Abstract
Return to a throwing sport after elbow or shoulder injury can be a daunting task. Return to play rates after ulnar collateral ligament reconstruction have been favorable but lower than once thought ( ). Many studies show a high return rate to major league baseball, but return to similar performance and workload is not as high ( ). Return to throwing after surgical treatment for superior labral lesions is even more debilitating and sometimes unattainable ( ).When helping guide patients back to throwing activities, a criteria-based algorithm should be followed that encompasses all aspects of the throwing motion and accounts for the physical characteristics of the athlete.
Keywords
Baseball Throwing Program, Interval Throwing Program, Pitching, Return to Sport, Rehabilitation for Throwers
Return to a throwing sport after elbow or shoulder injury can be a daunting task. Return to play rates after ulnar collateral ligament reconstruction have been favorable but lower than once thought ( ). Many studies show a high return rate to major league baseball, but return to similar performance and workload is not as high ( ). Return to throwing after surgical treatment for superior labral lesions is even more debilitating and sometimes unattainable ( ).
When helping guide patients back to throwing activities, a criteria-based algorithm should be followed that encompasses all aspects of the throwing motion and accounts for the physical characteristics of the athlete.
Phase 1
Progression Criteria
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0/10 pain Numeric Rating Pain Score (NRPS)
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No joint swelling
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Normalized range of motion (ROM)
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Shoulder external rotation + internal rotation (total rotational motion)
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176 to 180 degrees ( ): within 5 degrees of uninvolved side
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Shoulder horizontal adduction
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42 to 44 degrees ( )
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Elbow ROM
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4 to 6 degrees lack of extension is within normal for throwing athletes ( )
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Normalized strength
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5/5 strength of rotator cuff
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4/5 or > mid trap, low traps, and rhomboids
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Phase 1
Progression Criteria
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0/10 pain Numeric Rating Pain Score (NRPS)
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No joint swelling
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Normalized range of motion (ROM)
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Shoulder external rotation + internal rotation (total rotational motion)
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176 to 180 degrees ( ): within 5 degrees of uninvolved side
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Shoulder horizontal adduction
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42 to 44 degrees ( )
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Elbow ROM
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4 to 6 degrees lack of extension is within normal for throwing athletes ( )
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Normalized strength
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5/5 strength of rotator cuff
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4/5 or > mid trap, low traps, and rhomboids
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Phase 2
Progression Criteria
Isokinetic Shoulder Testing
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65% external rotation (ER)/internal rotation (IR) ratio at 180 degrees/sec, 61% ER/IR ratio at 300 degrees /sec ( )
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85% shoulder symmetry at both 180 and 300 degrees/sec
Balance
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Stand on balance leg with stride leg in 90 degrees of hip flexion and 90 degrees of knee flexion for 60 seconds without loss of balance
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Y-balance: anterior reach (within 4 cm side to side), posterolateral and posteromedial reach (within 6 cm side to side) ( )
Core and Hip Strength
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Front and side plank for 90 seconds without pelvic drop
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Single-leg glute bridge for 30 seconds without contralateral pelvic drop
Phase 3
Progression Criteria
Fatigue Superset
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(Superset) Double-arm overhead wall taps: 45 sec, 2000-g ball
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Faults: asymmetrical shrug
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(Superset) 90 degree/90 degree wall taps: 45 sec, 1000-g ball
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Faults: leading with the elbow, elbow drop below shoulder height
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(Superset) 12, 2, 3 o’clock wall taps: 45 sec, 1000-g ball
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Faults: increase in scapular winging, elbow dropping below shoulder height
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Eccentric ball catches over shoulder, 1000-g ball
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3 sets of 20 repetitions, 45-sec rest between sets
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Faults: trunk flexion <45 degrees, irregular arm path (not smooth, not across the body)
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Posterior shoulder endurance test ( )
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10 reps prone horizontal abduction with ER using 2% of body weight at 30 beats per minute
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Faults: elevation of entire upper torso; verbal report of inability to continue
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The purpose of phase 3 is to test the endurance of the athlete’s shoulder. Very few studies have examined shoulder endurance in overhead athletes ( ). To pass phase 3, the athlete cannot display more than one fault of the above program. They are to remain on phase 3 until able to complete all tasks with adequate control and endurance. After phase 3 is successfully completed, the athlete may progress to a structured interval throwing program.
