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Overarm throws with the nondominant arm: kinematics of accuracy.

1. Overarm throws made with the nondominant arm are usually less accurate than those made with the dominant arm. The objective was to determine the errors in the joint rotations associated with this inaccuracy, and thereby to gain insight into the neural mechanisms that contribute to skill in overarm throwing. 2. Overarm throws from both left and right arms were recorded on different occasions as six right-handed subjects sat with a fixed trunk and threw 150 tennis balls at about the same speed at a 6-cm square on a target grid 3 m away. Joint rotations at the shoulder, elbow, wrist, and finger, and arm translations, were computed from recordings of arm segment orientations made with the magnetic-field search-coil technique. 3. All subjects threw less accurately in this task with the left (nondominant) arm. For throws made with the left arm, the height of ball impact on the target grid was related to hand trajectory length and to hand orientation in space at ball release, but not to hand trajectory height. 4. Two hypotheses were proposed to explain the decreased ball accuracy in the high-low direction during throwing with the nondominant arm: that it was caused by increased variability in the velocity or timing of onset of rotations at proximal joints (which determine the path of the hand through space) or increased variability in the velocity or timing of onset of finger extension (which determine the moment of ball release). 5. A prediction of the first hypothesis was that proximal joint rotations should be more variable in throws with the left arm. This was the case for the majority of proximal joint rotations in the six subjects when variability was examined in joint space. However, some proximal joint rotations were more variable in the right arm. 6. The first hypothesis was directly tested by determining whether hand angular position in space (which represents the sum of all proximal joint rotations) was related to ball impact height on the target grid at a fixed translational position in the throw. No relation was found between these variables for throws with the left arm in four subjects, whereas a weak relation was found for two subjects. It was concluded that, considering all subjects, the first hypothesis could not explain the results. 7. In contrast, in agreement with the second hypothesis, a strong relation (P < 0.001) was found in all subjects between ball impact height on the target grid and time of ball release for throws with the left arm, and with time of onset of finger extension. 8. Across all six subjects the timing precision (windows) for 95% of the throws was (for ball release) right arm, 9.3 ms; left arm, 22.5 ms; (for onset of finger extension) right arm, 13.7 ms; left arm, 26.7 ms. 9. Timing of onset of finger extension was no less accurate than timing of onset of other joint rotations for both left and right arms. However, simulations of throws showed that, for the same error in timing, finger extension had twice as large an effect on ball direction as any other joint rotation. Timing errors at the fingers have a greater effect than errors at other joints because finger errors are scaled by the higher angular velocity of the hand in space rather than by the smaller angular velocities of the individual joints. 10. It is concluded that although rotations were in general more variable at both proximal and distal joints of the nondominant (left) arm, the major cause of its decreased throwing accuracy was increased variability at the distal joints, i.e., in the timing of onset of finger extension. This may be due to a lack of precision in the commands from the right hemisphere to the left fingers in right-handed throwers.

Arm↗

Injuries to the shoulder in the throwing athlete. Part one: Biomechanics/pathophysiology/classification of injury.

Over the last decade, significant advances have been made in the study and understanding of shoulder mechanics. Much of this may be attributed to the use of more sophisticated technology to improve our ability to assess the shoulder in real-time athletics. As a consequence of these advances, our understanding of the pathophysiology of injury has also increased. Our manual examination skills have improved and our noninvasive diagnostic techniques have advanced greatly. New insight into forces at play during actions as complex as the throwing motion has allowed us to develop better protocols for the prevention and treatment of the most common injuries. Additionally, paralleling improvements in the understanding of shoulder kinematics and the pathophysiology of injury, advances in surgical techniques, particularly arthroscopy, have aided in the diagnosis of and the development of less invasive surgical treatments for injuries that do not respond to nonoperative measures. Undoubtedly, an up-to-date understanding of the developments in shoulder biomechanics, pathophysiology of injury, diagnostic techniques, and surgical management is necessary for the clinician who wishes to continue to apply proper skills in the sports medicine setting.

