Addressing Core and Balance Deficits to Maximize Return to Sport in Overhead Athletes

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Agnes Dixon
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1 Addressing Core and Balance Deficits to Maximize Return to Sport in Overhead Athletes Meg Jacobs P.T. Momentum Physical Therapy and Sports Rehab Hands on care for faster results Through research, it has been shown that both elbow and shoulder injuries among athletes performing overhead activities is associated with shoulder and hip ROM deficits as well as with poor core strength and balance. ROM deficits have been shown to place additional demands on other joints throughout the body. Core stab is the ability to control position and movement of the trunk for optimal production, transfer and control of forces to and from the UE and LE during functional/sport activities. Balance is the dynamics of the body posture to prevent falling and is affected by inertial forces acting on the body. Pitching motion is complex and involves extreme transfer of energy through the entire body. Scapular and trunk control are a necessity for optimal overhead activities. Forces at the shoulder can escalate with an athlete that is compensating for injuries and or ROM deficits in other body joints low back, hip, knee, ankle S Scher et al. Hypothesized that limited ROM of the hip is associated with altered shoulder ROM and development of shoulder injuries. Poor extension of the dominant hip during acceleration phase of pitching motion, could cause pitcher to increase the amount of shoulder ER in attempt to achieve desired throwing motion. This flying open could increase stress to anterior shoulder structures, leading to chance for injury. Scher et al. Similar hypoth Restricted hip IR of the non dominant hip during follow through phase of throwing, may limit LE ability to absorb or dissipate energy generated during the acceleration phase, placing greater demands on the RC to act as a decelerator of arm at follow through, leading to posterior shoulder dysfunction.

2 Scher et al. Concluded that hip ext and shoulder ER ROM are related to BB players with history of shoulder injury. They demonstrated an association between shoulder and hip motion and the development of shoulder injuries. J.Craig Garrison et al. Hypothesized that BB players with ulnar collateral ligament (UCL) tears would have a greater glenohumeral IR deficit (GIRD) and deficit in overall total range of motion (TRM) in the throwing shoulder compared to the non throwing shoulder. BB players frequently demonstrate increased shoulder ER and decreased IR while maintaining normal TRM of the throwing shoulder Studies have shown that shoulder deficits of IR >25 and TRM >5, have tendency for higher risk of injury. Burkhart et al. developed the term GIRD and defined it as a deficit of shoulder IR > 20 in the throwing shoulder. GIRD has been documented in the dominant/throwing shoulder and is suggested to be pathological and assoc with shoulder and elbow injuries. Dinesetal et al. found a correlation with increased GRID in BB players with UCL injuries. J Craig Garrison et al. Concluded: there is a statistically significant difference in shoulder TRM in the UCL injured BB players compared to non UCL injured players. They were able to recognize that TRM deficits could play an important role in identifying players with UCL injuries or potential for injury. J Craig Garrison et al. Study BB players diagnosed with UCL tears demonstrate decreased balance compared to healthy controls. Objective: to compare LE balance and shoulder ROM in BB players with UCL tears to healthy BB players without UCL tears. Conclusion: BB players with UCL tears demonstrated decreased performance for their stance and lead LE during a Y balance test.

Kibler and Sciascia Proposed: inadequate ROM and poor balance may significantly affect athletes ability to transfer energy along the kinetic chain, resulting in dysfunctional movement and stresses at

3 Kibler and Sciascia Proposed: inadequate ROM and poor balance may significantly affect athletes ability to transfer energy along the kinetic chain, resulting in dysfunctional movement and stresses at various segments to include the elbow. Impaired control at the LE and trunk may alter position of shoulder and elbow through the throwing motion potentially leading to increased stress placed across those joints. In BB players, muscle activation patterns and transfer of energy begins in the Les and transfers up through their trunk, into the UE in order to achieve max throwing velocity. Inefficient movement patterns that begin at the LE, involving poor balance, could alter the throwing mechanism and lead to UE injuries. Integrating Shoulder and Core Ex with Rehab for Overhead Athletes Athletes involved in overhead activities are at risk for overuse and traumatic injuries Failure to identify and address all musculoskeletal dysfunctions may delay successful return to sport Proper use of kinetic chain allows for max force to be developed in the core which can be efficiently transferred to the UE Combining shoulder, core and balance ex can serve as a transitional program from general rehab to return to sport General Rehab Guidelines MD protocol Basic: decrease pain, increase ROM and flexibility, manual therapy to address decreased ROM and joint mobility, strengthening Integrate core strength, muscle activation and balance Establish Proper Motion Sleeper stretch IR ROM Horizontal add posterior capsular stretch Door/corner stretch pec and ant capsular stretch

Initial Strength address proximal dysfunction with emphasis on scapulothoracic dyskinesis

sidelye ER at 0 ABD Subscap scaption with shoulder IR Facilitate Scapular Motion

4 Initial Strength address proximal dysfunction with emphasis on scapulothoracic dyskinesis Rotator Cuff Supraspin: scaption with IR infraspinatus: horiz with ER Teres minor: sidelye ER at 0 ABD Subscap scaption with shoulder IR Facilitate Scapular Motion Incorporate trunk and hip for facilitating proximal and distal sequencing of muscle activity. Facilitate Scapular Motion Scapular Stabilizers Upper trap: rowing Mid Trap: horizontal ABD neutral and with ER Lower Trap: Abduction and rowing Rhomboid: scaption and horizontal ABD neutral

