1

Managing Overuse Injuries in the

Overhead Athlete Strategies for

Rehab and Injury Prevention

Brian Schiff PT OCS CSCS

Provider Disclaimer

bull Allied Health Education and the presenter of this

webinar do not have any financial or other

associations with the manufacturers of any products or

suppliers of commercial services that may be

discussed or displayed in this presentation

bull There was no commercial support for this

presentation

bull The views expressed in this presentation are the views

and opinions of the presenter

bull Participants must use discretion when using the

information contained in this presentation

Background

bull Supervisor - EXOS Raleigh Orthopaedic

bull Practiced since 1996 in outpatient sportsortho

clinics

bull S amp C coach for MLS - Columbus Crew 2002-2006

bull Owned my own training facility 2000-2010

bull FMS certified board certified orthopaedic clinical

specialist (OCS) credentialed in dry needling

bull Write for PFP Magazine

bull PT consultant for Carolina Hurricanes

2

wwwapcraleighcom

Objectivesbull Recognize and assess common injuries in the overhead

athlete

bull Design evidence-based rehab programs and implement

corrective and preventive exercise strategies to reduce

overuse injuries

bull Understand how to use screening and assessment tools

to detect asymmetry

bull Summarize current research on throwing mechanics and

the management of related overuse injuries

bull Learn how to integrate rehab and performance training for

optimal health and future injury prevention

2

wwwapcraleighcom

Objectivesbull Recognize and assess common injuries in the overhead

athlete

bull Design evidence-based rehab programs and implement

corrective and preventive exercise strategies to reduce

overuse injuries

bull Understand how to use screening and assessment tools

to detect asymmetry

bull Summarize current research on throwing mechanics and

the management of related overuse injuries

bull Learn how to integrate rehab and performance training for

optimal health and future injury prevention

3

Common Injuries

bull Rotator cuff tendinopathy

bull Labral tears

bull Instability

bull Bicipital tendinopathy

bull UCL sprain amp valgus extension overload

bull MedialLateral elbow pain

bull Little League shoulderelbow

Growth Plate Injuries

Type II SLAP

Anterior Posterior Ant to Post

Morgan amp Burkhart Arthroscopy 2003

4

Type II SLAPbull Involves disruption of

the proximal biceps

anchor

bull First reported by

Andrews and seen in

overhead athletes

(ldquopeel backrdquo injury)

bull Late cocking (max

ABD amp HER) is an at-

risk position

Youth Baseball bull Olsen et al revealed that

averaging more than 80 pitches

per game nearly quadrupled injury risk and pitching more than 8 months out of the year

raised it fivefold

bull Olsenrsquos study concluded pitching with a fatigued arm

increased chances of having surgery 36x

bull Fleisig et al showed that

pitching more than 100 competition innings per year more than tripled to risk for

serious shoulder or elbow injury In addition playing catcher as well as pitcher increased the

odds ratio of injury 27 times

Fleisig et al Sports Health 2012

Youth Baseballbull Biomechanics - improper form leads to increased

varus elbow torque Common flaws include hand

under ball during stride phase late arm rotation

excessive external rotation excessive elbow flexion

and improper abduction and trunk tilt

bull Pitch type - concern about curveballs revolves around

the thought that the elbow must be placed in a

position of stress to create spin Dun et al studied 11-

14 yo who threw fastballs change-ups and curves

There was greater supination with a curve but more

varus torque with a fastball UNC and ASMI studies

found no correlation wcurves before age 13 and an

elbow injuryFleisig et al Sports Health 2012

5

bull 449 players wo prior elbow pain were observed

prospectively for 1 season to study injury incidence in

relation to specific risk factors

bull Average age was 101 years (range 7-11 years) One

year later all players were examined by administering a questionnaire physical examination and radiographic

examination

bull 30 of youth baseball players have elbow pain each year

and nearly 60 of players welbow pain exhibit

radiographic abnormalities

bull The age of 12 years pitcher and catcher positions and

playing more than 100 games per year are risk factors for

elbow painMatsuura et al AJSM 2013

bull 23 uninjured asymptomatic male high schoolndashaged

baseball pitchers (mean age 16 years) with no

history of elbow injury all had a minimum of 3 yearsrsquo

experience with pitching as their primary position

(mean experience = 6 years)

bull Bilateral elbow MRI exam performed

bull Thickening of the anterior band of the ulnar collateral

ligament and posteromedial subchondral sclerosis of

the trochlea are common findings in the high schoolndash

aged pitcher and may be considered normal clinical

findings in the absence of symptom complaints

Hurd et al AJSM 2011

bull 23 adolescent pitchers (age 157 plusmn 14 years) were tested

bull 12 pitchers had throwing-related pain in the prior season

and were currently symptom-free while the remaining 11

pitchers had no such history of pain

bull 23 pitchers had a loss of internal rotation ROM (13deg plusmn 10deg P

lt 001) and gain in external rotation ROM (11deg plusmn 10deg P lt 001) on the dominant versus non-dominant arm with no

effect on total ROM (2deg plusmn 7deg loss P = 14)

bull Throwing-related pain in this population may be due to the

inability of weakened posterior shoulder musculature to

tolerate stress imparted on it by adaptively strengthened propulsive muscles

Trakis et al AJSM 2008

6

Pitch Counts

bull Age PitchesGame

bull 7ndash8 = 50

bull 9ndash10 = 75

bull 11ndash12 = 85

bull 13ndash16 = 95

bull 17ndash18 = 105

Source Little League

Baseball

Rest Periods Required

14 amp under 15ndash16 Days of Rest

66+ 76+ 4 calendar days

51-65 61-75 3 calendar days

36-50 46-60 2 calendar days

21-35 31-45 1 calendar day

1-20 1-30 None

Source Little League Baseball

Pitch Smart

Resource

httpswwwmlbcompitch-smart

4

Type II SLAPbull Involves disruption of

the proximal biceps

anchor

bull First reported by

Andrews and seen in

overhead athletes

(ldquopeel backrdquo injury)

bull Late cocking (max

ABD amp HER) is an at-

risk position

Youth Baseball bull Olsen et al revealed that

averaging more than 80 pitches

per game nearly quadrupled injury risk and pitching more than 8 months out of the year

raised it fivefold

bull Olsenrsquos study concluded pitching with a fatigued arm

increased chances of having surgery 36x

bull Fleisig et al showed that

pitching more than 100 competition innings per year more than tripled to risk for

serious shoulder or elbow injury In addition playing catcher as well as pitcher increased the

