Thrower's Shoulder: Difference between revisions

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<div class="noeditbox">Welcome to [[Texas State University Evidence-based Practice Project|Texas State University's Evidence-based Practice project space]]. This is a wiki created by and for the students in the Doctor of Physical Therapy program at Texas State University - San Marcos. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
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'''Original Editors'''
'''Original Editors''' - [[User:Samuel Jacob Melnick|Samuel Jacob Melnick]]


'''Lead Editors''' - Your name will be added here if you are a lead editor on this page.&nbsp; [[Physiopedia:Editors|Read more.]]
'''Lead Editors'''- [[User:Severo Saenz|Severo Saenz]], [[User:Samuel Jacob Melnick|Samuel Jacob Melnick]], [[User:Ian Wallace|Ian Wallace]], [[User:Matthew Seliga|Matthew Seliga]]
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== Search Strategy  ==
== Introduction ==
[[File:Internal impingement of the shoulder.jpg|thumb|High stressors in throwing motion]]
Overhead throwing places exceptionally high stresses on the [[shoulder]]. The thrower's shoulder must be loose enough to allow excessive external rotation but stable enough to prevent symptomatic humeral head [[Shoulder Subluxation|subluxation]]<nowiki/>s, requiring a delicate balance between mobility and functional stability. This balance is frequently compromised and believed to lead to various types of injuries to the surrounding tissues.<ref name="Wilk1">Wilk et al. [https://pubmed.ncbi.nlm.nih.gov/19194026/ Shoulder Injuries in the Overhead Athlete]. J Orthop Sports Phys Ther. 2009;39(2):38-54. Article. Available:https://pubmed.ncbi.nlm.nih.gov/19194026/ (accessed 12.1.2023)</ref>


add text here related to databases searched, keywords, and search timeline <br>
Treatment of the Thrower's shoulder is exceptionally challenging. Awareness and understanding of the throwing motion and the forces the structures are subject to are essential to diagnosis and treatment.<ref>Seroyer ST, Nho SJ, Bach Jr BR, Bush-Joseph CA, Nicholson GP, Romeo AA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445067/ Shoulder pain in the overhead throwing athlete.] Sports health. 2009 Jan;1(2):108-20.Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445067/ (accessed 12.1.2023)</ref> See  [[Throwing Biomechanics|Throwing biomechanics]]


== Definition/Description  ==
Huge stresses are placed on the thrower’s shoulder during the overhead motion. Isolated injuries of the shoulder structures may occur, but more typically a cascade of pathologic changes is commonly in the overhead throwing athlete. Common injuries seen in the Thrower's shoulder include superior [[Glenoid Labrum|labral]] tears, partial-thickness tears of the posterior [[Supraspinatus Tear|supraspinatus]] and anterior portion of the [[Infraspinatus Test|infraspinatus]], a tight posterior capsule, and [[Anterior Shoulder Instability|anterior instability]].<ref>Musculoskeletal Key [https://musculoskeletalkey.com/the-throwers-shoulder-3/ The Thrower’s Shoulder] Available:https://musculoskeletalkey.com/the-throwers-shoulder-3/ (accessed 12.1.2023)</ref>


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The typical injuries seen in the throwing shoulder seldom occur in isolation, with an overlap of symptoms and clinical findings being common.<ref>Medina G, Bartolozzi III AR, Spencer JA, Morgan C. [https://journals.lww.com/jbjsreviews/Abstract/2022/03000/The_Thrower_s_Shoulder.14.aspx The Thrower’s Shoulde]r. JBJS reviews. 2022 Mar 1;10(3):e21.Available:https://journals.lww.com/jbjsreviews/Abstract/2022/03000/The_Thrower_s_Shoulder.14.aspx (accessed 12.1.2023)</ref> Below are the main diagnoses associated with Thrower's Shoulder.


