Efficacy of Arm Care Programs for Injury Prevention

Purpose of ReviewArm care programs for baseball players are an increasingly popular area of interest for players, parents, coaches, sports performance staff, and team physicians. Once a general afterthought, the design of arm care programs is now heavily scrutinized in order to maximize performance and help reduce injury risk. Given the recent spike in interest for arm care programs for baseball players of all ages, the purpose of this work is to review the relevant literature regarding the efficacy of arm care programs and to discuss the authors’ preferred, evidence-based principles for arm care programs.Recent FindingsArm care programs appear to provide favorable results for performance, maintenance of strength and flexibility, and reduced injury risk. These programs should be tailored to the demands of the athlete, which can change based on the time of year and physical demands of the player’s position. A good program will incorporate flexibility, strengthening, proprioception, and joint mobility for the entire kinetic chain. Appropriate warm-up and cool-down periods are also important. Arm care programs should start with basic movement patterns before progressing to more advanced, coordinated exercises.SummaryArm care programs are an important piece of a holistic approach to caring for the throwing arm of baseball athletes. In general, they appear to be a safe and efficacious way to help prevent a portion of throwing arm injuries. Further research is needed to determine the optimal arm care program for each athlete.     

The Youth Throwers Ten Exercise Program: A variation of an exercise series for enhanced dynamic shoulder control in the youth overhead throwing athlete

The overhead throwing motion is an extremely stressful athletic movement. The high velocity and repetitive nature of this activity places immense pressure on the entire body, which can frequently result in injury to the throwing arm. Extensive literature exists with regards to the management of these injuries in the collegiate and professional level athlete; and it is well understood that a multiphasic approach is required to return an individual to prior level of play. However, there is a gap in the literature which fails to address the management of youth individuals. This article presents a new and innovative approach to the rehabilitation, training and management of the youth overhead throwing athlete, The Youth Throwers Ten Exercise Program. This program addresses principles of: coactivation, coordination, dynamic stabilization, neuromuscular control, proprioception, muscle strength, endurance and scapular rhythm all of which are vital for successful performance. This exercise series utilizes bodyweight and Theraband exercises that cater to the unique characteristics of the youth athlete making it a safe way to prepare for the demands of overhead throwing activities.     

Prevention of shoulder injuries in overhead athletes: a science-based approach

The shoulder is at high risk for injury during overhead sports, in particular in throwing or hitting activities, such as baseball, tennis, handball, and volleyball. In order to create a scientific basis for the prevention of recurrent injuries in overhead athletes, four steps need to be undertaken: (1) risk factors for injury and re-injury need to be defined; (2) established risk factors may be used as return-to-play criteria, with cut-off values based on normative databases; (3) these variables need to be measured using reliable, valid assessment tools and procedures; and (4) preventative training programs need to be designed and implemented into the training program of the athlete in order to prevent re-injury. In general, three risk factors have been defined that may form the basis for recommendations for the prevention of recurrent injury and return to play after injury: glenohumeral internal-rotation deficit (GIRD); rotator cuff strength, in particular the strength of the external rotators; and scapular dyskinesis, in particular scapular position and strength.     

Identifying Risk Factors of Upper Extremity Injuries in Collegiate Baseball Players: A Pilot Study

BackgroundRepetitive pitching places tremendous forces on the shoulder and elbow which can lead to upper extremity (UE) or lower extremity (LE) overuse injuries.PurposeThe purpose of this study was to evaluate pre-season physical measurements in collegiate baseball players and track in-season baseball throwing volume to determine which factors may predict throwing overuse injuries.Study DesignRetrospective Cohort study.MethodsBaseline preseason mobility, strength, endurance, and perception of function were measured in 17 collegiate baseball pitchers. Participants were then followed during the course of the season to collect rate of individual exposure, estimated pitch volume, and rating of perceived exertion in order to determine if changes in workload contributed to risk of injury using an Acute-to-Chronic Workload ratio (ACWR).ResultsParticipants developing an injury had greater shoulder internal rotator strength (p=0.04) and grip strength in a neutral position (p=0.03). A significant relationship was identified between ACWR and UE injuries (p <0.001). Athletes with an ACWR above or below 33% were 8.3 (CI₉₅ 1.8-54.1) times more likely to suffer a throwing overuse injury occurring to the upper or lower extremity in the subsequent week.ConclusionACWR change in a positive or negative direction by 33% was the primary predictor of subsequent injury. This finding may assist sports medicine clinicians by using this threshold when tracking pitch volume to ensure a safe progression in workload during a baseball season to reduce the risk of sustaining overuse upper or lower extremity injuries.Level of Evidence3b     