Athletic Injuries↗

Injuries to the shoulder in the throwing athlete. Part two: evaluation/treatment.

In part one of this three-part series (March/April 2000), I concentrated on summarizing the biomechanics of the normal throwing shoulder and the pathophysiology of injury. A classification of injury was presented that was based on the principles contained in that article. Part two of this series will focus on the evaluation and treatment of injuries, expanded from an understanding of the principles learned in part one. The ability to perform a skillful examination, and thus develop an accurate diagnosis, is the foundation for treatment. Fortunately, many difficulties encountered in a thrower's shoulder can be treated with a nonoperative approach. However, in instances where conservative measures fail, an improved understanding of the pathophysiology of injury and the development of improved surgical techniques are leading to more accurate diagnoses and more successful rates of return of the athlete to a premorbid level of activity.

Adult↗

Current concepts in the rehabilitation of the overhead throwing athlete.

The overhead throwing motion is an extremely skillful and intricate movement that is very stressful on the shoulder joint complex. The overhead throwing athlete places extraordinary demands on this complex. Excessively high stresses are applied to the shoulder joint because of the tremendous forces generated by the thrower. The thrower's shoulder must be lax enough to allow excessive external rotation, but stable enough to prevent symptomatic humeral head subluxations, thus requiring a delicate balance between mobility and functional stability. We refer to this as the "thrower's paradox." This balance is frequently compromised, which leads to injury. Numerous types of injuries may occur to the surrounding tissues during overhead throwing. Frequently, injuries can be successfully treated with a well-structured and carefully implemented nonoperative rehabilitation program. The key to successful nonoperative treatment is a thorough clinical examination and accurate diagnosis. Athletes often exhibit numerous adaptive changes that develop from the repetitive microtraumatic stresses observed during overhead throwing. Treatment should focus on the restoration of these adaptations during the rehabilitation program. In this article, the typical musculoskeletal profile of the overhead thrower and various rehabilitation programs for specific injuries are discussed. Rehabilitation follows a structured, multiphase approach with emphasis on controlling inflammation, restoring muscle balance, improving soft tissue flexibility, enhancing proprioception and neuromuscular control, and efficiently returning the athlete to competitive throwing.

Athletic Injuries↗

Medial collateral ligament reconstruction of the elbow using the docking technique.

BACKGROUND: Medial collateral ligament insufficiency of the elbow with resultant valgus instability in throwing athletes is typically treated with free tendon graft reconstruction as described by Jobe. HYPOTHESIS: Improved results could be obtained with the use of the docking technique. STUDY DESIGN: Uncontrolled retrospective review. METHODS: The study group consisted of 36 athletes who had symptomatic insufficiency of the medial collateral ligament confirmed by magnetic resonance imaging and by surgical findings. Average follow-up was 3.3 years. Key elements of the docking technique included a muscle-splitting approach without routine transposition of the ulnar nerve, routine arthroscopic assessment, treatment of associated lesions, and docking the two ends of the tendon graft into a single humeral tunnel. RESULTS: Thirty-three of 36 patients (92%) returned to or exceeded their previous level of competition for at least 1 year, meeting the Conway-Jobe classification criteria of "excellent." All 22 professional or collegiate athletes returned to or exceeded their previous competition level. CONCLUSIONS: The docking technique allowed simplified graft tensioning and improved graft fixation.

Adolescent↗

Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete.

