SportsMAP Advanced Upper Limb Rehab in Sport highlights
Highlights from SportsMAP Advanced Upper Limb Rehab in Sport, 30th Nov-1st Dec 2019
With a fair share of conferences covering injuries of the lower limb, the SportsMAP Advanced Upper Limb Rehab in Sport event provided a content rich weekend for those wishing to up skill in the management of shoulder, elbow and wrist injuries. Featuring some of the top clinicians in their field, the event did not fail to deliver, with the typical SportsMAP format of combining theory and practical sessions. This blog will present some of the key topics discussed throughout the weekend, and is by no means all the content covered over the 2 days!
Kicking the event off on Day 1 was Andrew McGough, Head Physiotherapist Diving Australia, with “The Sporting Shoulder”.
One of the recurring themes throughout the weekend was the importance of assessing the kinetic chain in athletes with injuries to the upper extremity: for a number of athletic actions (ie. throwing, hitting) the generation of force begins from the ground up. Neglecting to address issues further down the body may be the difference between failure and success in rehabilitating the athlete. Andrew used the case example of a 29 year old Strongman competitor with shoulder pain, who displayed poor trunk control.
“It must be realized that throwing is a whole body activity”
Andrew stressed the importance of both discussing with the athlete and then examining what they CAN and CAN’T do with their presenting complaint. “What can you do? Do that, What can’t you do? Modify that”
Examination of the throwing athlete
Physical examination of the athlete with shoulder pain should be comprehensive to address all potential contributions. This incorporates a full assessment of the kinetic chain. Andrew discussed some of the key tests that should form part of the examination:
When assessing flexibility, some tests that should be performed include:
Shoulder IR/ER range: total range 180 degrees
Lat dorsi/pec minor length
Thoracic extension/rotation range
Combined elevation test: should be able to get above ears
Knee to wall test
Hamstring/hip flexor/glut length
Active straight leg raise
Hip IR range (especially on lead leg)
Rubber duck test: get the athlete to close their eyes, squeeze a squeaky rubber duck and get them to touch it
Closed kinetic chain test
Upper limb Y balance test
Single leg squat (especially ability to load into trail leg)
Single arm wall push up
Side plank hold L vs R
Glut bridge single leg
Front plank hold
Int/ext rot in neutral: performed in standing, 3:2 ratio
Resisted ext and int rotation: can test at different ranges of external/internal rotation
Testing push and pulls at different positions and ranges
Following assessment, Andrew then discussed the possible intervention and rehab options that are available.
The Swimmers Shoulder
Session 2 saw Kylie Holt, Senior Sports Physio Swimming Australia, present on her area of expertise: the swimmer’s shoulder. Swimmers shoulder is a highly prevalent condition, occurring in 70% of swimmers and with no decrease in incidence in the last 36 years.
Kylie firstly clarified some of the potential contributors to the “swimmer’s shoulder”, with a number of often cited causes shown to be lacking in evidence, or with evidence to the contrary:
Absolute training volume: no studies linking absolute training volume
Limitation of ranges specific to swimming (internal rotation >40deg), external rotation (>93, <100): no difference in range with those with pain in Swimming Australia 70 swimmers Holt et al 2017. Not predictive of pain. Those with less humeral torsion were the higher level performers. Relatively antetorted bilaterally, not greatly different from the general population but different from throwing population.
Scapular dyskinesis: MacLaine 2018. Is important to assess. No necessarily strength related. Is dyskinesia secondary to pain?? Scapular upward rotation/ position is highly variable, don’t bother measuring just YES/NO
Strength imbalance: Boettcher et al 2019 in press: average ratio 3:2 Int/Ext, those with pain often maintain ratio but decrease strength in both. NOT predictive of pain. Using manual muscle testing to assess tendon health & monitoring.
Insufficient glenohumeral stability/laxity: vast majority of swimmers have laxity, but not classified as instability. They are just mobile. +ve sulcus sign in 82 of 84 (98%) shoulders examined. We want shoulder movement overhead, stop cueing down and back with shoulders.
Kylie then discussed her yet to be published research of the MRI imaging findings in 60 elite swimmers versus 22 aged matched controls.
Summary of the key findings from this study:
Tendinopathy is highly prevalent & major findings in swimmers
Anterior (subscap) and superior (supraspinatus) cuff affected equally: subscapularis (29.2% grade 3) and supraspinatus (30% grade 2) tendinopathic changes, with only 30% showing “normal” tendons in these regions
Biceps sheath effusion, labral pathology & lesser tubercle oedema not uncommon. 100% of all swimmers have swelling in the long head of biceps, leading to believe that this finding is “normal” in swimmers
AC joint pathology common
Subacromial bursa possibly less affected than thought: all subacromial bursa examined were within normal limits
Early phases of stroke most pain provoking
Single greatest predictor of tendinopathy in swimmers is years in squad training (especially for subscap tendinopathy).
