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TRANSCRIPT
1
Rotator Cuff Dysfunction Injury Prevention and Non-operative
Treatment
Brian Schiff PT OCS CSCS
Provider Disclaimer
bull Allied Health Education and the presenter of this webinar do not have any financial or other
associations with the manufacturers of any products or suppliers of commercial services that may be
discussed or displayed in this presentation bull There was no commercial support for this
presentationbull The views expressed in this presentation are the views
and opinions of the presenterbull Participants must use discretion when using the
information contained in this presentation
Backgroundbull Supervisor - Raleigh Orthopaedic Performance Center
bull Practiced since 1996 in outpatient sportsortho clinics
bull S amp C coach for MLS - Columbus Crew 2002-2006
bull Owned my own training facility 2000-2010
bull FMS certified board certified orthopaedic clinical specialist (OCS) credentialed in dry needling
bull Write for PFP Magazine
bull PT consultant for Carolina Hurricanes
2
Objectives
bull Review rotator cuff dysfunction and relevant research with respect to exercise and conservative
care
bull Discuss specific weight training and exercise related modifications to prevent shoulder injuries
bull Outline a comprehensive non-operative
rehabilitation approach to rotator cuff injuries including manual interventions and therapeutic
exercise
bull Review return to sportactivity considerations
Rotator Cuff Risk Factors
bull GHJ Laxity
bull Scapular dyskinesia
bull Postural dysfunction
bull Muscular imbalances
bull Overuse
3
Pertinent Anatomy
bull Scapula
bull Humerus
bull Ligaments
bull Labrum
bull Dynamic stabilizers
Static Restraints
Acromial Type
4
Rotator Cuff
Rotator Cuff
Shoulder Injuriesbull Up to 36 of weight lifting injuries
involve the shoulder
bull Why NWB joint becomes WB
bull Study ndash 90 men (19-47) w60 doing
RWT
bull darrrsquod L Trap strength darrrsquod IR ROM gt post shoulder tightness amp gt ER ROM
bull Need cuff amp scapular stabilizer workKolber et al J Strength Cond Res 2009
5
Recipe for Overuse bull Repetitive motion
bull Faulty muscle recruitment (poor stability)
bull Pec and lat tightness
bull Bad posture
bull Limited T-spine mobility
Balance Prevents Overtraining
Stress
Recovery
Youth Baseball bull Olsen et al revealed that
averaging more than 80 pitches
per game nearly quadrupled injury risk and pitching more than 8 months out of the year
raised it fivefold
bull Olsenrsquos study concluded pitching with a fatigued arm
increased chances of having surgery 36x
bull Fleisig et al showed that
pitching more than 100 competition innings per year more than tripled the risk for
serious shoulder or elbow injury In addition playing catcher as well as pitcher increased the
odds ratio of injury 27 times
Fleisig et al Sports Health 2012
6
bull 23 adolescent pitchers (age 157 plusmn 14 years) were tested
bull 12 pitchers had throwing-related pain in the prior season and were currently symptom-free while the remaining 11
pitchers had no such history of pain
bull 23 pitchers had a loss of internal rotation ROM (13deg plusmn 10deg P
lt 001) and gain in external rotation ROM (11deg plusmn 10deg P lt 001) on the dominant versus non-dominant arm with no
effect on total ROM (2deg plusmn 7deg loss P = 14)
bull Throwing-related pain in this population may be due to the inability of weakened posterior shoulder musculature to
tolerate stress imparted on it by adaptively strengthened propulsive muscles
Trakis et al AJSM 2008
GIRD
Image from Manske et al Int J Sports Phsy Ther 2013
ERD and GIRDbull ERD (ext rot deficiency) - 5 deg or less
wPROM increases injury risk in throwers
23x (unpublished data)
bull Anatomical GIRD - normal loss of IR (18-20 deg) with adequate ER gain and TROM
within 5 deg of the uninvolved side
bull Pathologic GIRD - A shoulder that has
GIRD more than 18-20 deg and a
concomitant loss of TROM gt 5 deg (= 25x
injury risk)Manske et al Int J Sports Phys Ther 2013
7
More on GIRDbull Burkhart reports that an acceptable level of
GIRD is defined as
bull 1) less than 20 deg loss of shoulder IR comparing shoulders bilaterally or
bull 2) no greater than 10 loss of the total rotation seen in the non-throwing
shoulder (Non dominant shoulder IR +
ER ROM) x 10)
bull 3) Ratio of GIRD to ERG needs to be 1
or lessManske et al Int J Sports Phys Ther 2013
Internal Impingement
bull Pathologic GIRD creates altered
biomechanics for overhead athletes
leading to posterosuperior glenoid impingement a common cause of pain
in throwing athletes
bull IR decreases with throwing as season goes along
Scapular Positioningbull The dominant-side scapula of overhead
athletes was more internally rotated and anteriorly tilted than the non-dominant side
scapula
bull The dominant-side scapula of tennis
players was more protracted than that on
the non-dominant side
bull Scapular posture asymmetry in unilateral
overhead athletes may be normal
Oyam et al J Athl Train 2008
8
Common Injuries
bull Tendinitis
bull Tendinosis
bull Impingement
bull Partial thickness tears
bull Full thickness tears
Exercise Trends
bull Crossfit
bull Kettlebells
bull HIT workouts
bull Extreme races
bull Obstacle course training
Crossfit Injury rates
bull An injury rate of 31 per 1000 hours trained was calculated
bull Injury rates with CrossFit training are similar to
that reported in the literature for sports such as Olympic weight-lifting power-lifting and
gymnastics and lower than competitive contact sports such as rugby union and rugby league
bull Shoulder and spine injuries predominate with no incidences of rhabdomyolysis obtained
Hak et al J Strength Cond Res 2013
9
Crossfit Injury ratesbull 486 CrossFit participants completed the survey
bull The overall injury rate was determined to be 194 (75386)
bull Males (53231) were injured more frequently than females (21150 P = 03)
bull Across all exercises injury rates were significantly different (P lt 001) with shoulder (2184) low back (1284) and knee (1184) being the most commonly injured overall
bull The shoulder was most commonly injured in gymnastic movements and the low back was most commonly injured in power lifting movements
Weisenthal et al Orthop J Sports Med 2014
Weight Training Considerations
bull Age
bull Acromial type
bull Prior injury
bull Instability
bull Scapular dyskinesia
bull Clavicular osteolysis and bone spurs
Instability
bull Acquired laxity gt anterior micro
instability
bull MDI
bull Secondary RC bicipital and labral
stress
bull Caution with loading (snatch jerks flies
pressing dips etc)
10
The Scapulabull Resting alignment
bull Dynamic mechanics
bull SICK scapula
1 Inferior border prominence
2 Medial border prominence
3 Superior border prominence
Distal Clavicle Osteolysis
Threatening Exercises
bull Full range chest press flies and dips
bull Long lever side raises
bull Wide grip pull-ups
bull Heavy overhead press hand stand push-ups
bull Burpees bear crawls undulating ropes
bull Overhead lifts (eg snatch) with improper form
and certain squat variations
11
Differential Diagnosis
bull Labral tears
bull AC joint pathology
bull Bicipital tendinopathy
bull Brachial plexus
bull Radicular pain
bull Myofascial pain
Shoulder Imaging
bull Common X-rays
1 AP (external rotation)
2 Lateral (Y View)
3 Axillary
12
AP View
Lateral View
Source - AAOS Website
Axillary View
13
MRI - Partial Tear
Angled oblique MRI views - source Medscape
MRI - Full Tear
Angled oblique MRI views - source Medscape
PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion
(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited
