Current concepts in the rehabilitation of the overhead throwing athlete

Therapy and Rehabilitation for Upper Extremity Injuries in Athletes

The approach to rehabilitation of upper extremity injuries in athletes differs from traditional rehabilitation protocols. In general, athletes have higher functional demands and wish to return to competitive sport in a timely manner. Comprehensive rehabilitation must therefore be balanced with a timely and safe return to sport. Several rehabilitation programs and adjunctive therapies are available to hasten convalescence while minimizing the athlete's risks of reinjury. Here, we review techniques for soft tissue mobilization and strength training in athletic populations. We also discuss orthotics, taping, and alternative therapies used in rehabilitation and evaluate the evidence in support of these modalities.

Baseball Players With an Ulnar Collateral Ligament Tear Display Increased Nondominant Arm Humeral Torsion Compared With Healthy Baseball Players

BACKGROUND

Previous work has suggested that an increase in the amount of developmentally acquired, dominant arm humeral retrotorsion (D HRT) in the thrower's shoulder may be a potentially protective mechanism. Although the relationship between HRT and shoulder injuries has been reported, the relationship between HRT and ulnar collateral ligament (UCL) tears in baseball players is not known.

PURPOSE

To determine whether D HRT and nondominant arm HRT (ND HRT) measurements in baseball players with a UCL tear differ statistically from a matched healthy cohort.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

D HRT and ND HRT were measured in 112 male competitive high school and collegiate baseball players seen over an 18-month period from 2013 to 2015. A total of 56 participants with a clinical and magnetic resonance imaging-confirmed diagnosis of a throwing-arm UCL tear (UCLInj group) were compared with 56 healthy baseball players with no history of an elbow injury who were matched for age, experience, and position (NUCLInj group). The mean ages in the UCLInj and NUCLInj groups were 17.9 ± 2.2 and 17.6 ± 2.8 years, respectively. Using a previously validated ultrasound method, D HRT and ND HRT were measured in the supine position, and the HRT side-to-side difference (D HRT - ND HRT) was calculated. A 1-way multivariate analysis of variance was used to determine the mean statistical differences between groups ( P < .05).

RESULTS

Baseball players with a UCL tear displayed significantly more humeral torsion (ie, less retrotorsion) in their nondominant arm compared with healthy baseball players (UCLInj = 33.27° ± 10.27°, NUCLInj = 27.82° ± 10.88°; P = .007). Baseball players with a UCL tear did not display any differences in D HRT compared with healthy baseball players (UCLInj = 18.67° ± 9.41°, NUCLInj = 17.09° ± 9.92°; P = .391). Significant side-to-side differences in HRT existed between groups (UCLInj = -14.60° ± 6.72°, NUCLInj = -10.72° ± 6.88°; P = .003).

CONCLUSION

There was a significant increase in mean nondominant arm humeral torsion (ie, less retrotorsion) in the UCL tear group, but there was no significant difference in the mean D HRT between the injured and uninjured groups. A greater HRT side-to-side difference was displayed in the UCL tear group. The extent to which a thrower has developmentally acquired both D HRT and ND HRT may affect elbow UCL tear risk. Furthermore, it is possible that the extent of genetically predisposed ND HRT may influence the throwing-related increase in D HRT.

Can posterior capsular stretching rehabilitation protocol change scapula kinematics in asymptomatic baseball pitchers?

PURPOSE

Scapular dyskinesis is a recognized cause of shoulder pain in the throwing shoulder of baseball pitchers and athletes who participate in overhead sports. Past studies have assessed scapular kinematics using electromagnetic tracking devices and have shown a correlation between posterior shoulder tightness and forward scapular posture. The purpose of our study is to evaluate the scapular kinematics, before and after a 4-week posterior stretching protocol in asymptomatic pitchers.

METHOD

Eleven asymptomatic collegiate baseball pitchers were involved in the study and divided into group A (6 pitchers) underwent 4 weeks of a regimented therapy protocol and group B (5 pitchers) did not receive any treatment. Each pitcher was tested on two separate days: at the first day of the study (S1) and after 4 weeks (S2).

RESULTS

The results demonstrate that there are statistically significant differences in the kinematics of several athletes from the "treated group" (group A) between S1 and S2. It is also important to notice that variations in group A occurred in both flexextension and ab/adduction movements, strengthening the conclusion that the variation was real.

CONCLUSION

The results of the study can indicate that, in order to prevent the pathologic cascade linked to these sports activities, this physical training protocol might become integral part of the normal daily exercises of baseball pitchers and overhead athletes. Level of evidence II.

Ultrasound Imaging of Ulnar Collateral Ligament Injury

The patient was an 18-year-old collegiate baseball pitcher who injured his right throwing elbow during an overhead slider pitch. As a part of a study, preinjury ultrasound images of the throwing arm were obtained 2 weeks prior to the injury. One day postinjury, repeat ultrasound imaging of the medial elbow was performed. The attending team physician ordered a magnetic resonance arthrogram 2 days after injury, which confirmed the presence of a complete tear of the ulnar collateral ligament. J Orthop Sports Phys Ther 2016;46(12):1086. doi:10.2519/jospt.2016.0420.

The Relationship Between Humeral Retrotorsion and Shoulder Range of Motion in Baseball Players With an Ulnar Collateral Ligament Tear

BACKGROUND

Humeral retrotorsion has been investigated in relation to shoulder range of motion (ROM) in healthy baseball players. Currently, there is limited information on the osseous anatomy and development of ulnar collateral ligament (UCL) tears.

PURPOSE

To determine the relationship between humeral retrotorsion and shoulder ROM in baseball players with a UCL tear.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Fifty-four baseball players (mean age, 18.5 ± 2.0 years) with a UCL tear volunteered for this study. Participants were measured bilaterally for shoulder internal (IR) and external rotation (ER) ROM and humeral retrotorsion. Differences between sides (involved to uninvolved) were used to calculate the glenohumeral internal rotation deficit (GIRD), external rotation ROM difference (ERDiff), total rotational motion difference (TRM), and humeral retrotorsion difference (HTDiff). A multivariate regression analysis was performed with GIRD, ERDiff, and TRM regressing on HTDiff. Univariate analysis was performed to further evaluate the effect of the predictors on each outcome separately. To control for the effect of age, weight, duration of symptoms, and years of experience, the variables were included as covariates. An a priori level was set at P < .05.

RESULTS

There was a statistically significant relationship between the GIRD, ERDiff, and TRM results compared with HTDiff (P = .003). Independent analysis revealed a statistically significant relationship between GIRD and HTDiff (P = .004) and between ERDiff and HTDiff (P = .003) but no significant relationship between TRM and HTDiff (P = .999). After adjusting for age, weight, duration of symptoms, years of experience, dominant arm, and position, a significant relationship was found between GIRD and HTDiff (P = .05) and between ERDiff and HTDiff (P = .01). No significant relationship was found between TRM and HTDiff (P = .54). Adjusted univariate regression analysis determined that HTDiff explains approximately 16% of the variance in GIRD (r² = 0.158) and approximately 24% of the variance in ERDiff (r² = 0.237).

CONCLUSION

In baseball players with a UCL tear, approximately 16% of the variance in GIRD and 24% of the variance in ERDiff can be attributed to differences found in humeral retrotorsion between sides. This indicates that humeral retroversion contributes significantly to GIRD and increased ER ROM in baseball players. Recognition of differences in humeral retrotorsion between the dominant and nondominant upper extremities may help explain some but not all of the changes in shoulder ROM commonly seen in baseball players.

