A Field-expedient Arm Care Screening Tool Can Identify Musculoskeletal Risk Factors in Baseball Players.

BACKGROUND: Preseason movement screening can identify modifiable risk factors, deterioration of function, and potential for injury in baseball players. Limited resources and time prevent high school baseball coaches from performing movement screens on their players. HYPOTHESIS: The arm care screen (ACS) will be highly sensitive to detecting musculoskeletal risk factors. STUDY DESIGN: Cross-sectional. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 150 baseball players were independently scored on the ACS electronically by reviewing a video recording of each player's screening performance. Discriminability of the ACS was determined with a 2 × 2 contingency table dichotomizing musculoskeletal risk factors as present or absent based on a predetermined cutoff value and those who passed or failed the corresponding ACS subtest. RESULTS: High sensitivity was observed on the reciprocal shoulder mobility (0.89; 95% CI 0.81-0.94), 90/90 total body rotation (0.86; 95% CI 0.79-0.92), and lower body diagonal reach (0.85; 95% CI 0.78-0.91) tests of the ACS suggesting sufficient ability to identify musculoskeletal impairments and risk factors. CONCLUSION: The ACS is a simplistic screening tool that the coach can administer to discriminate between youth, high school, and college-level baseball players who possess musculoskeletal risk factors. The ACS subtests demonstrated high sensitivity for correctly identifying musculoskeletal risk factors common in baseball players and can be useful as a screening tool for baseball coaches developing arm care exercise programs. CLINICAL RELEVANCE: A field-expedient screen could provide coaches the ability to identify musculoskeletal risk factors that need to be addressed to minimize injury risk factors in a time-efficient manner.

Effectiveness of Scapular Stabilization Versus Non-Stabilization Stretching on Shoulder Range of Motion, a Randomized Clinical Trial.

Background: Previous research has demonstrated the benefits of both stabilization and non-stabilization of the scapula during stretching in individuals with posterior shoulder tightness, but limited evidence exists in patients with shoulder pain. Hypothesis/Purpose: The aim of this study was to determine the effect of stabilized scapular stretching on patients with shoulder pain. The primary hypothesis of this study is that stabilized scapular stretching will improve glenohumeral motion and pain compared to non-stabilized stretch program. A secondary hypothesis of this study is that stabilized scapular stretching will produce greater improvement in function compared to the non-stabilized stretching program. Study Design: Randomized Clinical Trial. Methods: Sixteen patients with sub-acromial pain associated with tendinopathy and associated pathologies presenting to physical therapy were randomized into two groups (stabilized or non-stabilized scapular stretching). Baseline pain and range of motion were measured prior to and following each treatment session for three visits that occurred over the course five to seventeen days depending on the patients availability. The dependent measurements were stabilized horizontal adduction, stabilized internal rotation, stabilized shoulder flexion, non-stabilized shoulder flexion, and current pain level. Results: Patients in the scapular stabilization stretching group increased horizontal adduction 40° (CI95 31, 48°) compared to the non-stabilization stretching group increase of 8° (CI95 0, 17°) over the course of the three treatments (p<0.001). Similarly, the stabilized stretching group increased internal rotation 48° (CI95 26, 69°) compared to the non-stabilized stretching group increase of 26° (CI95 4, 48°) (p=0.001). Pain decreased in the stabilized stretching group by 1.4 points (CI95 -0.4, 3.2) but increased slightly in non-stabilized group by -0.5 points (CI95 -2.3, 1.3) which was not a clinically meaningful change. (p=0.03). Conclusion: Stabilized scapular stretching was more effective than non-stabilized stretching at gaining shoulder mobility in patients with shoulder pain. Benefits were immediate and sustained between treatment sessions. Stretching interventions improved range of motion but had limited effect on shoulder pain. Level of Evidence: 2.

The Intra- and Inter-rater Reliability of an Arm Care Screening Tool in High School Baseball Coaches.

