FWATA 2015 SMoore-Reed

1

California State University, Fresno – Department of Kinesiology

Corrective Exercise to Address Common

Biomechanical Alterations throughout

Each Phase of the Throwing Motion

Stephanie D. Moore-Reed, PhD, ATC

California State University, Fresno

OBJECTIVES

• Six phases of the throwing motion

• Key breakdowns in the kinetic chain

• Assessment Techniques

• Corrective Exercises

1.Windup

2.Early Cocking (Stride)

3.Late Cocking

4.Acceleration

5.Deceleration

6.Follow Through

SIX

PH

AS

ES

Meister, AJSM 2000

Terminology

• Lead/Stride leg:

contralateral to throwing arm

• Trail/Stance leg: ipsilateral to throwing

arm, used to balance

body during cocking phase

Importance of the

Kinetic Chain

• Pitching motion is not an upper extremity action (requires entire

body)

• Reduced stresses on shoulder �

reduced injury risk � increased durability and health of shoulder (career) (Seroyer, Sports Health 2010)

• Improved velocity (Matsuo et al, J Appl

Biomech 2001; Stodden et al, J Appl Biomech

2005; Werner et al, JSES 2008)

2

1.Windup


3.Late Cocking

4.Acceleration

5.Deceleration

6.Follow Through

Wind-up

• Start: weight shift from

stride leg to trail leg

• End: maximum knee lift

of stride leg

• Preparation phase –

establishes rhythm

(Meister, AJSM 2000; Dillman et al, JOSPT 1993)Seroyer et al, Sports Health 2010

Wind Up Considerations

• Keep Center of Gravity over trail leg

– Premature movement forward � KC disruption � more stress on UE (Burkhart et al,

Arthroscopy 2003)

• Trail leg characteristics

– Balance/postural control

– Hip abduction strength

• Good peak hip abductor activity � proper throwing mechanics and reduced risk of injury (Yamanouchi,

Kurume Med J 1998)

Seroyer et al, Sports Health 2010

Maintain COG over stance leg

Hip ABD strength

1.Windup


3.Late Cocking

4.Acceleration

5.Deceleration

6.Follow Through

Early Cocking (Stride)• Start: Maximum knee lift of stride leg &

ball removed from glove

• End: Stride foot contact

• Generate & transfer momentum up

through the kinetic chain (Stodden et al, J Appl

Biomech 2005)

3

Early Cocking Considerations

• Foot position at stride foot contact

– Foot should point toward home plate (slightly inward)

– Necessary for optimal rotation of hips, pelvis & trunk (Dillman et al, JOSPT 1993)

– Deviation may lead to problems

Stride foot lands in closed position

– Must throw across body

– Slows down rotation of the torso, reducing body’s momentum

�throw delivered entirely by arm

Stride foot lands in open position

– Arm lags behind body

– Pelvic rotation occurs too early �increased stress to anterior shoulder and elbow



• Quality of stride foot contact

– Hyperextension of knee while planting the stride foot OR landing on the heel � sudden

deceleration of the body (Meister, AJSM 2000)

• Proper pelvic orientation at stride foot contact requires sufficient hip:

– ER ROM of lead leg

– IR ROM of trail leg

– Decreased hip ROM associated with

decreased velocity and poor throwing mechanics (Robb et al AJSM 2010)


• Timing of trunk rotation

– Initiation of trunk rotation before stride foot contact � higher elbow valgus

torques (Aguinaldo & Chambers, AJSM 2009)

– Proper timing of pelvis rotation followed

by upper trunk rotation maximizes KC

• Improper stride foot angle or position �early rotation of pelvis � additional force

on shoulder and medial elbow (Fortenbaugh et

al, Sports Health 2009)

1.Windup

2.Early cocking (Stride)

3.Late Cocking

4.Acceleration

5.Deceleration

6.Follow Through

4

Late Cocking

• Start: stride foot

contact

• End: shoulder in

max ER (170-185º)

• Scapula retracts to

assist with

achieving this

position & forms a

stable base

Late Cocking Considerations

• Loss of Scapular Muscle Control

– Scapula: base for muscle attachment and link to transfer forces from trunk to arm (Kibler, AJSM

1998)

• Increased protraction

– Hyperangulation in cocking and follow through (Kibler, AJSM 1998)

– SubAC Impingement risk increases

– Disrupts Kinetic Chain

• 20% decrease in energy delivered from trunk�arm requires 33% increase in rotational velocity at the shoulder to deliver same amount of resultant force (Kibler, AJSM 1998)

• Consequence of increased protraction

• Complain of pain at late cocking and early

acceleration

• Posterior inferior supraspinatus tendon

impinged

Internal Impingement

1.Windup


3.Late Cocking

4.Acceleration

5.Deceleration

6.Follow Through

Acceleration

• Start: maximum ER

• End: ball release

• Scapula begins to protract (controlled!)