between June 2010 and February 2011
bull The clinical effect of the platelet-rich plasma injection
was superior to the dry needling from 6 weeks to 6 months after initial injection
bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group
bull No severe adverse effects were observed in either group
Rha et al Clin Rehabil 2013
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
2
Objectives
bull Review rotator cuff dysfunction and relevant research with respect to exercise and conservative
care
bull Discuss specific weight training and exercise related modifications to prevent shoulder injuries
bull Outline a comprehensive non-operative
rehabilitation approach to rotator cuff injuries including manual interventions and therapeutic
exercise
bull Review return to sportactivity considerations
Rotator Cuff Risk Factors
bull GHJ Laxity
bull Scapular dyskinesia
bull Postural dysfunction
bull Muscular imbalances
bull Overuse
3
Pertinent Anatomy
bull Scapula
bull Humerus
bull Ligaments
bull Labrum
bull Dynamic stabilizers
Static Restraints
Acromial Type
4
Rotator Cuff
Rotator Cuff
Shoulder Injuriesbull Up to 36 of weight lifting injuries
involve the shoulder
bull Why NWB joint becomes WB
bull Study ndash 90 men (19-47) w60 doing
RWT
bull darrrsquod L Trap strength darrrsquod IR ROM gt post shoulder tightness amp gt ER ROM
bull Need cuff amp scapular stabilizer workKolber et al J Strength Cond Res 2009
5
Recipe for Overuse bull Repetitive motion
bull Faulty muscle recruitment (poor stability)
bull Pec and lat tightness
bull Bad posture
bull Limited T-spine mobility
Balance Prevents Overtraining
Stress
Recovery
Youth Baseball bull Olsen et al revealed that
averaging more than 80 pitches
per game nearly quadrupled injury risk and pitching more than 8 months out of the year
raised it fivefold
bull Olsenrsquos study concluded pitching with a fatigued arm
increased chances of having surgery 36x
bull Fleisig et al showed that
pitching more than 100 competition innings per year more than tripled the risk for
serious shoulder or elbow injury In addition playing catcher as well as pitcher increased the
odds ratio of injury 27 times
Fleisig et al Sports Health 2012
6
bull 23 adolescent pitchers (age 157 plusmn 14 years) were tested
bull 12 pitchers had throwing-related pain in the prior season and were currently symptom-free while the remaining 11
pitchers had no such history of pain
bull 23 pitchers had a loss of internal rotation ROM (13deg plusmn 10deg P
lt 001) and gain in external rotation ROM (11deg plusmn 10deg P lt 001) on the dominant versus non-dominant arm with no
effect on total ROM (2deg plusmn 7deg loss P = 14)
bull Throwing-related pain in this population may be due to the inability of weakened posterior shoulder musculature to
tolerate stress imparted on it by adaptively strengthened propulsive muscles
Trakis et al AJSM 2008
GIRD
Image from Manske et al Int J Sports Phsy Ther 2013
ERD and GIRDbull ERD (ext rot deficiency) - 5 deg or less
wPROM increases injury risk in throwers
23x (unpublished data)
bull Anatomical GIRD - normal loss of IR (18-20 deg) with adequate ER gain and TROM
within 5 deg of the uninvolved side
bull Pathologic GIRD - A shoulder that has
GIRD more than 18-20 deg and a
concomitant loss of TROM gt 5 deg (= 25x
injury risk)Manske et al Int J Sports Phys Ther 2013
7
More on GIRDbull Burkhart reports that an acceptable level of
GIRD is defined as
bull 1) less than 20 deg loss of shoulder IR comparing shoulders bilaterally or
bull 2) no greater than 10 loss of the total rotation seen in the non-throwing
shoulder (Non dominant shoulder IR +
ER ROM) x 10)
bull 3) Ratio of GIRD to ERG needs to be 1
or lessManske et al Int J Sports Phys Ther 2013
Internal Impingement
bull Pathologic GIRD creates altered
biomechanics for overhead athletes
leading to posterosuperior glenoid impingement a common cause of pain
in throwing athletes
bull IR decreases with throwing as season goes along
Scapular Positioningbull The dominant-side scapula of overhead
athletes was more internally rotated and anteriorly tilted than the non-dominant side
scapula
bull The dominant-side scapula of tennis
players was more protracted than that on
the non-dominant side
bull Scapular posture asymmetry in unilateral
overhead athletes may be normal
Oyam et al J Athl Train 2008
8
Common Injuries
bull Tendinitis
bull Tendinosis
bull Impingement
bull Partial thickness tears
bull Full thickness tears
Exercise Trends
bull Crossfit
bull Kettlebells
bull HIT workouts
bull Extreme races
bull Obstacle course training
Crossfit Injury rates
bull An injury rate of 31 per 1000 hours trained was calculated
bull Injury rates with CrossFit training are similar to
that reported in the literature for sports such as Olympic weight-lifting power-lifting and
gymnastics and lower than competitive contact sports such as rugby union and rugby league
bull Shoulder and spine injuries predominate with no incidences of rhabdomyolysis obtained
Hak et al J Strength Cond Res 2013
9
Crossfit Injury ratesbull 486 CrossFit participants completed the survey
bull The overall injury rate was determined to be 194 (75386)
bull Males (53231) were injured more frequently than females (21150 P = 03)
bull Across all exercises injury rates were significantly different (P lt 001) with shoulder (2184) low back (1284) and knee (1184) being the most commonly injured overall
bull The shoulder was most commonly injured in gymnastic movements and the low back was most commonly injured in power lifting movements
Weisenthal et al Orthop J Sports Med 2014
Weight Training Considerations
bull Age
bull Acromial type
bull Prior injury
bull Instability
bull Scapular dyskinesia
bull Clavicular osteolysis and bone spurs
Instability
bull Acquired laxity gt anterior micro
instability
bull MDI
bull Secondary RC bicipital and labral
stress
bull Caution with loading (snatch jerks flies
pressing dips etc)
10
The Scapulabull Resting alignment
bull Dynamic mechanics
bull SICK scapula
1 Inferior border prominence
2 Medial border prominence
3 Superior border prominence
Distal Clavicle Osteolysis
Threatening Exercises
bull Full range chest press flies and dips
bull Long lever side raises
bull Wide grip pull-ups
bull Heavy overhead press hand stand push-ups
bull Burpees bear crawls undulating ropes
bull Overhead lifts (eg snatch) with improper form
and certain squat variations
11
Differential Diagnosis
bull Labral tears
bull AC joint pathology
bull Bicipital tendinopathy
bull Brachial plexus
bull Radicular pain
bull Myofascial pain
Shoulder Imaging
bull Common X-rays
1 AP (external rotation)
2 Lateral (Y View)
3 Axillary
12
AP View
Lateral View
Source - AAOS Website
Axillary View
13
MRI - Partial Tear
Angled oblique MRI views - source Medscape
MRI - Full Tear
Angled oblique MRI views - source Medscape
PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion
(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited
between June 2010 and February 2011
bull The clinical effect of the platelet-rich plasma injection
was superior to the dry needling from 6 weeks to 6 months after initial injection
bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group
bull No severe adverse effects were observed in either group
Rha et al Clin Rehabil 2013
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
3
Pertinent Anatomy
bull Scapula
bull Humerus
bull Ligaments
bull Labrum
bull Dynamic stabilizers
Static Restraints
Acromial Type
4
Rotator Cuff
Rotator Cuff
Shoulder Injuriesbull Up to 36 of weight lifting injuries
involve the shoulder
bull Why NWB joint becomes WB
bull Study ndash 90 men (19-47) w60 doing
RWT
