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Little League Injury Prevention Program

12yo - ER tubing 1 Thanks to those in attendance at the MGH Sports Medicine 2010 program last weekend.  My last talk was on the prevention of youth throwing injuries.  We discussed many of the topics associated with little league throwing injuries, including the use of injury prevention and strength and conditioning programs.

In the past, I developed a basic 10-exercise core program for youth athletes to help prevent throwing injuries.  This has been on the MGH Sports Medicine website for a couple of years now but thought it would be a good time to share here as well.

The concept behind the program isn’t rocket science – keep it simple!  I selected my top 10 basic exercises to address weaknesses that could be harmful for Little League pitchers.  This is from my past experience working with athlete of all levels and some of my research articles on exercise selection (check out my latest article in JOSPT).  One thing I have learned over the years is that an adolescent athlete performing ANY injury prevention program is better than NO program at all!  However, as always there is a BETTER way as well.

Below is a copy of this program but be sure to also visit MGH Sports Medicine’s site for more information.

Youth Throwing Injury Prevention Program

Reinold Little League Program

Does Reaching Behind the Back Reflect the Actual Internal Rotation of the Shoulder?

image It is no secret that I am not a big fan of stretching the shoulder behind the back to gain internal rotation.  I have written about this in the past and even included it in my list of the 5 least favorite exercises.  I received a lot of feedback for this opinion, both positively and negatively. 

Many people agree with me that this is an aggressive stretch and puts the rotator cuff in an extremely disadvantageous position while many argued that it is still a position of function for their patients.

Apparently I am not the only one who has questioned this in the past as I have come across some research studies that assess if reaching behind the back (BTB) is an accurate measurement of internal rotation.  This isn’t exactly the stretch that I dislike, but more of using the hand-behind-the-back technique to measure range of motion.

 

What Does the Research Say?

image Wakabayashi et al (JSES 2006) used electromagnetic tracking to assess the amount of shoulder internal rotation, extension, abduction, and elbow extension during this BTB movement.  The authors report that the majority of internal rotation at the shoulder occurs before the patient reaches the sacrum.  There is also a significant increase in shoulder extension and abduction to reach the sacrum.   After the hand passes the sacrum, the majority of motion is achieved by flexing the elbow.  After the hand passes T12, there is no significant increase in internal rotation.  So it appears that getting to the sacrum is the key to this motion and that shoulder internal rotation, abduction, and extension can all limit the ability to get to the sacrum.

Mallon et al (JSES 1996) uses radiographs in healthy individuals to assess contributing motions and concluded that 35% of the BTB motion actually occurs at the scapulothoracic joint.  They also agreed that elbow flexion was an important component of this motion and considered the BTB position invalid. 

More recently, Ginn et al (JSES 2006) assess the validity of the BTB motion in assessing a loss of internal rotation in a group of 137 subjects with shoulder pain.  The measured the BTB motion as well as standard goniometer of the shoulder IR at 45 and 90 degrees of abduction.  The results showed only a low to moderate correlation between the motions, the ability to reach behind the back did not correlate to loss of active IR of the shoulder.

 

Clinical Implications

Ok so what does all of this mean?  Here are my thoughts:

  • Reaching behind the back is not a valid measurement for internal rotation.  The motion is created by the combination of scapula tilt, shoulder internal rotation, abduction, extension, and elbow flexion.  Any combination of these factors will influence this motion.
  • Be careful when using a shoulder outcome scale that uses the BTB motion to quantify shoulder internal rotation.  Unfortunately some do, including the Constant scale and the American Shoulder Elbow Surgeons (ASES) scale.
  • If you want to measure internal rotation of the shoulder, actually measure internal rotation of the shoulder.  Grab that old goniometer out of the dusty drawer, it is actually pretty handy!
  • Don’t make treatment implications based on the BTB motion.  For example, don’t perform posterior capsule joint mobilizations on a person just because they can’t reach behind their back.

Based on all of this, what about the person that has a limitation with this movement, what should we do?

  • I understand and agree that this is a position of function.
  • I still recommend avoiding this as a stretch.  I have never had good outcomes and I really believe you are putting the shoulder joint and rotator cuff in a terrible position.  I talk about this in more detail in these past two posts on my 5 least favorite exercise here and here.
  • Use the information from these studies to explore why a person doesn’t have good BTB motion.  Assess the scapula, shoulder extension, abduction, and elbow flexion.  Don’t just assume it is all IR. 

If you are interested in more information about how I treat the shoulder, check out my Optimal Shoulder Performance DVD with Eric Cressey and some of my DVDs at AdvancedCEU.com.