odds ratio of injury 27 times

Fleisig et al Sports Health 2012

Youth Baseballbull Biomechanics - improper form leads to increased

varus elbow torque Common flaws include hand

under ball during stride phase late arm rotation

excessive external rotation excessive elbow flexion

and improper abduction and trunk tilt

bull Pitch type - concern about curveballs revolves around

the thought that the elbow must be placed in a

position of stress to create spin Dun et al studied 11-

14 yo who threw fastballs change-ups and curves

There was greater supination with a curve but more

varus torque with a fastball UNC and ASMI studies

found no correlation wcurves before age 13 and an

elbow injuryFleisig et al Sports Health 2012

5

bull 449 players wo prior elbow pain were observed

prospectively for 1 season to study injury incidence in

relation to specific risk factors

bull Average age was 101 years (range 7-11 years) One

year later all players were examined by administering a questionnaire physical examination and radiographic

examination

bull 30 of youth baseball players have elbow pain each year

and nearly 60 of players welbow pain exhibit

radiographic abnormalities

bull The age of 12 years pitcher and catcher positions and

playing more than 100 games per year are risk factors for

elbow painMatsuura et al AJSM 2013

bull 23 uninjured asymptomatic male high schoolndashaged

baseball pitchers (mean age 16 years) with no

history of elbow injury all had a minimum of 3 yearsrsquo

experience with pitching as their primary position

(mean experience = 6 years)

bull Bilateral elbow MRI exam performed

bull Thickening of the anterior band of the ulnar collateral

ligament and posteromedial subchondral sclerosis of

the trochlea are common findings in the high schoolndash

aged pitcher and may be considered normal clinical

findings in the absence of symptom complaints

Hurd et al AJSM 2011

bull 23 adolescent pitchers (age 157 plusmn 14 years) were tested

bull 12 pitchers had throwing-related pain in the prior season

and were currently symptom-free while the remaining 11

pitchers had no such history of pain

bull 23 pitchers had a loss of internal rotation ROM (13deg plusmn 10deg P

lt 001) and gain in external rotation ROM (11deg plusmn 10deg P lt 001) on the dominant versus non-dominant arm with no

effect on total ROM (2deg plusmn 7deg loss P = 14)

bull Throwing-related pain in this population may be due to the

inability of weakened posterior shoulder musculature to

tolerate stress imparted on it by adaptively strengthened propulsive muscles

Trakis et al AJSM 2008

6

Pitch Counts

bull Age PitchesGame

bull 7ndash8 = 50

bull 9ndash10 = 75

bull 11ndash12 = 85

bull 13ndash16 = 95

bull 17ndash18 = 105

Source Little League

Baseball

Rest Periods Required

14 amp under 15ndash16 Days of Rest

66+ 76+ 4 calendar days

51-65 61-75 3 calendar days

36-50 46-60 2 calendar days

21-35 31-45 1 calendar day

1-20 1-30 None

Source Little League Baseball

Pitch Smart

Resource

httpswwwmlbcompitch-smart

5

bull 449 players wo prior elbow pain were observed

prospectively for 1 season to study injury incidence in

relation to specific risk factors

bull Average age was 101 years (range 7-11 years) One

year later all players were examined by administering a questionnaire physical examination and radiographic

examination

bull 30 of youth baseball players have elbow pain each year

and nearly 60 of players welbow pain exhibit

radiographic abnormalities

bull The age of 12 years pitcher and catcher positions and

playing more than 100 games per year are risk factors for

elbow painMatsuura et al AJSM 2013

bull 23 uninjured asymptomatic male high schoolndashaged

baseball pitchers (mean age 16 years) with no

history of elbow injury all had a minimum of 3 yearsrsquo

experience with pitching as their primary position

(mean experience = 6 years)

bull Bilateral elbow MRI exam performed

bull Thickening of the anterior band of the ulnar collateral

ligament and posteromedial subchondral sclerosis of

the trochlea are common findings in the high schoolndash

aged pitcher and may be considered normal clinical

findings in the absence of symptom complaints

Hurd et al AJSM 2011

bull 23 adolescent pitchers (age 157 plusmn 14 years) were tested

bull 12 pitchers had throwing-related pain in the prior season

and were currently symptom-free while the remaining 11

pitchers had no such history of pain

bull 23 pitchers had a loss of internal rotation ROM (13deg plusmn 10deg P

lt 001) and gain in external rotation ROM (11deg plusmn 10deg P lt 001) on the dominant versus non-dominant arm with no

effect on total ROM (2deg plusmn 7deg loss P = 14)

bull Throwing-related pain in this population may be due to the

inability of weakened posterior shoulder musculature to

tolerate stress imparted on it by adaptively strengthened propulsive muscles

Trakis et al AJSM 2008

6

Pitch Counts

bull Age PitchesGame

bull 7ndash8 = 50

bull 9ndash10 = 75

bull 11ndash12 = 85

bull 13ndash16 = 95

bull 17ndash18 = 105

Source Little League

Baseball

Rest Periods Required

14 amp under 15ndash16 Days of Rest

66+ 76+ 4 calendar days

51-65 61-75 3 calendar days

36-50 46-60 2 calendar days

21-35 31-45 1 calendar day

1-20 1-30 None

Source Little League Baseball

Pitch Smart

Resource

httpswwwmlbcompitch-smart

6

Pitch Counts

bull Age PitchesGame

bull 7ndash8 = 50

bull 9ndash10 = 75

bull 11ndash12 = 85

bull 13ndash16 = 95

bull 17ndash18 = 105

Source Little League

Baseball

Rest Periods Required

14 amp under 15ndash16 Days of Rest

66+ 76+ 4 calendar days

51-65 61-75 3 calendar days

36-50 46-60 2 calendar days

21-35 31-45 1 calendar day

1-20 1-30 None

Source Little League Baseball

Pitch Smart

Resource

httpswwwmlbcompitch-smart

7

Pitch Types amp

Recommended Age

bull Fastball 8 +- 2

bull Change up 10 +- 3

bull Slider 16 +- 2

bull Curveball 14 +- 2

bull Forkball 16 +- 2

bull Knuckleball 15 +- 3

bull Screwball 17 +- 2

Source Little League

Baseball

Weighted Ball Trainingbull 38 healthy baseball pitchers were randomized into a control

group and an experimental group

bull Pitch velocity shoulder and elbow PROM shoulder

strength elbow varus torque and shoulder internal rotation

velocity were measured in both groups

bull Experimental group performed a 6-week weighted ball

throwing program 3 times per week using balls ranging from

2 to 32 oz while the control group only used a 5 oz

regulation baseball

bull Statistically significant increase of 43deg of shoulder external rotation in the experimental group while overall injury rate

was 24 (4 elbow injuries) in the experimental group

Reinold et al Sports Health 2018

Instability

bull Acquired laxity gt anterior micro

instability

bull MDI

bull Secondary RC bicipital and labral

stress

bull Caution with loading (snatch jerks flies

pressing dips etc)

