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The Throwing Shoulder
 

The Throwing Shoulder

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  • In this phase, the pitches lifts his front leg to maximum knee height in a very balanced position. Then, the front leg goes down and forward while the arms separate, swing down, then back up.
  • Lead foot should land in line with stance foot, if too far closed, pelvic rotation may be limited causing pitcher to throw across his body Supraspinatus, infraspinatus, and teres minor ER the shoulder Serratus anterior and scapular retractors (midle trap, rhomboid, and levator) position glenoid in upward rotation and retraction, providing stable base on which humerus can rotate
  • RC muscles provide compressive force during late cocking, resisting shoulder distraction caused by torque of rapidly rotating upper torso Teres minor and infraspinatus are active delivering extreme amounts of ER Supraspinatus is least active of RC muscles during this phase
  • Pitchers at various competition levels show varying muscle recruitment patterns and use of kinetic chain to differentially generate top velocities -pro pitchers predominantly use subscap and lats for acceleration, whereas amateurs use more of RC muscles with an active pec minor and relatively silent lats

The Throwing Shoulder The Throwing Shoulder Presentation Transcript

  • Michael D. Satterley PT, DPT, CIMT, CSCS Tidewater Physical Therapy, Inc. Oyster Point Physical Therapy Clinic in Newport News, Va. www.tpti.com THE THROWING SHOULDER: PREVENTING OVER-USE INJURIES
  • AGENDA
    • Statistics on Throwing Injuries
    • Anatomy of the Shoulder Girdle
    • Biomechanics of Pitching
    • Overuse in Throwing
    • Common Trouble Areas
    • Preventative Exercises
  • STATISTICS ON THROWING INJURIES
    • High Incidence of Arm Pain in Youth Baseball Pitchers
      • Each year 6 out of 10 young pitchers injure their elbow
      • Approx 50% of participants in 2002 study of youth pitchers reported elbow or shoulder pain at least once during season
      • 15% of college-level pitchers say that troubles in their current performance are based on injuries they received when they played youth baseball
    • Number of Throws and Length of Season Increases Risk of Pain and Surgery
      • Risk of pain increases if threw more than 75 pitches per game and more than 600 pitches per season
      • Pitchers who averaged more than 80 pitches per appearance were nearly 4 times more likely to require surgery
      • Pitchers who pitched competitively more than 8 months per year were 5 times more likely to require surgery
  • ANATOMY OF THE SHOULDER GIRDLE
    • Joints
      • Glenohumeral Joint
      • Scapulothoracic Joint
      • Thoracic Spine
      • Sternoclavicular Joint
      • Acromioclavicular Joint
    • Ball and Socket Joint
    • Allows for large ROM in the shoulder girdle
    • Glenoid Fossa
    • Head of Humerus
    • Acromion
    • Supraspinatus Tendon
    • Subacromial Bursa
    • Latissimus Dorsi
    • Impingement Syndrome
    GLENOHUMERAL JOINT
    • Not a true joint
    • Positions the Glenohumeral Joint for overhead throwing
    • Rotator Cuff Muscles
      • Supraspinatus
      • Infraspinatus
      • Subscapularis
      • Teres Minor
      • Teres Major
    • Serratus Anterior
    SCAPULOTHORACIC JOINT
    • Posture
    • Needs to extend and rotate well
    • Many muscles used in throwing at the shoulder girdle originate on the spine
      • Rhomboids
      • Lower Trapezius
      • Upper Trapezius
      • Middle Trapezius
    • Interplay with ribs
    THORACIC SPINE
    • Not a huge contributor
    • Connects to shoulder girdle via clavicle
    STERNOCLAVICULAR JOINT
    • Connection of Clavicle to Acromion
    • ACJ Sprain
    • Shoulder Separation
    ACROMIOCLAVICULAR JOINT
    • Windup and Stride
    • Early Cocking and Stride
    • Late Cocking
    • Acceleration
    • Deceleration
    • Follow-Through
    BIOMECHANICS OF PITCHING
