Presented by Matt Repa ATC,CES mrepa@ibji.com Illinois Bone & Joint Institute CSL Symposium 1/11/11
} Throwing is a very complex and dynamic activity. } As clinicians, how can we step in and make a difference? } What should we look for? } Are there normal asymmetries? } Treating and eliminating symptoms alone will not correct dysfunction.
Usual DX s RTC/Bicep tendonitis MDI Impingement (possible) Labral tear Medial epicondylitis/stress fx. Many patients will report with shoulder and or elbow pain only while throwing, and no other limitations. Go through a typical evaluation. Palpation, ROM, MMT s, Special Tests, etc.
} Assessment Shoulder AROM/PROM: All motions usually WNL except D-IR and D-ER (GIRD) 80% of SLAP tears show hip ND-IR (Morgan, UNPUBLISHED) Strength: Low Trap, Mid Trap, Rhomboid, Serratus Anterior, RTC Pec Major, Upper Trap } Assessment Elbow AROM/PROM: Flexion, Extension, Pronation, Supination Strength: Elbow musculature is typically strong: Flex, Ext, Pro, Sup Low Trap, Mid Trap, Rhomboid, Serratus Anterior, RTC Pec Major, Upper Trap
} Kinetic Chain Factors Baseball Elbow Injury Correlations 95% - GIRD 88% - Shoulder Dyskinesis, GIRD 50% - Contralateral Hip Weakness (Kibler, 2003) UCL Injury - REMEMBER! Common During Cocking/Acceleration Phase The flexor/pronator mass generates a varus torque that resists valgus, thus unloading the UCL. So when muscles are weak or fatigued, this may result in increased UCL strain, joint stress, and injury risk. (Escamilla, 2002)
} GIRD Number of different ways to define: Compare ROM bilaterally ± 1 ( 60% in IBJI Research) (NDIR DIR)/(DER-NDER) = X If X is 1, then (+)GIRD A study in 2008 showed that the arc of rotation is shifted 15 in dominant arm of habitual throwers. NOT GIRD? (Kuhn, 2008) Total Arc (IR+ER) > 25 compared bilaterally (Kibler, 1986)
} During the 2008 Colorado Rockies spring training, 23 asymptomatic pitchers ROM were measured. (Tokish, 2009) } 10/23 (43%) Had GIRD Loss of IR greater then gain of ER Greater than 25 loss of IR compared bilaterally } 4/10 (40%) Had shoulder pain during the season. } If GIRD is present in a high percentage of asymptomatic pitchers, one should use caution in stating that the loss of IR is the sole cause of a shoulder injury.
% IR of Total Arc (DIR+DER)/DIR=DIR% Presents a higher correlation to shoulder pain in initial research for baseball and softball players. (+) if by 4% for appropriate age group Little League: Dominant = 38% Non-Dominant= 40% High School: Dominant = 31% Non-Dominant = 34% Collegiate/Minor League: Dominant = 28% Non-Dominant = 37%
} Possible Reasons and Clinical Relevance for IR Humeral Retroversion (normal adaptation?) Muscular Underdevelopment (scapula) Significant Anterior Shoulder Tilt Muscular Contracture 1 st Rib Malalignment I DON T THINK WE HAVE THE ANSWER YET!
} What combination of other factors come into play? } The traditional shoulder exam is important, but incomplete. A nonshoulder exam provides the rest of the story.
Active shoulder flexion & abduction Symmetry, Definition, Winging, Snapping, Upper Trap Dominance Double Leg & Single Leg Squat (FMS) Pelvic Control Test Upper Extremity Stability Test Shoulder Mobility Test (FMS) Mod Trunk Stability Push Up (FMS)
} Double Leg Squat Assess bilateral, symmetrical mobility of the hips, knees, ankles, shoulders and thoracic spine. The squat is scored 1, 2, or 3, with 3 being a perfect score with heels flat, head/chest facing forward, and arms perpendicular to the floor. Throwers typically score in the (2-) range because they fail the UE portion of this test with limited thoracic extension. Scapular Strength is usually associated with this.
Double Leg Squat
} Single Leg Squat Same scoring as the DL squat, but athlete must demonstrate knee valgus control and limit their trunk flexion. Chronically injured throwers will fail this test the majority of the time on their non-dominant throwing leg (plant leg). They will exhibit decreased balance, functional gluteus medius strength, and increased trunk flexion.
} Pelvic Control Test Measures lumbar stability and pelvic motor control. Two clinicians are needed, one to take a measurement and the other to assess lumbar pressure. Once pelvic control is lost by decreased pressure on the clinician s hand, hip flexion is measured. Average score by test guideline: 45 Average score by student athlete testing: 35
} Pelvic Control Test
} Upper Extremity Stability Test Patient is in standard pushup position with arms spread three feet apart. The clinician will instruct the patient to tap their hands side to side for 15 seconds, as fast as they can while taking note any loss of pelvic or abdominal control. Hands must stay on the outside of the tape. Female athletes would perform this in a modified pushup position Ave Standard Power Male: 150 Ave Standard Power Female: 135 Ave Athletic Power Male: 197 Ave Athletic Power Female: 162
} Upper Extremity Stability Test
} Upper Extremity Stability Test Increased power by at least 15% above the athletic power average, with a (+) %IR GIRD score, correlates with shoulder pain 84% of the time. Can Increased Overall Power = Pain c (+) GIRD? Although the age groups were matched, the injured group was taller and heavier. (Andrews, 2002)
} Shoulder Mobility Test The clinician instructs the athlete to place their thumbs inside of their fist. The athlete will then maximally adduct and internally rotate one shoulder, while maximally adducting and externally rotating the other. The distance between their hands is measured. Compare bilaterally. A distance greater then 50% the length from athlete s wrist to distal 3 rd finger is a failed test. A failed test usually indicates a (+) GIRD. Other possibilities would be tight pectoralis and/or latissimus musculature.
} Shoulder Mobility Test
} Modified Trunk Stability Pushup The clinician will instruct the athlete to lie prone with their knees off of the ground and fingertips at chin level. The patient will be asked to push himself up maintaining lumbar control throughout. A "lag" in the lumbar spine indicates weak trunk stabilizers, and the inability to transfer force from the upper extremities to the lower or vice versa.
} Sx vs. Non-Sx Athletes } Age } Time of Year/Season } Throwing Progression When to Start? Asymptomatic Rebounder Toss Wall Toss c Arrhythmic Stabilization 90/90 & ¾ Position Flatground Long Toss Mound } Focusing on Mechanics IS KEY!
Early hand break Leg swing to midline No butt drive Reverse shoulder rotation Excessive trunk flexion/ extension Arm path and ball position Glove side elbow position Excessive shoulder tilt W vs. M Position L Position V Position Poor hip/shoulder timing Midline Casting Land on heel Poor back side drive Late forearm turnover Stride length Early toe off Poor finish
} Elbow Medial Elbow Issues Showing Ball to 1 st Base (R) ( L Position) Late Forearm Turnover Laid Back Forearm Arm Drag Elbow before head Excessive Stride Length Contractures Casting (Eccentric Bicep deceleration w/o pronation) Elbow Flexion at Release Point (Labrum as well) Olecronon Pain (+) Bump Test Casting Curve Ball vs. Fastball Pronator Teres } Shoulder M Position Reverse Shoulder Rotation Arm drag behind midline Hip Rotation Excessive Stride Length