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1.  Current Concepts in Examination and Treatment of Elbow Tendon Injury 
Sports Health  2013;5(2):186-194.
Injuries to the tendons of the elbow occur frequently in the overhead athlete, creating a significant loss of function and dilemma to sports medicine professionals. A detailed review of the anatomy, etiology, and pathophysiology of tendon injury coupled with comprehensive evaluation and treatment information is needed for clinicians to optimally design treatment programs for rehabilitation and prevention.
Evidence Acquisitions:
The PubMed database was searched in January 2012 for English-language articles pertaining to elbow tendon injury.
Detailed information on tendon pathophysiology was found along with incidence of elbow injury in overhead athletes. Several evidence-based reviews were identified, providing a thorough review of the recommended rehabilitation for elbow tendon injury.
Humeral epicondylitis is an extra-articular tendon injury that is common in athletes subjected to repetitive upper extremity loading. Research is limited on the identification of treatment modalities that can reduce pain and restore function to the elbow. Eccentric exercise has been studied in several investigations and, when coupled with a complete upper extremity strengthening program, can produce positive results in patients with elbow tendon injury. Further research is needed in high-level study to delineate optimal treatment methods.
PMCID: PMC3658379  PMID: 24427389
humeral epicondylitis; rehabilitation; elbow tendon injury
In most shoulder conditions a loss of glenohumeral motion results in shoulder performance impairments. However, in the overhead athlete loss of glenohumeral internal rotation, termed glenohumeral internal rotation deficiency (GIRD), is a normal phenomenon that should be expected. Without a loss of glenohumeral internal rotation the overhead athlete will not have the requisite glenohumeral external rotation needed to throw a baseball at nearly 100 miles per hour, or serve a tennis ball at velocities of 120 miles per hour or more. Not all GIRD is pathologic.
The authors of this manuscript have defined two types of GIRD; one that is normal and one that is pathologic. Anatomical GIRD (aGIRD) is one that is normal in overhead athletes and is characterized by a loss of internal rotation of less than 18°‐20° with symmetrical total rotational motion (TROM) bilaterally. Pathologic GIRD (pGIRD) is when there is a loss of glenohumeral internal rotation greater than 18°‐20° with a corresponding loss of TROM greater than 5° when compared bilaterally. A more problematic motion restriction may be that of a loss of TROM in the glenohumeral joint. Recent evidence supports that a loss of TROM is predictive of future injury to the shoulder in professional athletes. Additionally, external rotation deficiency (ERD), the difference between external rotation (ER) of the throwing shoulder and the non‐throwing shoulder of less than 5°, may be another predictor of future shoulder injury and disability.
Level of Evidence:
PMCID: PMC3811728  PMID: 24175137
External rotation deficiency; glenohumeral internal rotation deficit; total rotation motion
Examination of the shoulder complex has long been described as challenging. This is particularly true in the examination of the overhead athlete who has structural differences when compared to a shoulder patient who is a non‐athlete. Complexity with the examination is due to unique biomechanical and structural changes, multiple joint articulations, multiple pain patterns, and the potential of injury to structures both inside (intra‐articular) and outside (extra‐articular) the glenohumeral joint. Repetitive stresses placed on the shoulders of overhead athletes may affect range of motion, strength, scapular position, and ultimately, the integrity of soft tissue and bony structures in any of the joints that comprise the shoulder complex. Furthermore, many shoulder examination tests thought to be unique to a single structure, joint, or condition can be positive in multiple conditions. The examination of the overhead athletes shoulder, coupled with a thorough medical history will provide a solid foundation to allow a functional physical therapy diagnosis and provide clues as to the presence of the lesion (s) causing disability. The purpose of this clinical commentary is to assist the reader to understand the unique physical characteristics of the overhead athlete, which will lead to a more accurate and reproducible evaluation of athletes who sustain injuries while participating in overhead sports.
Level of Evidence:
PMCID: PMC3811732  PMID: 24175138
Overhead athlete; physical examination; shoulder
4.  Reliability of Scapular Classification in Examination of Professional Baseball Players 
Clinically evaluating the scapulothoracic joint is challenging. To identify scapular dyskinesis, clinicians typically observe scapular motion and congruence during self-directed upper extremity movements. However, it is unclear whether this method is reliable.
We therefore determined the interrater reliability of a scapular classification system in the examination of professional baseball players.
