Who is this pitcher?

1. Who is this pitcher?

2. What teams are Playing?

4. Rehabilitation Program for Overhead Activities for Micro-Instability

5. Phases in Rehabilitation • Acute Phase • Intermediate Phase • Advance Phase • Return to Activity Phase

6. Goals • ROM • Muscular Strength and endurance • Proprioception • Dynamic stability • Neuromuscular control

7. Acute Phase • Immediately following injury • Length amount of healing needed

8. Acute Phase - Goals • Minimize pain and inflammation • Normalize motion and muscle balance • Restore baseline propioception and kinesthetic awareness

9. ROM • Normalize motion bilaterally • IR and ER in restricted ROM • Based on the theory that motion assists in the enhancement and organization of collagen tissue • Stim of joint mechanoreceptors

10. Progressive applied loads • Gentle passive ROM • Active assist ROM (Cane or L bar) • Flexion progress as tolerated • Shoulder rotation ROM is progressed from 0 to 30, 45 and 90 degrees of abduction • Pendulum, rope and pulley exercises

11. Enhance Dynamic Stabilization Activities • Control anterior humeral head translation • Restore flexibility of the posterior rotator cuff muscles of the GH joint • Against stretching of the anterior or posterior GH structures

12. Posterior shoulder in thrower • Eccentric contractions • Soft tissue adaptation and loss of IR ROM • Stretching - horizontal adduction stretch for the posterior cuff muscles

13. Strengthening • Submaxpainfree isometrics for shoulder flexion, extension, abduction, ER,IR and elbow flexion • Isometrics are to reduce atrophy and restore voluntary muscle control while avoiding dynamic shoulder forces • Isometrics should be preform at multiple angles throughout the available ROM with emphasize at the end of the ROM

15. Strengthening • Manual rhythmic stabilization drills are performed for the shoulder internal and external rotators with the arm in the scapular plane at 30 degrees and 45 degrees of abduction. • Alternating isometrics contractions facilitate co-contraction of the anterior and posterior cuff muscles

17. Rhythmic Stabilization • Done with patient supine and the arm position at 100 degrees of flexion and 10 degrees of horizontal abduction • Humeral head compression forces at this angle

18. Acute Phase • Active ROM are started when adequate muscular strength and balance have been achieved • Passively ROM in all planes and repositions it with self repositioning

19. Closed vs Open Kinetic Exercises

20. Closed Kinetic Chain Exercises • Axial compression exercises • Stress the joint in weight bearing position • Joint approximation • Stimulates articular receptors • Facilitates co-contraction of the shoulder force couples • Incorporates a combination of eccentric and concentric contractions to provide joint stability

22. Acute Phase • Initial exercises below shoulder level • Weight bearing on a table while standing • Weight shifts in anterior/posterior and medial and lateral directions • Rhythmic stabilization may be perform during weight shift

23. Acute Phase • Ice • High voltage stimulation • Iontophoresis • Ultrasound • NSAD

24. Intermediate Phase • Begins when near normal passive motion • Sufficient muscle strength of the shoulder • Baseline proprioception, kinesthesia and dynamic stabilization are needed • Regain these sensory modalities throughout the ROM

25. Intermediate Phase - Goals • Enhance dynamic dynamic stability • Reestablish neuromusular control • Restore muscular strength and balance • Maintain full ROM

26. Intermediate Phase • ROM – joint mobilization and self capsular stretches • Strengthening advance – tubing against gravity, scaption exercises, emphasize on the posterior cuff and scapular strengthening exercises (Throwers Ten Program)

27. Throwers Ten Program • Elicits muscles most needed to provide dynamic stability on overhead athletes

28. Intermediate Phase • Dynamic stabilization – eyes closed and at the end of the ROM • PNF patterns

29. Intermediate Phase • Manual resistance ER – varying amount of resistant throughout the ROM and incorporate ecc and con contractions • Scapular strengthening and dynamic neuromuscular control (avoid fatigue)

30. Intermediate Phase • Isotonic exercises for the scapulothoracic • CKC exercises are advance • Push up on the ball or unstable surface on a tabletop

31. Intermediate Phase • Lower extremity • Core - Stabilization CKC • Trunk strength abd crunches and pelvic tilts • Double and single leg balances

33. Advance Phase • Progressive and neuromuscular control activities to return to activity • Minimum pain and tenderness • Full ROM Symmetrical capsular mobility • Good strength and endurance

34. Advance Phase • Full ROM and capsular mobility maintain throughout the ROM • Total motion is equal bilaterally

35. Strengthening • Throwers Ten Program • Exercises for the trunk and LE • IR and ER tubing to eccentric and high speed contractions

36. Aggressive Strengthening of the UE • Bench • Isotonic machines • Seated row • Lats pull down

38. Plyometrics • Train the UE to produce and dissipate forces • Provide quick powerful movement involving a prestretchpf the muscle • Activate the stretch-shortening cycle of the muscle tissue • Stimulate throwing • Increase neuromusular control and core strength

39. Plyometrics

40. Stretch Shortening Cycle • Prestretching of the muscle spindles and glgi tendon to produce a recoil action of the elastic tissues resulting in improve performance by the combine efforts of the stored elastic energy and the myotactic reflex activation of the muscle

44. Return to Activity Phase • Minimum complaints of pain and discomfort • Full ROM • Balance capsular mobility • Adequate pro, dynamic stabilization and neuromuscular control

45. Isokinetic testing • ER:IR strength ratio of 66 to 76% or higher at 180degrees/s

46. Isokinetic exercise? • Exercise performed with a specialized apparatus that provides variable resistance to a movement, so that no matter how much effort is exerted, the movement takes place at a constant speed. • Such exercise is used to test and improve muscular strength and endurance, especially after injury.

48. Summary • Overhead thrower • Pain due to anterior capsular micro-stability and increase demands placed on the dynamic stabilizers • Focus on loss IR and weakness of ER and scapular muscles • Gradual return to throw program • Emphasize on proprioception, neuromuscular control and dynamic stability