Interval Throwing Program Research Articles

Rehabilitation and Return to Play Following Superior Labral Anterior to Posterior Repair

Superior labral anterior to posterior (SLAP) tears are a pathology seen in the athletic population with greater frequency in the overhead athlete. Treatment is guided to some degree based on the type of the SLAP tear. In degenerative conditions, conservative treatment or debridement back to a stable base is indicated. In the case where the biceps-labral complex is detached from the glenoid, repair is the preferred method of treatment. However, some controversy exists surrounding how to treat the biceps, with either direct repair back to the labrum or tenodesis. Outcomes in either case tend to be good; however, they are less favorable in the overhead athlete. Part of the successful outcome of this surgery necessitates following a structured rehabilitation protocol, that is, based on biological healing timeframes, a graded range of motion program, targeted strengthening program, and in the case of the throwing athlete completion of an interval-throwing program with biomechanical evaluation from a professional pitching coach. Components that can be missed but are vital to a successful outcome, especially in the overhead throwing athlete, are optimization of the kinetic chain and completion of a return to throwing program. Objective return-to-play criteria is important to meet before releasing the athlete back to sport. The focus of this article is to outline the rehabilitation and return-to-play criteria following SLAP repair of a type II lesion with restoration of the biceps anchor, emphasizing the overhead throwing athlete.

Defining the Long-Toss: A Professional Baseball Epidemiological Study.

Background:Despite widespread use of long-toss throwing in baseball as a component of arm conditioning, interval throwing programs, and rehabilitation, long-toss distance and throwing mechanics remain controversial.Purpose:To ascertain the perceived definition of long-toss throwing through a survey of professional pitchers, pitching coaches (PCs), and certified athletic trainers (ATCs) associated with Major League Baseball.Study Design:Descriptive epidemiology study.Methods:Pitchers, PCs, and ATCs associated with 5 Major League Baseball organizations completed an anonymous survey that collected demographic data, personal use of long-toss throwing, and their perception of the distance and throwing mechanics that comprised long-toss.Results:A total of 321 surveys were completed by 271 pitchers, 19 PCs, and 31 ATCs. For all respondents, the mean distance considered as long-toss was 175 ft (95% CI, 170-181 ft). Respondents categorized the throwing mechanics of long-toss, with 36% reporting throwing “on a line” and 70% reporting long-toss as “not on a line.” Of those throwing “on a line,” 28% reported using crow-hop footwork while 60% used crow-hop footwork when throwing “not on a line.” Interpretation of long-toss distance significantly varied by position: pitchers, 177 ft (95% CI, 171-183 ft); PCs, 177 ft (95% CI, 155-200 ft); and ATCs, 157 ft (95% CI, 144-169 ft) (P = .048). When asked when long-toss throwing is used, pitchers reported using it more frequently in preseason (P = .007), during the season (P = .015), and in the off-season (P = .002) compared with that by ATCs. Functional goals for long-toss throwing demonstrated that pitchers and PCs use long-toss for shoulder stretching more frequently than ATCs (P < .001 and P = .026, respectively). ATCs used long-toss more than pitchers for interval throwing programs (P < .001).Conclusion:The definition varies for long-toss throwing distance and throwing mechanics. Pitchers and PCs believe that long-toss comprised longer distances than ATCs and employed long-toss differently for strength conditioning, training, stretching, and rehabilitation. This discrepancy highlights a potential lost opportunity for protecting the shoulder. While long-toss is an important tool, a more scientific definition is warranted to better elucidate its role in enhancing throwing performance and rehabilitation.

Principles of Postoperative Shoulder Rehabilitation in Throwing Athletes

The rehabilitation of the overhead throwing athlete is a complex and often lengthy process. After completion of the intial phases of rehab involving strength and motion recovery, sports specific throwing rehabilitation and graduated return to throwing are required. Safe and timely return to throwing following shoulder surgery in baseball players requires sophisticated coordination and communication between clinicians, coaches, and players. Strict adherence to underlying principles of an interval throwing program would afford players the best chance of successfully returning to his or her preinjury level of performance. Open and constant communication between players, trainers, and coaches would ensure that any soreness or pain experienced by the player would be reported and assessed in a timely manner. Such reporting would minimize the chance of delaying progress through the interval throwing program.

