Title: Watershed events and critical elements in the natural life of throwing athletes

Transcription

1 Title: Watershed events and critical elements in the natural life of throwing athletes Introduction of session There are watershed moments in life for most of us. These are all different, complex, and eventually define us. Baseball- Advancement of the Professional Game st organized baseball team in the US st bat dimension regulations 1876-National League organized* Bats only round American League founded* st World Series Dead Ball Era (Baseball Reference) Outfield fences Fenway Park to Babe Ruth led American League in HR s (29) Black Sox scandal Spitball banned Integration of baseball Mound Height reduced from 15 to 10 in height Introduction of the DH September 25, 1974, Frank Jobe, MD performed UCL reconstruction on Tommy John Steroids banned League wide PED testing Average fastball velocity (240 players pitched in MLB with avg fastball in excess 92.1 mph) Average fastball velocity players pitched in MLB with avg fastball in excess 92.1 mph Outfield Fenway park -420 *8 teams each Baseball- Amateur Sport Little League Baseball founded Williamsport PA LLWS st leagues outside US formed st non-us team to win LLWS (Monterrey, Mexico) Rules allow Girls to play outfield fences moved pitch count became a part of Little League Baseball /70 Program, for 12- and 13-year-old /70 programs expanded for y.o s

2 2011- composite bat moratorium Tee ball program added for 4-6 yo s 10, 15, 39 Academic & athletic life* o participating in several high school sports was the goal of many adolescent athletes. o No travel teams existed, and there were o Limited opportunities outside of high school sports except for summer leagues 1. Mid 2000 s- Advent & advancement of elite & travel teams in soccer, basketball, & baseball, etc Prior only sports with history of specialization- gymnastics, tennis, swimming o Current state- amateur athletes bypass school-sponsored programs Examples AAU basketball, USA hockey o Specialization in Sport Graduate from high school*- Few opportunities to play beyond high school o <2 % of high school athletes are awarded athletics scholarships to compete in college: o 138,000 scholarships / 7.34 million athletes participate in high school sports = 1.8% % of High School Athletes that will end up professional athletes o Baseball: 0.6% o Hockey: 0.1% o Football: 0.08% o Men s Soccer: 0.04% o Basketball: o Men s: 0.03% o Women s: 0.03% Graduate from college*- Opportunities to participate Professional o Men Baseball: 10.5% Hockey: 4.1% Football: 2% Soccer: 1.9% Basketball: 1.3% o Women Basketball: 1% Recreational Sport o Individual versus Team Traditional vs consequence athletics o Local vs Travel Attaining work life balance Events in Baseball that Shaped the present and future

3 Baseball is a game of tremendous cultural and athletic diversity 1. Diversity in Baseball 11 a man rosters i. 8.3% African American ii. 28.5% Latino iii. 1.7% Asian iv. 59% White, European/ North American b. % of players on MLB rosters born outside the US (18 countries) c. Little League World Series- 18th girls have played in LLWS game Mo'ne Ikea Davis- the first African-American girl to play in the Little League World Series 2. Steroid Era and its effect on Sabermetrics 3. Medicine plays a critical role in the success and future of baseball a. More than 1/3 of all MLB pitchers have undergone atleast one UCL reconstruction b. Over 1300, UCL reconstructions recorded in players that had a professional career approx pitchers. c. 67% league- European/NA but 78% TJ in MLB d. 29% Latin s but 19% TJ e. 73% Righties; 27% Lefties 2. Watershed events all Athletes 3. Risk Factors and Screening Techniques for Throwing Athletes Population Health Evidence o Common Physical and Performance Factors hypothesized to increase injury risk in Throwing Athletes 14, 18, 21 Age 8, 20, 21 Player Position 14, 18 Height 16, 21, 25, 26, 35, 37, 38 ROM differences Torsion and bony alterations Muscle weakness or asymmetry Years pitching 18 Pitching exposure and experience Poor pitching mechanics 6, 9 12, 32 Prior Injury 7, 18 Fatigue 17, 19, 36 5, 33, 34 6, 8, 9, 18, 40