bull darrrsquod L Trap strength darrrsquod IR ROM gt post shoulder tightness amp gt ER ROM
bull Need cuff amp scapular stabilizer workKolber et al J Strength Cond Res 2009
5
Recipe for Overuse bull Repetitive motion
bull Faulty muscle recruitment (poor stability)
bull Pec and lat tightness
bull Bad posture
bull Limited T-spine mobility
Balance Prevents Overtraining
Stress
Recovery
Youth Baseball bull Olsen et al revealed that
averaging more than 80 pitches
per game nearly quadrupled injury risk and pitching more than 8 months out of the year
raised it fivefold
bull Olsenrsquos study concluded pitching with a fatigued arm
increased chances of having surgery 36x
bull Fleisig et al showed that
pitching more than 100 competition innings per year more than tripled the risk for
serious shoulder or elbow injury In addition playing catcher as well as pitcher increased the
odds ratio of injury 27 times
Fleisig et al Sports Health 2012
6
bull 23 adolescent pitchers (age 157 plusmn 14 years) were tested
bull 12 pitchers had throwing-related pain in the prior season and were currently symptom-free while the remaining 11
pitchers had no such history of pain
bull 23 pitchers had a loss of internal rotation ROM (13deg plusmn 10deg P
lt 001) and gain in external rotation ROM (11deg plusmn 10deg P lt 001) on the dominant versus non-dominant arm with no
effect on total ROM (2deg plusmn 7deg loss P = 14)
bull Throwing-related pain in this population may be due to the inability of weakened posterior shoulder musculature to
tolerate stress imparted on it by adaptively strengthened propulsive muscles
Trakis et al AJSM 2008
GIRD
Image from Manske et al Int J Sports Phsy Ther 2013
ERD and GIRDbull ERD (ext rot deficiency) - 5 deg or less
wPROM increases injury risk in throwers
23x (unpublished data)
bull Anatomical GIRD - normal loss of IR (18-20 deg) with adequate ER gain and TROM
within 5 deg of the uninvolved side
bull Pathologic GIRD - A shoulder that has
GIRD more than 18-20 deg and a
concomitant loss of TROM gt 5 deg (= 25x
injury risk)Manske et al Int J Sports Phys Ther 2013
7
More on GIRDbull Burkhart reports that an acceptable level of
GIRD is defined as
bull 1) less than 20 deg loss of shoulder IR comparing shoulders bilaterally or
bull 2) no greater than 10 loss of the total rotation seen in the non-throwing
shoulder (Non dominant shoulder IR +
ER ROM) x 10)
bull 3) Ratio of GIRD to ERG needs to be 1
or lessManske et al Int J Sports Phys Ther 2013
Internal Impingement
bull Pathologic GIRD creates altered
biomechanics for overhead athletes
leading to posterosuperior glenoid impingement a common cause of pain
in throwing athletes
bull IR decreases with throwing as season goes along
Scapular Positioningbull The dominant-side scapula of overhead
athletes was more internally rotated and anteriorly tilted than the non-dominant side
scapula
bull The dominant-side scapula of tennis
players was more protracted than that on
the non-dominant side
bull Scapular posture asymmetry in unilateral
overhead athletes may be normal
Oyam et al J Athl Train 2008
8
Common Injuries
bull Tendinitis
bull Tendinosis
bull Impingement
bull Partial thickness tears
bull Full thickness tears
Exercise Trends
bull Crossfit
bull Kettlebells
bull HIT workouts
bull Extreme races
bull Obstacle course training
Crossfit Injury rates
bull An injury rate of 31 per 1000 hours trained was calculated
bull Injury rates with CrossFit training are similar to
that reported in the literature for sports such as Olympic weight-lifting power-lifting and
gymnastics and lower than competitive contact sports such as rugby union and rugby league
bull Shoulder and spine injuries predominate with no incidences of rhabdomyolysis obtained
Hak et al J Strength Cond Res 2013
9
Crossfit Injury ratesbull 486 CrossFit participants completed the survey
bull The overall injury rate was determined to be 194 (75386)
bull Males (53231) were injured more frequently than females (21150 P = 03)
bull Across all exercises injury rates were significantly different (P lt 001) with shoulder (2184) low back (1284) and knee (1184) being the most commonly injured overall
bull The shoulder was most commonly injured in gymnastic movements and the low back was most commonly injured in power lifting movements
Weisenthal et al Orthop J Sports Med 2014
Weight Training Considerations
bull Age
bull Acromial type
bull Prior injury
bull Instability
bull Scapular dyskinesia
bull Clavicular osteolysis and bone spurs
Instability
bull Acquired laxity gt anterior micro
instability
bull MDI
bull Secondary RC bicipital and labral
stress
bull Caution with loading (snatch jerks flies
pressing dips etc)
10
The Scapulabull Resting alignment
bull Dynamic mechanics
bull SICK scapula
1 Inferior border prominence
2 Medial border prominence
3 Superior border prominence
Distal Clavicle Osteolysis
Threatening Exercises
bull Full range chest press flies and dips
bull Long lever side raises
bull Wide grip pull-ups
bull Heavy overhead press hand stand push-ups
bull Burpees bear crawls undulating ropes
bull Overhead lifts (eg snatch) with improper form
and certain squat variations
11
Differential Diagnosis
bull Labral tears
bull AC joint pathology
bull Bicipital tendinopathy
bull Brachial plexus
bull Radicular pain
bull Myofascial pain
Shoulder Imaging
bull Common X-rays
1 AP (external rotation)
2 Lateral (Y View)
3 Axillary
12
AP View
Lateral View
Source - AAOS Website
Axillary View
13
MRI - Partial Tear
Angled oblique MRI views - source Medscape
MRI - Full Tear
Angled oblique MRI views - source Medscape
PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion
(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited
between June 2010 and February 2011
bull The clinical effect of the platelet-rich plasma injection
was superior to the dry needling from 6 weeks to 6 months after initial injection
bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group
bull No severe adverse effects were observed in either group
Rha et al Clin Rehabil 2013
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
4
Rotator Cuff
Rotator Cuff
Shoulder Injuriesbull Up to 36 of weight lifting injuries
involve the shoulder
bull Why NWB joint becomes WB
bull Study ndash 90 men (19-47) w60 doing
RWT
bull darrrsquod L Trap strength darrrsquod IR ROM gt post shoulder tightness amp gt ER ROM
bull Need cuff amp scapular stabilizer workKolber et al J Strength Cond Res 2009
5
Recipe for Overuse bull Repetitive motion
bull Faulty muscle recruitment (poor stability)
bull Pec and lat tightness
bull Bad posture
bull Limited T-spine mobility
Balance Prevents Overtraining
Stress
Recovery
Youth Baseball bull Olsen et al revealed that
averaging more than 80 pitches
per game nearly quadrupled injury risk and pitching more than 8 months out of the year
raised it fivefold
bull Olsenrsquos study concluded pitching with a fatigued arm
increased chances of having surgery 36x
bull Fleisig et al showed that
pitching more than 100 competition innings per year more than tripled the risk for
serious shoulder or elbow injury In addition playing catcher as well as pitcher increased the
odds ratio of injury 27 times
Fleisig et al Sports Health 2012
6
bull 23 adolescent pitchers (age 157 plusmn 14 years) were tested
bull 12 pitchers had throwing-related pain in the prior season and were currently symptom-free while the remaining 11
pitchers had no such history of pain
bull 23 pitchers had a loss of internal rotation ROM (13deg plusmn 10deg P
lt 001) and gain in external rotation ROM (11deg plusmn 10deg P lt 001) on the dominant versus non-dominant arm with no
