Rafael F. Escamilla

Shoulder Muscle Activity and Function in Common Shoulder Rehabilitation Exercises

The rotator cuff performs multiple functions during shoulder exercises, including glenohumeral abduction, external rotation (ER) and internal rotation (IR). The rotator cuff also stabilizes the glenohumeral joint and controls humeral head translations. The infraspinatus and subscapularis have significant roles in scapular plane abduction (scaption), generating forces that are two to three times greater than supraspinatus force. However, the supraspinatus still remains a more effective shoulder abductor because of its more effective moment arm.Both the deltoids and rotator cuff provide significant abduction torque, with an estimated contribution up to 35–65% by the middle deltoid, 30% by the subscapularis, 25% by the supraspinatus, 10% by the infraspinatus and 2% by the anterior deltoid. During abduction, middle deltoid force has been estimated to be 434 N, followed by 323N from the anterior deltoid, 283N from the subscapularis, 205N from the infraspinatus, and 117N from the supraspinatus. These forces are generated not only to abduct the shoulder but also to stabilize the joint and neutralize the antagonistic effects of undesirable actions. Relatively high force from the rotator cuff not only helps abduct the shoulder but also neutralizes the superior directed force generated by the deltoids at lower abduction angles. Even though anterior deltoid force is relatively high, its ability to abduct the shoulder is low due to a very small moment arm, especially at low abduction angles. The deltoids are more effective abductors at higher abduction angles while the rotator cuff muscles are more effective abductors at lower abduction angles.During maximum humeral elevation the scapula normally upwardly rotates 45–55°, posterior tilts 20–40° and externally rotates 15–35°. The scapular muscles are important during humeral elevation because they cause these motions, especially the serratus anterior, which contributes to scapular upward rotation, posterior tilt and ER. The serratus anterior also helps stabilize the medial border and inferior angle of the scapular, preventing scapular IR (winging) and anterior tilt. If normal scapular movements are disrupted by abnormal scapular muscle firing patterns, weakness, fatigue, or injury, the shoulder complex functions less efficiency and injury risk increases.Scapula position and humeral rotation can affect injury risk during humeral elevation. Compared with scapular protraction, scapular retraction has been shown to both increase subacromial space width and enhance supraspinatus force production during humeral elevation. Moreover, scapular IR and scapular anterior tilt, both of which decrease subacromial space width and increase impingement risk, are greater when performing scaption with IR (‘empty can’) compared with scaption with ER (‘full can’).There are several exercises in the literature that exhibit high to very high activity from the rotator cuff, deltoids and scapular muscles, such as prone horizontal abduction at 100° abduction with ER, flexion and abduction with ER, ‘full can’ and ‘empty can’, D1 and D2 diagonal pattern flexion and e The serratus anterior also helps stabilize the medial border and inferior angle of the scapular, preventing scapular IR (winging) and anterior tilt. If normal scapular movements are disrupted by abnormal scapular muscle firing patterns, weakness, fatigue, or injury, the shoulder complex functions less efficiency and injury risk increases.Scapula position and humeral rotation can affect injury risk during humeral elevation. Compared with scapular protraction, scapular retraction has been shown to both increase subacromial space width and enhance supraspinatus force production during humeral elevation. Moreover, scapular IR and scapular anterior tilt, both of which decrease subacromial space width and increase impingement risk, are greater when performing scaption with IR (‘empty can’) compared with scaption with ER (‘full can’).There are several exercises in the literature that exhibit high to very high activity from the rotator cuff, deltoids and scapular muscles, such as prone horizontal abduction at 100° abduction with ER, flexion and abduction with ER, ‘full can’ and ‘empty can’, D1 and D2 diagonal pattern flexion and extension, ER and IR at 0° and 90° abduction, standing extension from 90–0°, a variety of weight-bearing upper extremity exercises, such as the push-up, standing scapular dynamic hug, forward scapular punch, and rowing type exercises. Supraspinatus activity is similar between ‘empty can’ and ‘full can’ exercises, although the ‘full can’ results in less risk of subacromial impingement. Infraspinatus and subscapularis activity have generally been reported to be higher in the ‘full can’ compared with the ‘empty can’, while posterior deltoid activity has been reported to be higher in the ‘empty can’ than the ‘full can’.

