Renaissance Physical Therapy Newsletter

Renaissance Physical Therapy

RENAISSANCE PHYSICAL THERAPY

Research Update

This update is intended as a means for us to keep busy clinicians in the medical community up to date with recent research as it relates to physical therapy. Hopefully, this will increase the options you have when prescribing physical therapy for your patients.

Assessment of Shoulder Strength in Professional Baseball Players
Donatelli, et al. JOSPT 2000; 30(9): 544-551.

Common shoulder injuries in overhead throwing athletes include rotator cuff tendonitis, microinstabilities, glenoid labrum degenerative changes and tears, and secondary subacromial and scapular problems. The eccentric overload and repetitive microtrauma that occur in professional baseball pitchers can lead to musculotendinous injury. Also, subtle instabilities may exist in the glenohumeral joint, causing subacromial impingement.

Motion analysis studies on the normal patterns of throwing have been done and demonstrate that shoulder stability is, to a large degree, controlled by proper arm positioning and appropriate muscle balance around the shoulder. Undoubtedly, pitching requires scapular and glenohumeral stabilization. The balance of the scapulothoracic and glenohumeral joints is sustained by the strength of the rotator muscles; if the scapular rotators control the scapula, providing a stable glenoid, they in turn maintain optimal length-tension relationships of the glenohumeral muscles. Furthermore, the rotator cuff muscles dynamically stabilize the humeral head in the glenoid fossa and provide the main deceleration forces to the pitching arm during the follow-through portion of pitching. Shoulder muscle weakness has been indicated as a possible risk factor for injury development. Therefore, this study wanted to quantify and compare the passive ROM and muscle strength of the rotator cuff muscles in the pitching and non-pitching arms in a group of professional baseball players.

ROM and muscle testing were performed on both the pitching and non-pitching arms of the 39 professional baseball player participants. Goniometry was used for assessing external rotation (ER) and internal rotation (IR) with the upper extremity in 90 degrees of abduction, 90 degrees of elbow flexion, and forearm in neutral. Muscle strength was measured with a hand-held dynamometer. The muscles tested were supraspinatus, serratus anterior, lower trapezius, middle trapezius, and external and internal rotators (rotation strength was measured in 2 positions).

Results show that when compared with the nonpitching arm, the pitching arm demonstrates statistically greater passive ER and less passive IR. Hypotheses for the loss of IR ROM include fibrous tissue formation in the posterior capsule, musculotendinous tightness in the posterior cuff, and osseous changes secondary to the repetitive demands. This study also found significant deficit of the external rotators, significantly stronger internal rotators at 90 degrees of abduction, and no significant difference in the strength of the supraspinatus muscle group in the pitching arms of professional baseball pitchers when compared with their nonpitching arms. The absence of strength deficits of the supraspinatus could be a result of the significantly stronger middle and lower trapezius muscles that were discovered on the pitching side. Since these muscles control the amount of scapular protraction that occurs during deceleration, they help to decrease injury to the supraspinatus.

This study provides clinicians with a comprehensive look at ROM and muscle strength measurements in the pitching and non-pitching arms of professional baseball players. It gives us an important base line for assessing deficits in strength and motion for athletes who use one arm for overhead throwing, especially for recognizing the significance that the scapular retractor muscles play in decreasing excessive stressors on the rotator cuff.

Heel Pain Treatments Stretch Patient’s Tolerance
Walter JH, Biomechanics, March 2001, pages 53-66.

This article details the importance of aggressively treating plantar fasciitis with conservative measures to avoid unnecessary surgery. Plantar fasciitis is an inflammation of any portion of the plantar fascia from its origin at the medial and lateral tubercles of the calcaneus, extending distally into the toes. This is a common foot diagnosis usually associated with plantar heel spurs.