effect on total ROM (2deg plusmn 7deg loss P = 14)
bull Throwing-related pain in this population may be due to the inability of weakened posterior shoulder musculature to
tolerate stress imparted on it by adaptively strengthened propulsive muscles
Trakis et al AJSM 2008
GIRD
Image from Manske et al Int J Sports Phsy Ther 2013
ERD and GIRDbull ERD (ext rot deficiency) - 5 deg or less
wPROM increases injury risk in throwers
23x (unpublished data)
bull Anatomical GIRD - normal loss of IR (18-20 deg) with adequate ER gain and TROM
within 5 deg of the uninvolved side
bull Pathologic GIRD - A shoulder that has
GIRD more than 18-20 deg and a
concomitant loss of TROM gt 5 deg (= 25x
injury risk)Manske et al Int J Sports Phys Ther 2013
7
More on GIRDbull Burkhart reports that an acceptable level of
GIRD is defined as
bull 1) less than 20 deg loss of shoulder IR comparing shoulders bilaterally or
bull 2) no greater than 10 loss of the total rotation seen in the non-throwing
shoulder (Non dominant shoulder IR +
ER ROM) x 10)
bull 3) Ratio of GIRD to ERG needs to be 1
or lessManske et al Int J Sports Phys Ther 2013
Internal Impingement
bull Pathologic GIRD creates altered
biomechanics for overhead athletes
leading to posterosuperior glenoid impingement a common cause of pain
in throwing athletes
bull IR decreases with throwing as season goes along
Scapular Positioningbull The dominant-side scapula of overhead
athletes was more internally rotated and anteriorly tilted than the non-dominant side
scapula
bull The dominant-side scapula of tennis
players was more protracted than that on
the non-dominant side
bull Scapular posture asymmetry in unilateral
overhead athletes may be normal
Oyam et al J Athl Train 2008
8
Common Injuries
bull Tendinitis
bull Tendinosis
bull Impingement
bull Partial thickness tears
bull Full thickness tears
Exercise Trends
bull Crossfit
bull Kettlebells
bull HIT workouts
bull Extreme races
bull Obstacle course training
Crossfit Injury rates
bull An injury rate of 31 per 1000 hours trained was calculated
bull Injury rates with CrossFit training are similar to
that reported in the literature for sports such as Olympic weight-lifting power-lifting and
gymnastics and lower than competitive contact sports such as rugby union and rugby league
bull Shoulder and spine injuries predominate with no incidences of rhabdomyolysis obtained
Hak et al J Strength Cond Res 2013
9
Crossfit Injury ratesbull 486 CrossFit participants completed the survey
bull The overall injury rate was determined to be 194 (75386)
bull Males (53231) were injured more frequently than females (21150 P = 03)
bull Across all exercises injury rates were significantly different (P lt 001) with shoulder (2184) low back (1284) and knee (1184) being the most commonly injured overall
bull The shoulder was most commonly injured in gymnastic movements and the low back was most commonly injured in power lifting movements
Weisenthal et al Orthop J Sports Med 2014
Weight Training Considerations
bull Age
bull Acromial type
bull Prior injury
bull Instability
bull Scapular dyskinesia
bull Clavicular osteolysis and bone spurs
Instability
bull Acquired laxity gt anterior micro
instability
bull MDI
bull Secondary RC bicipital and labral
stress
bull Caution with loading (snatch jerks flies
pressing dips etc)
10
The Scapulabull Resting alignment
bull Dynamic mechanics
bull SICK scapula
1 Inferior border prominence
2 Medial border prominence
3 Superior border prominence
Distal Clavicle Osteolysis
Threatening Exercises
bull Full range chest press flies and dips
bull Long lever side raises
bull Wide grip pull-ups
bull Heavy overhead press hand stand push-ups
bull Burpees bear crawls undulating ropes
bull Overhead lifts (eg snatch) with improper form
and certain squat variations
11
Differential Diagnosis
bull Labral tears
bull AC joint pathology
bull Bicipital tendinopathy
bull Brachial plexus
bull Radicular pain
bull Myofascial pain
Shoulder Imaging
bull Common X-rays
1 AP (external rotation)
2 Lateral (Y View)
3 Axillary
12
AP View
Lateral View
Source - AAOS Website
Axillary View
13
MRI - Partial Tear
Angled oblique MRI views - source Medscape
MRI - Full Tear
Angled oblique MRI views - source Medscape
PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion
(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited
between June 2010 and February 2011
bull The clinical effect of the platelet-rich plasma injection
was superior to the dry needling from 6 weeks to 6 months after initial injection
bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group
bull No severe adverse effects were observed in either group
Rha et al Clin Rehabil 2013
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
5
Recipe for Overuse bull Repetitive motion
bull Faulty muscle recruitment (poor stability)
bull Pec and lat tightness
bull Bad posture
bull Limited T-spine mobility
Balance Prevents Overtraining
Stress
Recovery
Youth Baseball bull Olsen et al revealed that
averaging more than 80 pitches
per game nearly quadrupled injury risk and pitching more than 8 months out of the year
raised it fivefold
bull Olsenrsquos study concluded pitching with a fatigued arm
increased chances of having surgery 36x
bull Fleisig et al showed that
pitching more than 100 competition innings per year more than tripled the risk for
serious shoulder or elbow injury In addition playing catcher as well as pitcher increased the
odds ratio of injury 27 times
Fleisig et al Sports Health 2012
6
bull 23 adolescent pitchers (age 157 plusmn 14 years) were tested
bull 12 pitchers had throwing-related pain in the prior season and were currently symptom-free while the remaining 11
pitchers had no such history of pain
bull 23 pitchers had a loss of internal rotation ROM (13deg plusmn 10deg P
lt 001) and gain in external rotation ROM (11deg plusmn 10deg P lt 001) on the dominant versus non-dominant arm with no
effect on total ROM (2deg plusmn 7deg loss P = 14)
bull Throwing-related pain in this population may be due to the inability of weakened posterior shoulder musculature to
tolerate stress imparted on it by adaptively strengthened propulsive muscles
Trakis et al AJSM 2008
GIRD
Image from Manske et al Int J Sports Phsy Ther 2013
ERD and GIRDbull ERD (ext rot deficiency) - 5 deg or less
wPROM increases injury risk in throwers
23x (unpublished data)
bull Anatomical GIRD - normal loss of IR (18-20 deg) with adequate ER gain and TROM
within 5 deg of the uninvolved side
bull Pathologic GIRD - A shoulder that has
GIRD more than 18-20 deg and a
concomitant loss of TROM gt 5 deg (= 25x
injury risk)Manske et al Int J Sports Phys Ther 2013
7
More on GIRDbull Burkhart reports that an acceptable level of
GIRD is defined as
bull 1) less than 20 deg loss of shoulder IR comparing shoulders bilaterally or
bull 2) no greater than 10 loss of the total rotation seen in the non-throwing
shoulder (Non dominant shoulder IR +
ER ROM) x 10)
bull 3) Ratio of GIRD to ERG needs to be 1
or lessManske et al Int J Sports Phys Ther 2013
Internal Impingement
bull Pathologic GIRD creates altered
biomechanics for overhead athletes
leading to posterosuperior glenoid impingement a common cause of pain
in throwing athletes
bull IR decreases with throwing as season goes along
Scapular Positioningbull The dominant-side scapula of overhead
athletes was more internally rotated and anteriorly tilted than the non-dominant side
scapula
bull The dominant-side scapula of tennis
players was more protracted than that on
the non-dominant side
bull Scapular posture asymmetry in unilateral
overhead athletes may be normal
Oyam et al J Athl Train 2008
8
Common Injuries
