1/26/2015

ROBERT MCCABE , PT., OCS,

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COMMON INJURIES  Little Leaguer’s Shoulder  Medial Elbow Injuries (Little League Elbow)

1. UCL Injuries 2. Medial epicondyle apophysitis  Shoulder Microinstability  Posterior / Internal Impingement  SLAP Tears  Lateral Elbow - Compression Injuries

- osteochondritis dissecans 2

 Epiphysitis of humeral head  Traction injury to growth plate  Occurs during

deceleration of throwing / follow through ↑ distraction force with eccentric IR

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

Traction injury to UCL (anterior band) ligament Occurs during cocking phase of throwing and early acceleration



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 Apophysitis of medial

epicondyle

 Traction injury to

growth plate

 Occurs during cocking

phase of throwing ↑ valgus force with excessive ER

Osteochondritis

Dissecans

 Compression of radial

head / capitellum

 Occurs during cocking

phase of throwing and early acceleration

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COMMON FINDINGS  Scapular Dyskinesia  Tight Post-Inferior

GH Capsule  Poor Pitching

Mechanics  Overload/overuse 7

 Impairment in the normal resting position of

the scapula or alteration in normal dynamic scapular motion.

Type I-III Classification  Type I – Prominence of infero-medial border  Type II – Prom. of entire medial border  Type III – Prom. of entire scapula & superior translation of entire scapula 8

Classifications • Type I • Type II • Type III

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TYPE I and II Associated with:

 SLAP tears (type II)  Dysfunction of lower

trapezius

 Dysfunction of

serratus anterior

 Tightness of UT, post

GH capsule or PM

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SCAPULAR DYSKINESIA Common Pattern Post tilt, UR ,ER   Impingement (64%)  Instability (100%) Ludewig Physical Therapy 2000,Into JSES 92’. Ogston,AJSM2007. Matias. Clin.Biomech 2006

Causes- Impaired: Posture- ↑Kyphosis Muscle Performance Endurance (Acute effect) 3. ROM/Flexibility  Tight Posterior GH capsule 1. 2.

 Pectoralis Minor  Upper trapezius 11

EVALUATION- SCAPULA Dynamic/Objective Tests Lateral scapula glide test 2. Scapular Assistance test 3. Scapular Retraction Test 1.

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EVALUATION- SCAPULA  Lateral Scapular Glide Test • Horizontal Measurement (cm) from

inferior angle to spinous process in 3 positions:

- arms @ side - hands on hip - 90˚ GH abduction (IR) • “Semi-dynamic”

SCAPULA SLIDE TEST  + Test = > 1.5 cm side to side difference.  Test-retest reliability =

.43 -.92 (inter and intra)  Validity = .90

 Position 1 and 2 more reliable

 Screening Tool

Kibler 88, 90. Odom, PT, 01, Curtis, NAJSPT,06

SCAPULAR RETRACTION TEST Purpose- Determine if scapula dyskinesis is contributing to sp. weakness in pts. w/ shoulder pathology Technique- Empty can test manually produce scapular retraction.  repeat empty can test 15

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SCAPULAR RETRACTION TEST  (+) test = strength w/ scapula retracted

 Limitation: Threshold value for change not determined Kibler. AJSM 2006 16

SCAPULAR ASSISTANCE TEST • Purpose – Contribution

of scap. dyskinesis to pain/weakness in pts with shoulder pathology • Technique- Active elevation in sagittal or scapular plane  repeat with manual assistance to promote upward rot. & post. tilt

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SCAPULAR ASSISTANCE TEST

+ Test = 1. ↓pain of ≥ 2

points on 10 point scale 2. ↓Weakness Rabin. JOSPT 2006 Greenfield AJSM 1990

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Infraspinatus IGHL (posterior band) Teres Minor

Teres Major

» ↑ superior labrum strain via ↑ peel back forces » ↑ Compression on posterior labrum » ↓ ER  compensate w/ ↑

abd. ant capsule stress (tension)  micro-instability » Entrapment of undersurface of posterior RC ( Posterior/ Internal impingement )

Burkhart. Arthroscopy 2003 Clabbers J Sport Rehabil. 2007

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Burkhart. Arthroscopy 2003 22 Clabbers J Sport Rehabil. 2007

» Late Cocking Phase -

Burkhart, Arthroscopy 2003

 Bicep vector’s to more posterior position ↑ torsion of biceps anchor/labral attachment  medial/lateral gapping of labrum off glenoid » Normal response » Accentuated by Post GH tightness!!!

Repetitive Abd/ER »

Sup view (left)

Walch. JSES 92’

 Posterior-inferior capsule tightness Impingement of undersurface of postsup. RC between posterior labrum and greater tuberosity  ↑ Ant capsule laxity Superior view- left shoulder

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» HORIZONTAL ADDUCTION

Myers. AJSM 2007

 Meyers Post GH Test

• Technique- Pt. retracts scapula  clinician stabilizes scapula  passive horizontal adduct. (in neutral rot). Measure > formed between axis of humerus and horizontal plane from superior aspect of shld. • Inter tester reliability = .94 • Construct Validity p= .004 25

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MYERS. – SUPINE POST GH TEST Shoulder Baseball Players

Tennis players

Normal Subjects

Dom

105

103

107

Non-Dom

114

111

107

Look for symmetry

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 IR ROM :CAUSED BY RETROVERSION + GH TIGHTNESS !!

 LIMITATION

OF Measuring IR ROM!