I am sure there are a lot of people that have more thoughts, what do you think?  Agree with me?  Disagree?  Why?

 

 

 

Wakabayashi, I., Itoi, E., Minagawa, H., Kobayashi, M., Seki, N., Shimada, Y., & Okada, K. (2006). Does reaching the back reflect the actual internal rotation of the shoulder? Journal of Shoulder and Elbow Surgery, 15 (3), 306-310 DOI: 10.1016/j.jse.2005.08.022

The Wrong Way to do Shoulder Exercises

A couple of weeks ago I posted on the relationship of shoulder impingement and poor ratios of upper and lower trapezius strength.  For those that follow my writings, you’ll know that I am constantly stating that we need to emphasize lower trapezius strength to optimize shoulder performance.

I often see people recommending that their patients retract their scapulas during shoulder exercises to put the body in “proper posture.”  Well, if you are not careful, you may run into a good amount of people that don’t retract well and tend to shrug.  This is again the upper trap dominance that we see so commonly.  These people tend to pull their shoulders back and UP, not back and DOWN.  A big difference.

Watch this video for an example.  Notice that the person is shrugging while they retract.  One simple technique that I do to correct this is to have the person just bilaterally externally rotate their shoulders (similar to the “W” exercise that I talk about in last years JOSPT article) to get their shoulders back and down.  This recruits the external rotators and the lower trapezius.  Then hold this position and repeat the exercise.  You can see the noticeable improvement in technique.

Upper and Lower Trapezius Imbalances May Cause Subacromial Impingement

image A new journal article in Physical Therapy in Sport (the journal I recently reviewed) discusses imbalance between upper and lower trapezius muscle activity and the association of subacromial shoulder impingement.

The authors studied the EMG activity of the upper and lower trapezius in subjects with and without subacromial impingement.  Results show that subjects with impingement had a greater ratio of upper to trapezius to lower trapezius than the control group.  There was a large difference in group size (16 impingement subjects, 32 control), which is a limitation, I wonder why they choose to include so many controls.

Asymptomatic subjects had an upper trap (UT) to lower trap (LT) ratio of 1.80 while symptomatic subjects had a ratio of 3.15.  What this means is that the upper trapezius is a little more than 3 times more active than the lower trapezius during scapular plane elevation in patients with subacromial impingement.  This was a statistically significant finding.

Clinical Implications

I have noticed this imbalance in many shoulder patients as well and have always attempted to emphasize lower trapezius strengthening.  This is a part of what goes into my shoulder impingement treatments.

The authors also attempted to demonstrate that taping would then alter this imbalance and showed that upper trapezius activity was reduced after taping (lower trapezius remained the same).  While I commend the authors for attempting to tape and alter this imbalance, I would also state that this imbalance exists for a reason, and while it would be appropriate to try to reduce upper trapezius activity, I tend to focus on the following clinical guidelines:

  • Strengthen the lower trapezius.  This is a common area of weakness in shoulder patients.  See my article on shoulder exercises from JOSPT for some examples of good exercises for the lower trapezius.
  • Educate the patient during exercises to contract the lower trapezius and not the upper trapezius while elevating the arm.  I see this all the time.  I have even seen patients that attempt to “retract” the shoulder during exercises and inadvertently end up with predominantly the upper trapezius.  When you instruct people to “retract” or “pinch their shoulder blades” the emphasis should be back and DOWN.  I bet the majority of people will actually shrug their shoulders back and UP if not instructed properly.  I will work on a video of this to post over the next week or so.
  • Also consider the upper-cross syndrome.  This concept is discussed extensively in Janda and Chaitow’s works.  Inhibition of the lower trap is often associate with inhibition of the deep neck flexors and shortening of the pectoralis muscles, upper trapezius, and levator scapulae.  Attempting to address just one of these deficiencies will likely result in poor outcomes as the global issues have not all be corrected.  When you look at the image below, is it difficult to figure out why this is so prevalent in our population?

image    image

As this type of posture, muscle imbalance, and shoulder pain continue to become more and more prevalent in our society, what else have you done to try to help people like this?  What else have you focused on?

Arthroscopic Rotator Cuff Repair – A Prospective Evaluation of Tendon Integrity at 1- and 2-Years

massive RTC scope The amount of arthroscopic rotator cuff repairs being performed has skyrocketed in recent years.  The last 20 years or so have seen the transition from a full open approach, to a combined arthroscopic and mini-open technique, to the current all-arthroscopic technique.  The implications on rehabilitation are enormous, as patients are recovering faster with less pain and surrounding tissue involvement.

