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2/7/2017 www.prismsports.org PRiSM Presents: Management of Adolescent Shoulder Instability 7 February 2017 VuMedi Webinar Moderator: Matthew R. Schmitz, M.D. Pediatric Sports Medicine and Young Adult Hip Preservation San Antonio Military Medical Center www.prismsports.org Carlin Senter, MD, FACP • Associate Professor • Primary Care Sports Medicine • University of California San Francisco • Co-Director UCSF Sports Concussion Program • Head Team Physician SF Deltas www.prismsports.org Dele Kammen, MD • Pediatric Radiologist • UCSF Benioff Children’s Oakland • Harvard Medical School • UPenn Radiology Resiency • UCSF Peds Radiology Fellowship 1 2/7/2017 Michelle Cappello, PT, MSPT, SCS www.prismsports.org • Masters in PT from Boston University • Board Certified Sports Clinical Specialist • American Physical Therapy Association • Soccer player, coach, mom www.prismsports.org Dr Nirav K. Pandya • Assistant Professor, Orthopaedic Surgery, UCSF • Director of Pediatric Sports Medicine, UCSF Benioff Childrens’ Hospitals • Undergrad: Univ of Chicago • Med School: Univ of Chicago • Residency: Penn • Fellowship: Rady Children’s San Diego www.prismsports.org Brett Burton – Bio • Education: – University of Nebraska-Lincoln (Athletic Training) – University of Nebraska Medical Center (Physical Therapy) – St. Luke’s Sports Medicine (Physical Therapy Residency) • Experience: – Worked closely with the University of Nebraska Baseball Team – Trained at the Andrews Institute, Athletes’ Performance (currently EXOS), and the Mayo Clinic – Currently serves as physical therapist at Northwest Nazarene University and treats several adolescent patients in outpatient clinical setting at St. Luke’s Rehab in Idaho 2 2/7/2017 PRiSM is a multidisciplinary society focused on research in pediatric sports medicine. Features of PRiSM membership: • Guiding new research by joining a Research Interest Group • Leadership development through board and committee participation • Registration discounts to the Annual Meeting • Access to Clinical Orthopaedics and Related Research, PRiSM's official journal 3 2/7/2017 www.prismsports.org Adolescent Shoulder Instability: Patient Presentation Carlin Senter, MD Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthopaedics February 7, 2017 Epidemiology www.prismsports.org • Shoulder is most commonly dislocated joint in the body – 1-2% of the population • 90-95% of shoulder dislocations are anterior • 20% of shoulder dislocations occur in patients under 20 years of age. • Mechanism = fall on outstretched arm or collision, especially when arm is abducted and externally rotated www.prismsports.org Shoulder anatomy: Bony stability 1 2/7/2017 www.prismsports.org Injured structures • Anterior dislocation – Failure of anterior inferior glenohumeral ligaments – +/- axillary nerve injury https://posna.org/Physician-Education/Study-Guide/Shoulder-Dislocation-Instability. Accessed January 29, 2017. www.prismsports.org • • • • Traumatic Instability T – Traumatic U – Unidirectional B – Bankart Lesion S – Surgical Multidirectional Instability www.prismsports.org • • • • • A – Atraumatic M – Multidirectional B – Bilateral R - Rehab, rehab, rehab I – Inferior Capsular Shift 2 2/7/2017 Shoulder dislocation: History www.prismsports.org • Trauma vs atraumatic • Past history of dislocation or subluxation • Age at time of first dislocation www.prismsports.org Anterior shoulder dislocation: Acute exam • Athlete will use other arm to hold affected arm • Flat appearance of deltoid • Humeral head palpable anteriorly, below coracoid • Neurovascular status – Axillary nerve in particular • Sensation lateral shoulder • Contraction deltoid muscle www.prismsports.org • • • • Anterior shoulder dislocation: Full exam Inspection Palpation Range of Motion Neurovascular 3 2/7/2017 www.prismsports.org Anterior shoulder dislocation: Special tests • Load and shift – Patient supine – Shoulder abducted 45 degrees in plane of scapula, 30 degrees of flexion, neutral rotation – Axial force with examining hand centering humeral head in glenoid fossa – Other hand applies anterior force to check translation www.prismsports.org Anterior shoulder