Post Operative Rehab for the Throwing Athlete: What Ive learned in - - PowerPoint PPT Presentation

Post Operative Rehab for the Throwing Athlete: “What I’ve learned in 12 years”

Jonathan C. Sum, PT, DPT, OCS, SCS

Assistant Professor of Clinical Physical Therapy Clinic Director, USC Physical Therapy - HSC American Society of Shoulder & Elbow Therapists (ASSET)

• No financial disclosures

Here is what I have learned…

• 4 case vignettes, 4 lessons
• Key points based on current evidence
• Take home message for optimal patient/player

management

• Challenges

10 20 30 40 50 60 70 80 90 100

“Baseball” AND “Post-Operative” Articles Published from 1965-2017. Exported from Pubmed

1965 2017

~ 170 publications the past 2 years regarding baseball and surgery…ARE WE THAT MUCH BETTER AT MANAGING THESE PATIENTS???

Injury Trends in MLB over 18 seasons (1998-2015)

Conte et al, Am J Orthop 2016

• 8357 DL designations

(464 yearly)

• 460,432 total days lost

(25,186 days yearly)

• DL assignments and DL

days increased yr-yr

• Avg DL length (55.1 days)
• $7.6 Billion ($423M

yearly) costs

• 400 UCLR from 1974-

2015

• Mean RTS: 17.1 months
• Annual incidence of UCLR

increased year to year (p<.001)

• 32.8% of all UCLR

performed 2011-2015

• Shoulder injuries

declining, but elbow injuries are rising

Conundrum

Conte et al Am J Orthop 2016, Conte et al AJSM 2015, Erickson et al World J Orthop 2016, Erickson et al Orthop J Sports Med 2017

• Shoulder surgeries trending down
• Elbow injuries trending up
• DL time and lost salary $ at all time high
• More youth participation = more injuries

– More innings, less rest, no offseason

• More data = more knowledge = better
• utcomes?

Cases

• Case 1…2005

– RHD 21 yo collegiate softball catcher s/p SLAP repair – Post-operative wk 0-16

• Symptom control, tissue healing/protection
• Restored full ROM
• Normalized balanced strength as tested by Cybex

– ER/IR balanced ratio, RC strength normalized to body weight, ER/IR compared to non-operated side

• Performed plyometric movements simulating overhead

throwing

Baseballplusstor.eom

– Post operative wk 16-26

• Cleared by medical team to begin throwing
• Completed selected functional testing
• Progressed through Interval Throwing Program with PT and

teammates

• Discharged from PT

– Post operative ~ 8 months

• Doing arm circles at gym prior to workout with 2.5 lbs
• Felt a pop in throwing arm
• MRI confirmed re-tear of superior labrum

• Lesson 1

– Labral repairs are tenuous for throwers – Mobility vs. laxity – Strength vs. balance – Remove all doubt…

• Cybex tested, ITP, functional testing algorithm

– Can’t control everything…re-tear…

Biodex.com

• Case 2…2009

– RHD 25 yo catcher Colorado Rockies organization w/ olecranon stress fx s/p olecranon bone graft &

• pen drilling

– Post-operative wk 0-12 (at PT clinic near home)

• Symptom control
• Respect bone graft healing/protection
• Restored elbow ROM

Lifestyledenver.com

– Post operative wk 12-20

• Cleared to being Interval Throwing Program
• Continued with elbow ROM, advanced

stability/strengthening

– Post operative wk 20-32

• Collaborated with catching coaches to work on

technique/footwork

• Completed rehab during final semester of degree

program before returning to spring training

• Lesson 2

– Understanding physiologic demands of throwing is vital, and differs based on position and throwing mechanics

• C (short arm) vs. IF (position dependent) vs. OF (crow-

hop) vs. P (full mechanics)

– Communication with team head physician and rehab coordinator is critical

• Case 3…2015

– RHD 22 yo undrafted pitcher s/p UCL reconstruction with ulnar nerve transposition – Post-operative wk 0-16

• Symptom control, tissue healing/protection
• Restored elbow / wrist ROM
• Aggressive strengthening/conditioning for LE, core,

scapula, shoulder

twitter

– Post operative wk 16-6 months

• Cleared to begin Interval Throwing Program with pitching

coach

• Continue with elbow ROM, advanced stability/strengthening
• Discharged from PT, con’t to throw w/ pitching coach

– Post operative ~14 months

• Was back to 100% effort throwing low 90s
• Continued to do heavy strength training on his own
• Developed pain in medial elbow region after throwing
• MRI…common flexor tendinosis

• Lesson 3

– Emphasize patient education,

• symptom recognition

– Educate patient on perceived vs. true effort – Educate patient on lifting recommendations/precautions…they don’t always listen

Slopemedia.org

• Case 4…2017

– RHD collegiate-bound pitcher s/p UCL proximal avulsion repair (felt a “crack” during a pitch) – Post-operative wk 0-4

• Symptoms control, tissue healing
• Restored elbow/wrist ROM
• Aggressive strengthening/conditioning/stability for LE,

core, scapula, shoulder

– Post operative wk 4-12

• Continue with elbow ROM, advanced stability/strengthening
• Progress to 90-90 position proprioception, stabilization

training, functional testing

– Post operative wk 12-20

• Cleared to begin ITP, strength training on off days

– Post operative wk ~20-present…moved to college, continued ITP with college team – *Developed posterior elbow/triceps pain following throwing days…unable to progress through ITP

