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
“Baseball” AND “Post-Operative” Articles Published from 1965-2017. Exported from Pubmed 100 90 ~ 170 publications the past 80 2 years regarding baseball 70 60 and surgery…ARE WE 50 THAT MUCH BETTER AT 40 MANAGING THESE 30 PATIENTS??? 20 10 0 1965 2017
Injury Trends in MLB over 18 seasons (1998-2015) Conte et al, Am J Orthop 2016 • 8357 DL designations • 400 UCLR from 1974- (464 yearly) 2015 • 460,432 total days lost • Mean RTS: 17.1 months (25,186 days yearly) • Annual incidence of UCLR • DL assignments and DL increased year to year days increased yr-yr (p<.001) • Avg DL length (55.1 days) • 32.8% of all UCLR performed 2011-2015 • $7.6 Billion ($423M yearly) costs • 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 outcomes?
Cases
• Case 1…2005 Baseballplusstor.eom – 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
– 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 Biodex.com – 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…
• Case 2…2009 Lifestyledenver.com – RHD 25 yo catcher Colorado Rockies organization w/ olecranon stress fx s/p olecranon bone graft & open drilling – Post-operative wk 0-12 (at PT clinic near home) • Symptom control • Respect bone graft healing/protection • Restored elbow ROM
– 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 Slopemedia.org – Emphasize patient education, • symptom recognition – Educate patient on perceived vs. true effort – Educate patient on lifting recommendations/precautions…they don’t always listen
• 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) Drivelinebaseball.com – 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
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
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