    • Positions body to optimally generate forces and power required to achieve top velocity
    • If pitcher’s body and momentum fall forward prematurely, kinetic chain will be disrupted and greater shoulder force will be required to propel ball at top velocity
    WINDUP AND STRIDE
    • Begins once lead leg reaches max height and ball is removed from glove
    • Ends when lead foot contacts pitching mound
    • Stride allows for longer time for trunk motions to occur, which allows for increased energy production for transfer to upper extremity
    • Front foot is planted slightly to third-base (RH)
    • Pelvic rotation followed by upper trunk rotation
    • Shoulder externally rotates and trunk arches
    • Stance leg glute max fires to maintain slight dominant-sided extension and provide pelvic and trunk stability during coiling
    EARLY COCKING AND STRIDE
    • Occurs between lead foot contact and point of max ER of throwing shoulder
    • Pelvis reaches max rotation and upper torso continues to rotate
    • Max shoulder IR torque occurs just before max shoulder ER
    • Increased amounts of shoulder ER help to allow the accelerating forces to act over longest distance, allowing greater pre-stretch and elastic energy transfer to ball during acceleration
    • As shoulder approches max ER, subscapularis, pec major, and lats are eccentrically contracting, applying stabilizing anterior force to GHJ, and halting ER
    • Upward rotatation of scapula important for 80 to 100 degrees of humeral abduction in throwing position – no impingement
    LATE COCKING
    • Time between max ER of shoulder and ball release
    • Trunk continues to rotate and tilt, initiating transfer of potential energy through upper extremity
    • Increased forward trunk tilt allows pitching extremity to accelerate through a greater distance, allowing more force to be transferred to ball
    • Subscapularis reaches max activity during this phase along with pec major and lats, producing violent IR
    • Serratus anterior protracts scapula to maintain stable base as humerus undergoes violent IR
    ACCELERATION
    • Occurs between ball release and max humeral IR and elbow extension
    • Most violent phase of throwing cycle, resulting in greatest amount of joint loading encountered during throwing
    • Posterior shoulder soft tissues (teres minor, infraspinatus, and posterior deltoid) dissipate these enourmous forces during acceleration phase as arm continues to adduct and IR
      • Likely responsible for posterior capsular and soft tissue retraction commonly seen in throwing and for GHJ IR deficit seen in pitchers
    • Trapezius, rhomboids, and serratus anterior assist in stabilizing scapula
    DECELERATION
    • Body continues to move forward with arm until motion is ceased
    • Culminates with pitcher in fielding position
    • Unlikely culprit for injury due to decreased joint loading and minimal forces
    FOLLOW-THROUGH
  • OVERUSE IN THROWING
    • Fatigue
    • Pitch Count
    • Pitchers rely less on lower body and more on arms as they fatigue
      • Less maximum shoulder ER and knee flexion at ball release
      • Slightly more upright trunk position at ball release
      • As low as 2 MPH difference in velocity from 1 st to last inning considered significant
      • Poor ball location
    FATIGUE
    • Should also be used as a guide in determining fatigue
    • Little League Baseball pitcher regulation
    • Catcher is a repetitive throw risk too
      • Pitcher throwing 41 pitches or more cannot catch for remainder of day
      • Catcher for 4 or more innings not eligible to pitch for that calendar day
    PITCH COUNT Age Pitches per Day 17-18 105 13-16 95 11-12 85 10 and under 75
  • COMMON TROUBLE AREAS
    • Shoulder ROM
    • Joint Laxity
    • Scapular Position
    • Muscular Strength
    • Proprioception
    • Most overhead throwers display excessive ER vs. decreased IR at 90 degrees abduction
    • Adolescent players
      • Most dramatic at 13-14 years of age
    • Why?
