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Shoulder Rehab Phase 3: Advanced Strengthening Phase
The advanced strengthening phase is designed to initiate aggressive strengthening exercises, augment power and endurance, advance functional drills, and gradually initiate throwing activities. Full shoulder ROM and flexibility should be maintained throughout this phase; failure to maintain motion and flexibility at this point is a potential pitfall that can result in recurrent symptoms. Muscle fatigue has been shown to decrease neuromuscular control and diminish proprioceptive sense. In this phase, strengthening activities are advanced using the Advanced Thrower’s Ten program, which incorporates high-level endurance, alternating movement patterns to further challenge shoulder girdle neuromuscular control and facilitate the rotator cuff musculature via alternating dynamic movements with sustained hold drills (Table 3). The incorporation of sustained holds challenges the athlete to maintain a set position while superimposed isotonic movements are performed with the opposite extremity. Two sets are incorporated into each exercise, each following a sequential progression integrating bilateral isotonic movement and unilateral isotonic movement with contralateral sustained holds. The athlete can be instructed to perform these exercises on a stability ball to further challenge the core (Figure 10), as well as manual resistance drills to increase muscle excitation and promote endurance. Manual resistance provided by the clinician is used during seated stability ball exercises to augment muscle excitation and improve endurance of the shoulder and core musculature.
Dynamic stabilization drills such as RS (Rhythmic Stabilization) are performed in a functional throwing position. Ball throws are performed to improve proprioception and neuromuscular control of the upper extremity. The athlete can perform stabilization techniques that include perturbations to enhance end-range stability through RS with performance of ball tosses into a wall (Figure 11), push-ups onto an unstable surface with perturbations, and external rotation tubing with concomitant manual resistance. In addition, these exercises can be performed on a physio ball to improve dynamic stabilization of the shoulder and trunk musculature.
Advanced Thrower’s Ten exercises, including prone horizontal abduction and row into external rotation with sustained holds and alternating arm/sustained hold sequencing, are initiated to challenge the endurance of the posterior rotator cuff, scapular musculature, lumbar extensors, gluteals, and hamstrings (Figure 12).
These types of exercises engage the posterior lower extremity chain and again link the upper extremity with the lower extremity (Figure 13). Side-lying ER, prone row, and prone horizontal abduction manual resistance of the shoulder joint complex are utilized to promote increased muscular activity, neuromuscular control, and endurance, which are essential in the force production for overhead throwing athletes.
Plyometrics are initiated to further enhance dynamic stability and proprioception, as well as to introduce and gradually increase functional stresses to the shoulder joint. Wilk et al have described numerous plyometric exercises for the overhead thrower. Enhanced joint position sense and kinesthesia, as well as decreased time for peak torque generation, have been demonstrated with plyometric strengthening. Fortun et al compared 8 weeks of plyometrics with conventional isotonic training and reported an increase of shoulder IR power and throwing distance using plyometrics.
Plyometric exercises begin with a rapid eccentric prestretch that stimulates the muscle spindle, followed by the amortization phase, which is the time between the eccentric and concentric phase. To allow an effective transfer of energy and prevent the beneficial neurologic effects of the prestretch from being dissipated as heat, the amortization phase should be as short as possible. The athlete is instructed to coordinate the trunk and lower extremity to efficiently allow the transfer of energy into the upper extremity during the plyometric drills. Wilk et al have described a plyometric program that systematically introduces stresses upon the healing tissues beginning with 2-handed drills such as chest pass, side-to-side throws, side throws, and overhead soccer throws. Upon successful completion of these 2-handed drills, the athlete can progress to one-handed drills such as standing onehanded throws, wall dribbles, and plyometric step and throws.
Muscle fatigue has been shown to diminish proprioceptive sense and alter biomechanics, increasing the risk of injury; therefore, muscle endurance training should be included in the rehabilitation program for every overhead throwing athlete. Murray et al performed kinematic and kinetic motion analysis and reported that shoulder external rotation and ball velocity decreased along with lead knee flexion and shoulder adduction torque once a thrower became fatigued. Muscle fatigue has been shown to contribute to superior humeral head migration upon the initiation of arm elevation. Lyman et al noted that the greatest predisposing factor to shoulder injury was muscle fatigue in Little League pitchers. Endurance training is performed by the athlete, including wall dribbles with a plyoball, wall arm circles, upper body cycle, and the Advanced Throwers Ten exercise program.
An interval throwing program (ITP) can be introduced during this phase. The ITP was developed to gradually introduce quantity, distance, intensity, and types of throws needed to facilitate the restoration of normal throwing motions. The ITP is divided into 2 phases: Phase 1 is a long-toss program, and phase 2 is a mound throwing program used for pitchers. Phase 1 is initiated at 45 feet (15 m) and progresses with increasing distance and volume of throws. The athlete is instructed to use a crow-hop method for throwing to incorporate the trunk and lower extremities while throwing with a slight arc for each prescribed distance. Fleisig et al reported that when pitchers were asked to throw at 50% effort, radar analysis showed it was approximately 83% of their maximum speed, and at a requested effort of 75%, the pitchers threw at 90% of their maximum velocity.
This study demonstrates the inherent difficulty in self-imposing velocity controls; therefore, we implement a slight arc (versus throwing on a line) in the longtoss program as a means to regulate the intensity of each throw and ensure the athlete is not throwing harder than the desired effort, allowing the program to be successfully advanced. The long-toss program is designed to gradually introduce loads, stress, and strains and should be successfully completed before throwing from the mound is permitted. Fleisig et al reported increased forces on the medial elbow and anterior glenohumeral joint with increasing distance.
Furthermore, the players’ throwing biomechanics changed with increasing distance, including greater trunk extension, stride length, and shoulder ROM. Position players can in addition begin a progressive hitting program that begins with swinging a light bat and progresses to hitting off a tee, soft-toss hitting, and then batting practice.