BACKGROUND: Preseason movement screening can identify modifiable risk factors, deterioration of function, and potential for injury in baseball players. Limited resources and time intensive testing procedures prevent high school coaches from accurately performing frequent movement screens on their players. PURPOSE: To establish the intra-rater and inter-rater reliability of a novel arm care screening tool based on the concepts of the Functional Movement Screen (FMS™) and Selective Functional Movement Assessment (SFMA™) in high school coaches. STUDY DESIGN: Methodological intra- and inter-rater reliability study. METHODS: Thirty-one male high school baseball players (15.9 years ± 1.06) were independently scored on the Arm Care Screen (ACS) by three examiners (two coaches, one physical therapist) in real-time and again seven days later by reviewing video recordings of each players' initial screening performance. Results from each examiner were compared within and between raters using Cohen's kappa and percent absolute agreement. RESULTS: Substantial to excellent intra-rater and inter-rater reliability were established among all raters for each component of the ACS. The mean Cohen's kappa coefficient for intra-rater reliability was 0.76 (95% confidence interval, 0.54-0.95) and percent absolute agreement ranged from 0.82-0.94 among all raters. Inter-rater reliability demonstrated a mean Cohen's kappa value of 0.89 (95% confidence interval, 0.77-0.99) while percent absolute agreement between raters ranged from 0.81-1.00. Intra- and inter-rater reliability did not differ between raters with various movement screening experience (p>0.05). CONCLUSIONS: High school baseball coaches with limited experience screening movement can reliably score all three components of the ACS in less than three minutes with minimal training. LEVEL OF EVIDENCE: Level 3, Reliability study.

Interprofessional Inconsistencies in the Diagnosis of Shoulder Instability: Survey Results of Physicians and Rehabilitation Providers.

BACKGROUND: Clinicians of many specialties within sports medicine care for athletes with shoulder instability, but successful outcomes are inconsistent. Consistency across specialties in the diagnosis of shoulder instability is critical for care of the athlete, yet the extent of divergence in its diagnosis is unknown. HYPOTHESIS: Physicians differ from rehabilitation providers in which findings they deem clinically important to differentiate shoulder instability from impingement, and in how they diagnose athlete scenarios with atraumatic shoulder instability. STUDY DESIGN: Cross-sectional study. METHODS: Physicians (orthopaedic surgeons, primary care sports medicine physicians) and rehabilitation providers (physical therapists, athletic trainers) were asked via an online survey to rate clinical factors used to diagnose shoulder instability. Clinicians were also asked to diagnose two athlete scenarios with concurrent clinical findings of atraumatic shoulder instability and impingement, differentiated by the absence or presence of a positive sulcus sign. RESULTS: Responses were recorded from 888 clinicians. Orthopaedic surgeons (N=170) and primary care sports medicine physicians (N=108) ranked physical examination factors as more important for the diagnosis of shoulder instability than patient history factors, whereas physical therapists (N=379) and athletic trainers (N=231) preferred patient history factors. Orthopaedic surgeons differed from physical therapists and athletic trainers in their clinical diagnoses for both scenarios (P≤0.001). CONCLUSION: A lack of consistency exists among sports medicine clinicians in recognizing which clinical factors are important when used to diagnose shoulder instability and in diagnoses given with concurrent findings of impingement. LEVEL OF EVIDENCE: Level 3.

Post-operative Rehabilitation for Scapular Muscle Reattachment: A Case Report.

BACKGROUND AND PURPOSE: Scapular muscle detachment is a rare orthopedic problem that has been described in the literature in patients following traumatic events involving traction, direct trauma, or a motor vehicle accident. The purpose of this case report is to describe the post-operative rehabilitation following scapular muscle reattachment surgery. Unique to this case report is the patient's perspective, an orthopedic physical therapist with 25 years of experience. CASE DESCRIPTION: A 47-year-old female physical therapist experienced a traction injury to bilateral upper extremities during a medical procedure resulting in bilateral rhomboid, and bilateral lower trapezius muscles were detached from the medial scapular border. Reconstruction of the left scapulothoracic musculature occurred five and one-half years post-injury with the right repaired one year later. This case report describes the rehabilitation program that took one-year to recover for each arm with a period of protected motion for 16-weeks and gradual return to function as a manual physical therapist over a period of one-year. OUTCOMES: The American Shoulder and Elbow Surgeons (ASES) Standardized Assessment Form and pain-free range of motion was used pre- and postoperatively. Left and right shoulder pre-operative ASES scores were 68 and 72, respectively. At the one-year post-operative the left shoulder was rated at 82 and the right shoulder was 90. Pain-free range of motion was achieved in both arms by one year. Functional limitations requiring strength overhead were the slowest to return and were not completely back at one year following either surgery. DISCUSSION: Rehabilitation protocols for scapular muscle reattachment surgery are not commonly available to allow physical therapists to guide their patients and structure a rehabilitation program. This case report provides a sample pre-operative set of educational guidelines and a post-operative protocol for use after scapular reattachment surgery. This case report is unique because it offers a patient perspective who is a physical therapist and underwent this surgery twice. Therefore, providing insight on how to prepare for such a unique operation. The slow recovery is due to three issues 1) the prolonged time from injury to diagnosis created significant muscle wasting and muscular imbalance of surrounding tissues, 2) once this tissue was repaired it requires months of protection to recover, 3) the involved scapulothoracic muscle have to regain adequate strength as the foundation for upper extremity functions. LEVEL OF EVIDENCE: Level 5.