 Osseous adaptations in response to tensile stress on posterior capsule( humeral + glenoid retroversion)

Humeral Retroversion ~ Posterior torsion/rotation of humerus in horizontal plane

≮=30

Humeral / Glenoid Retroversion  IR  ↑˚17 in pitchers  Irreversible  Beneficial

? - ↑↑ in asymptomatic

throwers 

Crockett AJSM 02’ , Whitely, JOSPT 2009

Generalized

Ligamentous Laxity • Elbow recurvatum = >10˚ • Thumb to forearm

opposition = < 1cm • MCP hyperext. = > 60˚ • DIP hyperext = > 30˚ * Remember: Laxity ≠

Instability

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» Anterior Apprehension Test • 90/90 position • Passive overpressure at end-

range of ER • If (+) apprehension  apply

posterior glide to humerus • (+) Test = Elimination of

instability/apprehension 31

Farber, JBJS 2006, Hegedus, BJSM. 2008 Luime JAMA 2004

Test (+)

Sens.

Spec PPV/ LR+

NPV/ LR -

Accur.

88

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Apprehension ↑ Pain

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↑Apprehension

72

96

↓Pain

30

90

↓Apprehension

81

92

53/6.5 98/.18

91

64

99

__/58 __/.37

65

75/20 96/.29

93

Appre-Reloc. 19

94

86

Ant. Release ↑ Pain/Instab.

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» JOBE RELOCATION TEST • 90/90 position • Passive overpressure at end-

range of ER • If (+) Posterior shoulder

pain  apply posterior glide to humerus • (+) Test = Elimination of posterior shoulder pain 34

Biceps Anchor

Associated Pathologies/Conditions • Partial supraspinatus tear (45 %) • RCT (11%) • Bankart (11% • Partial biceps tear (20%) • Ganglion cyst- spinoglenoid • AC arthrosis • HAGL lesion (SLAP II) • Internal impingement (SLAPII) • Scapular Dyskinesis (SLAP II)

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SPECIAL TESTS- SLAP • Clunk Test

 Strong Evidence

• Anterior Slide Test • Active Compression Test • Dynamic Speed’s Test Biceps Load test I and II Resisted Supination –ER

Test • Pronated Load Test

Clunk Test- With

the arm abducted to varying degrees overhead, clinician applies anterior force to humeral head while passively rotating humerus (IR/ER). (+) test = “clunk”. Andrews AJSM 85 ’

Anterior Slide With pts. Hand on hip, clinician applies antero-superior force while manually stabilizing scapula. (+) test = pop/crack and pain Kibler. Arhroscopy 95’

CLUNK TEST

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ANTERIOR SLIDE TEST

Active Compression Test With the humerus in IR & flexed @ 90 and horiz adducted 30˚ , clinician applies downward force repeat w/ humerus in ER (+) test = Pain “inside” shoulder on 1st test and no pain on 2nd test. *AC pathology = pain @AC joint O’Brien AJSM 98’

Dynamic Speed’s – Clinician applies resistance to simultaneous shoulder elevation and elbow flexion. (+) test = Deep shoulder pain > 90˚ Wilk JOSPT 2005

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Biceps Load I • Shoulder @ 90˚ abduction

and max ER,(elbow flexed @ 90, supinated forearm)

• Resisted elbow flexion in

order to recreate “peel back” mechanism.

(+) test = Deep shoulder pain.  Biceps Load II – shoulder is positioned @120˚ abduction Kim. Arthroscopy 2001 Kim. AJSM 95’

Resisted Supination External-Rotation Test  Test position : @ 90˚ abduction and

max ER, (elbow flexed @ 65-70˚, neutral forearm)  resisted supination/simultaneous passive ER in order to recreate “peel back” mechanism. (+) test = Deep shoulder pain. Myers AJSM

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Pronated Load Test  Shoulder abducted 90˚ w/ full pronation  passive ER to endrange  contract biceps to provoke “peelback” force on labrum

(+) test = pain Wilk JOSPT 2005

SLAP- SPECIAL TESTS  Most Accurate Tests Biceps Load I Biceps Load II 3. Resisted Supination- External Rotation 1. 2.

Hegedus, BJSM 2008. Dessaur, JOSPT 2008

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REFERENCE SLIDE (NO AUDIO) Specificity Sensitivity LR+

LR-

Biceps Load I

91

97

29.1

.1

Biceps Load II

90

97

30.0

.1

SupinationER

83

82

4.6

.2

» Factors ↑GH Kinetic Force • Dropping of trail shoulder • No “hand on top” position • ↑ Sh ER > 56˚@ stride foot

contact • ↑ Toe out ( >10˚) • ↑ Lateral placement

( > 10 cm vs plant foot)

Stride Foot

Flesig 94’

Elbow Flexion < 90 degrees at glove

separation ( hand closer to head)  Excessive shoulder horizontal adduction  Arm slot position < ¾ position ( 120º )

 Arm slot determined by:  Shoulder abduction angle (90-100º)  Lateral trunk tilt angle

(20-30º)

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INJURY RISK FACTORS ↑Pitch count/game Throwing sliders (↑risk +86%) Throwing curveballs ( ↑ risk + 56%) Fatigue • ↓Velocity • ↑Upright trunk @ follow thru

Throwing change-ups ↓ risk by 12% Flesig AJSM 2002, 2006. Escambilla AJSM 2007

BIOMECHANICAL COUNSELING  Parameters for Safe Pitching • Stride length = 73-86% of height • Max Sh ER = 155˚ • Avoid toe out/ lateral placement of

lead foot

• Keep hand on top of ball thru early

cocking phase • “Pitch downhill”

EDUCATION  Patient/Parent/Coach  Follow UBMSA Guidelines • Pitch counts  Follow Interval Throwing program  Monitor signs/ symptoms of fatigue  STOPSPORTS INJURIES.ORG END OF AUDIO – REFERENCE SLIDES FOLLOW

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If any pain , Stop throwing for 1 week

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