Phase 4
Interval Throwing Program
An interval throwing program transitions the thrower back to the playing field. None of the exercises performed in rehabilitation or training can truly reproduce the forces and loads of throwing. The program prepares the thrower for the workloads required for competition. This interval throwing program is designed to minimize the chance of reinjury and can be adapted for pitchers and all position players.
The program:
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Progresses throwing volume, intensity, distance, and rest
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Consists of long tosses to improve arm strength and short tosses of higher intensity to reproduce the demands of each position
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Is designed to be progressed individually based on any symptoms the player may have
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Proper mechanics should be emphasized.
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Throwing velocity should only be sufficient to reach to target.
Dull pain or soreness is common during this program. However, one should never attempt to throw through sharp pain. If this pain persists, one should consult with a physician.
Finally, when beginning the throwing program, players should continue their training program to maintain strength, flexibility, and endurance because there is a tendency to “break down” as one begins advancing the throwing distance.
Instructions (Nonoperative, Mild Injury)
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Warm-up and stretching to be performed before throwing
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If the athlete has sharp pain during throwing, STOP immediately until pain ceases. Contact a physician or physical therapist if there is continued pain.
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Crow hop or side step should be used for flat ground throwing.
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Program to be performed every other day. Minimum of 1 day of rest between steps.
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If step is performed pain free, it is ok to progress to the next step.
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Do not continue with throwing if pain and soreness are noticed. Stop the step for that day and return to the same step after an additional rest day.
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Phases 1 to 6: 50% effort
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Phases 7 to 10: 75% effort
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Phases 10+ 100% effort
Instructions (Severe Tendon or Ligament Injury or Postoperative Elbow or Shoulder
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Phases 1 to 12: Advance no more than one phase every 3 days with 2 days of active rest after each workout.
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Phase 12 +: Advance no more than one phase every other day with 1 day of active rest between phases.
| Phase 1 (50%) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 30 | 20 | 5 |
| 30 | 20 | 10 |
| 45 | 10 | |
| Phase 2 (50%) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 30 | 20 | 5 |
| 30 | 20 | 10 |
| 45 | 20 | |
| Phase 3 (50%) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 45 | 20 | 5 |
| 45 | 20 | 10 |
| 60 | 10 | |
| Phase 4 (50%) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 45 | 20 | 5 |
| 45 | 20 | 10 |
| 60 | 20 | |
| Phase 5 (50%) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 60 | 20 | 5 |
| 60 | 20 | 10 |
| 75 | 10 | |
| Phase 6 (50%) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 60 | 20 | 5 |
| 60 | 20 | 5 |
| 75 | 20 | |
| Phase 7 (75%) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 75 | 20 | 5 |
| 75 | 20 | 10 |
| 90 | 10 | |
| Phase 8 (75%) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 75 | 20 | 5 |
| 75 | 20 | 10 |
| 90 | 20 | |
| Phase 9 (75%) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 90 | 20 | 5 |
| 90 | 20 | 10 |
| 120 | 10 | |
| Phase 10 (75%) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 90 | 20 | 5 |
| 90 | 20 | 10 |
| 120 | 20 | |
| Phase 11 (100%) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 120 | 20 | 10 |
| 120 | 20 | |
| Phase 12 (100%) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 120 | 20 | 10 |
| 120 | 20 | 10 |
| 120 | 20 | |
| Phase 13 (Optional) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 150 | 20 | 5 |
| 150 | 20 | |
| Phase 14 (Optional) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 150 | 20 | 10 |
| 150 | 20 | 10 |
| 150 | 20 | |
| Phase 15 (Optional) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 180 | 20 | 10 |
| 180 | 20 | |
| Phase 16 (Optional) | ||
| Distance (ft) | Number of Throws | Rest (min) |
| 180 | 20 | 10 |
| 180 | 20 | 10 |
| 180 | 20 | |
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