8

Rhythmic Stabilization

bull May be done in multiple planes and

functional positions

bull Encourages co-contraction joint

position sense and stability

bull Challenge the patient in OCK amp CKC

Rhythmic Stabilization

Video

PT Evaluation

bull Observe posture

bull APROM

bull MMT

bull Joint mobility

bull Palpation (TrPrsquos)

bull Special tests

9

The Scapulabull Resting alignment

bull Dynamic mechanics

bull SICK scapula

1 Inferior border

prominence

2 Medial border

prominence

3 Superior border

prominence

Scapular Positioning

bull The dominant-side scapula of overhead

athletes was more internally rotated and

anteriorly tilted than the non-dominant side

scapula

bull The dominant-side scapula of the tennis

players was more protracted than that on

the non-dominant side

bull Scapular posture asymmetry in unilateral

overhead athletes may be normal

Oyam et al J Athl Train 2008

Scapular Dyskinesia - MLB Pitcher

101818 111618

10

GIRD

Image from Manske et al Int J Sports Phsy Ther 2013

ERD and GIRDbull ERD (ext rot deficiency) - 5 deg or less

wPROM increases injury risk in throwers

23x (unpublished data)

bull Anatomical GIRD - normal loss of IR (18-

20 deg) with adequate ER gain and TROM

within 5 deg of the uninvolved side

bull Pathologic GIRD - A shoulder that has

GIRD more than 18-20 deg and a

concomitant loss of TROM gt 5 deg (= 25x

injury risk)Manske et al Int J Sports Phys Ther 2013

More on GIRDbull Burkhart reports that an acceptable level of

GIRD is defined as

bull 1) less than 20 deg loss of shoulder IR

comparing shoulders bilaterally or

bull 2) no greater than 10 loss of the total

rotation seen in the non-throwing

shoulder (Non dominant shoulder IR +

ER ROM) x 10)

bull 3) Ratio of GIRD to ERG needs to be 1

or lessManske et al Int J Sports Phys Ther 2013

11

GHJ PROM Deficits Increase

Risk of Elbow Injury in Prof

Baseball Playersbull Prospective study 2005 - 2012

bull 505 exams on 296 pitchers

bull Assess PROM for HER HIR amp shoulder

flexion for throwing amp non-throwing side

bull Bilateral differences greater than or

equal to 5 deg in total shoulder rotation

and flexion increase risk for elbow

injuries 26 and 28x respectivelyWilk et al AJSM 2014

Key Special Tests

bull Hawkins Neer impingement signs

bull OrsquoBrienrsquos pronated load Biceps Load

I amp II Speedrsquos for labrum

bull AC joint provocation

bull Sulcus sign Apprehension Jobe

relocation

bull UCL stress testing

OrsquoBrien Test Video

12

bull Sensitive OrsquoBrien Hawkins Speed

Neer Jobe

bull Specific None

bull ldquoThere is no single maneuver that can

accurately diagnosis SLAP lesionsrdquo

Pronated Load

Biceps Load 1 amp 2

13

Speedrsquos Test

Kinetic Assessment

bull Thoracic spine mobility

bull Core stability

bull Hip mobility

bull Hip stability

bull SL stance

bull Ankle mobility

bull Integrated movement (FMS)

FMS

14

FMS Shoulder

Mobility Video

FMS Trunk Stability

Push-up Video

Key Recovery Principles

bull Respect healing tissue

bull Progressive sequential amp functional

bull Embrace individual differences among

clients

bull Avoid loads to failure especially as they

ease back into training

bull Consistently assess and involve the

client with threshold training

15

Threshold Trainingbull Journal pain before during and after

activity

bull Mild soreness may be acceptable but

should not have pain with throwing

bull 24 hour rule = elevated soreness after a

workout or training session must return to

baseline level or less in 24 hours (or less)

bull Rehabtraining progression is based

100 on pain response

Balance Prevents

Overtraining

Stress

Recovery

Non-operative Rehabbull Resolve soft tissue

restrictions

bull Resolve unwanted

GIRD

bull Strengthen cuff and

scap stabilizers

bull Emphasize stability

bull Incorporate entire

kinetic chain

16

Rehab Approach

bull Visit 1 = HEP for cuffscapular PREs

STM and stretching

bull Manual techniques

bull Limit andor restrict throwing hitting and

OH training initially

bull Below shoulder height then scapular plane

and gradually move to overhead

bull Educate regarding pain and progression

Manual Therapy

bull GHJ mobilization

bull Dry Needling

bull IASTM

bull Stretching

Rehab Phases

1 Relative Rest Mobility amp Stabilization

2 Activation amp Strengthening

3 Integrated CKC Strengthening amp Power

4 Return to Play

17

Mobility Priorities

bull Pec majorminor

bull Lats

bull Posterior rotator cuffcapsule

bull Upper trap amp levator (TPDN amp IASTM)

9090 Arm Sweep

18

Shoulder Mobility

Exercises Video

Stretches

Posterior Shoulder

Stretchingbull Low load long duration

bull 30 seconds (8-10x)

bull Do not stretch into pain or impingement

bull Modified sleeper amp cross body stretch

can be used (roll posteriorly 20-30 deg)

bull Not encouraged prior to throwing or

prior to tennis match

Wilk et al JOSPT 2013

19

Scapular Activation

Scapular Activation

Video

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

8

Rhythmic Stabilization

bull May be done in multiple planes and

functional positions

bull Encourages co-contraction joint

position sense and stability

bull Challenge the patient in OCK amp CKC

Rhythmic Stabilization

Video

PT Evaluation

bull Observe posture

bull APROM

bull MMT

bull Joint mobility

bull Palpation (TrPrsquos)

bull Special tests

9

The Scapulabull Resting alignment

bull Dynamic mechanics

bull SICK scapula

1 Inferior border

prominence

2 Medial border

prominence

3 Superior border

prominence

Scapular Positioning

bull The dominant-side scapula of overhead

athletes was more internally rotated and

anteriorly tilted than the non-dominant side

scapula

bull The dominant-side scapula of the tennis

players was more protracted than that on

the non-dominant side

bull Scapular posture asymmetry in unilateral

overhead athletes may be normal

Oyam et al J Athl Train 2008

Scapular Dyskinesia - MLB Pitcher

101818 111618

10

GIRD

Image from Manske et al Int J Sports Phsy Ther 2013

ERD and GIRDbull ERD (ext rot deficiency) - 5 deg or less

wPROM increases injury risk in throwers

23x (unpublished data)

bull Anatomical GIRD - normal loss of IR (18-

20 deg) with adequate ER gain and TROM

within 5 deg of the uninvolved side

bull Pathologic GIRD - A shoulder that has

GIRD more than 18-20 deg and a

concomitant loss of TROM gt 5 deg (= 25x

injury risk)Manske et al Int J Sports Phys Ther 2013

More on GIRDbull Burkhart reports that an acceptable level of

GIRD is defined as

bull 1) less than 20 deg loss of shoulder IR

comparing shoulders bilaterally or

bull 2) no greater than 10 loss of the total

rotation seen in the non-throwing

shoulder (Non dominant shoulder IR +

ER ROM) x 10)

