SHOULDER
PREVENTION: BEFORE AND
AFTER
BlakeSwanC.S.C.S,TSAC-F,FMSC,CPT,
DirectorofSportsPerformance&Wellness
Disclosures
• Ihavenodisclosures
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Is it possible to prevent Shoulder Injury/Re-Injury in the athletic population
utilizing targeted prevention programs • LiteratureReview– SearchCriteria:• Shoulder+PrevenHon• Shoulder+Screening• Shoulder+Neuromuscular• Shoulder+Strength
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• AreviewofShoulderInjuryliterature(2005-2009)– ShoulderArHcles–11,262– Shoulder+Injury–3,994– Shoulder+PrevenHon–820
• 152/820(18.5%)prevenHonarHclesrelatedspecificallytosport
• Review2015(Pubmed)(2011-2015)– ShoulderArHcles–17,306– Shoulder+Injury–5665– Shoulder+PrevenHon–1,047
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Several Studies show a decrease risk of shoulder injury and/or associated risk factors after participating in a specific
training program
• NiederbrachtY,ShimAL,SlonigerMA,Paternostro-BaylesM,ShortTH,JSCR2008:22(1)140-145
• SeminaHE,SportsBiomech.2015:14(2)216–231• WilkKE,ArrigoCA,HooksTR,AndrewsJR,PM&R2015:8(3
Suppl)S78-90• QuesttovalidateShoulderInjuryinPrevenHonprogramswithin
theliterature.
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Creating Programs to Prevent Shoulder Injury/Re-Injury
• ShoulderRiskAssessment– Why?RateofInjuryinsport/acHvity– Who?Pre/PostInjuryRiskFactors
• ScreeningforInjuryRisk– Whatarewelookingfor?
• Hierarchyofmodifiablechanges– HowcanwequanHfytheserisk?
• UpperExtremityPhysicalPerformanceTesHng(PPT)• ProperlyuHlizingScreeningsasToolsofassessment
• TransiHoningfromTherapytoSport– ProtocolsforsuccessfulRTP– PreventaHveTrainingStrategies– OurStrategies
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Shoulder Risk Assessment RiskFactorstoConsiderwhendesigningaPreventa5veand/orRTPProtocol• Maturity(anatomicalvbiological)
– Linkbetweenthrowingvolumeandshoulder/elbowinjuriesamongyouthbaseballpitchers.• >8mo/yearincreasedtheoddsofsurgeryby5-fold.• Regularlypitchedw/armfaHgued=36xmorelikelytobeinthesurgerygroup.
– OlsenEetal,AmJSportsMed200634:905–912• Mechanics
– StudycomparedkinemaHcsofTradiHonalTechniquesvs.AlternaHveTechniquesevaluaHngsafetyw/respecttoperformancefor21EliteVolleyballATH• GlenohumoralJoinSet:ShoulderROM/AngularVelociHescalculatedandcomparedtojointlimits• Results:
– Trajectoryofhumerusaltered– DecMaxFlexofShoulder(10degrees)/IncHorAbd(15degrees)– NoDifferenceinExt.RotAngles,AxialRot.VelociHessignificantlyhigher(+5%higherballspeed)
• ATasapotenHalprevenHvesoluHontoshoulderchronicpathologies,reducingshoulderflexionduringspiking.
» SeminaHEetalSportsBiomech2015’14(2):230
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Shoulder Risk Assessment Continued: • RangeofMo5on(ROM)
– Theearlycockingphase:GreatestmaximalvoluntaryisometriccontracHon(MVIC)acHvityisseenintheinfraspinatus(46%)andsupraspinatus(45%)muscles(3).
– Thelatecockingphase:IncreasedglobalmuscleacHvityexceptinthemiddledeltoid.TheMVICacHvityintheinfraspinatus(69%)andsupraspinatus(65%)arehighestoverall(3).
– TheacceleraHonphase:OverallincreasedglobalacHvaHon.ThehighestMVICisseeninthepectoralismajor(86%)andsubscapularis(81%).
