1. Return to Play Considerations in the Shoulder Injured Athlete: Part 1
Created by:
Chip Hewgley, MPT
Emory Physical Therapy
Emory Sports Medicine

2. Throwers Paradox
The shoulder must be loose enough to allow excessive shoulder external rotation but stable enough to prevent symptomatic humeral head subluxation, thus requiring a delicate balance between mobility and functional stability.

3. The key to effective treatment is a complete and thorough exam with differential diagnosis.

4. Throwing Injuries
Typically the result of repetitive microtraumatic stresses put on the shoulder during the throwing motion.

5. Causes of Injury Alterations in throwing mechanics Muscle fatigue
Muscle imbalance/ weakness
Excessive capsular laxity

6. Common sites of Injury Glenohumeral capsule Glenoid labrum
Rotator cuff musculature

7. Evaluating the throwing athlete
Range of motion
Muscle strength
Laxity
Proprioception

8. Factors to Consider
Throwing a baseball requires transfer of energy from feet through the legs, pelvis and trunk out through the shoulder elbow and hand.
Reduce the risk of re-injury by following a GRADUAL progression of interval throwing.
Proper warm-up is crucial
Most injuries occur as a result of fatigue
Proper throwing mechanics lessen the incidence of re-injury

9. Total Motion Concept ER + IR = total motion
Sum of ER + IR = throwing vs. non throwing shoulder (+/- 5)

10. Wilk, K.E. ASMI 2003.
Study looked at 372 professional baseball players.
Pitchers averaged 130 degrees of ER and 63 degrees of IR at 90 degrees of abduction.
ER was 7 degrees > in throwing shoulder.
IR was 7 degrees > in non throwing shoulder.

11. Throwers Laxity / Acquired Laxity
Describes the anterior capsule and inferior capsule
Most likely is acquired over time.

12. Wilk, K.E. ASMI 2003
Isokinetic testing of ER strength of the throwing athlete is significantly weaker (6%) vs. non throwing shoulder.
IR strength was significantly stronger (3%) in throwing vs. non throwing shoulder.
Optimal ER/IR strength ratio should be between 66-75%.

13. Principles of Rehabilitation in the Thrower
1. Never overstress healing tissue.
2. Prevent negative effects of immobilization
3. Emphasize ER muscle strength.
4. Establish muscular balance.
5. Emphasize scapular muscle strength.
6. Improve posterior shoulder flexibility.
7. Enhance proprioception and neuromuscular control.
8. Establish biomechanically efficient throwing.
9. Gradually return to throwing activities.
10. Use established criteria to progress.

14. 4 Parts of Treatment Program
Activity modification
Flexibility exercises
Strengthening exercises
Gradual return to throwing

15. Rehabilitation Program for the Overhead Thrower
Phase 1 (Acute Phase)
Goals:
1. Decrease inflammation and pain
2. Increase flexibility and normalize ROM
3. Reestablish dynamic stability (muscle balance)
4. Retard muscle atrophy
5. Restore Proprioception

16. Phase 1 Treatment
1. Modalities: Cryotherapy, ultrasound, electric stimulation.
2. Exercise: flexibility/stretching for IR and horizontal adduction
Rotator cuff strengthening with emphasis on ER
Scapular muscle strengthening with emphasis on retractor, protractor and deep depressors
Dynamic stabilization (rhythmic stabilization)
Closed kinetic chain and Proprioceptive training
No Throwing!!!!

18. Phase 1

19. Phase 1

20. Phase 2- Intermediate Phase
Goals:
Progress strengthening exercise
Restore muscle balance
Enhance dynamic stability

21. Phase 2 Continue stretching and flexibility
Primarily IR and horizontal adduction
Progress strengthening program
Throwers Ten program
Core strengthening
LE strengthening

22. Phase 2

23. Phase 2

24. Phase 2

25. Strengthening Exercises
Sidelying ER and Prone Rowing with ER have been shown to elicit the highest EMG activity of post. Cuff muscles (Fleisig).
Scapula provides proximal stability to allow for distal mobility.