dislocation: Special tests • Apprehension test – Patient is supine – Affected arm in abduction, extension and external rotation – Apply gentle anterior translation on proximal humerus apprehension • Relocation test – Apply posteriorly directed force instability is relieved www.prismsports.org Instability: Sulcus Sign • Inferior instability • Arm relaxed in neutral position • Arm pulled downward at elbow • Positive test is a visible sulcus at infra-acromial area – Compare to contralateral side 4 2/7/2017 www.prismsports.org Anterior shoulder dislocation, recurrent • Beighton score for joint hypermobility – Passively dorsiflex 5th MCP joint by at least 90° – Oppose thumb to the volar aspect of the ipsilateral forearm – Hyperextend elbow by at least 10° – Hyperextend kne by at least 10° – Place hands flat on floor without bending knees • 1 point for each maneauver (R and L side) • 4 or more points generalized joint hypermobility www.prismsports.org Thank you! 5 1 Imaging of Glenohumeral Instability in the Adolescent Patient Dele Kammen MD bkammen@mail.cho.org Department of Diagnostic Imaging 2/7/17 2 Disclosure Advisory Board on Hypophosphatasia Alexion Pharmaceuticals, Inc. 3 Goals Imaging acute traumatic shoulder dislocation Imaging chronic instability with repeated dislocation Diagnostic Imaging Characterize extent of structural damage Show osseous and soft tissue abnormalities Guide surgical planning Choice of stabilization procedure 1 4 Imaging Modalities Radiographs MRI MR arthrography • • Direct Indirect CT 5 Radiographs Obtained following acute dislocation Routine series • • • AP internal and external rotation Scapular Y view Axillary view Post-reduction films • • Evaluate for fractures Residual malalignment 6 Radiographs Patient 2 Patient 1 External Rotation Internal Rotation Hills-Sachs Y-view External Rotation Y-view Bankart 2 7 MRI Conventional MRI Axial T2 FS Acute setting • Joint effusion or hemarthrosis • MR arthrogram not necessary • Mechanism evident by edema pattern s 8 Standard MRI Technique 3T Axial Sagittal Coronal T2 FS T2 FS T2 FS PD T2 T1 TE/TR T2 60/3000 PD 30/3000 T1 15/600 9 14 year old football player with 5 repeated traumatic dislocations Axial T2 FS Axial PD 3 10 14 year old football player with 5 repeated traumatic dislocations Sagittal T2 FS Sagittal T2 11 14 year old football player with 5 repeated traumatic dislocations Coronal T2 FS Coronal PD Osseous Bankart SLAP tear Rotator cuff tendinosis 12 Glenohumeral Joint Anatomy Like a golf ball on a tee The greatest range of motion of any joint Vulnerable to instability Dynamic and static stabilizers 4 13 Stabilizers of the Glenohumeral Joint Supraspinatus Biceps tendon SGHL MGHL Infraspinatus Glenoid and Labrum Teres minor IGHL Subscapularis 14 Inferior labroligamentous Injuries • Bankart • Perthes • ALPSA • GLAD • Floating • HAGL • BHAGL Glenoid Failure Humeral Failure 75% 15% Humeral and Glenoid Failure Capsular Failure AIGHL • Tear • Sprain 15 Patient with prior anterior shoulder dislocation MR Arthrogram T1 FS Courtesy of Dr. Diego Jaramillo, Miami Children’s Hospital Humeral Avulsion Glenohumeral Ligament HAGL 5 16 Capsulo-Labral Lesions Lesion Normal Soft Tissue Bankart Osseous Bankart Perthes Anterior Labroligamentous Periosteal Sleeve Avulsion ALPSA GlenoLabral Articular Disruption Periosteum Normal Stripped and Torn Torn Stripped Stripped Mildly Stripped Labrum Normal Displaced Displaced Nondisplaced Medially Displaced Nondisplaced GLAD 17 17 year old female with 5 episodes of anterior shoulder dislocation • Axial T2 FS • Axial T2 18 17 year old female with 5 episodes of anterior shoulder dislocation • Axial T2 FS • Axial T2 Anterior Labroligamentous Periosteal Sleeve Avulsion ALPSA 6 19 17 year old football player s/p several traumatic dislocations Axial T2 FS 20 Axial T2 FS 21 Axial T2 FS GlenoLabral Articular Disruption GLAD 7 22 MR Arthrogram Direct Indirect Arthrogram with dilute gadolinium solution IV injection of gadolinium Joint Distension Does not distend joint Provocative positioning maneuvers ABduction External Rotation (ABER) 23 Abduction External Rotation (ABER) Place anterior band of IGHL under tension Labral tear at attachment site of IGHL