• Arm internally

rotates 7000-9000

deg/sec (Dillman et al,

JOSPT 1993; Pappas et al, AJSM 1985)

• Stride leg stabilizing

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Shoulder Abduction & Lateral Trunk Tilt

• 90-100º

• Altered shoulder

abduction

– Decreased ball velocity (MacWilliams AJSM

1998)

– Increased varustorque at elbow (Matsuo,

J Appl Biomech 2001;

Aguinaldo & Chambers, AJSM

2009)

Arm Slot Variations

• Sidearm delivery �higher elbow valgus torques compared to overhand arm slot (Matsuo et al 2000;

Aguinaldo & Chambers, AJSM 2009)

Sidearm 3/4

Aguinaldo & Chambers, AJSM 2009

Submarine

Increased ball velocity associated with…

• Greater knee extension motion & velocity (Matsuo

et al, 2001; Escamilla et al, Sports Biomech 2002; Werner et al, JSES

2008)

• Greater forward trunk tilt (Stodden, J Appl Biomech 2005;

Escamilla et al, Sports Biomech2002)

…at ball release


1.Windup


3.Late Cocking

4.Acceleration

5.Deceleration

6.Follow Through

Deceleration

• Start: Ball

release

• End: Max IR

• Reversal of

earlier phases

• Most “violent”

phase – greatest

joint loads

Deceleration Characteristics

• Velocity -500,000 deg/sec2 (Pappas et al,

1985; Dillman et al, 1993)

• Distraction forces as high as 81% BW (Werner et al, JSES 2007)

– Compressive force >1000 N-m (Fleisig et al, 1995;

Dillman et, JOSPT 1993)

• Posterior musculature working

eccentrically to slow down arm

• Hip abductors of stride leg maintain

balance

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Deceleration Considerations

• Tightness of posterior shoulder

musculature

— Decreased Internal Rotation

— Decreased Horizontal Adduction

Infraspinatus

Teres minor

Posterior deltoid

Posterior Deltoid

Deceleration Considerations

• Posterior Capsule Tightness

• Decreased internal rotation

• Decreased horizontal adduction

• Decreased flexion

• Decreased abduction

(Tyler et al, AJSM 2000; Burkhart et al,

Arthroscopy 2003)

1.Windup


3.Late Cocking

4.Acceleration

5.Deceleration

6.Follow Through

Follow Through

• Body moves forward with the arm

• Rebalancing phase

• Culminates in pitcher in fielding position (Fleisig, AJSM 1995)

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1.Windup


3.Late Cocking

4.Acceleration

5.Deceleration

6.Follow Through

SIX

PH

AS

ES

KEY POINTS OF BREAKDOWN IN THE KINETIC CHAIN

Key Breakdowns – Lower

Extremity

1. Trail leg hip abductor weakness

2. Premature forward motion

3. Stride leg foot placement & quality

4. Limited hip ER/IR ROM

5. Too much knee flexion @ ball release

Key Breakdowns – Trunk

1. Timing of pelvis and trunk rotation

2. Decreased forward trunk tilt

3. Weakness in core strength

Key Breakdowns – Upper

Extremity

• Shoulder Abduction varies from 90-100º

• Scapular Muscle Imbalance/Scapular

Dyskinesis

• Increased scapular protraction

• Diminished max ER ROM

• Tightness of posterior capsule &

musculature

ASSESSMENT

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Assessment

• LE & Trunk

– Hip IR/ER ROM

– Hip abductor strength

– Single-leg stance & squat

– Three plane core assessment

• UE

– Glenohumeral ER/IR ROM

– Horizontal Adduction ROM

– Humeral Retroversion

– Scapular Dyskinesis

Hip IR/ER ROM

Laudner et al, AJSM 2010

Hip Abduction MMT

Laudner et al, AJSM 2010

Correct Trunk

Pelvis & Hip

Hip & Knee

SIN

GLE

LE

G S

QU

AT

3 - 5 repetitions

Cro

ssle

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t a

l, A

JS

M 2

011

Three Plane Core Assessment

Sagittal Plane Testing

Evaluates eccentric

strength of abdominals, quads, and hip flexors

Concentric strength of

hip and spine extensors

Frontal Plane

Testing

Evaluates eccentric strength of QL, hip

abductors

Transverse Plane

Testing

Evaluates abdominals, hip rotators, spine

extensors

Kibler et al, Sports Med 2006

• Decreased internal rotation (IR) with

concomitant external rotation (ER) gain

(Bigliani AJSM 1997; Ellenbecker JOSPT 1996)

