Advanced Rehabilitation of the Overhead Athlete

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Advanced Rehabilitation of the Overhead Athlete

• Brian Matson, MPT, CSCS
• PT Plus
• Christiana Care Health System

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PurposeThe purpose of this lecture is to
understand the key elements in safely and
effectively returning the most commonly injured
overhead athletes to play. Those key elements
are

• Understanding the demands of the sport
• Understanding the sport-specific biomechanics of
  the injured area
• Execution of a thorough evaluation
• Development of a comprehensive plan of care
  including advanced rehabilitation and functional
  training for the entire kinetic chain

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ObjectivesAfter the following lecture, you will

• Have an understanding of the biomechanics of the
  overhead tennis serve, freestyle swimming stroke,
  and overhand pitching motion.
• Be able to recognize common mechanical faults
  that often result in sports related upper
  extremity injuries.
• Be able to perform comprehensive evaluations of
  the athletic shoulder.
• Have an understanding of the development of a
  physical therapy plan of care for the athletic
  upper extremity with emphasis on advanced
  rehabilitation and functional training for return
  to play.

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Biomechanics of Overhead Pitching

• The overhead baseball pitching motion
• can be broken down into 5 phases
• Windup
• Cocking
• Acceleration
• Deceleration
• Follow-Through

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Windup PhaseOverhead Pitching

• Places the pitcher in a balanced position on the
  foot of the throwing side, preparing the pitcher
  to throw. Begins at the initiation of movement
  and ends at foot contact.
• The non-throwing side is closest to the target
  and the non-throwing side foot strides toward the
  target as the arms move away from each other.
• Very little energy is generated in this phase
  (potential energy)

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Cocking PhaseOverhead Pitching

• Begins at foot contact as both arms are abducted
  to approx 90 degs, elbow is flexed approx 90
  degs, and the pitching arm is horizontally
  abducted 20-30 degs behind trunk.
• Ends as the hips and trunk rotate toward the
  target, the pitching arm horizontally adducts to
  about 15 degs and reaches max ER at approx 165
  degs. The pitching arm maintains approx 90 degs
  of ABD. Sidearm pitchers have less contralateral
  lean.

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Acceleration PhaseOverhead Pitching

• Begins at max ER and ends at ball release
• The elbow begins to extend immediately after max
  ER secondary to the centrifugal force generated
  by trunk rotation and is at about 25 degs of
  flexion at ball release. High stress placed on
  UCL in this phase.
• The shoulder internally rotates up to speeds of
  7000 degs/sec and maintains approx 90 degs of ABD
  (relative to trunk). The trunk flexes forward
  and toward the non-throwing side. The shoulder
  maintains a 90 degs ABD position in the side-arm
  pitcher but the trunk does not lean to the
  non-throwing side.

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Deceleration PhaseOverhead Pitching

• Begins at ball release and ends at max IR
• Pronation and extension of the elbow continue
  after ball release as does shoulder IR and HADD.
  Large eccentric activity is noted in the
  supinators, elbow flexors, scap stabilizers, and
  posterior rotator cuff musculature. Undersurface
  tears of the supraspinatus are blamed on the
  repetitive tensile overload of the tissue during
  this phase.

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Follow-ThroughOverhead Pitching

• Begins at max IR and continues until the pitcher
  assumes a balance fielding position
• Important part of pitching motion because needs
  to dissipate energy generated in the acceleration
  phase by using long arching arm path and larger
  muscle groups (trunk and legs)

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Mechanical Faults in the Overhead Pitching
MotionOverhead Pitching

• Things to remember
• Should all pitchers be taught to pitch alike?
• I read that a guy figured out the proper
  pitching motion. The guys in the big leagues are
  doing it all wrong.
• Focus on mechanical fault with greatest
  implication for injury.
• Mechanical fault, weakness, or tightness causing
  injury may be further down kinetic.

