David McHenry DPT, COMT, SCS. Therapeutic Associates PACE

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Jeremy Barnett
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1 David McHenry DPT, COMT, SCS Therapeutic Associates PACE

Quarterback at Penn State 1995-1999 BS in kinesiology DPT from Slipper Rock University in 2002 Therapeutic Associates:

2 Quarterback at Penn State BS in kinesiology DPT from Slipper Rock University in 2002 Therapeutic Associates: Portland Athletic Center of Excellence (PACE) Director of the TAI Sports PT Residency Program Strength and Conditioning Coach

3 We are here discussing The Shoulder in 2011: Anatomy, Diagnosis and Treatment. My contribution deals with shoulder rehabilitation of the overhead athlete? What s the problem with this.. The body throws the ball, not just the shoulder! Shoulder might be the victim and not the culprit.

4 When we are talking about Functional Rehab of the Overhead Athlete EVALUATE the entire athlete and not just the shoulder TREAT the entire athlete and not just the shoulder.

5 No.. But you should be aware of certain kinetic chain parameters that might have particular impact on force production and transfer through the shoulder complex. Hip ROM and strength Core strength and coordination Vertebral motion and strength Anatomical adaptations of the shoulder

6 Phases of throwing Indentify contractile and non-contractile tissues that are vulnerable in each phase. Identify muscles most important for shoulder strength and stability within each phase (based on EMG studies). Identify common shoulder overuse pathologies that might develop within each phase due to excessive tissue loading. Other kinetic chain considerations Functional Rehab Progression

8 Not much occurring at the shoulder. Pre-loading for Stretch Shorten Cycle (SSC) Signifies the initiation of forward momentum. Powerful leg drive Powerful hip external rotation Initiation of trunk rotation

9 What % of the total ball velocity is developed in this phase? 50% Toyoshima et al 1974

11 Decreases in hip IR in the non dominant hip highly correlated with predisposition to shoulder injury in the non-pitchers P=.05 Decrease in dominant hip extension correlated with concurrent increase in shoulder ER in a non pitching group with history of shoulder injury r =.64

12 This marks the first phase where extraordinary forces are incurred upon the shoulder. Necessitates optimal RC performance Incredible amounts of external rotation! degrees of ER Continued need for large amounts of hip ROM and strength

13 Anterior shear force across shoulder = 400N (90 lb-force) Anterior muscular strength and stability to prevent shearing Subscapularis, Pec Major, Latissimus Dorsi = demonstrate high to very high activity

14 Contributes to anterior stability during late cocking phase Limits anterior translation of humeral head Acts as restraint to excess ER Alleviates strain on inferior GH ligament

16 Significant increase in activity of long head of biceps in patient with anterior GH instability. Greatest activity occurring between degrees ER

17 Infraspinatus and Teres Minor show very high activiation. Supraspinatus least active RC muscle during this phase.

18 Wolf s Law? Significant difference in Humeral head retroversion Glenoid retroversion

Humeral head retroversion (deg) 40 (9.9) vs 23 (10.4) P 0.001 Glenoid retroversion (deg) 14 (5.9) vs 11 (5.4) P 0.01 External rotation at 90 of abduction (deg) 128 (9.

19 Humeral head retroversion (deg) 40 (9.9) vs 23 (10.4) P Glenoid retroversion (deg) 14 (5.9) vs 11 (5.4) P 0.01 External rotation at 90 of abduction (deg) 128 (9.2) vs 119 (7.2) P Internal rotation at 90 of abduction (deg) 62 (7.4) vs 71 (9.3) P Total motion (deg) 189 (12.6) vs 189 (12.7)

21 Anterior GH instability Bankart lesions Subacromial impingement Internal (posterior) Impingement Syndrome Approximation of greater tuberosity and posterior-superior glenoid rim Impingement of posterior-superior RC tendons and labrum

Explosive acceleration of the ball from rest to 90-100 miles an hour

22 Explosive acceleration of the ball from rest to miles an hour in 50ms Body weight is transitioning from push off leg to landing leg

23 Very high activity from all scapular muscles Latissimus Dorsi and Pec Major are the primary muscles contributing to ball velocity Pec Major: 54% MVC Lat Dorsi: 88% MVC

Teres minor shows moderate activity Providing stabalizing

24 Subscapularis shows very high activity Acts to help maintain centric position of humeral head in glenoid. Teres minor shows moderate activity Providing stabalizing posterior restraint to limit humeral head translation Infraspinatus shows moderate activity

28 Not many injuries associated with this phase. RC relatively low activity Humeral head repositions as the capsule unwinds Surprisingly low shoulder loads during this phase 50N posterior shear stress (11 lb-force)

29 Subacromial Impingement Normally occurs when arm is in 90 degrees, moving into IR and horizontal adduction. Normally pain felt during late acceleration phase.