Outlines undersurface of Infraspinatus tendon 24 Pre-operative Planning MDCT or MRI with volume rendering • Quantify Glenoid deficiency • Measure Hills-Sachs 8 25 16 year old girl with shoulder instability and multiple dislocations Axial T2 FS Sagittal T2 FS Coronal T2 FS 26 The American Journal of Sports Medicine, Vol. 39, No. 11, 2011 DOI: 10.1177/0363546511398644 Engaging Hills-Sachs vs nonengaging • • More horizontally oriented to shaft 26˚vs 14˚ Engaging lesions - larger width and depth 27 No gold standard for quantification of Hill-Sachs defects Classifications based on size, depth, location No correlation between various classifications No treatment algorithm based on classifications 9 28 16 year old who experienced his first shoulder dislocation 1 year prior while playing football and has had multiple dislocations since. Courtesy of Dr. Mimi Lin, Washington Radiologist Medical Group 29 Critical Area for Glenoid Deficiency is 25% Defect greater than 25% glenoid width would need bone grafting (Burkhart, De Beer) Normal Glenoid Significant Bone Loss Burkhart SS, Debeer JF, Tehrany AM, et al (2002) Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy 18:488-491. 30 Contact area of humerus on glenoid = glenoid track for critical ROM Width of track is 84% glenoid width Bankart lesions decreases width of tract If medial margin of Hills-Sachs defect is more medial than glenoid tract, standard stabilization are unlikely to stabilize the shoulder 10 31 Goal Assess reproducibility of characterizing bipolar bone loss and treatment • • Method 71 patients with anterior inferior shoulder instability 4 Reviewers Good agreement between 4 observers about % glenoid bone loss Poor agreement assessing Hills-Sachs defect Poor reliability of the glenoid track classification 32 Summary In the acute setting radiographs MRI and MR arthrography • Osseous and soft tissue abnormalities CT and MRI with 3D reformations • Characterize and measure glenoid deficiency and Hill-Sachs lesions for preoperative planning 33 Imaging of Glenohumeral Instability in the Adolescent Patient THANK YOU!!! 11 2/7/2017 www.prismsports.org Traumatic Anterior Shoulder Instability: Rehabilitation Through Return to Play Michelle Cappello, PT, MSPT, SCS USCF Benioff Children’s Hospitals Sports Medicine Center for Young Athletes February 7th, 2017 www.prismsports.org Objectives • Review conservative management for primary TASI • Review evidence based return to sport criteria for traumatic anterior shoulder instability (TASI) www.prismsports.org Traumatic Anterior Shoulder Instability (TASI) • Treatment of first time traumatic GH dislocators will be different from that of a patient with atraumatic instability. Micro vs. Macro • A gradual graded advancement of ROM and exercise progression will be required, based on the degree of the acute injury • Goals remain the same; dynamically stabilize the inherently unstable glenohumeral joint. • Master the “Thrower’s Paradox”; Shoulder loose enough to throw yet stable enough to prevent injury (Wilk AJSM 2002) 1 2/7/2017 Rehabilitation Overview www.prismsports.org • • • • • • Reduce acute pain & inflammation Restore motion and soft tissue mobility Emphasize strength balance Enhance dynamic humeral head control Integrate kinetic chain Return to Sports Specific Activity/PLF TASI Goals of Rehab www.prismsports.org OUTCOME MEASURES • Patient Reported • Shoulder ROM • Movement Segment Strength • Functional Testing: Ybalance, SL squat, CKCUET, OH Squat, Seated shot put • Sports Specific training to competition Rehabilitation Timeline www.prismsports.org Sling Brace PT Day 3-4 Injury Acute Phase DX Specific Initiate Return to Sport Testing 2 weeks Intermediate Phase 4 weeks Advanced Strengthening Phase Pain Management >> Functional Progression 8 weeks + Return to Play Athlete Specific 2 2/7/2017 Acute Phase www.prismsports.org Goals: Protect the injured, healing capsular & labral structures 1. Abstain from Sport 2+ weeks (control stresses) – Sling for comfort, no evidence on duration, inconclusive ER vs. IR of shoulder position 2. Diminish pain & inflammation 3. Reestablish pain –free ROM, Do not push range 4. Delay muscle atrophy & reestablish voluntary muscle activity Intermediate Phase www.prismsports.org Goals: 1. Improve strength 1. 