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Mechanical Faults in the Windup PhaseOverhead
Pitching

• Momentum of body not going directly toward the
  target places additional demands on the upper
  extremity.
• Foot placement crosses target line forcing
  pitcher to throw across their body placing
  additional stresses on decelerators secondary to
  the affects of the follow-through posture, that
  relatively shortens the available time to
  dissipate forces. Inhibits trunk from helping
  produce power within the movement. Foot
  placement on non-throwing side of target line
  prematurely rotates trunk/hips to non-throwing
  side (opens) and places shoulder and elbow in
  more precarious position and forces upper
  extremity to produce more of the power for ball
  velocity.

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Mechanical Faults in the Cocking PhaseOverhead
Pitching

• Trunk/hips open prematurely
• Excessive shoulder ABD increases risk for
  impingement
• Excessive lean backwards and/or to throwing side
• Hips drifting prematurely towards target
• Poor arm action creates number of problems in
  acceleration phase

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Mechanical Faults in the Acceleration
PhaseOverhead Pitching

• Decreased horizontal adduction, which leads to
  dragging throwing arm increasing anterior shear
  forces to shoulder. May contribute to additional
  valgus stress to elbow
• Not keeping chin on target pulls body off target
  line
• Not getting enough extension through release
  places greater demands on shoulder/elbow
• Lack of emphasis on lower half and trunk

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Mechanical Faults in the Deceleration
PhaseOverhead Pitching

• Abbreviated deceleration phase (either trunk or
  arm path) increases eccentric impulse to
  posterior rotator cuff and elbow flexors by
  requiring them to dissipate the same amount of
  energy in a shorter period of time.
• Excessive horizontal adduction moves shoulder
  into impingement position considering internal
  rotation combined with excessive horizontal
  adduction.

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Mechanical Faults in the Follow-Through
PhaseOverhead Pitching

• Abbreviated deceleration phase (either trunk or
  arm path) increases eccentric impulse to
  posterior rotator cuff and elbow flexors by
  requiring them to dissipate the same amount of
  energy in a shorter period of time.
• Excessive horizontal adduction moves shoulder
  into impingement position considering internal
  rotation.
• Poor follow-through with stance leg gives
  indication of improper usage of lower half during
  acceleration.

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Common Physical and Training Components that
Contribute to Injuries in Pitchers

• Excessive anterior joint capsule laxity requiring
  increased workload from the glenohumeral dynamic
  stabilizers. Can lead to tendinopathy or labral
  pathology secondary to repetitive microtrauma.
  Humeral torsion?
• Tight posterior capsule increasing risk of
  internal impingement increased risk of labral
  pathology and additional valgus stress at elbow.
• Weak or deconditioned scapular and glenohumeral
  stabilizers unable to meet demands of the
  throwing motion.
• Weak or deconditioned trunk and/or legs requiring
  upper extremity to provide more power for ball
  velocity.
• Excessive medial elbow laxity that could lead to
  valgus extension overload or presentation of
  osteophytes in the posterior/medial olecranon
  fossa.
• Tight LE musculature making it impossible to
  execute proper mechanics Just keep your
  balance point!!!!!, says the frustrated parent
  to the equally frustrated athlete.
• Excessive training/performance demands placed on
  athletes, namely number of pitches per calendar
  week (player may be expected to pitch for more
  than one team), and types of pitches.

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Biomechanics of the Overhead Tennis Serve

• The overhead tennis serve can be broken down into
  four phases
• Windup
• Cocking
• Acceleration
• Deceleration

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Windup PhaseOverhead Tennis Serve

• This stage begins with the initiation of the
  serving stance and ends when the ball is tossed
  upward.
• Low EMG activity of the shoulder musculature

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Cocking PhaseOverhead Tennis Serve

