Development of a Shoulder Care Program for Overhead Throwing Athletes
Sieara Bishop, SPT
Background:
My passion for preventing injuries in overhead athletes began during my collegiate softball career. I had multiple periods of shoulder pain during my four years and I witnessed almost every one of my teammates experience some level of pain or injury during or after overhand throwing. The mindset among many collegiate softball and baseball players is that shoulder pain is typical, and you manage the pain anyway you can. I remember thinking that their had to be a way to prevent the pain instead of just managing it. I was able to work multiple college softball camps, coach adolescent teams, and instruct lessons where I realized that shoulder pain and injuries were extremely common even at younger ages. I did not think that there was enough being done to educate players, their families, and their coaches on how to prevent shoulder pain and injuries.
Throughout my three years in UNC’s DPT program, I was able to gain a greater understanding for what can be done for this population. I was fortunate enough to work with a few overhead athletes in the clinic. One young baseball player inspired my critically appraised topic on treatment options for those with multidirectional shoulder instability in the Evidence Based Practice II course. I realized that working with these athletes, particularly pediatric athletes, was so meaningful to me. I understood where they were at physically and mentally, and where they needed to go to return to play at a high level. This is where my idea for not just treating but preventing injuries in this population originated from.
Statement of Need:
In America, youth athletic participation is a common pastime. ESPN called youth sports “so big that no one knows quite how big it is”.1 They estimated that 21.5 million kids between the ages of 6 and 17 played team sports.1 A study by the Women’s Sports Foundation found that 75% of boys and 69% of girls from ages 8 to 17 played organized, team sports in 2008.2 With large numbers of children and adolescents participating in sports comes injuries related to their play. However, the real issue comes from the recent transition to early sport specialization for youth athletes. Sports specialization has been defined as year-round, rigorous training for one sport that lasts more than 8 months a year and is at the exclusion of other sports.3,4 The pressure is high for many young athletes to specialize in order to reach their, or their parents, goals of collegiate or professional play. However, early sport specialization has been found to be harmful to young athletes’ physical and mental health and lead to musculoskeletal injuries, burnout and depression.3,4 The American Academy of Pediatrics, the American Orthopedic Society for Sports Medicine, and the American Medical Society for Sports Medicine have all issued policy statements advising against early sport specialization.4 They instead have set recommendations for specialization age, training volume, rest time, and the benefits from having a diverse skillset from multiple sports.4
Youth baseball and softball athletes are particularly at risk for overuse injuries. Shoulder pain is common in the hypercompetitive travel team environments that are found in baseball and softball. The literature has found that the majority (up to 75%) of youth baseball players have baseline pain during or after throwing.5 Baseball pitchers are especially at risk, as overhand pitching is the most common mechanism for shoulder injury.6
There are pitch count, pitch type, and rest recommendations set for baseball pitchers.7 However, studies have shown that 56% of youth coaches are noncompliant with these pitch count recommendations.8 From all the above information, plus my communication with high school, travel ball, and college athletes and coaches, I recognized that there is a great need for prevention in this population. Many coaches I spoke with were interested in keeping their players healthy, they just lacked the information to implement a program like this one. So, my capstone project focused on taking a preventative approach to educate these youth baseball and softball coaches and players by creating a program that would prepare their shoulders for increasingly lengthy and demanding seasons.
