Rehabilitation in the over-head athlete: a cheat sheet
Before my athletic training career began, I had been exposed to multiple bouts of overuse injuries in my shoulder. I was in and out of physical therapy 8 different times by the time I was 16 years old; I clearly didn’t understand Einstein’s definition of insanity then. Baseball gave me a love of sports medicine and a long list of overhead injuries from pitching. My personal experience with injury has helped me greatly throughout my athletic training career. Upper extremity rehabilitation in the overhead athlete can be a challenge to get right.
Here’s my upper extremity rehab cheat sheet for the overhead athlete.
Focus on the big picture
It’s easy to get focused on the specific joint that’s injured. Yes, rotator cuff weakness, postural abnormalities, and faulty shoulder girdle kinematics need to be addressed. However, these athletes often have many more movement issues outside of their shoulder. Here’s what I’m concerned with regarding my overhead athletes.
Thoracic spine rotation. Particularly to the non-throwing side.
The ability to command hip internal and external rotation, along with flexion and extension. In better words…hip mobility and neuromuscular control.
The ability to stabilize the ribs over the hips with overhead activity. This may be better conceptualized as ‘core control,’ but I want the athlete to understand that their arm needs to move independently from the torso.
The ability to perform 3-way lunges and one leg straight leg dead lifts on both legs.
The ability to perform one arm suitcase, rack position, and overhead carrying patterns.
To me, those are all low hanging fruit general movement abilities that, in my experience, can mitigate some injury risk in the overhead athlete. They also are great skills to enhance performance.
Know your anatomy
The most important thing in any rehabilitation process is both understanding the anatomy and the specific injury the patient has. Our anatomy classes teach us ‘dead person’ anatomy; anatomy as it relates to a cadaver. We must know this inside and out. However, this is only part of the puzzle. Studying functional anatomy is key to producing high quality outcomes from a rehabilitation process. The joint-by-joint approach Gray Cook and Mike Boyle have popularized is a great place to start. Understanding how each joint in the body interrelates in movement is critical. Most injuries from overuse stem from a movement problem, so we need to understand how our anatomy moves.
Understand the demands of the sport
If you’re going to be a rehabilitation professional with an overhead sport, learn from the sport coaches about the demands of throwing or overhead striking if you’re unfamiliar. The 2 pages in our clinical training textbooks really aren’t enough information to fully understand what’s happening along the kinetic chain; the textbook and sports terminology differ too. I’m fortunate to have grown up around baseball and have been trained by many great coaches. My first job was coaching baseball when I was a teenager. If you want to try to master what’s happening while throwing, try teaching a group of 6-year-old kids how to throw a baseball or softball.
The rotator cuff gets plenty of attention already
In rehabilitation, it’s important to focus on rotator cuff strengthening. But, we must direct our attention to the entire body as well. Pitchers use their whole body to pitch and field players use their whole body to throw the baseball around the field. Strictly focusing on rotator cuff strengthening only produces a strong rotator cuff, which won’t help if there’s an inability to transfer force throughout the body. That’s like having a Ferrari without an engine.
Always throw to a target
I’m not a pitching coach, but I do know that players throw to targets. Anytime throwing is part of the program, make sure your athlete is throwing to a target. If they can’t do it in rehab, how can we expect them to do it in a game?
Be simple
Programs with 15 or more exercises take too long and get boring. I found myself writing long programs early in my career, which I found to be tedious and I’m sure it had a mind-numbing effect on my athletes. In many situations, I find myself trying to keep myself between 8-12 exercises. This maximizes our use of time and keeps me focused on a topic that I love to follow: the minimal effective dose. I’m not advocating for doing the bare minimum, quite the contrary. I want the maximum effect with the least amount of time needed. If there are exercises that are used to fill time, I get rid of them. Everything in my programs has a ‘why’ behind it.
Upper extremity rehab is incredibly challenging as a clinician. I’ve found that the more I try to simplify what I’m doing, the easier it is to effect change. In my clinical experience I’ve also found that simplifying has effect better results. I’m still trying to improve what I do, now I need to find a way to be more objective with what I’m doing.
