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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