Ellen Shanley

Shoulder Range of Motion Measures as Risk Factors for Shoulder and Elbow Injuries in High School Softball and Baseball Players

Background: Range of motion deficits in shoulder external rotation (ER), internal rotation (IR), total rotation range of motion (ER + IR), and horizontal adduction (HA) have been retrospectively associated with overhand athletes’ arm injuries. Hypothesis: The authors expected the incidence of upper extremity injury in high school softball and baseball players with side-to-side shoulder range of motion deficits to be greater than the incidence of upper extremity injury in players with normal shoulder range of motion. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: High school softball and baseball players (N = 246) participated. Before the start of the season, passive shoulder ER, IR, and HA were assessed at 90° of abduction with the scapula stabilized. Relative risk (RR) was calculated to examine range of motion measure, by categorical criteria, and risk of upper extremity injury. Results: Twenty-seven shoulder and elbow injuries (9 softball, 18 baseball) were observed during the season. The dominant shoulder of all injured players and baseball players displayed a significant decrease in HA (P = .05) and IR (P = .04). The dominant shoulder total rotation of injured baseball players displayed a significant decrease (mean difference = 8.0° ± 0.1°; P = .05) as compared with the dominant shoulder of uninjured baseball players. Players who displayed a decrease of ≥25° of IR in the dominant shoulder were at 4 times greater risk of upper extremity injury compared with players with a <25° decrease in IR, especially for baseball players. While we observed a 1.5 to 2 times increased risk of injury for the 10° to 20° loss in rotational range of motion for the overall sample and baseball, the risk estimates were not statistically significant (P > .05). Conclusion: There are large mean deficits in shoulder IR and HA between injured and noninjured players, but not in ER or total rotation. Passive shoulder IR loss ≥25° as compared bilaterally was predictive of arm injury. Shoulder range of motion deficits differed between sports and appeared more predictive of injury for baseball players.

Shoulder Range of Motion Deficits in Baseball Players With an Ulnar Collateral Ligament Tear

Background: Shoulder range of motion (ROM) deficits are associated with elbow injury in baseball players. Purpose: To compare the ROM characteristics of baseball players with a diagnosed ulnar collateral ligament (UCL) tear with those of a group of age-, activity-, and position-matched healthy controls. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Sixty male competitive high school and collegiate baseball players participated. Thirty athletes (age [mean ± standard deviation], 18.20 ± 1.56 years) with a diagnosed UCL tear were compared with 30 (age, 18.57 ± 0.86 years) age-, activity-, and position-matched players without a UCL injury. Of the 60 participants, there were 44 pitchers, 4 catchers, 5 infielders, and 7 outfielders. Participants were measured for shoulder internal rotation (IR), external rotation (ER), and horizontal adduction (HA) at 90° of shoulder elevation. Participants were also measured for elbow extension in a seated position. Group comparisons were made between participants with and without a UCL injury using independent t tests with an α level set at P < .05. All measurements were taken bilaterally, and the differences (involved to uninvolved) were used to calculate means for all variables, including glenohumeral internal rotation deficit (GIRD), total rotational motion (TRM), HA, and elbow extension. Results: Baseball players with a UCL tear (UCLInj) exhibited significantly greater deficits in TRM compared with the control group of healthy baseball players (NUCLInj) (UCLInj = −6.67° ± 11.82°, NUCLInj = 0.93° ± 9.91°; P = .009). No group differences were present for GIRD (UCLInj = −12.53° ± 5.98°, NUCLInj = −13.63° ± 5.90°; P = .476), HA (UCLInj = −3.00° ± 5.01°, NUCLInj = −3.23° ± 5.15°; P = .860), or elbow extension (UCLInj = −2.63° ± 7.86°, NUCLInj = −1.17° ± 2.76°; P = .339). Pitchers with a UCL tear had significantly greater deficits in TRM (UCLInjPitch = −6.96° ± 11.20°, NUCLInjPitch = 1.29° ± 8.33°; P = .0087) and dominant shoulder ER (UCLInjPitch = 112.04° ± 14.35°, NUCLInjPitch = 121.85° ± 9.46°; P = .011) than pitchers without a UCL tear. Conclusion: A deficit in TRM is associated with a UCL tear in baseball players. Although GIRD may be prevalent in throwers, it may not be associated with a UCL injury. When examining ROM in baseball players, it is important to assess both TRM and GIRD.