Which Risk Factors Are Associated with Pain and Patient-reported Function in Patients with a Rotator Cuff Tear?

BACKGROUND: Patient-reported measures guide physicians in clinical decision making and therefore it is critical to determine what clinical factors are associated with these scores. Psychological and physical factors are commonly studied separately in patients with rotator cuff tears to determine their influence on outcomes. It is well established that psychological distress and scapular motion change in the presence of a symptomatic rotator cuff tear. However, these factors have not been studied simultaneously in a clinical setting to determine their association with shoulder outcome scores. QUESTION/PURPOSE: After controlling for relevant confounding variables, what physical and psychological factors are associated with better (1) American Shoulder and Elbow Surgeons (ASES) scores for function, (2) ASES pain scores, and (3) total ASES scores? METHODS: Fifty-nine patients with a potential symptomatic rotator cuff tear were recruited and agreed to participate in this cross-sectional study. Of those, 85% (50 of 59) met eligibility criteria for a primary diagnosis of an MRI-confirmed symptomatic partial-thickness or full-thickness rotator cuff tear without a history of shoulder surgery. Demographics, rotator cuff tear size, arm flexion, and clinical scapular motion during active arm flexion were evaluated by experienced examiners using standardized procedures. Patients completed the ASES questionnaire and the Optimal Screening for Prediction of Referral and Outcomes-Yellow Flag assessment form, which measures 11 different pain-related psychological distress symptoms. Three separate stepwise multiple linear regression analyses were performed for ASES pain, function, and total scores, with significance set at p < 0.05. RESULTS: This model found that ASES function scores were associated with four factors: older age, increased arm flexion, increased percentage of scapular external rotation during arm flexion, and increased scores for acceptance of chronic pain (adjusted r2 = 0.67; p = 0.01). Those four factors appear to explain 67% of the observed variance in ASES function scores in patients with rotator cuff tears. Furthermore, increased percentage of scapular external rotation during arm flexion and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.36; p < 0.01) were associated with better ASES pain scores. And finally, better ASES total scores were associated with four factors: increased arm flexion, increased percentage of scapular upward rotation, increased scapular external rotation during arm flexion, and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.65; p < 0.001). CONCLUSION: Our results favor adopting a comprehensive biopsychological clinical assessment for patients with rotator cuff tears that specifically includes humeral and scapular motion, fear-avoidance behaviors, and pain coping behaviors along with demographics. These particular physical and psychological variables were found to be associated with the ASES and, therefore, should be clinically examined simultaneously and targeted as part of a tailored treatment plan. LEVEL OF EVIDENCE: Level II, prognostic study.

Physical Therapists' Assessment of Patient Self-Efficacy for Home Exercise Programs.

BACKGROUND: Patient adherence to home exercise programs (HEPs) is low, and poor patient self-efficacy is a barrier clinicians can influence. However, little evidence suggests that clinicians assess level of patient self-efficacy before prescribing HEPs. PURPOSE: To determine the importance of patient self-efficacy to physical therapists (PTs) when addressing patient barriers, determine how PTs assess and use patient self-efficacy for HEPs, and describe the barriers facing PTs when assessing patient self-efficacy for HEPs. STUDY DESIGN: Survey. METHODS: Practicing PTs were recruited from the American Physical Therapy Association's Orthopedic Section and emailed the electronic survey. RESULTS: Email invitations were sent to 17730 potential participants, and 462 PTs completed the survey over one month. PTs rated self-efficacy as "very" to "extremely" important for patient adherence (58%, 265/454). Most (71%, 328/462) reported assessing self-efficacy before prescribing HEPs and did so through verbal discussion and observation of the patient (50% and 38% respectively). Half of respondents individualized HEPs through self-efficacy related themes. PTs not assessing self-efficacy reported not knowing how (51%, 68/134), being unsure what to do with the information (24%, 32/134), or reporting other barriers (21%, 28/134). CONCLUSIONS: Most PTs indicated that self-efficacy was important for patient adherence, but assessment strategies reported, such as verbal discussion and observation, may not be the most accurate. PTs who did not assess self-efficacy reported not knowing how or what to do with the information once collected. These findings suggest that there is a gap in knowledge related to how to evaluate self-efficacy for HEPs. Better assessment of self-efficacy may lead to more appropriate and effective implementation strategies. LEVEL OF EVIDENCE: Level II.