[Surgical treatment of anterosuperior impingement of the shoulder]

OBJECTIVE

Therapy of intraarticular lesions and elimination of structural risk factors for those suffering from clinical manifest anterosuperiorer impingement (ASI) of the shoulder. This includes as a maximum version the arthroscopic repair of supraspinatus (SST) and subscapularis tendon (SCT) tears with subsequent subpectoral tenodesis of the long head of the biceps tendon (LBT) and arthroscopic coracoplasty.

INDICATIONS

Clinical manifest anterosuperiorer impingement of the shoulder with anterior shoulder pain, failed conservative treatment and clear intraarticular damage in radiological imaging. This involves in detail lesions of the SST, SCT and damage to the LBT.

CONTRAINDICATIONS

Lack of structural intraarticular lesions or massive osteoarthritis. Persistent dysfunction of active and passive glenohumeral and scapulathoracal motion, due to neurologic deficits or stiff shoulder. A hypertrophic or deformed healed coracoid process is seen as a structural risk factor for suffering from ASI and should be addressed surgically when causing impingement.

SURGICAL TECHNIQUE

Arthroscopic tenotomy of the LBT with subsequent repair of the SST and SCT. Arthroscopic coracoplasty if indicated and subpectoral tenodesis of the long head of the biceps.

POSTOPERATIVE MANAGEMENT

No biceps activity and intermittent immobilization in sling for 6 weeks. Limitation of abduction, flexion and external rotation for 6 weeks depending on rotator cuff tendon repair. Start of sport-specific training after 3 months, over-head sports 6 months postoperatively.

RESULTS

The arthroscopic repair of anterosuperior rotator cuff tears provides reliable results for improvement in function, decreases in pain and improvement in shoulder scores. The overall rate of adverse events is low.

Influence of Playing a Prolonged Tennis Match on Shoulder Internal Range of Motion

BACKGROUND

Shoulder range of motion (ROM) deficits have been identified as an injury risk factor among tennis players. It is well known that shoulder internal rotation deficit increases with age and years of play, but there is a lack of knowledge regarding the influence of a prolonged tennis match on shoulder ROM.

PURPOSE

To examine changes in shoulder ROM during a prolonged tennis match.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Shoulder passive internal and external rotation ROM were measured on 8 male tennis players before, every 30 minutes during, and just after a 3-hour tennis match. Total ROM was calculated as the combination of shoulder internal and external rotations. Ball velocity on the serve was measured with a radar gun before, at midmatch, and just after the match.

RESULTS

Decreases in shoulder internal rotation (-20.8°; P = .005), total ROM (-24.6°; P = .001), and serve velocity (-1.8 m/s; P = .002) were observed at the end of the match. No statistically significant difference was observed for shoulder external rotation after the match (P = .460).

CONCLUSION

Passive shoulder internal rotation and total ROM are significantly decreased during a 3-hour tennis match.

CLINICAL RELEVANCE

The results show that a prolonged tennis match play can modify values of shoulder ROM.

Glenohumeral and Hip Range-of-Motion and Strength Measures in Youth Baseball Athletes

CONTEXT

The repetitive demands of throwing affect glenohumeral (GH) range of motion (ROM) and strength. Less is known about hip alterations in skeletally immature athletes.

OBJECTIVE

To compare GH and hip ROM and strength between age, position, and side of youth baseball athletes.

DESIGN

Cross-sectional study.

SETTING

Multicenter testing.

PATIENTS OR OTHER PARTICIPANTS

Seventy-two healthy baseball athletes. Participants' self-reported characteristics were age group (7-11 years [n = 28] or 12-18 years [n = 44]), position (pitcher [n = 22], position player [n = 47], unreported [n = 3]), and side (throwing or nonthrowing arm, lead or stance leg).

MAIN OUTCOME MEASURE(S)

Bilateral GH and hip internal- and external-rotation ROM were measured passively and summed for total arc of motion (TAM). Glenohumeral and hip rotation and gluteus medius strength were measured. Analyses included linear mixed models.

RESULTS

Glenohumeral internal rotation was less in throwing than in nonthrowing arms (P < .05) except in younger pitchers (P = .86). Compared with older athletes, younger athletes had more GH external rotation (103.3° ± 7.7° versus 97.5° ± 9.4°; P = .002), TAM (156.4° ± 8.7° versus 147.9° ± 10.9°; P = .04), and external rotation in throwing compared with nonthrowing arms (101.9° ± 1.2° versus 97.9° ± 1.1°; P < .001). Glenohumeral TAM was less in throwing than in nonthrowing arms (150.5° ± 2.1° versus 154.9° ± 1.3°; P = .01). Younger athletes had more hip internal rotation (38.9° ± 6.8° versus 31.2° ± 7.5°; P < .001) and TAM (68.4° ± 10.0° versus 60.7° ± 9.8°; P = .001) than older athletes. Lead-leg hip internal-rotation ROM was greater than in the stance leg (34.8° ± 8.9° versus 32.8° ± 7.7°; P = .01). Overall, older players were stronger than younger players (P < .05), and the throwing arm was stronger in internal rotation than the nonthrowing arm (10.12 ± 3.72 lb [4.59 ± 1.69 kg] versus 9.43 ± 3.18 lb [4.28 ± 1.44 kg]; P = .047).

CONCLUSIONS

Youth baseball athletes had typical GH ROM adaptations of less internal rotation and more external rotation in the throwing versus the nonthrowing arm. Greater ROM in younger athletes may be explained by prepubertal characteristics. We obtained hip-strength values in youth baseball athletes, and as expected, older athletes were stronger.

Increasing Ball Velocity in the Overhead Athlete: A Meta-analysis of Randomized Controlled Trials

Overhead athletes routinely search for ways to improve sport performance, and one component of performance is ball velocity. The purpose of this meta-analysis was to investigate the effect of different strengthening interventions on ball and serve velocity. A comprehensive literature search with pre-set inclusion and exclusion criteria from 1970 to 2014 was conducted. Eligible studies were randomized control trials including the mean and SDs of both pretest and posttest ball velocities in both the experimental and the control groups. The outcome of interest was ball/serve velocity in baseball, tennis, or softball athletes. Level 2 evidence or higher was investigated to determine the effect different training interventions had on velocity. Pretest and posttest data were extracted to calculate Hedges's g effect sizes with 95% confidence intervals (CIs). Methodological qualities of the final 13 articles within the analysis were assessed using the Physiotherapy Evidence Database scale. The majority of the articles included in this analysis had an effect on velocity with the strongest effect sizes found in periodized training (Hedges's g = 3.445; 95% CI = 1.976-4.914). Six studies had CI that crossed zero, indicating that those specific interventions should be interpreted with caution. Consistent and high-quality evidence exists that specific resistance training interventions have an effect on velocity. These findings suggest that interventions consisting of isokinetic training, multimodal training, and periodization training are clinically beneficial at increasing velocity in the overhead athlete over different windows of time.

