introduction return to play criteria in the overhead...
TRANSCRIPT
Return to Play Criteria in the Overhead Thrower
Kevin E. Wilk, PT, DPT,FAPTA
2018
The Overhead ThrowerIntroduction
• Highly skilled athlete
• Requires flexibility, muscle strength, coordination, synchronicity & NM efficiency
• Proper throwing mechanics
• Proper training programInjuries Are Common to the
Throwers Shoulder & ElbowTremendous stresses & velocities
The Overhead ThrowerIntroduction
• Overhead throwing motion• Extraordinary demands on shoulder
& elbow joint• Fastest human movement – 7,230 o/s• Late cocking to ball release 0.03sec
• Tremendous forces generated• Anterior displacement 0.5 x BW• Distraction forces 1 x BW at ball
releaseFleisig et al: Am J Spts Med ’95
Fleisig et al: J Biomech ‘99
Thrower’s ShoulderKey Points
Pitchers sustain injuries at the highest rate 61% of all team injuries pitchers compared position players
>72% of all pitchers injuries are to their shoulder/elbow
Specific risk factors increases injuriesPitching when fatigued, or pitch too much (volume), improper
throwing mechanics, or max effort - all increase injury risk
GIRD & GERI is predominantly due to boney adaptations ~83% boney & ~17% due to soft tissue
Maintaining motion in throwing shoulder when healthy isn’t difficult
Specific exercises & stretches are important – maintain !
Side Slides with ER
Side Slides with ER Bilateral Side Plank with ER
Prone Plyoball Drops on Stability Ball Serratus Anterior Exercises
Reverse Wall Slides www.Kevinwilk.com
Wilk_kevin
Return to Play CriteriaObjective Test Criteria
Criteria to initiate: Interval throwing program
Return to play criteria
Rehabilitation of Overhead AthleteRehab Plan
Biomechanics of the Biomechanics of the Shoulder Joint Complex Shoulder Joint Complex
During ThrowingDuring Throwing
CRITERIA TO RETURN TO THROWING
Full non-painful ROM
Elbow stability
Satisfactory isokinetic test
Satisfactory clinical exam moving valgus stress test (-)
Adequate healing time
How long is that? 6, 9 or 12 mos.
Return to Play in Throwers
Specific Objective Criteria
Objective Functional Testing
Clinical Exam
ROM
Objective Muscle Strength Test
Successful Completion of Rehab
Rehab Overhead AthleteReturn to Play Criteria
Rehab Overhead AthleteReturn to Play Criteria
Full sport specific non painful ROM
Strength which meets the criteria
Excellent stability and no painful special tests
Demonstrates proper throwing mechanics
Successfully has completed rehab program
Appropriate rehab progression completed
Satisfactory functional scoring
An Objective Criteria is Important
The Thrower’s ShoulderRange of Motion: ER/IR
Visual inspection Humeral Stabilization
Scapular Stabilization
J Sports Health ‘09
The Thrower’s ShoulderRange of Motion
Adaptations
Total Rotational Motion Concept
ER + IR = Total Motion
“Envelope of Motion”
Wilk AJSM ’02
Total Rotational Motion is equal bilaterally (within 5 degrees)
Non- Throwing Shoulder
Throwing Shoulder
Wilk, Macrina, Porterfield et al: 2015Pitchers Shoulder ROM (‘05-’15)
D ND
• ER at 90° abduction: 131.1 125.1
• IR at 90° abduction 53.3 63.2
• Total Rotational ROM: 184.3 187.4
• Horizontal adduction: 42.9 45.2
• ER Horz Adduction: 32.5 28.1
N= 1226
N=369
Thrower’s Shoulder ROMPROM Assessment
Shoulder Flexion
Shoulder Horz Abd
Criteria to RTP Thrower’sRange of Motion Goals
TROM within 5°
Horizontal adduction 40°>
GIRD < 20°
Elbow full ROM
Wrist full ROM
Non-painful ROM
Professional Tennis Player
Criteria to RTP Thrower’sClinical Exam
Satisfactory Clin Exam
Laxity Assessment
Posterior Drawer TestAnterior Drawer Test
Anterior Fulcrum Test
Clunk TestSLAP & Cuff
Biceps/Labrum Tests’
O’Brien et al: AJSM ‘98
Objective Muscle Testing - Isokinetics
Criteria to RTP Thrower’sMuscle Strength Goals
ER/IR Ratio: 72-76%
ER/ABD Ratio: 68-72%
ER: 95%>
IR: 115%>
Elbow Flexion: 110-115%
Elbow extension: 115-120%
Assess Muscular StrengthBiodex –Isokinetics Throwers
• ER / IR ratios72 - 76%
• ER / ABD ratios68 - 73%
• Torque / BW ratiosER 18 - 23%IR 26 - 32%
• Bilateral comparisonER 95-100%; IR 115%
Wilk et al: AJSM ’93Wilk et al: AJSM ‘95
“Objective MMT”
Scapular Strength RatiosWilk, Reinold, Hooks…Unpublished data ‘07
Pitchers Non-throwers
D ND D ND
Elev / Depress 400% 480% 520% 540%
Retract / Protract 88% 71% 78% 71%
Return to Play CriteriaAppropriate Rehab Progression
Dynamic stabilization drills RS drills at 90/90 (P/F)
Prone ball drops
Plyoball Wall Throws with RS
Return to Play CriteriaBall Drop Test
Dynamic stabilization tests Prone ball drops 30 sec test
prone on plinth
number of releases/catches
compare Dom to Non Dom
score: %
Goal: 90%>
Expectation: 110%>
mean score: 115% (range 53- 102)
Return to Throw CriteriaBall Drop Test (T Side)
Return to Throw CriteriaBall Drop Test (T Side)
Return to Throw CriteriaBall Drop Test (NT Side)
Return to Throw CriteriaOne Hand Ball Throws Against Wall
Ball Wall Throws Baseball Style Throws 2 Ib plyoball
baseball style throws
30 sec duration
bilateral comparison
Successful Criteria:
no pain
proper mechanics
no change with fatigue
Return to Play CriteriaBall Throws into Wall Test
Dynamic stabilization tests Ball Throws into wall 30 sec test
standing
number of throws/catches
compare Dom to Non Dom
score: %
Goal: 90%>
Expectation: 110%>
Mean score: 110% (range 51-97)
Return to Play CriteriaAppropriate Rehab Progression
Throwing Activities: painfree 1 hand
throwing
20 ft away
1 Ib plyoball
Return to Play CriteriaSingle Leg Squat
Single leg squat test Floor or 8 in step 30 sec test on each leg
assess technique & numbers
assess valgus/varus
assess lateral trunk movt.
assess trunk flexion
looking for symmetrical motion with no pain &/or dysfunction
ability to maintain balance & form for all reps
Return to Play CriteriaAppropriate Rehab Progression
Subjective Shoulder Questionnaire & Scoring System
AJSM ‘11
Return to Play CriteriaProne Plank on Elbows Test
Prone Plank test Test Procedure: prone on elbows
maintain position
duration of proper hold
Strand et al: J Hum Kinet ‘14Men 124 sec + 72
Woman 83 sec + 63
Return to Play CriteriaQuick Board Test
Reaction test Quick Board Test: 30 sec test
side to side comparison
number of touches/misses
Return to Play Criteria ThrowersKey Points & Conclusions
Determining when to initiate ITP can be difficult
Strict objective criteria (knee)
Time based & assessment (healing)
RTP criteria based on: Clinical exam
Functional tests
Subjective patient
Successful Return to Play Throwing