Shoulder Muscle Recruitment Patterns and Related Biomechanics during Upper Extremity Sports

Understanding when and how much shoulder muscles are active during upper extremity sports is helpful to physicians, therapists, trainers and coaches in providing appropriate treatment, training and rehabilitation protocols to these athletes. This review focuses on shoulder muscle activity (rotator cuff, deltoids, pectoralis major, latissimus dorsi, triceps and biceps brachii, and scapular muscles) during the baseball pitch, the American football throw, the windmill softball pitch, the volleyball serve and spike, the tennis serve and volley, baseball hitting, and the golf swing. Because shoulder electromyography (EMG) data are far more extensive for overhead throwing activities compared with non-throwing upper extremity sports, much of this review focuses on shoulder EMG during the overhead throwing motion. Throughout this review shoulder kinematic and kinetic data (when available) are integrated with shoulderEMG data to help better understand why certain muscles are active during different phases of an activity, what type of muscle action (eccentric or concentric) occurs, and to provide insight into the shoulder injury mechanism.Kinematic, kinetic and EMG data have been reported extensively during overhead throwing, such as baseball pitching and football passing. Because shoulder forces, torques and muscle activity are generally greatest during the arm cocking and arm deceleration phases of overhead throwing, it is believed that most shoulder injuries occur during these phases. During overhead throwing, high rotator cuff muscle activity is generated to help resist the high shoulder distractive forces ≈0–120% bodyweight during the arm cocking and deceleration phases. During arm cocking, peak rotator cuff activity is 49–99% of a maximum voluntary isometric contraction (MVIC) in baseball pitching and 41–67% MVIC in football throwing. During arm deceleration, peak rotator cuff activity is 37–84% MVIC in baseball pitching and 86–95% MVIC in football throwing. Peak rotator cuff activity is also high is the windmill softball pitch (75–93% MVIC), the volleyball serve and spike (54–71% MVIC), the tennis serve and volley (40–113% MVIC), baseball hitting (28–39% MVIC), and the golf swing (28–68% MVIC).Peak scapular muscle activity is also high during the arm cocking and arm deceleration phases of baseball pitching, with peak serratus anterior activity 69–106% MVIC, peak upper, middle and lower trapezius activity 51–78% MVIC, peak rhomboids activity 41–45% MVIC, and peak levator scapulae activity 33–72% MVIC. Moreover, peak serratus anterior activity was ≈60% MVIC during the windmill softball pitch, ≈75% MVIC during the tennis serve and forehand and backhand volley, ≈0–40% MVIC during baseball hitting, and ≈70% MVIC during the golf swing. In addition, during the golf swing, peak upper, middle and lower trapezius activity was 42–52% MVIC, peak rhomboids activity was ≈60% MVIC, and peak levator scapulae activity was ≈60% MVIC.

Pitching Biomechanics as a Pitcher Approaches Muscular Fatigue During a Simulated Baseball Game

Background The effects of approaching muscular fatigue on pitching biomechanics are currently unknown. As a pitcher fatigues, pitching mechanics may change, leading to a decrease in performance and an increased risk of injury. Hypothesis As a pitcher approaches muscular fatigue, select pitching biomechanical variables will be significantly different than they were before muscular fatigue. Study Design Controlled laboratory study. Methods Ten collegiate baseball pitchers threw 15 pitches per inning for 7 to 9 innings off an indoor throwing mound during a simulated baseball game. A pitching session ended when each pitcher felt he could no longer continue owing to a subjective perception of muscular fatigue. A 6-camera 3D automatic digitizing system collected 200-Hz video data. Twenty kinematic and 11 kinetic variables were calculated throughout 4 phases of the pitch. A repeated-measure analysis of variance (P < .01) was used to compare biomechanical variables between innings. Results Compared with the initial 2 innings, as a pitcher approached muscular fatigue during the final 2 innings he was able to pitch, there was a significant decrease in ball velocity, and the trunk was significantly closer to a vertical position. There were no other significant differences in kinematics or kinetics variables. Conclusion The relatively few differences observed imply that pitching biomechanics remained remarkably similar between collegiate starting pitchers who threw between 105 and 135 pitches for 7 to 9 innings and approached muscular fatigue. Clinical Relevance This study did not support the idea that there is an increase in shoulder and elbow forces and torques as muscular fatigue is approached. It is possible that if a pitcher remained in a fatigued state for a longer period of time, additional changes in pitching mechanics may occur and the risk of injury may increase.