bull 3) Ratio of GIRD to ERG needs to be 1

or lessManske et al Int J Sports Phys Ther 2013

11

GHJ PROM Deficits Increase

Risk of Elbow Injury in Prof

Baseball Playersbull Prospective study 2005 - 2012

bull 505 exams on 296 pitchers

bull Assess PROM for HER HIR amp shoulder

flexion for throwing amp non-throwing side

bull Bilateral differences greater than or

equal to 5 deg in total shoulder rotation

and flexion increase risk for elbow

injuries 26 and 28x respectivelyWilk et al AJSM 2014

Key Special Tests

bull Hawkins Neer impingement signs

bull OrsquoBrienrsquos pronated load Biceps Load

I amp II Speedrsquos for labrum

bull AC joint provocation

bull Sulcus sign Apprehension Jobe

relocation

bull UCL stress testing

OrsquoBrien Test Video

12

bull Sensitive OrsquoBrien Hawkins Speed

Neer Jobe

bull Specific None

bull ldquoThere is no single maneuver that can

accurately diagnosis SLAP lesionsrdquo

Pronated Load

Biceps Load 1 amp 2

13

Speedrsquos Test

Kinetic Assessment

bull Thoracic spine mobility

bull Core stability

bull Hip mobility

bull Hip stability

bull SL stance

bull Ankle mobility

bull Integrated movement (FMS)

FMS

14

FMS Shoulder

Mobility Video

FMS Trunk Stability

Push-up Video

Key Recovery Principles

bull Respect healing tissue

bull Progressive sequential amp functional

bull Embrace individual differences among

clients

bull Avoid loads to failure especially as they

ease back into training

bull Consistently assess and involve the

client with threshold training

15

Threshold Trainingbull Journal pain before during and after

activity

bull Mild soreness may be acceptable but

should not have pain with throwing

bull 24 hour rule = elevated soreness after a

workout or training session must return to

baseline level or less in 24 hours (or less)

bull Rehabtraining progression is based

100 on pain response

Balance Prevents

Overtraining

Stress

Recovery

Non-operative Rehabbull Resolve soft tissue

restrictions

bull Resolve unwanted

GIRD

bull Strengthen cuff and

scap stabilizers

bull Emphasize stability

bull Incorporate entire

kinetic chain

16

Rehab Approach

bull Visit 1 = HEP for cuffscapular PREs

STM and stretching

bull Manual techniques

bull Limit andor restrict throwing hitting and

OH training initially

bull Below shoulder height then scapular plane

and gradually move to overhead

bull Educate regarding pain and progression

Manual Therapy

bull GHJ mobilization

bull Dry Needling

bull IASTM

bull Stretching

Rehab Phases

1 Relative Rest Mobility amp Stabilization

2 Activation amp Strengthening

3 Integrated CKC Strengthening amp Power

4 Return to Play

17

Mobility Priorities

bull Pec majorminor

bull Lats

bull Posterior rotator cuffcapsule

bull Upper trap amp levator (TPDN amp IASTM)

9090 Arm Sweep

18

Shoulder Mobility

Exercises Video

Stretches

Posterior Shoulder

Stretchingbull Low load long duration

bull 30 seconds (8-10x)

bull Do not stretch into pain or impingement

bull Modified sleeper amp cross body stretch

can be used (roll posteriorly 20-30 deg)

bull Not encouraged prior to throwing or

prior to tennis match

Wilk et al JOSPT 2013

19

Scapular Activation

Scapular Activation

Video

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

9

The Scapulabull Resting alignment

bull Dynamic mechanics

bull SICK scapula

1 Inferior border

prominence

2 Medial border

prominence

3 Superior border

prominence

Scapular Positioning

bull The dominant-side scapula of overhead

athletes was more internally rotated and

anteriorly tilted than the non-dominant side

scapula

bull The dominant-side scapula of the tennis

players was more protracted than that on

the non-dominant side

bull Scapular posture asymmetry in unilateral

overhead athletes may be normal

Oyam et al J Athl Train 2008

Scapular Dyskinesia - MLB Pitcher

101818 111618

10

GIRD

Image from Manske et al Int J Sports Phsy Ther 2013

ERD and GIRDbull ERD (ext rot deficiency) - 5 deg or less

wPROM increases injury risk in throwers

23x (unpublished data)

bull Anatomical GIRD - normal loss of IR (18-

20 deg) with adequate ER gain and TROM

within 5 deg of the uninvolved side

bull Pathologic GIRD - A shoulder that has

GIRD more than 18-20 deg and a

concomitant loss of TROM gt 5 deg (= 25x

injury risk)Manske et al Int J Sports Phys Ther 2013

More on GIRDbull Burkhart reports that an acceptable level of

GIRD is defined as

bull 1) less than 20 deg loss of shoulder IR

comparing shoulders bilaterally or

bull 2) no greater than 10 loss of the total

rotation seen in the non-throwing

shoulder (Non dominant shoulder IR +

ER ROM) x 10)

bull 3) Ratio of GIRD to ERG needs to be 1

or lessManske et al Int J Sports Phys Ther 2013

11

GHJ PROM Deficits Increase

Risk of Elbow Injury in Prof

Baseball Playersbull Prospective study 2005 - 2012

bull 505 exams on 296 pitchers

bull Assess PROM for HER HIR amp shoulder

flexion for throwing amp non-throwing side

bull Bilateral differences greater than or

equal to 5 deg in total shoulder rotation

and flexion increase risk for elbow

injuries 26 and 28x respectivelyWilk et al AJSM 2014

Key Special Tests

bull Hawkins Neer impingement signs

bull OrsquoBrienrsquos pronated load Biceps Load

I amp II Speedrsquos for labrum

bull AC joint provocation

bull Sulcus sign Apprehension Jobe

relocation

bull UCL stress testing

OrsquoBrien Test Video

12

bull Sensitive OrsquoBrien Hawkins Speed

Neer Jobe

bull Specific None

bull ldquoThere is no single maneuver that can

accurately diagnosis SLAP lesionsrdquo

Pronated Load

Biceps Load 1 amp 2

13

Speedrsquos Test

Kinetic Assessment

bull Thoracic spine mobility

bull Core stability

bull Hip mobility

bull Hip stability

bull SL stance

bull Ankle mobility

bull Integrated movement (FMS)