30 Violent deceleration of momentum! Values approaches - 500,000 deg/sec^2 Shoulder joint loads at their peak during this phase Characterized by most authors as the most violent phase of throwing Associated with the many of the throwing shoulder injuries.

31 Posterior shear force of 400N (90 lb-force) Inferior shear force of 300N (67 lb-force) Compressive forces > 1000N (225 lb-force)

32 All Rotator Cuff muscles are highly active (eccentrically) Teres Minor most highly active = 84% MVC Scapular stabilizers are all very active Middle and Posterior heads of the deltoid are highly active Latissimus Dorsi still highly active

Rotator Cuff Pathology due to excessive and repetitive eccentric loading Friden et al, 1992 Sarcolemmal disruption Dilation of the transverse tubule system Distortion of the

33 Rotator Cuff Pathology due to excessive and repetitive eccentric loading Friden et al, 1992 Sarcolemmal disruption Dilation of the transverse tubule system Distortion of the myofibrillar components Fragmentation of the sarcoplasmic reticulum Lesions of plasma membrane Cytoskeleton damage Changes in extracellular myofiber matric Swollen Mitochondria

34 Consequence of repetitive eccentric overload Wilk et al ER strength in pitching arm: 6% weaker P =.005 IR strength in pitching arm: 3% stronger P =.05

35 Posterior impingement during late cocking phase Subacromial impingement during acceleration phase Repetitive microtrauma during deceleration phase

36 4 types of SLAP lesions: Type 1: fraying and degeneration Type 2: fraying and detachment Type 3: Bucket handle tear Type 4: Bucket handle tear extending in to biceps tendon

37 Repetitive traction during dec. phase Anterior GH instability Peel-Back Mechanism during Late Cocking phase Tight posteriorinferior capsule Burkhart et al 2000

1. Never overstress healing tissue 2. Prevent negative effects of immobilization 3. Emphasize external rotation muscle strength 4. Establish muscle balance 5. Emphasize scapular muscle strength 6.

39 1. Never overstress healing tissue 2. Prevent negative effects of immobilization 3. Emphasize external rotation muscle strength 4. Establish muscle balance 5. Emphasize scapular muscle strength 6. Improve posterior shoulder flexibility (IR) 7. Enhance proprioception and NM control 8. Establish biomechanically efficient throwing 9. Gradual return to throwing activities 10. Use established criteria to progress

40 Muscle sequencing of simple right arm elevation Deactivation of the left soleus Activation of the right TFL and rectus femoris Activation of left semitendinosis and glute max Activation of right erector spinae Initial deltoid activity

41 Push of leg extension ROM and strength. Landing leg hip IR ROM and eccentric strength Scapular strength and stability Rotation core strength and stability Anterior chest wall flexibility Thoracic extension and rotation ROM Overhead mechanics

42 Phase One: Acute Phase Phase Two: Intermediate Phase Phase Three: Advances Strengthening Phase Phase Four: Return to Throwing Phase

43 Decrease Pain and Inflammation Rest, ice, modalities, gentle AAROM Improve flexibility Shoulder, hip, spine, thoracic cage Reestablish adequate shoulder IR Reestablish dynamic stability Normalize muscle balance Restore proprioception Activity modification No throwing or modified to pain free

44 Continue to work on progressive strengthening. Thrower s 10 Scapular strength and stability Progressive hip/core strengthening Kinetic Chain integration Continue to improve flexibility. Begin/Progress rhythmic stabilization program

Progress to aggressive strengthening drills Enhance Power and Endurance Progress hip/core program Continue with Thrower s 10 Continue more aggressive

45 Progress to aggressive strengthening drills Enhance Power and Endurance Progress hip/core program Continue with Thrower s 10 Continue more aggressive proprioceptive activities Begin UE plyometric exercises Continue with Kinetic Integration Continued work with improving flexibility as needed Begin light throwing drills

46 Continue Strengthening progressions Continue flexibility as needed Progress throwing program (supervised) Increasing speed Increasing volume Acute attention to mechanics Routine re-assessment of strength, flexibility, joint ROM

47 Scapular Retraction Landing hip IR Drive Leg Miscellaneous

52 (Basic Guidelines)

53 Need to control anterior humeral head translation. Dynamic stabilization in range of impingement Length specific RC strengthening (90/90 position) Reestablish posterior GH tissue flexibility Rotator Cuff Tissue mobilization Stretching Capsule (with caution!) Scapular strength, stability (especially retraction) Hyperangulation (Jobe et al)