bull Tendinitis
bull Tendinosis
bull Impingement
bull Partial thickness tears
bull Full thickness tears
Exercise Trends
bull Crossfit
bull Kettlebells
bull HIT workouts
bull Extreme races
bull Obstacle course training
Crossfit Injury rates
bull An injury rate of 31 per 1000 hours trained was calculated
bull Injury rates with CrossFit training are similar to
that reported in the literature for sports such as Olympic weight-lifting power-lifting and
gymnastics and lower than competitive contact sports such as rugby union and rugby league
bull Shoulder and spine injuries predominate with no incidences of rhabdomyolysis obtained
Hak et al J Strength Cond Res 2013
9
Crossfit Injury ratesbull 486 CrossFit participants completed the survey
bull The overall injury rate was determined to be 194 (75386)
bull Males (53231) were injured more frequently than females (21150 P = 03)
bull Across all exercises injury rates were significantly different (P lt 001) with shoulder (2184) low back (1284) and knee (1184) being the most commonly injured overall
bull The shoulder was most commonly injured in gymnastic movements and the low back was most commonly injured in power lifting movements
Weisenthal et al Orthop J Sports Med 2014
Weight Training Considerations
bull Age
bull Acromial type
bull Prior injury
bull Instability
bull Scapular dyskinesia
bull Clavicular osteolysis and bone spurs
Instability
bull Acquired laxity gt anterior micro
instability
bull MDI
bull Secondary RC bicipital and labral
stress
bull Caution with loading (snatch jerks flies
pressing dips etc)
10
The Scapulabull Resting alignment
bull Dynamic mechanics
bull SICK scapula
1 Inferior border prominence
2 Medial border prominence
3 Superior border prominence
Distal Clavicle Osteolysis
Threatening Exercises
bull Full range chest press flies and dips
bull Long lever side raises
bull Wide grip pull-ups
bull Heavy overhead press hand stand push-ups
bull Burpees bear crawls undulating ropes
bull Overhead lifts (eg snatch) with improper form
and certain squat variations
11
Differential Diagnosis
bull Labral tears
bull AC joint pathology
bull Bicipital tendinopathy
bull Brachial plexus
bull Radicular pain
bull Myofascial pain
Shoulder Imaging
bull Common X-rays
1 AP (external rotation)
2 Lateral (Y View)
3 Axillary
12
AP View
Lateral View
Source - AAOS Website
Axillary View
13
MRI - Partial Tear
Angled oblique MRI views - source Medscape
MRI - Full Tear
Angled oblique MRI views - source Medscape
PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion
(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited
between June 2010 and February 2011
bull The clinical effect of the platelet-rich plasma injection
was superior to the dry needling from 6 weeks to 6 months after initial injection
bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group
bull No severe adverse effects were observed in either group
Rha et al Clin Rehabil 2013
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
6
bull 23 adolescent pitchers (age 157 plusmn 14 years) were tested
bull 12 pitchers had throwing-related pain in the prior season and were currently symptom-free while the remaining 11
pitchers had no such history of pain
bull 23 pitchers had a loss of internal rotation ROM (13deg plusmn 10deg P
lt 001) and gain in external rotation ROM (11deg plusmn 10deg P lt 001) on the dominant versus non-dominant arm with no
effect on total ROM (2deg plusmn 7deg loss P = 14)
bull Throwing-related pain in this population may be due to the inability of weakened posterior shoulder musculature to
tolerate stress imparted on it by adaptively strengthened propulsive muscles
Trakis et al AJSM 2008
GIRD
Image from Manske et al Int J Sports Phsy Ther 2013
ERD and GIRDbull ERD (ext rot deficiency) - 5 deg or less
wPROM increases injury risk in throwers
23x (unpublished data)
bull Anatomical GIRD - normal loss of IR (18-20 deg) with adequate ER gain and TROM
within 5 deg of the uninvolved side
bull Pathologic GIRD - A shoulder that has
GIRD more than 18-20 deg and a
concomitant loss of TROM gt 5 deg (= 25x
injury risk)Manske et al Int J Sports Phys Ther 2013
7
More on GIRDbull Burkhart reports that an acceptable level of
GIRD is defined as
bull 1) less than 20 deg loss of shoulder IR comparing shoulders bilaterally or
bull 2) no greater than 10 loss of the total rotation seen in the non-throwing
shoulder (Non dominant shoulder IR +
ER ROM) x 10)
bull 3) Ratio of GIRD to ERG needs to be 1
or lessManske et al Int J Sports Phys Ther 2013
Internal Impingement
bull Pathologic GIRD creates altered
biomechanics for overhead athletes
leading to posterosuperior glenoid impingement a common cause of pain
in throwing athletes
bull IR decreases with throwing as season goes along
Scapular Positioningbull The dominant-side scapula of overhead
athletes was more internally rotated and anteriorly tilted than the non-dominant side
scapula
bull The dominant-side scapula of tennis
players was more protracted than that on
the non-dominant side
bull Scapular posture asymmetry in unilateral
overhead athletes may be normal
Oyam et al J Athl Train 2008
8
Common Injuries
bull Tendinitis
bull Tendinosis
bull Impingement
bull Partial thickness tears
bull Full thickness tears
Exercise Trends
bull Crossfit
bull Kettlebells
bull HIT workouts
bull Extreme races
bull Obstacle course training
Crossfit Injury rates
bull An injury rate of 31 per 1000 hours trained was calculated
bull Injury rates with CrossFit training are similar to
that reported in the literature for sports such as Olympic weight-lifting power-lifting and
gymnastics and lower than competitive contact sports such as rugby union and rugby league
bull Shoulder and spine injuries predominate with no incidences of rhabdomyolysis obtained
Hak et al J Strength Cond Res 2013
9
Crossfit Injury ratesbull 486 CrossFit participants completed the survey
bull The overall injury rate was determined to be 194 (75386)
bull Males (53231) were injured more frequently than females (21150 P = 03)
bull Across all exercises injury rates were significantly different (P lt 001) with shoulder (2184) low back (1284) and knee (1184) being the most commonly injured overall
bull The shoulder was most commonly injured in gymnastic movements and the low back was most commonly injured in power lifting movements
Weisenthal et al Orthop J Sports Med 2014
Weight Training Considerations
bull Age
bull Acromial type
bull Prior injury
bull Instability
bull Scapular dyskinesia
bull Clavicular osteolysis and bone spurs
Instability
bull Acquired laxity gt anterior micro
instability
bull MDI
bull Secondary RC bicipital and labral
stress
bull Caution with loading (snatch jerks flies
pressing dips etc)
10
The Scapulabull Resting alignment
bull Dynamic mechanics
bull SICK scapula
1 Inferior border prominence
2 Medial border prominence
3 Superior border prominence
Distal Clavicle Osteolysis
Threatening Exercises
bull Full range chest press flies and dips
bull Long lever side raises
bull Wide grip pull-ups
bull Heavy overhead press hand stand push-ups
bull Burpees bear crawls undulating ropes
bull Overhead lifts (eg snatch) with improper form
and certain squat variations
11
Differential Diagnosis
bull Labral tears
bull AC joint pathology
bull Bicipital tendinopathy
bull Brachial plexus
bull Radicular pain
bull Myofascial pain
Shoulder Imaging
bull Common X-rays
1 AP (external rotation)
2 Lateral (Y View)
3 Axillary
12
AP View
Lateral View
Source - AAOS Website
Axillary View
13
MRI - Partial Tear
Angled oblique MRI views - source Medscape
MRI - Full Tear
Angled oblique MRI views - source Medscape
PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion
(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited
between June 2010 and February 2011
bull The clinical effect of the platelet-rich plasma injection
was superior to the dry needling from 6 weeks to 6 months after initial injection
bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group
bull No severe adverse effects were observed in either group
Rha et al Clin Rehabil 2013
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
7
More on GIRDbull Burkhart reports that an acceptable level of
GIRD is defined as
bull 1) less than 20 deg loss of shoulder IR comparing shoulders bilaterally or
bull 2) no greater than 10 loss of the total rotation seen in the non-throwing
shoulder (Non dominant shoulder IR +
ER ROM) x 10)
bull 3) Ratio of GIRD to ERG needs to be 1
or lessManske et al Int J Sports Phys Ther 2013
Internal Impingement
bull Pathologic GIRD creates altered
biomechanics for overhead athletes
leading to posterosuperior glenoid impingement a common cause of pain
in throwing athletes
bull IR decreases with throwing as season goes along
Scapular Positioningbull The dominant-side scapula of overhead
athletes was more internally rotated and anteriorly tilted than the non-dominant side
scapula
bull The dominant-side scapula of tennis
players was more protracted than that on
the non-dominant side
bull Scapular posture asymmetry in unilateral
overhead athletes may be normal
Oyam et al J Athl Train 2008
8
Common Injuries
bull Tendinitis
bull Tendinosis
bull Impingement
bull Partial thickness tears
bull Full thickness tears
Exercise Trends
bull Crossfit
bull Kettlebells
bull HIT workouts
bull Extreme races
bull Obstacle course training
Crossfit Injury rates
bull An injury rate of 31 per 1000 hours trained was calculated
bull Injury rates with CrossFit training are similar to
that reported in the literature for sports such as Olympic weight-lifting power-lifting and
gymnastics and lower than competitive contact sports such as rugby union and rugby league
bull Shoulder and spine injuries predominate with no incidences of rhabdomyolysis obtained
Hak et al J Strength Cond Res 2013
9
Crossfit Injury ratesbull 486 CrossFit participants completed the survey
bull The overall injury rate was determined to be 194 (75386)
bull Males (53231) were injured more frequently than females (21150 P = 03)
bull Across all exercises injury rates were significantly different (P lt 001) with shoulder (2184) low back (1284) and knee (1184) being the most commonly injured overall
bull The shoulder was most commonly injured in gymnastic movements and the low back was most commonly injured in power lifting movements
Weisenthal et al Orthop J Sports Med 2014
Weight Training Considerations
bull Age
bull Acromial type
bull Prior injury
bull Instability
bull Scapular dyskinesia
bull Clavicular osteolysis and bone spurs
Instability
bull Acquired laxity gt anterior micro
instability
bull MDI
bull Secondary RC bicipital and labral
stress
bull Caution with loading (snatch jerks flies
pressing dips etc)
10
The Scapulabull Resting alignment
bull Dynamic mechanics
bull SICK scapula
1 Inferior border prominence
2 Medial border prominence
3 Superior border prominence
Distal Clavicle Osteolysis
Threatening Exercises
bull Full range chest press flies and dips
bull Long lever side raises
bull Wide grip pull-ups
bull Heavy overhead press hand stand push-ups
bull Burpees bear crawls undulating ropes
bull Overhead lifts (eg snatch) with improper form
and certain squat variations
11
Differential Diagnosis
bull Labral tears
bull AC joint pathology
bull Bicipital tendinopathy
bull Brachial plexus
bull Radicular pain
bull Myofascial pain
Shoulder Imaging
bull Common X-rays
1 AP (external rotation)
2 Lateral (Y View)
3 Axillary
12
AP View
Lateral View
Source - AAOS Website
Axillary View
13
MRI - Partial Tear
Angled oblique MRI views - source Medscape
MRI - Full Tear
Angled oblique MRI views - source Medscape
PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion
(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited
between June 2010 and February 2011
bull The clinical effect of the platelet-rich plasma injection
was superior to the dry needling from 6 weeks to 6 months after initial injection
bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group
bull No severe adverse effects were observed in either group
Rha et al Clin Rehabil 2013
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
8
Common Injuries
bull Tendinitis
bull Tendinosis
bull Impingement
bull Partial thickness tears
bull Full thickness tears
Exercise Trends
bull Crossfit
bull Kettlebells
bull HIT workouts
bull Extreme races
bull Obstacle course training
Crossfit Injury rates
bull An injury rate of 31 per 1000 hours trained was calculated
bull Injury rates with CrossFit training are similar to
that reported in the literature for sports such as Olympic weight-lifting power-lifting and
gymnastics and lower than competitive contact sports such as rugby union and rugby league
bull Shoulder and spine injuries predominate with no incidences of rhabdomyolysis obtained
Hak et al J Strength Cond Res 2013
9
Crossfit Injury ratesbull 486 CrossFit participants completed the survey
bull The overall injury rate was determined to be 194 (75386)
bull Males (53231) were injured more frequently than females (21150 P = 03)
bull Across all exercises injury rates were significantly different (P lt 001) with shoulder (2184) low back (1284) and knee (1184) being the most commonly injured overall
bull The shoulder was most commonly injured in gymnastic movements and the low back was most commonly injured in power lifting movements
Weisenthal et al Orthop J Sports Med 2014
Weight Training Considerations
bull Age
bull Acromial type
bull Prior injury
bull Instability
bull Scapular dyskinesia
bull Clavicular osteolysis and bone spurs
Instability
bull Acquired laxity gt anterior micro
instability
bull MDI
bull Secondary RC bicipital and labral
stress
bull Caution with loading (snatch jerks flies
pressing dips etc)
10
The Scapulabull Resting alignment
bull Dynamic mechanics
bull SICK scapula
1 Inferior border prominence
2 Medial border prominence
3 Superior border prominence
Distal Clavicle Osteolysis
Threatening Exercises
bull Full range chest press flies and dips
bull Long lever side raises
bull Wide grip pull-ups
bull Heavy overhead press hand stand push-ups
bull Burpees bear crawls undulating ropes
bull Overhead lifts (eg snatch) with improper form
and certain squat variations
11
Differential Diagnosis
bull Labral tears
bull AC joint pathology
bull Bicipital tendinopathy
bull Brachial plexus
bull Radicular pain
bull Myofascial pain
Shoulder Imaging
bull Common X-rays
1 AP (external rotation)
2 Lateral (Y View)
3 Axillary
12
AP View
Lateral View
Source - AAOS Website
Axillary View
13
MRI - Partial Tear
Angled oblique MRI views - source Medscape
MRI - Full Tear
Angled oblique MRI views - source Medscape
PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion
(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited
between June 2010 and February 2011
bull The clinical effect of the platelet-rich plasma injection
was superior to the dry needling from 6 weeks to 6 months after initial injection
bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group
bull No severe adverse effects were observed in either group
Rha et al Clin Rehabil 2013
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
9
Crossfit Injury ratesbull 486 CrossFit participants completed the survey
bull The overall injury rate was determined to be 194 (75386)