BACKGROUND: Midfoot sprains in athletes represent a spectrum of injuries to the Lisfranc ligament complex, from partial sprains with no displacement to complete tears with frank diastasis. Treatment of these injuries varies from the treatment of high-velocity injuries seen in nonathletes. PURPOSE: We wanted to report the outcome of treatment in athletes with Lisfranc injuries classified according to our system. STUDY DESIGN: Retrospective cohort study. METHODS: Weightbearing radiographs and bone scintigrams were used to diagnose midfoot sprains in 15 athletes who were treated surgically or nonoperatively according to the following classification: nonoperative management for stage I injuries (undisplaced) and anatomic reduction with fixation for stage II (diastasis with no arch height loss) and stage III (diastasis with arch height loss) injuries. RESULTS: We achieved an excellent outcome in 93% of 15 athletes with midfoot sprains at an average follow-up of 27 months (range, 9 to 72). CONCLUSIONS: Weightbearing radiographs and bone scintigrams are sensitive, reproducible, and relatively inexpensive methods of investigation of these injuries. Restoration and maintenance of the anatomic alignment of the Lisfranc joint is the key to appropriate treatment of injury to the midfoot.

Adolescent↗

Assessment of shoulder proprioception in the female softball athlete.

BACKGROUND: There have been reports of overhand throwing athletes having decreased joint position sense in their dominant shoulder as compared with the nondominant shoulder. Very little research, however, exists concerning joint position sense in the female athlete. HYPOTHESIS: Female softball athletes have decreased joint position sense in their dominant shoulder as compared with their nondominant shoulder. STUDY DESIGN: Factorial design with investigation of multiple independent variables. METHODS: Joint position sense was assessed in 50 female softball players and 50 nonthrowing female athletes by using an inclinometer during four glenohumeral joint motions. Both the dominant and nondominant shoulders were assessed and error scores were calculated to describe joint position sense. Data were collected during the course of a fall semester and analyzed by using a mixed model analysis of variance with repeated measures on the dependent variable (error scores). RESULTS: A significant group by movement interaction was observed, with the softball athletes demonstrating significantly greater external rotation error scores than the nonthrowing athletes. CONCLUSION: We failed to reject the null hypothesis. Increased error scores (less joint position sense) were observed in both arms of subjects in the softball group. CLINICAL RELEVANCE: This study suggests that there is decreased shoulder proprioception in asymptomatic female athletes involved in overyhand throwing sports, which may predispose them to injury.

Adult↗

Isokinetic eccentric-to-concentric strength ratios of the shoulder rotator muscles in throwers and nonthrowers.

BACKGROUND: One of the possible mechanisms leading to shoulder injury may be a strength imbalance between those muscles that accelerate the upper limb and those responsible for deceleration. Many studies have examined shoulder balance through a concentric strength ratio of external and internal shoulder rotator muscles. HYPOTHESIS: A functional external eccentric-to-internal concentric ratio may be a better identifier of muscular imbalance in dominant and nondominant shoulders of throwers and nonthrowers. STUDY DESIGN: Controlled laboratory study. METHODS: Eccentric external and concentric internal peak torques were measured bilaterally in 59 men (16 throwers and 43 nonthrowers) at 300 deg/sec. Subjects were tested in the supine position with the shoulder abducted to 90 degrees and the elbow flexed to 90 degrees. RESULTS: Throwers exhibited significantly lower ratios than nonthrowers in their dominant limb; there was no difference between groups for the nondominant limb. CONCLUSIONS: The lower ratio in the throwers' dominant limb was attributed to significantly greater concentric internal rotation torques without concomitant eccentric external torque gains. CLINICAL RELEVANCE: Rehabilitation and injury prevention regimens that include functional exercises to improve eccentric external rotation strength may bring more balance to the dominant shoulder of throwing athletes.

Adolescent↗

Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study.