Findings from this study are not consistent with an external impingement model: In the catch position the subscap is impinging with labrum, and the Supraspinatus is NOT in contact with the acromion. Subacromial external impingement probably less a factor than what previously thought, time for a new model?
"Swimmers Shoulder" Tendinopathy- Anterior superior internal impingement (ASII) and Posterior superior internal impingement (PSII)
Normal physiological internal contact in high degrees of elevation and internal rotation
Elite training volume potential to drive pathological response
Tendinopathy caused by mixed loading ie tensile, compressive & intra-substance shear
This ASII and PSII explains pathoanatomical findings i.e. subscapularis, biceps, supraspinatus & intra-articular changes
Things to keep in mind for management of the “Swimmers shoulder”:
Tendinosis is highly prevalent in swimmers
Changes in load therefore likely to be an issue (ACWR rather than absolute)
In many situations not a case of "here now- gone tomorrow"
Monitor and strengthen the muscle/tendon unit
Scapular upward rotation likely to be important
Avoid hyper elevated position where possible (i.e. kickboard kicking, chin-ups)
Are bursal injections as necessary as once thought?
Keeping with the SportMAP mix of theory and practical, it was time to get moving with a breakout into practical workshops.
First up Bruce Rawson, Head Physiotherapist Australian Baseball, took attendees through a throwing rehab workshop. Attendees were fortunate to have former Major League Baseball player, Brad Harman assist in this workshop, giving his unique experience of playing in the majors.
Again reiterating what was taught in the earlier theory session, attendees were reminded that throwing is:
Whole body activity
Therefore, when presented with an injury in the throwing athlete, important to address the 2 above factors.
Fundamentals are important in throwing, and one must not overlook the grip in throwers: if this is not right, then everything else can follow. The correct grip on a ball is 2 fingers on top thumb UNDERNEATH. A common error seen in throwers is the thumb coming up near the index finger, which tends to create a sideways movement when throwing. It is also important to have a gap between the ball and hands.
Other key aspects of throwing techniques examined in this workshop were:
Have the body is squared up side on to target
Step towards the target not off to the side.
Ensure that the arm does not winding back before lifting the front leg: they should be simultaneous to help with energy storage.
Follow through with the thumb down and across the body NOT just across the body
The second workshop with Andrew McGough saw attendees split into small groups and get creative with finding suitable rehabilitative exercises for case studies of 2 injured athletes. What was interesting to observe in this workshop was that all groups came up with different exercises, which demonstrates the multitude of rehabilitative options we have for the injured athlete.
The second day started with Bruce Rawson discussing rehabilitation of the shoulder and elbow in the throwing athlete. In late stage rehab & conditioning it’s important to consider both:
General conditioning AND
Throwing specific conditioning
Bruce then discussed some of the key exercises which should be part of a throwers rehabilitation program:
Power (again remember that throwing is from the ground up!):
Throwing creates 1-1.5x body weight distraction force through the shoulder, therefore the value of exercises like heavy carries and deadlifts can not be underestimated.
To address trunk rotation some potential exercises that can be used include:
Medicine ball throw: under arm, over arm focusing more on push
Tornado ball twist: standing or sitting on floor
Swinging ball on rope above head
To progress a throwing athlete through throwing progressions, simply increase resistance by increasing distance. Athletes need to “earn the right” to throw hard and often.
Focusing on the injured shoulder is not enough, you must assess the whole chain
Don’t forget the kinetic chain of developing force in the throwing athlete: Each body segment starts accelerating when the previous reaches its peak. Those injured will often have incorrect timing in linking these segments.
Ask the athlete when does their shoulder hurt?
Before release/cocking phase/acceleration: result = reduced velocity of throw. Check ER ROM
Release after the throw (velocity OK). Check IR ROM, strength (posterior cuff & capsule)
Bruce then discussed injuries to the elbow in the throwing athlete.
For suspicion of UCL injury at the elbow, it’s important to determine if the ligament is torn or not:tears don’t tend to heal often need surgery.
What protects the UCL? biceps and forearm flexors. Will often see tenderness in distal biceps and forearm as a sign of overload at the elbow.
When assessing the UCL, the standard tests don’t stress the UCL highly enough in throwers, so Bruce uses the “bounce test” in the cocking position. Look for pain reproduction in this position. Additionally, another test that can be used is getting them in the cocking position and then flexing and extending the elbow, again looking for pain reproduction.
This session then lead into another practical workshop with both Bruce and Andrew demonstrating some of the key exercises that can be used for the throwing athlete.
Next up Phil Cossens, Senior Sports Physio Rowing Australia, explored the unusual wrist & elbow presentations in the athlete.