• Total arc of motion

(IR+ER) similar bilaterally (Borsa MSSE 2006; Ellenbecker MSSE 2002)

Typical Motion Alterations in

Overhead Athletes

Consequences of repetitive

throwing


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Bony Contribution

• Humeral retroversion: angle of the axis of the humeral head in a medial and

posterior direction relative to the axis of the elbow joint (Reagan et al, AJSM 2002; Kronberg et

al, CORR 1990, Gordon et al, JSES 2000)

• At birth = MORE retroverted, diminishes over time (Gordon et al, JSES 2000)

Bony Contribution

• Larger angle of retroversion associated with greater ER motion (Kronberg CORR 1990)

• May be advantageous for achieving max ER and ball velocity

More humeral retroversion

Less humeral retroversion

Pieper AJSM 1998

Glenohumeral Internal Rotation

Deficit (GIRD)

– 15°loss of IR compared

to non-dominant arm

and

– 10°loss of total arc of

motion compared to

non-dominant arm

Association of Limited ROM with

Injury

• Secondary subacromial impingement (Tyler et al, AJSM 2000; Warner et al, AJSM 1990)

• Superior labral lesions (Burkhart et al, Arthroscopy 2003; Huffman et al, AJSM 2006)

• Internal impingement (Myers et al, AJSM 2006; Tyler et al, AJSM 2010)

• Ulnar Collateral Ligament tears(Garrison et al, AJSM 2012)

Passive Rotational ROM

Internal

Rotation ROM

• Internal and External Rotation

• Total Arc of Motion

• Supine

• 90°shoulder abduction

• 90°elbow flexion

• Humerus supported to maintain alignment

• Scapula stabilized at coracoid (Wilk, Sports

Health 2009)

0º

Passive Horizontal Adduction

Laudner, JAT 2006

• Supine

• Begin in 90°shoulder abduction and neutral rotation

• Stabilize scapula at lateral border with downward force

• Move humerustoward midline of

body

0º

Angle created by the end

position of the humerus with respect to 0°horizontal

adduction (vertical dotted line).

(-)(+)

10

True Glenohumeral MotionScapula stabilized

Scapula stabilized

Scapula unstabilized

Scapula unstabilized

Internal Rotation

ROM

Horizontal Adduction

ROM

Clinical Assessment of Humeral

Retroversion

Dominant (right) armMore resting ER

Non-Dominant (left) arm

Normal Scapular Kinematics• During humeral elevation:

– Upward rotation

– External rotation

– Posterior tilt

POSTERIOR TILTUPWARD ROTATION EXTERNAL ROTATION

Normal Scapular Kinematics

• During humeral elevation:– Elevation– Retraction (adduction + ER)

Force Couples at Scapulothoracic Joint

Serratus anterior –

trapezius

Upper trapezius – lower

trapezius

SICK Scapula

• Scapular malposition

• Inferior medial border

prominence

• Coracoid pain &

malposition

• dysKinesis of scapular

movementBurkhart et al, Arthroscopy 2003

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Scapular Examination: Observation

Static resting position:

• Elevation/depression

• ABD/ADD

• Up/downward rot

• Winging

– Med border

– Inferior angle

• Atrophy

Dynamic movement:

• Scapulohumeralrhythm

• Concentric &

eccentric phases

• Repetition

• With load

Scapular Testing/Strengthening

• Trapezius

– Upper

– Middle

– Lower

• Serratus anterior

• Rhomboids

• Latissimus dorsi/teres major

• Levator scapulae

Scapular Assistance Test

Positive test �issue with muscular balance

during scapular upward rotation

1. Unassisted active humeral elevation

– Rate pain

2. Assist scapular upward rotation during active

humeral elevation

– Rate pain

• Positive test = ↓pain

– Implications?

Force Couples at Scapulothoracic Joint

Serratus anterior –

trapezius

Upper trapezius – lower

trapezius

Scapular Retraction Test

1. Resisted elevation (isometric) in

scaption

– Note strength & pain

2. Add manual scapular retraction

– Note strength & pain

• Positive test = ↑strength or ↓pain

– Implications?

