A big thank you to attendee Luke Nelson for doing a fantastic job in providing this educational summary of our recent course, The Advanced Upper Limb Rehab in Sport.

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 upskill 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
• Cervical ROM
• 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)

Neuromuscular tests

• 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)

Strength testing

• 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.

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:

1. Absolute training volume: no studies linking absolute training volume
2. 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 ante torted bilaterally, not greatly different from the general population but different from throwing population.
3. 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
4. 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.
5. 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 ie 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 (ie. 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, attendees were reminded that throwing is

• Whole body activity
• Complex skill

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 2 cases of an injured athlete. What was interesting to observe in this workshop was that pretty much all groups came up with different exercises, which demonstrates the multitude of rehabilitative options we have for the injured athlete.

Day 2

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:

1. General conditioning AND
2. 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!):

1. Push press
2. Hang clean
3. Olympic lifts

Throwing creates 1-1.5x bodyweight 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 a “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

• Palpate and feel for radial head moving posterior
• Positive test is reproduction of their symptoms

Posterolateral rotatory instability test (pivot shift of elbow)

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

May involve:

• Joint effusion
• Calcification/osteophytes
• Loose bodies
• Ulnar neuritis
• Thickening of triceps tendon
• Thickening of ulnar collateral ligament

(Tyrdal 1999)

Posterior medial impingement or Valgus instability.

• More seen in elbow flexion

TFCC

• Ulnar sided pain with WB and/or traction forces
• Significant injury=instability
• 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

Prognosis

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

Differentials

• Tenosynovitis
• Tendinopathy
• Subluxation: get them to grip then supinate and pronate
• Rupture

Management

• Differs significantly depending on diagnosis (Campbell 2013)
• Consider grip & wrist postures

Intersection syndrome

• 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

Management

• 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)

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

• (Abduction and internal rotation): elbow in armpit, lift elbows up, want to see >140 degrees
• 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.

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

● Thoracic mobilization

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/shoulder 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

UCL thumb injury:
● If they have a high degree of laxity surgery rather than splint
● Usually injured with hyperextension and abduction
● Taping for UCL injuries: Standard Taping is good for abduction but often doesn’t stop extension at thumb. Craig uses a tape underneath in addition to the standard tape.

Extensor tendinopathy
● 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- countermovement 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.

So as you can see there was a LOT of content covered in the weekend, with this blog the tip of the iceberg. I’d like to thank SportsMAP and the speakers for making this such a great event, and I look forward to attending future events in 2020!

 

Many thanks to Luke Nelson from Health and High Performance for his contribution with this blog and allowing us to share it our platform.