By: Cristian GuillaumaEXS 250-602

OverviewThere are several purposes that can be derived from this research done on upper extremity injuries and their effect on pitchers.

● What are the lasting effects that these injuries have on the upper extremities, before and after surgery.

● Where and how do these injuries occur.● How can one go about preventing and/or rehabilitating such an injury.

All of these are important when discussing this topic.

Vocabulary

Before delving into the topic, it is vital that certain terms are defined so you, the viewer, understands just exactly what is being talked about. This also saves me from having to backtrack to describe certains words. Here are some that may cause confusion.

1. SLAP tear- Stands for Superior Labral tear from the anterior to posterior2. Debridement- Removal of dead/damaged tissue3. Tenodesis- Surgical anchoring of a tendon to a bone4. External Rotation- The arm and wrist moving away from the body from a fixed position5. Internal Rotation- The arm and wrist moving towards the body from a fixed position6. Abduction- Movement of a limb away from the midline of the body7. Adduction- Movement of a limb towards the midline of the body8. Torsion- Action of twisting or being twisted9. Tomography- Imaging by sections or a section through the use of a penetrating wave

10. Flexion- Bending movement of a limb

Post-Injury Effects (study one)

❖ A study conducted in 2012 by Garrison and his associates attempts to depict shoulder ROM deficits in tandem with elbow injuries.

❖ 60 High School and Collegiate athletes were chosen, half of which suffered an ulnar collateral ligament tear.❖ 44 out of 60 participants were pitchers.❖ Measured shoulder IR, shoulder ER, horizontal adduction at a 90° angle, and elbow extension from a seated

position.❖ Conclusion/Results: Athletes that experienced this tear showed significant decreases in total ROM of the

shoulder and dominant arm ER.

Study Two

❖ This is a study done by Laughlin and his team where they measured the biomechanics of pitchers with a SLAP tear and those without one and then compared.

❖ They collected data of 13 pitchers with a SLAP tear and 52 pitchers without one using a 3-D motion analysis system.

❖ Players threw fastballs from the windup and the biomechanics of the shoulder, elbow, and trunk were reported.❖ Conclusion/Results: Pitchers in the SLAP group showed less horizontal abduction and shoulder ER. Another

noteworthy finding was that they threw from a more upright position from a less forward tilt at the release of the ball. This could be from a mental barrier to prevent injury again.

Study Three❖ Continuing the trend from the other slides, this study is one that was done on High School players by Oyama

and a few other researchers.❖ Instead of seeing how an elbow injury can affect the shoulder, this one looks at improper trunk rotation and how

it may place negative emphasis on the shoulder.❖ 3-D kinematics were gathered from 72 pitchers to see how trunk rotation affects ball speed and upper extremity

biomechanics.❖ It was concluded that proper or improper rotation is based upon peak pelvic rotation velocity.❖ Conclusion/Results: Pitchers with improper trunk rotation were found to have greater shoulder ER and

shoulder proximal force. This can lead to greater pressure on the shoulder joints leading to injury.

Study Four

❖ Another perspective on how one can possibly injury the shoulder was displayed by Shanley and his team.❖ They believe that side-to-side shoulder ROM will lead to more upper extremity injuries than those with a normal

ROM.❖ 227 High School baseball and softball players will looked at initially but only 27 (18 baseball, 9 softball) ended up

being evaluated further because they suffered shoulder or elbow injuries.❖ Shoulder ER, shoulder IR, and horizontal adduction at a 90° angle while the scapula was stabilized were all

measured.❖ Conclusion/Results: All of the 27 participants suffered a decrease in horizontal adduction and shoulder IR thus putting

them at a 4x greater risk for a future injury. Another result was that a 10°-20° loss in total shoulder ROM was witnessed.

Study Five

❖ Study five has to do with a field based observation conducted by Wassinger and Myers..❖ They break down the pitching motion into five different phases in order to pinpoint where the upper extremity

injuries occur.❖ They theorized that majority of the injuries involve several different body parts (bicep, glenohumeral,

scapulothoracic, humeral, and subcromial).❖ Conclusion/Results: It was thus concluded that the late cocking and deceleration portion of the throwing motion

is where these injuries occurred and that multiple injuries could occur during one phase.

Critical Review of Study Five

❖ It’s always important in research to have an opposing viewpoint to that of yours to offer a different perspective. This is what is offered with Dr. Mary Magarey’s criticism of Wassinger and Myers’ study.