Movement System Dysfunction Applied to Youth and Young Adult Throwing Athletes

Shoulder and elbow injuries in overhead athletes, especially baseball pitchers, have become more common and result in limited participation. Upper extremity injuries in baseball can occur secondary to high velocity repetitive loading at extreme ranges of motion causing microtrauma to the musculoskeletal structures. With the vast number of youth and young adult baseball players in the United States and the increasing number of throwing related injuries, it is crucial that clinicians can perform a movement system evaluation of the throwing motion. An adequate evaluation of the movement system as it relates to the throwing motion can provide insight into abnormal throwing mechanics and provide rationale for selecting appropriate interventions to address identified impairments that may lead to injury. The purpose of this clinical commentary is to present a recommended movement system evaluation that can be utilized during both pre-season and in-season to assess for modifiable injury risk factors in youth and young adult baseball players.Level of Evidence5     

The Kerlan-Jobe Orthopaedic Clinic Shoulder & Elbow Score used as a Patient-Reported Outcome Measure for the Youth and High School Aged Baseball Athlete

BackgroundThe Kerlan-Jobe Orthopaedic Clinic Shoulder & Elbow Score (KJOC) provides questions for the overhead athlete that can aid with determining if someone is throwing with or without pain. However, this scale was initially created for the adult baseball athlete and has not been validated for younger male demographics.Hypothesis/PurposeTo (1) determine if the scores on the KJOC are different between those throwing with and without pain in male youth and high school-aged baseball athletes, and (2) establish a prediction score for whether a young baseball athlete is throwing with symptoms.MethodsThe KJOC questionnaire was used to compare scores in male baseball players between the ages of 10 through 18. This questionnaire consists of 10 questions that each contain a 10-point visual analogue scale (VAS). When all questions are added together the highest possible score is 100 points, with a higher score equating to a better outcome of throwing without symptoms. Retrospective data from 28 subjects with throwing arm pain were compared to 28 prospective subjects actively participating in baseball with no pain. A Mann Whitney-U test was used to compare the mean scores, and regression analysis was used to establish a threshold score between those throwing with and without pain.ResultsSignificant differences were found between the groups (U = 698.5, p < .001) with capability to discriminate those throwing with pain versus those throwing without pain (Area Under Curve (AUC) .891). Results indicate this discriminating threshold score to be at 68.6 points, which signifies anyone scoring above this threshold would be throwing with no pain and a score below this number indicating throwing with pain.ConclusionThe KJOC can differentiate between younger baseball athletes throwing with and without pain. The predictive threshold score can be used in a clinical setting to aid with determining if a youth or high school-aged athlete is suffering from pain while participating in overhead throwing, and to guide rehabilitation management.Level of EvidenceLevel III     

MICROINSTABILITY OF THE SHOULDER IN THE OVERHEAD ATHLETE

The overhead throwing athlete is an extremely challenging patient in sports medicine. The repetitive microtraumatic stresses and extreme ranges of motion observed within the athlete’s shoulder joint complex during the throwing motion constantly place the athlete at risk for injury. While gross instability of the shoulder is possible, microinstability is seen far more frequently and is associated with a variety of different pathologies, including rotator cuff tendonitis, internal impingement, and labral lesions. Treatment of the overhead athlete requires the understanding of several principles based on the unique physical characteristics of this type of athlete and the demands placed upon the static stabilizing structures during the act of throwing. The purpose of this paper is to describe these principles and incorporate them into in a multi‐phase progressive rehabilitation program designed to prevent injuries and rehabilitate the injured athlete, both non‐operatively and postoperatively.     

Can the Scapular Dyskinesis Test be Associated with Throwing Related Injuries During the Course of Collegiate Baseball Seasons?

