Treatment of Shoulder Injury in the Overhead Athlete

TREATMENT OF SHOULDER INJURIES IN OVERHEAD ATHLETES

Jason Bottoms, SPT

Background

Prior to starting physical therapy school, I worked as a physical therapy tech at a local outpatient orthopedic clinic. We saw a wide variety of patient populations and saw a fair number of athletes – from recreational “weekend warrior” types to Division I football players. Many athletes that played sports requiring frequent overhead striking or throwing had a particular pathology in common – shoulder pain or injury. I saw this pattern replicated in my first clinical rotation at an outpatient clinical in Brevard, NC. These patients were typically over 40 and many played tennis but a few high school baseball and volleyball players also sought treatment through physical therapy. Again, almost all of them were being seen for shoulder pain or post-operatively after shoulder surgery. I enjoyed working with these patients, helping them get back to the activities and sports they enjoyed. However, I also found these patients to be challenging. The shoulder can be a complex joint to treat in any patient and these athletes required a high degree of range of motion, exceptional strength and power, and excellent control throughout the throwing or striking motion.

I decided to use an assignment during a course on evidence based practice to research underlying causes for the injuries I was seeing in the clinic as well as some treatment ideas to safely rehabilitate these challenging patients. I was surprised to find little hard evidence for treatment specific to overhead athletes with various shoulder pathologies. This made me more interested in understanding the pathomechanics of shoulder pain in this patient population as well as the best treatment options to help return these athletes to the sports they love. For my Capstone Project, I developed an evidence table and synthesis summarizing my findings in the literature for prevalence, prevention and treatment of shoulder injury in overhead athletes. I also created a PowerPoint on this topic to be presented during my final clinical rotation in an outpatient orthopedic clinic.

 

Statement of Need/Purpose

Shoulder injury is the most common form of injury in overhead athletes.^1-3 Furthermore, overhead athletes are at a risk for chronic overuse pathologies of the shoulder and mismanagement of these athletes can lead to prolonged disability and further injury.⁴ Therefore, education on injuries and rehabilitation in this patient population is crucial for physical therapists in a variety of settings but particularly in outpatient or sports medicine clinics. Specifically, focusing on ways to prevent serious injury could potentially reduce total rehabilitation time and avoid costly surgery. If injury does occur, understanding the evidence that supports the best rehabilitation strategies can improve outcomes and reduce time away from sport in surgical and non-surgical rehabilitation.

As mentioned above, I was shocked at the paucity of high-quality evidence on intervention efficacy and outcomes for overhead athletes when I conducted an initial search of the literature in fall of 2019. Most of the research I found consisted of either small case studies or expert opinion. Given the complexity of shoulder pain and the high demands on the joint in the overhead athlete, evidenced based guidelines for management of these athletes would be helpful when creating a plan of care and selecting interventions in an outpatient physical therapy setting. To ensure that this topic would be relevant to the therapists at my next clinical rotation, I contacted James Curtis at Carolina Pointe II and discussed my topic with him. He reported that shoulder injury in overhead athletes would be a worthwhile topic for an in-service and could benefit the staff. My hope is that the materials developed for this Capstone project serve as an educational tool for physical therapists and eventually leads to better outcomes for the target patient population.

 

Overview

Overall, the literature is lacking in high-level evidence regarding prevalence, intervention ideas and outcomes for shoulder injuries in overhead athletes. However, rotator cuff tears and labral injuries are among the most commonly cited^6-8 and are the focus of this project. Risk factors for shoulder injury are more widely understood and agreed upon. They are addressed in the project along with recommendations for injury prevention related to these risk factors. Mechanisms of injury, examination techniques, surgical options, and intervention concepts are discussed for both rotator cuff tears and larbal injuries specifically. Finally, gaps in the literature and areas for further research are addressed.

Products

I created three products that comprise my Capstone Project. The first is a summary and synthesis of my research. The second is an evidence table of the articles selected and reviewed for this project with information on purpose, study design, level of evidence and outcomes for each article. The final product is a PowerPoint presentation on my findings that attempts to provide clinically relevant information to other physical therapists and physical therapist assistants on the management of shoulder injuries in the overhead athlete. I plan to present this during my final clinical rotation over the summer. I have incorporated concepts to make my presentation more engaging and effective such as reducing bullets points and lines of text, opting for more images and diagrams. I’ve also interviewed a key consultant to ensure the need for my project, incorporated multiple learning styles and plan to utilize a “motivational hook” at the beginning of my presentation to capture the audience’s attention.⁵

 

Evaluation

I incorporated feedback from my advisor and committee members to advance and improve my project. I sent multiple drafts to my advisor and made edits based on his suggestions. I sent a nearly finalized draft of my project to my committee members and made final adjustments based on their recommendations. The contributions from my advisor and committee members cannot be overstated. They provided a wide range of suggestions ranging from technical formatting changes to tips for improving the visual appearance to identifying gaps in content that could be expanded upon.