– Thefollow-throughphase:IncreasedMVICoftheinfraspinatus(86%)andsupraspinatus(87%)tojointhepectoralismajor(79%)andsubscapularis(95%)inhighlevelsofacHvity.• HarriesSKetal.JSciMedSport201215:532–540
• TrainingStatus– Experience[General/SportsSpecific]– Capacity[STR/END/POW]
• Volume– SeasonalWorkload:
• AverageReps[PracHcev.Game]• MaxRepe55ons[PerSeason/PerYear]
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Physical Performance Test: Potential Screening Tool
Reviewof6PPTsthrough11ar5cles• ClosedKineHcChainUpperExtremityStabilityTest(CKCUEST)• SeatedShotPut(2hands)• UnilateralSeatedShotPut• MedicineBallThrow• ModifiedPush-UpTest• 1-armHopTest• Bestevidence
– CKCUEST– UnilateralSeatedShotPut(mod.PosiHve)
• LimitedposiHveevidence– medicineballthrow– 1-armhoptest.
Limited#ofUEPPTsu5lizedinscreeningexamina5onsperformancemeasuresinATHpopula5on.WhileCKCUESTandUnilateralShotPutarepromisingPPTsinhealthypopula5ons,furtherinves5ga5onsintouseforinjuredpopula5onasbenefitsunsubstan5atedinliterature.• BrJSportsMed.2016May;50(9):545-51
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Physical Performance Tests: Potential Screening Tool
• Observa5onalStudyEstablishesNorma5veDataforClosedKine5cChainUpperExtremityStabilityTest(CKCUEST)andUpperQuarterY-BalanceTest™(UQYBT)whenusedaspartofcomprehensiveinjury-riskscreeningbafery– InCollegiateATHwithcomparisonbetweensports– AnalyzerelaHonshipbetweentwotest
• 257(male=118,female=139)D-1ATHinbasketball,soccer,baseball,lacrosse,volleyball,trackandfieldandcrosscountry.
• NormaHvevaluesfortheCKCUESTandUQYBTestablishedforninemen'sandwomen'scollegiatesports.– PPTscoresshowednosignificantrelaHonship
• MalesscoredsignificantlyhigherthanfemalesbothPPTs– UQYBTsignificantlyhigherinBaseballplayersthanathletesfromallothersports– CKCUESTshowednon-significanttrendsoflowerscoresthanLEdominantathletes(ex.runners)
CKCUESTandUQYBTpoten5allycomplimentaryPPTsaspartofscreeningbafery;appeartomeasuredifferentconstructsofperformancepartofascreeningbafery.
– AVGCKCUESTandUQYBTscoresofD1ATHdisHnctfromrecreaHonally-acHvepopulaHons• Differenceinperformanceexistbetweensex/sports
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Study of Throwing Mechanics
Kinema5cfactorsofthrowingrelatedtoinjuryandperformance• Mechanicalaspects
– FootposiHonatStrideFootContact– Elbowflexionduringthrowing– ArmrotaHonduringthrowing– ArmhorizontalabducHonduringthrowing– ArmabducHonduringthrowing– LeadkneeposiHonduringthrowing– PelvicorientaHonduringthrowing– DeceleraHon-phaserelatedissues
Teachingthrowingmechanics• ThrowingskillorspeedunrelatedtoamountofAcHveERRange@ShoulderHorizontalABD/ADD
– Clinically,PassiveArmERmoreuseful,closelyreflectsthenatureofthemovement• Clementsetal.,PhysicalTherapyinSportJournal2001:2,4-14
• TotalRangeofExt/IntRot.indominant/non-dominantarmsofhighlevelbaseballplayers• Baltachietal.,JSportsMedPhysFitness.2001Jun;41(2):236-42.• Crockevetal.,AmJSportsMed.2002Jan-Feb;30(1):20-6.
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ThrowingMechanics• Long-standingmotorpafernscanbedifficulttoalter
– Earlyinthethrower’scareermustemphasizecorrectmechanics.• Diminishedperformanceandpathologicforcescanberelatedtoaberrant
mechanics.– InvesHgated17kinemaHcand8kineHcparametersinagroupof231pitchers
• OnlypaperdocumenHngkinemaHcskineHcsacrossvaryingages– Subdividedinto4groupsbasedontheirage:
• 23youth(agerange:10-15years)• 33highschool(15-20years)• 115college(17-23years)• 60professional(20-29years)
– Eachofthe8kineHcvariablesinc• Coincidesw/increasingagegroup• IncreasedforcegeneraHngpotenHalassociatedwithskeletallymaturity.
– FewdifferencesinposiHonal/temporalparametersacrossallsubjects• Representsmostaspectsofthrowingages
– Reasonabletosuggestthatteachingcorrectmechanicscanbeperformedfromtheearliestpar5cipa5oninthesport.
