What’s Missing in your Examination of the Overhead Athlete
What is Different About the Overhead Athlete?
The prevalence of injury in overhead athletes is high. Six out of ten youth baseball pitchers will hurt their elbow. Many of these young athletes develop painful and unstable shoulders as well.
The peak angular velocities of shoulder internal rotation and elbow extension during the acceleration phase of throwing are 6180 degrees per second and 4595 degrees per second respectively. With such high forces being exerted on the joints, it’s no surprise that these young athletes develop injuries and structural changes such as humeral retroversion. Overhead athletes need to be strong enough to control these high forces. Weak rotator cuff muscles along with poor throwing mechanics could lead to rotator cuff tears, labral tears, elbow injuries, and so on.
As Kevin Wilk says, the overhead athlete should be “Loose enough to throw, but stable enough to prevent symptoms.”
Now, are all the upper extremity injuries we see in overhead athletes due to a problem in the upper extremity or are they due to muscle imbalances and mobility deficits elsewhere in the kinetic chain? Our job is determine where in the kinetic chain these injuries are stemming from and help prevent them.
Key Concepts in Examination of the Overhead Athlete
- Clinician must understand triplane loading cycle of throwing
- Don’t get caught only looking at the explosive phase. Spend more time assessing the loading phase because that’s where the movement starts and where the power comes from.
- Don’t be fooled by where symptoms appear, there is often a glitch somewhere else up or down the chain
- Be consistent in the exam process: start from ground up because that’s where power starts.
- Break down motion into components and assess patient’s ability to control body in each plane during each phase of the combined total motion
- Understand that muscles must react to gravity, ground reaction forces, body mass momentum, and other muscles.
In order to treat throwers, you must understand the loading and unloading phases of throwing.
Loading Phase
For the rest of this article, we will be referring to baseball athletes, but the concepts can be adapted to any overhead athlete.
Let’s discuss the loading phase. This is the cocking-back phase of throwing in which the athlete is building up energy before the throw and loading the joints and muscles in preparation for the high velocity unloading phase.
Pitching Form
Now, understand that there is no perfect form. If you look at some MLB pitchers, there are all sorts of variations in form. Use the athlete’s preferred form as a template. Don’t go trying to change everything about their form to what you’ve learned to be the ideal form because there are plenty of pitchers who have made it to the major leagues with odd pitching styles.
Pitcher’s Prayer Position
Pitcher’s prayer is a position you should be using as an assessment and treatment tool. This position is described below and shown in the following video.
Pitcher’s prayer loading form: knee should come parallel or above waist, foot should be directly under knee and relaxed. Hips should be closed off from target, shoulders should not be over-rotated away from target.
- 50% of overhead throwing power comes from the lower limb
- 30% from the trunk
- 20% from upper extremity
The loading phase of overhead throwing requires dorsiflexion, eversion, and big toe extension of loaded foot (Need eversion in pitcher’s prayer position to fully load the hip and prevent from opening up pelvis early).
Here is a video of dynamic rotations in pitcher’s prayer position
Examination Tips
- First off, ensure the overhead athlete has adequate ankle and foot ROM. If they don’t, consider having them stand in pitcher prayer stance with their foot everted on a slant board and manually assisting patient into trunk rotation over that foot.
- Observe ankle in pitchers prayer position (shown in video above). Have the athlete open up hips to evert foot, then have close up to look at inversion. Assessing these motions in weight-bearing is key.
- Again in pitchers prayer, have the athlete on one leg and have them rotate quickly to see how their foot handles rotational stress.
- Consider single-leg stance rotation with theratubing (progress to using partner for handling reactive rotational forces).
- To analyze frontal plane loading, have athlete in pitchers prayer position and observe the ability to drop hip (trendalenbug)
- Consider step downs while holding weight in pitchers prayer position as intervention
- For throwing, the opposite (non-throwing) scapula needs to have proper protraction in order to complete full range of motion during the loading phase
- Consider multi-directional reaches on single-leg to gain scapular mobility and incorporate scapular mobilization with movement as necessary.
- Assess single-leg squat ability and ability to flex and extend trunk while on one leg to get an idea how the patient functions under sagittal plane loading
- Consider starting pt with lunge with knee reach and overhead reach, progressing to adding external resistance.
Unloading Phase
Of course, this is the phase where all the action takes place. However, to improve the unloading phase you must first improve the loading phase. Set your athletes up for success.
