In our conversations with new DC, Dr. Serrano, we uncover many integrated concepts for rehabilitation of the shoulder complex and the importance of overhead motion.

1. What is overhead rehabilitation?

When people think about Overhead sport, usually baseball comes to mind[1,2]. And of course, baseball falls into this category along with other well-known sports such as: volleyball, softball (exception of pitchers), tennis, and swimming[3-6]. I would like to mention less-known sports such as Olympic Weightlifting , CrossFit, and Dance[7-9]. And introduce the idea of treating people who work in occupations that involve overhead movements into this population. For example, a construction worker hauling materials and supplies for at least 8 hours and an educator writing on a whiteboard for intermittent classes throughout the day are prone to obtain shoulder injuries[10,11]. The goal of any rehab program is to allow the patient to return to their sport, activity, or occupation pain free with better movement patterns that may lead to additional increases in function and performance. The purpose of this article is to first identify what classifies an overhead athlete, to identify a purposeful approach to common injuries and how to manage them. Lastly I will lay out a rehab protocol to use with overhead athletes that is evidence based while incorporating clinical experience. 

1. What are some injuries that need overhead rehabilitation?

Common injuries seen in the overhead population primarily involve the shoulder joint and are linked to overuse, increases in volume, increases in load, or prolonged postures[12]. The proximal long head of the biceps tendon (LHBT) is prone to pathological changes that may be inflammatory (-itis) or degenerative in nature (-osis)[13]. Thus, to make things inclusive I will use the suffix (-opathy) such as tendinopathy to include the wide variety of pathological changes[14]. Rotator cuff pathology usually involves the supraspinatus and infraspinatus tendons or musculotendinous junctions[15]. The labrum can undergo pathological changes. Please note the shoulder labrum can compared to the face of a clock and all portions can become injured. So, when performing a physical exam, think beyond the anterior labrum which are SLAP tears and Bankart lesions[16]. The posterior labrum becomes injured more often than you would expect (Kim’s lesion, Bennet’s Lesion, Posterior SLAP tear)[17,18]. This is not meant to be an exhaustive list by any means, but a magnifying glass on the more commonly encountered injuries. 

1. Is surgery needed for overhead injuries?

This question is answered best by including the patient, the rehabilitation clinician, and physician (usually an orthopedic surgeon in this case). It is best to have the patient consult with an orthopedic surgeon to determine if advanced imaging is needed along with other treatment interventions that conservative-based clinicians do not have access to (i.e. chiropractors, physical therapists, athletic trainers). These treatment interventions may include platelet-rich plasma, stem cell therapy, and hyaluronic acid (orthobiologics) to name a few[19]. While the efficacy of these treatments has not been thoroughly established for any musculoskeletal pathology it is a popular topic that patients may have questions about thus it is important for us be educated or direct to someone like a physician who is educated on orthobiologics[20]. In general, if a patient has minimal symptoms, minimal disruption to activities of daily life, and tolerable pain levels which will vary widely since pain is a psychosomatic experience a trial of conservative care (rehab, corrective exercise, manual therapy) can be started for at least 6-8 weeks. If the patient is not progressing or regressing in their condition then a surgical consult is warranted. 

1. Rehab Guidelines

Once a trial of conservative care has been established it is the job of the rehabilitation clinician to give a patient their best chance at returning to function. However, most rehab guidelines are made for post-surgical status. The purpose of this guideline is to serve for the rehab clinician working with the non-surgical overhead population.

1. Phase 1: This phase is meant to regain full range of motion if a patient does not have it or has pain in a certain range. For example, in subacromial impingement there may be loss of motion due to pain between 90-120 degrees of shoulder abduction[21]. This phase may include joint mobilizations, manual therapy techniques, IASTM, along with pain relief modalities that allow for ROM to be regained.

2. Phase 2: The purpose of this phase is to rebuild strength and endurance in the mid-back muscles in movements below the plane of the shoulder (90 degrees). Focus should be on strengthening: rhomboids, mid/lower traps, serratus anterior, and rotator cuff muscles. This phase may benefit from blood flow restriction training if the patient is limited in lifting adequate loads to gain strength[22]. 

3. Phase 3: This is when patient should have enough baseline strength and scapulothoracic stability to begin progressive overhead activity. This means performing strengthening above the shoulder plane and using concepts like end-range strengthening. Focus on strengthening and increasing the endurance of the rotator cuff musculature and their ability to promote a proper gleno-humeral rhythm and scapula-thoracic rhythm[23].

4. Phase 4: This is the phase where a patient begins activities that will translate directly into their activity or occupation. Clinicians should strive to mimic the same motor control patterns as will be encountered by the patient[24]. For example: a teacher may benefit from strengthening in the 90/90 position (shoulder abduction+ external rotation) and a firefighter may benefit from performing sled pulls and farmer’s carry because of its translation into hose carries and carrying heavy equipment in one arm[25,26].