== Epidemiology /Etiology  ==
* [[SLAP Lesion|SLAP Tears]]
* [[Biceps Tendinopathy]] and [[Rupture Long Head Biceps|Rupture long head of biceps]]
* [[Rotator Cuff Tendinopathy]] and [[Rotator Cuff Tears|Tears]]
* [[Internal Impingement of the Shoulder|Internal Impingement]]
* [[Shoulder Instability|Instability]]
* Glenohumeral Internal Rotation Deficit (GIRD): a condition resulting in the loss of internal rotation of the glenohumeral joint as compared to the contralateral shoulder, most commonly seen in the throwing athlete.
* [[Scapular Dyskinesia]]<ref>Orthobullets [https://orthoinfo.aaos.org/en/diseases--conditions/shoulder-injuries-in-the-throwing-athlete/ Shoulder Injuries in the Throwing Athlete] Available:https://orthoinfo.aaos.org/en/diseases--conditions/shoulder-injuries-in-the-throwing-athlete/ (accessed 12.1.2023)</ref>
[[File:Baseball pitching motion 2004.jpg|center|thumb|715x715px|Baseball pitching motion]]


While many sports involve overhead throwing, baseball pitchers compromise a plurality of those throws and over half of the throws made in a baseball game<ref name="null">Whiteley R. Baseball Throwing Mechanics as They Relate to Pathology and Performance – A Review. J Sports Sci &amp;amp; Med 2007 6:1-20.</ref>.
== Characteristics/Clinical Presentation  ==
*Thrower's Paradox - The balance between mobility and functional stability. -JM_Wilk Article
The ability to provide the best physical therapy for&nbsp;the throwing patient involves understanding the phases and biomechanics behind throwing. It is important to note that while these athletes are throwing with their arms, that they gain a large, important&nbsp;amount of momentum and force through the use of their legs and torso. This section will mostly pertain to the upper extremity's influence on throwing.
The picture below depicts an overhead view of the&nbsp;alignment of the body during the acceleration phase of throwing. Note the 15 degree angle of the foot away from the center of the mound<ref name="Fleisig" />. The stride&nbsp;ankle also typically lands approximately 10cm away from the same midline with a distance from the rubber averaging 87% of the pitcher's height<ref name="Fleisig" />. Fleisig emphasizes the importance of these values by describing the change in force exhibited on the shoulder when they deviate from the norm. During the cocking phase, Fleisig reports a 3.0N increase in anterior force at the shoulder for every extra cm. and a 2.1N increase in anterior force at the shoulder with every degree increase. Please note that decreasing the distance away from center or decreasing the angle did not result in increased anterior force on the shoulder. So, because of the increased anterior force on the shoulder, it can be assumed that over time the anterior ligamentous structures to the glenohumeral joint may be compromised. This finding is consistent with the&nbsp;anterior&nbsp;glenohumeral&nbsp;instability found in many throwing athletes and emphasizes the importance of proper mechanics throughout the entire kinematic chain<ref name="Whiteley" />.
[[Image:Pitching angle foot and leg.png|frame|Image:Pitching_angle_foot_and_leg.png]]&nbsp;
There is inconclusive evidence as to whether or not glenohumeral external rotation during the earlier phases of throwing (such as stride foot contact) has a positive or negative impact on throwing kinematics or injury occurrence<ref name="Whiteley" />. Some studies claim that increased external rotation increases the risk for injury while others refute the same statement. It is hypothesized that total amount of external rotation at the glenohumeral joint (PROM)&nbsp;may be predictive of increased throwing velocity and increased risk for injury at the glenoid labrum and/or rotator cuff, especially when the loss of internal rotation exceeds the gained external rotation<ref name="Whiteley" />. It is possible that the mechanism for labral tear is caused by the deceleration force imposed by the biceps tendon's attachment to the superior labrum.
== Differential Diagnosis <ref>Wilk et al. Shoulder Injuries in the Overhead Athlete. J Orthop Sports Phys Ther. 2009;39(2):38-54. Article</ref> ==
*Rotator Cuff Tear
*Rotator Cuff Tendonosis/itis
*SLAP Tear
*Internal Impingement&nbsp;
== Examination  ==
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== Medical Management (current best evidence)  ==
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== Physical Therapy Management (current best evidence)<ref name="Wilk">Wilk KE, Meister K, Andrews JR. Current Concepts in the Rehabilitation of the Overhead Throwing Athlete. Am J Sports Med 2002 30:136.</ref><ref name="Meister">Meister K. Injuries to the Shoulder in the Throwing Athlete: Part Two: Evaluation/Treatment. Am J Sports Med 2000 28:587.</ref>&nbsp;  ==
Pitchers have the option of throwing from "The Stretch" or "The Wind-up" positions. It is important for them to be comfortable with both deliveries and for both to be mechanically similar during the follow-through phase<ref name="Whiteley">Whiteley R. Baseball Throwing Mechanics as They Relate to Pathology and Performance – A Review. J Sports Sci &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Med 2007 6:1-20.</ref>.
[http://www.youtube.com/watch?v=46l6avAdpQ0 "The Stretch" vs "The Wind-up"]
Wilk, Meister, and Andrews define 4 phases to the rehab of the throwing athlete: Acute, Intermediate, Advanced Strengthening, and Return-to-Throwing<ref name="Wilk" />. They also discuss more specific rehab principles for common injuries to overhead throwing athletes. These rehab&nbsp;specifics will be illustrated in the following charts<ref name="Wilk" />.<br>[[Image:Shoulder acute phase rehab2.png|frame|left]]&nbsp;
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[[Image:Shoulder intermediate phase rehab.png|frame|left]]&nbsp;
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[[Image:Shoulder_advanced_strengthening_rehab_phase.png|frame|left]]
[http://www.athleticmed.com/pdf/Throwers_Ten_Exercise_Program.pdf Throwers' Ten Exercise Program]
== Key Research  ==
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== Resources <br> ==
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== Clinical Bottom Line  ==
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== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
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== References  ==
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[[Category:Texas_State_University_EBP_Project|Template:TXSTEBP]]
[[Category:Texas_State_University_EBP_Project]]
[[Category:Conditions]]
[[Category:Sports_Injuries]]
[[Category:Shoulder]]
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]
[[Category:Sports Medicine]]