2. 3. Rotator cuff anterior and posterior Scapular “stabilizers” – incl. serratus anterior Core for energy transfer 2. Normalization of shoulder girdle motion and arthorkinematics, manual therapy for tissue mobility 3. Enhancing dynamic stabilization of cuff and scapular muscles & neuromuscular control with upper extremity activities – – BALANCE net force ant/post/distraction of humoral head 3-4% decrease in RTC strength results in loss of dynamic stability (Reinhold, Sports Health 2010) www.prismsports.org The Adolescent Shoulder: Linking development into the plan of care CORE: • Group of muscles that form a cylinder around your waist TA,RA, IO, EO Paraspinals Diaphragm Pelvic Floor Hip Muscles Thoracolumbar Fascia • Optimum production, transfer, and control of force delivered to the terminal segment • Core provides 65% force production, 85% force attenuation • Glut Max 100% MVIC stride to late cocking phase, Glut Med 40% • Poor Single leg squat associated with posterior chain weakness which is underdeveloped in pre/adolescents (Wilk PMR 2016) Oliver JSCR 2010 & 2015 3 2/7/2017 www.prismsports.org The Adolescent Shoulder: Linking Core into the plan of care The Adolescent Shoulder: Linking UE & LE www.prismsports.org www.prismsports.org The Adolescent Shoulder: Exercises Examples Linking UE & LE 4 2/7/2017 www.prismsports.org Advanced Strengthening Phase Goal: improve strength, power, endurance, MOTOR CONTROL, enhance dynamic stabilizers of the GH joint and Scapula. www.prismsports.org Stabilization • Rapid torque control progressing into 90/90 shoulder position • Closed Kinetic chain for proprioception training www.prismsports.org Return to Play Phase Goal: Athletes need to be resilient, strong, technically proficient to robustly maintain proper motor skill competence within the demands of their sport OUTCOME MEASURES • Patient Reported • Shoulder ROM • Movement Segment Strength • Functional Testing 5 2/7/2017 Criteria for Return to Play www.prismsports.org 1. Patient Reported Outcome Measures • Quick Dash • • • developed by Amer. Society of Ortho Surgeons 11 questions, 4 additional with sports activity module goal is < 5 Best possible score = 0 • Kerlan -Jobe Orthopedic Shoulder and Elbow Score Alberta AJSM 2010 • KJOC > 90% (best possible = 100%) www.prismsports.org Criteria for Return to Play 2. ROM Shoulder & Posture & Stability Testing • Demonstrate pain free range of motion with Active shoulder total arc of motion within 5 degrees of non-throwing side Wilk AJSM 2002. Manske & Ellenbecker IJSM 2005 • Passive shoulder flexion within 5 degrees of non-throwing side Wilk AJSM 2014 • Scapular anterior tilt symmetry within 10 degrees of non-dominant side to decrease scapular dyskinesia. Kibler et al. JShouderElbow Surg 2002 • Active internal rotation deficit no greater than 20 degrees of non-throwing side Meister , Keith, et al. AJSM 2005 • Thoracic Kyphosis – no real studies on posture, adult norms = 40°kyphosis • Demonstrate negative results for shoulder stability with no pain for the Glenohumeral anterior and posterior drawer with arm elevated to 90 degrees in scapular plane Sportsfisio 2015 Kevin Wilk, “Return to Play Criteria for the Overhead Athlete.” www.prismsports.org Criteria for Return to Play 3. Strength • Dominant side 10% stronger • Scapular dynamic stabilizers – Endurance test • Gluteals included • Isokinetic Strength Testing (to be performed before and after functional testing. Ratio demands remain the same for both pre and post fatigue) Ratios for isokinetic strength testing from Wilk et al: AJSM ’93, ‘95 • • • • External Rotation/Internal Rotation ratio 70-76% External Rotation/Body Weight ratio 18-23% Internal Rotation/Body Weight ratio 26-32% Isometric scapular strength for mid trap and lower trapezius within 10% of nonthrowing / dominant side • Gluteals: Limited studies out there talking about expected/normative strength for hip musculature. In our practice, we set a goal of 1/3rd the body weight with HHD 6 2/7/2017 www.prismsports.org Criteria for Return to Play 4. Functional Testing These are the ones we use regularly. • CKCUEST – Place tape 