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Who is this pitcher? What teams are Playing? Rehabilitation Program for Overhead Activities for Micro-Instability Phases in Rehabilitation • • • • Acute Phase Intermediate Phase Advance Phase Return to Activity Phase Goals • • • • • ROM Muscular Strength and endurance Proprioception Dynamic stability Neuromuscular control Acute Phase • Immediately following injury • Length amount of healing needed Acute Phase - Goals • Minimize pain and inflammation • Normalize motion and muscle balance • Restore baseline propioception and kinesthetic awareness 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 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 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 Posterior shoulder in thrower • Eccentric contractions • Soft tissue adaptation and loss of IR ROM • Stretching - horizontal adduction stretch for the posterior cuff muscles Strengthening • Submax painfree 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 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 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 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 Closed vs Open Kinetic Exercises 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 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 Acute Phase • • • • • Ice High voltage stimulation Iontophoresis Ultrasound NSAD 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 Intermediate Phase - Goals • • • • Enhance dynamic dynamic stability Reestablish neuromusular control Restore muscular strength and balance Maintain full ROM 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) Throwers Ten Program • Elicits muscles most needed to provide dynamic stability on overhead athletes Intermediate Phase • Dynamic stabilization – eyes closed and at the end of the ROM • PNF patterns 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) Intermediate Phase • Isotonic exercises for the scapulothoracic • CKC exercises are advance • Push up on the ball or unstable surface on a tabletop Intermediate Phase • Lower extremity • Core - Stabilization CKC • Trunk strength abd crunches and pelvic tilts • Double and single leg balances Advance Phase • Progressive and neuromuscular control activities to return to activity • Minimum pain and tenderness • Full ROM Symmetrical capsular mobility • Good strength and endurance Advance Phase • Full ROM and capsular mobility maintain throughout the ROM • Total motion is equal bilaterally Strengthening • Throwers Ten Program • Exercises for the trunk and LE • IR and ER tubing to eccentric and high speed contractions Aggressive Strengthening of the UE • • • • Bench Isotonic machines Seated row Lats pull down Plyometrics • Train the UE to produce and dissipate forces • Provide quick powerful movement involving a prestretch pf the muscle • Activate the stretch-shortening cycle of the muscle tissue • Stimulate throwing • Increase neuromusular control and core strength Plyometrics 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 Return to Activity Phase • • • • Minimum complaints of pain and discomfort Full ROM Balance capsular mobility Adequate pro, dynamic stabilization and neuromuscular control Isokinetic testing • ER:IR strength ratio of 66 to 76% or higher at 180degrees/s 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. 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