Rehabilitation of the Overhead Throwing Athlete: There Is More to It Than Just External Rotation/Internal Rotation Strengthening.

The repetitive nature of throwing manifests characteristic adaptive changes to the shoulder, scapulothoracic, and hip/pelvis complexes that result in a set of unique physical traits in the overhead throwing athlete. An effective rehabilitation program is dependent upon an accurate evaluation and differential diagnosis to determine the causative factors for the athlete's pathologic features. The treatment program should be individualized with specific strengthening and flexibility exercises to achieve the dynamic stability that is required for overhead function. In this article we describe the characteristics of the throwing shoulder, along with a multiphased rehabilitation program that allows for the restoration of strength, mobility, endurance, and power and is aimed toward a return to unrestricted sporting activity. We also describe exercises that link the upper and lower extremities because of the importance of core control and leg strength in the development of power during the act of throwing. Additionally, proper throwing mechanics, utilization of pitch counts, appropriate rest, and proper off-season conditioning will help decrease overall injury risk in the overhead throwing athlete.

Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial.

BACKGROUND: Although commonly utilized interventions, no studies have directly compared the effectiveness of cervical and thoracic manipulation to mobilization and exercise in individuals with cervicogenic headache (CH). The purpose of this study was to compare the effects of manipulation to mobilization and exercise in individuals with CH. METHODS: One hundred and ten participants (n = 110) with CH were randomized to receive both cervical and thoracic manipulation (n = 58) or mobilization and exercise (n = 52). The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included headache frequency, headache duration, disability as measured by the Neck Disability Index (NDI), medication intake, and the Global Rating of Change (GRC). The treatment period was 4 weeks with follow-up assessment at 1 week, 4 weeks, and 3 months after initial treatment session. The primary aim was examined with a 2-way mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization and exercise) as the between subjects variable and time (baseline, 1 week, 4 weeks and 3 months) as the within subjects variable. RESULTS: The 2X4 ANOVA demonstrated that individuals with CH who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001) than those who received mobilization and exercise at a 3-month follow-up. Individuals in the upper cervical and upper thoracic manipulation group also experienced less frequent headaches and shorter duration of headaches at each follow-up period (p < 0.001 for all). Additionally, patient perceived improvement was significantly greater at 1 and 4-week follow-up periods in favor of the manipulation group (p < 0.001). CONCLUSIONS: Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months. TRIAL REGISTRATION: NCT01580280 April 16, 2012.

The Painful Long Head of the Biceps Brachii: Nonoperative Treatment Approaches.

The long head of the biceps has garnered increased attention and interest due to the high prevalence of pain that can be a primary condition or occur secondary to shoulder dysfunction. The successful treatment of biceps tendinopathy is dependent on an accurate diagnosis and recognizing all causative factors. The treatment program will be individualized with a rehabilitation program designed to restore strength and flexibility and restore normal tendon mechanics.

Rehabilitation of the throwing athlete: where we are in 2014.

The overhead athlete has unique physical traits and adaptive changes as a result of the repetitive nature of throwing. An effective rehabilitation program depends on an accurate evaluation to determine the causative factors for an athlete's pathology. A treatment program is individualized with specific strengthening and flexibility exercises to achieve dynamic stability that is required for overhead function. In this article the characteristics of the throwing shoulder and specific injuries are described. The rehabilitation program is described in a multiphased approach that allows for the restoration of strength, mobility, endurance, and power to return to sporting activity.

Optimal management of shoulder impingement syndrome.

Shoulder impingement is a progressive orthopedic condition that occurs as a result of altered biomechanics and/or structural abnormalities. An effective nonoperative treatment for impingement syndrome is aimed at addressing the underlying causative factor or factors that are identified after a complete and thorough evaluation. The clinician devises an effective rehabilitation program to regain full glenohumeral range of motion, reestablish dynamic rotator cuff stability, and implement a progression of resistive exercises to fully restore strength and local muscular endurance in the rotator cuff and scapular stabilizers. The clinician can introduce stresses and forces via sport-specific drills and functional activities to allow a return to activity.

The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete.

SYNOPSIS: Stretching techniques that focus on increasing posterior shoulder soft tissue flexibility are commonly incorporated into prevention and treatment programs for the overhead athlete. The cross-body and sleeper stretch exercises have been described as stretching techniques to improve posterior shoulder soft tissue flexibility and to increase glenohumeral joint internal rotation and horizontal adduction range of motion in the overhead athlete. But, based on the inability to stabilize the scapula and control glenohumeral joint rotation with the cross-body stretch and the potential for subacromial impingement with the sleeper stretch, the authors recommend modifications to both of these commonly performed stretches. This clinical commentary reviews the literature on posterior shoulder stretches, describes modifications to both of these commonly performed stretches, and outlines a strategy to maintain or improve posterior shoulder soft tissue flexibility and glenohumeral joint internal rotation range of motion in the overhead athlete. LEVEL OF EVIDENCE: Therapy, level 5.

Biomechanical evaluation of the docking plus ulnar collateral ligament reconstruction technique compared with the docking technique.

