Michael M. Reinold

Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature

SYNOPSIS The biomechanical analysis of rehabilitation exercises has led to more scientifically based rehabilitation programs. Several investigators have sought to quantify the biomechanics and electromyographic data of common rehabilitation exercises in an attempt to fully understand their clinical indications and usefulness. Furthermore, the effect of pathology on normal shoulder biomechanics has been documented. It is important to consider the anatomical, biomechanical, and clinical implications when designing exercise programs. The purpose of this paper is to provide the clinician with a thorough overview of the availableliterature relevant to develop safe, effective, and appropriate exercise programs for injury rehabilitation and prevention of the glenohumeral and scapulothoracic joints. LEVEL OF EVIDENCE Level 5.

Changes in shoulder and elbow passive range of motion after pitching in professional baseball players.

Background The overhead throwing athlete has unique range of motion characteristics of the shoulder and elbow. Numerous theories exist to explain these characteristics; however, the precise cause is not known. Although it is accepted that range of Motion is altered, the acute effect of baseball pitching on shoulder and elbow range of motion has not been established. Hypothesis There will be a reduction in passive range of motion immediately after baseball pitching. Study Design Controlled laboratory study. Methods Sixty-seven asymptomatic male professional baseball pitchers participated in the study. Passive range of motion Measurements were recorded using a customized bubble goniometer for shoulder external rotation, shoulder internal rotation, total shoulder rotational motion, elbow flexion, and elbow extension on the dominant and nondominant arms. Testing was performed on the first day of spring training. Measurements were taken before, immediately after, and 24 hours after pitching. Results A significant decrease in shoulder internal rotation (−9.5°), total motion (−10.7°), and elbow extension (−3.2°) occurred immediately after baseball pitching in the dominant shoulder (P < .001). These changes continued to exist 24 hours after pitching. No differences were noted on the nondominant side. Conclusion Passive range of motion is significantly decreased immediately after baseball pitching. This decrease in range of motion continues to be present 24 hours after throwing. High levels of eccentric muscle activity have previously been observed in the shoulder external rotators and elbow flexors during pitching. These eccentric muscle contractions may contribute to acute musculotendinous adaptations and altered range of motion. The results of this study may suggest a newly defined mechanism to range of motion adaptations in the overhead throwing athlete resulting from acute musculoskeletal adaptations, in addition to Potential osseous and capsular adaptations.

Correlation of Range of Motion and Glenohumeral Translation in Professional Baseball Pitchers

Background Altered mobility patterns in the throwing shoulders of professional baseball pitchers have been reported. Most published reports examining glenohumeral laxity have not used an objective testing device. Objective Quantify and compare glenohumeral translation and rotational range of motion between the throwing and non-throwing shoulders in professional baseball pitchers. Study Design Descriptive laboratory study. Methods Force-displacement and range of motion measures were performed bilaterally on 43 asymptomatic professional baseball pitchers. Ultrasound imaging was used to measure glenohumeral translations under stressed and unstressed conditions. Results No significant difference in translation was found between the throwing and nonthrowing shoulders. For both shoulders, posterior translation (5.38 ± 2.7 mm) was significantly greater (P < .001) than was anterior translation (2.81 ± 1.6 mm). External rotation in the throwing shoulder was significantly greater than that in the nonthrowing shoulder (P < .001), whereas internal rotation in the throwing shoulder was significantly less than that in the nonthrowing shoulder (P < .001). The total arc of rotation for the throwing shoulder was not significantly different than that for the nonthrowing shoulder, and correlation coefficients were poor between rotational and translational range of motion in the throwing shoulder, ranging from r = 0.232 to 0.209 between variables. Conclusion No significant difference in glenohumeral translation exists between the throwing and nonthrowing shoulders in asymptomatic professional baseball pitchers, posterior translation is significantly greater than anterior translation in the throwing shoulders of professional baseball pitchers, and glenohumeral translation is not related to rotational range of motion in the throwing shoulders of professional baseball pitchers. Clinical Relevance Altered mobility patterns in asymptomatic professional baseball pitchers may be due to factors other than capsular adaptive changes.

