points out the need for conditioning, the necessity of a warmup, and the importance of flexibility in order to maintain the proper biomechanical glenohumeral rhythm during the act of throwing. When injury occurs he impresses upon us the need for adequate rest, followed by a functional rehabilitation program which steadily guides the athlete’s gradual resumption of throwing and his progressing to a return to competitive pitching. Dr. Peter Fowler, London, Ontario (a former Pan American Games swimmer for Canada), emphasizes the importance of maintaining flexibility programs and dry land strength training programs during the competitive season. He elucidates some
of the morphologic changes that occur during certain strokes which may precipitate injury. He classifies the swimmer’s shoulder syndrome into different phases and recommends a treatment program for each. Dr. Douglas Jackson, Long Beach, California, notes that proper form or technique will not necessarily protect an athlete from overuse and abuse. He emphasizes the role of conditioning, warm-up, and stretching in the prevention of injury. Dr. Jackson relates his experiences in the surgical treatment of chronic shoulder impingement syndrome which have failed to respond to conservative measures. He also discusses his rationale of treatment in those athletes with shoulder instability.
Symposium: SHOULDER PROBLEMS
IN
OVERHEAD-OVERUSE SPORTS September 10, 1978 Ann Arbor, Michigan
Thrower problems FRANK W. JOBE, M.D., Inglewood , California
BASEBALL
This
discussion is limited to the shoulder arbitrarily, although it is understood, in any discussion of injuries caused by throwing, that the elbow is equally susceptible. It is generally agreed that the margin between throwing hard enough to get a major league batter out, and not so hard as to cause injury, is a very fine margin indeed. In other words, on almost every pitch the shoulder is placed under the maximum stress it can tolerate. Considerable accumulative stress has been applied to this joint after 100 to 150 pitches in a game and overuse is the key word in our title. It is because of these demands that such emphasis is placed on prevention of injury. Methods include proper conditioning and training, sufficient and correct warm-up, and proper biomechanics of pitching.
PREVENTION OF INJURY Prevention of injury begins with conditioning, i.e., developing the biochemical mechanism to handle metabolites and mechanically stretching and developing soft tissues to accomodate increased loads, as well as to accelerate tissue regeneration and muscle hypertrophy. About 6 weeks are required, and this conditioning must include the entire body, particularly the legs which are so important for balance, rhythm, and alignment.
WARM-UP A warm-up must be
completed before pitching to bring about of the joints through changes in the lubricating fluids, as well as the stretching of the joint capsules. Change in the chemistry of the tissue fluid also improves the tissue fiber articulation within the muscle itself. the
loosening
BIOMECHANICS biomechanics of pitching is understood only in general terms, it can be described as a total body motion in which a ball is delivered by the hand at speeds up to 100 mph. A number of conditions must exist to accomplish this. There must be an acceleration of the hand which involves a turning of the body (including the trunk), bringing the arm around with the trunk, and shifting of body weight from the push-off leg to the contrateral leg, adding the wrist and forearm motion, and then providing a proper deceleration of the arm in order to prevent
Although
injury. It appears that may be related to
injuries occur during acceleration and faulty biomechanics, such as opening up too soon and dropping the elbow. These injuries may be related to the levering mechanism set up when the trunk is turned rapidly, dragging the arm behind it. At the same time, the shoulder capsule is externally rotated as tightly as possible. This motion most
139
sometimes overpowers the protective action of the muscle and causes inflammatory response in the capsule. In Dr. Ann Atwater’s studies on throwers, it has become obvious that nearly all pitchers, whether overhand, sidearm, or three-quarter, throw the ball with the arm held somewhere near 95 degrees in relation to the upper trunk. The change in position is accomplished by turning the trunk to the side away from the pitching arm, or turning the trunk straight up or toward the pitching arm. It seems that with any swelling an impingement begins between the humerus and the acromion, and as the arm is brought forward there is an abrading action between the two structures. However, the most common complaint is the sore shoulder which could be called a Grade I sprain, with early inflammatory reaction. It is no doubt due to the overriding of the protective mechanism of the shoulder muscles previously mentioned, in conjunction with overuse in relation to the player’s state of condition, warm-up, or proper mechanics.
TREATMENT OF SORE SHOULDER REST is the most important single treatment; the length of time depends on the extent of injury. However, it is vital that while the patient is resting he continue a stretching program to maintain length of fibers in the capsule and around the joint. We use oral anti-inflammatory medication rather freely, plus physical therapy in the form of alternating hot and cold packs. Under certain circumstances we use injections of Xylocaine (lidocaine; Astra Pharmaceutical Products, Inc.) and steroids, but I think this treatment must have strong justification, particularly in early stages. In the treatment of chronic problems such as the anterior impingement syndrome and posterior capsulitis, all of the above are used, but a much longer time is needed. Here we are more likely to use injections of Xylocaine with steroid, but I feel the number of injections should be limited to two or three. The important element continues to be rehabilitation, carried out very carefully, in order to avoid a recurrence of injury as the patient progresses. We have learned over the last few years that we have tried to get pitchers back to pitching too quickly following severe injury. Aggravation of the problem, with an additional period of disability, has been the result. Dr. Clancy: You talked about opening up. This is frequently used in the literature but has never been explained. Can you briefly tell us what you mean by &dquo;opening up on the delivery?&dquo; Dr. Jobe: Yes, generally a pitcher tries to bring his arm around as he brings his trunk around. If he lets his arm drag behind he considers that &dquo;opening up&dquo; his delivery by leaving the arm behind, and so the natural reaction then is to try and catch up.
