 / 배팅볼30구 14단계 :75%-30구직구배팅볼50구 / 변화구20구 15단계 : 연습경기등판해서 15구 사랑하는선수들과함께 105 SLAP 수술후재활에따른 ROM 변화 IV. Case 주후 6 주후 8 주후 10 주후 extension flexion abductionadduction external rotation internal rotation Standing potion Horizen 90 degree abduction Shoulder Joint

19 Biodex Evaluation Shoulder IR/ER Rotation,Mod-Standing 180 Speed / Total Work(BWR)(Joule) IR(L) ER(L) IR(R) ER(R) 수술전수술후 5 개월수술후 2 년후 109 경청해주셔서감사합니다. Sports Medicine Clinic SKY