Latest revision as of 02:50, 12 January 2023

Original Editors - Samuel Jacob Melnick

Lead Editors- Severo Saenz, Samuel Jacob Melnick, Ian Wallace, Matthew Seliga

Introduction[edit | edit source]

High stressors in throwing motion

Overhead throwing places exceptionally high stresses on the shoulder. The thrower's shoulder must be loose enough to allow excessive external rotation but stable enough to prevent symptomatic humeral head subluxations, requiring a delicate balance between mobility and functional stability. This balance is frequently compromised and believed to lead to various types of injuries to the surrounding tissues.[1]

Treatment of the Thrower's shoulder is exceptionally challenging. Awareness and understanding of the throwing motion and the forces the structures are subject to are essential to diagnosis and treatment.[2] See Throwing biomechanics

Huge stresses are placed on the thrower’s shoulder during the overhead motion. Isolated injuries of the shoulder structures may occur, but more typically a cascade of pathologic changes is commonly in the overhead throwing athlete. Common injuries seen in the Thrower's shoulder include superior labral tears, partial-thickness tears of the posterior supraspinatus and anterior portion of the infraspinatus, a tight posterior capsule, and anterior instability.[3]

The typical injuries seen in the throwing shoulder seldom occur in isolation, with an overlap of symptoms and clinical findings being common.[4] Below are the main diagnoses associated with Thrower's Shoulder.

Baseball pitching motion

References[edit | edit source]

  1. ↑ Wilk et al. Shoulder Injuries in the Overhead Athlete. J Orthop Sports Phys Ther. 2009;39(2):38-54. Article. Available:https://pubmed.ncbi.nlm.nih.gov/19194026/ (accessed 12.1.2023)
  2. ↑ Seroyer ST, Nho SJ, Bach Jr BR, Bush-Joseph CA, Nicholson GP, Romeo AA. Shoulder pain in the overhead throwing athlete. Sports health. 2009 Jan;1(2):108-20.Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445067/ (accessed 12.1.2023)
  3. ↑ Musculoskeletal Key The Thrower’s Shoulder Available:https://musculoskeletalkey.com/the-throwers-shoulder-3/ (accessed 12.1.2023)
  4. ↑ Medina G, Bartolozzi III AR, Spencer JA, Morgan C. The Thrower’s Shoulder. JBJS reviews. 2022 Mar 1;10(3):e21.Available:https://journals.lww.com/jbjsreviews/Abstract/2022/03000/The_Thrower_s_Shoulder.14.aspx (accessed 12.1.2023)
  5. ↑ Orthobullets Shoulder Injuries in the Throwing Athlete Available:https://orthoinfo.aaos.org/en/diseases--conditions/shoulder-injuries-in-the-throwing-athlete/ (accessed 12.1.2023)
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