BackgroundA pattern of scapular dyskinesis on the dominant side has been demonstrated to be associated with a decrease in throwing arm conditions identified by a self-report outcome assessment in collegiate baseball pitchers during the course of a single season. However, it is unclear if symptomatic shoulders in baseball pitchers may be associated with the presence of scapular dyskinesis.PurposeTo study the relationship between the presence of scapular dyskinesis and throwing-related injury in collegiate baseball pitchers during each respective course of up to four subsequent seasons.MethodsA single Division 1 National Collegiate Athletic Association team participated in this study over a four-year-period. The scapular dyskinesis test was implemented during the preseason for baseball pitchers. Players were followed throughout each respective season to track the incidence of throwing-related upper extremity injuries.ResultsA total of 36 collegiate baseball pitchers (height: 185.3 ± 5.6 cm, weight: 88.8 ± 7.8 kg, age: 20.0 ± 1.5 years) consisting of 57 pitcher seasons were followed in this study, in which 18 pitchers remained with the team for more than one year. Twenty-seven of the 57 pitchers were classified as having scapular dyskinesis demonstrated at around 90° of shoulder flexion on the throwing side. Five injuries (13.2% of a total of 38 injuries) were diagnosed as throwing-related shoulder injuries during the course of the intercollegiate baseball seasons. Four of the five throwing-related shoulder injuries occurred in pitchers who had scapular dyskinesis on their dominant side. Consequently, the odds ratio was 5.04 for the collegiate pitchers with scapular dyskinesis on the throwing arm side associated with a throwing-related shoulder injury compared to those with no scapular dyskinesis (p = 0.16). No relationship was identified between scapular dyskinesis on the throwing arm side and throwing-related elbow injury. Eighty-one percent of the scapular dyskinesis test results were not changed on the throwing side from the previous to the following year for those 18 pitchers who were followed for more than one season, whereas 42.9% of the results remained unchanged on the non-throwing side.ConclusionThe results suggest that collegiate baseball pitchers with dominant arm scapular dyskinesis likely are at increased risk of throwing-related shoulder injury.Level of evidenceLevel 2, Prospective Cohort Study     

INTEGRATION OF STRENGTH AND CONDITIONING PRINCIPLES INTO A REHABILITATION PROGRAM

Background and Purpose:

Rehabilitation and strength and conditioning are often seen as two separate entities in athletic injury recovery. Traditionally an athlete progresses from the rehabilitation environment under the care of a physical therapist and/or athletic trainer to the strength and conditioning coach for specific return to sport training. These two facets of return to sport are often considered to have separate goals. Initial goals of each are often different due to the timing of their implementation encompassing different stages of post-injury recovery. The initial focus of post injury rehabilitation includes alleviation of dysfunction, enhancement of tissue healing, and provision of a systematic progression of range-of-motion and strength. During the return to function phases, specific return to play goals are paramount. Understanding of specific principles and program parameters is necessary when designing and implementing an athlete''s rehabilitation program. Communication and collaboration amongst all individuals caring for the athlete is a must. The purpose of this review is to outline the current evidence supporting utilization of training principles in athletic rehabilitation, as well as provide suggested implementation of such principles throughout different phases of a proposed rehabilitation program.

Evidence Acquisition:

The following electronic databases were used to identify research relevant to this clinical commentary: MEDLINE (from 1950–June 2011) and CINAHL (1982–June 2011), for all relevant journal articles written in English. Additional references were accrued by independent searching of references from relevant articles.

Results:

Currently evidence is lacking in the integration of strength and conditioning principles into the rehabilitation program for the injured athlete. Numerous methods are suggested for possible utilization by the clinician in practice to improve strength, power, speed, endurance, and metabolic capacity.

Conclusion:

Despite abundance of information on the implementation of training principles in the strength and conditioning field, investigation regarding the use of these principles in a properly designed rehabilitation program is lacking.     