Biomechanical Comparison of Three Perceived Effort Set Shots in Team Handball Players

Plummer, HA, Gascon, SS, and Oliver, GD. Biomechanical comparison of three perceived effort set shots in team handball players. J Strength Cond Res 31(1): 80-87, 2017-Shoulder injuries are prevalent in the sport of team handball; however, no guidelines currently exist in the implementation of an interval throwing protocol for players returning from an upper extremity injury. These guidelines exist for the sport of baseball, but team handball may present additional challenges due to greater ball mass that must be accounted for. The purpose of this study was to examine kinematic differences in the team handball set shot at 50, 75, and 100% effort which are common throwing intensities in throwing protocols. Eleven male team handball players (23.09 ± 3.05 years; 185.12 ± 8.33 cm; 89.65 ± 12.17 kg) volunteered. An electromagnetic tracking system was used to collect kinematic data at the pelvis, trunk, scapula, and shoulder. Kinematic differences at the shoulder, trunk, and pelvis were observed across effort levels throughout the set shot with most occurring at ball release and maximum internal rotation. Significant differences in ball speed were observed between all 3 effort level shots (p < 0.001). Team handball players are able to gauge the effort at which they shoot; however, it cannot be assumed that these speeds will be at a certain percentage of their maximum. The results of this study provide valuable evidence that can be used to prepare a team handball player to return to throwing activities.

Effect of fatigue caused by a simulated handball game on ball throwing velocity, shoulder muscle strength and balance ratio: a prospective study

BACKGROUND

Arm throwing represents a deciding element in handball. Ball velocity, aim accuracy, and dynamic stability of the shoulder are factors that influence throwing effectiveness. The purpose of this study was to examine the influence of muscle fatigue caused by simulated game activities (SGA) on shoulder rotational isokinetic muscle strength, muscle balance and throwing performance, and to examine the relationship between muscle strength and throwing performance.

METHODS

Ten national elite adult handball athletes were evaluated. Isokinetic internal (IR), external (ER) rotators peak torque, and balance ratio were measured before and after SGA. Ball throwing velocity was assessed by radar gun.

RESULTS

Both internal (IR) and external (ER) rotators peak torque were significantly lower after SGA (p = 0.0003 and p = 0.02, respectively). However, the deleterious effect was more evident for IR than ER muscles (effect size r = 0.39 and r = 0.18, respectively). Balance ratio before and after SGA did not differ (p = 0.06). Ball throwing velocity was not impaired by SGA. Moreover, isokinetic variables correlated positively with ball velocity (r ≥ 0.67).

CONCLUSIONS

SGA affected the muscle strength of IR more than ER, predisposing the shoulder joint to muscular imbalance. The muscular impairment after SGA was insufficient to impair ball throwing velocity.

Shoulder proprioception - lessons we learned from idiopathic frozen shoulder

Background

Of all the most frequent soft tissue disorders of the shoulder, idiopathic frozen shoulder (IFS) offers the greatest potential for studying proprioception. Studies concerning the presence of proprioception dysfunctions have failed to determine the potential for spontaneous healing of passive shoulder stabilizers (anterior and posterior capsule, middle and inferior gleno-humeral ligaments), its relationship with passive (PJPS) and active (AJPS) shoulder proprioception for internal and external rotation (IR, ER), as well as the isokinetic muscle performance of the internal and external rotators. This study investigates these dependencies in the case of arthroscopic release of IFS.

Methods

The study group comprised 23 patients (average aged 54.2) who underwent arthroscopic release due to IFS and 20 healthy volunteers. The average follow-up time was 29.2 months. The Biodex system was used for proprioception measurement in a modified neutral arm position and isokinetic evaluation. The results were analysed using the T-test, Wilcoxon and interclass correlation coefficient. P-values lower than 0.05 were considered significant.

Results

Statistically significant differences were found between involved (I) and uninvolved (U) shoulders only in the cases of PJPS and AJPS, peak torque, time to peak torque and acceleration time for ER (p < 0.05). No statistically significant difference was noted between PJPS IR and PJPS ER or between AJPS IR and AJPS ER (p > 0.05) for the U shoulders.

Conclusions

The anatomical structure of anterior (capsule, middle and anterior band of inferior gleno-humeral ligament) and posterior (capsule and posterior band of inferior gleno-humeral ligament) passive shoulder restraints has no impact on the difference in PJPS values between ER and IR in a modified neutral shoulder position. The potential for spontaneous healing of the anterior and posterior passive shoulder restraints influences PJPS recovery after arthroscopic release of IFS. ER peak torque deficits negatively affect AJPS values. PJPS and AJPS of ER and IR can be measured with a high level of reproducibility using an isokinetic dynamometer with the arm in a modified neutral shoulder position. Differences greater than 15 % for PJPS and >24 % for AJPS for ER and IR can be helpful for future studies as baseline data for identification of particular passive and active shoulder stabilizers at risk.

Evidence-based rehabilitation of athletes with glenohumeral instability

PURPOSE

To give an overview of current knowledge and guidelines with respect to evidence-based rehabilitation of athletes with glenohumeral instability.

METHODS

This narrative review combines scientific evidence with clinical guidelines based on the current literature to highlight the different components of the rehabilitation of glenohumeral instability.

RESULTS

Depending on the specific characteristics of the instability pattern, the severity, recurrence, and direction, the therapeutic approach may be adapted to the needs and demands of the athlete. In general, attention should go to (1) restoration of rotator cuff strength and inter-muscular balance, focusing on the eccentric capacity of the external rotators, (2) normalization of rotational range of motion with special attention to the internal rotation ROM, (3) optimization of the flexibility and muscle performance of the scapular muscles, and (4) gradually increasing the functional sport-specific load on the shoulder girdle. The functional kinetic chain should be implemented throughout all stages of the rehabilitation program. Return to play should be based on subjective assessment as well as objective measurements of ROM, strength, and function.

CONCLUSIONS

This paper summarizes evidence-based guidelines for treatment of glenohumeral instability. These guidelines may assist the clinician in the prevention and rehabilitation of the overhead athlete.

LEVEL OF EVIDENCE

Expert opinion, Level V.

The effects of plane and arc of elevation on electromyography of shoulder musculature in patients with rotator cuff tears

BACKGROUND

Arm elevations in different planes are commonly assessed in clinics and are included in rehabilitation protocols for patients with rotator cuff pathology. The aim of this study was to quantify the effect of plane and angle of elevation on shoulder muscles activity in patients with symptomatic rotator cuff tear to be used for rehabilitation purposes.

METHODS

Eight symptomatic patients with rotator cuff tears were assessed by using EMG (11 surface and 2 fine wire electrodes) synchronized with a motion analysis. The subjects completed five elevations in full can position (arm externally rotated and thumb up) in frontal, scapular and sagittal planes. Muscle activity in three elevation arcs of 20° (from 0° to 60°) was presented as the percentage of mean activity. Data were analyzed by mixed linear models (α=0.003), and Tuckey Post-hoc comparisons for significant effects (α=0.05).

FINDINGS

The effect of plane was significant for supraspinatus, middle trapezius, anterior, middle, and posterior deltoid, triceps, and pectoralis major (P<0.001). Supraspinatus was more active during abduction than scaption and flexion (P<0.05), and its activity did not increase significantly after 40° of elevation (P>0.05). Infraspinatus had similar activity pattern in the three planes of elevation (P>0.003) with increasing trend in accordance with the elevation angle.

INTERPRETATION

In any rehabilitation protocol, if less activity of supraspinatus is desired, active arm elevation should be directed toward flexion and scaption and postponed abduction to prevent high level of activity in this muscle.

