1. Preventative Care for the Throwing Athlete Scott Sheridan, MS PT ATC CSCS Head Athletic Trainer The Phillies

2. Youth Injuries - Data  3.5 million kids under age of 14 receive medical treatment for sports injuries each year  62% of injuries occur in practice, but same precautions are not put in place in practice as they are in games.  By age 13, 70% of kids drop out of youth sports, The top three reasons: adults, coaches, parents

3. Youth Injuries - Data  Among athletes 5 to 14 years of age, 25% of baseball players were injured while playing there sport  Since 2000 there has been a fivefold increase in the number of serious shoulder and elbow injuries in youth baseball and softball  False: Players do not come back stronger and throwing harder after Tommy John Surgery!!  More than 50% of all sports injuries in children are preventable

4. Definition of Prevention  Primary – avoids the development of disease  Secondary – early disease detection  Tertiary – reduces impact on already existing condition Want to detect problems as early as possible

5. Things We Can Not Prevent  Genetics  Quality of Tissue?

6. What is Happening Biomechanically with Throwing a Ball  Not a “Normal” Act  Calculated stress with throwing exceeds the load to failure of the native ligament.  Flexor Muscle – Intimately attached to UCL, assist w/ stability  Extensors - Increase ESM activation and Decrease FPM activation in injured pitchers during acceleration**

7. Muscular Fatigue - Biomechanics  EMG Activity with Pitching (% of Max Muscle Test)  Early Cocking – Upper Trap (64%), Supraspinatus(60%)  Late Cocking – Serratus Anterior (106%), Subscapulairs (99%), Levator (72%), Infraspinatus (74%), Extensor Carpi Radialis (72%), Extensor Carpi Radialis Brevis (75%)  Acceleration – Lower Trap (76%), Levator (77%),Subscapularis (115%), Latissimus (88%), Tricep (89%), Pronator Teres (85%), Flexor Carpi Radialis (120%), Flex Dig Superficialis (80%), Flexor Carpi Ulnaris (112%)  Deceleration – Lower Trap (78%), Teres Minor (84%), Flexor Carpi Radialis (79%), Flexor Carpi Ulnaris (77%)  Follow Through – All less than 42% DiGiovine et al.- J Sh and Elbow 1992

8. “Not the Reaction You Want!”

9. How Do We Prevent Injuries?  Screenings / Pre Participation Examinations  Importance of the Active Warm Up  Gradual / Appropriate Progression of Activity / Conditioning  Understand What to Do When an Injury Occurs!

10. Screening  The purpose of the screening is to create a list of dysfunctions.  Ultimately the goal is to provide the throwing athlete the best possible anatomical and physiological base to achieve throwing efficiency.

11. Types of Examinations  Medical History / Questionnaire  Information Gathering  Communication

12. Types of Examinations  Functional Movement Screen  Performed by Athletic Trainer / Physical Therapist  Objective is to identify limitations / asymmetry  Restrictions / Imbalances will distort motor learning, movement perception, body awareness, and mechanics

13. Deep Squat

14. Hurdle Step

15. In Line Lunge

16. Shoulder Mobility

17. Active Straight Leg Raise

18. Trunk Stability Pushup

19. Rotary Stability

20. Types of Examinations  Orthopedic  Shoulder  Range of Motion  Strength  Special Testing  Posture  Scapular Assessment  Spinal Assessment  Lower Extremity  Hip Range of Motion Changes

21. Shoulder Examination  Range of Motion  Decreased Internal Rotation (GIRD), increase posterior capsule thickness with throwing  Change in Total ROM (IR + ER)  Humeral Retroversion (maintain what given at birth on dominant / throwing side)

22. Posture Assessment  Areas to Evaluate  Forward Head  Forward Shoulder  Coracoid  Antecubital Fossa  TS – Kyphosis, Flat, Scoliosis  LS – Flat, Lordotic  Shoulder Position  Inferior Ang. Mid-Thorax

23. Scapular Assessment  Shoulder pain is the result of movement impairment of the scapula, that disrupts relationship of glenoid and the humerus

24. Scapular Assessment

25. Spinal Assessment

27. Lower Extremity

28. Why Evaluate All These Areas? Kinetic Chain Progression  Core is active with any movement  Velocity most directly correlated with Lower extremity strength  Exercise in manner that they will be used (functional) FORCE GENERATION LEGS TRUNK / BACK SHOULDER ELBOW WRIST

29. The Injury “Cause List”  Range of Motion Changes Reinold et al – AJSM 2008; decrease in sh. IR, total motion, and elbow extension immediately after, lasting 24 hours  Scapular Dyskinesis (Kibler)  Muscular Fatigue(shoulder, scap, forearm)*  Core Stability  Spinal Mobility (wind up vs. follow through)  Limitations in the Lower Body (opening up?)

30. Importance of Active Warm Up  Should always be the first thing that is done before practice or game.  Not just a static stretching program.  Developed to address consistent concerns found during screening process.  Should be sweating after completing.

31. Gradual and Appropriate Progression of Activity / Conditioning  Equipment  Weekly Inspections  Hitting Progressions  Indoor, Tee, # of Swings  Throwing Programs  Long Toss – Distance?  Types of Exercises

32. What to do if an injury occurs?  Symptoms are present for a reason.  Do not let a minor problem progress into a major problem.  Remember types of prevention!  Compensations will occur  Seek appropriate medical advice  Orthopedist, Physical Therapist, Athletic Trainer @ School

33. Red Flag Symptoms  Elbow  Medial Elbow Pain  Ulnar Nerve Symptoms  Shoulder  Deltoid Soreness  Posterior Shoulder Pain  Performance Concerns  Control and Velocity  Duration of Symptoms  Sore During – Sore After – Sore Next Day

34. “Don’t Bring Me a Problem, Bring Me a Solution!” ① Pre Participation Exam / Screening ② Warm Up Appropriately ③ Do Not Pitch Through Symptoms ④ Do Not Play Year-Round ⑤ Communicate to players regarding how they are feeling ⑥ Emphasize, control, accuracy, and age appropriate skills ⑦ Speak to a medical professional if you have concerns about an injury or to develop a prevention strategy.

35. Special Thank You - Acknowledgement  Kinetic Rehab  Phil Donley, MS PT ATC  Jeff Cooper, MS ATC  Gray Cook, PT  Gary Gray, PT  Craig Morgan, MD  Shirley Sahrmann  Ron Hruska

36. Questions / Solutions