Changes in passive range of motion and development of glenohumeral internal rotation deficit (GIRD) in the professional pitching shoulder between spring training in two consecutive years

BACKGROUND Pitching causes increased mechanical stress to the arm and is thought to result in alterations in range of motion (ROM) as a result of osseous and soft tissue adaptations. Understanding the factors that contribute to alterations in ROM will allow for improved understanding of the pitching shoulder. This study examined humeral torsion (HT) and shoulder mobility over 2 consecutive years. METHODS Bilateral shoulder mobility and HT were assessed in 33 asymptomatic professional pitchers over 2 spring trainings. A repeated-measures analysis of covariance was used to assess the change in motion of the dominant side/nondominant side across seasons while quantifying pre-existing HT. Prevalence of glenohumeral internal rotation deficit (GIRD) between seasons was compared with χ(2) analysis, and GIRD and non-GIRD pitchers were compared with the independent t test. RESULTS The dominant shoulder displayed increased external rotation (11.5° ± 0.1°, P = .02) and decreased internal rotation (-8.4° ± 11.0°, P = .03) and horizontal adduction (-17.6° ± 13.8°, P = .01). The nondominant shoulder remained the same. Mean HT was significantly different (P = .001) in the dominant (10° ± 11°) arm than in the nondominant arm (23° ± 11°). A significant number of pitchers had with GIRD (P < .01) at each assessment. CONCLUSIONS ROM was significantly altered between seasons of pitching. These changes likely resulted from soft tissue adaptations because we accounted for humeral retrotorsion. Pitchers who developed GIRD displayed a 7° increase in retrotorsion on the dominant shoulder. Changes in the pitching shoulder over time accounting for humeral retrotorsion may suggest pitching ROM is transient and should be monitored.

Bony Adaptation of the Proximal Humerus and Glenoid Correlate Within the Throwing Shoulder of Professional Baseball Pitchers

Background: Elite throwing athletes have increased proximal humeral retrotorsion (HRT) and glenoid retroversion (GRV) in their throwing shoulders compared with their nonthrowing shoulders. These adaptive morphologic changes are thought to be independently protective against shoulder injury; however, their relationship to each other is poorly understood. Purpose: To determine if an association exists between HRT and GRV within the same shoulders of professional pitchers. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The HRT and GRV measurements were determined using published techniques in asymptomatic bilateral shoulders of 32 professional pitchers (mean age, 23 years). Three measurements for each variable were averaged, and the reliability of the techniques was verified. The relationship between HRT and GRV within the same shoulders was determined with Pearson correlation coefficients. Paired t tests were used to compare HRT and GRV between the throwing and nonthrowing shoulder. Simple ratios were calculated between HRT and GRV. Results: Humeral retrotorsion and GRV were both significantly greater on the throwing side compared with the nonthrowing side (HRT: throwing = 9.0° ± 11.4° and nonthrowing = 22.1° ± 10.7°, P < .001; GRV: throwing = 8.6° ± 6.0° and nonthrowing = 4.9° ± 4.8°, P = .001). Within the same shoulders, there was a statistically significant positive association between HRT and GRV on the throwing side (r = 0.43, P = .016) but not on the nonthrowing side (r = −0.13, P = .50). The HRT:GRV ratio was 2.3:1 for throwing shoulders and 7:1 for nonthrowing shoulders. Conclusion: The concurrent increases in dominant shoulder HRT and GRV were observed as a 2:1 “thrower’s ratio.” As this relationship was not observed on the nondominant shoulder, it suggests that bony adaptation of the proximal humerus and glenoid are coupled during skeletal development in the throwing shoulder. Longitudinal studies are needed to confirm this hypothesis.