140
In order to do that he drops his elbow and short-arms the ball. Dr. Clancy: Can you also briefly tell us about the fungo routine you use in your rehabilitation? Dr. Jobe: The fungo routine is used to begin pitching or throwing in a very easy manner, but yet bringing the arm through a full range of motion. The distances could be measured but it is easier to explain to a ball player as: &dquo;Start at the outfield and throw the ball in toward home plate, letting it
bounce three or four times on the way, but use your full range of motion.&dquo; He does that for 15 min. On the second day he moves in a little closer and throws just a little bit harder with only one or two bounces. The third day he moves in a little closer, throws with only one bounce, and a little bit harder. Eventually he reaches the mound and begins to pitch off of the mound with a full wind-up at about one-half speed and then gradually works up to three-quarters speed. He should skip days if any stiffness occurs. This whole process may take 3 weeks to reach three-quarter speed. We do not recommend that any pitcher throw all out except just before competitive
throwing. So you would use this in someone who has an strain, who you have rested and put on your stretching routine, and when you felt he was asymptomatic you start him out the first few days just throwing from the outfield on a few bounces and he would wait for a few days before he moved in. It would not be done in I full day. Dr. Jobe: No, it would be done over a period of maybe 10 days, depending on the severity of the injury, but could take 3 weeks. If it had taker us 3 weeks to get him asymptomatic you might spend 3 weeksgetting him back up to the mound, but if it was just a turn tvpe of injury then you might try and do it in a week or so. Dr. Clancy: Do you use neuromuscular facilitation in your treatment program on these shoulders that you have had to remove from competition and start them on the glenohumeral rhythm exercises that you talked about? Do you have them do any neuromuscular facilitation exercises before their exercise phase of throwing the ball? Dr. Jobe: By that you mean what? Dr. Clancy: Stretching against resistance in the opposite phase and then passive stretching the other way. Dr. Jobe: We do some but not a tremendous amount. Dr. Clancy: Are there any other techniques that you have found successful in the good athlete who has a significant strain in a thrower besides what you mentioned already? Dr. Jobe: I think the important things are rest and keeping the capsule and muscle stretched out while he is healing, and not trying to get him back too soon. As I said, if you hurry, you start the same inflammatory process over again. Dr.
Clancy:
acute shoulder
of the morphologic changes that occur during certain strokes which may precipitate injury. He classifies the swimmer’s shoulder syndrome into different phases and recommends a treatment program for each. Dr. Douglas Jackson, Long Beach, California, notes that proper form or technique will not necessarily protect an athlete from overuse and abuse. He emphasizes the role of conditioning, warm-up, and stretching in the prevention of injury. Dr. Jackson relates his experiences in the surgical treatment of chronic shoulder impingement syndrome which have failed to respond to conservative measures. He also discusses his rationale of treatment in those athletes with shoulder instability.
Symposium: SHOULDER PROBLEMS
IN
OVERHEAD-OVERUSE SPORTS September 10, 1978 Ann Arbor, Michigan
Thrower problems FRANK W. JOBE, M.D., Inglewood , California
BASEBALL
This
discussion is limited to the shoulder arbitrarily, although it is understood, in any discussion of injuries caused by throwing, that the elbow is equally susceptible. It is generally agreed that the margin between throwing hard enough to get a major league batter out, and not so hard as to cause injury, is a very fine margin indeed. In other words, on almost every pitch the shoulder is placed under the maximum stress it can tolerate. Considerable accumulative stress has been applied to this joint after 100 to 150 pitches in a game and overuse is the key word in our title. It is because of these demands that such emphasis is placed on prevention of injury. Methods include proper conditioning and training, sufficient and correct warm-up, and proper biomechanics of pitching.
PREVENTION OF INJURY Prevention of injury begins with conditioning, i.e., developing the biochemical mechanism to handle metabolites and mechanically stretching and developing soft tissues to accomodate increased loads, as well as to accelerate tissue regeneration and muscle hypertrophy. About 6 weeks are required, and this conditioning must include the entire body, particularly the legs which are so important for balance, rhythm, and alignment.