Kinematics used by world class tennis players to produce high-velocity serves

The purpose of this study was to quantify ranges and speeds of movement, from shoulder external rotation to ball impact, in the tennis service actions of world class players. Two electronically synchronised 200 Hz video cameras were used to record 20 tennis players during singles competition at the Sydney 2000 Olympic games. Three-dimensional motion of 20 landmarks on each player and racquet were manually digitized. Based upon the mean values for this group, the elbow flexed to 104 degrees and the upper arm rotated into 172 degrees of shoulder external rotation as the front knee extended. From this cocked position, there was a rapid sequence of segment rotations. The order of maximum angular velocities was trunk tilt (280 degrees/s), upper torso rotation (870 degrees/s), pelvis rotation (440 degrees/s), elbow extension (1510 degrees/s), wrist flexion (1950 degrees/s), and shoulder internal rotation. Shoulder internal rotation was greater for males (2420 degrees/s) than females (1370 degrees/s), which may be related to the faster ball velocity produced by the males (50.8 m/s) than the females (41.5 m/s). Although both genders produced segment rotations in the same order, maximum upper torso velocity occurred earlier for females (0.075 s before impact) than for males (0.058 s). At impact, the trunk was tilted 48 degrees above horizontal, the arm was abducted 101 degrees and the elbow, wrist, and lead knee were slightly flexed. Male and female players should be trained to develop the kinematics measured in this study in order to produce effective high-velocity serves.Abstract The purpose of this study was to quantify ranges and speeds of movement, from shoulder external rotation to ball impact, in the tennis service actions of world class players. Two electronically synchronised 200 Hz video cameras were used to record 20 tennis players during singles competition at the Sydney 2000 Olympic games. Three‐dimensional motion of 20 landmarks on each player and racquet were manually digitised. Based upon the mean values for this group, the elbow flexed to 104° and the upper arm rotated into 172° of shoulder external rotation as the front knee extended. From this cocked position, there was a rapid sequence of segment rotations. The order of maximum angular velocities was trunk tilt (280°/s), upper torso rotation (870°/s), pelvis rotation (440°/s), elbow extension (1510°/s), wrist flexion (1950°/s), and shoulder internal rotation. Shoulder internal rotation was greater for males (2420°/s) than females (1370°/s), which may be related to the faster ball velocity produced by the males (50.8 m/s) than the females (41.5 m/s). Although both genders produced segment rotations in the same order, maximum upper torso velocity occurred earlier for females (0.075 s before impact) than for males (0.058 s). At impact, the trunk was tilted 48° above horizontal, the arm was abducted 101° and the elbow, wrist, and lead knee were slightly flexed. Male and female players should be trained to develop the kinematics measured in this study in order to produce effective high‐velocity serves.

Patellofemoral compressive force and stress during the forward and side lunges with and without a stride.

BACKGROUNDnAlthough weight bearing lunge exercises are frequently employed during patellofemoral rehabilitation, patellofemoral compressive force and stress are currently unknown for these exercises.nnnMETHODSnEighteen subjects used their 12 repetition maximum weight while performing forward and side lunges with and without a stride. EMG, force platform, and kinematic variables were input into a biomechanical model, and patellofemoral compressive force and stress were calculated as a function of knee angle.nnnFINDINGSnPatellofemoral force and stress progressively decreased as knee flexion increased and progressively increased as knee flexion decreased. Patellofemoral force and stress were greater in the side lunge compared to the forward lunge between 80 degrees and 90 degrees knee angles, and greater with a stride compared to without a stride between 10 degrees and 50 degrees knee angles. There were no significant interactions between lunge variations and stride variations.nnnINTERPRETATIONnA more functional knee flexion range between 0 degrees and 50 degrees may be appropriate during the early phases of patellofemoral rehabilitation due to lower patellofemoral compressive force and stress during this range compared to higher knee angles between 60 degrees and 90 degrees. Moreover, when the goal is to minimize patellofemoral compressive force and stress, it may be prudent to employ forward and side lunges without a stride compared to with a stride, especially at lower knee angles between 0 degrees and 50 degrees. Understanding differences in patellofemoral compressive force and stress among lunge variations may help clinicians prescribe safer and more effective exercise interventions.