Current Concepts in Arm Care Exercise Programs and Injury Risk Reduction in Adolescent Baseball Players: A Clinical Review.

CONTEXT: Awareness of important injury risk factors associated with excessive pitching volume has been highlighted in the literature, but injury rates remain high. Shoulder pain in baseball players is associated with various changes in musculoskeletal movements, which presents as measurable impairments throughout the kinetic chain. Baseball coaches and rehabilitation professionals have utilized exercise programs targeting strength and flexibility of the throwing arm to prevent injuries. The purpose of this review is to summarize the current evidence regarding the effectiveness of arm care exercise programs in reducing upper extremity injury rates in adolescent baseball players. EVIDENCE ACQUISITION: A search of electronic databases, including CINAHL with full text, MEDLINE, and SPORTDiscus was conducted to retrieve available articles in English from the years 2010 through 2020. The search terms injury prevention, exercise, and adolescent baseball were used. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: Improving shoulder internal rotation range of motion by stretching the posterior shoulder muscles daily was associated with a 36% risk reduction of shoulder and elbow injuries. Group-based arm care exercise programs that target multiple musculoskeletal impairments demonstrated an approximately 50% reduced risk of elbow injury. CONCLUSION: For adolescent baseball players, arm care injury prevention programs focusing on important musculoskeletal impairments are effective at reducing injury incidence rates. Multimodal injury prevention programs that improve multiple musculoskeletal impairments are more comprehensive and may result in better injury reduction than programs focusing on a singular impairment.

The Effect of Scapular Muscle Strengthening on Functional Recovery in Patients With Lateral Elbow Tendinopathy: A Pilot Randomized Controlled Trial.

CONTEXT: There is a lack of consensus on the best management approach for lateral elbow tendinopathy (LET). Recently, scapular stabilizer strength impairments have been found in individuals with LET. OBJECTIVE: The purpose of this study was to compare the effectiveness of local therapy (LT) treatment to LT treatment plus a scapular muscle-strengthening (LT + SMS) program in patients diagnosed with LET. DESIGN: Prospective randomized clinical trial. SETTING: Multisite outpatient physical therapy. PATIENTS: Thirty-two individuals with LET who met the criteria were randomized to LT or LT + SMS. INTERVENTIONS: Both groups received education, a nonarticulating forearm orthosis, therapeutic exercise, manual therapy, and thermal modalities as needed. Additionally, the LT + SMS group received SMS exercises. MAIN OUTCOME MEASURE: The primary outcome measure was the patient-rated tennis elbow evaluation; secondary outcomes included global rating of change (GROC), grip strength, and periscapular muscle strength. Outcomes were reassessed at discharge, 6, and 12 months from discharge. Linear mixed-effect models were used to analyze the differences between groups over time for each outcome measure. RESULTS: The average duration of symptoms was 10.2 (16.1) months, and the average total number of visits was 8.0 (2.2) for both groups. There were no significant differences in gender, age, average visits, weight, or height between groups at baseline (P > .05). No statistical between-group differences were found for any of the outcome measures. There were significant within-group improvements in all outcome measures from baseline to all follow-up points (P < .05). CONCLUSION: The results of this pilot study suggest that both treatment approaches were equally effective in reducing pain, improving function, and increasing grip strength at discharge as well as the 6- and 12-month follow-ups. Our multimodal treatment programs were effective at reducing pain and improving function up to 1 year after treatment in a general population of individuals with LET.

Grip strength is more sensitive to changes in elbow position than isolated wrist extension strength in patients with lateral elbow tendinopathy.

STUDY DESIGN: This is an observational study. INTRODUCTION: Because isometric wrist extension minimizes the effects of other muscles, the sensitivity of wrist extension strength testing on patients with lateral elbow tendinopathy (LET) should be evaluated. PURPOSE OF THE STUDY: The purpose of the study was to compare the effects of the elbow position on wrist extension and grip strength in patients with LET. METHODS: Patients were screened for at least 2 of 5 clinical tests for LET. Between-day intraclass correlation coefficients (ICC3, 1) for healthy individuals were examined for both grip and wrist extension strength at 0° and 90°. To compare the effects of elbow position on wrist extension strength to grip strength, a repeated measure analysis of variance was run using 2 within-group factors, test angles (0° and 90°), and the test type (wrist extension and grip). RESULTS: Nineteen patients with LET and twenty-one healthy participants were included. The between-day intrarater reliability for both wrist extension and grip strength was excellent for the healthy subjects across the 0° and 90° positions (ICC > .95). The analysis of variance yielded a significant interaction between the type of test and the angle of testing (P = .00). DISCUSSION: Both wrist extension strength and grip strength are reliable between-day measures. For patients with LET, there was a significant decrease in grip strength when testing at 0° compared with 90°. CONCLUSION: In patients with LET, clinicians can expect wrist extension strength at 0° and 90° to be similar. Grip strength testing may be a more relevant clinical test at the initial evaluation.