Electromyographic analysis of the infraspinatus and scapular stabilizing muscles during isometric shoulder external rotation at various shoulder elevation angles

[Purpose] This study aimed to clarify activation of the infraspinatus and scapular stabilizing muscles during shoulder external rotation at various shoulder elevation angles. [Subjects] Twenty subjects participated in this study and all measurements were performed on the right shoulder. [Methods] Isometric shoulder external rotation strength and surface electromyographic data were measured with the shoulder at 0°, 45°, 90°, and 135° elevation in the scapular plane. The electromyographic data were collected from the infraspinatus, upper trapezius, middle trapezius, lower trapezius, and serratus anterior muscles. These measurements were compared across the various shoulder elevation angles. [Results] The strength measurements did not differ significantly by angulation. The infraspinatus activity was 92%, 75%, 68%, and 57% of the maximum voluntary contraction, which significantly decreased as shoulder elevation increased. The serratus anterior activity was 24%, 48%, 53%, and 62% of the maximum voluntary contraction, which significantly increased as shoulder elevation increased. [Conclusion] Shoulder external rotation torque was maintained regardless of shoulder elevation angle. The shoulder approximated to the zero position as the shoulder elevation increased so that infraspinatus activity decreased and the scapular posterior tilting by the serratus anterior might generate shoulder external rotation torque.

GIRD, TRROM, and humeral torsion-based classification of shoulder risk in throwing athletes are not in agreement and should not be used interchangeably

OBJECTIVES

Clinicians commonly interpret the findings of shoulder rotational ranges of motion using various approaches: an apparent reduction in dominant arm internal rotation ("GIRD"), a difference in total rotational range of motion-i.e. differences in the sum of internal and external rotational range (TRROM), and a combination of rotational ROM and torsional difference ("GIRD-torsion"). We have noticed that these approaches are being considered to provide equivalent estimates of shoulder rotational range. This investigation sought to document the extent of agreement of these three different approaches when classifying athletes' "at-risk" status.

DESIGN

Observational cohort study.

METHODS

162 professional male athletes participating in overhead sports (baseball, handball, and volleyball) had their GIRD, TRROM, and GIRD-torsion calculated, and classified as "at risk" using standard cut-points of 20°, 5°, and 10°, respectively.

RESULTS

25 (15.4%) athletes were classified as "at-risk" using GIRD, 55 (34%) with TRROM, and 30 (18.5%) using GIRD-torsion. Only 3/162 (1.9%) athletes were classified as "at-risk" by all 3 approaches, 4 athletes were concurrently classified as "at-risk" by GIRD and TRROM (Kappa=-0.142, poor agreement), 11 by GIRD and GIRD-torsion (Kappa=0.279, fair agreement), and 11 by TRROM and GIRD-torsion (Kappa=0.025, slight agreement).

RESULTS

25 (15.4%) athletes were classified as at risk using GIRD, 55 (34%) with TRROM, and 30 (18.5%) using GIRD-torsion. Only 3/162 (1.9%) athletes were classified as at risk by all 3 approaches, 4 athletes were concurrently classified as at risk by GIRD and TRROM (Kappa=-0.142, poor agreement), 11 by GIRD and GIRD-torsion (Kappa=0.279, fair agreement), and 11 by TRROM and GIRD-torsion (Kappa=0.025, slight agreement).

CONCLUSIONS

The three described approaches yield demonstrably different findings, and these approaches cannot be used interchangeably. Examples of clinical reasoning are provided to assist with the interpretation of these different measures.

Scapular Resting Position and Gleno-Humeral Movement Dysfunction in Asymptomatic Racquet Players: A Case-Control Study

Background:

Racquet sports, especially lawn tennis and badminton have been gaining popularity in Asian countries like India. With this increase in popularity, the injury rate in the sport has also increased.

Objectives:

The study will help detect the presence of gleno-humeral movement dysfunction and scapular resting position abnormality in asymptomatic racquet players, thus providing basis for screening the players and allow the clinician to determine if the asymmetry is a normal adaptation in the player or an abnormal change associated with injury.

Materials and Methods:

46 asymptomatic professional players were divided into a study group of 23 players (16 tennis and 7 badminton) and control group of 23 football players. Assessment of passive gleno-humeral range of motion and distance of spine and inferior angle of scapula from corresponding spinous process were measured bilaterally and between groups.

Results:

There was statistically significant reduction in range of internal rotation (62.17 ± 8.09), extension (39.78 ± 4.12) and an increase in the external rotation (106.95 ± 7.49) of dominant compared to non-dominant arm of racquet players and a statistically significant decrease in internal rotation (78.69 ± 10.24), extension (44.78 ± 3.19), adduction (37.39 ± 6.54) and an increase in external rotation (102.6 ± 5.19) of dominant arm of racquet players compared to football players. Study also showed statistically significant increase in the spino-scapular distance at the level of inferior angle of scapula (10.23 ± 1.43) on dominant side compared to non-dominant.

Conclusions:

The dominant side scapula of asymptomatic racquet players showed increased external rotation and elevation as compared to the non-dominant side. Also, reduced shoulder internal rotation, extension and adduction and gain in shoulder external rotation was observed on the dominant side of racquet players when compared to the control group.

The Relationship Between Glenohumeral Internal Rotational Deficits, Total Range of Motion, and Shoulder Strength in Professional Baseball Pitchers

INTRODUCTION

Although the lack of internal rotation (IR) and total range of motion (TRM) has been identified as a significant contributing factor of shoulder injuries, our goal was to determine whether a relationship exists between glenohumeral internal rotational deficits (GIRD), TRM, and shoulder strength in professional baseball pitchers. Our hypothesis was that GIRD with TRM differences within 5° will not lead to decreased shoulder strength; however, a shoulder with >5° of TRM difference with GIRD will lead to decreased shoulder strength.

METHODS

The study was conducted over a 4-year period and included 193 major and minor league pitchers. All measurements were taken prior to the pitcher's engaging in any baseball-related activities on the day of measurements. The entire measurement arc of passive range of motion (PROM), including external rotation (ER) and IR, was defined as the TRM. GIRD was defined as a loss of 25° or more of IR of the throwing shoulder compared with the nonthrowing shoulder. Shoulder strength measurements were obtained using a validated digital dynamometer with the arm in 90° of abduction and with the arm in 110° of flexion and 30° of abduction measured in pounds.

RESULTS

The IR deficit was 5.89° (SD = 9.24°) in non-GIRD pitchers and 25.52° (SD = 4.35°) in GIRD pitchers (P > 0.001). The ER change was 124.08° (SD = 11.21°) in non-GIRD pitchers and 127.79° (SD = 9.15°) in GIRD pitchers. The total arc of motion was 179.54° (SD = 14.53°) in non-GIRD pitchers and 171.93° (SD = 12.34°) in GIRD pitchers (P > 0.001). The strength in the shoulder, measured with the arm in 90° of abduction, was 29.61 lb (SD = 4.76 lb) in non-GIRD pitchers versus 28.65 lb (SD = 4.81 lb) in GIRD pitchers. The strength with the arm in 110° of flexion and 30° of abduction was 29.43 lb (SD = 5.01 lb) in non-GIRD pitchers versus 28.13 lb (SD = 4.76 lb) in pitchers with GIRD (P = 0.043). Deficiencies in total arc of motion (P < 0.001) and shoulder strength (P < 0.043) were significantly associated with GIRD.