Seventy-one healthy uninjured professional baseball players between the ages of 18 and 32 years volunteered to participate. We used a digital video camera to film five repetitions of scapular plane elevation while holding a 2-pound weight. Four examiners then independently classified the motions on video into one of four types. Interrater reliability analysis using the kappa (k) statistic was performed for: (1) classifying each scapula into one of the four types; (2) classifying each scapula as being abnormal (Types I–III) or normal (Type IV); and (3) classifying both scapula as both being symmetric (both normal or both abnormal) or asymmetric (one normal, one abnormal).
We found low reliability for all analyses. In classifying each scapula as one of the four types, reliability was k = 0.245 for the left limb and k = 0.186 for the right limb. When considering the dichotomous classifications (abnormal versus normal), reliability was k = 0.264 for left and k = 0.157 for right. For bilateral symmetry/asymmetric, reliability was k = 0.084.
We found low reliability of visual observation and classification of scapular movement.
Clinical Relevance
Current evaluation strategies for evaluating subtle scapular abnormalities are limited.
Level of Evidence
Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3348317  PMID: 22167659
5.  Effects of A 6-Week Junior Tennis Conditioning Program on Service Velocity 
This study examined the effects of a 6-week strength-training program on serve velocity in youth tennis players. Thirty competitive healthy and nationally ranked male junior tennis players (13 years of age) were randomly and equally divided into control and training groups. The training group performed 3 sessions (60-70 min) weekly for 6 weeks, comprising core strength, elastic resistance and medicine ball exercises. Both groups (control and training) also performed a supervised stretching routine at the end of each training session, during the 6 week intervention. Service velocity, service accuracy and shoulder internal/external rotation were assessed initially and at the end of the 6-week conditioning program for both, control and training groups. There was a significant improvement in the serve velocity for the training group (p = 0. 0001) after the intervention, whereas in the control group there were no differences between pre and post-tests (p = 0.29). Serve accuracy was not affected in the training group (p = 0.10), nor in the control group (p = 0.15). Shoulder internal/external rotation ROM significantly improved in both groups, training (p = 0.001) and control (p = 0.0001). The present results showed that a short- term training program for young tennis players, using minimum equipment and effort, can result in improved tennis performance (i.e., serve velocity) and a reduction in the risk of a possible overuse injury, reflected by an improvement in shoulder external/internal range of motion.
Key PointsA short-term training program for young tennis players, using minimum equipment and effort, can result in improved tennis performance and a reduction in the risk of a possible overuse injury, reflected by an improvement in shoulder external/internal range of motionA combination of core stabilization, elastic resistance exercises, and upper body plyometric exercises (i.e., medicine ball throws), focussing on the primary muscle groups and stabilizers involved in tennis specific movement patterns, could be appropriate for development tennis playersStretching exercises are recommended in the cool-down phase following matches or training sessions.
PMCID: PMC3761833  PMID: 24149801
tennis; strength; flexibility; service; performance
6.  An 8-Stage Model for Evaluating the Tennis Serve 
Sports Health  2011;3(6):504-513.
The tennis serve is a complex stroke characterized by a series of segmental rotations involving the entire kinetic chain. Many overhead athletes use a basic 6-stage throwing model; however, the tennis serve does provide some differences.
Evidence Acquisition:
To support the present 8-stage descriptive model, data were gathered from PubMed and SPORTDiscus databases using keywords tennis and serve for publications between 1980 and 2010.
An 8-stage model of analysis for the tennis serve that includes 3 distinct phases—preparation, acceleration, and follow-through—provides a more tennis-specific analysis than that previously presented in the clinical tennis literature. When a serve is evaluated, the total body perspective is just as important as the individual segments alone.
The 8-stage model provides a more in-depth analysis that should be utilized in all tennis players to help better understand areas of weakness, potential areas of injury, as well as components that can be improved for greater performance.
PMCID: PMC3445225  PMID: 23016050
biomechanics; serve; tennis; kinetic chain
7.  Incidence of Injuries in High School Softball and Baseball Players 
Journal of Athletic Training  2011;46(6):648-654.
Participation in high school sports has grown 16.1% over the last decade, but few studies have compared the overall injury risks in girls' softball and boys' baseball.
To examine the incidence of injury in high school softball and baseball players.
Cohort study.
Greenville, South Carolina, high schools.
Patients or Other Participants:
Softball and baseball players (n = 247) from 11 high schools.
Main Outcome Measure(s):
Injury rates, locations, types; initial or subsequent injury; practice or game setting; positions played; seasonal trends.
