Evidence Based Approach to Returning Baseball Pitchers to ... Winter... · 14. Motus Global: New...

Evidence Based Approach to Returning Baseball Pitchers to Participation

Cage SA, Gallegos DM, Warner BJ

Thank you

Outline

• Quick reminder on evidence based practice

• PICO Question

• Phases of throwing

• Relevant anatomy of the shoulder complex

• Pitching injury epidemiology

• Best available evidence for return to throwing

• Anecdotal evidence for return to throwing

• Conclusions

Obligatory Evidence Based Practice Refresher

What is evidence based practice?

• This is the wrong question.

• We need to be asking, what EBP is NOT

• “EBM is not a blueprint on how to practice athletic training. Decisions on how to care for athletes are not based solely on the available evidence. Factors such as personal experience, judgement, and patient preferences must be considered. Any clinician who feels restricted to behave only as the evidence dictates is missing the concept of EBM.” (Steves and Hootman, 2004)

What is evidence based practice?

• Incorporates

• Best Research Evidence

• Clinical Expertise

• Patient Values and Preferences

EBP

Pro

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al E

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PICO Question

PICO Question

• Patients – Baseball pitchers undergoing rehabilitation following a shoulder or elbow injury

• Intervention – Pitching off of a 10” mound at 60’6”

• Control – Pitching off flat ground at 60’6”

• Outcome – Increased stresses at the elbow and shoulder

Phases of Throwing

Phases of throwing

• Wind up

• Neutral GH position

• Varied elbow position

• Low GH joint stress

• Lower body/core muscle contraction

Phases of throwing

• Cocking

• 90 degree GH rotation

• Maximal ER

• Concentric external rotators

• Eccentric internal rotators

• Anterior/Inferior GH capsule stress

• 90 degrees elbow flexion*

• Valgus stress

• Varus torque

Phases of throwing

Phases of throwing

• Acceleration

• GH moving into IR to release

• Anterior GH capsule stress

• Concentric internal rotators

• Serratus anterior

• Upper trap

• Trunk

• Eccentric external rotators

• Rhomboids

• Middle/Lower trap

• Elbow moving into extension

Phases of throwing

• Deceleration

• GH moving into IR after release

• Poster GH capsule stress

• Concentric Internal Rotators

• Triceps Brachii

• Eccentric External Rotators

• Biceps Brachii

• Brachialis

• Elbow moving into extension

Phases of throwing

• Follow through

• GH horizontal adduction

• GH internal rotation

• GH adduction

• Posterior GH capsule stress

• Concentric internal rotators

• Eccentric external rotators

• Elbow extension

Relevant Shoulder Anatomy

Shoulder “Complex”

• 4 Articulations

• Glenohumeral Joint

• Acromioclavicular Joint

• Sternoclavicular Joint

• Scapulothoracic Articulation

• 16,000+ possible positions

• ↑Mobility → ↓Stability

Relevant Elbow Anatomy

The Ulnar Collateral Ligament


• Anterior bundle

• Primary restraint against valgus force

• Transverse bundle

• Little support

• Posterior bundle

• Taut beyond 60 degrees of flexion

Shoulder & Elbow Epidemiology

Shoulder & Elbow Epidemiology

• Incidence of shoulder and elbow injuries in adolescent baseball players has increased over the past 20 years.

• Of all overhead athletes, baseball pitchers are uniquely susceptible to acute and chronic upper extremity pathologies

• Particularly ulnar collateral ligament sprains

• Generally require surgery and ~10 months of therapy

UCL Sprains

• Valgus load at the UCL experienced by professional pitchers when throwing is greater than what the body can produce with a maximal isometric contract

• This valgus stress must be countered by a varus moment distributed across:

• Muscles & tendons

• Osseous articulation

• UCL

• To support a varus moment, the UCL has to undertake an elevated amount of tension

UCL Sprains

• Tension at the UCL can be reduced through contraction of the wrist flexor and pronator muscles

• Generates joint compression

• Pitching motion imparts the largest valgus moments during the cocking and acceleration phases of throwing

What is being done?

• Baseball organizations are taking steps to limit the number of pitches thrown per game

• Required days of rest between pitching outings

• Age limits being placed on certain types of pitches

Why the rise injury incidence?

When the inevitable happens

Best available evidence

• Generally agreed upon that it is necessary to gradually increase throwing distance, volume and intensity after injury

• What do you progress first?

• How fast do you progress?

• When do you put them on the mound?


• Considerations

• Severity of injury

• Nature of surgery

• Time of year

• Patient’s eligibility/contract status

• No universally accepted throwing program


• Shoulder and elbow torque greater when throwing at distances of 120-180 feet when compared to throwing from a mound at 60.5 feet

• Timing of mechanical events appears to be similar when throwing on flat ground compared to the mound

• Pitch cycle slightly shorter off a mound


• Joint velocity similar when throwing from flat ground compared to off a mound

• GH and elbow joint moments significantly greater when throwing off a mound

• Maximum and average pitch velocities higher when throwing off a mound

• Another indication of increased force?


• Ground reaction forces on the plant leg are greater when throwing off a mound

• There is still a measure of difficulty assessing these values in game situations

What we’ve been working on

Motus Sleeve

• Acquires motion data through a 3d Motion sensor embedded in a device the size of a thumb drive

• Housed in a spandex sleeve

• Provides information such as:• Arm speed

• Varus moment torque

• Elbow height

• Release point

Motus Sleeve

Motus Sleeve

• Previous used in study on arm torque at various elbow angles

• Analyzed 82,000 pitches by 81 professional pitchers

• Elbow torque increased significantly as pitchers increased their GH rotation during cocking phase

• Increased arm speed is directly related to increased in elbow torque

Is this the safest way to throw?