1. Sport Specific Rehab Guidelines

This phase is meant for longer-term rehab and higher demand activities such as CrossFit, Olympic Weightlifting, and Baseball. My approach to this phase is one of gradual progression with increasing volume and intensity[27]. For example, an interval throwing program would be began here and involves increasing distance and amount of throwing[28]. Similarly, in Olympic weightlifters a progression from least intense to most intense would be clean+ strict press> clean+ push press> clean+ push jerk> clean + split jerk. Using patient soreness as a load indicator is a great tool in assessing tolerance. In my practice I like assessing patient soreness the following day compared to a numerical rating scale (NRS). For example, after a workout a 3-4/10 NRS may be rated as appropriate soreness, in the return to sport athlete the same criteria applies. If a patient is below or above these numbers load should be modified respectively. 

1. When to return to sport/activity?

Once again, this decision should be made including the patient and should take into account their psychological readiness. You can use a patient reported outcome such as the Tampa Scale of Kinesiophobia or simply observe the patient and interact with them when making this decision[29]. Objectively: the patient should have at least 90% strength of the uninvolved limb as a minimum when returning to full competition. In the upper extremity, measures of power and strength may expensive to obtain . In my practice I like using bodyweight pushups, the shoulder tap test, plank endurance  test, and seated medicine ball chest throw as functional readiness tests[30]. When returning to sport, use the same concept of gradual progression. For example, increasing the amount of reps, innings, lifts, or time making sure to track responses during and after each session. 

1. Final Thoughts

The topic of non-surgical management in the overhead population is a complex and broad topic because it encompasses different ages, activities and level of function. As Chiropractors with an expertise in rehabilitation it is our duty to give patients their best chance at returning to their sport/activity of choice. To summarize key concepts, I will start by saying how the non-surgical route should be a shared decision-making process between the patient, the rehab chiropractor, and a physician. Rehab is not a quick fix, and patients should be educated on how correcting dysfunctional movement patterns will slowly begin a change that will yield good results. Most pathology stems from dysfunctional movement patterns that are repeated and reinforced over time so having a good movement assessment is important when evaluating patients. From here, begin working on those dysfunctions which will include the scapular muscles, mid back muscles, and rotator cuff muscles. The importance of manual therapy techniques can’t be understated as fascial dysfunction can result in pain and decreased ROM. As the patient begins progressing, it is time to begin strengthening and increasing endurance in the overhead position they will be in. This may be pitching during the late cocking phase or the high windmill phase of the cricket pitch. No matter the sport/activity, it is important the clinician has a basic understanding of its physiological and biomechanical demands. Lastly, power exercises may be introduced and playing time can begin. In this phase, communication is important with coaches and patients to understand how their body is responding to the demands of the sport. This blog post is not meant to cover all aspects of overhead rehabilitation. I seek to humbly present guidance when it comes to non-surgical management in these injuries and the overhead population as the literature is scare. 

References 

1. Wilk, K. E., Obma, P., Simpson, C. D., Cain, E. L., Dugas, J., & Andrews, J. R. (2009). Shoulder injuries in the overhead athlete. journal of orthopaedic & sports physical therapy, 39(2), 38-54.

2. Wilk, K. E., Macrina, L. C., Fleisig, G. S., Porterfield, R., Simpson, C. D., Harker, P., ... & Andrews, J. R. (2011). Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. The American Journal of Sports Medicine, 39(2), 329-335.

3. Krajnik, S., Fogarty, K. J., Yard, E. E., & Comstock, R. D. (2010). Shoulder injuries in US high school baseball and softball athletes, 2005–2008. Pediatrics, 125(3), 497-501.

4. Cools, A. M., & Reeser, J. C. (2017). Shoulder injuries in volleyball. Handbook of Sports Medicine and Science, Volleyball, 93.

5. Skillgate, E., Cools, A., Fernandez-Fernandez, J., & Johansson, F. (2020). 101 Multiple workload spikes and the risk of shoulder injuries in adolescent competitive tennis players: the SMASH cohort study.

6. van Dorssen, E., & Stubbe, J. (2017). Shoulder injuries in talented, competitive swimmers. British Journal of Sports Medicine, 51(4), 402-402.

7. Summitt, R. J., Cotton, R. A., Kays, A. C., & Slaven, E. J. (2016). Shoulder injuries in individuals who participate in CrossFit training. Sports health, 8(6), 541-546.

8. Aasa, U., Svartholm, I., Andersson, F., & Berglund, L. (2017). Injuries among weightlifters and powerlifters: a systematic review. Br J Sports Med, 51(4), 211-219.