FMS

14

FMS Shoulder

Mobility Video

FMS Trunk Stability

Push-up Video

Key Recovery Principles

bull Respect healing tissue

bull Progressive sequential amp functional

bull Embrace individual differences among

clients

bull Avoid loads to failure especially as they

ease back into training

bull Consistently assess and involve the

client with threshold training

15

Threshold Trainingbull Journal pain before during and after

activity

bull Mild soreness may be acceptable but

should not have pain with throwing

bull 24 hour rule = elevated soreness after a

workout or training session must return to

baseline level or less in 24 hours (or less)

bull Rehabtraining progression is based

100 on pain response

Balance Prevents

Overtraining

Stress

Recovery

Non-operative Rehabbull Resolve soft tissue

restrictions

bull Resolve unwanted

GIRD

bull Strengthen cuff and

scap stabilizers

bull Emphasize stability

bull Incorporate entire

kinetic chain

16

Rehab Approach

bull Visit 1 = HEP for cuffscapular PREs

STM and stretching

bull Manual techniques

bull Limit andor restrict throwing hitting and

OH training initially

bull Below shoulder height then scapular plane

and gradually move to overhead

bull Educate regarding pain and progression

Manual Therapy

bull GHJ mobilization

bull Dry Needling

bull IASTM

bull Stretching

Rehab Phases

1 Relative Rest Mobility amp Stabilization

2 Activation amp Strengthening

3 Integrated CKC Strengthening amp Power

4 Return to Play

17

Mobility Priorities

bull Pec majorminor

bull Lats

bull Posterior rotator cuffcapsule

bull Upper trap amp levator (TPDN amp IASTM)

9090 Arm Sweep

18

Shoulder Mobility

Exercises Video

Stretches

Posterior Shoulder

Stretchingbull Low load long duration

bull 30 seconds (8-10x)

bull Do not stretch into pain or impingement

bull Modified sleeper amp cross body stretch

can be used (roll posteriorly 20-30 deg)

bull Not encouraged prior to throwing or

prior to tennis match

Wilk et al JOSPT 2013

19

Scapular Activation

Scapular Activation

Video

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

10

GIRD

Image from Manske et al Int J Sports Phsy Ther 2013

ERD and GIRDbull ERD (ext rot deficiency) - 5 deg or less

wPROM increases injury risk in throwers

23x (unpublished data)

bull Anatomical GIRD - normal loss of IR (18-

20 deg) with adequate ER gain and TROM

within 5 deg of the uninvolved side

bull Pathologic GIRD - A shoulder that has

GIRD more than 18-20 deg and a

concomitant loss of TROM gt 5 deg (= 25x

injury risk)Manske et al Int J Sports Phys Ther 2013

More on GIRDbull Burkhart reports that an acceptable level of

GIRD is defined as

bull 1) less than 20 deg loss of shoulder IR

comparing shoulders bilaterally or

bull 2) no greater than 10 loss of the total

rotation seen in the non-throwing

shoulder (Non dominant shoulder IR +

ER ROM) x 10)

bull 3) Ratio of GIRD to ERG needs to be 1

or lessManske et al Int J Sports Phys Ther 2013

11

GHJ PROM Deficits Increase

Risk of Elbow Injury in Prof

Baseball Playersbull Prospective study 2005 - 2012

bull 505 exams on 296 pitchers

bull Assess PROM for HER HIR amp shoulder

flexion for throwing amp non-throwing side

bull Bilateral differences greater than or

equal to 5 deg in total shoulder rotation

and flexion increase risk for elbow

injuries 26 and 28x respectivelyWilk et al AJSM 2014

Key Special Tests

bull Hawkins Neer impingement signs

bull OrsquoBrienrsquos pronated load Biceps Load

I amp II Speedrsquos for labrum

bull AC joint provocation

bull Sulcus sign Apprehension Jobe

relocation

bull UCL stress testing

OrsquoBrien Test Video

12

bull Sensitive OrsquoBrien Hawkins Speed

Neer Jobe

bull Specific None

bull ldquoThere is no single maneuver that can

accurately diagnosis SLAP lesionsrdquo

Pronated Load

Biceps Load 1 amp 2

13

Speedrsquos Test

Kinetic Assessment

bull Thoracic spine mobility

bull Core stability

bull Hip mobility

bull Hip stability

bull SL stance

bull Ankle mobility

bull Integrated movement (FMS)

FMS

14

FMS Shoulder

Mobility Video

FMS Trunk Stability

Push-up Video

Key Recovery Principles

bull Respect healing tissue

bull Progressive sequential amp functional

bull Embrace individual differences among

clients

bull Avoid loads to failure especially as they

ease back into training

bull Consistently assess and involve the

client with threshold training

15

Threshold Trainingbull Journal pain before during and after

activity

bull Mild soreness may be acceptable but

should not have pain with throwing

bull 24 hour rule = elevated soreness after a

workout or training session must return to

baseline level or less in 24 hours (or less)

bull Rehabtraining progression is based

100 on pain response

Balance Prevents

Overtraining

Stress

Recovery

Non-operative Rehabbull Resolve soft tissue

restrictions

bull Resolve unwanted

GIRD

bull Strengthen cuff and

scap stabilizers

bull Emphasize stability

bull Incorporate entire

kinetic chain

16

Rehab Approach

bull Visit 1 = HEP for cuffscapular PREs

STM and stretching

bull Manual techniques

bull Limit andor restrict throwing hitting and

OH training initially

bull Below shoulder height then scapular plane

and gradually move to overhead

bull Educate regarding pain and progression

Manual Therapy

bull GHJ mobilization

bull Dry Needling

bull IASTM

bull Stretching

Rehab Phases

1 Relative Rest Mobility amp Stabilization

2 Activation amp Strengthening

3 Integrated CKC Strengthening amp Power

4 Return to Play

17

Mobility Priorities

bull Pec majorminor

bull Lats

bull Posterior rotator cuffcapsule

bull Upper trap amp levator (TPDN amp IASTM)

9090 Arm Sweep

18

Shoulder Mobility

Exercises Video

Stretches

Posterior Shoulder

Stretchingbull Low load long duration

bull 30 seconds (8-10x)

bull Do not stretch into pain or impingement

bull Modified sleeper amp cross body stretch

can be used (roll posteriorly 20-30 deg)

bull Not encouraged prior to throwing or

prior to tennis match

Wilk et al JOSPT 2013

19

Scapular Activation

Scapular Activation

Video

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

11

GHJ PROM Deficits Increase

Risk of Elbow Injury in Prof

Baseball Playersbull Prospective study 2005 - 2012

bull 505 exams on 296 pitchers

bull Assess PROM for HER HIR amp shoulder

flexion for throwing amp non-throwing side

bull Bilateral differences greater than or

equal to 5 deg in total shoulder rotation

and flexion increase risk for elbow

injuries 26 and 28x respectivelyWilk et al AJSM 2014

Key Special Tests

bull Hawkins Neer impingement signs

bull OrsquoBrienrsquos pronated load Biceps Load

I amp II Speedrsquos for labrum

bull AC joint provocation

bull Sulcus sign Apprehension Jobe

relocation

bull UCL stress testing

OrsquoBrien Test Video

12

bull Sensitive OrsquoBrien Hawkins Speed

Neer Jobe

bull Specific None

bull ldquoThere is no single maneuver that can

accurately diagnosis SLAP lesionsrdquo

Pronated Load

Biceps Load 1 amp 2

13

Speedrsquos Test

Kinetic Assessment

bull Thoracic spine mobility

bull Core stability

bull Hip mobility

bull Hip stability

bull SL stance

bull Ankle mobility

bull Integrated movement (FMS)