Cage, et al, (In Preparation)

• 11 collegiate pitchers

• Wore Motus Sleeve on medial joint line of elbow

• 5 max effort 4-seam fastballs

• 60’6” from 10” pitching mound

• 50’6” from 10” pitching mound

• 60’6” from flat ground


Motus Sleeve


• Arm Speed in RPM

• 60’6” from 10” mound

• 991.96


• 980.4


• 973.4


• 985.93


• Arm Speed

• No significant differences caused by throwing surface or distance


• Torque in N m


• 47.18


• 46.8


• 43.58


• 41.76


• Torque

• Significant differences (p=0.021) were observed between mound and flat ground throws

• No significant effects (p=0.515) from distance

Until we have more information

• Rely on pitch velocity and location rather than pitch counts

• Injury rates have improved

• Is this practical for everyone?

Next Phases

• Evaluate arm speed and elbow torque at more distances

• Evaluate effect of arm slot on arm speed and elbow torque

PICO Question

• Patients – Baseball pitchers undergoing rehabilitation following a shoulder or elbow injury

• Intervention – Pitching off of a 10” mound at 60’6”

• Control – Pitching off flat ground at 60’6”

• Outcome – Increased stresses at the elbow and shoulder

Conclusions

• Researches and clinicians have yet to universally agree on a return to throwing protocol

• The diligent clinician must consider all aspects of their patient’s injury when designing a protocol

• Severity

• Type of surgery

• Length of time post surgery

• Eligibility/contract status

• Phase in life

Conclusions

• Things we do know

• Increased elbow and shoulder torque when distance is increased (120’-180’ vs. 60’6”)

• Joint velocity is similar when throwing from a mound or flat ground

• Maximum and average pitch velocities are higher when throwing from a mound compared to flat ground

• The elbow and shoulder experience greater forces when throwing from a mound compared to flat ground at similar distances

Conclusions

• This information cannot be ignored

• Begin to incorporate pitching “motion” into throwing program prior to placing patient on mound

• Ensure adequate strength and endurance prior to increasing volume, distance, and intensity of throws

Conclusions

• Evaluation and re-evaluation of throwing program outcomes is crucial to advancing patients appropriately

• When the evidence is lacking, use what you have available

• Do not forget your clinical expertise

Quiz Time

Question 1

• Which of the following is NOT a common site of upper extremity injury in baseball pitchers?

• Biceps brachii tendon

• Medial epicondyle/Ulnar collateral ligament

• Rotator Cuff

• All of these are common sites of upper extremity injury in baseball pitchers.

Question 2

• True/False: Distance thrown can play a factor in the forces exerted on the shoulder and elbow complexes during throwing.

Question 3

• True/False: Traditionally, throwing off of a mound has been thought to exert the same forces on the elbow and the shoulder as throwing from flat ground from an equal distance.

Question 4

• True/False: Throwing programs should be done in conjunction with therapeutic exercise, not to replace a therapeutic exercise program.

Question 5

• True/False: Throwing program progression should only be re-evaluated at patient prompting.

References

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2. Axe M. Recommendations for protecting youth baseball pitchers. Sports Med Arthrosc Rev. 2001;9:147-153.

3. Buffi JH, Werner K, Kepple T, Murray W. Computing Muscle, Ligament, and Osseous Contributions to the Elbow Varus Moment During Baseball Pitching. Annals of Biomedical Engineering. 2015;43(2):404-415.

4. Camp CL, Tubbs TG, Fleisig GS, Dines JS, Dines DM, Altchek DW, Dowling B. The Relationship of Throwing Arm Mechanics and Elbow Varus Toque: Within-Subject Variation for Professional Pitchers Across 82,000 Throws. Am J Sports Med. 2017;45(13):3030-3035.

5. Dines J, Altchek D. Elbow Ulnar Collateral Ligament Injury: A Guide to Diagnosis and Treatment. New York, NY: Springer Science; 2015.

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12. Lin FN, Kohli N, Perlmultter S, Lim D, Nuber G, Makhsous M. Muscle contribution to elbow joint valgus stability. J Shoulder Elb Surg. 2007;16:795-802.

13. McGraw MA, Kremchek TE, Hooks TR, Papangelou C. Biomechanical evaluation of the docking plus ulnar collateral ligament reconstruction technique. Am J Sports Med. 2013;41:313-320.

14. Motus Global: New Way to Keep Baseball Players in the Game: Motus’ Motion-Sensing ‘Sleeve’. Journal of Engineering. 2014:956.

15. Nelson CW, Solomito M, Garibay E, Ounpuu S, Westwell M. A Biomechanical Comparison of Pitching From a Mound Versus Flat Ground in Adolescent Baseball Pitchers. Sports Health. 2013;(6):530-536.

16. Nissen C, Westwell M, Ounpuu S, et al. Adolescent baseball pitching technique: a detailed three-dimensional biomechanical analysis. Med Sci Sports Exerc. 2007;39:1347-1357.

17. Regular season pitching rules. Baseball. http://www.littleleague.org/Assets/forms_pubs/ media/PitchingRegulationCHanges_BB_11-13-09.pdf.

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19. Udall J, Fitzpatrick M, McGarry M, Leba T, Lee T. Effects of flexor-pronator muscle loading on valgus stability of the elbow with an intact, stretched, and resected medial ulnar collateral ligament. J Shoulder Elb Surg. 2009;18:773-778.

http://www.littleleague.org/Assets/forms_pubs/media/PitchingRegulationCHanges_BB_11-13-09.pdf

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