Glenohumeral Internal Rotation Measurements Differ Depending on Stabilization Techniques

Background: The loss of glenohumeral internal rotation range of motion in overhead athletes has been well documented in the literature. Several different methods of assessing this measurement have been described, making comparison between the results of studies difficult. Hypothesis: Significant differences in the amount of internal rotation range of motion exist when using different methods of stabilization. Study Design: Descriptive laboratory study. Methods: Three techniques were used bilaterally in random fashion to measure glenohumeral internal rotation range of motion: stabilization of the humeral head, stabilization of the scapula, and visual inspection without stabilization. An initial study on 20 asymptomatic participants was performed to determine the intrarater and interrater reliability for each measurement technique. Once complete, measurements were performed on 39 asymptomatic professional baseball players to determine if a difference existed in measurement techniques and if there was a significant side-to-side difference. A 2-way repeated-measures analysis of variance was used. Results: While interrater reliability was fair between all 3 methods, scapular stabilization provided the best intrarater reliability. A statistically significant difference was observed between all 3 methods (P < .001). Internal rotation was significantly less in the dominant shoulder than in the nondominant shoulder (P < .001). Conclusion: Differences in internal rotation range of motion measurements exist when using different methods. The scapula stabilization method displayed the highest intrarater reproducibility and should be considered when evaluating internal rotation passive range of motion of the glenohumeral joint. Clinical Relevance: A standardized method of measuring internal rotation range of motion is required to accurately compare physical examinations of patients. The authors recommend the use of the scapula stabilization method to assess internal rotation range of motion by allowing normal glenohumeral arthrokinematics while stabilizing the scapulothoracic articulation.

Principles of Patellofemoral Rehabilitation

Patellofemoral disorders continue to present as some of the most common and challenging pathologic conditions of the orthopedic and sports medicine community. Numerous surgical and rehabilitative approaches have been suggested to treat patients with such conditions, but no single approach has been shown to be the most beneficial because of the numerous etiologic factors associated with patellofemoral pain. Rehabilitation programs should be implemented based on a thorough clinical evaluation and continuously modified based on the unique and specific presentation of each patient. Early emphasis is placed on eliminating pain and inflammation. In addition, reestablishing soft tissue and muscular balance is an essential component to patellofemoral rehabilitation programs. As the patient improves, the rehabilitation program is advanced in a progressive and sequential manner to ensure that adequate stress is applied to the injured tissues to facilitate healing while minimizing detrimental loads. This article outlines specific treatment principles commonly associated with nonoperative and postoperative patellofemoral management to restore function as quickly and safely as possible.

Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes, Part 2: Injury Prevention and Treatment

The overhead throwing athlete is an extremely challenging patient in sports medicine. The repetitive microtraumatic stresses imposed on the athlete’s shoulder joint complex during the throwing motion constantly place the athlete at risk for injury. Treatment of the overhead athlete requires the understanding of several principles based on the unique physical characteristics of the overhead athlete and the demands endured during the act of throwing. These principles are described and incorporated in a multiphase progressive rehabilitation program designed to prevent injuries and rehabilitate the injured athlete, both nonoperatively and postoperatively.

Current concepts in the evaluation and treatment of the shoulder in overhead-throwing athletes, part 1: physical characteristics and clinical examination.

The overhead-throwing athlete is a challenging sports medicine patient. The repetitive microtraumatic stresses imposed on the athlete’s shoulder joint complex during the throwing motion constantly places the athlete at risk for injury. These stresses may effect several adaptations to normal shoulder range of motion, strength, and scapula position. The clinician should therefore appreciate the unique physical characteristics of the overhead-throwing athlete to accurately evaluate and treat throwing-related injuries.

The Effect of Neuromuscular Electrical Stimulation of the Infraspinatus on Shoulder External Rotation Force Production After Rotator Cuff Repair Surgery