Plantar fasciitis, which is mostly biomechanical in origin, is hall-marked by pain that is worse when standing first thing in the morning or after sitting for 10 minutes or more. The pain appears to subside after walking for a period of time, only to worsen as the day pro-gresses. An attempt to avoid the pain is seen with walking of the sides of the feet or toes. This response actually aggravates the inflammation and can lead to further alterations in gait patterns. Secondary problems are commonly generated from these gait alterations and may replace the heel pain as most severe. If this occurs, a biomechanical examination of the lower extremity is needed to view the function of the foot in gait and stance to determine what gait compensations have occurred to cause the secondary problems.

The key factor in treatment and care of heel pain is exercise. Non-weight bearing stretches are especially beneficial in reducing severe morning pain. With mild, moderate or severe pain, treatment recommendations include supportive taping, orthotic arch support, and elimination of barefoot walking. Also used are supportive lace-up shoes, anti-inflammatories, night splints, or injection therapy, if needed. Factors that reduce pain, such as heel elevation, should be incorporated into footwear.

With only a 50% success rate with heel spur surgeries, and the risks and complications associated with plantar release, incisional surgery, or endoscopic surgery, it is important for plantar fasciitis to be dealt with swiftly. This article shows that treating plantar fasciitis in a consistent and systematic manner can render a patient asymptomatic with the fewest complications.

End-Range Mobilization Techniques in Adhesive Capsulitis of the Shoulder Joint:
A Multiple-Subject Case Report
H.M. Vermeulen, et al., Physical Therapy, Volume 80, Number 12. December 2000. 1204-1213.

The deleterious effects of shoulder adhesive capsulitis involve progressive loss of both active and passive range of motion of the involved shoulder. In addition, there is an associated loss of function with pain symptoms experienced. The purpose of this study was to examine the efficacy of glenohumeral joint mobilizations in the management of shoulder adhesive capsulitis.

Subjects were 4 men and 3 women, mean age of 50.2 years, mean disease duration of 8.4 months, and the cause of the adhesive capsulitis was not known (no specific injury, diabetes, or significant OA involved). Active mobility and pain levels were the primary outcome measures used. Pain indexes and active/passive range of motion for shoulder abduction, flexion in the sagittal plane, and external rotation were measured prior to treatment, after 3 months of treatment, and again at 9 months post-treatment.

Treatment involved only the use of end-range mobilization techniques (EMT’s) to the glenohumeral joint. No other modalities or interventions were utilized. EMT’s were done 2X/week for 30 minutes each time, for a period of 3 months. Number of treatment sessions amongst the subjects ranged from 14 to 22 (mean = 18).

Mean increase in active shoulder motion over the first 3 months was as follows: abduction = 60 degrees, flexion = 34 degrees, external rotation = 18 degrees. Mean increase in passive shoulder motion was as follows: abduction = 63 degrees, flexion = 34 degrees, external rotation = 20 degrees. Mean increase in active shoulder motion 9 months following treatment was as follows: abduction = 70 degrees, flexion = 38 degrees, external rotation = 21 degrees. Mean increase in passive shoulder motion 9 months post treatment was as follows: abduction = 73 degrees, flexion = 39 degrees, and external rotation = 22 degrees. Five of the 7 patients reported having no pain after 3 months of treatment, and 9 months post-treatment. The 2 patients that continued to report pain were subsequently diagnosed with rotator cuff tears.

The results of this multiple-subject case study suggest that the use of EMT’s to the glenohumeral joint, to address adhesive capsulitis, produced significant increases in shoulder ROM, and significant decreases in pain amongst the majority of the subjects. A control group was not examined to measure changes in ROM and perceived pain in the absence of intervention. However, a previous study found the mean duration of adhesive capsulitis to be 30 months. Because the mean duration of symptoms for the test subjects in this study was 8.4 months, it can be inferred that the subjects’ shoulders were not significantly influenced by the “natural progression of the disease,” and that the changes observed were due more to the interventions done.

Renaissance’s clinicians are all skilled in a variety of joint specific mobilization techniques. Our treatment approaches involve a balance between manual therapy techniques and therapeutic exercise to obtain the best possible treatment outcomes.