Project Overview and Purpose:
The primary purpose of this Capstone project was to create a Shoulder Care Program for overhead athletes from the best available literature. While this program could be used for various other overhead sports such as volleyball, tennis or swimming, it is primarily created from literature based on baseball and softball athletes. This Shoulder Care Program was intended for motivated high school and college-aged athletes, although middle school athletes could still participate with appropriate direction. It can be used as a tool for an individual athlete or for a coach, athletic trainer, or physical therapist that works in a team setting. A portion of the Shoulder Care Program is the Advanced Throwers 10 Exercise Program, created by lead author Kevin Wilk, PT, DPT, FAPTA. He is a well-known physical therapist, researcher, and educator that has generously contributed to sports rehabilitation over the last 30 years. On top of his clinical and educational roles, he also has served as the Rehabilitation Consultant for the Tampa Bay Ray’s baseball team for the last 18 years. Wilk has led a distinguished career and much of his research was used in the creation of this Capstone project. The Advanced Throwers 10 Program by Wilk et al. emphasizes dynamic stabilization, coordination, neuromuscular control, and endurance training in thrower-specific positions.9 It has traditionally been used as a bridge to return to play for overhead throwers that are returning to sport after a shoulder injury.9 However, within this Capstone project it is combined with stretching and plyometric exercises to create an injury prevention program.
This Capstone project was created with two very different audiences and presentations in mind. The first presentation was created for physical therapists. It focuses on evaluating and treating overhead athletes, but it also includes information about the preventative Shoulder Care Program. This presentation will be given during my last clinical rotation as an in-service.
The second presentation was given to a varsity high school softball team and their coaching staff. The presentation included about 15 minutes of lecture on general shoulder care information and then about 20 minutes of active athlete participation as they were led through the Shoulder Care Program. No PowerPoint was used as we were on the field. However, the athletes and coaches were given printed educational materials as well as emailed the pdf versions of the materials after the presentation. My goal was to expand the coaches’ and athletes’ knowledge on general shoulder care information such as throwing mechanics, rest recommendations, and appropriate health care professionals to contact should they suffer a shoulder injury. My hopes are that the athletes and coaches will incorporate this Shoulder Care Program in their training a few times a week in order to strengthen the shoulder and its surrounding musculature.
Products:
- The Shoulder Care Program was designed to be a workout for adolescent baseball and softball players to help prevent shoulder injuries and also to increase throwing velocity. Based on recommendations from the literature and my previous experiences, it is recommended to be used in the pre-season, in-season, or off-season by healthy athletes with no current shoulder pain or injury. It can be used up to 3 days a week, but game days and consecutive days should be avoided. The athletes and coaches were able to try the Shoulder Care Program during the active workout portion of my presentation to ensure they had a full understanding of each exercise.
- The Shoulder Care Information Brochure was designed to be a quick reference guide for athletes, coaches and even parents. It was given to the athletes and coaches during the presentation. It includes a brief description of the Shoulder Care Program, when and why to use it, and other general care information such as pitch count guidelines and tips for preventing injury.
- The “Evaluating and Treating Shoulder Injuries in Overhead Athletes” PowerPoint was designed to be presented to physical therapists as an in-service during my last clinical rotation. It more thoroughly covers physical therapy-related information for this population. The PowerPoints ends with information on prevention and the Shoulder Care Program.
- Lastly, two feedback response forms were created. The first form is a more simplified version that I used for the athletes and coaches during the first presentation. The second form is designed for feedback from the physical therapists that I will present to during my last clinical rotation.
Evaluation:
During the process of creating the above products, I sought feedback from my Capstone advisor and committee members. They were able to give feedback on flow, depth of material, readability, and overall design. I also used multiple family members to ensure that the documents were appropriately readable. Lastly, I lead my sister through the entire Shoulder Care Program to practice demonstrating and using simple, non-medical terminology while instructing. I gained valuable feedback from these steps.
Immediately after giving the presentation to the athletes and their coaches, I had them all fill out the players and coaches feedback form. I plan to give an in-service presentation this summer using the PowerPoint that I created. After giving that presentation, I plan to hand out the clinician feedback forms. This will help me to determine if my objectives were met and if the clinicians felt the presentation and materials were organized and relevant. I believe this is a necessary step to continue improving as a presenter as well.