36” apart with arms in push up position (hands/toes). Tap across each tape alternately many times as they can in 15 sec. Repeat 3 trials and take average them. >23 touches in 15 seconds BMC musculoskeletal disorders 2014: • LE Y balance: Composite score > 92% (Baseball Players Diagnosed With Ulnar Collateral Ligament Tears Demonstrate Decreased Balance Compared to Healthy Controls, J. Craig Garrison et al, JOSPT, Oct 2013) www.prismsports.org Criteria for Return to Play 4. Functional Testing (cont.) • Perform maximum effort 2 handed chest passes with 8 lb. medicine ball 2 x 20 Sportsfisio 2015 Kevin Wilk • Perform maximum effort 1 handed “shot-put” throw with 4 lb. medicine ball 2 x 20 (just need to complete without pain/instability) • Prone Y endurance test for scapular stabilizers • Tests fatigue in middle and lower traps. • Testing performed with 3% of body weight. Metronome set to 60Hz. • Task failure was defined as: 1. Unable to keep up with metronome, 2. Demonstration of compensatory strategies, 3. Inability to go above horizontal each time. • Only norms available on Football players (26-28 repetitions). • For OH athlete I would aim for 10% better on dominant side Pontillo, Marisa, Bryan A. Spinelli, and Brian J. Sennett. "Prediction of in-season shoulder injury from preseason testing in division I collegiate football players." Sports Health: A Multidisciplinary Approach (2014): 1941738114523239 www.prismsports.org Criteria for Return to Play 5. Return to Sports • Begin a specified return to throwing program for throwing athletes • Work with a sports specific skills coach • Build intensity and volume, as well as impact • Single sports specific task, then add complexities and reactive drills • Start with non-contact practice • Full practice for 2 full weeks • Competition 7 2/7/2017 www.prismsports.org Summary 1. Return to sports after a shoulder dislocation involves many factors 2. There are ideal criteria that give some guidelines for when to return the athlete to play, this will be athlete specific, more research need for proven battery of outcome measures. 3. Timelines for return to play will be athlete specific, and only should occur after attainment of full strength, motion, stability, and confidence. 4. Fatigue is above all the biggest injury risk, train for dynamic stability / postural endurance then power/speed 5. Core/Legs provide >65% of power/torque to the UE – “Train the Chain” 8 2/3/2017 www.prismsports.org Operative Management of Adolescent Shoulder Instability: Keys for Success Dr. Nirav K. Pandya Assistant Professor of Orthopaedic Surgery Director of Pediatric Sports Medicine University of California San Francisco Nirav.Pandya@ucsf.edu www.prismsports.org Disclosures Consultant - Orthopediatrics Common Scenario www.prismsports.org “So I heard you are the person who is going to make my shoulder normal again?” “Can I go back and play 6 weeks after surgery?” “I will never dislocate out again right?” “Are you going to do the surgery with a laser?” 1 2/3/2017 Common Scenario www.prismsports.org Key Point www.prismsports.org Studies cite up to a 30% re-dislocation rate with arthroscopic treatment in this age group PREPARE PATIENTS EARLY Key H and P www.prismsports.org • Sport: collision vs. non-collision • Sport: throwing / swimming • Hand dominance • Number of prior dislocations • Force needed to dislocate and re-locate • In-season vs. out-of-season • Ligamentous laxity • Expectations 2 2/3/2017 Key H and P www.prismsports.org Remember to differentiate atraumatic instability from traumatic instability www.prismsports.org What Can I Do? Open vs. Arthroscopic www.prismsports.org How Do I Decide? It’s not just about throwing some anchors in and fixing the labrum! 