Examination Tips
- Hip extension on the throwing side is necessary for effective and powerful release
- Here is a video of some anterior hip mobility drills I like to use
- Use a single leg rotational hop to assess ballistic motion of unload phase. Have patient in pitchers prayer position and jump while rotating toward lunge foot
- Translate this test directly into treatment to improve weight acceptance onto lunge leg
- Work on explosive transition from back leg to front leg with a smooth controlled landing on front foot
- Think of the lunge leg as a fulcrum. When lunge leg hits ground, it allows for continuation of throw. Force is absorbed through that front lunge leg. If lunge leg gets tired, it will affect the throw because you’ll want to lunge out with a stiff leg because your leg muscles cannot control the force.
- Consider working on eccentric control and plyometrics to improve lunge leg ability to absorb forces repeatedly.
- Start with double leg plyos and move to single leg plyos in multiple planes.
- Again, you can use the explosive drill described above to work on the eccentric control of the lunge leg
- Balance and the ability to decelerate rotational forces are critical to prepare to field a ball after pitching. Assess the athlete’s ability to stand on the throwing leg and reach across body to floor in anterolateral direction.
- Consider varying the speed of this motion and placing targets on floor to challenge athlete.
- You can use elastic bands and have the athlete eccentrically control anterolateral SL reach with resistance
- Try making this drill reactive so that the athlete is challenge to control changing force vectors
- If the leg, hip, and trunk cannot effectively decelerate the concentric action of the throw, the stress will be translated up the kinetic chain. This means that the posterior rotator cuff is going to be overworked. It is going to have to decelerated the force created by the throw, leading to increased stress to that area.
- Consider implementing transverse plane med ball throws against a wall to practice rotational deceleration.
- The transverse plane is arguably the most powerful for throwing because of the powerful external rotators of the hip and trunk. This is where most of the force is. Train the athlete to use this to their advantage.
- Thoracic rotation is critical along with hip rotation because limited TS rotation will cause excessive stress to other structures such as the shoulder and lumbar spine
- Always assess thoracic motion with your overhead athletes and any shoulder patient for that matter.
- Consider thoracic mobilization with movement drills with both top-down and bottom-up drivers (meaning that the rotation is either initiated from above or below).
- Thoracic rotation activities as a warm up have actually been shown to increase scapular and rotator cuff recruitment. (No I do not have the exact source for this claim. I learned it from a podcast and it is a clinical pearl that has stuck with me).
Exercise Ideas for the Overhead Athlete
If you haven’t already, I encourage you to check out these three shoulder exercises and use them with your throwers and overhead athletes.
Here are some other ideas to try out. I’ll soon be posting video demos of many of these on our Instagram page so stay tuned.
- Utilize joint compression forces to help improve rotator cuff recruitment.
- Closed chain scap exercises are great as long as you bring it back to function
- Closed chain helps add compressive forces which fire mechanoreceptors and improve timing of rotator cuff firing.
- 90/90 ER with tubing in functional lunge position (may not be functional for non-athletes but very functional for throwers)
- SL squat – advancing to slanted surface to encourage calcaneal eversion. Also try on dynamic surface
- Partner scapular reaction exercises
- Upper extremity plyo push ups on med ball
- PNF D2 pattern manual rhythmic stabilization for lower level patients. (Used by James Andrews and Kevin Wilk especially after Tommy John Surgery)
- Body Blade D2 pattern for rotator cuff endurance
- Chops and Lifts in tandem stance and SL stance
- One handed med ball tosses in 90/90 position
- Towel drill: for proper timing and form
- 1 foot of towel from hand, 2-4lbs in glove hand to keep glove in line with stool
- stool should be about 5 foot lengths from where stride lands
- head should stay in line with stool and not sway in frontal plane
Think Out of the Box
If traditional interventions aren’t working, take a step back. You probably did a good job of assessing the thoracic spine but don’t forget that shoulder mechanics also involve the AC and SC joint! These are often overlooked in most shoulder patients but may need to be addressed in the overhead athlete. The same goes for the ribs. The ribs need to rotate with the trunk and collapse and expand with breathing. Rib mobilizations with breathing can benefit scapular mobility. Just as the glenohumeral joint needs a stable base, the scapula does too. It should glide along ribs properly without restriction. It was not discussed in this article but it may be important to look at wrist motion and forearm muscle strength of throwing arm.
If you would like to learn more about the rehabilitation and training of the overhead athlete, particularly with baseball athletes, I highly encourage you to check out Elite Baseball Performance created by Mike Reinold
References
Much of the content provided I learned from my friend, colleague, and mentor Chris Ingstad. He is a former collegiate level and minor league baseball player that now works with many overhead athletes. He is now actively involved in the Brazilian Jiu Jitsu community and owns his own clinic in Carlsbad, CA. You can check out his page here.
Some of the content here was also adapted from things I learned through Gary Gray and his videos on assessment and treatment of overhead athletes.