Nonoperative and postoperative rehabilitation for injuries of the throwing shoulder

In Season Return to Play Issues for the Baseball Player

Major League Baseball has one of the most physically demanding schedules in professional sports. It is common for injuries to occur because of the volume of games and generally most of the injuries are from overuse and fatigue. This article will outline some injuries in baseball that sideline the athlete for some time but when treated adequately allow players to return-to-sport in the same season. Managing these injuries with established return-to-play protocols will also be detailed.

Criterion-Based Rehabilitation and Return to Play in Fast Bowlers Following Arthroscopic Bankart Repair: Recommendations Based on a Detailed Clinical Review

Background

Anterior shoulder instability due to labral tears in the dominant arm of cricket fast bowlers can be particularly disabling and results in significant match time loss. This often follows injuries sustained during fielding and training, although micro-instability following repetitive throwing progressing to overt anterior shoulder instability is also known. To ensure ball release speeds of over 140 km/h with different ball variations, these athletes require not only physical fitness and technical skill, but also a completely stable shoulder.

Methods

A literature search of "MEDLINE", "SPORT DISCUSS", and "GOOGLE SCHOLAR" was done to identify relevant articles published till the year 2023.

Results

A treatment approach that involves anatomic restoration of the shoulder via an arthroscopic Bankart capsulo-labral repair, followed by functional and biomechanical restoration via rehabilitation is the most predictable method to ensure a successful return to pre-injury fast-bowling status. A post-operative rehabilitation program that ensures a quick return to fast bowling without disrupting the surgical repair is crucial. Timely integration of exercises to recruit and strengthen the kinetic chain used for bowling and throwing plays a key role in this faster recovery. This current review provides a phase-wise, evidence-based rehabilitation guideline for return to competitive cricket after arthroscopic Bankart repair in a fast bowler. This review also highlights a structured return to bowling, throwing, and fielding program with a clinical decision-making process.

Conclusion

Exercise selection at an early stage that does not compromise the healing tissue, and timely integration of workouts to recruit and strengthen the kinetic chain used for bowling and throwing is the key strategy to allow faster recovery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00931-5.

Postoperative Rehabilitation After Superior Labrum Anterior Posterior Repair

The 4-phase rehabilitation protocol outlined in this article provides a comprehensive 26-week program to return patients with superior labrum anterior posterior repairs to their preinjury states. It is guided by the principle of gradual return to preinjury function while preserving the integrity of the surgical repair. Objective criteria are present at the conclusion of each phase to ensure patients are progressing appropriately. The goal is to allow patients to return to their previous functional ability in their sport-specific or occupational-specific training.

Glenohumeral Internal Rotation Deficit in the Adolescent Overhead Athlete: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this review was to investigate the average glenohumeral internal rotation deficit (GIRD) in the dominant arm of adolescent overhead athletes and to examine the association with shoulder and elbow injuries.

DESIGN

Systematic review and meta-analysis.

SETTING

MEDLINE, Embase, and PubMed were searched from inception to August 1, 2020.

PARTICIPANTS

Adolescent overhead athletes with glenohumeral range of motion (ROM) measurements.

INTERVENTIONS

Nonoperative treatments of GIRD.

MAIN OUTCOME MEASURES

Glenohumeral ROM measurements comparing the dominant and nondominant extremities were pooled in a meta-analysis.

RESULTS

Twenty-five studies were included in this review, which involved 2522 overhead athletes. Pooled internal rotation (IR) deficit of the dominant arm was 9.60° (95% confidence interval [CI] 7.87°-11.32°, P < 0.00001), with an external rotation (ER) gain of 6.78° (95% CI 4.97°-8.59°, P < 0.00001) and a total ROM (TROM) deficit of 1.78° (95% CI -0.70° to 4.26°, P = 0.16). The association between GIRD and shoulder or elbow injury was not clearly defined. Two studies reported treatment, and both used nonoperative treatment in the form of physiotherapy and sleeper stretches.