3 2/3/2017 How Do I Decide? www.prismsports.org • I am searching for evidence that I need to do more than just an arthroscopic labral repair • History = collision sports, number of dislocations, compliance? • Imaging!!! www.prismsports.org What’s In My Tool Box? • Arthroscopic labral repair • Arthroscopic remplissage • Open labral repair • Open Latarjet www.prismsports.org Pearl #1 Collision athlete / extreme athlete = consider open repair 4 2/3/2017 www.prismsports.org Pearl #2 On – Track vs. Off – Track Pearl #2 www.prismsports.org Engaging Hill Sach’s => Remplissage www.prismsports.org Pearl #3 Glenoid Bone Loss > 25% = Open Latarjet 5 2/3/2017 www.prismsports.org • • • • What’s In My Tool Box? Arthroscopic labral repair • • • Arthroscopic remplissage Engaging / off-track Hill-Sach’s Open labral repair Collision / extreme athlete Open Latarjet > 25% bone loss www.prismsports.org • • • • • • Labral Repair Keys Beach chair vs. lateral Mobilize labrum! Knotless vs. standard (dealer’s choice) Get down low (5:30 – 6:00 o’clock) Grab capsule AND labrum AND advance tissue Don’t be an anchor animal (space out) www.prismsports.org Remplissage Keys • Engaging / Off-Track • Prepare bed • Pass sutures before performing anterior stabilization 6 2/3/2017 Post-Op www.prismsports.org • Not worried about stiffness • Worried about compliance!! www.prismsports.org What’s The Data?? • 17 studies comprising 654 total shoulder instability events • Patients grouped non-operative vs operative treatment • Primary non-operative group was more likely to have recurrence compared to the primary operative group (OR=13.41; 99% CI 3.60 to 49.93, p<0.001) • The rate of recurrence in patients aged <14 years was high (44.44%) • For RTP, there is evidence that RTP rates were higher for primary operative patients (95.3%) versus primary non-operative (41.3%, Z=6.12, p<0.001) and secondary operative patients (77.6%, Z=2.66, p=0.008). www.prismsports.org What’s The Data?? • 21% re-dislocation rate • 18.75% re-dislocation rate 7 2/3/2017 www.prismsports.org What’s The Data?? • 25% re-dislocation rate www.prismsports.org • • • • What’s The Data?? 6 studies, 167 patients 5.4 % re-dislocation rate Low complication rate No significant loss of shoulder motion www.prismsports.org Key Summary • High repeat dislocation rate in this population • Assess activity level and expectations • Know your tools: arthroscopic, open, remplissage, Latarjet • Engaging / off-track = remplissage; glenoid loss > 25% = Latarjet • Start low, shift capsule-labrum arthroscopically • Be prepared to do a remplissage if necessary • Post-op = compliance, compliance, compliance 8 2/3/2017 www.prismsports.org Thank You 9 2/7/2017 www.prismsports.org Postoperative Management and Return to Play for Adolescent Shoulder Instability Brett Burton, PT, DPT, SCS, ATC, CSCS St. Luke’s Sports Medicine burtonbr@slhs.org February 7, 2017 Disclosure www.prismsports.org • There are no relevant financial relationships to disclose. www.prismsports.org Postoperative Management • Guiding Principles1 – Communication with surgeon is imperative – Understand the surgery • Know all structures involved – Understand structures to be protected, how they are stressed, and healing rates – Impart appropriate levels of stress to the tissue • Absolute ROM, controlled submaximal loading, and dynamic stability – Management of initial immobilization and understanding rate of ROM progression protection stress 1 2/7/2017 www.prismsports.org Postoperative Management • Rehabilitation Overview - approximate timelines2 – Weeks 0-6: Immobilization in sling – Weeks 2-4: PROM at graded intervals; isometric exercise • Screen trunk and lower extremity (mobility, stability, and strength) and address limitations3 – Weeks 4-8: Basic strengthening exercise – Weeks 5-6: Begin AROM – Weeks 8-12: Advanced strengthening and plyometrics – Week 16: Return to play testing performed – Week 24: Contact and overhead sports begin Return to Play www.prismsports.org Foundational Criteria Advanced Criteria Advanced Criteria Under Fatigue – Pain free movement – Range of motion established • Minimize glenohumeral internal rotational deficit (GIRD) and total range of motion (TROM) deficits4,5 • Consider specific surgery • Loss of motion does increase risk of shoulder or elbow injury6,7 – Strong and pain free manual muscle testing • Test throwers in 90/90 position • Weakness of supraspinatus is also related to increased risk of injury8,9 Return to Play www.prismsports.org Foundational Criteria Advanced Criteria Advanced Criteria Under Fatigue Trunk Stability Push Up10 Single Arm Seated Shot-Put11 • Assesses trunk stability in sagittal plane while performing