WARM-UP A warm-up must be
completed before pitching to bring about of the joints through changes in the lubricating fluids, as well as the stretching of the joint capsules. Change in the chemistry of the tissue fluid also improves the tissue fiber articulation within the muscle itself. the
loosening
BIOMECHANICS biomechanics of pitching is understood only in general terms, it can be described as a total body motion in which a ball is delivered by the hand at speeds up to 100 mph. A number of conditions must exist to accomplish this. There must be an acceleration of the hand which involves a turning of the body (including the trunk), bringing the arm around with the trunk, and shifting of body weight from the push-off leg to the contrateral leg, adding the wrist and forearm motion, and then providing a proper deceleration of the arm in order to prevent
Although
injury. It appears that may be related to
injuries occur during acceleration and faulty biomechanics, such as opening up too soon and dropping the elbow. These injuries may be related to the levering mechanism set up when the trunk is turned rapidly, dragging the arm behind it. At the same time, the shoulder capsule is externally rotated as tightly as possible. This motion most
139
sometimes overpowers the protective action of the muscle and causes inflammatory response in the capsule. In Dr. Ann Atwater’s studies on throwers, it has become obvious that nearly all pitchers, whether overhand, sidearm, or three-quarter, throw the ball with the arm held somewhere near 95 degrees in relation to the upper trunk. The change in position is accomplished by turning the trunk to the side away from the pitching arm, or turning the trunk straight up or toward the pitching arm. It seems that with any swelling an impingement begins between the humerus and the acromion, and as the arm is brought forward there is an abrading action between the two structures. However, the most common complaint is the sore shoulder which could be called a Grade I sprain, with early inflammatory reaction. It is no doubt due to the overriding of the protective mechanism of the shoulder muscles previously mentioned, in conjunction with overuse in relation to the player’s state of condition, warm-up, or proper mechanics.
TREATMENT OF SORE SHOULDER REST is the most important single treatment; the length of time depends on the extent of injury. However, it is vital that while the patient is resting he continue a stretching program to maintain length of fibers in the capsule and around the joint. We use oral anti-inflammatory medication rather freely, plus physical therapy in the form of alternating hot and cold packs. Under certain circumstances we use injections of Xylocaine (lidocaine; Astra Pharmaceutical Products, Inc.) and steroids, but I think this treatment must have strong justification, particularly in early stages. In the treatment of chronic problems such as the anterior impingement syndrome and posterior capsulitis, all of the above are used, but a much longer time is needed. Here we are more likely to use injections of Xylocaine with steroid, but I feel the number of injections should be limited to two or three. The important element continues to be rehabilitation, carried out very carefully, in order to avoid a recurrence of injury as the patient progresses. We have learned over the last few years that we have tried to get pitchers back to pitching too quickly following severe injury. Aggravation of the problem, with an additional period of disability, has been the result. Dr. Clancy: You talked about opening up. This is frequently used in the literature but has never been explained. Can you briefly tell us what you mean by &dquo;opening up on the delivery?&dquo; Dr. Jobe: Yes, generally a pitcher tries to bring his arm around as he brings his trunk around. If he lets his arm drag behind he considers that &dquo;opening up&dquo; his delivery by leaving the arm behind, and so the natural reaction then is to try and catch up.
140
In order to do that he drops his elbow and short-arms the ball. Dr. Clancy: Can you also briefly tell us about the fungo routine you use in your rehabilitation? Dr. Jobe: The fungo routine is used to begin pitching or throwing in a very easy manner, but yet bringing the arm through a full range of motion. The distances could be measured but it is easier to explain to a ball player as: &dquo;Start at the outfield and throw the ball in toward home plate, letting it
bounce three or four times on the way, but use your full range of motion.&dquo; He does that for 15 min. On the second day he moves in a little closer and throws just a little bit harder with only one or two bounces. The third day he moves in a little closer, throws with only one bounce, and a little bit harder. Eventually he reaches the mound and begins to pitch off of the mound with a full wind-up at about one-half speed and then gradually works up to three-quarters speed. He should skip days if any stiffness occurs. This whole process may take 3 weeks to reach three-quarter speed. We do not recommend that any pitcher throw all out except just before competitive
throwing. So you would use this in someone who has an strain, who you have rested and put on your stretching routine, and when you felt he was asymptomatic you start him out the first few days just throwing from the outfield on a few bounces and he would wait for a few days before he moved in. It would not be done in I full day. Dr. Jobe: No, it would be done over a period of maybe 10 days, depending on the severity of the injury, but could take 3 weeks. If it had taker us 3 weeks to get him asymptomatic you might spend 3 weeksgetting him back up to the mound, but if it was just a turn tvpe of injury then you might try and do it in a week or so. Dr. Clancy: Do you use neuromuscular facilitation in your treatment program on these shoulders that you have had to remove from competition and start them on the glenohumeral rhythm exercises that you talked about? Do you have them do any neuromuscular facilitation exercises before their exercise phase of throwing the ball? Dr. Jobe: By that you mean what? Dr. Clancy: Stretching against resistance in the opposite phase and then passive stretching the other way. Dr. Jobe: We do some but not a tremendous amount. Dr. Clancy: Are there any other techniques that you have found successful in the good athlete who has a significant strain in a thrower besides what you mentioned already? Dr. Jobe: I think the important things are rest and keeping the capsule and muscle stretched out while he is healing, and not trying to get him back too soon. As I said, if you hurry, you start the same inflammatory process over again. Dr.
Clancy:
acute shoulder