      • Bony adaptations
      • Anterior capsule laxity, posterior capsule tightness
      • Large eccentric forces in external rotators during deceleration phase
        • Infraspinatus and teres minor
    SHOULDER ROM
    • Excessive motion usually found in GHJ
      • Excessive ER due to anterior capsule laxity
        • Repetitive throwing or congenital
    JOINT LAXITY
    • Alterations in resting position may contribute to injury
      • Anterior tilt and protraction
    • Protracted and anteriorly tilted position
      • May be normal adaptation to throwing and can be progressive
      • Correlated with increase in shoulder IR
      • Correlated to significant decrease in significant decrease in serratus anterior and lower trapezius strength
    SCAPULAR POSITION
    • Rotator Cuff Fatigue
      • Loss of abduction strength through season
      • Inability to center and stabilite GHJ
        • Subacromial impingement
    • Timing must be considered when assessing strength
      • Profound weakness on manual strength testing 2 days following a start
        • Also at end of season
      • Again pitch count and rest days are important as season continues
    MUSCULAR STRENGTH
    • Where various parts of the body are located in relation to one another
    • Those with capsular laxity and excessive ROM must rely on this to dynamically stabilize the GHJ
    • Especially important at end ranges of motion
    • Significantly decreases after throwing to fatigue
      • Deficits return to normal within 10 minutes after throwing
    PROPRIOCEPTION
    • Goal is to prevent repetitive injury, not to necessarily improve performance
    • Must focus on trouble areas
      • Proper Shoulder/Spinal ROM
      • Scapular Positioning/Stability
      • Balanced Strength
      • Proprioception
    PREVENTATIVE EXERCISES
  • PREVENTATIVE EXERCISES
    • Proper Shoulder/Spinal ROM
      • Sleeper Stretch
      • Standing Cross-Arm Stretch
      • Seated Mid-Back Rotational Stretch
      • Quadruped Opposite Elbow/Knee Touches
    • Sleeper Stretch
      • 3x for 30 seconds
      • Do not stretch through pain
    PREVENTATIVE EXERCISES
    • Standing Cross-Arm Stretch
      • 3x for 30 seconds
      • Do not stretch through pain
    PREVENTATIVE EXERCISES
    • Seated Mid-back Rotational Stretch
      • 3x for 30 seconds
      • Do not stretch through pain
    PREVENTATIVE EXERCISES
    • Quadruped Opposite Knee/Elbow
      • 2 sets of 10 reps
      • Slow and in control
      • Be sure to actually touch the elbow to the knee
    PREVENTATIVE EXERCISES
  • PREVENTATIVE EXERCISES
    • Scapular Positioning/Stability
      • Bodyweight Rows
      • Bent Over Rows
      • Band Standing Rows
      • Prone Shoulder Circuit
    • Bodyweight Rows
      • 3-4 sets of 10 reps
    PREVENTATIVE EXERCISES
    • Bent Over One Arm Rows
      • 2 sets of 10 reps
      • Focus on bringing your elbow back
        • Making the medial part of your scapula go towards your spine
    PREVENTATIVE EXERCISES
    • Standing Band Rows
      • 2 sets of 10 reps
      • Trying to squeeze your shoulder blades together
    PREVENTATIVE EXERCISES
    • Prone Shoulder Circuit
      • Y
      • T
      • W
      • L
        • 2 sets of 10 reps
        • Hold at the top for 2 seconds
        • Trying to squeeze shoulder blades on each
    PREVENTATIVE EXERCISES
    • Prone Shoulder Circuit
      • Y
      • T
      • W
      • L
        • 2 sets of 10 reps
        • Hold at the top for 2 seconds
        • Trying to squeeze shoulder blades on each
    PREVENTATIVE EXERCISES
  • PREVENTATIVE EXERCISES
    • Balanced Strength
      • Pull-ups/Hangs
      • Reverse Shrugs/Chair Dips
      • High Rows
      • Push-ups/Bosu
      • Bench Presses
      • Shoulder Presses
      • Plank Holds
    • Pull-ups/Hangs
      • If you can’t do more than 5 pull-ups at a time, try hangs 5 times for as long as you can
      • Ideally, 3-4 sets of 10 reps
      • Great exercise to battle impingement
    PREVENTATIVE EXERCISES
    • Reverse Shrugs/Chair Press Ups