4 From Injury to Return to Sport for the Overhead Athlete Lane Bailey, PhD, PT. 2 Disclosures I have no Relevant Commercial or Financial Conflicts of Interest. 3 AGENDA 1. Brief Lit Review of Return to Play (RTP) in OH Athletes 2. Discuss Healing Principles for Consideration 3. Emphasize Key Components of Return to sport 4. Provide guidelines for Return to Sport. 4 What Does The Science Say? Relying on Previous Literature we can conclude the following: A phased approach is needed Consider tissue healing and maturation factors Resolve detraining affects and premorbid deficits Address and mitigate tissue shortening due to disuse & injury Consider whole athlete throughout course of rehab. 5 What Does The Science Say? Professional Baseball % of all baseball injuries occur to shoulder 22-25% of all baseball injuries involve the elbow Overall # of injuries & days on DL increasing Conte AJSM 01 Posner AJSM 12 Wilk AJSM What Does The Science Say? RUSH AJSM 2017 Systematic Review of 49 Baseball Clinical Outcome Studies. 7 What Does The Science Say? RUSH AJSM 2017 Systematic Review of 49 Baseball Outcome Studies 1

5 27 different validated & non-validated PROs were used 8 What Does The Science Say? Conte AJSM 01 uncontrolled environment Posner AJSM 12 Wilk AJSM 11 6 What Does The Science Say? RUSH AJSM 2017 Systematic Review of 49 Baseball Clinical Outcome Studies 7 What Does The Science Say? RUSH AJSM 2017 Systematic Review of 49 Baseball Outcome Studies 27 different validated & non-validated PROs were used 8 What Does The Science Say? Hartwell Sports Health ,988 match exposures USTA Pros Injury incidence of 3.34/1000 exposures Overall Rate 2x Higher for Men Surface type influenced injury Males 4x higher risk on Hard Courts Females 4x higher risk on Clay Courts 9 What Does The Science Say? Be aware of conditions relevant to specific demographics Heyworth - AJSM Adolescents diagnosed with LLS Normalizing Joint Tolerance To Stresses 1. Reliant on Tissue Healing 2. Dependent upon tissue 3.

6 Varies by Position/Movement 4. Harness Remodeling Phase 5. Applying Progressive Load 11 TISSUE STRESS Normalizing Joint Tolerance To Stresses Monitor Tissue Irritability Baseball 13 Normalizing Joint Tolerance To Stresses Monitor Tissue Irritability Tennis 14 Goals For Return to Play 1 1. Provide transition from safe controlled to an unrestricted 11 TISSUE STRESS 12 Normalizing Joint Tolerance To Stresses Monitor Tissue Irritability Baseball Normalizing Joint Tolerance To Stresses Monitor Tissue Irritability Tennis Goals For Return to Play 1. Provide transition from safe controlled to an unrestricted uncontrolled environment 2. Promote return to pre injury performance 3. Reduce risk of recurrent and subsequent injury Strategies To Progress To Demands Of Sports

7 Phased Progression 1. Light Endurance -> 2. Strengthening - > 3. Plyometrics -> 4. Sport Specific Movements ALSO Improve cardiovascular conditioning Advance Single Leg Balance Hannon IJSPT 2014 Can be improved within 12 weeks Strategies To Progress To Demands Of Sports Phased Progression 1. Light Endurance -> 2. Strengthening - > 3. Plyometrics -> 4. Sport Specific Movements ALSO Regain acceptable shoulder & elbow ROM Bailey AJSM 2015, Laudner 2012, Tyler AJSM 2012 Improve deficits in core & LE weakness 17 Strategies To Progress To Demands Of Sports Phased Progression 1. Light Endurance -> 2. Strengthening - 3. Plyometrics -> 4. Sport Specific Movements ALSO Regain acceptable shoulder & elbow ROM Bailey AJSM 2015, Laudner 2012, Tyler AJSM 2012 Improve deficits in core & LE weakness Strategies To Progress To Demands Of Sports Phased Progression 1. Light Endurance -> 2. Strengthening -

8 > 3. Plyometrics -> 4. Sport Specific Movements ALSO Normalize Rotator Cuff Strength Byram AJSM 2010 Associated with Injury Byram AJSM 2010, Tyler AJSM 2014, Garrison IJSPT 2015 Isokinetic 66% ratio Ellenbecker JSMS 2003 Isometric 75% ratio Byram AJSM Strategies To Progress To Demands Of Sports Patient Education Place Responsibility on the Athlete Understand the risk of motion and strength loss Tactics should vary based on maturity and playing level Develop a strategy for the athlete to monitor themselves Strategies To Progress To Demands Of Sports Evaluation of progress Test-Retest Evaluation Intra-Session Inter-session Fatigued Assessment NM control Endurance Strength Recovery 21 Evaluation Of Progress The Need for Serial Measures Requires collection of objective data