Professional Pitchers With Glenohumeral Internal Rotation Deficit (GIRD) Display Greater Humeral Retrotorsion Than Pitchers Without GIRD

Background: Dominant shoulder glenohumeral internal rotation deficit (GIRD) has been associated with pitching arm injuries. The relationship of humeral torsion on development of GIRD is not clear. Hypothesis: Pitchers displaying GIRD will display greater humeral retrotorsion when compared with those without GIRD. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Humeral torsion and shoulder range of motion (ROM) were measured in 222 professional pitchers before spring training from 2009 to 2012. Shoulder external rotation (ER) and internal rotation (IR) ROM were assessed in 90° of abduction with the scapula stabilized. Humeral torsion was measured via ultrasound using previously described and validated methods. Side-to-side differences in total arc of motion (ER + IR), ER, and IR ROM and humeral torsion were calculated as nondominant minus dominant arm measures for analysis. Pitchers were classified as having GIRD if their dominant arm displayed an IR deficit ≥15° concomitant with a total arc of motion deficit ≥10° compared with their nondominant arm. A mixed-model analysis of variance (side × GIRD) was used to compare dominant and nondominant humeral torsion between pitchers with GIRD (n = 60) and those without GIRD (n = 162). Independent t tests were used to compare the side-to-side difference in humeral torsion between pitchers with GIRD and those without GIRD (α = 0.05). Results: Pitchers with GIRD displayed significantly less humeral torsion (ie, greater retrotorsion) in their dominant arm as compared with those without GIRD (GIRD = 4.5° ± 11.8°, no GIRD = 10.4° ± 11.7°; P = .002). Pitchers with GIRD also displayed a greater side-to-side difference in humeral torsion (GIRD = 19.5° ± 11.9°, no GIRD = 12.3° ± 12.4°; P = .001). However, pitchers with GIRD did not display an increase in dominant ER ROM (dominant ER = 131.8° ± 14.3°, nondominant ER 126.6° ± 13.1°) when compared with those without GIRD (dominant ER = 132.0° ± 14.2°, nondominant ER 122.6° ± 13.1°; P = .03). Pitchers with GIRD displayed expected alterations in ROM (IR = 28.8° ± 9.6°, total arc = 160.6° ± 15.4°; P < .01 for both) when compared with those without GIRD (IR = 39.9° ± 9.9°, total arc = 171.2° ± 15.5°). Conclusion: Pitchers with GIRD displayed greater side-to-side differences and dominant humeral retrotorsion as compared with those without GIRD. The greater humeral retrotorsion may place greater stress on the posterior shoulder resulting in ROM deficits. Pitchers with greater humeral retrotorsion appear to be more susceptible to developing ROM deficits associated with injury and may need increased monitoring and customized treatment programs to mitigate their increased injury risk.

Between-session changes predict overall perception of improvement but not functional improvement in patients with shoulder impingement syndrome seen for physical therapy: An observational study

Do between-session changes in global rating of change (GRoC) predict change in GRoC and self-report of function at discharge in patients with shoulder impingement that initially improve in early sessions of treatment (GRoC>5)? Is there a difference between individuals who initially respond to treatment (GRoC>5) compared to those that do not (GRoC<5) for self-report of function? This longitudinal, observational study had 55 patients seen for a formal physical therapy program after a medical diagnosis of shoulder impingement. Physical therapy used a standardized protocol. The American Shoulder and Elbow Surgeons Subjective Shoulder Scale (ASES) and self-report of improvement of condition using the GRoC were measured. We found no significant correlation between the first visits between-sessions changes of the GRoC and the change score of the ASES (r=0.13; p=0.39) in patients with shoulder impingement that initially improve in early sessions of treatment (GRoC>5). There was a moderate correlation between the first visits between-session changes of the GRoC and the final reported GRoC (r=0.48; p<0.01) for the patients who responded to treatment. There was no difference in ASES change scores between those who initially respond to treatment (N=10) and those who do not (N=34). ASES mean change scores were 21.5 for the responders and 14.3 for the non-responders. These findings suggest that a GRoC of 5 or greater is related to a perceived change in ones condition upon termination of formal physical therapy but is not related to actual improvement in ones self-report of function. This finding suggests that the construct of the GRoC may not be related to the constructs of the ASES, or between-session changes are not prognostic in patients with shoulder impingement and should not solely dictate treatment decision making.