Self-assessment:
Throughout this entire process, I have improved in many areas of my professional development. I have gained confidence evaluating and treating shoulder injuries in the clinic throughout this process. My literature review allowed me to understand the unique characteristics of this population as well as what characteristics are associated with increased risks of shoulder injury. I also feel prepared to implement a prevention program in the future. I believe that this process and my past experience as an athlete prepares me well to educate players, coaches, parents, and other healthcare professionals on the need for a prevention program such as this one. Additionally, I saw improvements in my abilities to search, sort and synthesize literature. This should serve me well in the future as I may need to create and implement another prevention program or just perform a literature review on a topic I have seen in the clinic. Lastly, I gained experience presenting. It provided another good learning experience for me and will only improve my public speaking skills for the future.
My feedback from the athletes and coaches that I presented to left me with many positives and a few areas for improvement. The main aspect of the presentation that I would modify is to better include the coaches. In a future presentation where coaches are present, I would like to involve them more in the active portion of the workout. I would like to give them the opportunity to coach their team through the Shoulder Care Program and I can clarify information and cue the coaches on how to best instruct their team.
Overall, I am very satisfied with the products I have created. I am pleased that I chose a topic that I am passionate about and that is related to my clinical practice goals in the future. I would love to work with youth and adult athletes in a setting that allows me to not only treat injuries but to prevent injuries as well. Therefore, I believe that this capstone project will serve me well as I start my career as a physical therapist.
Acknowledgements:
I would like to first thank my Capstone advisor, Dr. Michael Gross, PT, PhD, FAPTA. Thanks for your accessibility and quick feedback. Your clinical expertise certainly made you an invaluable part of this team.
I would like to thank my committee members, David Gerrer, PT, COMT, and Dr. Chris Cox, PT, DPT. David, you have been a great mentor for me throughout the last half of this program. Even though you insist that you learn just as much from me as I do from you, I know that is far from true. Thanks for believing in me as a clinician. Chris, thanks for sharing your time with me in the clinic and answering countless questions. I appreciate your willingness to serve as a committee member and your skills as a clinician.
To Dr. Deborah Thorpe, PT, PhD, thanks for all your time and work that went into making this Capstone course a success.
I would also like to thank Dr. Kevin Wilk, PT, DPT, FAPTA and his colleagues for leading the way in the rehabilitation of many sports injuries over the last 30 years. Much of their work was read, appraised, and included in the creation of this Capstone project.
Lastly, I would like to thank all those closest to me for their support throughout the Capstone project. Your time and feedback were greatly appreciated. Also, thank you for your constant encouragement and patience throughout my journey through physical therapy school.
Reference List:
- Kelley B, Carchia C. Hey, data data – swing! http://www.espn.com/espn/story/_/id/9469252/hidden-demographics-youth-sports-espn-magazine. Published July 11, 2013. Accessed April 2, 2019.
- Sabo D, Veliz P. Go Out and Play: Youth Sports in America. Women’s Sports Foundation. East Meadow, NY: 2008.
- Myer GD, Jayanthi N, Difiori JP, et al. Sport specialization, part I: does early sports specialization increase negative outcomes and reduce the opportunity for success in young athletes? Sports Health 2015;7(5):437-442. doi:10.1177/1941738115598747.
- Pasulka J, Jayanthi N, McCann A, Dugas LR, LaBella C. Specialization patterns across various youth sports and relationship to injury risk. Sportsmed. 2017;45(3):344-352. doi:10.1080/00913847.2017.1313077.
- Makhni EC, Morrow ZS, Luchetti TJ, et al. Arm pain in youth baseball players: a survey of healthy players. J. Sports Med. 2015;43(1):41-46. doi:10.1177/0363546514555506.
- Zaremski JL, Krabak BJ. Shoulder injuries in the skeletally immature baseball pitcher and recommendations for the prevention of injury. PM R 2012;4(7):509-516. doi:10.1016/j.pmrj.2012.04.005.
- Pitch Smart- Guidelines for Youth and Adolescent Pitchers. Major League Baseball. https://www.mlb.com/pitch-smart/pitching-guidelines. Accessed April 2, 2019.