26. Supraspinatus Strengthening
Empty can exercise originally highlighted by Jobe for high EMG levels.
Townsend reported highest EMG activity in the military press but this exercise is not recommended for throwers.
Blackburn noted prone lying with arm abducted to 100 degrees and full ER had the highest EMG activity.
We recommend the use of the “full can” exercise to avoid superior humeral head migration secondary to ER weakness.

28. Phase 3- Advanced Strengthening Phase
Goals: begin aggressive strengthening
Increase power and endurance
Begin more functional drills
Initiate throwing activities as tolerated

29. Exercises: Phase 3 Throwers Ten Program Manual Rhythmic Stabilization
Plyometric drills
Dynamic stabilization

30. Phase 3

31. Phase 3

32. Plyometric Program Two handed drills: Chest Pass Overhead soccer throw
Side to side throw
Side throw

33. Phase 3

34. Phase 3

35. Plyometric Program cont’d
One handed drills
standing throw (feet fixed)
wall dribbling
Plyometric step and throw

36. Phase4 Throwing Program Initiation
Begin with shadow / mirror throwing to work on proper mechanics.

37. Phase 4

38. Criteria to begin Throwing
Satisfactory clinical exam
Painfree ROM
Satisfactory isokinetic test results
Appropriate rehab progress

39. Unilateral Muscle Ratios
Velocity
ER/IR
ABD/ADD
180 deg/sec
65-75%
78-85%
300 deg/sec
61-71%
88-94%

40. Interval Throwing Program
Designed to gradually increase quantity, distance and intensity.

41. Throwing Program (2 Phases)
Phase 1: long toss program
Phase 2: off the mound
45 feet and progress to 60 feet.

42. Sample long toss program
25 45 feet, rest 5 min. 25 feet.
35 45 feet, rest 5 minutes, 35 feet.
25 60 feet, rest 5 minutes, feet.
35 feet, rest 5 minutes, 35 feet.
25 90 feet, rest 5 minutes, 25 feet.
35 feet, rest 5 minutes, feet.
feet, rest 5 minutes, feet.
feet, rest 5 minutes, feet.

43. Sample mound program 25 throws @ 50% 35 throws @ 50% 50 throws @ 50%
25 throws live BP
50 throws live BP
1 inning game
2 inning game
3 inning game
1 inning game on back to back days

44. Phase 4: Return to Throwing
Progression of long toss program to 120 feet.
When the pitcher can throw from 120 feet pain free he may begin throwing from the windup on flat ground and progress to the mound.

45. Biomechanics of Pitching
1. Windup: begins with foot drop and ends with hand separation.
2. Stride: front foot moves towards home plate.
3. Arm cocking: pelvis and upper trunk face home plate and ER occurs.
4. Arm acceleration: from maximum ER to ball release.
5. Arm deceleration: from ball release to end range IR
6. Follow through: from maximal IR until pitcher regains balanced position.

46. Softball vs. Baseball Pitch
Fast Pitch softball (windmill style)
Humerus in plane of scapula
Adduction of humerus- power generator is pec major
Forearm strikes lateral thigh at ball release to decelerate arm vs. ER in baseball for deceleration

47. Sample Softball Throwing Program
10 rest 8 min., 10 30’
10 rest 8 min, 10 45’
10 60’, rest 8 min, 10 60’
10 75’, rest 8 min, 10 75’
10 90’, rest 8 min, 10 90’
10 105’, rest 8 min, ’

48. Softball ITP Cont’d
10 60’,10 20’, rest 8 min, 10 60’, 5 20’
10 60’, 10 35’, rest 8 min, 10 60’, 10
10 60’, 10 46’, rest 8 min, 10 60’, 10 46’.
10 60’, 10 46’, rest 8 min, 10 46’, rest 8 min, 10 60’, 10

49. Soreness Rules for ITP (Axe, Windley, Snyder-Mackler)
If no soreness, advance 1 step every throwing day.
If sore during warm-up but soreness is gone within the first 15 throws, repeat previous workout. If shoulder becomes sore during this workout, stop and take 2 days off. Upon return to throwing drop down 1 step.
If sore more than 1 hour after throwing on the next day, take 1 day off and repeat the most recent throwing program workout.
If sore during the warmup and soreness continues through the first 15 throws, stop and take 2 days off. Upon return to throwing, drop down 1 step.