DISCUSSION

In our evaluation of 193 pitchers examined during their preseason physical examinations, we identified a statistically significant association between decreased total arc of motion, decreased shoulder strength, and GIRD.

Glenohumeral range of motion (ROM) and isometric strength of professional team handball athletes, part III: changes over the playing season

INTRODUCTION

The aim of our study was to investigate the relation of workload on range of motion and isometric strength of team handball athletes' shoulders over a competitive season.

MATERIALS AND METHODS

31 Professional male handball athletes underwent clinical shoulder examinations. Athletes were examined subsequently during the complete playing season (week 0, 6, 22 and 40) to determine bilateral isometric shoulder rotational strength and active range of motion (ROM). In addition, relative (intraclass correlation coefficients (ICC) and absolute (standard error of measurement) reliability were calculated.

RESULTS

Intraobserver reliability was excellent (ICC 0.76-0.98) for isometric strength and flexibility measurements. Internal rotation (IR) and total arc ROM in the throwing shoulder (TS) decreased significantly (p < 0.05) in both sequences (week 22 to week 40, week 0 to week 40). External rotation (ER) ROM and isometric strength in IR and ER did not change significantly. Glenohumeral internal rotation deficit (GIRD) and external rotation gain (ERG) of the TS decreased significantly between week 22 and week 40, but both did not change overall (week 0 to week 40). There was significant influence on IR ROM (week 22 to week 40) and strength in ER (week 0 to week 40) in the non-throwing shoulder.

CONCLUSIONS

Several characteristics of handball players' shoulders changed significantly from the beginning to the end of a season. More specifically, the repetitive forces accumulated during the competitive season resulted in altered GIRD, ERG and isometric strength of the dominant glenohumeral joint.

First-rib stress fracture in two adolescent swimmers: a case report

First-rib stress fractures have been described in adolescent athletes in various sports, with only one prior case report of first-rib stress fractures in an adolescent female swimmer. There is a need for research on the cause, management, and prevention of these injuries as they lead to significant morbidity and critical time away from sport for these aspiring athletes. We aimed to describe first-rib stress fractures as a potential cause for non-specific atraumatic chronic shoulder pain in adolescent swimmers and to discuss the different presentations, unique risk factors, treatment, and potential injury prevention strategies of such fractures. We discussed two such cases which were successfully treated with activity modification with restriction of all overhead activity, gradually progressive physical therapy and a return to swimming protocol. First-rib stress fractures can vary in presentation and should be in the differential diagnosis in adolescent swimmers with chronic shoulder pain. These injuries can be successfully managed with rest from overhead activities and physical therapy. Gradual return to competitive swimming can be achieved even with non-union of a first-rib stress fracture. Emphasis on balanced strength training in different muscle groups and proper swimming technique is essential to prevent these injuries.

Acute changes in glenohumeral range-of-motion following in-season minor league pitching starts

BACKGROUND

Asymmetric glenohumeral range-of-motion (ROM) between the throwing and non-throwing arms of overhead athletes has been well described in the literature. Thresholds of internal rotation (IR) loss have been associated with throwing arm injury in baseball players. Acute changes in shoulder ROM following an individual pitching appearance remain poorly understood.

OBJECTIVES

To determine the acute change of external rotation (ER), IR, and total arc-of-motion (TAM) in minor league starting pitchers immediately following an in-season starting pitching appearance.

METHODS

Nine minor league starting pitchers participated in the study with data collected for 22 individual starts. IR, ER and TAM were measured in the throwing shoulder and non-throwing shoulder at three time points for each appearance: before, immediately following, and at 24 hours following the pitching appearance.

RESULTS

In the throwing arm, IR significantly decreased (49.4 vs 46.0, p = 0.037) immediately after pitching, and ER significantly increased immediately following an appearance (150.7 vs 153.6, p = 0.030) and at 24 hours (150.7 vs 154.0, p = 0.028). No difference was detected in throwing arm TAM and IR at 24 hours, or TAM immediately following an appearance.

CONCLUSIONS

Minor league pitchers demonstrate the dynamic glenohumeral ROM changes after starting appearances of increased ER and diminished IR with maintenance of TAM. At 24 hours, the observed loss of IR had resolved, whereas the gains in ER remained present. Our study supports the need to further assess the acute changes of glenohumeral ROM in pitchers, and the association of acute glenohumeral ROM change with the development of pathologic ROM profiles and injury.

Mechanisms of Shoulder Range of Motion Deficits in Asymptomatic Baseball Players

BACKGROUND

Shoulder range of motion (ROM) deficits have been identified as injury risk factors among baseball athletes. Despite the knowledge surrounding these risk factors, there is a lack of consensus regarding the specific tissues responsible for these deficits in ROM.

PURPOSE/HYPOTHESIS

The purpose of this study was to elucidate the primary mechanisms of posterior shoulder tightness (capsular, musculotendinous, bony) by examining the tissue responses that occur with the application of an acute intervention in baseball players with ROM deficits. The hypothesis was that posterior rotator cuff stiffness, not glenohumeral joint mobility, would be primarily responsible for ROM gains observed within an acute treatment setting.

STUDY DESIGN

Controlled laboratory study.

METHODS

Through use of ultrasound elastography, electromagnetic motion analysis, and ultrasound imaging, posterior rotator cuff stiffness, glenohumeral joint translation, and humeral torsion were examined in 60 asymptomatic baseball players (age, mean ± SD, 19 ± 2 years) with shoulder ROM deficits. Tissue mechanisms were examined concurrently, with the ROM gains elicited by an acute application of instrument-assisted soft tissue mobilization plus self-stretching (n = 30) versus self-stretching only (n = 30). Separate 3-way analyses of variance (group × arm × time) and linear regression analyses were used to determine the treatment effects and relationships between tissue mechanisms and ROM gains.

RESULTS

ROM gains were associated with decreases in rotator cuff stiffness (internal rotation: r = 0.35, P = .034; horizontal adduction: r = 0.44, P = .008) and increased humeral retrotorsion (internal rotation: r = -0.35, P = .034), not joint translation (P > .05). Players receiving instrument-assisted soft tissue mobilization plus stretching displayed greater shoulder ROM gains (internal rotation, +5° ± 2° [P = .010]; total arc of motion, +8° ± 6° [P = .010]; horizontal adduction, +7° ± 2° [P = .004]; and decreased posterior rotator cuff stiffness, -0.2 ± 0.3 kPa [P = .050]) compared with players receiving self-stretching alone.

CONCLUSION

Decreases in rotator cuff stiffness were associated with acute ROM gains in baseball players. The study results show that changes in rotator cuff stiffness, not glenohumeral joint mobility or humeral torsion, are most likely associated with the ROM deficits observed in adolescent baseball players.

CLINICAL RELEVANCE

Reducing rotator cuff stiffness may be beneficial in improving the ROM deficits associated with injury risk in overhead athletes.

Humeral retroversion and shoulder rotational mobility in young handball practitioners

OBJECTIVE

: To evaluate the prevalence of humeral retroversion and rotational mobility (RHH) in young handball practitioners and non-practitioners.

METHODS

: This is a cross-sectional study performed with two groups: the handball group, with 14 female students practicing handball and the control group, with 13 young participants non-practicing pitch sports.