Professional Baseball Player Type and Geographic Region of Origin Impacts Shoulder External and Internal Rotation Strength

BackgroundShoulder strength deficits are implicated in arm injuries and performance deficits in baseball players.PurposeTo characterize shoulder external (ER) and internal (IR) rotation strength in professional baseball players, and compare strength across player type (pitchers, position players) and geographic origin (North America, Latin America).Study DesignCross-sectional.MethodsMinor league professional baseball players from North America and Latin America (n=242; age=22.4±2.3 years; n=135 pitchers and n=107 position players; n=162 North American and n=80 Latin American players) volunteered at spring training. Bilateral shoulder IR and ER isometric strength was measured in sitting with the arm at the side using a handheld dynamometer stabilized on a wall via a specialized jig. Strength was normalized to body weight, and compared using t-tests between player type and geographic area of origin (p < 0.05).ResultsPosition players had greater strength in ER, IR and ER:IR (ER:0.7-2.7N/kg; IR:1.3-3.8N/kg; ER:IR ratio 0.36-1.22) compared to pitchers (ER:0.5-2.5N/kg; IR:0.6- 4.2N/kg; ER:IR ratio 0.44-1.16) on the throwing arm. North American pitchers had lower ER [MD= -0.4 (95%CI:-0.7,-0.2);p=0.002] and IR [MD= -0.2 (95%CI:-0.4,-0.1);p=0.006] than Latin American pitchers on the throwing arm. There were no differences between geographic groups for position players.Discussion/ConclusionsPlayer position and geographic origin influence shoulder rotational strength values in professional baseball players. Position players have 14 – 20% higher ER and IR isometric strength than pitchers. Moreover, Latin American pitchers exhibited 11.8% greater ER strength and 16.7% greater IR strength as compared to North American pitchers. Normative values can be used to determine player deficits, declines in performance, and targets for return to play after injury.Level of EvidenceLevel II     

Youth Baseball Caregiver Understanding of Safe Pitching Guidelines and Player Injury

BackgroundAs more athletes participate in youth baseball, there has been an associated increase in upper extremity injuries. Knowledge of baseball injury prevention guidelines continues to be developed and defined as throwing-related injuries rise. The purpose of this study was to evaluate how knowledgeable youth baseball caregivers were about safe pitching guidelines and secondarily determine pitching practices which may be associated with increased risk of player injury.MethodsA twenty-two question survey comprised of demographic data, knowledge of overhead throwing guidelines, pitching history, presence of risk factors associated with overhead throwing and pitching habits was distributed to the caregivers of youth baseball pitchers in North Central Florida.ResultsEighty-three percent (81/98) of those polled were unaware of the existence of safe pitching guidelines, regardless of the pitcher’s playing experience (p > 0.05). Those who pitched more than six months out of the year were significantly more prone to experience throwing arm pain after a performance (p < 0.05). Fifty-two percent (51/98) of the caregivers recalled their child having throwing arm pain as a direct result of pitching, with twenty-six percent (25/98) of pitchers having to miss either a game or a pitching appearance. Twenty-seven percent (26/98) of all players went on to seek medical evaluation for arm discomfort due to pitching. Pitchers 13 years of age and older were more likely to throw curveballs and miss games because of throwing arm pain (p < 0.05).ConclusionDespite implementation and accessibility of safe pitching guidelines, a large portion of those surveyed were unaware or noncompliant with these established recommendations. Given the results of this study, further measures need to be taken to improve caregivers’ understanding of current guidelines to help increase compliance and protect youth pitchers.Level of EvidenceCross-sectional survey study, 3b     

Return to Throwing after Shoulder or Elbow Injury

Purpose of review

Throwing places high demands on the human body, and specific characteristics are developed over time unique to these athletes. When returning to throw after injury, it is important to follow a criterion-based progression that allows the body to be prepared appropriately for the stresses that throwing will require. There is currently a void in the literature for criteria-based progression that helps these athletes return to the highest level of play.

Recent findings

As injury rates continue to rise in baseball, there is increased evidence showing contributions of the core and lower extremity to the baseball pitch. There is also additional data showing pitcher specific characteristics such as range of motion and scapular position in this unique population. The rehab professional should take into account every phase of the pitch starting from balance through ball release when designing a comprehensive return-to-throwing program.