• Begins when the racquet is brought upward and
  ends when the shoulder is elevated and fully
  externally rotated in preparation for the
  acceleration phase.
• Moderately high EMG activity of the ssp, isp,
  subscap, bi, and serratus ant
• Mm activity is necessary to stabilize the
  scapulothoracic and glenohumeral joints
• Max ER has been measured as high as 150 degs
• Shoulder ABD (_at_ time of elbow 90 flexion) is
  approx. 80-90 degs.
• Contralateral trunk lean and scapular ABD
  contribute to the apparent vertical orientation
  of the racquet arm during the cocking and
  acceleration phases

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Acceleration PhaseOverhead Tennis Serve

• Begins when trunk rotation and glenohumeral
  internal rotation are initiated in an act to
  strike the ball and ends at ball strike.
• High EMG activity of pec maj, isp, subscap, lat,
  serratus ant, delt, trap
• Mm activity necessary to develop arm speed to
  impart extreme force on ball (Roddick .22 secs,
  Sharipova .24 secs)
• Internal rotation angular velocities have been
  measured in excess of 2000 degs/sec

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Deceleration PhaseOverhead Tennis Serve

• Begins immediately after ball strike and
  continues through the follow-through until
  service motion ends.
• High EMG activity of ssp, isp, teres minor,
  serratus ant, bi, delt, and lat
• Mm activity is mainly eccentric and necessary in
  decelerating the humerus and keep glenohumeral
  joint stability as well as decelerating the
  forearm at the elbow joint

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Mechanical Faults of the Overhead Tennis Serve
Leading to Injuries
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Mechanical Faults in the Windup PhaseOverhead
Tennis Serve

• Tossing ball directly overhead leads to increased
  glenohumeral ABD and/or excessive contralateral
  trunk lean and/or lumbar hyperextension to strike
  ball in acceleration phase

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Mechanical Faults in the Cocking PhaseOverhead
Tennis Serve

• Trunk orientation too vertical in sagittal plane
  places excessive demands on shoulder ER and elbow
  orientation
• Trunk orientation too vertical in frontal plane
  forces excessive glenohumeral ABD and increases
  risk of impingements

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Mechanical Faults in the Acceleration
PhaseOverhead Tennis Serve

• Excessive ABD coupled with internal rotation
  increases risk of impingement and labral
  irritation
• Rigid wrist/hand at impact places extra demands
  on forearm musculature and also places extra
  demands on shoulder to produce force

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Mechanical Faults in the Deceleration
PhaseOverhead Tennis Serve

• Abbreviated follow-through places extra demands
  on forearm musculature, biceps brachii, and
  posterior rotator cuff / scap stabilizers to
  decelerate arm in a shorter time period
• Racquet arm following through on the ipsilateral
  side places unnatural stresses on shoulder
  secondary to excessive internal rotation

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Physical Components That Commonly Lead to Upper
Extremity Injuries in TennisOverhead Tennis
Serve

• Weak, deconditioned scapular stabilizers and
  rotator cuff musculature decreasing dynamic
  stability
• Weakness or deconditioned trunk and/or legs
  placing additional stress on upper extremity
• Excessive glenohumeral external rotation compared
  to nondominant side may indicate increased laxity
  of anterior and inferior joint capsule which
  leads to less stable joint
• Tight glenohumeral internal rotation can lead to
  internal impingement or peel-back labral
  pathology, both placing additional stress to
  medial elbow
• Poor choice of equipment including heavy racquet,
  excessively large racquet, wrong grip size, and
  high string tension can lead to additional
  stresses to the elbow and shoulder
• Fast court surface leading to higher impact
  forces on ground strokes

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Biomechanics of the Freestyle Swimming Stroke

• All swimming strokes can be broken down into two
  basic phases
• Pull
• Recovery

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Pull-Through PhaseFreestyle Swimming Stroke

• Hand Entry - the hand enters near midline the
  shoulder is externally rotated and abducted the
  body roll begins
• Mid Pull-Through the shoulder is at 90 degs.
  ABD and neutral rotation body roll is 40-60 degs
  from horizontal
• End of Pull-Through the shoulder is fully
  internally rotated and abducted body returns to
  horizontal position
• Richardson (1980)