Initially, the strength of these arthroscopic rotator cuff repairs was in question and still lagged behind the strength of the mini-open procedure.  But recently, more and more studies are being published that show the strength of the new techniques are comparable.

A recent study in AJSM prospectively evaluated the integrity of the rotator cuff repair in 127 patients at the 1-year and 2-year postoperative marks.  The authors used ultrasound to evaluate the tendons.

Results showed that:image

  • At one year, 68% had an intact rotator cuff.  32% had a full thickness tear again.
  • All the tendons that were intact at 1-year were still intact at 2-years.
  • Interestingly, 8% of the tendons that were not intact at 1-year were intact at 2-years.
  • All patients demonstrated significant improvement in ASES scores from baseline to 2-year follow-up.  Patients with intact cuffs had ASES scores of ~95 in comparison to ~86 with tendon defects.

Clinical Implications

The finding that all patients with an intact cuff at 1 year still were intact at 2-years is significant, showing that the repairs are providing good results over a decent amount of time.  In general, characteristics that led to more cases of intact rotator cuffs were:

  • Age – the younger the better.  All patients with cuff defects were > 60 years old.
  • Tear size – the smaller the better.  All patients with cuff defects had tears > 4cm.
  • Tendon involvement – the less the better.  75% of patients with cuff defects had more than one rotator cuff tendon intact.

It should also be noted that patients with an intact cuff demonstrated significantly great external rotation strength.

The finding that 32% had cuff tears sounds alarming at first but is in line with past reports on rotator cuff repairs.  This is a little known secret that we don’t promote to our patients, because, as this study and several other studies have shown, patients improve regardless of whether or not the cuff is intact.  The key comes down to rehab after surgery, as usual!

Nho SJ, Adler RS, Tomlinson DP, Allen AA, Cordasco FA, Warren RF, Altchek DW, & MacGillivray JD (2009). Arthroscopic rotator cuff repair: prospective evaluation with sequential ultrasonography. The American journal of sports medicine, 37 (10), 1938-45 PMID: 19531660

How Fast Do You Rehab Your Rotator Cuff Repair Patients?

That seems to be one of the most common questions I get regarding rehabilitation of the shoulder.  It seems like clinicians want to know how everyone else is rehabilitation their patients following rotator cuff repair surgery.  My guess is because most people feel that their physicians are too restrictive in their postoperative guidelines?  Does that sound like you?

DSC01366Unfortunately the most optimal rehabilitation progression following a cuff repair has not  been documented.  There are no research reports stating that one technique is better than another, that starting ROM immediately is better than not, or that avoiding isometrics for 12 weeks is safer for the repair than beginning immediately.

Notice above that I highlighted “optimal.”  That was a specific choice of wording.  Optimal can mean many things.  For these patients it could mean “safest rehabilitation progression” or even “most effective rehabilitation progression.”  But even those phrases are vague.

Let me ask you a question:

What is your definition of the optimal outcome following rotator cuff repair?

Is it that the patients returns to their premorbid work or athletic activity?  That the patient restores ROM and strength as quickly and safely as possible?  Or that the patient have an intact cuff repair when performing a MRI or ultrasound 2 years after surgery?

We may all have a different answer to that question, but let me share with your how I would answer.  The most optimal outcome following rotator cuff repair for me is having your patient return to their normal activities as quickly and safely as possible.  I would bet that if you asked this question to a surgeon, they would respond with the above comment regarding having the repair intact at time X after surgery.  I would also bet that if you ask the patient this same question, they would respond with something along the lines of “I want to be able to lift my arm overhead while doing [insert activity here!] without pain.”

What would you say if I told you that 35% of rotator cuff repair surgeries fail?  Again, I highlighted “fail” because I am talking about two research reports that examined the percentage of repairs that were still intact 5 years after surgery (Harryman: JBJS ‘91 & Fealy: Arthroscopy ‘02).  Here are some interesting findings:

  • 35% of all tears fail
  • 20% of supraspinatus repairs fail
  • 50% of repairs of two tendons fail
  • 68% of repairs of three tendons fail
  • 25% of repairs to people aged 34-55 fail
  • 35% of repairs to people aged 56-70 fail
  • 45% of repairs to people aged 71-85 fail

Pretty shocking, right?

