Rehabilitation Considerations for the Overhead Athlete
Paige Kensrue, SPT
Overview
My interest in the sports medicine niche of physical therapy came from my personal experiences as a competitive athlete through college. I am particularly interested in the treatment of overhead athletes, as my chosen sport was tennis. Throughout my career I had numerous injuries, but none as debilitating as a shoulder injury. An overhead athlete’s shoulder is their lifeline, allowing them to complete the required motions for their sport successfully.
What It’s All About
Overhead athletes participate in a variety of different sports including baseball, tennis, volleyball, handball, swimming, football, track and field (javelin), etc. Each of these overhead activities require incredibly specific mechanics in order to meet the demands of the motion and of the particular sport. It is essential to understand these mechanics and just how the body is responding to those demands throughout the motion in order for the athlete to be successful. This is always the first step in determining a plan of care for an overhead athlete!
Take a look at a slow-motion depiction of a baseball pitch:
[youtube]http://www.youtube.com/watch?v=jZKvJY6gDfg[/youtube]
Here you can watch a slow-motion replay of professional tennis player Roger Federer’s serve
[youtube]http://www.youtube.com/watch?v=vcjZ5r_YHV0[/youtube]
Also take a look at the slow-motion mechanics of a volleyball spike:
[youtube]http://youtu.be/FMtUqoxfR50[/youtube]
It is very important to be aware of adaptations that occur to various tissues of the body with repetitive overhead motion such as humeral torsion and altered length-tension relationships of the musculature due to development of certain muscles more so than others. One of the most common maladaptations that can occur is that of a SICK scapula, or scapular dyskinesis. SICK is an acronym that stands for the observed poor positioning of the scapula: Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement. Here you can see an individual with observable scapular dyskinesis (can you tell which shoulder is affected?):
[youtube]https://www.youtube.com/watch?v=HRalJc5T_5g[/youtube]Overhead athletes are unique and, therefore, require certain types of interventions to assure successful return to their sport. The therapist should always include a strengthening program for their athlete, but this cannot be your run-of-the-mill program. For overhead athletes, you must include a fatiguing program that works to build the endurance of the muscles of the shoulder the athlete is required to use for hours and hours of play and practice. Also, the eccentric control of the musculature must be on point to prevent maladaptation and subsequent injury. Plyometrics should be incorporated into a strengthening program as well to enhance the neuromuscular stabilization of the joint. The therapist’s plan of care should also include exercises emphasizing proper joint proprioception so that these athletes know where their arms are in space. This allows the athlete’s musculature to fire appropriately and in the correct sequence to maintain normal biomechanical motion. While all of these ideas are great, in the end, we cannot treat the shoulder in isolation! The overhead motion is comprised of a kinetic chain, where power and force are generated first in the lower body and is then transferred through the core and trunk into the shoulder and arm. We must be treating overhead athletes as a whole, recognizing when compensations that start lower affect the shoulder. Once the athlete has progressed through the various stages of rehab, there are helpful return-to-sport programs that have been made specifically for certain sports or sport positions. These can be a great resource to incorporate as the last step in completing your athlete’s rehab.
The Project
I was able to present these ideas in a lecture to the first year students while they were completing the shoulder unit of the Musculoskeletal I course (I had to post the PPT without videos, but the notes under the slides provide a lot of content). The end-goal of my project was to provide the students with a resource they could use in their clinical experiences if they were to have an overhead athlete as a patient. I also wanted to provide the content as an introduction into the specialty of sports medicine for the program. I hope to combine my project with others to build a comprehensive sports medicine resource for students. With the presentation I provided a video demonstration of intervention ideas and a handout to use as a reminder of the important points.
Here is the video:
[vimeo]http://vimeo.com/64255225[/vimeo]My references were listed along with the presentation in case there was any special interest in an article I mentioned or any desire to learn more about this topic. After my presentation, I provided the students and professors with an evaluation to fill out concerning the content, and you can see their comments here. My evidence table was also part of this process in order to ensure I included current evidence-based practice to support these intervention ideas.
Thank You!
A big thank you and shout out to my committee members Mike Essa and Nicole Fox for their guidance and support. Also thank you to Jon Hacke, Mike McMorris and Mike Gross for their valued input and advice. I must also thank Betsy Frederick, Angela Gisselman, and Mike McMorris for their A/V help!