Additionally, I created an evaluation form to assess the effectiveness of my presentation. I developed this form based on previous presentation evaluations that I’ve used in the past in combination with concepts on evaluation discussed during PHYT 824. I’ve also incorporated comments from my capstone advisor into the form to make it more visually appealing and easier to follow and fill out. This form will be provided to the audience prior to the presentation during my final clinical rotation this summer. I plan to use the information provided to improve my presentation skills moving forward.

 

Self Reflection

This Capstone project has been a valuable learning opportunity for me. As someone who occasionally struggles with procrastination and staying on task for long-term projects, I have improved my ability to create and follow a timeline with relatively few issues. Along with other courses in my third year of the DPT program, this project has vastly improved my ability to search for peer-reviewed articles and analyze them for risk of bias. I’ve also improved in my ability to find clinically relevant information in the literature and hope that this will translate to utilizing the best available evidence as a clinician in the future. I’ve developed a PowerPoint presentation that I feel is professional and will be an effective tool to educate a group of peers with more experience than me in treating the types of patients I will be discussing. I certainly feel more informed about managing overhead athletes with shoulder injuries backed by a thorough understanding of the pathomechanics of the injury and intervention concepts to help return them to sport.

Looking back for ways to improve upon the process, it would have been ideal to identify a patient for a case study to supplement my research. This would have required more advanced planning and would have needed to start in the early fall of 2019 if not earlier. Perhaps I could develop a case study with a future patient based on the concepts learned during this Capstone project.

Overall, I’m proud of the work that I put into this project. I feel that I have developed three professional products that provide useful information to my peers on a topic that interests me. I’m thankful for this learning opportunity and consider it an excellent way to finish my last semester of full-time academic work before starting my final clinical rotation.

 

Acknowledgements

I would like to thank all of the people involved in guiding, supporting and assisting me throughout this process. Without all of you, this project would not have been possible.

First, I would like to thank my Capstone advisor Mike McMorris. Thank you for your numerous edits and suggestions throughout the process – you were always timely and insightful with your responses. Importantly, thank you for helping me create a realistic timeline back in January and helping me to stick to our key dates throughout this project.

To my committee members Jo Gupta and Jon Hacke, thank you for taking time during your busy schedules to review my project and make useful suggestions. You both added valuable contributions that made my project more professional and more effective as a teaching instrument.

I would also like to send a thank you to the entire UNC DPT faculty for an excellent three years of education and guidance that has molded me into the person and clinician I am today. Furthermore, you all have been incredibly accessible and helpful in dealing with all the changes and uncertainty related to the COVID-19 pandemic. It has made completing this Capstone project and other requirements as easy as possible given the circumstances.

Finally, I’d like to thank my loving wife, Anna who has been a soundboard for many of my thoughts and concerns with the project. She has provided endless love, encouragement and support throughout our relationship and my time in the DPT program.

References

1. Cools AM, Johansson FR, Borms D, et al. Prevention of shoulder injuries in overhead athletes: a science-based approach. Braz J Phys Ther 2015;19:331–9. 10.1590/bjpt-rbf.2014.0109
2. Zaremski JL, Wasser JG, Vincent HK. Mechanisms and treatments for shoulder injuries in overhead throwing athletes. Curr Sports Med Rep. 2017;16(3):179–188. doi: 10.1249/JSR.0000000000000361.
3. Reinold MM, Gill TJ, Wilk KE, Andrews JR. Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes, part 2: injury prevention and treatment. Sports Health. 2010;2:101–115.
4. Menge TJ, Byram IR, Boykin RE, Bushnell BD. Labrum and rotator cuff injuries in the throwing athlete. Phys Sportsmed. 2015 Feb;43(1):65-72. doi: 10.1080/00913847.2015.1005546.
5. Plack M, Driscoll M. Systematic Effective Instruction: Keys to Designing Effective Presentations. In: Teaching and Learning in Physical Therapy: From Classroom to Clinic.; 2011.
6. Lin D, Wong T, Kazam J. Shoulder injuries in the overhead-throwing athlete: epidemiology, mechanisms of injury and imaging findings. Radiology. 2018. Vol. 286, No. 2. https://doi.org/10.1148/radiol.2017170481
7. Edmonds E W, Dengerink D D. Common conditions in the overhead athlete. Am Fam Physician. 2014;89:537–541.
8. Stone MA, Jalali O, Alluir RK, et al. Nonoperative treatment for injuries to the in-season throwing shoulder: a current concepts review with clinical commentary. Int J Sports Phys Ther. 2018 Apr; 13(2): 306–320.

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