Interval Program and Its Implication for the Throwing Athlete

Michael W. Allen

Sumant G. Krishnan

The kinematics and kinetics of full effort pitching are well documented (1). Shoulder internal rotation velocity can exceed loads of 7,000 degrees per second, while ball velocity approaches 90 to 100 mph (2,3). Despite continued advancements in rehabilitation techniques, these forces are impossible to reproduce in a clinical or training room setting. Therefore, a gradual transition to sport-specific functional programs must be developed. Interval throwing programs (ITP) assist athletes in their physiologic and neuromuscular reconditioning. This process is based on “specific adaptation to imposed demand,” or the SAID principle (4). It requires progressive adaptations by increasing loads to the skeletal, articular, neural, and soft tissue systems. Establishing a sufficient strength and endurance base with appropriate functional intervention is essential in returning an athlete to preinjury/surgery status expeditiously and with minimal complications (Fig. 8-1).

FIGURE 8-1. Game participation.

In developing an ITP, the chronologic and physiologic time of healing following a surgery or injury must be well understood. Table 8-1 depicts time frames established for initiation of ITP for throwing athletes. Clinicians must be patient during this often difficult and lengthy phase of rehabilitation. The time frame in returning the athlete to a “competitive” level wherein performance matches or exceeds preinjury/surgery status is often longer than anticipated. It is common for an athlete to endure several setbacks or regressions during the ITP. Creating a well-designed rehabilitation approach is an essential element in returning a throwing athlete to full, unrestricted participation. This chapter outlines a concise, methodical, reproducible model for returning to competition at a high level of performance.

TABLE 8-1. EXAMPLE OF GENERAL TIME FRAMES FOR INITIATION OF INTERVAL THROWING AFTER COMMON SURGICAL PROCEDURES

*Shoulder*
Subacromial decompression	6 weeks—as tolerated
Anterior heat capsulorrhaphy	4 months
Posterior heat capsulorrhaphy	4 months
Heat capsulorrhaphy with SLAP repair	4 months
Rotator cuff repair	4 months
*Knee*
Knee meniscectomy	1-2 weeks
Meniscus repair	3 months
ACL reconstruction	3 months
Patella tendon fenestration	3 months
Microfracture condyle	3 months
Microfracture trochlear groove	3 months
*Elbow*
Arthroscopic debridement	6 weeks—as tolerated
UCL reconstruction	3-4 months
ACL, anterior cruciate ligament; UCL, ulnar collateral ligament.

Nonsurgical versus Postsurgical Approach

In establishing an appropriate strategy for returning the throwing athlete to competition, we must first turn our attention to the basic science of healing. Nonsurgical progression through the ITP is more rapid and based on the athlete’s symptoms. Postsurgical progression is generally slower and based on the physiologic healing process involved for that particular procedure. Nonsurgical athletes may bypass lower levels of the program whereas postsurgical athletes generally follow each level sequentially.

For both nonsurgical and surgical intervention, the clinician must first give strong attention to the global deconditioning process that occurs when an athlete is injured and unable to throw for an extended period of time. Arm strength and, in particular, endurance is lost rapidly. This is extremely important to understand because complications can arise when an athlete is progressed too rapidly through the program.

Criteria for Entry into the Interval Throwing Program

Before the initiation of the ITP, a well-designed strength and endurance program must be completed. Initiating the ITP for either the nonsurgical or postsurgical athlete requires the following six criteria:

No subjective complaints
Full pain-free range of motion (ROM)
Full strength
Negative clinical examination
Adequate endurance
Maintenance program in strength, flexibility, and conditioning

TABLE 8-2. GUIDELINES FOR PROBLEM-BASED MODIFICATION OF A THROWING PROGRAM

Soreness at beginning of session but subsides after warm up:

Treatment intervention: continue session at that level

Soreness at beginning of session that does not resolve:

Treatment intervention: attempt to reduce sore level, if soreness persists, end session. Take appropriate measures to reduce inflammation. Reassess range of motion (ROM), strength, flexibility, and endurance. Resume throwing at one level lower once a negative clinical examination is present.

Soreness during a session associated with pain:

Treatment intervention: end session. Pain is often associated with a rapid decrease in performance. Throwing mechanics change: change in velocity, location, arm action, or body lean. Take appropriate measures to reduce inflammation.

Reassess ROM, strength, flexibility, and endurance. Resume throwing at one level lower once a negative clinical examination is present.

Soreness during a session associated with fatigue:

Treatment intervention: The athlete reports a gradual increase in fatigue in the latter portions of the throwing session. The fatigue is usually reported in the posterior shoulder region as a response to sports-specific reconditioning of the rotator cuff decelerators. The timing of this subjective report during a session is an excellent measure of the athlete’s improvement in throwing endurance (i.e., a later onset of fatigue equates to improved endurance). The athlete should stay at the current level of throwing until he is able to complete the level without significant reports of fatigue.

No soreness during session, soreness and fatigue the next day, no pain

Treatment intervention: This is the expected post-throwing response. Continue at the current level of throwing. Soreness should resolve within 24 hours.

No soreness during session, soreness, fatigue and pain lasting greater than 2 days

Treatment intervention: Take one session off. If symptoms resolve, resume throwing at one level lower. If symptoms continue, discontinue throwing until a negative clinical examination is present. Initiate antiinflammatory measures and address strength, ROM, flexibility, and endurance deficits.

Allowing an athlete to return without meeting these six criteria assures certain failure and potential reinjury. Moreover, the athlete should have these variables reassessed frequently as they progress through the program. Close monitoring of these criteria enables the therapist or trainer to “back down” or modify the athlete’s program appropriately. Table 8-2 lists modifications to programs when complications arise.

Controlling Exercise Variables

Before initiating the ITP, the primary focus for the throwing athlete is centered on restoring full ROM, strength, flexibility, and endurance. It is common for an athlete to be involved in some aspect of rehabilitation, strength, or conditioning 3 to 8 hours per day for 4 to 6 days per week. Without question, total training volume can reach high levels, which, if not controlled, can lead to fatigue and overuse. The end result is decreased performance, frustration, and possibly injury. The ITP must be considered an exercise modality in itself. Once initiated, it must have first priority in the athlete’s rehabilitation program. Table 8-3 establishes appropriate sequencing. The ITP should follow a 10-minute cardiovascular warm-up and thorough upper and lower extremity stretch. Global weight room strength and conditioning are modified and likely reduced. The total volume of rotator cuff and scapular strengthening must also
decrease. Plyometric exercises for the upper extremity are decreased or eliminated. Although these essential components are being deemphasized, it is essential that the throwing athlete not be allowed to regress in flexibility, strength, or overall conditioning. Undoubtedly, controlling and monitoring these variables is difficult but essential to successfully directing the program.

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