8 Responses to “Rehabilitation Considerations for the Overhead Athlete”
Paige Kensrue
Hey Kendall – Thanks for your interest in my project! It does seem as though we had similar perspectives in our capstones, trying to address the whole person instead of zooming in on one issue and restricting treatment to focus on that one body part or impairment. As to your specific question, I feel as though I only grazed the surface when it comes to looking at the kinetic chain affecting the shoulder girdle. I would think there could be a ton of different compensations that could occur throughout the chain to place increased stress on the glenohumeral and scapulothoracic joints. In addition to weak hip abduction, authors also mentioned limited hip mobility (IR and ER) that can affect overall trunk rotation in the movement. Also, there could be deficits at the ankle (i.e. pronation out the wazoo!) that force the knee into a bad position, that then also affects the hips, etc. I also recently read an article from an elite strength and conditioning coach who works with baseball pitchers and said that solely changing a pitcher’s planting foot position can increase velocity and accuracy. Pretty crazy to think about, but I certainly believe it!
Mike – Thank you so much for your help and feedback throughout the course of completing this project!
Paige
Mike Gross
Paige- Excellent work on your capstone. The vidoes are great- especially liked the one demonstrated scapular dyskinesia. Very nice power point and handouts- great resources. Mike Gross
kendalls
Hey Paige!
I wanted to take some time to comment on your Capstone research because it was very interesting to me! Our projects were kind of similar in that we both looked effects along the kinetic chain that can lead to impairments and hinder proper function, leading to devastating effects down the road if they are not appropriately addressed. I focused more on the lower quarter kinematics associated with limb length inequality, while you provided an excellent review of the upper quarter complaints (and associated lower quarter dysfunction) associated with scapular dyskinesias.
I wanted to compliment you on the quality of all your products! They are excellent tools that I am so glad I am able to add to my toolbox after learning about them through your research. I chose to gear my research towards practicing therapists via a case report publication in JOSPT, but now after seeing your project, I am sort of wishing I had geared my project towards educating our fellow class members!
I was wondering if through your research, you came across any lower quarter impairments that were a kind of “common thread” throughout the studies you looked at, or even if clinically, you have been able to observe any lower quarter trends in dysfuncton that are associated with scapular dyskinesia? I know that core strength and trunk stability are huge components of having healthy biomechanics, but what certain lower quarter components have you been able to take note of that need to be addressed specifically in these athletes? I know you mentioned weakness of the hip abductors in your powerpoint. Were there any other lower extremity kinetic chain deficits that you took note of that were concomitant to scapular dyskinesia? I find this stuff so interesting!!
Again, great job, Paige! Your project was incredibly comprehensive!
Kendall
ekensrue
Hey guys! Thanks for visiting my capstone site and for all the great feedback!
Angela – I would have to say that I was actually very disappointed with the research in terms of it being VERY biased towards baseball. It seems that baseball has gotten the most attention, followed by tennis and then volleyball (hence why those are included in my presentation), but there can be SO much more done for other sports. Like I said in my summary, it is so imperative that as the therapist for these athletes, we understand the mechanics of their motion and the physiological needs for them to compete successfully. I think also, in terms of joint focus, I see a lot of attention on return-to-sport programs for knees (which is super important!) but I also think it would be beneficial to investigate the effectiveness of return-to-sport programs for the shoulder as well due to the nature of repeated overhead motion. Thanks for your interest and for being a great audience member!! ☺
Donna – Great question! I think this is an issue with an athlete no matter what you are treating. I personally was a terrible patient because I wanted to play and be on the court as much as possible. I think the biggest tool we can use to try and help these athletes to remain patient is education. We need to be able to explain to these athletes why we have a progression in place and some of the potential ramifications if they do not adhere. This also depends on the athletes themselves and also the rapport you have with them. Some athletes may just need a real sit-down talk/coach intervention while others do well with an explanation. ***Please note that I am suggesting these from personal experiences and I did not include any research in my presentation specifically addressing psychological factors for these athletes.