FMS

14

FMS Shoulder

Mobility Video

FMS Trunk Stability

Push-up Video

Key Recovery Principles

bull Respect healing tissue

bull Progressive sequential amp functional

bull Embrace individual differences among

clients

bull Avoid loads to failure especially as they

ease back into training

bull Consistently assess and involve the

client with threshold training

15

Threshold Trainingbull Journal pain before during and after

activity

bull Mild soreness may be acceptable but

should not have pain with throwing

bull 24 hour rule = elevated soreness after a

workout or training session must return to

baseline level or less in 24 hours (or less)

bull Rehabtraining progression is based

100 on pain response

Balance Prevents

Overtraining

Stress

Recovery

Non-operative Rehabbull Resolve soft tissue

restrictions

bull Resolve unwanted

GIRD

bull Strengthen cuff and

scap stabilizers

bull Emphasize stability

bull Incorporate entire

kinetic chain

16

Rehab Approach

bull Visit 1 = HEP for cuffscapular PREs

STM and stretching

bull Manual techniques

bull Limit andor restrict throwing hitting and

OH training initially

bull Below shoulder height then scapular plane

and gradually move to overhead

bull Educate regarding pain and progression

Manual Therapy

bull GHJ mobilization

bull Dry Needling

bull IASTM

bull Stretching

Rehab Phases

1 Relative Rest Mobility amp Stabilization

2 Activation amp Strengthening

3 Integrated CKC Strengthening amp Power

4 Return to Play

17

Mobility Priorities

bull Pec majorminor

bull Lats

bull Posterior rotator cuffcapsule

bull Upper trap amp levator (TPDN amp IASTM)

9090 Arm Sweep

18

Shoulder Mobility

Exercises Video

Stretches

Posterior Shoulder

Stretchingbull Low load long duration

bull 30 seconds (8-10x)

bull Do not stretch into pain or impingement

bull Modified sleeper amp cross body stretch

can be used (roll posteriorly 20-30 deg)

bull Not encouraged prior to throwing or

prior to tennis match

Wilk et al JOSPT 2013

19

Scapular Activation

Scapular Activation

Video

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

12

bull Sensitive OrsquoBrien Hawkins Speed

Neer Jobe

bull Specific None

bull ldquoThere is no single maneuver that can

accurately diagnosis SLAP lesionsrdquo

Pronated Load

Biceps Load 1 amp 2

13

Speedrsquos Test

Kinetic Assessment

bull Thoracic spine mobility

bull Core stability

bull Hip mobility

bull Hip stability

bull SL stance

bull Ankle mobility

bull Integrated movement (FMS)

FMS

14

FMS Shoulder

Mobility Video

FMS Trunk Stability

Push-up Video

Key Recovery Principles

bull Respect healing tissue

bull Progressive sequential amp functional

bull Embrace individual differences among

clients

bull Avoid loads to failure especially as they

ease back into training

bull Consistently assess and involve the

client with threshold training

15

Threshold Trainingbull Journal pain before during and after

activity

bull Mild soreness may be acceptable but

should not have pain with throwing

bull 24 hour rule = elevated soreness after a

workout or training session must return to

baseline level or less in 24 hours (or less)

bull Rehabtraining progression is based

100 on pain response

Balance Prevents

Overtraining

Stress

Recovery

Non-operative Rehabbull Resolve soft tissue

restrictions

bull Resolve unwanted

GIRD

bull Strengthen cuff and

scap stabilizers

bull Emphasize stability

bull Incorporate entire

kinetic chain

16

Rehab Approach

bull Visit 1 = HEP for cuffscapular PREs

STM and stretching

bull Manual techniques

bull Limit andor restrict throwing hitting and

OH training initially

bull Below shoulder height then scapular plane

and gradually move to overhead

bull Educate regarding pain and progression

Manual Therapy

bull GHJ mobilization

bull Dry Needling

bull IASTM

bull Stretching

Rehab Phases

1 Relative Rest Mobility amp Stabilization

2 Activation amp Strengthening

3 Integrated CKC Strengthening amp Power

4 Return to Play

17

Mobility Priorities

bull Pec majorminor

bull Lats

bull Posterior rotator cuffcapsule

bull Upper trap amp levator (TPDN amp IASTM)

9090 Arm Sweep

18

Shoulder Mobility

Exercises Video

Stretches

Posterior Shoulder

Stretchingbull Low load long duration

bull 30 seconds (8-10x)

bull Do not stretch into pain or impingement

bull Modified sleeper amp cross body stretch

can be used (roll posteriorly 20-30 deg)

bull Not encouraged prior to throwing or

prior to tennis match

Wilk et al JOSPT 2013

19

Scapular Activation

Scapular Activation

Video

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

13

Speedrsquos Test

Kinetic Assessment

bull Thoracic spine mobility

bull Core stability

bull Hip mobility

bull Hip stability

bull SL stance

bull Ankle mobility

bull Integrated movement (FMS)

FMS

14

FMS Shoulder

Mobility Video

FMS Trunk Stability

Push-up Video

Key Recovery Principles

bull Respect healing tissue

bull Progressive sequential amp functional

bull Embrace individual differences among

clients

bull Avoid loads to failure especially as they

ease back into training

bull Consistently assess and involve the

client with threshold training

15

Threshold Trainingbull Journal pain before during and after

activity

bull Mild soreness may be acceptable but

should not have pain with throwing

bull 24 hour rule = elevated soreness after a

workout or training session must return to

baseline level or less in 24 hours (or less)

bull Rehabtraining progression is based

100 on pain response

Balance Prevents

Overtraining

Stress

Recovery

Non-operative Rehabbull Resolve soft tissue

restrictions

bull Resolve unwanted

GIRD

bull Strengthen cuff and

scap stabilizers

bull Emphasize stability

bull Incorporate entire

kinetic chain

16

Rehab Approach

bull Visit 1 = HEP for cuffscapular PREs

STM and stretching

bull Manual techniques

bull Limit andor restrict throwing hitting and

OH training initially

bull Below shoulder height then scapular plane

and gradually move to overhead

bull Educate regarding pain and progression

Manual Therapy

bull GHJ mobilization

bull Dry Needling

bull IASTM

bull Stretching

Rehab Phases

1 Relative Rest Mobility amp Stabilization

2 Activation amp Strengthening

3 Integrated CKC Strengthening amp Power

4 Return to Play

17

Mobility Priorities

bull Pec majorminor

bull Lats

bull Posterior rotator cuffcapsule

bull Upper trap amp levator (TPDN amp IASTM)

