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ROBERT MCCABE , PT., OCS,

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COMMON INJURIES Little Leaguer’s Shoulder

Medial Elbow Injuries (Little League Elbow)1. UCL Injuries2. Medial epicondyle apophysitis

Shoulder Microinstability Posterior / Internal Impingement

SLAP Tears Lateral Elbow - Compression Injuries

- osteochondritis dissecans

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Epiphysitis of humeral head Traction injury to

growth plate

Occurs during deceleration of throwing / follow through↑ distraction force

with eccentric IR

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Traction injury to UCL (anterior band) ligament

Occurs during cocking phase of throwing and early acceleration

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Apophysitis of medial epicondyle

Traction injury to growth plate

Occurs during cocking phase of throwing ↑ valgus force with

excessive ER

OsteochondritisDissecans

Compression of radial head / capitellum

Occurs during cocking phase of throwing and early acceleration

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COMMON FINDINGS Scapular Dyskinesia

Tight Post-InferiorGH Capsule

Poor PitchingMechanics

Overload/overuse

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Impairment in the normal resting position of the scapula or alteration in normal dynamic scapular motion.

Type I-III ClassificationType I – Prominence of infero-medial borderType II – Prom. of entire medial borderType III – Prom. of entire scapula

& superior translation of entire scapula

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Classifications• Type I

• Type II

• Type III

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TYPE I and IIAssociated with:

SLAP tears (type II)

Dysfunction of lower trapezius

Dysfunction of serratus anterior

Tightness of UT, post GH capsule or PM

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SCAPULAR DYSKINESIACommon Pattern

Post tilt, UR ,ER Impingement (64%) Instability (100%)

Ludewig Physical Therapy 2000,Into JSES 92’. Ogston,AJSM2007. Matias. Clin.Biomech 2006

Causes- Impaired:1. Posture- ↑Kyphosis2. Muscle Performance Endurance

(Acute effect)3. ROM/FlexibilityTight Posterior GH capsule Pectoralis Minor Upper trapezius

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EVALUATION- SCAPULA

Dynamic/Objective Tests

1. Lateral scapula glide test2. Scapular Assistance test3. Scapular Retraction Test

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

inferior angle to spinous process in 3 positions:

- arms @ side - hands on hip- 90˚ GH abduction (IR)

• “Semi-dynamic”

SCAPULA SLIDE TEST + Test => 1.5 cm side to side

difference.

Test-retest reliability = .43 -.92 (inter and intra)

Validity = .90

Position 1 and 2 more reliable

Screening ToolKibler 88, 90. Odom, PT, 01, Curtis, NAJSPT,06

Purpose- Determine if scapula dyskinesis is contributing to sp. weakness in pts. w/ shoulder pathology

Technique- Empty can test manually produce scapular retraction. repeat empty can test

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SCAPULAR RETRACTION TEST

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SCAPULAR RETRACTION TEST

(+) test = strength w/ scapula retracted

Limitation:Threshold value for change not determined

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Kibler. AJSM 2006

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SCAPULAR ASSISTANCE TEST

• Purpose – Contribution of scap. dyskinesis to pain/weakness in pts with shoulder pathology

• Technique- Active elevation in sagittal or scapular plane repeat with manual assistance to promote upward rot. & post. tilt

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SCAPULAR ASSISTANCE TEST

+ Test =1. ↓pain of ≥ 2

points on 10 point scale

2. ↓Weakness

Rabin. JOSPT 2006

Greenfield AJSM 1990

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IGHL (posterior band)Teres Minor

Infraspinatus

Teres Major

» ↑ superior labrum strain via ↑ peel back forces

» ↑ Compression on posterior labrum

» ↓ ER compensate w/ ↑ abd. ant capsule stress (tension) micro-instability

» Entrapment of undersurface of posterior RC ( Posterior/ Internal impingement ) Burkhart. Arthroscopy 2003

Clabbers J Sport Rehabil. 2007

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Burkhart. Arthroscopy 2003

Clabbers J Sport Rehabil. 2007

» Late Cocking Phase - Bicep vector’s to more posterior position↑ torsion of biceps anchor/labral attachment medial/lateral gapping of labrum off glenoid

» Normal response» Accentuated by Post GH

tightness!!!Sup view (left)

Burkhart, Arthroscopy 2003

Repetitive Abd/ER » Posterior-inferior

capsule tightnessImpingement of

undersurface of post-sup. RC between posterior labrum and greater tuberosity ↑Ant capsule laxity

Superior view- left shoulder

Walch. JSES 92’

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» HORIZONTAL ADDUCTION

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Meyers Post GH Test

• Technique- Pt. retracts scapula clinician stabilizes scapula passive horizontal adduct. (in neutral rot). Measure > formed between axis of humerus and horizontal plane from superior aspect of shld.

• Inter tester reliability = .94

• Construct Validity p= .004

Myers. AJSM 2007

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MYERS. – SUPINE POST GH TEST

Shoulder Baseball

Players

Tennis

players

Normal Subjects

Dom 105 103 107

Non-Dom 114 111 107

Look for symmetry

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IR ROM :CAUSED BY RETROVERSION + GH TIGHTNESS !!

LIMITATIONOF Measuring IR ROM!