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Recovery PhaseFreestyle Swimming Stroke

• Elbow Lift shoulder begins ABD and ER body
  rolls begins to opposite side from pull-through
• Midrecovery shoulder ABD to 90 degs and
  externally rotated past neutral body roll
  reaches max of 40-60 degs breathing occurs to by
  turning head to recovery side
• Hand Entry shoulder is externally rotated and
  max ABD body roll returns to neutral
• The kick is continuous and an important part of
  swimming technique. It aids in propulsion,
  reduces drag (keeping the body horizontal), and
  serves as an anchoring mechanism for the body
  roll.
• Richardson (1980)

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Mechanical Faults of the Freestyle Stroke That
Leads to Injuries in Swimmers

• Pull-Through Phase
• Hand-Entry the hand enters across midline or
  moves across midline in early pull-through,
  possibly as a result of excessive body roll.
  This increases degree of impingement and
  decreases stroke efficiency (leads to greater
  number of strokes for given distance)
• Mid Pull-Through Head down position may lead to
  deeper arm pull adding more stress to upper
  extremity during pull-through. Crossover leads
  to additional vascular insufficiency to the
  rotator cuff
• Insufficient kick increases drag, makes body roll
  less consistent

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Mechanical Faults of the Freestyle Stroke That
Leads to Injuries in Swimmers

• Recovery Phase
• Elbow Lift Insufficient elbow lift may cause
  hand to stay submersed during the initial
  recovery phase, delaying ER and fatiguing
  external rotators
• Midrecovery less than 40 degs of body roll
  places greater demands on shoulder to externally
  rotate and ABD. Abduction will also be out of
  the plane of scapula. Continued IR position of
  arm past midrecovery leads to impingement
• Insufficient kick increases drag and makes body
  roll less consistent

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Common Physical and Training Components that
Contribute to Injuries in Freestyle Swimmers

• Tight posterior shoulder capsule which increases
  risk of internal impingement.
• Excessive laxity of anterior and inferior
  shoulder capsule that places extra demands on the
  glenohumeral stabilizers. Most swimmers execute
  flexibility program emphasizing anterior and
  inferior capsule stretches although most swimmers
  already display excessive laxity in those areas.
• Weak and/or deconditioned external rotators that
  inhibit timely ER during recovery phase
  increasing chances to cause impingement.
• Tight of anterior shoulder / chest mm
  (particularly pec minor) worsening postural
  positional faults (scap, etc.) and result in
  hyper HABD in midrecovery.
• Weak and/or deconditioned trunk and leg
  musculature that provide anchoring system for
  body roll, provide propulsion, and keep body
  horizontal.
• Training methods emphasizing ultralong distances
  and anterior mm strength as opposed to higher
  intensity interval workouts with strengthening
  goals emphasizing musculature balance.

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Review Evaluation of Athletic Shoulder

• Subjective
• Objective
• Observation/Palpation
• AROM/PROM
• Strength
• Joint Capsule Assessment
• Special Test
• Mechanical Assessment
• Assessment
• Plan
• Think Return to Play

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Manual Techniques and Therapeutic Exercise

• Neuromuscular Reeducation
• Prone mid trap, prone low trap, ECC elevation for
  overactive upper trap
• Rhythmic Stab for glenohumeral joint and scap
• PNF D1/D2 flex and ext, scap diagonals

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Manual Techniques and Therapeutic Exercise

• Therapeutic Exercise
• Closed chain scap ex thumb tacks, t-ball circles
• T-band scap/RTC ER, IR, Rows, shld Ext,
  lawnmower, no money, reverse throwing
• DB S/L ER, prone mid trap/low trap (4 phase -gt
  table -gt t-ball -gt w/ hyper (static then
  dynamic), full can, RTC blast
• Plyos prone ball drop (table -gt t-ball -gt
  hypers), ball drop throw on hypers, seated ball
  toss on t-ball, ½ kneel reverse throw

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Thank you.