9090 Arm Sweep

18

Shoulder Mobility

Exercises Video

Stretches

Posterior Shoulder

Stretchingbull Low load long duration

bull 30 seconds (8-10x)

bull Do not stretch into pain or impingement

bull Modified sleeper amp cross body stretch

can be used (roll posteriorly 20-30 deg)

bull Not encouraged prior to throwing or

prior to tennis match

Wilk et al JOSPT 2013

19

Scapular Activation

Scapular Activation

Video

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

14

FMS Shoulder

Mobility Video

FMS Trunk Stability

Push-up Video

Key Recovery Principles

bull Respect healing tissue

bull Progressive sequential amp functional

bull Embrace individual differences among

clients

bull Avoid loads to failure especially as they

ease back into training

bull Consistently assess and involve the

client with threshold training

15

Threshold Trainingbull Journal pain before during and after

activity

bull Mild soreness may be acceptable but

should not have pain with throwing

bull 24 hour rule = elevated soreness after a

workout or training session must return to

baseline level or less in 24 hours (or less)

bull Rehabtraining progression is based

100 on pain response

Balance Prevents

Overtraining

Stress

Recovery

Non-operative Rehabbull Resolve soft tissue

restrictions

bull Resolve unwanted

GIRD

bull Strengthen cuff and

scap stabilizers

bull Emphasize stability

bull Incorporate entire

kinetic chain

16

Rehab Approach

bull Visit 1 = HEP for cuffscapular PREs

STM and stretching

bull Manual techniques

bull Limit andor restrict throwing hitting and

OH training initially

bull Below shoulder height then scapular plane

and gradually move to overhead

bull Educate regarding pain and progression

Manual Therapy

bull GHJ mobilization

bull Dry Needling

bull IASTM

bull Stretching

Rehab Phases

1 Relative Rest Mobility amp Stabilization

2 Activation amp Strengthening

3 Integrated CKC Strengthening amp Power

4 Return to Play

17

Mobility Priorities

bull Pec majorminor

bull Lats

bull Posterior rotator cuffcapsule

bull Upper trap amp levator (TPDN amp IASTM)

9090 Arm Sweep

18

Shoulder Mobility

Exercises Video

Stretches

Posterior Shoulder

Stretchingbull Low load long duration

bull 30 seconds (8-10x)

bull Do not stretch into pain or impingement

bull Modified sleeper amp cross body stretch

can be used (roll posteriorly 20-30 deg)

bull Not encouraged prior to throwing or

prior to tennis match

Wilk et al JOSPT 2013

19

Scapular Activation

Scapular Activation

Video

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

15

Threshold Trainingbull Journal pain before during and after

activity

bull Mild soreness may be acceptable but

should not have pain with throwing

bull 24 hour rule = elevated soreness after a

workout or training session must return to

baseline level or less in 24 hours (or less)

bull Rehabtraining progression is based

100 on pain response

Balance Prevents

Overtraining

Stress

Recovery

Non-operative Rehabbull Resolve soft tissue

restrictions

bull Resolve unwanted

GIRD

bull Strengthen cuff and

scap stabilizers

bull Emphasize stability

bull Incorporate entire

kinetic chain

16

Rehab Approach

bull Visit 1 = HEP for cuffscapular PREs

STM and stretching

bull Manual techniques

bull Limit andor restrict throwing hitting and

OH training initially

bull Below shoulder height then scapular plane

and gradually move to overhead

bull Educate regarding pain and progression

Manual Therapy

bull GHJ mobilization

bull Dry Needling

bull IASTM

bull Stretching

Rehab Phases

1 Relative Rest Mobility amp Stabilization

2 Activation amp Strengthening

3 Integrated CKC Strengthening amp Power

4 Return to Play

17

Mobility Priorities

bull Pec majorminor

bull Lats

bull Posterior rotator cuffcapsule

bull Upper trap amp levator (TPDN amp IASTM)

9090 Arm Sweep

18

Shoulder Mobility

Exercises Video

Stretches

Posterior Shoulder

Stretchingbull Low load long duration

bull 30 seconds (8-10x)

bull Do not stretch into pain or impingement

bull Modified sleeper amp cross body stretch

can be used (roll posteriorly 20-30 deg)

bull Not encouraged prior to throwing or

prior to tennis match

Wilk et al JOSPT 2013

19

Scapular Activation

Scapular Activation

Video

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

16

Rehab Approach

bull Visit 1 = HEP for cuffscapular PREs

STM and stretching

bull Manual techniques

bull Limit andor restrict throwing hitting and

OH training initially

bull Below shoulder height then scapular plane

and gradually move to overhead

bull Educate regarding pain and progression

Manual Therapy

bull GHJ mobilization

bull Dry Needling

bull IASTM

bull Stretching

Rehab Phases

1 Relative Rest Mobility amp Stabilization

2 Activation amp Strengthening

3 Integrated CKC Strengthening amp Power

4 Return to Play

17

Mobility Priorities

bull Pec majorminor

bull Lats

bull Posterior rotator cuffcapsule

bull Upper trap amp levator (TPDN amp IASTM)

9090 Arm Sweep

18

Shoulder Mobility

Exercises Video

Stretches

Posterior Shoulder

Stretchingbull Low load long duration

bull 30 seconds (8-10x)

bull Do not stretch into pain or impingement

bull Modified sleeper amp cross body stretch

can be used (roll posteriorly 20-30 deg)

bull Not encouraged prior to throwing or

prior to tennis match

Wilk et al JOSPT 2013

19

Scapular Activation

Scapular Activation

Video

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

17

Mobility Priorities

bull Pec majorminor

bull Lats

bull Posterior rotator cuffcapsule

bull Upper trap amp levator (TPDN amp IASTM)