RESULTS

: The handball group presented full rotational movement (FRM) hi-gher than the control group in both the dominant shoulder (p=0.001) and the non-dominant shoulder (p=0.0001). The mobility of active and passive internal rotation was significantly higher in handball players in both shoulders. The handball group presented lower internal rotation range of motion for the dominant shoulder as compared to the non-dominant shoul-der (p=0.001).

CONCLUSION

: Young handball practitioners, des-pite skeletally immature, showed a higher MRT than the control group. The handball group showed loss of internal rotation (medial) on the dominant shoulder as compared to the non--dominant shoulder. Level of Evidence II, Prospective Study.

Deficits in Glenohumeral Passive Range of Motion Increase Risk of Shoulder Injury in Professional Baseball Pitchers: A Prospective Study

BACKGROUND

Shoulder injuries from repetitive baseball pitching continue to be a serious, common problem.

PURPOSE

To determine whether passive range of motion of the glenohumeral joint was predictive of shoulder injury or shoulder surgery in professional baseball pitchers.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Passive range of motion of the glenohumeral joint was assessed with a bubble goniometer during spring training for all major and minor league pitchers of a single professional baseball organization over a period of 8 successive seasons (2005-2012). Investigators performed a total of 505 examinations on 296 professional pitchers. Glenohumeral external and internal rotation was assessed with the pitcher supine and the arm abducted to 90° in the scapular plane with the scapula stabilized anteriorly at the coracoid process. Total rotation was defined as the sum of internal and external glenohumeral rotation. Passive shoulder flexion was measured with the pitcher supine and the lateral border of the scapula manually stabilized. After examination, shoulder injuries and injury durations were recorded by each pitcher's respective baseball organization and reported to the league as an injury transaction as each player was placed on the disabled list.

RESULTS

Highly significant side-to-side differences were noted within subjects for each range of motion measurement. There were 75 shoulder injuries and 20 surgeries recorded among 51 pitchers, resulting in 5570 total days on the disabled list. Glenohumeral internal rotation deficit, total rotation deficit, and flexion deficit were not significantly related to shoulder injury or surgery. Pitchers with insufficient external rotation (<5° greater external rotation in the throwing shoulder) were 2.2 times more likely to be placed on the disabled list for a shoulder injury (P = .014; 95% CI, 1.2-4.1) and were 4.0 times more likely to require shoulder surgery (P = .009; 95% CI, 1.5-12.6).

CONCLUSION

Insufficient shoulder external rotation on the throwing side increased the likelihood of shoulder injury and shoulder surgery. Sports medicine clinicians should be aware of these findings and develop a preventive plan that addresses this study's findings to reduce pitchers' risk of shoulder injury and surgery.

The Development of Humeral Retrotorsion and Its Relationship to Throwing Sports

Context:

Several investigations have noted that throwing athletes exhibit a more posteriorly oriented humeral head (humeral retrotorsion) in the dominant arm. This asymmetry is believed to represent an adaptive response to the stress of throwing that occurs during childhood. The significance of this alteration and factors that affect its development are currently not clear.

Evidence Acquisition:

Basic science, research studies, and review articles were searched through PubMed with search terms including humeral torsion, humeral retrotorsion, and with 1 of the following: pediatric, adult, baseball, pitching, shoulder, and range of motion. The references from each article were reviewed for further inclusion. This review included articles through March 2015.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results:

The throwing motion creates stressors that result in bony adaptations that occur while skeletally immature. These osseous changes likely contribute to the observed shift in the arc of rotational range of motion noted in throwing athletes and may play a protective role against injury. However, too much or too little retrotorsion may predispose the shoulder to injury. The degree of “optimal” humeral retrotorsion and factors that influence its development are not fully understood.

Conclusion:

Evidence supports the assertion that the throwing motion creates stressors that alter bony anatomy while young. It is important to determine what specific factors affect this adaptation and its relationship to injury.

Reliability of a New Clinical Instrument for Measuring Internal and External Glenohumeral Rotation

Background:

The shoulder plays a critical role in many overhead athletic activities. Several studies have shown alterations in shoulder range of motion (ROM) in the dominant shoulder of overhead athletes and correlation with significantly increased risk of injury to the shoulder and elbow. The purpose of this study was to measure isolated glenohumeral joint internal/external rotation (IR/ER) to determine inter- and intraobserver reliability of a new clinical device.

Hypothesis:

(1) Inter- and intraobserver reliability would exceed 90% for measures of glenohumeral joint IR, ER, and total arc of motion; (2) the dominant arm would exhibit significantly increased ER, significantly decreased IR, and no difference in total arc of motion compared with the nondominant shoulder; and (3) a significant difference exists in total arc between male and female patients.

Study Design:

Case series.

Level of Evidence:

Level 4.

Methods:

Thirty-seven subjects (mean age, 23 years; range, 13-54 years) were tested by 2 orthopaedic surgeons. A single test consisted of 1 arc of motion from neutral to external rotation to internal rotation and back to neutral within preset torque limits. Each examiner performed 3 tests on the dominant and nondominant shoulders. Each examiner completed 2 installations.

Results:

Testing reliability demonstrated that neither trial, installation, nor observer were significant sources of variation. The maximum standard deviation was 1.3° for total arc of motion and less than 2° for most other measurements. Dominant arm ER was significantly greater than nondominant arm ER (P = 0.02), and dominant arm IR was significantly less than nondominant arm IR (P = 0.00). Mean total rotation was 162°, with no significant differences in total rotation between dominant and nondominant arms (P = 0.34). Mean total arc of motion was 45° greater in female subjects. Differences in total arc of motion between male and female subjects was statistically significant (P < 0.00).

Conclusion:

This simple, clinical device allows for both inter- and intraobserver reliability measurements of glenohumeral internal and external rotation.

Professional Pitchers With Glenohumeral Internal Rotation Deficit (GIRD) Display Greater Humeral Retrotorsion Than Pitchers Without GIRD

BACKGROUND

Dominant shoulder glenohumeral internal rotation deficit (GIRD) has been associated with pitching arm injuries. The relationship of humeral torsion on development of GIRD is not clear.

HYPOTHESIS

Pitchers displaying GIRD will display greater humeral retrotorsion when compared with those without GIRD.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Humeral torsion and shoulder range of motion (ROM) were measured in 222 professional pitchers before spring training from 2009 to 2012. Shoulder external rotation (ER) and internal rotation (IR) ROM were assessed in 90° of abduction with the scapula stabilized. Humeral torsion was measured via ultrasound using previously described and validated methods. Side-to-side differences in total arc of motion (ER + IR), ER, and IR ROM and humeral torsion were calculated as nondominant minus dominant arm measures for analysis. Pitchers were classified as having GIRD if their dominant arm displayed an IR deficit ≥15° concomitant with a total arc of motion deficit ≥10° compared with their nondominant arm. A mixed-model analysis of variance (side × GIRD) was used to compare dominant and nondominant humeral torsion between pitchers with GIRD (n = 60) and those without GIRD (n = 162). Independent t tests were used to compare the side-to-side difference in humeral torsion between pitchers with GIRD and those without GIRD (α = 0.05).