Reliability and Validity of a Clinical Assessment Tool for Measuring Scapular Motion in All 3 Anatomical Planes.

CONTEXT: A single clinical assessment device that can be used to objectively measure scapular motion in each anatomical plane is not currently available. The development of a novel electric goniometer would allow scapular motion in all 3 anatomical planes to be quantified. OBJECTIVE: To investigate the reliability and validity of an electric goniometer for measuring scapular motion in each anatomical plane during upper extremity elevation. DESIGN: Cross-sectional study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: Sixty participants (29 women, 31 men; age = 30 ± 14 years, height = 1.73 ± 0.10 m, mass = 75.32 ± 16.90 kg) recruited from the general population. INTERVENTION(S): An electric goniometer was used to record clinical measurements of scapular position at rest and total arc of motion (excursion) during active upper extremity elevation in 2 testing sessions separated by several days. Measurements were recorded independently by 2 examiners. In 1 session, scapular motion was recorded simultaneously using a 14-camera, 3-dimensional optical motion-capture system. MAIN OUTCOME MEASURE(S): Reliability analysis included examination of clinical measurements for scapular position at rest and excursion during each condition. Both the intrarater reliability between testing sessions and the interrater reliability recorded in the same session were assessed using intraclass correlation coefficients (ICCs [2,3]). The criterion validity was examined by comparing the mean excursion values of each condition recorded using the electric goniometer and the 3-dimensional optical motion-capture system. Validity was assessed by evaluating the average difference and root mean square error. RESULTS: The between-sessions intrarater reliability was moderate to good (ICC [2,3] range = 0.628-0.874). The within-session interrater reliability was moderate to excellent (ICC [2,3] range = 0.545-0.912). The average difference between total excursion values recorded using the electric goniometer and the 3-dimensional optical motion-capture system ranged from -7° to 4°, and the root mean square error ranged from 7° to 10°. CONCLUSIONS: The reliability of scapular measurements was best when a standard operating procedure was used. The electric goniometer provided an accurate measurement of scapular excursions in all 3 anatomical planes during upper extremity elevation.

Reproducibility and discriminant validity of the Posterior Shoulder Endurance Test in healthy and painful populations.

OBJECTIVE: This investigation measured the reproducibility and discriminant validity of the Posterior Shoulder Endurance Test (PSET) on painful and non-painful populations. DESIGN: Reliability and validity study. SETTING: Laboratory setting. PARTICIPANTS: Thirty subjects (male = 11; female = 19). MAIN OUTCOME MEASURES: Time to failure (TTF) was the primary outcome measure to determine reliability of the PSET. Discriminant validity identified with receiver operator characteristic (ROC) curves utilized TTF separately in men and women since they used different loads. RESULTS: There were 25/30 subjects (painful = 12; non-painful = 13) tested a second time. ICC, SEM, and MDC90 ranged respectively from 0.77, 13.1 s, 30.6 s in the painful group to 0.85, 7.3 s, 17 s in the non-painful group. The male ROC curve AUC was 0.833 with 47 s resulting in the best combination of sensitivity = 0.833, and specificity = 0.80. The female ROC curve AUC was 0.633 with 46 s resulting in the best combination of sensitivity = 0.600 and specificity = 0.889 at 46 s. CONCLUSION: The PSET is a reliable way to measure shoulder girdle muscular endurance. These data suggest that the PSET discriminates painful and non-painful individuals better in men compared to women.

The Self-Efficacy for Home Exercise Programs Scale: Development and Psychometric Properties.

