Return to Play Criteria in the Overhead Thrower

Transcription

1 in the Overhead Thrower Kevin E. Wilk, PT, DPT,FAPTA 2018 The Overhead Thrower Introduction Highly skilled athlete Requires flexibility, muscle strength, coordination, synchronicity & NM efficiency Proper throwing mechanics Proper training program Injuries Are Common to the Tremendous stresses & velocities Throwers Shoulder & Elbow The Overhead Thrower Introduction Overhead throwing motion Extraordinary demands on shoulder & elbow joint Fastest human movement 7,230 o/s Late cocking to ball release 0.03sec Tremendous forces generated Anterior displacement 0.5 x BW Distraction forces 1 x BW at ball release Fleisig et al: Am J Spts Med 95 Fleisig et al: J Biomech 99 Thrower s Shoulder Key Points Pitchers sustain injuries at the highest rate 61% of all team injuries pitchers compared position players >72% of all pitchers injuries are to their shoulder/elbow Specific risk factors increases injuries Pitching when fatigued, or pitch too much (volume), improper throwing mechanics, or max effort - all increase injury risk GIRD & GERI is predominantly due to boney adaptations ~83% boney & ~17% due to soft tissue Maintaining motion in throwing shoulder when healthy isn t difficult Specific exercises & stretches are important maintain! Side Slides with ER

2 Side Slides with ER Bilateral Side Plank with ER Prone Plyoball Drops on Stability Ball Serratus Anterior Exercises Reverse Wall Slides Instagram Wilk_kevin

3 Objective Test Criteria Criteria to initiate: Interval throwing program Return to play criteria Rehabilitation of Overhead Athlete Rehab Plan

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5 Biomechanics of the Shoulder Joint Complex During Throwing

6 CRITERIA TO RETURN TO THROWING Full non-painful ROM Elbow stability Satisfactory isokinetic test Satisfactory clinical exam moving valgus stress test (-) Adequate healing time How long is that? 6, 9 or 12 mos. Return to Play in Throwers Rehab Overhead Athlete Specific Objective Criteria Objective Functional Testing Clinical Exam ROM Objective Muscle Strength Test Successful Completion of Rehab

7 Rehab Overhead Athlete Full sport specific non painful ROM Strength which meets the criteria Excellent stability and no painful special tests Demonstrates proper throwing mechanics Successfully has completed rehab program Appropriate rehab progression completed Satisfactory functional scoring The Thrower s Shoulder Range of Motion: ER/IR An Objective Criteria is Important J Sports Health 09 Visual inspection Humeral Stabilization Scapular Stabilization

8 The Thrower s Shoulder Range of Motion Total Rotational Motion Concept ER + IR = Total Motion Envelope of Motion Throwing Shoulder Adaptations Wilk AJSM 02 Total Rotational Motion is equal bilaterally (within 5 degrees) Non- Throwing Shoulder Wilk, Macrina, Porterfield et al: 2015 Pitchers Shoulder ROM ( 05-15) D ND ER at 90 abduction: IR at 90 abduction Total Rotational ROM: Horizontal adduction: ER Horz Adduction: N= 1226 N=369 Thrower s Shoulder ROM PROM Assessment Criteria to RTP Thrower s Range of Motion Goals TROM within 5 Horizontal adduction 40 > GIRD < 20 Elbow full ROM Wrist full ROM Non-painful ROM Shoulder Flexion Shoulder Horz Abd

9 Professional Tennis Player Criteria to RTP Thrower s Clinical Exam Satisfactory Clin Exam Laxity Assessment Clunk Test SLAP & Cuff Anterior Drawer Test Posterior Drawer Test Anterior Fulcrum Test

10 Biceps/Labrum Tests O Brien et al: AJSM 98 Criteria to RTP Thrower s Muscle Strength Goals ER/IR Ratio: 72-76% ER/ABD Ratio: 68-72% ER: 95%> IR: 115%> Elbow Flexion: % Elbow extension: % Objective Muscle Testing - Isokinetics Assess Muscular Strength Biodex Isokinetics Throwers ER / IR ratios 72-76% ER / ABD ratios 68-73% Torque / BW ratios ER 18-23% IR 26-32% Bilateral comparison ER %; IR 115% Wilk et al: AJSM 93 Wilk et al: AJSM 95 Objective MMT

11 Scapular Strength Ratios Wilk, Reinold, Hooks Unpublished data 07 Pitchers Non-throwers D ND D ND Elev / Depress 400% 480% 520% 540% Retract / Protract 88% 71% 78% 71% Appropriate Rehab Progression Plyoball Wall Throws with RS Dynamic stabilization drills RS drills at 90/90 (P/F) Prone ball drops Ball Drop Test Return to Throw Criteria Ball Drop Test (T Side) Dynamic stabilization tests Prone ball drops 30 sec test prone on plinth number of releases/catches compare Dom to Non Dom score: % Goal: 90%> Expectation: 110%> mean score: 115% (range )

12 Return to Throw Criteria Ball Drop Test (T Side) Return to Throw Criteria Ball Drop Test (NT Side) Return to Throw Criteria One Hand Ball Throws Against Wall Ball Wall Throws Baseball Style Throws 2 Ib plyoball baseball style throws 30 sec duration bilateral comparison Successful Criteria: no pain proper mechanics no change with fatigue Ball Throws into Wall Test Dynamic stabilization tests Ball Throws into wall 30 sec test standing number of throws/catches compare Dom to Non Dom score: % Goal: 90%> Expectation: 110%> Mean score: 110% (range 51-97) Appropriate Rehab Progression Throwing Activities: painfree 1 hand throwing 20 ft away 1 Ib plyoball Single Leg Squat Single leg squat test Floor or 8 in step 30 sec test on each leg assess technique & numbers assess valgus/varus assess lateral trunk movt. assess trunk flexion looking for symmetrical motion with no pain &/or dysfunction ability to maintain balance & form for all reps

13 Appropriate Rehab Progression AJSM 11 Subjective Shoulder Questionnaire & Scoring System Prone Plank on Elbows Test Prone Plank test Test Procedure: prone on elbows maintain position duration of proper hold Strand et al: J Hum Kinet 14 Men 124 sec + 72 Woman 83 sec + 63 Quick Board Test Reaction test Quick Board Test: 30 sec test side to side comparison number of touches/misses

14 Throwers Key Points & Conclusions Determining when to initiate ITP can be difficult Strict objective criteria (knee) Time based & assessment (healing) RTP criteria based on: Clinical exam Functional tests Subjective patient Successful Return to Play Throwing