FleisigGSetal.,JBiomech.1999Dec;32(12):1371-5.
Considerations
• PrimaryPrevenHon– TrainingStatus
• TesHngandPPTs– Mechanics:ProgressiveModel– RangeofMoHon:AvailablevDesired– Volume:WorkloadDesiredvWorkloadRequired
• SecondaryPrevenHon– TrainingStatus
• LimitedTesHng,NoPPTs– Mechanics:RegressiveModel– RangeofMoHon:AvailablevRequired– Volume:RegressedModel
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Considerations: Contact v Non-Contact
• ShoulderinjuriesareoneofthemostcommoninjuriesinfootballQBs(6).
– ManycoachesinstructQBstoperformastructuredthrowersprogramandinmanyprogramsthisisverysimilartothepre-habilitaHonorinjuryprevenHonprogramsthatareusedwithotheroverheadsports(baseballpitchers,volleyball,andtennis).
• However,oneareathatdoesseparatefootballQBscomparedwithsomeotheroverheadsportsisthepotenHalfortheQBtobehitorbumpedduringthethrowingmoHon.
– Althoughthisdoesnothappenregularly,itisoneaspectofthethrowingmoHonthatneedstobetrained.
• 90°/90°ShoulderTubingIsolaHonwithFlexBarPerturbaHon(Figure5).– TheperturbaHonsprovidedbythemanualoscillaHonoftheFlexbarprovideadynamicreacHve
instrumentthatprovidesoscillatoryresistanceproporHonaltotheforceappliedtoitandthespeedofoscillaHon.
– Thisrequirestheglenohumeraljointandsurroundingmusclestostabilizeunderavariedexternalload.
– ThistypeofstabilizaHonmaybeneededduringgamesituaHonifaQBishit/bumpedwhilethrowing.
MarkSK,ThomasK,JournalofStrength&Cond:2015Dec,37(6):37-42
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Screening for Injury Risks:
How to Quantify Risks • Crea5ngAthle5cProfile
– Maturity,*BodyComposiHon,Hypermobility– Sport:PosiHonDemands,Experience,Skill
• TrainingAge– ExerciseExperience,Technique– Volumerequirementsforsport
• Screening– FMS,CKCUET/YQTMO
• Warm-UpProgram
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Program Design Guidelines (Study) Studyofresistanceprogramtoevaluateeffectsofall3methodsofresistancetrainingsimultaneouslyonthrowingvelocitywith6HSandNCAABaseballcurrentlyintheiroff-seasonandplayingsummersession(min1-3games/week)• GeneralFull-Bodystepwiseresistanceprogramw/specialmedballandspecificweightedballexercises:
– MedBall:5DBLArmThrowExercises(Phasesofthrowing)– WeightedBall:SingleArmthrowsw/7ozball(explosiveelementsofmoHon)
• 3x/wkfor10weeks– 3RMforSquatandBenchPressmeasured@Start,3wks,6wk,and10weeks
Results:• Throwingvelocityinc5.6%(1.9m/sor4.2mph)• Increased1RMformeasureliys• 10wkcombinaHonofgeneral,special,andspecificresistancetrainingprogramcanincreasevelocityamongHSandNCAAplayerswhoplayedascholasHcseasonandwere
playingasummerbaseballseason.• DoesnotidenHfywhichindividualaspectwasmostimpaczulonincreasingthrowingvelocity.*Recommendedthatfutureresearchevaluatetheeffectsofcombinedresistancetrainingasathletesrou5nelyperformthistypeoftrainingonanannualbasis.
Significantincreaseinthrowingvelocity(1.0m/s[2.24mph])foryouth(11-15yrs)baseballplayers4wksresistancetraining3x/wk• 17UEexercises
– 1setof20-25repsuHlizingelasHctubingprogram• 30mindistanced-basedintervallongtossthrowingprogram.
– 5minwarm-up– 15minpivotthrowsw/arc– 10minlongtossthrowsw/arc
• Differentdifficultybasedonmaturity(13-15higherthan11-12)– 5minext.rot.StretchingEscamillaRF,etal.,2010:JStrengthCondRes24:3247–3254
• ControlgroupofNCAAplayersw/8wkLongTossprogramdidnotimprove,thusimprovementin4wkprogramnotavributabletolongtossprogram– LachowetzT,etal.,1998:JStrengthCondRes12:116–119
ExaminaHonofkinemaHcandkineHcdifferencesbetweenpitchingfromamoundvlongtossthrows(hard/onahorizontalline).