BACKGROUND: The Self-Efficacy for Home Exercise Programs Scale (SEHEPS) was developed to help clinicians evaluate patients' self-efficacy for performing prescribed home exercise programs. Prior to clinical adoption, the scale's psychometric properties need to be examined. OBJECTIVE: To determine the psychometric properties of the SEHEPS. METHODS: Eighty-one patients (32 men, 49 women; mean ± SD age, 42 ± 17 years) with varying musculoskeletal conditions participated in this cohort study. Patients were given a home exercise program at the initial physical therapy visit and completed the SEHEPS and a modified Self-Efficacy for Exercise (SEE) scale. The SEHEPS is a 12-item patient-reported questionnaire designed to assess self-efficacy for prescribed home exercise. Patients rated their confidence on a 7-point scale that ranged from 0 (not confident) to 6 (very confident). Total scores ranged from 0 (low self-efficacy) to 72 (high self-efficacy). We assessed the internal consistency of the SEHEPS using Cronbach's alpha and its test-retest reliability using an intraclass correlation coefficient. Convergent validity between the SEHEPS and SEE scale was evaluated with a Spearman correlation. RESULTS: High internal consistency (α = .96) and good test-retest reliability (intraclass correlation coefficient = 0.88; SEM, 4; minimal detectable change at the 95% confidence level, 12) were demonstrated. The SEHEPS was strongly correlated with the SEE scale (ρ = 0.83, P<.01), indicating strong convergent validity. CONCLUSION: The SEHEPS demonstrates excellent internal consistency and convergent validity with the SEE scale. Overall, the SEHEPS is a clinically useful tool to evaluate a patient's self-efficacy in home-based musculoskeletal exercise programs. This scale can be used prior to prescribing a home exercise program for patients with musculoskeletal conditions. LEVEL OF EVIDENCE: Therapy, level 4. J Orthop Sports Phys Ther 2019;49(9):647-655. Epub 10 Jul 2019. doi:10.2519/jospt.2019.8779.

Considerations of Conservative Treatment After a Partial Ulnar Collateral Ligament Injury in Overhead Athletes: A Systematic Review.

CONTEXT: Ulnar collateral ligament (UCL) reconstructions continue to increase without consensus on an evidence-based treatment protocol for nonoperative management. Currently, there is no consensus on an effective nonoperative protocol for partial UCL injuries that uses return-to-play (RTP) rates in determining the outcome of conservative treatment. OBJECTIVE: To systematically review RTP rates after conservative treatment of partial UCL injuries in overhead athletes along with descriptive components of each conservative intervention to identify an effective evidence-based nonoperative rehabilitation protocol. DATA SOURCES: Articles in PubMed, CINAHL, MEDLINE, Academic Search Complete, and SPORTDiscus were identified in October 2018 based on the following terms: overhead athlete, ulnar collateral ligament, nonoperative treatment, and return to play. STUDY SELECTION: Seven retrospective, level 4 studies (n = 196) qualified for analysis. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Study design, level of evidence, demographics, sample size, sports involved, level of competition, grade or type of UCL diagnosis, conservative treatment components, and percentage RTP were extracted. RESULTS: Overall, RTP rates after conservative treatment ranged between 42% and 100% (mean, 78% ± 20%). The most frequently reported components of rehabilitation protocols were (1) a period of rest, (2) stretching, (3) strengthening, and (4) a throwing program. Platelet-rich plasma injections were included in 5 (71%) of the 7 protocols with a rehabilitation period. CONCLUSION: Conservative treatment is a viable option for partial UCL tears in overhead athletes. A successful rehabilitation protocol includes the use of patient-reported outcomes, a sport-specific tailored treatment plan, kinetic chain strengthening, and an interval throwing program. Factors such as age, grading of tear, level of play, sport, and athlete's perceived well-being should all be considered during treatment decisions.

NEUROMUSCULAR ADAPTIONS FOLLOWING A DAILY STRENGTHENING EXERCISE IN INDIVIDUALS WITH ROTATOR CUFF RELATED SHOULDER PAIN: A PILOT CASE-CONTROL STUDY.