Background Muscle weakness, particularly of shoulder external rotation, is common after rotator cuff repair surgery. Neuromuscular electrical stimulation has been shown to be an effective adjunct in the enhancement of muscle recruitment. Hypothesis Shoulder external rotation peak force can be enhanced by neuromuscular electrical stimulation after rotator cuff repair surgery. Study Design Controlled laboratory study. Methods Thirty-nine patients (20 men, 19 women) who had undergone rotator cuff repair surgery were tested a mean of 10.5 days after surgery. Testing consisted of placing patients supine with the shoulder in 45° of abduction, neutral rotation, and 15° of horizontal adduction. Neuromuscular electrical stimulation was applied to the infraspinatus muscle belly and inferior to the spine of the scapula. Placement was confirmed by palpating the muscle during a resisted isometric contraction of the external rotators. Patients performed 3 isometric shoulder external rotation contractions with and without neuromuscular electrical stimulation, each with a 5-second hold against a handheld dynamometer. Neuromuscular electrical stimulation was applied at maximal intensity within comfort at 50 pulses per second, symmetrical waveform, and a 1-second ramp time. The 3 trials under each condition were recorded, and an average was taken. The order of testing was randomized for each patient tested. A paired samples t test was used to determine significant differences between conditions (P < .05). Each group was also divided based on age, rotator cuff tear size, number of days postoperative, and neuromuscular electrical stimulation intensity. Analysis of variance Models were used to determine the influence of these variables on external rotation force production (P < .05). Results Peak force production was significantly greater (P < .001) when tested with neuromuscular electrical stimulation (3.75 kg) as opposed to without neuromuscular electrical stimulation (3.08 kg) for all groups tested. There was no significant difference based on the size of the tear, age of the patient, number of days after surgery, or level of neuromuscular electrical stimulation intensity. Conclusion Peak shoulder external rotation force was significantly increased by 22% when tested with neuromuscular electrical stimulation after rotator cuff repair surgery. Neuromuscular electrical stimulation significantly increased force production regardless of the age of the patient, size of the tear, intensity of the current, or the number of days postoperative. Clinical Relevance Neuromuscular electrical stimulation may be used concomitantly with exercises to enhance the amount of force production and potentially minimize the inhibition of the rotator cuff after repair surgery.

Postoperative Treatment Principles in the Throwing Athlete

Rehabilitation plays a vital role in the ultimate functional outcome after surgery in the overhead-throwing athlete. The ultimate goal of the postoperative rehabilitation program is to return the athlete to unrestricted sport specific activities as expeditiously and safely as possible while minimizing postsurgical complications. Rehabilitation after surgical procedures to stabilize the throwing shoulder must allow adequate healing time without allowing significant loss of motion to occur. Emphasis is placed on immediate but restricted and controlled motion, as well as the development of proprioception, neuromuscular control, and dynamic stabilization of the glenohumeral and scapulothoracic joint. The rehabilitation program will vary based on the unique characteristics and pathology of each patient, the specific surgical procedure performed, and the healing rate of the soft tissues involved. All of these factors must be considered when designing a postsurgical rehabilitation program for the overhead-throwing athlete. This article discusses the postoperative rehabilitation principles for the overhead athlete as well as specific programs used following thermal-assisted capsular shrinkage, arthroscopic Bankart repairs, open anterior capsular shift procedures, and glenoid labrum procedures.

Treatment of Recalcitrant Iliotibial Band Friction Syndrome With Open Iliotibial Band Bursectomy: Indications, Technique, and Clinical Outcomes

Background Iliotibial band friction syndrome (ITBFS) is an overuse injury causing lateral knee pain. There is evidence that the pathological lesion is in fact an inflamed bursa underlying the iliotibial band (ITB) rather than an inflamed ITB itself. Hypothesis Resection of the bursa underlying the ITB in ITBFS patients will relieve their pain and allow them to return to their preinjury activity level. Study Design Case series; Level of evidence, 4. Methods We describe the technique of ITB bursectomy and report a minimal 20-month follow-up of patients who had ITB bursectomies performed by a single surgeon. The patients completed a survey detailing their preoperative and postoperative symptoms and activities. Results The senior author performed 12 consecutive cases of ITB bursectomies (12 patients). One was excluded from the study (previous microfracture). The average age at surgery was 32 years (standard deviation, 5; range, 24-41). There were 7 men and 4 women. Postoperatively, patients were able to return to their preinjury Tegner activity levels, and the visual analog pain scores decreased by an average of 6 points (P < .001). Six patients were completely satisfied with the surgical outcome, 3 were mostly satisfied, 2 were somewhat satisfied, and none were dissatisfied. Nine of 11 patients said that knowing what they know now, they would have the surgery performed again for the same problem. Conclusion Iliotibial band bursectomy successfully reduces knee pain in patients with ITBFS and allows them to return to their preinjury level of activity. The great majority of patients were satisfied with the results of the procedure.