Influence of a Prevention Program on Arm Injury Risk: An RCT in Adolescent Pitchers

Objectives:High school pitchers are at three times greater risk of an upper extremity (UE) injury compared to position players, with most (69%) injuries occurring during the first month of the season. Therefore, a prevention program for pitchers targeting known risk factors may reduce their injury risk, particularly early in the season. The purpose of this study was to determine the effectiveness of a preseason training program in decreasing the injury rate and altering the pattern of UE injuries in a cohort of high school pitchers.Methods:Healthy high school pitchers (n=196) who were participating in all team activities were block randomized by school to intervention (INV, n=103) or control (CON, n=93) groups. The INV group received a scapular stability, rotator cuff strength, and posterior shoulder flexibility program (3 times/week for 8 consecutive weeks) supervised by an Athletic Trainer. The CON group participated in the teams’ usual preseason training. Training activities for all teams were recorded. All players participated in a 4-week interval-throwing program. Athletic exposures (AEs), injury incidence (participation absence or limitation due to injury) were tracked from the first day of practice until the last day of competition. Incidence rates were calculated per 1,000 AEs and monthly trends for injury were examined for occurrence by group, injury history, and body location. As a secondary analysis, published injury rates from 2009 in the same high schools were compared to their 2012 data. Rate ratios (RR) and 95% confidence intervals (CIs) were used to compare injury rates by group, injury history, body location, and year.Results:Overall, there were 27 UE injuries incurred among the pitchers; 15 in the INT group (10 shoulder & 5 elbow injuries) and 12 in the CON group (10 shoulder & 2 elbow injuries). The injury rate was similar in the INT and CON groups (RR=0.86; 95% CI: 0.43-2.2). The pattern of arm injuries throughout the season was evenly distributed in both groups. In 2012, 67% of CON teams were observed participating in a general “arm care” program as compared to 6% of CON teams in 2009. Previous arm injury did not increase the risk of an UE injury in the INV group (RR=1.0; 95% CI: 0.38-2.8) but did increase the risk of an UE injury almost 4-fold (RR= 3.7,95% CI: 1.3-10.7) in the CON group. The injury incidence rate for pitchers was 12 times higher in 2009 (29.3/1,000 AEs) than in 2012 (3.4/1,000 AEs) (RR=11.6, 95% CI: 7.1-16.1). The risks of shoulder (RR=11.0; 95% CI: 6.6-15.4) and elbow injury (RR=12.6; 95% CI: 8.0-17.3) were higher in 2009 compared to 2012. The pattern of upper extremity injuries was higher in the first quarter of the season compared to 2012 (See Figure 1).Conclusion:The main finding of this study is that INV and CON pitchers had a similar injury rate, however, the overall injury rates were significantly lower in 2012 than in 2009. Thus it appears that a general “arm care” and interval-throwing program may also be effective in reducing the injury rate in high school pitchers, perhaps in the early part of the season as injury rates based on the differences in rates between 2012 and 2009. Pitchers with a previous injury in the INV group were less likely to suffer an injury in 2012 than pitchers’ with a previous injury in the CON group. Thus, a targeted pre-season conditioning program may help reduce the injury risk in pitchers with a history of of previous arm injury. Further studies are warranted to confirm our results.

The Thrower’s Shoulder

When rehabilitating the thrower’s shoulder it is critical to understand the functional requirements and common adaptions of the athlete. The scapula is a key component when rehabilitating the throwing athlete. The functional demands of the shoulder include restoring muscular balance, training force couples, and incorporating eccentric activities. In addition, proprioception must be normalized throughout the functional range of motion. The athlete must be progressed to overhead activities and trained for power and endurance. The shoulder must also be trained as a component of the kinetic chain along with the hips, legs, and trunk. Finally, common adaptions such as a loss of glenohumeral internal rotation may result in several common pathologies in the throwing population and must be addressed comprehensively. Upon completion of a rehabilitation program, the athlete, when meeting the appropriate criteria, will begin an interval throwing program. The throwing program should be individualized. It should be age, competitive level, and position specific.