BACKGROUND: The goal of therapeutic exercise is to facilitate a neuromuscular response by increasing or decreasing muscular activity in order to reduce pain and improve function. It is not clear what dosage of exercise will create a neuromuscular response. PURPOSE: The purpose of this study was to assess the effects following a three-week home program of a daily single exercise, the prone horizontal abduction exercise (PHA), on neuromuscular impairments of motor control as measured by scapular muscle EMG amplitudes, strength, and secondarily outcomes of self-reported pain and function between individuals with and without subacromial pain syndrome. STUDY DESIGN: Prospective Case-Control, Pilot Study. METHODS: Twenty-five individuals participated; eleven with shoulder pain during active and resistive motions (Penn Shoulder Score: 77 ± 11) and 14 matched healthy controls (Penn Shoulder Score: 99 ± 27) (p < 0.001). Participants underwent baseline and follow up testing at three weeks including surface electromyography (EMG) of the serratus anterior, upper, and lower trapezius of the involved (painful group) or matched shoulder (control group) during an elevation task and maximal isometric shoulder strength testing. All participants were instructed in a PHA exercise to be performed daily (3 sets; 10 reps). Subjects logged daily exercise adherence. Neuromuscular adaptations were defined by changes in EMG amplitudes (normalized to MVIC) of serratus anterior, upper trapezius, and lower trapezius and strength. Secondary outcomes of self-reported pain and function were also compared between groups following the three-week intervention. RESULTS: After three weeks of a daily PHA exercise, the painful group demonstrated a greater decrease in baseline-elevated EMG amplitudes in the lower trapezius by 7% (95%CI 2.6-11%) during the concentric phase of the overhead lifting task (p 0.006). EMG amplitudes of the healthy control group did not change at three-week follow-up. Additionally, the change in serratus anterior mean EMG amplitude in the painful group -1.6% (IQR -22.9 to 0.8%) was significantly greater (p 0.033) than the healthy group change score, 2.5% (IQR -2.3 to 5.7%) during the eccentric phase (p 0.034). While the painful group was weaker in abduction and flexion at baseline and at follow up, both groups had a significant increase in all strength measures (p≤0.014). Concurrent with increased strength and normalizing EMG amplitudes, the painful group significantly improved on the Penn Shoulder Score with a mean change 9.8 points (95%CI 7.0, 12.6) (p < 0.001). CONCLUSION: In this pilot case-control study, a single home exercise performed daily for three weeks demonstrated neuromuscular adaptations with improvements in muscle activity and strength. These were concurrent with modest, yet significant improvements pain and function in individuals with mild rotator cuff related shoulder pain. LEVEL OF EVIDENCE: 3.

THE RELATIONSHIP BETWEEN PITCHING VOLUME AND ARM SORENESS IN COLLEGIATE BASEBALL PITCHERS.

BACKGROUND: Excessive baseball pitch volume has been associated with increased risk of injury in adolescents. However, many collegiate athletes report non-time loss injuries over the course of the season. It is unknown how pitch volume throughout a collegiate baseball season affects arm soreness. PURPOSE: The primary purpose of this study was to determine the relationship between pitch volume and self-reported arm soreness. A secondary purpose was to determine the relationship between change in pitch volume and change in arm soreness over the course of the season for collegiate baseball pitchers. STUDY DESIGN: Prospective Cohort. METHODS: Seven collegiate baseball pitchers volunteered to participate in a yearlong prospective study. The seven pitchers reported daily pitch volume and level of soreness from the fall through spring collegiate baseball season during practices and games. The athletic trainer, a member of the research team, tracked athletic exposures and injuries for the entire season. Frequency counts of athletic exposures were categorized by game, practice, conditioning and injury status. Frequency counts of pitch volume was categorized by game, game bullpen, practice bullpen, flat ground, long toss and warm-up pitches. The pitch volume and soreness levels for each athlete were used to determine the relationship between these two variables using a Pearson correlation. RESULTS: The seven pitchers were involved with 1,256 athletic exposures and a total of 54,151 throws, averaging 7,735 throws per player for the entire season. The pitch volume and self-reported arm soreness for the entire season revealed a correlation of r = .72 (p = .004). The relationship between change in pitch volume and change in arm soreness was r = .635 (p = .001) over the season. CONCLUSION: There was a moderate significant correlation between arm soreness and pitch volume across the whole season. This relationship was maintained when evaluating weekly changes. LEVEL OF EVIDENCE: 4.

VOLLEYBALL OVERHEAD SWING VOLUME AND INJURY FREQUENCY OVER THE COURSE OF A SEASON.

BACKGROUND: Overuse injuries are common in volleyball; however, few studies exist that quantify the workload of a volleyball athlete in a season. The relationship between workload and shoulder injury has not been extensively studied in women's collegiate volleyball athletes. HYPOTHESIS/PURPOSE: This study aims to quantify shoulder workloads by counting overhead swings during practice and matches. The purpose of the current study is to provide a complete depiction of typical overhead swings, serves, and hits, which occur in both practices and matches. The primary hypothesis was that significantly more swings will occur in practices compared to matches. The secondary hypothesis was that greater swing volume and greater musculoskeletal injury frequency will occur in the pre-season than during the season. STUDY DESIGN: Prospective cohort. METHODS: Researchers observed practice and match videos and counted overhead serves and attacks of 19 women's collegiate volleyball players for two seasons. Serves, overhead hits, and total swings (serves + hits) were the dependent variables; event (matches and practice) along with position (defensive specialists, setter, outside hitter, and middle blocker) were the independent variables. Musculoskeletal injury frequency and swing volume workload were compared across pre-season and competitive season time periods. RESULTS: Across all positions except outside hitters twice as many total swings occurred in practices compared to matches (p=.002) resulting in an average of 19 (CI95 16.5, 21.5) more swings in practice than in matches. The average number of total swings during the pre-season 47.1 (CI95 44.1, 50.1) was significantly greater than average swings per session during the competitive season 37.7 (CI95 36.4, 38.9) (p < 0.001) resulting in a mean difference of 9.4 (CI95 6.1, 12.7) swings. The number of athletes limited in participation or out due to a musculoskeletal injury during the pre-season (2.9%) was greater than during the season (1.1%) (p=0.042). CONCLUSION: These findings support the primary hypothesis that women's collegiate volleyball athletes swing more during practices than in matches. The higher average number of serves in the pre-season and the greater frequency of musculoskeletal injuries requiring participation restriction or removal from participation suggest that a concordant relationship may exist between workload and injury variables. LEVEL OF EVIDENCE: 2.