Matt – Yes, our projects are very similar, but I think they complement each other very well!! In some of the general athlete shoulder rehabilitation articles (i.e. the ones by Kevin Wilk), I did see information given on taping and the proper use of it. (I purposely did not include any of that information because I knew what your capstone project was about!) I think taping is a great tool to use for athletes with shoulder issues. I would especially think taping could be useful when they are just returning to the court/field in order to reinforce proper scapular positioning. Unfortunately, I do not remember seeing any evidence that specifically addresses scapular taping in terms of return-to-sport. It’s mention was mainly for intervention ideas concerning scapular dyskinesia.
Thanks again guys for your interest! If you have any other questions, please let me know!
-Paige
Matthew Medlin
Paige,
Awesome information! Your topic and mine are very similar and I think combined it gives an excellent glimpse into overhead athletic tools for rehabilitation. I love the great examples you have on protocols and specific parameters for return to sport, etc. In my project I have specific outcome measures utilized for athletes and return to sport and I think we both would agree that OH athletes require specific attention to and utilization of appropriate tools that may be different from normal patients. I see that you mention this in regard to ROM differences that may exist in this population. Overall I think you do an outstanding job here establishing a foundation for the topic at hand and expanding nicely for all experience levels.
Some questions I very much would love to hear what you think include: what type of research did you find on scapular taping, if any, in regards to these rehabilitation considerations and return to sport? Moreover, what do you see as the potential role for taping in this population in general? Specifically, as I found in my research, exercise may not always be effective in some individuals, what do you believe are other options for enhancing rehabilitation in those individuals? Would you consider taping, and scapular taping explicitly, a viable option?
Donna Dean
Hi Paige,
I also wanted to comment on your Capstone since I was able to attend your presentation. To me, the shoulder must be the most complex part of the human body! You certainly made the basic anatomy, biomechanics, and rehabilitation of the should for overhead athletes much more clear. My next clinical rotation is in outpatient ortho where I have been told we will see many sports-related injuries. Previously, any athlete with a shoulder injury/dysfunction would have intimidated me, but after your presentation I feel much more confident.
Your handout is an EXCELLENT supplement to the presentation. I plan on printing it out and bringing it with me on Day 1 of my rotation. I am sure the other therapists will be impressed with the multitude of creative exercises I now have in my toolbox for overhead athletes. The clear progression you presented through different programs will be incredibly helpful.
In your research, did you find that it was often difficult to hold athletes back in the progression? They obviously want to return to sport as soon as possible, were there suggestions or guidance on how to educate and implement a safe progression?
Thank you again for this wonderful presentation, handouts, and videos!
Donna
alauten
Paige,
First of all, what a great web page layout! Secondly, I wanted to respond to your page since I was able to attend your actual presentation. And really, I can only echo all the awesome feedback you got from the 1st year students and those of us in attendance. You clearly have a good grasp on the shoulder, specifically as it relates to the overhead athlete. I think your personal experience (with being a tennis player) adds so much depth to your understanding of these concepts, and it really shows.
I’m super impressed by the amount of information and materials you put together: an 1.5hr live presentation, evidence table, exercise handout AND videos?! Amazing! And within your handout, I think the rehab flow sheet provided by Kibler et al. provides a good foundation for us to treat any overhead athlete (or someone whose job requires a lot of dynamic overhead activity, like a painter for ex).
Given all the information you found (which is a lot), was there anything in your research that kind of left you hanging? Or were you displeased with the amount of research for certain athletes versus others? I’d be interested to know – obviously, baseball is one of the most commonly looked at sports when it comes to the shoulder, but I was just wondering what your feelings were on the matter.
Again, PHENOMENAL job on all your materials and presentation!
nclawler
Hey Paige!
I really enjoyed looking through your Capstone materials! With shoulder issues being so prevalent in outpatient orthopedics, this is a great overview of the desired mechanics of an overhead athlete. Though I am not an overhead athlete myself, I can appreciate the importance of technique in preventing injury and creating the optimal biomechanics to complete a powerful throw, serve or spike.
I think I would have benefitted in musculoskeletal I from the videos you presented. I really liked watching the video of overhead athlete exercises to target the shoulder complex. Thinking back to my outpatient orthopedic rotation, we had several patients who would have benefitted from these exercises, especially those baseball and volleyball players who presented with various issues. The great part about your presentation is that virtually anyone can glean something constructive from it. With most individuals presenting clinically and otherwise with poor posture and poor scapulohumeral rhythm, these exercises would be valuable to the wider population with shoulder, neck and upper thoracic pain or weakness.
Thanks for sharing!!
Natalie