9. Allen, N. (2019). Injury Prevention and Management for Dancers. The Crowood Press.

10. Nyawose, Z. Z., & Naidoo, R. (2019). Prevalence of shoulder musculoskeletal disorders among school teachers: a systematic review. South African Journal for Research in Sport, Physical Education and Recreation, 41(3), 51-61.

11. Saedpanah, K., Motamedzade, M., Salimi, K., Eskandari, T., & Samaei, S. E. (2018). Physical Risk Factors among Construction Workers by Workplace Ergonomic Risk Assessment (WERA) Method. Archives of Occupational Health, 2(1), 56-62.

12. Mihata, T. (2020). Shoulder Injuries in Overhead Athletes. In Sports Injuries of the Shoulder (pp. 23-51). Springer, Cham.

13. Leroux, T. S., & Romeo, A. A. (2017). Management of proximal biceps pathology in overhead athletes: What is the role of biceps tenodesis?. Am J Orthop, 46(1), E71-E78.

14. Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine, 43(6), 409-416.

15. Kuhn, J. E. (2013). Current concepts: rotator cuff pathology in athletes—a source of pain or adaptive pathology?. Current sports medicine reports, 12(5), 311-315.

16. Abrams, G. D., & Safran, M. R. (2010). Diagnosis and management of superior labrum anterior posterior lesions in overhead athletes. British journal of sports medicine, 44(5), 311-318.

17. Owen, J. M., Boulter, T., Walton, M., Funk, L., & Mackenzie, T. A. (2015). Reinterpretation of O'Brien test in posterior labral tears of the shoulder. International journal of shoulder surgery, 9(1), 6.

18. Bateman, D. K., Black, E. M., Lazarus, M. D., & Abboud, J. A. (2017). Outcomes following arthroscopic repair of posterior labral tears in patients older than 35 years. Orthopedics, 40(2), e305-e311.

19. Wiseman, S. P., Nelson, S. J., Tyagi, V., Kovacevic, D., & Blaine, T. A. (2017). Current trends in orthobiologics and shoulder surgery. Current Orthopaedic Practice, 28(2), 135-141.

20. Cole, B. J., & Frank, R. M. (2019). OrthoBiologics in Sports Medicine: Real-Time Applications Are Here, and Future Developments Are Promising!. Clinics in sports medicine, 38(1), xiii-xiv.

21. Baumann, A., & Morgan, B. (2017). Subacromial Impingement Syndrome. In Diagnostic Clusters in Shoulder Conditions (pp. 57-63). Springer, Cham.

22. Serrano, B., & Serrano, J. (2019). The Efficacy And Validity Of Blood Flow Restriction Training In Clinical And Post-Surgical Populations. International Journal of Physiotherapy, 6(5). doi: 10.15621/ijphy/2019/v6i5/18683

23. Flores-Hernandez, C., Eskinazi, I., Hoenecke, H. R., & D'Lima, D. D. (2019). Scapulothoracic rhythm affects glenohumeral joint force. JSES open access, 3(2), 77-82.

24. Ellenbecker, T. S., & Wilk, K. (2016). Sport therapy for the shoulder: evaluation, rehabilitation, and return to sport. Human Kinetics.

25. Wise, S. R., & Trigg, S. D. (2020). Optimizing Health, Wellness, and Performance of the Tactical Athlete. Current Sports Medicine Reports, 19(2), 70-75

26. Sefton, J.M., & Burkhardt, L.C.T.A. (2016). Introduction to the tactical athletes special issue. Journal of athletic training. 51(11). 845

27. Ardern, C. L., Glasgow, P., Schneiders, A., Witvrouw, E., Clarsen, B., Cools, A., ... & Mutch, S. A. (2016). 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British journal of sports medicine, 50(14), 853-864.

28. Reinold, M. M., Wilk, K. E., Reed, J., Crenshaw, K., & Andrews, J. R. (2002). Interval sport programs: guidelines for baseball, tennis, and golf. Journal of Orthopaedic & Sports Physical Therapy, 32(6), 293-298.

29. Lundberg, M. K., Styf, J., & Carlsson, S. G. (2004). A psychometric evaluation of the Tampa Scale for Kinesiophobia—from a physiotherapeutic perspective. Physiotherapy theory and practice, 20(2), 121-133.

30. Harris, C., Wattles, A. P., DeBeliso, M., Sevene-Adams, P. G., Berning, J. M., & Adams, K. J. (2011). The seated medicine ball throw as a test of upper body power in older adults. The Journal of Strength & Conditioning Research, 25(8), 2344-2348.

Brian Serrano, D.C., Ph.D., ATC, CSCS, TSAC-F, CES

Dr. Serrano serves as the Director of Rehabilitation and Performance at HPI Sports Medicine in Laguna Niguel, CA. His speciality is within overhead athletes in sports such as Baseball, CrossFit, and Olympic Weightlifting. His current research interests involve rotator cuff injury and shoulder labral tears. 

HPIsportsmed.com

Instagram