BACKGROUND: Surgical techniques for ulnar collateral ligament (UCL) reconstruction have evolved since first described by Jobe. A modified reconstruction technique has been developed, called the docking plus technique, and the authors biomechanically compared it to the commonly performed docking technique. HYPOTHESIS: The docking plus technique for UCL reconstruction will demonstrate greater ligament stiffness than the docking technique. STUDY DESIGN: Controlled laboratory study. METHODS: Ten matched pairs of human cadaveric specimens (mean age ± SD, 52 ± 6 years) were loaded to failure at an elbow flexion angle of 30° at a compressive rate of 14 mm/s. The specimens underwent reconstruction with an autologous graft using the docking plus or docking technique. The reconstructed and native specimens were loaded to failure at the same parameters. RESULTS: The most common mode of failure in the native UCL was midsubstance rupture and avulsion from the ulnar ligament insertion, while the docking plus group failed by suture rupture and the docking group by suture pullout and midsubstance rupture. The mean ± SD stiffness of the native UCL was 21.0 ± 9.0 N/mm, docking plus technique was 11.2 ± 6.6 N/mm, and docking technique was 5.3 ± 1.5 N/mm. The mean stiffness of the docking plus reconstruction was statistically greater (P = .004) than that of the docking technique. The mean ± SD ultimate moment for the native UCL was 35.0 ± 14.0 N·m, docking plus technique was 20.6 ± 7.3 N·m, and docking technique was 8.6 ± 5.1 N·m. The moment across the elbow joint at failure of the docking plus reconstruction was statistically greater (P = .002) than that of the docking technique. CONCLUSION: The docking plus technique reproduces greater ligament stiffness and demonstrates a higher failure moment immediately after reconstruction than does the docking technique. CLINICAL RELEVANCE: The docking plus technique allows greater stiffness and a higher moment to failure immediately after reconstruction and describes a way to maintain constant graft tension during fixation, resulting in a biomechanically stronger UCL reconstruction.

Thermal-assisted capsular shrinkage of the glenohumeral joint in overhead athletes: a 15- to 47-month follow-up.

STUDY DESIGN: Descriptive postoperative follow-up research. OBJECTIVES: The purpose of this investigation was to describe the return-to-competition rate and functional outcome of overhead athletes following arthroscopic thermal-assisted capsular shrinkage (TACS). BACKGROUND: Traditional open procedures to correct instability in overhead athletes, such as capsulolabral repairs and capsular shifts, have produced less-than-favorable results, which have led to the development of TACS. Currently there are no long-term follow-up studies documenting the efficacy of this procedure in groups greater than 31 subjects or for a time period greater than 27 months. METHODS AND MEASURES: Two hundred thirty-one consecutive overhead athletes who due to symptoms of hyperlaxity had previously undergone a TACS procedure from 1997 to 1999 were selected for inclusion in the study. During a 1-month period, 130 of these athletes (mean age +/- SD, 24 +/- 6 years; 113 male, 17 female) were contacted by phone for follow-up at a mean of 29.3 months postoperatively (range, 15.4-46.6 months). Of the 130, 105 participated in baseball (80 pitchers), 14 in softball, 4 in football (quarterbacks), 4 in tennis, and 3 in swimming. Fifty-four (42%) subjects were professional, 49 (38%) collegiate, 16 (12%) high school, and 11 (8%) recreational athletes. One hundred twenty-three of the 130 (95%) underwent 1 or more concomitant procedure(s) at the time of TACS. Most commonly performed were labral debridements (69%), rotator cuff debridements (65%), and superior labral repairs (35%). Subjects who returned to competition were retrospectively evaluated using a modified Athletic Shoulder Outcome Rating Scale to subjectively assess pain, strength and endurance, stability, intensity, and performance. Overall results were based on a 90-point scale with scores of 80 to 90 representing excellent, 60 to 79 good, 40 to 59 fair, and less than 40 poor results. RESULTS: One hundred thirteen out of 130 subjects (87%) returned to competition. Mean (+/-SD) time from surgery to return to competition was 8.4 +/- 4.6 months. Mean outcome score for all subjects was 79/90; 75 (66%) subjects had excellent, 24 (21%) good, 11 (10%) fair, and 3 (3%) poor result. The mean outcome score for males was 80/90 and for females was 70/90. CONCLUSIONS: The majority of overhead athletes (87%) successfully returned to competition following a TACS procedure with good-to-excellent long-term outcomes (88%). Based on the results of this study, TACS of the glenohumeral joint is a viable option for overhead athletes with pathological instability.

Recent advances in the rehabilitation of isolated and combined anterior cruciate ligament injuries.

The rehabilitation process begins immediately following ACL injury, with emphasis on reducing swelling and inflammation; improving motion; regaining quadriceps control; allowing immediate weight-bearing; and restoring full passive knee extension and, gradually, flexion. The goal of preoperative rehabilitation is to prepare the patient mentally and physically for surgery. Once the ACL surgery is performed, it is important to alter the rehab program based on the type of graft used and any concomitant procedures performed. This will aid in preventing several postoperative complications, such as loss of motion, patellofemoral pain, graft failure, and muscular weakness. The goal of this article has been to provide an overview of the application and the scientific basis for formulating a rehabilitation protocol following ACL surgery. For an athlete to return to competition, it is imperative that he or she regain muscular strength and neuromuscular control in their injured leg while maintaining static stability. In the past, rehabilitation programs attempted to prepare the athlete for return to sports by using resistance exercise alone. Current rehabilitation programs focus not only on strengthening exercises, but also on proprioceptive and neuromuscular control drills in order to provide a neurologic stimulus so that the athlete can regain the dynamic stability needed in athletic competition. We believe that it is important to use this approach not only possible causes that might predispose the individual to future injury.