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

Transcription

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

2 Disclosure No conflicts to disclose

3 Throwing Athlete Dilemma The shoulder must have enough range of motion to allow excessive ER and enough stability to prevent humeral subluxation. There must be a balance between mobility and functional stability.

4 Muscles acting on scapula Scapulothoracic group Rhomboid major Rhomboid minor Levator scapula Trapezius Serratus anterior Scapulohumeral group Subscapularis Supraspinatus Infraspinatus Teres Minor Teres Major Deltoid Thoracohumeral group Pectoralis Major Latissimus Dorsi Extrinsic Muscles Coracobrachials Triceps Biceps Omohyoid

5 Scapulothoracic rotation Upward scapular rotators Downward scapular rotators Upper trapezius Lower trapezius Serratus anterior Levator scapula Pectoralis Minor Rhomboids

6 Scapulohumeral rotators Support the head of humerus on the glenoid. Speed of movement affects the activation of rotator cuff. Load affects activation of rotator cuff. Internal rotation, external rotation and elevation of shoulder.

7 The Rotator Cuff Muscles: SITS Supraspinatus ABD Infraspinatus ER Teres minor ER Supscapularis IR Depress humeral head against glenoid to allow full abduction

8 So what causes shoulder pain? Impingement Labrum and biceps pathology A-C joint pathology Rotator Cuff Injury Instability Among other things

9 Clinical Exam History Pain Acute Chronic Weakness Abnormality Single event Repetitive overload Instability Does it feel like it s going to come out? Catching/Locking Sport or Occupation Previous injury/surgery/fx to elbow, wrist, neck, arm, back, knee, ankle Previous treatment

10 Initial Evaluation-Objective Elbow/Shoulder ROM Trunk ROM-Thoracic/Lumbar Rotational movement 45 bilaterally should be minimum Flexion/Extension Important for follow-through Hip ROM Rotational Mobility: IR= 30 ± 5 ER=45 ± 7

11 Initial Evaluation-Objective(cont.) Strength Shoulder/Scapular Strength-All planes Pain or crepitation w/ resisted motion? Assessment at neutral and 90/90 position ER/IR IR: 35-40% stronger than ER Elbow/Wrist strength Core strength/stability VERY important in mechanics Hip/Knee Strength Base is EVERYTHING Rotational Hip Strength Special Tests Hawkins-Kennedy, O Brien s, Speed s, etc.

12 Treatment Phases Acute Phase Diminish pain and inflammation Modalities as appropriate-ice,ionto,etc. Mobilization-manual/self stretch Modification of activities Limiting throwing and certain exercises Stretching exercises- with limitation of IR GIRD-Glenohumeral Internal Rotation Deficit Diagnosed by more than loss of IR when compared to other side- Posterior capsule tightness? Limitation in horizontal adduction Supine Horz. Add w/ IR(Hawkins)

13 Clinical Diagnosis When evaluating an over head athlete for shoulder or elbow pain it is pertinent to look at the entire kinetic chain. Faulty biomechanics can produce shoulder and elbow pain which may lead many patients into a rehabilitation setting to seek care to solve this problem.

14 Scapulothoracic Nerves 1.Spinal Accessory 2.Long Thoracic 3.Dorsal Scapular 1.Trapezius depression and lateral translation 2.Serratus- superior and medial translation 3.Rhomboidsdepression and lateral translation

15 Causes of Scapular Dyskinesis 1.Postural 2.Nerve 3.Lack of muscular/capsular flexibility or contracture 4.Muscular weakness 5.Proprioceptive Dysfunction

16 Learning to throw with proper form

17 Special test Scapular retraction test Patient is asked to retract both scapula s to hold an isometric contraction for seconds. Reports of pain with burning in the rhomboid region suggests paresis. Scapular assistance test Useful in determining if poor scapular control weakness in the serratus or lower trapezius musculature as a cause for impingement. Examiner will assist patient by pushing laterally and upward on the inferior scapular border to simulate serratus and trapezius. A positive test is indicated by a decrease or abolishment of impingement symptoms.

18 Lateral Scapular SlideTest superior angle T2/ scapular spinet4/ inferior anglet7,8

19 Inclinometer Test Testing at rest, 60,90, 120 degrees. From Abduction and flexion at 40 degrees From root of scapular spine and posterior lateral acromion. 90 degrees should have about 25 degrees of upward rotation.

20 Pitch Cycle When looking at the pitch cycle as a kinetic chain the body can be split up into four segments (1)the hips (2)trunk/core (3)shoulder (4) the arm and ball. These segments must produce what is called angular velocity. Each segment has it s contribution in this cycle where the hips will rotate first, followed by the trunk, then followed by the shoulder in which the velocity gained from each segment produces momentum to propel the baseball.

21 Balance Point Gluteus medius Quads Hip mobility Core strength

22 Exercise Level 1 Hip Abduction Clam Hip slides- 4 ways Hip hikes Tubing squats Core single/dbl leg extension add upper extremities Torso rotations

23 Exercise level 2 Hip Internal rotation Fire Hydrant Advanced Clam Lateral Step up Single leg bridge Dying Bug Ball touch

24 Exercise Level 3 Bosu or Tramp balance T Single leg Bridge 4 way kicks Lateral tubing Monster Walks Single leg chair rise

25 Exercise Level 4 Torso rotations SB Single leg balance SB Alternate arm/leg Single leg STAR

26 Y-T-W

27 Exercise Serratus Trapezius Upper/Lower 90/90 IR/ER D2 Side lying ER ABC s SLA scaption Full can Whizzer Dynamic wall stabs Ball walk outs Push up plus Wall dribble

28 External Rotation 65-67% activation of Infraspinatus occurs in side-lying position. 25% more effective with towel roll.

29 Prone Series

30 Throwing Special Drills Wall Drill Protects thrower from getting too much horizontal abduction in cocking phase. Towel snap Ball Touch from balance point to opposite leg throw Decel Plyo Toss

31 Questions?