Current Rehabilitation Applications for Shoulder Ultrasound Imaging

SYNOPSIS The available body of knowledge on shoulder ultrasound imaging has grown considerably within the past decade, and physical therapists are among the many health care professions currently exploring the potential clinical integration of this imaging technology and the knowledge derived from it. Therefore, the primary purpose of this commentary was to review the recent evidence and emerging uses of ultrasound imaging for the clinical evaluation of shoulder disorders. This includes a detailed description of common measurement techniques along with their known clinimetric properties. Specifically provided are critical appraisals of the existing measures used to estimate soft tissue and bony morphometry, muscle contractile states, and lean muscle density. These appraisals are intended to help clinicians clarify the scope of physical therapy practice for which these measurement techniques are effectively utilized and to highlight areas in need of further development.

A Comparison of Glenoid Morphology and Glenohumeral Range of Motion Between Professional Baseball Pitchers With and Without a History of SLAP Repair

PURPOSE We sought to examine the relation among glenoid morphology, glenohumeral range of motion (ROM), and history of shoulder injury in professional baseball pitchers. METHODS We studied 58 professional baseball pitchers. Internal rotation (IR) and external rotation (ER) ROM was measured at 90° of abduction. Horizontal adduction (HAdd) ROM was also measured. Glenoid superior inclination and glenoid retroversion (GRV) were then measured radiographically. Separate mixed-model analyses of variance were used to compare dependent measures between the dominant and nondominant shoulders of pitchers with or without a history of SLAP repair. Significant interaction effects were interpreted by use of a test for simple main effects (α = .05). RESULTS GRV was significantly greater on the dominant side (8.7° ± 5.6°) versus nondominant side (5.5° ± 5.2°) (P = .001), whereas glenoid superior inclination was equivalent (99.5° ± 4.3° for dominant side v 99.2° ± 4.4° for nondominant side, P = .853). Post hoc analysis indicated that pitchers with a history of SLAP repair did not display an adaptive increase in dominant GRV compared with nondominant GRV (P = .016). There were no statistical differences between groups for ER (P = .29), IR (P = .39), or HAdd (P = .39). The dominant shoulder displayed greater ER (mean increase, 6.2° ± 12.2°) with a complementary decrease in IR (mean decrease, 5.8° ± 13.2°) and HAdd (mean decrease, 8.9° ± 13.7°) compared with the nondominant side. CONCLUSIONS Our findings suggest that the development of increased GRV in the dominant shoulder of professional baseball pitchers may be a protective adaptive change not reflected in glenohumeral ROM measures. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Mechanisms of Shoulder Range of Motion Deficits in Asymptomatic Baseball Players