RESULTS

Pitchers with GIRD displayed significantly less humeral torsion (ie, greater retrotorsion) in their dominant arm as compared with those without GIRD (GIRD = 4.5° ± 11.8°, no GIRD = 10.4° ± 11.7°; P = .002). Pitchers with GIRD also displayed a greater side-to-side difference in humeral torsion (GIRD = 19.5° ± 11.9°, no GIRD = 12.3° ± 12.4°; P = .001). However, pitchers with GIRD did not display an increase in dominant ER ROM (dominant ER = 131.8° ± 14.3°, nondominant ER 126.6° ± 13.1°) when compared with those without GIRD (dominant ER = 132.0° ± 14.2°, nondominant ER 122.6° ± 13.1°; P = .03). Pitchers with GIRD displayed expected alterations in ROM (IR = 28.8° ± 9.6°, total arc = 160.6° ± 15.4°; P < .01 for both) when compared with those without GIRD (IR = 39.9° ± 9.9°, total arc = 171.2° ± 15.5°).

CONCLUSION

Pitchers with GIRD displayed greater side-to-side differences and dominant humeral retrotorsion as compared with those without GIRD. The greater humeral retrotorsion may place greater stress on the posterior shoulder resulting in ROM deficits. Pitchers with greater humeral retrotorsion appear to be more susceptible to developing ROM deficits associated with injury and may need increased monitoring and customized treatment programs to mitigate their increased injury risk.

The effect of glenohumeral internal rotation deficit on the isokinetic strength, pain, and quality of life in male high school baseball players

Objective

To investigate the effects of glenohumeral internal rotation deficit (GIRD) on the isokinetic strength, body pain, and the quality of life in male high school baseball players of Korea.

Methods

Fifty-six male high school baseball players were divided into either group A (GIRD≥20°, n=12) or group B (GIRD<20°, n=44). The range of motion in the shoulder and the isokinetic strength were measured. Questionnaires were administered regarding the body pain location by using the visual analogue scale, and the quality of life was measured by using the SF-36 Form.

Results

All subjects had increased external rotation range of motion and decreased internal rotation in the throwing shoulder. The incidence of GIRD (≥20°) was 21.43% in the present study. In the isokinetic strength test, a significantly weaker muscular state at an angular velocity of 180°/s was observed in group A, compared to group B. For the comparison of the pain, the frequency of shoulder pain was higher (33.93%) than other body pain, among the study subjects.

Conclusion

GIRD is one of the main risk factors of glenohumeral joint damage, and it is correlated with reduced isokinetic strength and quality of life. High school baseball players will need appropriate shoulder rehabilitation programs for the improvement in their quality of life and performance.

Current rehabilitation applications for shoulder ultrasound imaging

The available body of knowledge on shoulder ultrasound imaging has grown considerably within the past decade, and physical therapists are among the many health care professions currently exploring the potential clinical integration of this imaging technology and the knowledge derived from it. Therefore, the primary purpose of this commentary was to review the recent evidence and emerging uses of ultrasound imaging for the clinical evaluation of shoulder disorders. This includes a detailed description of common measurement techniques along with their known clinimetric properties. Specifically provided are critical appraisals of the existing measures used to estimate soft tissue and bony morphometry, muscle contractile states, and lean muscle density. These appraisals are intended to help clinicians clarify the scope of physical therapy practice for which these measurement techniques are effectively utilized and to highlight areas in need of further development.

Range of motion and isometric strength of shoulder joints of team handball athletes during the playing season, Part II: changes after midseason

OBJECTIVE

Our objective was to investigate the influence of workload and consecutive changes on active range of motion and isometric strength of team handball athletes' throwing shoulders (TSs) because the available data are insufficient.

METHODS

In a longitudinal investigation, 31 professional male handball athletes underwent a clinical shoulder examination. Athletes were examined at the beginning (week 0), at the end (week 6) of the preseasonal training, and at the end of the half-season (week 22) on both shoulders to determine isometric rotational strength (hand held dynamometer) and active range of motion (goniometer).

RESULTS

This analysis demonstrates the results subsequently from week 6 to week 22 and from week 0 to week 22. The glenohumeral internal rotation (IR) deficit (GIRD), external rotation (ER) gain, and ER at the TS increased significantly (P < .05, η(2) > 0.10, d > 0.30) in the first sequence (week 6 to week 22) but not significantly from week 0 to week 22. The total range of motion remained stable, and IR changed but not significantly. There was no influence on IR, ER, and total range of motion at the non-TS. The isometric strength of the TS and non-TS IR did not change. The isometric strength in ER significantly increased bilaterally during the investigation period.

CONCLUSIONS

Our data verify changes and influences, such as an increasing GIRD, at the overhead TS joint in accordance with the workload during team handball season. ER gain did improve after the half-season period but did not fully compensate the GIRD at the TS.

Acquired and adaptive changes in the throwing athlete: implications on the disabled throwing shoulder

The throwing shoulder continues to be one of the most actively studied and poorly understood aspects of sports medicine. The act of throwing itself transfers tremendous power throughout the kinetic chain, resulting in forces experienced in the shoulder that can exceed its physiologic limits. These forces over time lead to many adaptive changes in the bone, capsule, and muscular structures of the shoulder girdle. An understanding of these acquired changes is critical to differentiate between normal or protective adaptation and pathologic change. The purposes of this article were to elucidate the adaptive and acquired changes, which commonly develop in the throwing shoulder, to explain how these changes contribute in both protective and pathologic roles, and to apply these principles into a deeper understanding of the care of the disabled throwing shoulder.

Nonoperative and postoperative rehabilitation for injuries of the throwing shoulder

The repetitive overhead motion involved in throwing is responsible for unique and sport-specific patterns of injury to the shoulder joint. Specific strengthening and flexibility plays a vital role in the ultimate function and injury prevention in the overhead-throwing athlete. The clinician must achieve a delicate balance between mobility and stability, which often presents as a significant challenge. Most shoulder injuries in the overhead thrower can be successfully treated nonoperatively to allow the athlete to return to competition. A well-structured, in-season strengthening program that is designed to maintain the athlete's strength, power, and endurance while not inhibiting with the athlete's ability to compete on a regular basis is critical.

Understanding and evaluating shoulder pain in the throwing athlete

Shoulder pain in the throwing athlete can present at any age and in any level of sport and can lead to dysfunction. A thorough evaluation of the throwing athlete can often determine the cause of symptoms, which is frequently multifactorial. Although the pathophysiology leading to pain in the shoulder of the throwing athlete is not entirely known, nonoperative modalities remain the mainstay of treatment. In general, surgical intervention should be reserved as a last resort. Effective treatment often requires collaboration among trainers, players, physicians, and therapists to determine an appropriate course of action.

Reliability of measurement of glenohumeral internal rotation, external rotation, and total arc of motion in 3 test positions

CONTEXT

Athletes who participate in throwing and racket sports consistently demonstrate adaptive changes in glenohumeral-joint internal and external rotation in the dominant arm. Measurements of these motions have demonstrated excellent intrarater and poor interrater reliability.

OBJECTIVE

To determine intrarater reliability, interrater reliability, and standard error of measurement for shoulder internal rotation, external rotation, and total arc of motion using an inclinometer in 3 testing procedures in National Collegiate Athletic Association Division I baseball and softball athletes.

DESIGN

Cross-sectional study.

SETTING

Athletic department.

PATIENTS OR OTHER PARTICIPANTS

Thirty-eight players participated in the study. Shoulder internal rotation, external rotation, and total arc of motion were measured by 2 investigators in 3 test positions. The standard supine position was compared with a side-lying test position, as well as a supine test position without examiner overpressure.