Summary

Returning an athlete back to a throwing sport can be an overwhelming task. The rehabilitation specialist must have a sound understanding of the throwing motion as well as any biomechanical implications on the body, contributions throughout the kinetic chain, range of motion, and strength characteristics specific to the thrower as well as proper tissue loading principles. It is important that these athletes are not progressed too quickly through their programs and that a criteria-based progression is followed. They should have normalized range of motion, strength, and scapular mechanics, followed by a sound plyometric progression. Once this is achieved, they are advanced to an interval throwing program with increasing distance, effort, and volume which should be tracked for workload, making sure they do not throw more than their body is prepared for.

     

Stride Length and Torso Biomechanics As They Relate To Medial Elbow Injuries In Adolescent Aged Baseball pitchers: A Clinical Commentary

There is a limited amount of literature examining torso biomechanics and stride length while addressing their relationship to medial elbow injuries in the adolescent baseball pitcher. Anatomical changes, growth, early sport specialization, multiple team participation, mound distance, mound height, and high pitch counts place adolescent pitchers at an exceptionally higher risk for medial elbow injuries. Existing evidence indicates that decreased stride length and altered trunk rotation is correlated with increased medial elbow loading for the adolescent overhead athlete. Further research is required to quantify adequate parameters for torso kinematics, control, and their correlation to stride length, in order to positively affect the biomechanical transfer of energy and potentially prevent injuries during the overhead throwing motion. The purpose of this clinical commentary is to examine and summarize the role of torso biomechanics and stride length in relation to medial elbow injuries in adolescent baseball pitchers.Level of Evidence5     

Throwing Injury Prevention Strategies with a Whole Kinetic Chain-Focused Approach

Purpose of ReviewThis review examines the relationship between the baseball pitching motion and the kinetic chain. The goal was to determine the underlying causes of a deficiency in throwing mechanics throughout a throwing motion, and to provide an evidence-based approach on how to prevent injuries caused by a lack of proper mechanics. In doing so, we sought to provide a warm-up strategy that can be added to every baseball player’s daily on-field routine that is tailored to each phase of the throwing motion.Recent FindingsTo help minimize the risk of injury to overhead throwing athletes, a thorough understanding of the throwing motion is critical. Throwing a ball places extreme stress on the body, notably the shoulder and elbow joints. With a clear understanding of the biomechanics of throwing, we can develop an injury prevention routine to minimize unnecessary stresses throughout the kinetic chain.SummaryThe throwing cycle is a complex motion that places various stresses throughout the thrower’s body, from the ankle to the core, and from the back to the shoulder and elbow. A thorough understanding of the mechanics of this motion, along with specific exercises to target the specific actions of each phase, may allow for throwers, regardless of their age and experience, to minimize injury risk.     