bilateral, closed chained, upper extremity movement • Desired score: 2/3 • Utilizes a 6 lb. medicine ball to assess unilateral, open chained, upper extremity power movement • Desired score: < 10% difference between extremities 2 2/7/2017 Return to Play www.prismsports.org Foundational Criteria Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST)12,13 Advanced Criteria Advanced Criteria Under Fatigue Upper Quarter Y-Balance Test (UQ-YBT)12 • Assesses unilateral stability, proprioception, and mobility of thoracic spine, scapula, and upper extremity • Desired score: Composite score of > 80% and < 4 cm reach difference between extremities • Assesses power, speed, and stability while performing bilateral, closed chained, upper extremity movement • Desired score: minimum of 21 touches, see sport specific norms Return to Play www.prismsports.org Foundational Criteria Advanced Criteria Advanced Criteria Under Fatigue • Why re-test while fatigued? – It’s a better simulation of upper extremity performance during sport – Fatigue impacts joint position and sensorimotor system14,15 – Fatigue should show symmetrical decrease in performance – Asymmetrical decrease may indicate greater compensation and increased injury risk during play stability www.prismsports.org 1. 2. 3. 4. 5. 6. 7. 8. mobility References Gaunt BW, Shaffer MA, Sauers EL, Michener LA, McCluskey III, GM, Thigpen CA. The American Society of Shoulder and Elbow Thearpists’ Consensus Rehabilitation Guideline for Arthroscopic Anterior Capsulolabral Repair of the Shoulder. J Orthop Sports Phys Ther. 2010; 40: 155-168. Milewski MD, Nissen CW. Pediatric and Adolescent Shoulder Instability. Clin Sports Med. 2013; 32: 761-779. Laudner L, Wong R, Onuki T, Lynall R, Meister K. The relationship between clinically measured hip rotational motion and shoulder biomechanics during the pitching motion. J Sci Med Sport. 2015; 18: 581-584. Shanley E, Rauh MJ, Michener LA, Ellenbecker TS, Garrison JC, Thigpen CA. Shoulder range of motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players. Am J Sports Med. 2011; 39: 2997-2006. Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball players. Am J Sports Med. 2013; 39(2):329-335. Wilk KE, Lacrina LC, Fleisig GS, et al. Deficits in glenohumeral range of motion increase risk of elbow injury in professional baseball pitchers: A prospective study. Am J Sports Med. 2014; 20: 1-7. Wilk KE, Macrina LC, Fleisig GS, et al. Deficits in glenohumeral passive range of motion increase risk of shoulder injury in professional baseball pitchers: A prospective study. Am J Sports Med. 2015; 43: 2379-2385. Byram IR, Bushnell BD, Dugger K, Charron K, Harrell FE, Noonan TJ. Preseason shoulder strength measurements in professional baseball pitchers: Identifying players at risk for injury. Am J Sports Med. 2010; 38: 1375-1382. 3 2/7/2017 www.prismsports.org 9. 10. 11. 12. 13. 14. 15. References Tyler TF, Mullaney MJ, Mirabella MR, Nicholas SJ, McHugh MP. Risk factors for shoulder and elbow injuries in high school baseball pitchers: The role of preseason strength and range of motion. Am J Sports Med. 2014; 42: 1993-1999. Cook G, Burton L, Hoogenboom BJ, Voight M. Functional Movement Screening: The Use of Fundamental Movements as an Assessment of Function – Part 2. Int J Sports Phys Therapy. 2014; 9: 549-563. Negrete RJ, Hanney WJ, Kolber MJ, et al. Reliability, Minimal Detectable Change, and Normative Values for Test of Upper Extremity Function and Power. J Strength and Cond Res. 2010; 24: 3318-3325. Taylor JB, Wright AA, Smoliga JM, DePew T, Hegedus EJ. Upper extremity physical performance tests in collegiate athletes. J Sport Rehabil. 2016; 25: 146-154. Pontillo M, Spinelli BA, Sennett BJ. Prediction of In-Season Shoulder Injury From Preseason Testing in Division I Collegiate Football Players. Sports Health. 2014; 6: 497-503. Tripp BL, Yochem EM, Uhl TL. Functional Fatigue and Upper Extremity Sensorimotor System Acuity in Baseball Athletes. J Athl Train. 2007; 42: 90-98. Grantham WJ, Byram IR, Meadows MC, Ahmad CS. The Impact of Fatigue on the Kinematics of Collegiate Baseball Pitchers. Orthop J of Sports Med. 2014; 2: 1-10. 4
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