CONCLUSIONS

The adolescent overhead athlete has roughly 10° of IR deficit in their dominant arm, accompanied by nearly 7° of ER gain, with similar ROM measurements for injured and uninjured athletes. Those with pathological GIRD have a greater degree of IR deficit, but without an accompanying compensatory increase in ER, leading to a TROM deficit of nearly 15°. Surgical treatment in the absence of other indications is rare, whereas physiotherapy and sleeper stretches remain the first-line treatment.

Impact of Different Isokinetic Movement Patterns on Shoulder Rehabilitation Outcome

Shoulder pain is regularly associated with limited mobility and limitations in activities of daily living. In occupational therapy, various interventions, including active isokinetic training with a Baltimore Therapeutic Equipment (BTE) Work Simulator, help the patient improve shoulder mobility and alleviate pain. This randomized controlled cohort study aims to evaluate the impact of different isokinetic movement patterns on the DASH score, pain, and objective performance measures, such as range of motion (ROM) and hand grip strength. Patients that participated in a specific 3-week inpatient orthopedic rehabilitation were divided into two groups. The first group (UNI-group, n = 9) carried out uniplanar exercises for shoulder flexion, abduction, and external rotation. The patients in the second group (ADL-group, n = 10) imitated multiplanar everyday movements, such as climbing on a ladder, loading a shopping cart, and raising a glass to their mouth. Compared to the UNI-group, the ADL-group improved significantly in DASH scores (mean -10.92 ± 12.59 vs. -22.83 ± 11.31), pain (NPRS -1.11 ± 2.37 vs. 3.70 ± 2.00), and shoulder abduction (+2.77 ± 15.22 vs. +25.50 ± 21.66 degrees). In conclusion, the specific BTE exercise program with multiplanar movement patterns contributed considerably to the therapeutic improvement.

Posterior Labral Injury and Glenohumeral Instability in Overhead Athletes: Current Concepts for Diagnosis and Management

Posterior glenohumeral instability in overhead athletes presents a unique set of challenges for both diagnosis and treatment. Although a great deal of attention has been focused on the management of injuries to the biceps-labrum complex and rotator cuff in throwers, comparatively less has been written about posterior glenohumeral instability within this unique cohort. Historically, posterior instability has been observed secondary to either acute trauma or repetitive microtrauma, usually among collision athletes, weight lifters, and rowers. However, posterior glenohumeral instability resulting from pathology of the posterior capsulolabral tissues in throwers is a different entity, and the clinical assessment begins with an accurate differentiation between adaptive capsular laxity and labral injury with pathologic instability. Some posterior capsule labrum tears confirmed on arthroscopy will require nothing more than débridement. However, for more extensive lesions, surgical treatment must balance the necessity to repair torn capsulolabral tissues with the tendency to over constrain the shoulder. The literature provides mixed results regarding the likelihood of overhead athletes with posterior glenohumeral instability and labral injury treated surgically returning to their preinjury level of sport performance.

Glenohumeral Internal Rotation Deficit and Injuries: A Systematic Review and Meta-analysis

Background:

There is an association between throwing activity and glenohumeral internal rotation deficit (GIRD). An 18° to 20° deficit has been adopted as the standard definition of pathological GIRD, but specific findings as to how GIRD relates to an injury are inconsistent.

Purpose:

To systematically review the literature to clarify the definition of GIRD diagnosis for adolescent and adult overhead athletes and to examine the association between GIRD and an increased risk of injuries in these athletes.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review of the literature was performed. Observational studies comparing glenohumeral internal rotation range of motion (ROM) in injured and uninjured overhead athletes were included for the meta-analysis. Studies of adolescent and adult athletes were analyzed separately. ROM was compared for the injured and uninjured groups, and a weighted mean GIRD was estimated. To account for potential heterogeneity across studies, both fixed- and random-effects models were used to calculate a standardized mean difference (SMD).