BACKGROUND: Although several studies have described magnetic resonance imaging findings in shoulders of asymptomatic volunteers, no such investigation has been performed on asymptomatic dominant and nondominant shoulders of elite overhead athletes. HYPOTHESIS: Asymptomatic dominant shoulders of elite overhead athletes may have a higher incidence of magnetic resonance imaging abnormalities than either their nondominant shoulder or shoulders of asymptomatic volunteers. STUDY DESIGN: Prospective cohort study. METHODS: Detailed magnetic resonance imaging scans of asymptomatic dominant and nondominant shoulders of elite overhead athletes were obtained. Three experienced musculoskeletal radiologists interpreted each scan for multiple variables, including rotator cuff appearance. Images from a surgical control group were intermixed to assess accuracy and control for observer bias. A 5-year follow-up interview was performed to determine whether magnetic resonance imaging abnormalities found in the initial stage of the study represented truly clinical false-positive findings or symptomatic shoulders in evolution. RESULTS: Eight of 20 (40%) dominant shoulders had findings consistent with partial- or full-thickness tears of the rotator cuff as compared with none (0%) of the nondominant shoulders. Five of 20 (25%) dominant shoulders had magnetic resonance imaging evidence of Bennett's lesions compared with none (0%) of the nondominant shoulders. None of the athletes interviewed 5 years later had any subjective symptoms or had required any evaluation or treatment for shoulder-related problems during the study period. CONCLUSIONS: Magnetic resonance imaging alone should not be used as a basis for operative intervention in this patient population.

Adult↗

Differences in the ultimate strength of the biceps anchor and the generation of type II superior labral anterior posterior lesions in a cadaveric model.

BACKGROUND: The pathogenesis of superior labral anterior posterior lesions remains controversial. HYPOTHESIS: The biceps anchor is more vulnerable to loading with a posterior vector as opposed to an in-line pull. STUDY DESIGN: Controlled laboratory study. METHODS: Eight pairs of cadaveric shoulders were dissected, and the biceps tendon was loaded to failure in 1 of 2 loading patterns. Loading pattern A was meant to simulate the eccentric load of the biceps in the deceleration phase of throwing; loading pattern B was meant to simulate the posterior biceps load of the late cocking phase. RESULTS: The biceps anchor demonstrated significantly increased ultimate strength with in-line loading (group A, 508 N) as opposed to posterior loading (group B, 262 N, P < .001). All group B specimens failed at the biceps anchor, resulting in a type II superior labral anterior posterior lesion. Specimens in group A did not create a superior labral anterior posterior lesion. CONCLUSIONS: Direction of biceps loading resulted in significant differences in the ultimate strength of the biceps anchor and the generation of superior labral anterior posterior lesions. The biceps anchor was significantly weaker when loaded with a posterior vector. RELEVANCE: The superior labrum may be most vulnerable to injury in late cocking. The reproducible generation of type II superior labral anterior posterior lesions may have applications as a biomechanical model.

Aged↗

Elbow medial ulnar collateral ligament insufficiency alters posteromedial olecranon contact.

BACKGROUND: The effect of elbow medial ulnar collateral ligament injury on posteromedial compartment contact is unknown. HYPOTHESIS: Medial ulnar collateral ligament injury causes altered contact area and pressure in the posteromedial compartment of the elbow. STUDY DESIGN: Controlled laboratory study. METHODS: Seven elbow cadaveric specimens were tested in an apparatus that positioned the elbow at 30 degrees and 90 degrees of flexion. Partial and full tears were simulated by releasing the medial ulnar collateral ligament. Pressure-sensitive film was placed in the posteromedial compartment for each condition. Valgus torques of 1.25 and 2.0 N.m were applied for each ligament condition, and kinematic data were obtained at each flexion angle using a 3-dimensional digitizer. RESULTS: Both ligament condition and valgus load had significant effects on contact area and pressure (P<.05). For a given load and flexion angle, the contact area decreased and the pressure increased with increasing medial ulnar collateral ligament insufficiency. Within these trends, statistical significance was found at 30 degrees of elbow flexion for both area and pressure (P<.05); at 90 degrees of elbow flexion, increasing medial ulnar collateral ligament insufficiency did not significantly affect contact area or pressure (P>.05). DISCUSSION: Medial ulnar collateral ligament insufficiency alters contact area and pressure between the posteromedial trochlea and olecranon and helps explain the development of posteromedial osteophytes.

Athletic Injuries↗

The "moving valgus stress test" for medial collateral ligament tears of the elbow.