50. Softball ITP Cont’d
2 throws to each base, 15 pitches (50%), rest 8 min, 15 pitches (50%), 1 throw to each base, 15 pitches (50%).
2 throws to each base, 15 pitches (50%) X 3 w/ 8 min rest, 1 throw to each base, 15 pitches 50%.
2 throws to each base, 15 pitches (50%), 15 pitches (75%) X 2 w/ 8 min rest, 1 throw to each base, 15 pitches (50%).
2 throws to each base, 15 pitches(50%), 15 pitches (75%),15 pitches (75%), 20 pitches (50%), 1 throw to each base, 15 pitches (50%).
2 throws to each base, 75%, 75%, 75%, 75%, 1 throw to each base, 75%.
1 throw to each base, 100%, 75%, 100%, 75%, 1 throw to each base, 75%.
1 throw to each base, 100%, 75%, 100%, 75%, 1 throw to each base, 75%.

51. Softball ITP Cont’d
1 throw to each base, 100%, 100, 100%, 100%, 1 throw to each base, 100%.
1 throw to each base, 100%, 100%, 100%, 100%, 100%, 100%, 1 throw to each base, 100%.
BP pitches total, 1 throw to each base per 25 pitches.
Simulated game, 7 innings, pitches /inning, 8 min rest between innings.

52. The Overhead Throwing Athlete
Extreme stresses applied to the shoulder.
Tremendous angular velocities (greater than 7000o/s).
Throwers Paradox: loose enough to throw but stable enough to prevent symptoms. Mobility<> stability

53. USA Baseball Recommendations
9-10 year olds
50 pitches per game
75 pitches per week
1000 pitches per season
2000 pitches per year

54. USA Baseball Recommendations
11-12 year old pitchers:
75 pitches per game
100 pitches per week
1000 pitches per season
3000 pitches per year

55. USA Baseball Recommendations
13-14 year old pitchers
75 pitches per game
125 pitches per week
1000 pitches per season
3000 pitches per year

56. References
Wilk, K.E., Meister, K., Andrews, J.R. Current Concepts in the Rehabilitation of the Overhead Throwing Athlete. AJSM, vol30, No
Paine, Russell M. The Role of the Scapula in the Shoulder. The Athletes Shoulder.
Wilk, K.E., Andrews, J.R. et al. Interval Sports Programs: Guidelines for Baseball, Tennis and Golf. JOSPT, vol 32, June 2002.
Davies, G.J. Proprioception in the Thrower. ASMI
Wilk, K.E. Rehabilitation Guidelines for the Thrower with Internal Impingement. ASMI
Andrews JR, Chmielewski T, Escamilla RF, Fleisig GS, Wilk KE. Conditioning program for professional baseball pitchers. ASMI, Birmingham, AL 1997.
Andrews JR, Fleisig GS. How many pitches should I allow my child to throw? USA Baseball News, April, 1996.
Fleisig GS, Barrentine SW, Zheng N Escamilla RF, Andrews JR. Kinematic and kinetic comparison of baseball pitching among various levels of development. Journal of Biomechanics 32 (12): , 1999.
Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. AJSM 30(4): , 2002.
Ellenbecker, T.S., Davies, G.J. The Application of Isokinetics in Testing and Rehabilitation of the Shoulder Complex. Journal of Athletic Training, 2000;35(3):
Meister, K. Injuries to the Shoulder in the Throwing Athlete. Part Two Evaluation/Treatment. AJSM, vol. 28, No
Axe, M.J., Windley, T.C., Snyder-Mackler, L. Data Based Interval Throwing Programs for Collegiate Softball Players. Journal of Athletic Training. 2002;37(2):

57. Thank You