      • Great for promoting scapular stability
      • If reverse shrugs are too easy with heavy resistance band, try chair dips
      • 2 sets of 10 reps
      • Can do chair press-ups for a hold
    PREVENTATIVE EXERCISES
    • High Rows
      • Focusing on scapular squeeze
      • Make sure elbows are getting behind the torso
      • 2 sets of 10 reps
    PREVENTATIVE EXERCISES
    • Push-ups/Bosu Push-ups
      • Nose to floor
      • 2 sets of 20
      • If too easy, try Bosu Push-ups
    PREVENTATIVE EXERCISES
    • Bench Presses
      • Bar or Free Weights
      • Free Weights harder
        • Makes you stabilize independently
      • Try alternating arms or holding 1 high, while repping the other
      • 4 sets of 10 reps
    PREVENTATIVE EXERCISES
    • Shoulder Presses
      • Bar or Free Weights
      • Alternating or Holds
      • 3-4 sets of 10 reps
    PREVENTATIVE EXERCISES
    • Plank Holds
      • Focus on getting in solid, stable position and holding
      • Great for the core and shoulder girdle
      • Can do 2 sets of 10 with at least 10 second holds
        • Or, can do 3-5 minutes total and hold for as long as you can
    PREVENTATIVE EXERCISES
  • PREVENTATIVE EXERCISES
    • Proprioception
      • Rhythmic Stabilization Drills
        • Weightbearing
          • Quadruped Position
        • Non-weightbearing
          • Late Cocking
          • Acceleration
          • Deceleration
      • Plyometric Deceleration Ball Flips
    • Weight-bearing Rhythmic Stabilization
      • Alternating forces applied to all sides of the arm to try to slightly push the athlete off balance
      • Non-specific pattern
      • Usually done for time
        • 30 – 60 seconds
    PREVENTATIVE EXERCISES
    • Non-Weightbearing Rhythmic Stabilization
      • Late Cocking
      • Acceleration
      • Deceleration
    PREVENTATIVE EXERCISES
    • Plyometric Deceleration Ball Flips
      • Start with very light baseball-sized med ball
      • Progress to weight that is pain-free and maintains fluid motion in deceleration and flip back
      • 4 sets of 10 reps
    PREVENTATIVE EXERCISES
  • SUMMARY
    • Overhand throwing is a very violent motion
    • We need to make sure all joints are moving correctly and have well-balanced strength
    • “ Coaches have to watch for what they don’t want to see and listen to what they don’t want to hear.”
      • John Madden
        • We must pay attention to athletes’ verbal complaints as well as signs of fatigue to avoid injury
    • Be proactive and institute preventative exercises into your warm-up routines
    • Staying injury free is the key to a successful sports season
  • COMMENTS AND QUESTIONS
  • REFERENCES
    • Corrao M, Kolber MJ, Wilson SH. Addressing Posterior Shoulder Tightness in the Athletic Population. Strength and Conditioning Journal. 2009; 31(6): 61-65.
    • Seroyer ST, Nho SJ, Bach BR, et al. The Kinetic Chain in Overhand Pitching: Its Potential Role for Performance Enhancement and Injury Prevention. Sports Health: A Multidisciplinary Approach. 2010; 2(2): 135-146.
    • Fortenbaugh D, Fleisig GS, Andrews JR. Baseball Pitching Biomechanics in Relation to Injury Risk and Performance. Sports Health: A Multidisciplinary Approach. 2009; 1(4): 314-320.
    • Reinhold MM, Gill TJ. Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes, Part 1: Physical Characteristics and Clinical Examination. Sports Health: A Multidisciplinary Approach. 2010; 2(1): 39-50.
    • Fleisig GS, Bolt B, Fortenbaugh D, et al. Biomechanical Comparison of Baseball Pitching and Long-Toss: Implications for Training and Rehabilitation. Journal of Orthopedic and Sports Physical Therapy. 2011; 41(5): 296-303.
    • Reinhold MM, Gill TJ, Wilk KE, et al. Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes, Part 2: Injury Prevention and Treatment. Sports Health: A Multidisciplinary Approach. 2010; 2(2): 101-115.
    • Cook G, Burton L, Kiesel K, et al. Movement: Functional Movement Systems: Screening, Assessment and Corrective Strategies. Aptos, CA: On Target Publications; 2010.