BACKGROUND: The diagnosis of a painful partial tear of the medial collateral ligament in overhead-throwing athletes is challenging, even for experienced elbow surgeons and despite the use of sophisticated imaging techniques. HYPOTHESIS: The "moving valgus stress test" is an accurate physical examination technique for diagnosis of medial collateral ligament attenuation in the elbow. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Twenty-one patients underwent surgical intervention for medial elbow pain due to medial collateral ligament insufficiency or other abnormality of chronic valgus overload, and they were assessed preoperatively with an examination called the moving valgus stress test. To perform the moving valgus stress test, the examiner applies and maintains a constant moderate valgus torque to the fully flexed elbow and then quickly extends the elbow. The test is positive if the medial elbow pain is reproduced at the medial collateral ligament and is at maximum between 120 degrees and 70 degrees. RESULTS: The moving valgus stress test was highly sensitive (100%, 17 of 17 patients) and specific (75%, 3 of 4 patients) when compared to assessment of the medial collateral ligament by surgical exploration or arthroscopic valgus stress testing. The mean shear range (ie, the arc within which pain was produced with the moving valgus stress test) was 120 degrees to 70 degrees. The mean angle at which pain was at a maximum was 90 degrees of elbow flexion. CONCLUSIONS: The moving valgus stress test is an accurate physical examination technique that, when performed and interpreted correctly, is highly sensitive for medial elbow pain arising from the medial collateral ligament.

Adolescent↗

Stress distribution in the superior labrum during throwing motion.

BACKGROUND: Superior labrum anterior posterior lesions are common among athletes participating in overhead throwing sports. One described mechanism of injury is application of high local stress via repetitive loading of the long head of the biceps tendon attached to the superior labrum; however, the stress environment within the labrum has not been investigated to date. HYPOTHESIS: Biceps origin locations and throwing phases determine the stress distributions causing lesions of the superior labrum within the labrum itself. STUDY DESIGN: Descriptive laboratory study. METHODS: Three-dimensional finite element models of the labrum glenoid complex with anterior, central, and posterior biceps origins were developed at 4 orientations to simulate the phases of pitching: early cocking, late cocking, acceleration, and deceleration. RESULTS: The stress magnitudes at the labrum glenoid interface for the deceleration phase were highest for all biceps origins. Anatomical variations of the biceps insertion affected the stress only during the deceleration phase. Both the biceps origin and throwing phase influenced the location of high stress. CONCLUSION: Deceleration could be the throwing phase that causes tearing at the superior labrum. This finding provides further understanding for localizing the possible initiation of superior labrum anterior posterior lesions.

Arm↗

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Aging↗

The resisted supination external rotation test: a new test for the diagnosis of superior labral anterior posterior lesions.

PURPOSE: To evaluate a new clinical test, the resisted supination external rotation test, for the diagnosis of superior labral anterior posterior lesions of the shoulder. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Forty athletes (average age, 23.9 years) with activity-related shoulder pain were enrolled in the study. The patients underwent 3 different tests designed specifically to detect superior labral anterior posterior lesions (the resisted supination external rotation test, the crank test, and the active compression test); the tests were performed in a random order on the affected shoulder. The results of the tests were compared with arthroscopic findings. RESULTS: Out of 40 athletes, 29 (72.5%) had superior labral anterior posterior tears. The resisted supination external rotation test had the highest sensitivity (82.8%), specificity (81.8%), positive predictive value (92.3%), negative predictive value (64.3%), and diagnostic accuracy (82.5%) of all tests performed. CONCLUSION: By re-creating the peel-back mechanism, the resisted supination external rotation test is more accurate than 2 other commonly used physical examination tests designed to diagnose superior labral anterior posterior tears in overhead-throwing athletes. By using this test in the context of a thorough clinical history and physical examination, lesions of the superior labrum can be more reliably diagnosed.

Acromioclavicular Joint↗