54 Pre-season Strength and Conditioning!! Easier to prevent then to treat Look for possible underlying cause Anterior laxity SLAP lesion Re-establish RC strength and dynamic stability Throwing mechanics flying open throwing across the body hyperangulation

55 Must differentiate from posterior impingement Pain in deceleration phase = Rotator Cuff Pain in Late Cocking Phase = Posterior Impingement Rotator Cuff Strength and Dynamic Stab. Eccentric Strength in deceleration phase Scapular Retractors Strength and Stab. Eccentric Strength in deceleration phase Rotator Cuff tightness? Throwing mechanics

56 Depends on type: Type 1: non-operative Type 2: possibly non-operative Type 3 and 4: Most likely operative Non-operative treatment strategy Identify possibly underlying causes Anterior laxity Weak/tight RC Hyperangulation Restore ROM RC Strengthening and Stab. (possibly limited ROM)

57 Five Step Program (Wilk et al, 2002) 1. Abstain from irritating activities for 7-10 days 2. Normalize glenohumeral motion and capsular mobility 3. Enhance dynamic stability of GH joint and scapula 4. Emphasize strength of scapular retraction 5. Gradual return to throwing

58 David McHenry DPT, COMT, SCS

McMullen, John, and Timothy Uhl. "A Kinetic Chain Approach for Shoulder Rehabilitation." Journal of Athletic Training. 35.3 (2000): 329-337. Print.

59 McMullen, John, and Timothy Uhl. "A Kinetic Chain Approach for Shoulder Rehabilitation." Journal of Athletic Training (2000): Print. Park, Samuel, Mark Loebenberg, Andrew Rokito, and Joseph Zuckerman. "The Shoulder in Baseball Pitching." Hospital for Joint Diseases (2002): Print. Wilk, Kevin, Keith Meister, and James Andrews. "Current Concepts in the Rehabilitation of the Overhead Throwing Athlete." American Journal of Sports Medicine (2002): Print. Meister, Keith. "Injuries to the Shoulder in the Throwing Athlete." American Journal of Sports Medicine. 28. (2000): Print. Dwelly, Priscilla, Brady Tripp, Patricia Tripp, Lindsey Eberman, and Steven Gorin. "Glenohumeral Rotational Range of Motion in Collegiate Overhead-Throwing Athletes During an Athletic Season." Journal of Athletic Training (2009): Print. Scher, Steve, Kyle Anderson, Nick Weber, Jeff Bajorek, Kevin Rand, and Michael Bey. "Associations Among Hip and Shoulder Range of Motion and Shoulder Injury in Professional Baseball Players." Journal of Athletic Training (2010): Print.

60 Hayes, Ronnie, Peter Hamer, Robert Grove, and Bruce Elliot. "Effects of Strength Training on Shoulder Pain and Perceived Health of the Throwing Arm in Baseball Pitchers." Applied Research in Coaching and Athletics Annual. 16. (2001): Print. Page, Phil. "Shoulder Muscle Imbalance and Subacromial Impingment Syndrome in Overhead Athletes." International Journal of Sports Physical Therapy. 6.1 (2011): Print. Crockett, Heber, Lyndon Gross, Kevin Wilk, Martin Schwatz, Jamie Reed, Jay O Mara, Michael T Reilly, Jeffery Dugas, Keith Meister, and Stephen Lyman. "Osseous Adaptation and Range of Motion at the Glenohumeral Joint in Professional Baseball Pitchers." American journal of Sports Medicine (2002): Print. Lorenz, Daniel, and Michael Reiman. "The Role and Implementation of Eccentric Training in Athletic Rehabilitation: Tendinopathy, Hamstring Strains, and ACL Reconstruction." International Journal of Sports Physical Therapy. 6.1 (2011): Print. Kibler, Ben, Joel Press, and Aaron Sciascia. "The Role of Core Stability in Athletic Function." Journal of Sports Medicine (2006): Print.

61 Sciascia, Aaron, and Ben Kibler. "The Pediatric Overhead Athlete: What is the Real Problem?." Clinical Journal of Sports Medicine (2006): Print. Miniaci, Anthony, Anthony Mascia, David Salonen, and Edna Becker. "Magnetic Resonance Imaging of the Shoulder in Asymptomatic Professional Baseball Pitchers." American Journal of Sports Medicine (2002): Print.

Rehabilitation of Overhead Shoulder Injuries

Rehabilitation of Overhead Shoulder Injuries 16 th Annual Primary Care Orthopaedic & Sports Medicine Symposium January 29, 2016 Jeremy Sherman, PT, MPT Disclosures No financial disclosures to note. Jeremy