Athletic Shoulder Test Differences Exist Bilaterally in Healthy Pitchers

BackgroundThere is a lack of valid and reliable tests that assess upper extremity strength and function for rehabilitation and injury prevention purposes in throwing athletes. The Athletic Shoulder (ASH) test has been proposed as a reliable measure of shoulder strength, but has not yet been studied in baseball pitchers.Hypothesis/PurposeThe purpose of this study was to establish values for healthy baseball pitchers performing the ASH test, compare those values with other common tests of shoulder strength and function, and compare ASH test performance bilaterally. It was hypothesized that the dominant arm would perform significantly better on the ASH test compared to the non-dominant arm. A secondary purpose of the study was to evaluate if ASH test performance was related to fastball velocity in baseball pitchers. It was hypothesized that ASH test performance would positively correlate with fastball velocity.Study DesignCross-Sectional StudyMethodsCollege and high school baseball pitchers were recruited to complete shoulder range of motion (ROM), isokinetic shoulder strength, and isometric shoulder strength testing using the ASH test. The ASH test was used to assess force production as a proxy for strength bilaterally at four levels of shoulder abduction (0°, 90°, 135°, and 180°), using a force plate. Approximately one-week later subjects returned for a bullpen session where fastball velocity was recorded with a radar gun. Bilateral differences in passive ROM, isokinetic, and isometric shoulder strength were examined using paired t-tests while linear relationships between isometric shoulder strength and fastball velocity were assessed using Pearson correlations.ResultsThirty-five healthy pitchers participated in the study (19.7 ± 1.8 years). Pitchers demonstrated significantly greater isometric shoulder strength at the 90° and 135° abduction positions with the throwing arm compared to the non-throwing arm. Pitchers also demonstrated commonly observed musculoskeletal adaptations in the throwing arm such as increased passive external rotation, decreased passive internal rotation, and greater internal and external rotator strength during isokinetic testing. Peak force production during the ASH test was not related to fastball velocity.ConclusionThe ASH test is capable of detecting bilateral shoulder strength adaptations commonly observed in other clinical tests in healthy pitchers. Pitchers demonstrated greater isometric peak force during the ASH test at levels of shoulder abduction similar to those observed in pitching. While these results may be intriguing for clinical use, peak force from the ASH test was not correlated to fastball velocity in pitchers, and therefore should be used with caution for predictions in this realm.Level of Evidence2Clinical RelevanceA need exists for objective measures of shoulder strength for rehabilitation and injury risk monitoring in throwing athletes that are easy to administer, have high reliability and validity, and provide minimal re-injury risk to athletes recovering from injury.What is known about the subjectData from the ASH test has been published previously in non-throwing athletes and was shown to be valid and reliable in that group. However, the test has not been explored widely in throwing athletes who are known to have significant musculoskeletal adaptations to the throwing shoulder.What this study adds to existing knowledgeThe results from this study confirm that the ASH test is sensitive enough to detect the adaptations that are present in the healthy throwing athlete’s shoulder. Due to the prior proven validity and reliability and these results, the test can be used to monitor throwing arm strength and function during rehabilitation or as a pre/intra-season screening tool to help describe arm health.     

RETURN TO SPORT PARTICIPATION CRITERIA FOLLOWING SHOULDER INJURY: A CLINICAL COMMENTARY

Context:The shoulder complex is frequently injured during sports. The tremendous mobility of the shoulder makes returning to sport participation following shoulder injury a challenging task for both the clinician and athlete. The purpose of this clinical commentary is to review the current literature on return to sport criteria and provide evidence-informed and clinically useful guidelines and recommendations to aid in clinical decision making for return to sports after shoulder micro- and macro-traumatic injuries.Evidence Acquisition:A search of the PubMed database using the terms functional tests, upper extremity testing, return to play, and shoulder injury was performed. Further evaluation of the bibliographies of the identified articles expanded the evidence. This evidence was used to inform the clinical commentary.ResultsReturn to sport decision making is a sequential, criterion-based process. Assessment of patient reported outcomes, range of motion, strength, and functional performance must all be considered. Numerous tests are available for the clinician to determine whether a patient is ready to return to sports following a shoulder injury or surgery. A different set of tests should be utilized for the overhead athlete (microtrauma injury) compared to the patient with a macrotraumatic shoulder injury because of the differing demands and sports requirements.Conclusion:Use of pre-determined criteria, available in the literature, minimizes the reliance on the subjective element alone during takes athlete progression and provides everyone involved in the process with known, pre-established, measurable markers and goals that must be achieved prior to progressing to practice and returning to competition. This type of performance progression assessment testing provides the clinician with a useful set of tools to objectively assist and guide the determination regarding when an athlete can safely progress back to practice and then return to unrestricted athletic activitiesLevel of evidence:5     

CURRENT CONCEPTS OF MUSCLE AND TENDON ADAPTATION TO STRENGTH AND CONDITIONING

Injuries to the muscle and/or associated tendon(s) are common clinical entities treated by sports physical therapists and other rehabilitation professionals. Therapeutic exercise is a primary treatment modality for muscle and/or tendon injuries; however, the therapeutic exercise strategies should not be applied in a “one‐size‐fits‐all approach”. To optimize an athlete''s rehabilitation or performance, one must be able to construct resistance training programs accounting for the type of injury, the stage of healing, the functional and architectural requirements for the muscle and tendon, and the long‐term goals for that patient. The purpose of this clinical commentary is to review the muscular and tendinous adaptations associated with strength training, link training adaptations and resistance training principles for the athlete recovering from an injury, and illustrate the application of evidence‐based resistance training for patients with a tendinopathy.

Level of Evidence

5