❖ Magarey states that Wassinger and Myers don’t understand the complexities that go into the throwing motion.❖ She praises their idea for breaking the motion into phases but immediately discredits the deceleration phase as

a possibility for injury because a known study was done that involved the use of cadavers and 9/10 times the injury occurred in the late cocking phase.

❖ She also questions their method of field based analysis, deeming that visual and video analysis of the mechanics of the throw is much more accurate to a physiotherapist.

Study Six❖ The last study that we will look at that has to do with injury and the analysis of it is Polster’s research that he

believes is to prove that humeral torsion is related to upper extremity injuries.❖ He took 25 players from a professional organization and used computed tomography on the dominant and

nondominant humeri couple with image data that is processed from a 3-D volume-rendering postprocessing system. This program allowed the researchers to slow down and simplify the throwing motion in order to clearly see points of impingement.

❖ Conclusion/Results: What was found was a strong relationship between lower degrees of dominant humeral torsion and more severe upper extremity injuries.

Findings➔ UCL tear decreases shoulder ROM and shoulder ER/IR➔ SLAP tear decrease in HA and shoulder ER➔ Improper trunk rotation leads to greater shoulder ER and proximal force and pressure on shoulder joints➔ Side-to-side throwing motion more detrimental than overhand throwing motion➔ Late cocking phase of throwing motion where majority of upper extremity injuries occur➔ Low degrees of humeral torsion in dominant hand equate to more severe upper extremity injuries

Treatment Studies (study one)

❏ A study done by Chalmers and six of his associates depicts what they believe to be the best treatment for restoring a SLAP tear.

❏ The three options are debridement, tenodesis, and surgical repair, which they hypothesized to be the most effective.

❏ Seven players were normal, six underwent SLAP repair, and the rest did biceps tenodesis.❏ Through the use of electromyography at 1500 hertz, motion analysis at 120 hz, and high speed video at 120 hz,

the researchers were able to ensure accurate motion tracking❏ Conclusion/Results: Tenodesis and SLAP repair can both restore a pitcher back to normal neuromuscular

control and pitching mechanics. Pitchers that underwent repair were subjected to altered thoracic rotation and did not repeat their old knee flexion and lead foot contact.

Treatment Study Two

❏ In a study done by Fedoriw, Ramkumar, McCulloch, and Linter, they delve into player Return To Play (RTP) rates and their Return to Prior Performance rates after surgical repair of a SLAP tear.

❏ They hypothesized that surgical repair produces a low RTP rate for the athletes.❏ 68 out of 119 players in a single organization were documented as having a SLAP lesion that could be visible

with the use of an MRI scan.❏ All 68 failed at least one form of nonsurgical repair and if the failed two forms then surgery was performed.❏ 21 pitchers treated nonsurgically had 40% RTP and 22% RPP.❏ 27 pitchers treated surgically had 48% RTP and 7% RPP.❏ Conclusion/Results: Nonsurgical treatment should be considered against surgical means.

Findings➔ Tenodesis and SLAP repair can restore a pitcher to normal neuromuscular control and pitching mechanics with

altered thoracic rotation, knee flexion, and lead foot contact.➔ Nonsurgical means should be looked at equally with surgical means as it produces almost as high as a RTP

rate.

Training/Rehabilitation

★ Slenker’s study illustrates different throwing programs that could be helpful in rehab and training for upper extremities injuries.

★ Three programs are looked at and they are fastball throwing, variable effort pitching, and flat ground throwing at various distances.

★ 29 healthy players were observed using a motion analysis system and torque force in the shoulder and elbow is what was measured. All participants tried all three programs.

★ Conclusion/Results: Partial effort program showed a significant less load on the shoulder than the other two and flat ground throwing from any distance yielded similar results to throwing from the mound but with less velocity. Also, the “crow hop” was shown to have protective elements for players due to involvement of lower extremities.

Prevention

➢ A study that looked at 754 youth pitchers from the ages of nine to 18 were looked at in order to determine whether high volume and little recovery would result in elbow and shoulder problems with significant arm fatigue.

➢ 43.4% players pitched on consecutive days.➢ 30.7% players pitched on multiple teams with overlapping seasons.➢ 19.0% players pitched in two games in one day over a 12 month span.➢ 70.0% were reported as using curveballs.➢ Conclusion/Results: These statistics can be linked to elbow issues in youth pitchers and would be at a much

greater chance for a pitching-related injury as they mature.

Slap Repair Procedure Video

https://www.youtube.com/watch?v=38DZgGjaPOA