bull Males (53231) were injured more frequently than females (21150 P = 03)
bull Across all exercises injury rates were significantly different (P lt 001) with shoulder (2184) low back (1284) and knee (1184) being the most commonly injured overall
bull The shoulder was most commonly injured in gymnastic movements and the low back was most commonly injured in power lifting movements
Weisenthal et al Orthop J Sports Med 2014
Weight Training Considerations
bull Age
bull Acromial type
bull Prior injury
bull Instability
bull Scapular dyskinesia
bull Clavicular osteolysis and bone spurs
Instability
bull Acquired laxity gt anterior micro
instability
bull MDI
bull Secondary RC bicipital and labral
stress
bull Caution with loading (snatch jerks flies
pressing dips etc)
10
The Scapulabull Resting alignment
bull Dynamic mechanics
bull SICK scapula
1 Inferior border prominence
2 Medial border prominence
3 Superior border prominence
Distal Clavicle Osteolysis
Threatening Exercises
bull Full range chest press flies and dips
bull Long lever side raises
bull Wide grip pull-ups
bull Heavy overhead press hand stand push-ups
bull Burpees bear crawls undulating ropes
bull Overhead lifts (eg snatch) with improper form
and certain squat variations
11
Differential Diagnosis
bull Labral tears
bull AC joint pathology
bull Bicipital tendinopathy
bull Brachial plexus
bull Radicular pain
bull Myofascial pain
Shoulder Imaging
bull Common X-rays
1 AP (external rotation)
2 Lateral (Y View)
3 Axillary
12
AP View
Lateral View
Source - AAOS Website
Axillary View
13
MRI - Partial Tear
Angled oblique MRI views - source Medscape
MRI - Full Tear
Angled oblique MRI views - source Medscape
PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion
(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited
between June 2010 and February 2011
bull The clinical effect of the platelet-rich plasma injection
was superior to the dry needling from 6 weeks to 6 months after initial injection
bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group
bull No severe adverse effects were observed in either group
Rha et al Clin Rehabil 2013
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
10
The Scapulabull Resting alignment
bull Dynamic mechanics
bull SICK scapula
1 Inferior border prominence
2 Medial border prominence
3 Superior border prominence
Distal Clavicle Osteolysis
Threatening Exercises
bull Full range chest press flies and dips
bull Long lever side raises
bull Wide grip pull-ups
bull Heavy overhead press hand stand push-ups
bull Burpees bear crawls undulating ropes
bull Overhead lifts (eg snatch) with improper form
and certain squat variations
11
Differential Diagnosis
bull Labral tears
bull AC joint pathology
bull Bicipital tendinopathy
bull Brachial plexus
bull Radicular pain
bull Myofascial pain
Shoulder Imaging
bull Common X-rays
1 AP (external rotation)
2 Lateral (Y View)
3 Axillary
12
AP View
Lateral View
Source - AAOS Website
Axillary View
13
MRI - Partial Tear
Angled oblique MRI views - source Medscape
MRI - Full Tear
Angled oblique MRI views - source Medscape
PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion
(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited
between June 2010 and February 2011
bull The clinical effect of the platelet-rich plasma injection
was superior to the dry needling from 6 weeks to 6 months after initial injection
bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group
bull No severe adverse effects were observed in either group
Rha et al Clin Rehabil 2013
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
11
Differential Diagnosis
bull Labral tears
bull AC joint pathology
bull Bicipital tendinopathy
bull Brachial plexus
bull Radicular pain
bull Myofascial pain
Shoulder Imaging
bull Common X-rays
1 AP (external rotation)
2 Lateral (Y View)
3 Axillary
12
AP View
Lateral View
Source - AAOS Website
Axillary View
13
MRI - Partial Tear
Angled oblique MRI views - source Medscape
MRI - Full Tear
Angled oblique MRI views - source Medscape
PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion
(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited
between June 2010 and February 2011
bull The clinical effect of the platelet-rich plasma injection
was superior to the dry needling from 6 weeks to 6 months after initial injection
bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group
bull No severe adverse effects were observed in either group
Rha et al Clin Rehabil 2013
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
12
AP View
Lateral View
Source - AAOS Website
Axillary View
13
MRI - Partial Tear
Angled oblique MRI views - source Medscape
MRI - Full Tear
Angled oblique MRI views - source Medscape
PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion
(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited
between June 2010 and February 2011
bull The clinical effect of the platelet-rich plasma injection
was superior to the dry needling from 6 weeks to 6 months after initial injection
bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group
bull No severe adverse effects were observed in either group
Rha et al Clin Rehabil 2013
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
13
MRI - Partial Tear
Angled oblique MRI views - source Medscape
MRI - Full Tear
Angled oblique MRI views - source Medscape
PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion
(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited
between June 2010 and February 2011
bull The clinical effect of the platelet-rich plasma injection
was superior to the dry needling from 6 weeks to 6 months after initial injection
bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group
bull No severe adverse effects were observed in either group
Rha et al Clin Rehabil 2013
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
14
PT Evaluation
bull Observe posture
bull APROM
bull MMT
bull Joint mobility
bull Palpation (TrPrsquos)
bull Special tests
Key Special Tests
bull Hawkins Neer impingement signs
bull OrsquoBrienrsquos pronated load Speedrsquos for labrum
bull AC joint provocation
bull Sulcus sign Apprehension Jobe
relocation
bull C-spine clearing tests
OrsquoBrien Test (video)
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
15
Speedrsquos Test
Pronated Load Test
Kinetic Assessmentbull Thoracic spine mobility
bull Core stability
bull Hip mobility
bull Hip stability
bull SL stance
bull Ankle mobility
bull Integrated movement (FMS)
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
16
T-spine Rotation
Tall Plank Diagonal
FMS
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
17
QuickTimetrade and a decompressor
are needed to see this picture
Shoulder Mobility FMS (video)
Trunk Stability Push-Up FMS (video)
Key Recovery Principles
bull Respect healing tissue
bull Progressive sequential amp functional
bull Embrace individual differences among clients
bull Avoid loads to failure especially as they ease
back into training
bull Consistently assess and involve the client with pain threshold training
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
18
Pain Threshold
bull Journal pain before during and after activity
bull Mild soreness may be acceptable but should not have pain with throwing
bull 24 hour rule = elevated soreness after a
workout or training session must return to baseline level or less in 24 hours (or less)
bull Rehabtraining progression is based 100 on
pain response
Non-operative Rehabbull Resolve soft tissue
restrictions
bull Resolve unwanted GIRD
bull Strengthen cuff and scap stabilizers
bull Emphasize stability
bull Incorporate entire
kinetic chain