This is the primary factor why I believe surgeons promote a decelerated rehabilitation approach – they do not want failure

Well how about this information, also from those studies:

  • 96% of patients with intact cuff report being satisfied
  • 87% without cuff intact are STILL satisfied

What does this mean to me?  This tells me that integrity of the repair is not the most optimal factor associated with success following rotator cuff repair.  I would argue that we should be more worried about satisfaction than integrity of the cuff

Now don’t get me wrong, I realize that if your cuff remains intact that you will likely have a better outcome.  I am just saying that I don’t believe that we need to be unnecessarily cautious and decelerate our rehabilitation approaches.

There are safe and effective ways to achieve satisfaction and integrity of the repair

Want to know how I believe we can achieve this?  Want to know how I rehabilitate my patients using what limited evidence we have?  Want to know what I do each week following surgery, and more importantly – why?

Click here to see more about how I rehabilitation rotator cuff repair patients and download free copy of my arthroscopic rotator cuff repair protocol.

Harryman DT 2nd et al (1991). Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff J Bone joint Surg, 73 (7), 982-989 DOI: 12098132

The Rationale Behind Shoulder Exercises

imageI am lucky to be able to share my latest journal article from this month’s JOSPT with you,  entitled Current Concepts in the Scientific and Clinical Rationale Behind  Exercises for Glenohumeral and Scapulothoracic Musculature.  I am very excited about this paper and have been working on the concept and background information on this paper for years.

prone 2Despite a couple of decades of EMG research on shoulder exercises, there were still many unanswered questions regarding the optimal exercise for each muscle.   In the early 2000’s we sought to answer some of the questions that were looming regarding the selection of exercises by performing our own versions of EMG studies.  You can find these in two articles on the external rotators and the supraspinatus.  In addition, I have written a couple of book chapters over the years that gradually built on this concept.  But what put this all over the edge was my collaboration with Rafael Escamilla, a colleague I truly respect and admire.  Rafael really put this paper over the edge and I couldn’t have done it without him.

Thanks to JOSPT for allowing me to share this for educational purposes to all of those that are not subscribers.

Click below to download:

Current Concepts in the Scientific and Clinical Rationale Behind Exercises for the Glenohumeral and Scapulothoracic Musculature

Would really like to hear your thoughts and comments on the rationale behind why you choose some of these or other exercises for the glenohumeral and scapulothoracic joints.

UPDATE: There will soon be a webinar on this topic at RehabWebinars.com.  Learn more about RehabWebinars.com.

Preventing Shoulder Stiffness After Rotator Cuff Repair Surgery

I think that stiffness following any surgery, especially rotator cuff repair, is a common problem that we face in physical therapy. I found a great blog today by another physical therapist, Rod Henderson. As I was reading I noticed that we shared some similar interests and taste for good research! He did an excellent job reviewing a research article on postoperative stiffness following rotator cuff repair. The article was published in 2005 in CORR – Clinical Orthopedics and Related Research.

To summarize, it appears that if you are tight going into surgery, you are going to be tight coming out of surgery. Makes sense. Also, patients that are stiff during the first 4-6 weeks postop will eventually catch up. But I have to think that they are much less satisfied during the first 3 months after surgery than the patients that did not develop stiffness. And isn’t satisfaction really what we are trying to achieve?

This is an important topic as I hear questions about this frequently at meetings and seminars. I also feel that stiffness can be prevented by one of two ways:

  1. Get the patients into rehabilitation quickly after surgery. Unfortunately delaying the start of PT is a trend that I don’t like from orthopedic surgeons. There is still a lot of debate over the safety and efficacy of postoperative rehabilitation programs following cuff repair. With full open repairs (and detachment of deltoid tissue) there was a need for delayed rehab, but as we transition from open to mini-open to full arthroscopic repairs, our rehabilitation should progress in parallel. Fixation strength of arthroscopic repairs have been shown to be as strong as mini-open repairs so I am not sure why the delay. I don’t think all surgeons share our thought that that gentle, controlled therapy can be safe and enhance patient satisfaction. This is a hot topic now at all the national meetings and I am involved in a group of all the top PTs in the USA in drafting a consensus statement on postop cuff rehab. Hopefully we will start to make an impact over time.
  2. Begin early passive range of motion. While internal rotation, adduction, and extension are all potentially harmful for a rotator cuff repair, passive flexion and external rotation have actually been shown to reduce tension on a rotator cuff repair. You want to get your cuff patients moving quickly in these directions because there is often scarring in the subacromial space (especially with a concomitant subacromial decompression) and a chance to develop inferior capsular restrictions.

Rather than rehash the entire information, click here to read the full review on Rod’s blog or click here to view the abstract from CORR.