9090 Arm Sweep

18

Shoulder Mobility

Exercises Video

Stretches

Posterior Shoulder

Stretchingbull Low load long duration

bull 30 seconds (8-10x)

bull Do not stretch into pain or impingement

bull Modified sleeper amp cross body stretch

can be used (roll posteriorly 20-30 deg)

bull Not encouraged prior to throwing or

prior to tennis match

Wilk et al JOSPT 2013

19

Scapular Activation

Scapular Activation

Video

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

18

Shoulder Mobility

Exercises Video

Stretches

Posterior Shoulder

Stretchingbull Low load long duration

bull 30 seconds (8-10x)

bull Do not stretch into pain or impingement

bull Modified sleeper amp cross body stretch

can be used (roll posteriorly 20-30 deg)

bull Not encouraged prior to throwing or

prior to tennis match

Wilk et al JOSPT 2013

19

Scapular Activation

Scapular Activation

Video

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

19

Scapular Activation

Scapular Activation

Video

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

20

EMG Activitybull Side lying ER produced the greatest

amount of EMG activity for the

infraspinatus (62 MVIC) and teres

minor (67 MVIC)

bull The greatest amount of activity of the

supraspinatus (82 MVIC) middle

deltoid (87 MVIC) and posterior deltoid

(88 MVIC) was observed during prone

horizontal abduction at 100 degrees with

full ER Reinold et al JOSPT 2004

Overhead Athletes

Strengthening Exercises

Video

Blood Flow Restriction (BFR)

Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps

triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

21

BFR Exercise Video

Body Blade Video

Integrated Closed

Chain Shoulder

Exercises Video

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

22

Benefits of unstable training surfaces include

increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al

revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Unstable Closed Chain

Shoulder Exercise

Video

Rehab to Performance

bull Rehab exercises should include core and

LE strengthening as well

bull Develop pre-practicegame dynamic

warm-up routines

bull Plyometric progressions (wall dribbles

chest pass etc)

bull Unilateral loading (sliders pressing

pulling)

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

23

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility

and stability define risk

and ability

bull Recreational vs elite

bull Individualized plan

based on history

needs analysis and

goals

Threatening

Exercisesbull Full range chest press flies and dips

bull Wide grip pull-ups

bull Heavy overhead lifts hand stand push-

ups

bull Burpees bear crawls undulating ropes

bull OH lifts and certain squat variations

Return to Play

bull Re-assess FMS (if needed)

bull Begin interval throwing hitting or

swimming training program (evidence-

informed and graded dosage)

bull Maintain daily mobility work and

essential scapular and RC exercises 2-

3xweek

bull Use video analysis for feedback

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

24

Upper Quarter YBT

Video

Interval Throwingbull Typical program in non-operative

thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in

long toss in most cases before mound

throwing

bull Focus on fastball and change up initially

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

25

Long Toss Research

bull Hard horizontal flat-ground throws have

biomechanical patterns similar to those of

pitching and are therefore reasonable

exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max

distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Changes in Throwing Arm Mechanics at

Increased Throwing Distances During

Structured Long-Toss

bull Arm slot ( P lt 01) arm speed ( P lt 01) shoulder

external rotation ( P lt 01) and elbow varus torque ( P

lt 01) were significantly associated wlong-toss throw

distance

bull As throw distance increased there was an increase in

arm speed and shoulder external rotation and a

decrease in arm slot for each distance

bull Elbow varus torque increased with each distance up to

120rsquo m and then remained the same at 150rsquo

Dowling et al AJSM 2018

SLAP Repairs

bull Arthroscopic repair of type II SLAP tears

results in overall excellent results for

individuals not involved in throwing or

overhead sports

bull Results of type II SLAP repair in

throwing or overhead athletes are much

less predictable with rate of return for

baseball players 22-64

Arthroscopy2010 Apr26(4)537-45

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

26

Elite Pitchers After

Shoulder Surgerybull 287 elite male pitchers who underwent shoulder surgery

with 99 on the dominant throwing shoulder

bull Most pitchers (276) were professional with a mean

career length of 658 years Post-operative clinical

follow-up within these studies was 362 years

bull Primary diagnoses treated were RC tear = 120 (43)

Internal impingement = 82 (30) and labral tear = 74

(27)

bull Surgical procedures performed Labral repair (157) or

labral debridement (99) RC repair (29) or debridement

(162) Thermal capsulorrhaphy (63) and subacromial

decompression (42)Harris et al Sports Health 2013

Elite Pitchers After Shoulder

Surgery - Results

bull The overall rate of return to sport was low at 68

bull Mean time to return to competitive pitching in a game situation

was 12 months (range = 9 -17)

bull 22 of MLB pitchers never pitched again in MLB

bull Only 14 returned to competitive pitching in the same season as

labral surgery

bull No one returned to competitive pitching in the same season after

rotator cuff surgery

bull Reynolds et al reported a median of 2 seasons of pitching after

debridement of partial thickness cuff tears

bull Mazoue and Andrews reported a mean of 07 seasons pitching

(range 3 innings to 3 seasons) after mini-open RC repair

Harris et al Sports Health 2013

Return to Pitching amp Performance in

MLB Pitchers After Tommy John

bull A total of 179 pitchers with UCL tears who underwent

reconstruction met the inclusion criteria and were analyzed

bull 148 pitchers (83) were able to RTP in the MLB and 174

pitchers were able to RTP in the MLB and minor league

combined (972)

bull Only 5 pitchers (28) were never able to RTP in either the

MLB or minor league

bull Pitchers returned to the MLB at a mean 205 plusmn 972 months

after UCL reconstruction

bull The length of career in the MLB after UCL reconstruction was

39 plusmn 284 years although 56 of these patients were still

currently actively pitching in the MLB at the start of the 2013

season

bull The revision rate was 39Erickson et al AJSM 2014

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

27

Questions

Contact Information

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

ReferencesCrotin RL Ramsey DK Injury prevention for throwing athletes part I baseball bat training to enhance medial elbow dynamic stability Strength Cond J 201234(2)79-85

Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

Dankel SJ Jessee MB Abe T Lonneke JP The effects of blood flow restriction on upper-body

musculature located distal and proximal to applied pressure Sports Med 2016 Jan46(1)23-33

Dodson CC Altchek DW SLAP Lesions An Update on Recognition and Treatment J Orthop Sports Phys Ther 200939(2)71-80

Dowling B McNally MP Laughling WA Onate JA Changes in throwing arm mechanics at increased throwing distances during structured long-toss Am J Sports Med 2018 Oct46(12)3002-3006

Ellenbecker TS Wilk KE Altchek DW Andrews JR Current concepts in rehabilitation following ulnar

collateral ligament reconstruction Sports Health 2009 Jul1(4)301-13

Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with implications about injury mechanism Am J Sports Med 199523(2)233- 239

References

Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball

pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303

Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseballbridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

Haag SJ Wright GA Gillette CM Greany JF Effects of acute static stretching of the throwing shoulder on pitching performance of national collegiate athletic association division III baseball players J Strength Cond Res 201024(2)452-427

Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of

shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9

Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead Athlete Int J Sports Phys Ther 20135(8)556-578

28

ReferencesManske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10

Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570

Reinold MM Curtis AS Microinstability of the shoulder in the overhead athlete Int J Sports Phys Ther 20138(5)601-616

Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117

Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15

Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94

Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527

References

Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40

Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006

Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is

associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119

Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4

Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136