Effective for RC Tearsbull Moon group cohort consists of 452 patients
wFT tears
bull Patient reported outcomes improved significantly at 6 and 12 weeks
bull Patients elected to undergo surgery less than 25 of the time
bull Patients who decided to have surgery generally did so between 6 and 12 weeks
and few had surgery between 3 and 24 months
Kuhn et al J Shoulder Elbow Surg 2013
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
19
Rehab Approachbull Visit 1 = HEP for cuffscapular PREs
STM and stretching
bull Manual techniques
bull Limit andor restrict throwing hitting and OH training initially
bull Below shoulder height then scapular plane and gradually move to overhead
bull Educate regarding pain and progression
Manual Therapy
bull GHJ mobilization
bull IASTM
bull Stretching
bull Dry Needling
Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle
pain gt 3 months duration and active MTrPs were
recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and
mean age was 358 years
bull 3 weekly dry needling treatments of a single active MTrP
bull A total of 41 subjects had a change in trigger point
status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all
pain scores was significant (P lt 001)Gerber et al PM R 2015
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
20
Rehab Phases
1 Relative Rest Mobility amp Stabilization
2 Activation amp Strengthening
3 Integrated CKC Strengthening amp Power
4 Return to Activity
Mobility Priorities
bull Pec majorminor
bull Lats
bull Posterior rotator cuffcapsule
bull Upper trap amp levator (TPDN amp IASTM)
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
21
9090 Arm Sweep
Shoulder STM (Video)
Stretches
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
22
Posterior Shoulder
Stretching
bull Low load long duration
bull 30 seconds (8-10x)
bull Do not stretch into pain or impingement
bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)
bull Not encouraged prior to throwing or prior
to tennis match
Wilk et al JOSPT 2013
Stretching (Video)
RC Exercises
bull Side lying DB external rotation
bull Scaption
bull Prone I T Y and Ws
bull HER and HIR
bull D2 exercises
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
23
EMG Activity
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)
and teres minor (67 MVIC)
bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid
(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER
Reinold et al JOSPT 2004
Blood Flow Restriction (BFR) Training
Low-load BFR training increased muscle
size and strength in limbs located proximal
(chest shoulders) and distal (biceps triceps) to the restrictive stimulus
Dankel et al Sports Med 2016
BFR Exercise Video
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
24
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt
thus decreasing subacromial space
bull Scapular muscle activity was generally higher with the
EC which may be an attempt to control the impingement-related scapular motion
Timmons et al J Shoulder Elbow Surg 2015
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced
significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the
posterior deltoid muscle
Reinold et al J Athl Train 2007
Scapular Exercises
bull Quadruped and tall plank exercise
bull Serratus anterior variations
bull Pulls rows depressions wall walks
wall slide shrugs
bull Integrated shoulder core and hip
exercise
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
25
Scapular Activation
Benefits of unstable training surfaces include increased scapular activation In a recent study
published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus
activity while doing a push-up plus on a stability ball
Stability Exercises (video)
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
26
Strengthening (Video)
Rehab to Performance
bull Rehab exercises should include core and LE strengthening as well
bull Must modify ldquoriskyrdquo exercises in the gym
bull Develop pre-practicegame dynamic warm-up
routines
bull Plyometric progressions (wall dribbles chest pass etc) if applicable
bull Unilateral loading (sliders pressing pulling)
Exercise Prescriptionbull Risk vs reward
bull Kinetic chain mobility and stability define risk and ability
bull Recreational vs elite
bull Individualized plan
based on history needs analysis and
goals
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
27
Exercise Modifications (video)
Return to Activitybull Re-assess FMS (if needed)
bull Observe Upper Quarter Y-Balance Test
bull Maintain daily mobility work and essential
scapular and RC exercises 2-3xweek
bull Gradually work back to overhead work
bull Begin interval throwing hitting lifting or swimming training program (evidence-
informed and graded dosage)
Upper Quarter YBT (Video)
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
28
Interval Throwing
bull Typical program in non-operative thrower lasts 4-6 weeks
bull Post-op throwing depends on procedure
bull Demands vary based on position
bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing
bull Focus on fastball and change up initially
Long Toss Research
bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of
pitching and are therefore reasonable exercises for pitchers
bull However maximum-distance throws produce
increased torques and changes in kinematics
bull Caution is advised in the use of these max distance throws for rehabilitation and training
Fleisig et al JOSPT 2011
Conclusion
bull Find right balance bw mobility amp stability
bull Assess the entire kinetic chain
bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury
bull Utilize evidence-based client-specific
exercises and functional progressions
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
29
Contact Info
bull Brian Schiff PT OCS CSCS
bull wwwBrianSchiffcom
bull infoBrianSchiffcom
bull Twitter - brianschiff
Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff
balance strength and endurance in young swimmers during a competitive season J
Strength Cond Res 2013 Sep27(9)2562-8
bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57
bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25
years Orthopedics 2015 Jul 138(7)e631-e634
bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat
Res 2012 Jun470(6)1540-4
bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement
syndrome Open Access J Sports Med 2014 Feb 28513-24
Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with
implications about injury mechanism Am J Sports Med 199523(2)233-239
bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437
bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports
Phys Ther 201141 296-303
bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8
bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88
bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil
2013 Nov22(4)313-9
bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136
30
Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-
blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10
bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570
bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15
bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG
Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527
bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22
bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40
bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28
Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of
motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006
bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]
bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119
bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136