- Knapik DM, Continenza SM, Hoffman K, Gilmore A. Youth baseball coach awareness of pitch count guidelines and overuse throwing injuries remains deficient. J Pediatr Orthop doi:10.1097/BPO.0000000000001244.
- Wilk KE, Yenchak AJ, Arrigo CA, Andrews JR. The Advanced Throwers Ten Exercise Program: a new exercise series for enhanced dynamic shoulder control in the overhead throwing athlete. Sportsmed. 2011;39(4):90-97. doi:10.3810/psm.2011.11.1943.
Note: The full citations of references used in the Shoulder Care Program and Brochure were left out for the sake of brevity as the materials are intended for athletes and their coaches. The citations can be found here:
Wilk KE, Yenchak AJ, Arrigo CA, Andrews JR. The Advanced Throwers Ten Exercise Program: a new exercise series for enhanced dynamic shoulder control in the overhead throwing athlete. Phys. Sportsmed. 2011;39(4):90-97. doi:10.3810/psm.2011.11.1943.
Wilk KE, Arrigo CA, Hooks TR, Andrews JR. Rehabilitation of the overhead throwing athlete: there is more to it than just external rotation/internal rotation strengthening. PM R 2016;8(3 Suppl):S78-90. doi:10.1016/j.pmrj.2015.12.005.
5 Responses to “Development of a Shoulder Care Program for Overhead Throwing Athletes”
Lukas Sand
Hey Sieara!
Fantastic work on this capstone project. Given your background in softball, this seemed like it would be something you would excel at, and you did exactly that! As an ex-pitcher that blew out his shoulder, I would have really appreciated if I had been exposed to this program during my baseball career. I think that you did a very good job of incorporating evidence, personal experience, and academic material into your capstone. You were very detailed, as well, and this is why I think you will be a fantastic physical therapist!
With regards to content, I thought I was awesome that you included the throwers 10 program into your project. We used this in my undergraduate athletic training curriculum when working with the baseball team, and it was extremely effective for addressing post-shoulder injury strengthening. I will say, however, that I had never considered an advanced throwers 10 program! Great work incorporating this into your project!
Finally, it was incredible to see that you discussed a pitch-count for youth baseball players. In today’s youth sports and the problem with overbearing parents and coaches, pitch counts are so crucial to shoulder health. I hope that your presentation and capstone is something that is shared across western North Carolina to ensure that children and adolescents aren’t being put at risk of shoulder problems.
Again, congrats on producing an incredible capstone! I am excited to see where your future as a physical therapist leads you!
Debbie Thorpe
Sierra
Great job on this capstone project! I too was softball player in college..pitcher. Lucky to never have shoulder problems but it is a HUGE problem in surprisingly very young athletes. Your products are very well done, professional and informative. Great addition to resources for coaches, families and PTs!
sieara
Ashley,
Thanks so much for your feedback! I definitely enjoyed creating this material. There are a few ways to progress this program. The most basic way that I have taught to the players and coaches so far is to simply increase the duration by adding additional sets (up to 3) for each Advanced Throwers 10 exercise. I advise the athletes to start by going through each exercise only once, assess how their body responds, and to progress from there. Once an athlete has progressed to 3 sets each of the Advanced Throwers 10 exercises, I suggest that they progressively add weight to each component. This could be as simple as going from no weight to a 1lb weight, and so on. I’ve completed the workout with 3lb weights, and it is surprisingly challenging. So, I advise that the athletes work up to the full workout duration, and then progressively add weight up to 3-5lbs. This Shoulder Care Program incorporates endurance training so weights above ~5lbs are not encouraged. By starting low and progressively loading the athlete, excessive soreness should be avoided while still strengthening the shoulder unit.
This program is created to be performed during any season of play (in, out, or pre-season). I did include some guidelines for the athletes and coaches to follow if they are following this program in season as far as no game days, no consecutive days, and up to 3 days a week.