5 As strength improves, progress to sport specific movement patterns that address core and balance issues Identify core weakness Trendelenburg sign (during gait) Femoral add (lunge) Femoral IR (lunge) Knee valgus (lunge) Tibial IR (lunge) Various levels of ex can address core weakness Isometric shoulder ex activate trunk muscles and can be started early rehab Small amplitude isotonic ther ex (body blade) activate various trunk muscles in addition to shoulder stabilizers Fast isotonic shoulder movements increase trunk muscle activation Movement speed can also greatly influence core activation Advanced shoulder/core stab can be addressed when performed correctly and symptom free Side plank with ER obliques and transverse abdominals 3pt plank with shoulder horiz abd with ERsupraspin, mid trap and rhomb 3pt plank with shoulder ext mid trap and post deltoid 3pt plank with shoulder row trap, rhomboid and post deltoid 3pt plank with diagonal arm raise mid and low traps Side Plank with ER 3 Pt Plank with Horiz ABD

6 3 Pt Plank with Ext 3 Pt Plank with Row 3 Pt Plank with Diagonal Sports Specific Integrating sports specific ex that encourages improved LE muscle endurance and strength to facilitate proper UE mechanics, muscle activation, proprioception and muscle sequencing High rep/low weight address power and endurance deficits Power Position with Trunk Twist Step Back with Power Position

7 Step Back with Power Position Rebounder with Power Position Primal 7 Pull Up A system that works through suspension and resistance bands together which maximizes movement patterns Allows for graduated loading Allows for training in all planes 7 movement patterns that are building blocks for all activities Assisted Pull Up Unassisted Pull Up

8 Assisted Push Up Assisted Push up on Rings Unassisted Push up on Rings Assisted Flys Assisted Roll Outs Push to Pike

9 Conclusion Don t overlook core stab, balance and distal dysfunction (poor rear foot control, decreased ankle ROM, hip ext and abductor tightness/weakness, limited spine mobility, limited core strength, poor scapular control) as all are limitations to a successful rehabilitation and return to sport for our athletes. Create a STABLE BASE for proper development and transfer of energy to the shoulder and elbow of our overhead athletes. Bibliography Burkhart SS, et al. The disabled throwing shoulder: spectrum of pathology. Part I: patho anatomy and biomechanics. Arthroscopy. 2003;19(4): Burkhart SS, et al. The disabled throwing shoulder: spectrum of pathology. Part III: the sick scapula, scapular dyskinesis, the kinetic chain and rehabilitation. Arthroscopy. 2003;19: Crosbie J, et al. Scapulohumeral rhythm and associated spinal motion. Clin Biomech. 2008;23: Dines JS, et al. Gleno humeral internal rotation deficits in baseball players with ulnar collateral ligament insufficiency. Am J Sports Med. 2009;37(3): Elliot B, Timing of the lower limb drive and throwing limb movement in baseball pitching. Intl J Sports Biomech. 1998;4(1):59 67 Garrison JC, et al. Shoulder range of motion deficits in baseball players with ulnar collateral ligament tear. Am J of Sports Med, Vol 40, No Hodges PW, et al. Relationship between limb movement speed and associated contraction of the trunk muscles. Ergonomics 1997;40: Kibler WB, et al. Shoulder rehabilitation strategies, guidelines and practice. Orthop Clin North AM. 2001;32: Kibler WB, et al. The role of core stability in the athletic function Sports Med. 2006;35: Kibler WB, et al. Kinetic chain contributions to elbow function and dysfunction in sports. Clin Sports Med. 2004;23: Leetun DT, et al. Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports Exerc 2004;36: Meister K, et al. Rotational motion changes in the gleno humeral joint of the adolescent/little League baseball player. Am J Sports Med. 2005;33(5): Moseley JB, et al. EMG analysis of the scapular muscles during shoulder rehabilitation program. Am J Sports Med. 1992;20: Myers JB, et al. Gleno humeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med. 2006;34(3): Ruotolo C, et al. Loss of total arc of motion in collegiate baseball players. J Shoulder Elbow Surg. 2006;15(1): Scher S, et al. Associations among hip and shoulder range of motion and shoulder injury in professional baseball players. J of Athletic Training. 2010;45(2): Sciascia A, et al. Kinetic chain rehabilitation: a theoretical framework. Rehabil Res Pract. 2012;2012: Shanley E. et al. Shoulder range of motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players. Am J Sports Med. 2011;39(9): Wilk KE, et al. Current concepts in the rehabilitation of the overhead throwing athletes. Am J Sports Med 2002;30: Wilk KE, et al. Correlation of gleno humeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med. 2011;39(2): Wilson JD, et al. Core stability and its relationship to lower extremity function and injury. J Am Acad Orthop Surg. 2005;13: Winter DA. Human balance and posture control during standing and walking. Gait Posture. 1995;3:

Throwing Athlete Rehabilitation. Brett Schulz LAT/CMSS Sport and Spine Physical Therapy

Throwing Athlete Rehabilitation Brett Schulz LAT/CMSS Sport and Spine Physical Therapy Disclosure No conflicts to disclose Throwing Athlete Dilemma The shoulder must have enough range of motion to allow