– @maxdistance,>shoulderER,ElbowFlex,ShoulderIRTorque,andElbowVarusTorqueduringcockingphase.– ElbowExtVelocitygreatestformaxdistancethrows– ForwardtrunkHlt@HmeofballreleaseconHnuedtodecreasew/increasedthrowingdistance
*Cau5onadvisablewhenpitchersimplementlongtossprogramforrehab/training.
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ThrowingVelocityforHS/NCAA/ElitePlayerscanincreasewith6to12-wkgeneraloff-seasonresistancetrainingprogram.• UsingFull-BodyorUpperBodyClosedKineHcChainExercisesw/loadsbetween55%/95%1RM• Special:6-12wklighttomoderateloadsof30-80%1RM• Specific:20%-140%ofstandardballweight
4wkLongTossprogram
• AltersmechanicsinNCAApitchers(IncreasedIRShoulderRot/ElbowVarusTorques)Usecau5onwhenimplemen5nglongtossprogram.Amerthrowingvelocityincrease,discon5nueweightimplementthrowingprogram.
• Canbemaintainedbysimplythrowingastandard5ozbaseballNoresearchthatsubstan5atessafeandposi5vetrainingeffectsforspecificweightedimplementtrainingprogramsin-season.Male&Femaleeliteteamhandballplayers:
• 8-10wkgeneralheavyupper-body/lower-bodyresistancetrainingprogram• 2x/wkduringcompeHHveseason
FemaleHSHandballPlayerscanu5lize6wkcorestabilitytrainingin-seasonresultedinincreasedthrowingvelocity.SpecificthrowingresistancetrainingprogramfornoviceHSandNCAAindividualsw/sametotalworkload(velocity,resistance,oracombina5on)canincreasethrowingvelocityofsoccerballthrow-inamer6-8wkoftraining.Allthrowing/overheadathletescanbenefitfromgeneral,specific,andspecialresistancetraining.Itisuptothecoachandcondi5oningprofessionaltodesignthespecificandspecialelementsthatappropriateaccommodatetherequirementsoftheathletefortheirspecific.
MarkSK,ThomasK.,JournalofStrength&Cond:2015Dec,37(6):37-42
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Sports Performance Protocol Example: General and Specific Resistance Training
• 7-14y.o.
• 7-9y.o.
Szymanski,DJ,Strength&Condi5oningJournal.35(3):63-76,June2013
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Sports Performance Protocol: General Resistance Training (More Mature) • 10-12y.o.
Szymanski,DJ,Strength&CondiHoningJournal.35(3):63-76,June2013
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Sports Performance Protocol: Special Resistance Training
ExerciseaccountsforuniqueelementsofmoHonforthisthrowingathlete.ProgramisdesignedforPerformanceandInjuryPrevenHon
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MarkSK,ThomasK,JournalofStrength&Cond:2015Dec,37(6):37-42
Sports Performance Protocol: Special Resistance Training
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RyanLC,andDanKR,JournalofStrength&CondApr2012:34(2)79-85
UOA Recommendations
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MarkSK,ThomasK,JournalofStrength&Cond:2015Dec,37(6):37-42
Conclusion Theshoulderrepresentsanumberofchallengeswithregardtoinjurypreven5onaswellasperformanceenhancement.Professionalsmusttakeintoconsidera5onriskfactorsassociatedwithinjuryhx,maturity,sporttechnique,trainingvolumeandloadSystemicandrou5neScreeningofathletes:
- ROM- PPTs
Workingwithcoachesallowsforamoretailoredresistancetrainingprogram- U5lizingall3typesoftrainingappropriateforseason
- Off-Season/Pre-Season/In-Season/Post-Season- U5lizeLongTossasrecommendedbasedonriskfactors(maturity)
- Noresearchsuppor5ngresearchonusingwithinjuredpopula5on- Workingwithcoachesallowsforamoretailoredresistancetrainingprogram
Effec5veProgramParameters- 6-12Weeks- 2-3x/week- AppropriateSetsxRepsbasedonathle5cprofile
- Lesssetsmorerepsforyoungerathletes- Repe55onmaxtes5ngforolderathletes
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