Optimal management of shoulder impingement syndrome

Shoulder impingement is a progressive orthopedic condition that occurs as a result of altered biomechanics and/or structural abnormalities. An effective nonoperative treatment for impingement syndrome is aimed at addressing the underlying causative factor or factors that are identified after a complete and thorough evaluation. The clinician devises an effective rehabilitation program to regain full glenohumeral range of motion, reestablish dynamic rotator cuff stability, and implement a progression of resistive exercises to fully restore strength and local muscular endurance in the rotator cuff and scapular stabilizers. The clinician can introduce stresses and forces via sport-specific drills and functional activities to allow a return to activity.

Biomechanical Performance of Baseball Pitchers With a History of Ulnar Collateral Ligament Reconstruction

Background: A relatively high number of active professional baseball pitchers have a history of ulnar collateral ligament reconstruction (UCLr) on their throwing elbow. Controversy exists in the literature about whether professional baseball pitchers regain optimal performance after return from UCLr. It has been suggested that pitchers may have different biomechanics after UCLr, but this has not been previously tested. Hypothesis: It was hypothesized that, compared with a control group without a history of UCLr, professional pitchers with a history of UCLr would have (1) significantly different throwing elbow and shoulder biomechanics; (2) a shortened stride, insufficient trunk forward tilt, and excessive shoulder horizontal adduction, characteristics associated with “holding back” or being tentative; (3) late shoulder rotation; and (4) improper shoulder abduction and trunk lateral tilt. Study Design: Controlled laboratory study. Methods: A total of 80 active minor league baseball pitchers (and their 8 Major League Baseball organizations) agreed to participate in this study. Participants included 40 pitchers with a history of UCLr and a matched control group of 40 pitchers with no history of elbow or shoulder surgery. Passive ranges of motion were measured for each pitcher’s elbows and shoulders, and then 23 reflective markers were attached to his body. The pitcher took as many warm-up pitches as desired and then threw 10 full-effort fastballs for data collection. Ball speed was recorded with a radar gun. The reflective markers were tracked with a 10-camera, 240-Hz automated motion analysis system. Eleven biomechanical parameters were computed for each pitch and then averaged for each participant. Demographic, range of motion, and biomechanical parameters were compared between the UCLr group and the control group by use of Student t tests (significance set at P < .05). Results: All hypotheses were rejected, as there were no differences in pitching biomechanics between the UCLr group and the control group. There were also no differences in passive range of motion between the 2 groups. Conclusion: Compared with a control group, active professional pitchers with a history of UCLr displayed no significant differences in shoulder and elbow passive range of motion and no significant differences in elbow and shoulder biomechanics. Clinical Relevance: Clinical studies have previously shown that 10% to 33% of professional pitchers do not return to their preinjury level; however, the current study showed that those pitchers who successfully return to professional baseball after UCLr pitch with biomechanics similar to that of noninjured professionals.

Cruciate ligament tensile forces during the forward and side lunge

BACKGROUNDnAlthough weight bearing lunge exercises are frequently employed during anterior cruciate ligament and posterior cruciate ligament rehabilitation, cruciate ligament tensile forces are currently unknown while performing forward and side lunge exercises with and without a stride.nnnMETHODSnEighteen subjects used their 12 repetition maximum weight while performing a forward lunge and side lunge with and without a stride. A motion analysis system and biomechanical model were used to estimate cruciate ligament forces during lunging as a function of 0-90 degrees knee angles.nnnFINDINGSnComparing the forward lunge to the side lunge across stride variations, mean posterior cruciate ligament forces ranged between 205 and 765N and were significantly greater (P<0.0025) in the forward lunge long at 40 degrees , 50 degrees , 60 degrees , 70 degrees , and 80 degrees knee angles of the descent phase and at 80 degrees , 70 degrees , 60 degrees knee angles of the ascent phase. There were no significant differences (P<0.0025) in mean posterior cruciate ligament forces between with and without stride differences across lunging variations. There were no anterior cruciate ligament forces quantified while performing forward and side lunge exercises.nnnINTERPRETATIONnClinicians should be cautious in prescribing forward and side lunge exercises during early phases of posterior cruciate ligament rehabilitation due to relatively high posterior cruciate ligament forces that are generated, especially during the forward lunge at knee angles between 40 degrees and 90 degrees knee angles. Both the forward and side lunges appear appropriate during all phases of anterior cruciate ligament rehabilitation. Understanding how forward and side lunging affect cruciate ligament loading over varying knee angles may help clinicians better prescribe lunging exercises in a safe manner during anterior cruciate ligament and posterior cruciate ligament rehabilitation.