Elastic Resistance Effectiveness on Increasing Strength of Shoulders and Hips.

Picha, KJ, Almaddah, MR, Barker, J, Ciochetty, T, Black, WS, and Uhl, TL. Elastic resistance effectiveness on increasing strength of shoulders and hips. J Strength Cond Res 33(4): 931-943, 2019-Elastic resistance is a common training method used to gain strength. Currently, progression with elastic resistance is based on the perceived exertion of the exercise or completion of targeted repetitions; exact resistance is typically unknown. The objective of this study was to determine whether knowledge of load during elastic resistance exercise will increase strength gains during exercises. Participants were randomized into 2 strength training groups, elastic resistance only and elastic resistance using a load cell (LC) that displays force during exercise. The LC group used a Smart Handle (Patterson Medical Supply, Chicago, IL, USA) to complete all exercises. Each participant completed the same exercises 3 times weekly for 8 weeks. The LC group was provided with a set load for exercises, whereas the elastic resistance only group was not. The participant's strength was tested at baseline and program completion, measuring isometric strength for shoulder abduction (SAb), shoulder external rotation (SER), hip abduction (HAb), and hip extension (HEx). Independent t-tests were used to compare the normalized torques between groups. No significant differences were found between groups. Shoulder strength gains did not differ between groups (SAb p > 0.05; SER p > 0.05). Hip strength gains did not differ between groups (HAb p > 0.05; HEx p > 0.05). Both groups increased strength because of individual supervision, constantly evaluating degree of difficulty associated with exercise and providing feedback while using elastic resistance. Using an LC is as effective as supervised training and could provide value in a clinical setting when patients are working unsupervised.

Return to Play Following Nonoperative Treatment of Partial Ulnar Collateral Ligament Injuries in Professional Baseball Players: A Critically Appraised Topic.

Clinical Scenario: Ulnar collateral ligament (UCL) injuries are highly prevalent in professional baseball players with the success of operative management being well known in the literature. Return to play (RTP) rates following nonoperative management of partial UCL injuries in professional baseball players are not well established in the literature. With a UCL tear being a potential career-ending injury, it is imperative that the best treatment option is provided to these throwing athletes. There is an increase in the incidence of UCL surgical rates and a lack of general agreement on nonoperative treatment of partial UCL injuries as reported by the American Shoulder and Elbow Surgeons in 2017. There is also a lack of clarity on when to initiate rehabilitation, which may be due to the limited amount of studies reporting success of RTP rates and time to RTP following conservative interventions of partial UCL injuries. Evidence on the RTP rates seen following conservative management of partial UCL tears injuries can help guide health care providers in deciding on the best treatment option for professional baseball athletes who desire to return to their athletic careers. These rates of RTP will add valuable objective input when determining if conservative management is the best choice. To determine the current evidence, inclusion criteria for the literature search consisted of RTP rates following conservative treatment in professional baseball players between inception and 2018. Clinical Question: Is there evidence for successful RTP rates in professional baseball players following conservative treatment of a UCL injury? Summary of Key Findings: Three retrospective studies met the inclusion criteria and were included. Of those, 2 reported RTP rates following a nonoperative rehabilitation program of a UCL injury, whereas 1 reported RTP rates after injection therapy in subjects who attempted a trial of conservative treatment. All 3 studies considered location and grade of UCL tear. Successful RTP rates (66%-100%) were reported in professional baseball players following nonoperative treatment of partial UCL injuries. Clinical Bottom Line: Current evidence supports high success with RTP rates up to 100% after nonoperative treatment of grade 1 UCL injuries in professional baseball players and between 66% and 94% for a grade 2 and above. Strength of Recommendation: There is level C evidence for high RTP rates following nonoperative treatment of partial UCL injuries in professional baseball players.