Ideally, this program would be initially taught to the athletes and coaches by a physical therapist. However, a physical therapist assistant or possibly an athletic trainer who has some knowledge of correct form would be acceptable. When I presented to the athletes and coaches, I made sure to emphasize proper technique and point out any common mistakes as the athletes worked through the program. One of my goals was that after my presentation, the coaches would feel comfortable correcting any obvious errors during the exercises. This is also a program that a motivated high school or college athlete may use independently so I really focused on making sure the athlete could perform each exercise correctly and that they had access to appropriate videos to review for each exercise. This way if they forgot some component of the exercise, then they have the Shoulder Care Program document with pictures, verbal explanations, and hyperlinks to videos to review. There will inevitably be some athletes who struggle more with this program as it requires a certain amount of neuromuscular control, strength, and proprioceptive awareness. However, it is geared towards higher level athletes. Therefore, they likely have established some level of ability to replicate an exercise when given visual and verbal direction.
Rachel,
Thank you! The three products can be accessed at https://issuu.com/siearabishop. Additionally, anyone can feel free to email me at sieara_bishop@med.unc.edu for the pdf files directly. They were too large to hyperlink directly on this site without the use of Sakai.
Rachel Earnhardt
Sieara,
Wonderful capstone project! As being a former overhead athlete and battling shoulder injuries myself, there is such a large need for preventative measures. College athletes get hundreds of repetitions through practice with little focus on shoulder care and injury prevention. And by that time of their career, there is already extensive wear and tear through use and lack of preventative care. In your shoulder care program, it was extremely helpful to have pictures of all of the exercises given as a tool to look back on and mimic. It is sometimes hard to describe exercises through description, so the pictures were nice. The pamphlet you prepared on shoulder care information for softball and baseball players was also great. It had good aesthetics, was easy to follow, and was very informative. Lastly, the PowerPoint you created was very well put together. I knew exactly what you were attempting to present and it had good flow/clear breaks in topics. I think this would be a wonderful project to share with the community and would actually like to send it to my old coach at Davidson to use with the current athletes. Would you consider making the handouts accessible for people outside of the program? When clicking on the links, it had me sign into Sakai to view the material, so I am unsure if people without a log-in could see it. Thanks for your information and I’m sure your last clinical is going to benefit from your presentation!
ashley3
Sieara,
Excellent job on your Capstone project! I really enjoyed reading through your capstone and thought that the resources you created were very useful and helpful. I was particularly interested in your project as I played softball for many years, including middle school, high school, and travel ball. I had many teammates over the years who suffered from shoulder injuries, and I had always wondered if there was a program that could help prevent these common injuries from occurring. Your passion and enthusiasm for working with these athletes and helping create a program to prevent shoulder injuries was evident in your project. This capstone project was a great way for you to do research on a topic that you are passionate about and develop your clinical practice goals. Your project provides an evidence based, applicable, and practical intervention program to improve the safety of overhead athletes that you have such a passion and desire for serving.
I thought your shoulder care program handout was very easy to read and follow, which will be beneficial for clinicians and coaches to use. Your brochure also was neatly organized and simple to read making it very useful for athletes and coaches to use in the future. I also thought you did a great job on your PowerPoint presentation as you incorporated a lot of high quality research evidence to support your program. I thought you did a great job explaining what a typical evaluation sequence would be for these athletes, as this will help future clinicians have a simple guide to follow. I also thought that it was very beneficial how you described each phase of the rehabilitation program including goals and treatment focus. This was helpful to understand the point of each phase and how they each contribute to helping an athlete return to play. One question that I had is would you want the athletes to progress this program as they become skilled and able to complete it without any trouble or is this program meant to be performed just as it is during all seasons of play? Also, with this program who would be teaching the coaches how to perform the exercises/stretches correctly and how to monitor that the athletes are doing it correctly? I figured it would be vital for them to also know proper cues and correct techniques, so that the athletes are performing everything correctly and benefiting from the program. Overall, I thought you did a great job on this project, and it will definitely be beneficial for overhead athletes to use in the future to prevent injuries!