Cruciate ligament loading during common knee rehabilitation exercises

Cruciate ligament injuries are common and may lead to dysfunction if not rehabilitated. Understanding how to progress anterior cruciate ligament and posterior cruciate ligament loading, early after injury or reconstruction, helps clinicians prescribe rehabilitation exercises in a safe manner to enhance recovery. Commonly prescribed therapeutic exercises include both weight-bearing exercise and non-weight-bearing exercise. This review was written to summarize and provide an update on the available literature on cruciate ligament loading during commonly used therapeutic exercises. In general, weight-bearing exercise produces smaller loads on the anterior cruciate ligament and posterior cruciate ligament compared with non-weight-bearing exercise. The anterior cruciate ligament is loaded less at higher knee angles (i.e. 50–100°). Squatting and lunging with a more forward trunk tilt and moving the resistance pad proximally on the leg during the seated knee extension unloads the anterior cruciate ligament. The posterior cruciate ligament is less loaded at lower knee angles (i.e. 0–50°), and may be progressed from level ground walking to a one-leg squat, lunges, wall squat, leg press, and the two-leg squat (from smallest to greatest). Exercise type and technique variation affect cruciate ligament loading, such that the clinician may prescribe therapeutic exercises to progress ligament loading safely, while ensuring optimal recovery of the musculoskeletal system.

Muscle Activation Among Supine, Prone, and Side Position Exercises With and Without a Swiss Ball

Background: Prone, supine, and side position exercises are employed to enhance core stability. Hypothesis: Overall core muscle activity would be greater in prone position exercises compared with supine and side position exercises. Study Design: Controlled laboratory study. Methods: Eighteen men and women between 23 and 45 years of age served as subjects. Surface electrodes were positioned over the upper and lower rectus abdominis, external and internal obliques, rectus femoris, latissimus dorsi, and lumbar paraspinals. Electromyography data were collected during 5 repetitions of 10 exercises, then normalized by maximum voluntary isometric contractions (MVIC). Differences in muscle activity were assessed using 1-way repeated-measures analysis of variance, while t tests with a Bonferroni correction were employed to assess pairwise comparisons. Results: Upper and lower rectus abdominis activity was generally significantly greater in the crunch, bent-knee sit-up, and prone position exercises compared with side position exercises. External oblique activity was significantly greater in the prone on ball with right hip extension, side crunch on ball, and side bridge (plank) on toes compared with the prone and side bridge (plank) on knees, the crunch, or the bent-knee sit-up positions. Internal oblique activity was significantly greater in the prone bridge (plank) on ball and prone on ball with left and right hip extension compared with the side crunch on ball and prone and side bridge (plank) on knees positions. Lumbar paraspinal activity was significantly greater in the 3 side position exercises compared with all remaining exercises. Latissimus dorsi activity was significantly greater in the prone on ball with left and right hip extension and prone bridge (plank) on ball and on toes compared with the crunch, bent-knee sit-up, and prone and side bridge (plank) on knees positions. Rectus femoris activity was significantly greater in the prone on ball with left hip extension, bent-knee sit-up, or prone bridge (plank) on toes compared with the remaining exercises. Conclusion: Prone position exercises are good alternatives to supine position exercises for recruiting core musculature. Side position exercises are better for oblique and lumbar paraspinal recruitment. Clinical Relevance: Because high core muscle activity is associated with high spinal compressive loading, muscle activation patterns should be considered when prescribing trunk exercises to those in which high spinal compressive loading may be deleterious.