Defining Safe Rehabilitation for Ulnar Collateral Ligament Reconstruction of the Elbow

Background Ulnar collateral ligament reconstruction of the elbow using a variety of techniques has been successful in enabling overhead athletes with ulnar collateral ligament insufficiency to return to competition. Most current postoperative rehabilitation programs begin with a period of motion restriction, including limiting elbow extension, that is followed by a transition from elbow strengthening to an interval throwing program, to competition. Motion restrictions early in the postoperative period may increase the risk for contractures. There is limited information to support current motion restrictions. Purpose (1) To determine strain on the reconstructed ulnar collateral ligament during a rehabilitation protocol that includes passive range of motion, isometric muscle contraction, and varus and valgus torques. (2) To develop guidelines for a safe initial rehabilitation protocol. Study Design Controlled laboratory study. Methods Eight cadaveric elbows underwent ulnar collateral ligament reconstruction with the docking technique using a gracilis tendon graft. Differential variable reluctance transducers on the anterior and posterior bands of the reconstructed anterior bundle of the ulnar collateral ligament were used to measure strain, while an optical motion tracking system monitored elbow motion. Strain was measured in the following 3 settings: passive range of motion, 22.2 N isometric flexion and extension contractions, and 3.34 N·m varus and valgus torques with the arm at 90° of flexion. Results Range of motion from maximum extension to 50° of flexion produced 3% or less strain in both bands of the reconstructed ligament. Forearm rotation did not significantly affect strain in the anterior or posterior bands (P = .336 and P = .357). Strain at 90° approached 7% in the posterior band (upper 95% confidence interval). Isometric muscle contractions had no measurable effect on strain. Varus torques decreased and valgus torques increased strain significantly (P < .05). Conclusion In the immediate postoperative period, full extension is safe, while flexion beyond 50° may place deleterious strain on the reconstruction. Isometric flexion and extension exercises do not increase ligament strain but may be unsafe at 90° of flexion, while valgus exercises (internal rotation at the shoulder) can increase strain in the reconstructed ligament. Clinical Relevance The results have implications for the development of appropriate rehabilitation protocols after ulnar collateral ligament reconstructive surgery.

Data-Based Interval Throwing Programs for Baseball Players

Context:Baseball throwing injuries are common. Emphasis on injury prevention and rehabilitation is made in an attempt to keep athletes on the field of competition. Interval throwing programs are an integral part of training, conditioning, and returning an injured baseball player to the game.Evidence Acquisition:Development of data-driven programs was based on the number, type, distance, and intensity of throws during games, across the spectrum of ages and positions for baseball athletes at all levels of play. Statistical analysis by age, position, and level of play determined the need for separate throwing programs. Means, the high range, game rules, and practical considerations were used to develop each data-based interval throwing program.Results:Data-based age and level-of-play interval throwing programs for pitchers, catchers, infielders, and outfielders have been developed, tested, and implemented for more than 10 years. Progression is based on type and location of injury, symptoms in response to throwing, and preinjury performance profile. Although the throwing programs are highly structured, there is ample opportunity to modify them to meet the needs of individual athletes.Conclusion:Data-based interval throwing programs for baseball athletes are an integral training and conditioning element for both injured and uninjured athletes who are preparing for sports participation. Medical team members should equip themselves with an understanding of how to use the programs for safe training, conditioning, and return to play.