• Lesson 4

– Be proactive in communication with athlete and athletic training staff – Don’t assume all athletic training staff have expertise in overhead throwing – Respect the body…the body is the boss

Evidence-Based Key Points

• ER deficit (not GIRD or TRM deficit) in pros…2.2x more

likely to be on DL, 4x more likely to have surgery Wilk et al AJSM

2016

• Supraspinatus weakness associated with higher injury

risk in high schoolers Tyler et al AJSM 2014

• Horizontal adduction and IR deficits in adolescents…

4-6x more likely to have injury Shanley at al JSES 2015

• Kinetic chain is vital to offload UE post surgically Chu et al PM&R

2016

• Slow and steady wins the race Conte et al Am J Orthop 2016

Take Home Message(s)

• Communication is vital

– athlete, surgeon, training staff, coaches, (parents)

• Utilize everything!!!

– MOTUS sleeve (and other wearable tech) – Sports psychology, IASTM, LLLT, VibTherapy, Dynavision, video analysis (Coach’s Eye, Dartfish), etc

• Individualize each rehab program, using current

evidence to guide

• Respect the rehab process, don’t be a rehab hero
• Return the play progression is critical (don’t rush)
• Most pro athletes should RTP with good surgery and

good rehab (~80-86%) Erickson et al 2016, Cain et al 2010, Makhani et al 2014

Drivelinebaseball.com

Future Challenges

• For pros…delayed throwing, slower return to pitching

may be better, is that possible?

• For everyone else…creative utilization of insurance visits

is needed

• Keep kids engaged

– 70% of kids participating in sports drop out by the age of 13 because of adults: www.stopsportsinjuries.org

• 33% of players were told by coaches to specialize Padaki et al Sports Health 2017
• 50% of players were encouraged by parents to specialize) Padaki et al OJSM

2017

• Specialization

– Watch for burnout or overuse injuries – Not necessary for long term athletic success, unsure if it is detrimental, still a multifactorial challenge LaPrade et al OJSM 2016

Thank you!!!

sum@pt.usc.edu

References

• Erickson BJ, Bach BR Jr, Bush-Joseph CA, Verma NN, Romeo AA. Medial ulnar collateral ligament reconstruction of the elbow in major

league baseball players: Where do we stand? World J Orthop. 2016 Jun 18;7(6):355-60.

• Erickson BJ, Chalmers PN, Axe MJ, Romeo AA. Exceeding Pitch Count Recommendations in Little League Baseball Increases the Chance
• f Requiring Tommy John Surgery as a Professional Baseball Pitcher. Orthop J Sports Med. 2017 Mar 24;5(3):2325967117695085.
• Conte S, Camp CL, Dines JS. Injury Trends in Major League Baseball Over 18 Seasons: 1998-2015. Am J Orthop (Belle Mead NJ). 2016

Mar-Apr;45(3):116-23.

• Conte SA, Fleisig GS, Dines JS, Wilk KE, Aune KT, Patterson-Flynn N, ElAttrache N. Prevalence of Ulnar Collateral Ligament Surgery in

Professional Baseball Players. Am J Sports Med. 2015 Jul;43(7):1764-9.

• Padaki AS, Ahmad CS, Hodgins JL, Kovacevic D, Lynch TS, Popkin CA. Quantifying Parental Influence on Youth Athlete Specialization: A

Survey of Athletes' Parents. Orthop J Sports Med. 2017 Sep 21;5(9):2325967117729147

• Padaki AS, Popkin CA, Hodgins JL, Kovacevic D, Lynch TS, Ahmad CS. Factors That Drive Youth Specialization. Sports Health. 2017

Nov/Dec;9(6):532-536

• Shanley E, Kissenberth MJ, Thigpen CA, Bailey LB, Hawkins RJ, Michener LA, Tokish JM, Rauh MJ. Preseason shoulder range of motion

screening as a predictor of injury among youth and adolescent baseball pitchers. J Shoulder Elbow Surg. 2015 Jul;24(7):1005-13.

• Wilk KE, Macrina LC, Fleisig GS, Aune KT, Porterfield RA, Harker P, Evans TJ, Andrews JR. Deficits in Glenohumeral Passive Range of

Motion Increase Risk of Shoulder Injury in Professional Baseball Pitchers: A Prospective Study. Am J Sports Med. 2015 Oct;43(10):2379- 85.

• LaPrade RF, Agel J, Baker J, Brenner JS, Cordasco FA, Côté J, Engebretsen L, Feeley BT, Gould D, Hainline B, Hewett T, Jayanthi N, Kocher

MS, Myer GD, Nissen CW, Philippon MJ, Provencher MT. AOSSM Early Sport Specialization Consensus Statement. Orthop J Sports Med. 2016 Apr 28;4(4):2325967116644241.

• Tyler TF, Mullaney MJ, Mirabella MR, Nicholas SJ, McHugh MP. Risk Factors for Shoulder and Elbow Injuries in High School Baseball

Pitchers: The Role of Preseason Strength and Range of Motion. Am J Sports Med. 2014 Aug;42(8):1993-9.