RESULTS

Excellent intrarater reliability was noted for all 3 test positions and ranges of motion, with intraclass correlation coefficient values ranging from 0.93 to 0.99. RESULTS for interrater reliability were less favorable. Reliability for internal rotation was highest in the side-lying position (0.68) and reliability for external rotation and total arc was highest in the supine-without-overpressure position (0.774 and 0.713, respectively). The supine-with-overpressure position yielded the lowest interrater reliability results in all positions. The side-lying position had the most consistent results, with very little variation among intraclass correlation coefficient values for the various test positions.

CONCLUSIONS

The results of our study clearly indicate that the side-lying test procedure is of equal or greater value than the traditional supine-with-overpressure method.

Deficits in glenohumeral passive range of motion increase risk of elbow injury in professional baseball pitchers: a prospective study

BACKGROUND

Injuries to the elbow joint in baseball pitchers appear common. There appears to be a correlation between shoulder range of motion and elbow injuries.

PURPOSE

To prospectively determine whether decreased ROM of the throwing shoulder is correlated with the onset of elbow injuries in professional baseball pitchers.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

For 8 consecutive years (2005-2012), passive range of motion of both the throwing and nonthrowing shoulders of all major and minor league pitchers within a single professional baseball organization were measured by using a bubble goniometer during spring training. In total, 505 examinations were conducted on 296 pitchers. Glenohumeral external rotation and internal rotation were assessed in the supine position with the arm at 90° of abduction and in the plane of the scapula. The scapula was stabilized per methods previously established. Total rotation was defined as the sum of external rotation and internal rotation. Passive shoulder flexion was assessed with the subject supine and the scapula stabilized per methods previously established. Elbow injuries and days missed because of elbow injuries were assessed and recorded by the medical staff of the team. Throwing and nonthrowing shoulder measurements were compared by using Student t tests; 1-tailed Fisher exact tests were performed to identify significant associations between shoulder motion and elbow injury. Nominal logistic regression was performed to determine the odds of elbow injury.

RESULTS

Significant differences were noted during side-to-side comparisons within subjects. There were 49 elbow injuries and 8 surgeries in 38 players, accounting for a total of 2551 days missed. Neither glenohumeral internal rotation deficit nor external rotation insufficiency was correlated with elbow injuries. Pitchers with deficits of >5° in total rotation in their throwing shoulders had a 2.6 times greater risk for injury. Pitchers with deficit of ≥5° in flexion of the throwing shoulder had a 2.8 times greater risk for injury.

CONCLUSION

Bilateral differences in shoulder total rotation and flexion had a significant effect on the risk for elbow injuries in pitchers. Clinicians need to be aware of these findings and plan preventive programs that address these issues in hopes of reducing elbow injuries.

Does adding a 12-month exercise programme to usual care after a rotator cuff repair effect disability and quality of life at 12 months? A randomized controlled trial

Objective:

To compare a 12-month home-based exercise programme with usual care for disability and health-related quality of life after rotator cuff repair.

Design:

Randomized controlled trial.

Setting:

Outpatient physical and rehabilitation medicine clinic.

Subjects:

Consecutive patients ( n = 67, mean age 54 years) who underwent rotator cuff repairs were randomized into an experimental group (EG) or a usual care group (UCG).

Interventions:

The UCG received ordinary postoperative instructions, while the EG were given advice and instructions on a shoulder muscle strengthening programme to be undertaken at home.

Main measures:

Disability was assessed with the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and quality of life with the Short-Form 36 Health Survey (SF-36).

Results:

At the follow-up, no between-group differences were observed in any of the outcomes. The mean (SD) ASES score improved by 21 points (95% CI, 16 to 26, p < 0.001) in the EG from the baseline 74 (14) and by 25 points (95% CI, 20 to 31, p < 0.001) in the UCG from the baseline 70 (18). Both groups exhibited significant improvements ( p < 0.001) in the SF-36 physical component score. In the UCG, improvements were observed in the Social Functioning ( p = 0.034) and Role Emotional ( p = 0.003) dimensions. In the EG, 57% of the patients completed the exercises twice weekly for the first six months, after which training adherence declined.

Conclusions:

The home exercise programme and usual care were equally effective in improving disability and quality of life after rotator cuff repair. The extra time involved in teaching the home exercise programme is not warranted.

Dominant-limb range-of-motion and humeral-retrotorsion adaptation in collegiate baseball and softball position players

CONTEXT

Biomechanically, the motions used by baseball and softball pitchers differ greatly; however, the throwing motions of position players in both sports are strikingly similar. Although the adaptations to the dominant limb from overhead throwing have been well documented in baseball athletes, these adaptations have not been clearly identified in softball players. This information is important in order to develop and implement injury-prevention programs specific to decreasing the risk of upper extremity injury in softball athletes.

OBJECTIVE

To compare range-of-motion and humeral-retrotorsion characteristics of collegiate baseball and softball position players and of baseball and softball players to sex-matched controls.

DESIGN

Cross-sectional study.

SETTING

Research laboratories and athletic training rooms at the University of North Carolina at Chapel Hill.

PATIENTS OR OTHER PARTICIPANTS

Fifty-three collegiate baseball players, 35 collegiate softball players, 25 male controls (nonoverhead athletes), and 19 female controls (nonoverhead athletes).

INTERVENTION(S)

Range of motion and humeral retrotorsion were measured using a digital inclinometer and diagnostic ultrasound.

MAIN OUTCOME MEASURE(S)

Glenohumeral internal-rotation deficit, external-rotation gain, total glenohumeral range of motion, and humeral retrotorsion.

RESULTS

Baseball players had greater glenohumeral internal-rotation deficit, total-range-of-motion, and humeral-retrotorsion difference than softball players and male controls. There were no differences between glenohumeral internal-rotation deficit, total-range-of-motion, and humeral-retrotorsion difference in softball players and female controls.

CONCLUSIONS

Few differences were evident between softball players and female control participants, although range-of-motion and humeral-retrotorsion adaptations were significantly different than baseball players. The throwing motions are similar between softball and baseball, but the athletes adapt to the demands of the sport differently; thus, stretching/strengthening programs designed for baseball may not be the most effective programs for softball athletes.

Immediate effects and short-term retention of multi-modal instruction compared to written only on muscle activity during the prone horizontal abduction exercise in individuals with shoulder pain

In rehabilitation, exercise instructions are multi-modal and can include a focus of increasing mean activity of a target muscle and inhibiting aberrant synergistic muscle activity, particularly during shoulder exercises, such as the prone horizontal abduction (PHA). The objective was to compare the immediate effects and short-term retention of multi-modal exercise instruction by a physical therapist written only instruction on normalized mean upper and lower trapezius muscle activity during three phases (concentric/isometric/eccentric) versus of an isotonic PHA exercise between participants with and without shoulder pain. Surface electromyography (EMG) was recorded from fourteen healthy participants and twelve participants with shoulder pain during the PHA exercise under two conditions: (1) written only instructions and (2) multi-modal instruction. Retention of multi-modal instruction on muscle activity was assessed one week later. Results demonstrate 12.8-16.0% increase in lower trapezius muscle activity during the concentric and isometric phases with multi-modal instructions in both groups. Inhibition of the upper trapezius did not occur in either group. Facilitation effects were maintained in short-term follow-up. Findings suggest that regardless of shoulder pain, multi-modal instruction by a physical therapist facilitates greater neuromuscular activity of a targeted muscle compared to written instructions alone and these effects are retained.