Data-Based Interval Throwing Programs for Baseball Position Players from Age 13 to College Level

Objective:To design interval throwing programs for baseball players other than pitchers from 13 years of age to the college level.Design:The authors recorded throws to base, distance of throws, and perceived effort of throws at 4 levels of play. For catchers they also recorded number of throws to the pitcher, number of sprints to first or third base, and time in the squat stance. From these data they designed throwing programs specific to outfielders, infielders, and catchers.Results:No significant difference was found between the number of throws and distance of throws for infielders and catchers across all age groups. The mean distance of throws differed significantly between 13-year-olds and all other levels of play.Conclusion:The authors devised 1 program for infielders and catchers of all age groups, 1 program for 13-year-old outfielders, and 1 for all other levels.

Data-Based Interval Throwing Programs for Little League, High School, College, and Professional Baseball Pitchers

An injured baseball pitcher must pitch to return to competition. A databased interval throwing program for Little League baseball was previously defined by the authors. In that program, children 9 to 12 years old pitch 19.53 pitches per inning; 2.58 innings per outing; and 52.34 pitches per outing from a 46-foot mound distance. Children 13 or 14 years old pitch 19.15 pitches per inning; 2.65 innings per outing; and 58 pitches per outing from a 60-foot 6-in mound distance. Starting pitchers and high school, college, and professional team players pitch 14.93 to 16.45 pitches per inning; 5 to 6 innings per outing; and 76 to 94 pitches per outing. The integration of pitching statistics, field dimensions, performance restrictions, biomechanical studies, and a basic understanding of healing tissue have reduced the myriad of available pitchers’ programs to just three programs. They are for the following groups: children 12 years old and younger; children 13 to 14 years old; and high school, college, and professional players. These programs can be used for training and conditioning and can be applied across a wide range of pathologies.

Operative treatment of ulnar collateral ligament injuries of the elbow in athletes.

Over a 6-year period, the senior author (JRA) performed 91 ulnar collateral ligament reconstructions (N = 78) or repairs (N = 13). All patients were male and between the ages of 15 and 39 years (average, 21.6). Thirty-seven patients (41%) were professional baseball players, 41 (45%) were collegiate baseball players, and 7 (7.7%) were high school or recreational players. Subcutaneous ulnar nerve transposition with stabilization of the nerve with fascial slings of the flexor pronator mass was performed in all patients, and additional procedures were performed in 27 patients (29.7%), including 22 excisions of posteromedial olecranon osteophytes. Average follow-up was 35.4 months. Ten patients had preoperative ulnar nerve symptoms, nine of whom had complete resolution of symptoms after surgery. Complications occurred in eight patients. The average time from surgery to initiation of the interval throwing program was 3.4 months, and the average time to return to competitive throwing was 9.8 months. Sixty-seven patients (74%) were available for follow-up; of these, 53 (79%) had returned to their previous levels of competition or to a higher level. Reconstruction of the ulnar collateral ligament, with transposition and stabilization of the ulnar nerve and appropriate rehabilitation, was found to be effective in correcting medial instability of the elbow and allowed most athletes to return to previous levels of play in less than 1 year.

Interval Throwing Program for Football Quarterbacks

The implementation of interval throwing programs during rehabilitation has been suggested in the literature to allow for a quicker and safer return of the throwing athlete to competition. Many programs have clearly focused on baseball players. This program is specifically designed for the football quarterback. The program encompasses a sound flexibility and strength training regime and provides for a supervised step-by-step progression of throwing. Although the authors have found success with early results, practitioners should apply this program with caution, as it may need to be modified for each athlete. The purpose of this paper is to establish a foundation for future work in the area of the throwing shoulder for the football quarterback.

Distance Based Criteria Interval Throwing Program

The decision of how to progress a baseball player through a throwing program following an injury has been a difficult one for the sports medicine population to address. Numerous programs have been suggested to allow a player a gradual return to competitive throwing. These programs are primarily based on previous experience of the clinician designing the program, simply because this may be the only objective material that can be used to determine parameters of a program of such diverse individualism. This paper identifies those components that play a critical role in the designing of any interval throwing program and outlines a program based on position and distance specific phases.