Background: Shoulder range of motion (ROM) deficits have been identified as injury risk factors among baseball athletes. Despite the knowledge surrounding these risk factors, there is a lack of consensus regarding the specific tissues responsible for these deficits in ROM. Purpose/Hypothesis: The purpose of this study was to elucidate the primary mechanisms of posterior shoulder tightness (capsular, musculotendinous, bony) by examining the tissue responses that occur with the application of an acute intervention in baseball players with ROM deficits. The hypothesis was that posterior rotator cuff stiffness, not glenohumeral joint mobility, would be primarily responsible for ROM gains observed within an acute treatment setting. Study Design: Controlled laboratory study. Methods: Through use of ultrasound elastography, electromagnetic motion analysis, and ultrasound imaging, posterior rotator cuff stiffness, glenohumeral joint translation, and humeral torsion were examined in 60 asymptomatic baseball players (age, mean ± SD, 19 ± 2 years) with shoulder ROM deficits. Tissue mechanisms were examined concurrently, with the ROM gains elicited by an acute application of instrument-assisted soft tissue mobilization plus self-stretching (n = 30) versus self-stretching only (n = 30). Separate 3-way analyses of variance (group × arm × time) and linear regression analyses were used to determine the treatment effects and relationships between tissue mechanisms and ROM gains. Results: ROM gains were associated with decreases in rotator cuff stiffness (internal rotation: r = 0.35, P = .034; horizontal adduction: r = 0.44, P = .008) and increased humeral retrotorsion (internal rotation: r = −0.35, P = .034), not joint translation (P > .05). Players receiving instrument-assisted soft tissue mobilization plus stretching displayed greater shoulder ROM gains (internal rotation, +5° ± 2° [P = .010]; total arc of motion, +8° ± 6° [P = .010]; horizontal adduction, +7° ± 2° [P = .004]; and decreased posterior rotator cuff stiffness, −0.2 ± 0.3 kPa [P = .050]) compared with players receiving self-stretching alone. Conclusion: Decreases in rotator cuff stiffness were associated with acute ROM gains in baseball players. The study results show that changes in rotator cuff stiffness, not glenohumeral joint mobility or humeral torsion, are most likely associated with the ROM deficits observed in adolescent baseball players. Clinical Relevance: Reducing rotator cuff stiffness may be beneficial in improving the ROM deficits associated with injury risk in overhead athletes.

Humeral Torsion as a Risk Factor for Shoulder and Elbow Injury in Professional Baseball Pitchers

Background: Numerous studies have demonstrated that humeral retrotorsion is increased in the dominant arms of throwing athletes. No study has clearly defined the relationship between humeral retrotorsion and shoulder and elbow injury. Hypothesis: Uninjured professional pitchers will display more dominant humeral torsion (HT) than professional pitchers who sustain shoulder injuries but less than pitchers who sustain elbow injuries. Study Design: Case-control study; Level of evidence, 3. Methods: Pitchers from the Colorado Rockies professional baseball organization were recruited for participation for this prospective injury study from 2009 to 2013. HT was assessed using indirect ultrasonographic techniques and was measured prospectively in 255 pitchers before each spring training (average of 2 trials). From the beginning of the preseason to the end of the postseason, overuse upper extremity injuries (shoulder or elbow) were tracked for each participating athlete. All athletes who reported pain or injury to their coach were referred to the organization’s athletic trainer for evaluation and classification of each injury. The difference in HT was calculated by subtracting measurement of the dominant arm from the nondominant arm, and 3 separate mixed-model analyses of variance (side × injury group) were used to compare the dominant and nondominant HT between all pitchers who developed an arm injury (shoulder and elbow combined), as well as comparing pitchers who developed a shoulder or elbow injury to those who did not miss games due to shoulder or elbow injury (α = .05). Results: During the course of the study, 60 arm (30 shoulder; 30 elbow) injuries were observed; 195 pitchers did not suffer an injury. There were no differences when HT was compared between all injured (shoulder and elbow injuries combined) and uninjured pitchers (P = .13; effect size 0.14). There was a significant interaction effect showing that pitchers who suffered a shoulder injury displayed 4° less dominant humeral retrotorsion compared with pitchers without injury (P = .04) and that pitchers with elbow injury displayed 5° greater humeral retrotorsion (P = .04). In addition, those who suffered an ulnar collateral ligament injury requiring reconstruction (n = 17) also displayed 4o greater dominant retrotorsion and 5° less nondominant humeral retrotorsion compared with pitchers who did not suffer an injury (n = 195; P = .05). There was not a significant difference between nondominant HT among pitchers who sustained shoulder and elbow injuries and pitchers without injury. Conclusion: The results of this study show a contrast in dominant humeral retrotorsion between pitchers who suffered shoulder and elbow injuries compared with those without an injury. Pitchers who sustained shoulder injuries had less dominant humeral retrotorsion compared with noninjured pitchers. In contrast, pitchers who sustained time-loss elbow injuries displayed increased humeral retrotorsion compared with noninjured pitchers. Together, these results suggest that increased adaptive humeral retrotorsion is protective against shoulder injuries but a harmful contributor for elbow injuries in professional pitchers. This is the first study to show differing injury risk profiles for shoulder and elbow injury.