9 Test-Retest Evaluation Intra-Session Inter-session Fatigued Assessment NM control Endurance Strength Recovery Evaluation Of Progress The Need for Serial Measures Requires collection of objective data Utilization both within and between visits Practical Example - Intersession Strategies To Progress To Demands Of Sports Evaluation Of Progress Fatigability Preparation For The Demands of Sport Progressive Loading Baseball Normalizing Joint Tolerance To Stresses Interval Tennis Program Myers Sports Health 2016 Return To Play Criteria for Progress to ITP 2/10 Pain w/ Plyometrics Painfree ROM TARC ROM Deficits < 5 o Rotator Cuff MM Performance 90% Symmetry w/ HHD

10 ER/IR ratio > 66% 90/90 for 30secs w/sport cord 26 Return To Play Criteria for Progress to ITP 2/10 Pain w/ Plyometrics Painfree ROM TARC ROM Deficits < 5 o Rotator Cuff MM Performance 90% Symmetry w/ HHD ER/IR ratio > 66% 90/90 for 30secs w/sport cord Scapula subtle scapular dyskinesis w/ 3# or 5# weight for 10 reps 60 secs w/ 90 reps of CKC stability test Single Leg Balance < 4 cm deficit on stance leg Rotator Cuff Strength Rotator Cuff Endurance UECKCST Seated Shot Put Test 1. Single Arm 2. 6-pound medicine ball 3. One hand, palm 0 degree of shoulder elevation 4. Warm-up: Perform 4 gradient sub-maximal throws followed by 2 maximal warm-up throws 5. Test: 3 maximal effort throws, and avg distance in meters Push-up Test 1. Set-up: Prone with hands shoulder width apart and straight 2. Test: Begin in up position with elbows fully extended. Descend until the upper arm parallel to surface Score: Max effort of 15 sec with 45 sec of rest. The avg of 3

11 -15 second bouts Modified Pull-Up Test 1. Set-Up: Bar 7.6 cm out of arms reach when supine on the floor with legs supported at heels 2. Test: Hang from the bar with arms fully extended and pull so the upper arms are parallel to the floor. Then lower back to the elbows fully extended position. Trial last for 15 sec 3. Score: Avg of 3 maximal effort trials 34 Ideal Athlete RTP Flow MD Medical Clearance Descend until the upper arm parallel to surface Limited Game Exposure Score: Max effort of 15 sec with 45 sec of rest. The avg of 3-15 second bouts 33 Modified Pull-Up Test 1. Set-Up: Bar 7.6 cm out of arms reach when supine on the floor with legs supported at heels 2. Test: Hang from the bar with arms fully extended and pull so the upper arms are parallel to the floor. Then lower back to the elbows fully extended position. Trial last for 15 sec 3. Score: Avg of 3 maximal effort trials 34 Ideal Athlete RTP Flow MD Medical Clearance

12 PT Functional Clearance/ Return to Participation ATC Competition Clearance/Return to Play 35 Underkoeffler Softball Throw for Distance 1. Warm-up: 3 self-selected sub-maximal effort softball throws 2. Test: Experimenter records the distance of 3 maximal effort throw by measuring from the line to the site where the ball first struck the ground 3. Score: Average distance of the 3 maximal effort throws 36 Functional Throwers Performance Index (FTPI) 1. Stand 15 from a 1 ft square on the wall, 4 ft above floor 2. 4 submaximal to maximal controlled gradient warm-ups (25/50/75/100 %) 3. Test: Count number of accurate throws for 30 seconds 4. 3 sets of throws are averaged 5. FTPI = (Total # of throws / accurate # of throws) x by Normative Data 38 Upper Extremity Algorithm 39 Return To Play Phased Approach Individual Drills Pitching/Ground Strokes/Serving Fielding Responding to other Players Situations Practice Situations with other players 1-2 Innings or a set in Tennis

13 37 Normative Data 38 Upper Extremity Algorithm 39 Return To Play Phased Approach Individual Drills Pitching/Ground Strokes/Serving Fielding Responding to other Players Situations Practice Situations with other players 1-2 Innings or a set in Tennis Limited Game Exposure Full Game Exposure 40 Metrics For The Demands of Sport Performance Metrics: Accuracy Volume Ball / Racquet Velocity Distance Innings Pitched ERA SO SO/Inning WHIP PROs (KJOC, etc) SUMMARY 1. Allow healing to guide initiation of activity timelines 2. Consider variability of healing timelines based on involved tissue 3. Understand how tissue demands will vary by sport, position, and playing level 4. Develop an objective assessment to monitor progress within and between sessions 5. Be sensitive to tissue irritability and symptoms 6. Track progress with the use of on-field

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