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

Humeral Retroversion

~ Posterior torsion/rotation of humerus in horizontal plane

Humeral / Glenoid Retroversion IR ↑˚17 in pitchers

Irreversible

Beneficial ? - ↑↑ in asymptomatic throwers

Crockett AJSM 02’ , Whitely, JOSPT 2009

≮=30

Generalized Ligamentous Laxity

• Elbow recurvatum = >10˚

• Thumb to forearm opposition = < 1cm

• MCP hyperext. = > 60˚

• DIP hyperext = > 30˚

* Remember: Laxity ≠ Instability

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» Anterior Apprehension Test

• 90/90 position• Passive overpressure at end-

range of ER • If (+) apprehension apply

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

instability/apprehension

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Test (+) Sens. Spec PPV/LR+

NPV/

LR -

Accur.

Apprehension

↑ Pain 50 56 14 88 55

↑Apprehension 72 96 75/20 96/.29 93

Appre-Reloc.

↓Pain 30 90 19 94 86

↓Apprehension 81 92 53/6.5 98/.18 91

Ant. Release

↑ Pain/Instab. 64 99 __/58 __/.37 65

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

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» JOBE RELOCATION TEST

• 90/90 position• Passive overpressure at end-

range of ER • If (+) Posterior shoulder

pain apply posterior glide to humerus

• (+) Test = Elimination of posterior shoulder pain

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Biceps Anchor

Associated Pathologies/Conditions• Partial supraspinatus tear (45 %)• RCT (11%)• Bankart (11%• Partial biceps tear (20%)

• Ganglion cyst- spinoglenoid• AC arthrosis

• HAGL lesion (SLAP II)• Internal impingement (SLAPII)• Scapular Dyskinesis (SLAP II)

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SPECIAL TESTS- SLAP

• Clunk Test• Anterior Slide Test• Active Compression Test • Dynamic Speed’s TestBiceps Load test I and IIResisted Supination –ER

Test• Pronated Load Test

Strong Evidence

Clunk Test- With the arm abducted to varying degrees overhead, clinician applies anterior force to humeral head while passively rotating humerus (IR/ER).

(+) test = “clunk”. Andrews AJSM 85

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

CLUNK TEST

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ANTERIOR SLIDE TEST

Active Compression Test -With the humerus in IR & flexed @ 90 and horiz adducted 30˚ , clinician applies downward force repeat w/ humerus in ER

(+) test = Pain “inside” shoulder on 1st

test and no pain on 2nd test.

*AC pathology = pain @AC jointO’Brien AJSM 98’

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

Wilk JOSPT 2005

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Biceps Load I• Shoulder @ 90˚ abduction

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

• Resisted elbow flexion in order to recreate “peel back” mechanism.

(+) test = Deep shoulder pain.

Biceps Load II – shoulder ispositioned @120˚ abductionKim. Arthroscopy 2001

Kim. AJSM 95’

Resisted Supination External-Rotation Test

Test position : @ 90˚ abduction and max ER, (elbow flexed @ 65-70˚, neutral forearm)

resisted supination/simultaneous passive ER in order to recreate “peel back” mechanism.

(+) test = Deep shoulder pain.

Myers AJSM

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Pronated Load Test Shoulder abducted

90˚ w/ full pronation passive ER to end-range contract biceps to provoke “peelback” force on labrum

(+) test = painWilk JOSPT 2005

SLAP- SPECIAL TESTS Most Accurate Tests

1. Biceps Load I2. Biceps Load II3. Resisted Supination- External Rotation

Hegedus, BJSM 2008. Dessaur, JOSPT 2008

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REFERENCE SLIDE (NO AUDIO)

Biceps Load I

91 97 29.1 .1

Biceps Load II

90 97 30.0 .1

Supination-ER

83 82 4.6 .2

Specificity Sensitivity LR+ LR-

» Factors ↑GH Kinetic Force

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

contact

• ↑Toe out ( >10˚)• ↑ Lateral placement( > 10 cm vs plant foot)

Stride

Foot

Flesig 94’

Elbow Flexion < 90 degrees at glove separation ( hand closer to head)

Excessive shoulder horizontal adduction

Arm slot position < ¾ position ( 120º )

Arm slot determined by:

Shoulder abduction angle (90-100º)

Lateral trunk tilt angle (20-30º)

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INJURY RISK FACTORS

↑Pitch count/gameThrowing sliders (↑risk +86%)Throwing curveballs ( ↑ risk + 56%)Fatigue• ↓Velocity• ↑Upright trunk @ follow thru

Throwing change-ups ↓ risk by 12%

Flesig AJSM 2002, 2006. Escambilla AJSM 2007

BIOMECHANICAL COUNSELING Parameters for Safe Pitching

• Stride length = 73-86% of height• Max Sh ER = 155˚• Avoid toe out/ lateral placement of

lead foot• Keep hand on top of ball thru early

cocking phase• “Pitch downhill”

EDUCATION

Patient/Parent/Coach

Follow UBMSAGuidelines

• Pitch counts

Follow Interval Throwing program

Monitor signs/ symptoms of fatigue

STOPSPORTS INJURIES.ORG

END OF AUDIO – REFERENCE SLIDES FOLLOW

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If any pain , Stop throwing for 1 week

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