Posterior Shoulder Endurance Test (PSET)

• Metronome with verbal cues

• 2% of body weight

• 90 degree arc of motion

• Repetitions to fatigue

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CORRECTIVE EXERCISE TECHNIQUES

Lower Extremity

Lateral Slide Supported SL Squats

Monster Walks

Trunk / Core

Chop Lift

Ellenbecker & Cools BJSM 2010

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Posterior Shoulder Stretching:

Patient AppliedSleeper Stretch (Oyama AT and Sports Healthcare 2010; Laudner JAT

2008)

1 2

3


Patient Applied

Cross-Body Stretch (McClure, JOSPT 2007; Manske, Sports Health, 2010)

Self-applied cross-body, scapula unstabilized

Self-applied cross-body, scapula stabilized


Clinician Applied

Clinician-applied cross-body,

scapula stabilized

Clinician-applied internal rotation,

scapula stabilized

Pectoralis Major

Pectoralis Minor Quadratus Lumborum

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Latissimus Dorsi T-Spine Mobility

Bow & Arrow Circle Stretches

Self-mobilizations

But what if static stretching isn’t

effective?!

Other interventions to consider…

• Hold-relax techniques

• Muscle Energy Techniques

• Soft tissue mobilization

• Massage

• Cross friction massage/Instrument

assisted mobilization

• Assess for altered arthrokinematics

• Joint mobilizations

Muscle Energy Techniques

MET for the Horizontal Abductors

• Parameters of

Application (Moore, JOSPT 2011)

→5 second isometric contraction (Horiz

Abd)

→30 second active

assistive stretch

(Horiz Add)

→3 repetitions total

Improved HA ROM 7±11º

IR ROM 4±5º

Muscle Energy Techniques

• Parameters of

Application • (Moore, JOSPT 2011)

→5 second isometric contraction (ER)

→30 second active assistive stretch (IR)

→3 repetitions total

MET for the External Rotators

Improved HA ROM 5±9º

Soft Tissue Mobilization

• Ischemic compression• Transverse friction massage

• Focused myofascial stretch• Instrument assisted (IASTM)• “Massage” ??

• Reduces pain and sensitivity of trigger points

(Chatchawan, J Bodywork and Mvmt Ther 2005;

Hong, J Musculoskeletal Pain 1993)

• Improves function and ROM (McKechnie, J Sport Sci and Med 2007; Hunter, BJSM 2006;

van den Dolder, Aust J Physio 2003)

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Joint Mobilizations

• Posterior mobilizations directed at posterior

capsule (Manske, Sports Health 2010; Muraki, JOSPT 2011)

• Parameters of Application

– Grades III and IV

– 10 minute treatment

(Manske, Sports Health 2010)

Strengthening / Neuromuscular

Re-Education

• Arm fatigue while pitching is a risk factor

for shoulder and elbow pain in youth baseball pitchers (Lyman et al, MSSE 2001)

Scap

ula

r C

lock

Dynamic Low Row

Mid

Ro

w

Serratus Anterior – Punches

Serratus Anterior – Push Up Plus

Fe

nc

ing

Robbery

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Shoulder Dump (Lawnmower Overhead)

Lawnmower

Eccentrics & Plyometric Deceleration

Sid

ely

ing

ER

Neg

ati

ves

Sidelying Ball Drops

Prone Ball Drops

1 2

3 4

Standing ER Plyos

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IWTYC: “I Would Throw You a

Curveball”

Throw Like A Pro App

• 14 HS baseball players

• Age 16 ± 2 years

• Height 182 ± 8 cm

• Mass 75 ± 11 kg

• No recent UE injury

• Compliant to protocol

– attended 2/3 of sessionsSports Health 2009

Intervention: Clinic (20 weeks)

• UBE warm up

• Theraband

– Rows

– ER & IR at 90-90

– Prone ER

• PHA (“T”s)

• Sidelying ER neg

• Rebounder at 90-90

• Wrist curls

• Rice bucket

• 4 way hip

• Lateral step (80 ft)

• Hamstring curls (bilateral & single

neg)

• Calf raises

Intervention: Field (Weeks 1-10)

• Warm up run

• Theraband

– Rows

– ER & IR at 90-90

– Bicep curls

– Tricep extensions

– Chest press

– Twists

• Power cord

– Squats

– Lateral step

– Backward step

• Calf raises

• Abdominals

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Intervention: Weight Room

(Weeks 11-20)

• Seated rows

• Lat pulls

• Calf raises

• Hamstring curls

• Leg press

• Squats

• Knee extensions

• Abdominals

• Warm up run

• Theraband

– Rows

– ER & IR at 90-90

– Bicep curls

– Tricep extensions

– Twists

• Supine chest press

Results

• Posterior shoulder endurance improved

– Baseline: 30 ± 14 reps

– 4 weeks: 66 ± 26 reps

– 20 weeks: 88 ± 36 reps

California State University, Fresno – Department of Kinesiology

Thank You!

Questions?

Stephanie Moore-Reed, PhD, ATC

Email: [email protected]

fresnostate.box.com/FWATA2015

FWATA 2015 SMoore-Reed

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