Posterolateral instability of the elbow
Can be traumatic and acute or develop over a period of time
Posterior subluxation of the radial head
Rotation of ulna/olecranon in fossa
Severe cases can click
Mild cases associated with other conditions
Clinical assessment should include:
Table top test: (click here to view)
Palpate and feel for radial head moving posterior
Positive test is reproduction of their symptoms
Posterolateral rotatory instability test (pivot shift of elbow) (click here to view test)
Flex and extend the elbow, feel for movement or reproduction of symptoms.
Osteochondritis dissecans of the capitellum
Be aware of niggling soreness
This is a diagnosis that should not be missed
MRI is essential
Clicking & locking indicates a worse prognosis
Weight bearing (ie gymnastics) or throwing
Palpating capitellar WB surface: flex the elbow (to expose the weight bearing aspect of joint) and you can palpate it
May have small loss of flexion
Palpating for swelling in Elbow joint: elbow extended, palpate in olecranon fossa
Management: conservative management does work, but expect 6-12months
Hyperextension induced posterior impingement
Thickening of triceps tendon
Thickening of ulnar collateral ligament
Posterior medial impingement or Valgus instability.
More seen in elbow flexion
Ulnar sided pain with WB and/or traction forces
Those with instability will often have a more supinated position of hand on radius and ulna. Distal Ulna may be more prominent
Pronation of hand may relieve symptoms
There is a continuum from missing 1 week to career ending instability
Overload injuries do well with conservative management if caught early enough
Significant TFC tears require arthroscopic surgery
Extensor carpi ulnaris injury
Common in racquet sports
Subluxation: get them to grip then supinate and pronate
Differs significantly depending on diagnosis (Campbell 2013)
Consider grip & wrist postures
More commonly seen in rowers
Test resisted extension and Finkelstein's test - these tests should be negative before resuming rowing
More common on inside arm for rowers
Address technique: excess wrist extension, ulnar deviation & grip
External factors: rough waters, change grip
Hard to row through
Splint, anti inflams, corticosteroids, surgery (Hoy et al 2019)
Assessment of the swimmer
Attendees then broke into more workshops firstly with Kylie demonstrating assessment of the swimmer, then Craig with rehabilitation of the wrist and elbow.
Some of Kylie’s key tips to assessment of the swimmers shoulder include:
Scapula assessment: Observe both at rest with arms by side and overhead in streamline position. Not necessarily looking at symmetry of movement, more just that they move
Catch position range (Abduction and internal rotation): elbow in armpit, lift elbows up, want to see >140 degrees (see video below)
Resisted catch position: look for pain provocation
Supine internal rotation: 45-60deg
Supine external rotation: 90+. But greater than 105 is a red flag. You can compensate much easier for a loss of internal rotation vs external rotation
Combined elevation test: hands together, ideal range is humerus 10 degrees above parallel (see video below)
This assessment then followed by some good manual therapy techniques to use on the swimmer:
Prone lat release: arms above head in catch position
Seated lat release: towel around back to grasp lats, then get them to raise arms above head
Assessment & Rehabilitation of the elbow
Shifting our attention down to the wrist and elbow, Craig then discussed assessment and rehabilitation of the wrist and elbow.
Some of his go to tests for the elbow include:
Forearm Flexor range test:
Have 3rd finger facing directly down
Then slide up the wall as high as you can until the heel of your hand comes off.
Ensure they don’t rotate the hand to cheat
Can either measure angle of arm or tape under their fingers
Forearm dissociation test:
Check internal and external rotation holding a dowel with elbow extended: can they disassociate their elbow and shoulder movement.
They can have their opposite finger on their elbow crease to ensure they are just using more forearm
In regards to rehabilitation for elbow issues, Craig uses pronation & supination exercises a lot: supinator is an important stabilizer of the elbow.
The anconeus should also not be neglected: Important in supporting the radial lateral component. To palpate this muscle, extend the elbow. Feel the muscle bulk just lateral to the olecranon
Craig will often do hands on work on flexor/pronators as tightness in this group can bring the radial head more anterior and potentially increase tendon compression
Again look for dissociation of forearm & shoulder
Strengthen supination and pronation as they are important stabilizers.
Weight bearing exercises are really important as they can often be done pain free and therefore allows the patient to be able to use the arm.
The final sessions of the weekend featured Head Physio from the Melbourne Storm, Meirion Jones, who delved into the management of the “Contact shoulder”.
Some of the key takeaways from these final sessions include:
Isolated strength: Get volume into cuff with time under tension: 12-15 reps, slow
Pulling technique: ensure that the shoulder does not dump anteriorly, and allow the scapula to fully retract at the bottom
Concentric RFD- plyo press, medicine ball throw
Eccentric RFD- drop and stick
Reactive RFD- counter movement plyo press
Proprioceptive rich: isometrics in outer ranges, KB get ups, arm bar trunk rotations, wall walks
Just like we learnt earlier in the weekend with throwing, technique for tackling is also just as important. Early in the rehab, non contact tackling technique drills can be performed, with progression to contact drills when within 15% strength of other side has been achieved.