Results:

Nine studies of level 3 or 4 evidence were included. From these, 12 study groups (4 adolescent, 8 adult) comprising 819 overhead athletes (226 injured, 593 uninjured) were included in the meta-analysis. The estimated SMD in GIRD between the injured and uninjured groups was 0.46 (95% CI, 0.15-0.77; P < .01) for the overall sample. The between-group effect was larger for adults (SMD, 0.60 [95% CI, 0.18 to 1.02]; P < .01) than adolescents (SMD, 0.20 [95% CI, –0.24 to 0.63]; P = .13). The weighted mean GIRD for the injured and uninjured groups was 13.8° ± 5.6° and 9.6° ± 3.0°, respectively, which also differed by age group. Moderate study heterogeneity was observed (I² = 69.0%).

Conclusion:

Based on this systematic review, the current definition of pathological GIRD may be too conservative, and a distinct definition may be required for adolescent and adult athletes. While the results indicate a link between internal rotation deficits and upper extremity injuries in the overhead athlete, higher quality prospective research is needed to clarify the role that GIRD plays in future injuries to overhead athletes of various ages.

Glenohumeral internal rotation deficit in throwing athletes: current perspectives

Glenohumeral internal rotation deficit (GIRD) is an adaptive process in which the throwing shoulder experiences a loss of internal rotation (IR). GIRD has most commonly been defined by a loss of >20° of IR compared to the contralateral shoulder. Total rotational motion of the shoulder is the sum of internal and external rotation and may be more important than the absolute value of IR loss. Pathologic GIRD has been defined as a loss of IR combined with a loss of total rotational motion. The leading pathologic process in GIRD is posterior capsular and rotator-cuff tightness, due to the repetitive cocking that occurs with the overhead throwing motion. GIRD has been associated with numerous pathologic conditions, including posterior superior labral tears, partial articular-sided rotator-cuff tears, and superior labral anterior-to-posterior tears. The mainstay of treatment for patients with GIRD is posterior capsular stretching and strengthening to improve scapular mechanics. In patients who fail nonoperative therapy, shoulder arthroscopy can be performed. Arthroscopic surgery in the high-level throwing athlete should be to restore them to their functional baseline with the minimum amount of intervention possible.

Exercise prescription for overhead athletes with shoulder pathology: a systematic review with best evidence synthesis

OBJECTIVE

To produce a best evidence synthesis of exercise prescription used when treating shoulder pathology in the overhead athlete.

DESIGN

A systematic review of exercises used in overhead athletes including case studies and clinical commentaries.

DATA SOURCES

MEDLINE, PubMed, SPORTDiscus and CINAHL from database inception through July 8, 2016.

METHODS

We examined data from randomised controlled trials and prospective cohort (level I-IV evidence) studies that addressed exercise intervention in the rehabilitation of the overhead athlete with shoulder pathology. Case studies and clinical commentaries (level V evidence) were examined to account for expert opinion-based research. Data were combined using best evidence synthesis and graded (A-F) recommendations (Centre for Evidence-Based Medicine).

RESULTS

There were 33 unique exercises in six level I-IV studies that met our inclusion criteria. Most exercises were single-plane, upper extremity exercises performed below 90^o of elevation. There were 102 unique exercises in 33 level V studies that met our inclusion criteria. These exercises emphasised plyometrics, kinetic chain and sport-specific training.

CONCLUSIONS AND RELEVANCE

Overall, evidence for exercise interventions in overhead athletes with shoulder pathology is dominated by expert opinion (grade D). There is great variability between exercise approaches suggested by experts and those investigated in research studies and the overall level of evidence is low. The strongest available evidence (level B) supports the use of single-plane, open chain upper extremity exercises performed below 90° of elevation and closed chain upper extremity exercises. Clinical expert pieces support a more advanced, global treatment approach consistent with the complex, multidimensional nature of sport.