The overall incidence injury rate was 4.5/1000 athlete-exposures (AEs), with more injuries overall in softball players (5.6/1000 AEs) than in baseball players (4.0/1000 AEs). Baseball players had a higher initial injury rate (75.9/1000 AEs) than softball players (66.4/1000 AEs): rate ratio (RR) = 0.88, 95% confidence interval (CI) = 0.4, 1.7. The initial injury rate was higher than the subsequent injury rate for the overall sample (P < .0001) and for softball (P < .0001) and baseball (P < .001) players. For both sports, the injury rate during games (4.6/1000 AEs) was similar to that during practices (4.1/1000 AEs), RR = 1.22, 95% CI = 0.7, 2.2. Softball players were more likely to be injured in a game than were baseball players (RR = 1.92, 95% CI = 0.8, 4.3). Most injuries (77%) were mild (3.5/1000 AEs). The upper extremity accounted for the highest proportion of injuries (63.3%). The incidence of injury for pitchers was 37.3% and for position players was 15.3%. The rate of injury was highest during the first month of the season (7.96/1000 AEs).
The incidence of injury was low for both softball and baseball. Most injuries were minor and affected the upper extremity. The injury rates were highest in the first month of the season, so prevention strategies should be focused on minimizing injuries and monitoring players early in the season.
PMCID: PMC3418943  PMID: 22488191
injury rates; injury epidemiology; athletic injuries
Injury rates for softball players are similar to baseball players yet information regarding risk factors, pitching, and physical characteristics for high school windmill softball pitchers is limited. This information is needed to guide prevention, training, and rehabilitation efforts. The purpose of this study was to report descriptive data regarding the physical characteristics and pitching volume experienced by high school softball pitchers during one academic season. A secondary aim was to track and describe upper extremity injuries suffered by high school softball pitchers throughout the course of the 2009 season.
Twelve uninjured female softball pitchers (13‐18y) from 5 Greenville, South Carolina high schools participated. Prior to the 2009 season, the pitchers' shoulder internal, external, total arc of rotation and horizontal adduction PROM was measured. During the 10‐week season, aggregate pitch counts (pitch volume) and occurrence of upper extremity injury were tracked for each pitcher.
Mean preseason internal, external, and total arc of rotation PROM was observed to be similar between the pitchers' dominant and non‐dominant shoulders. The PROM measures of horizontal abduction (HA) appear to demonstrate a side‐to‐side difference with less HA on the dominant arm of the pitchers who were examined. Subjects threw in an average of 10.1 games (±4.9) during the season. Six pitchers threw in 60% or more of the team's games and 3 of 12 pitchers pitched less than 25% of games. Pitchers averaged 61.8 pitches per game (±31.5) and 745.8 (±506.4) per season. Pitch count data did not appear to be different between injured and non‐injured pitchers.
Knowledge of pitch volume can be used to prepare windmill softball pitchers for the seasonal stresses, guide establishment of goals when recovering from injury, or assist in training for an upcoming season. Further research is needed to examine larger samples of pitchers over multiple seasons and years.
Level of Evidence:
PMCID: PMC3474308  PMID: 23091788
Pitch count; shoulder; softball
9.  A descriptive profile of age‐specific knee extension flexion strength in elite junior tennis players 
British Journal of Sports Medicine  2007;41(11):728-732.
Tennis requires repetitive multidirectional movement patterns that can lead to lower extremity injury. Knowledge of population and age‐specific strength parameters can be used during performance enhancement training and rehabilitation of tennis players.
The purpose of this study was to generate population and age‐specific descriptive profiles of concentric isokinetic knee extension and flexion strength in elite junior tennis players, and determine whether bilateral differences exist between extremities and across age ranges.
A total of 103 elite male tennis players (mean (SD) 15.92 (2.14), range 11–21) and 53 female tennis players (mean (SD) 15.0 (2.30, range 11–21) were isokinetically tested on a Cybex 6000 isokinetic dynamometer at 180 and 300°/s to assess bilateral concentric knee extension and flexion strength using a standard bilateral testing protocol.
No significant bilateral difference between the dominant (racquet side) lower extremity and the contralateral non‐dominant side were measured in lower extremity knee extension or flexion strength normalised to body weight, or in the hamstring quadriceps strength ratios in male and female subjects. Male subjects did show significant (p<0.001) increases in knee extension and flexion strength across the age ranges from 11–15 years of age to 16–21 years. Female subjects did not show any significant change in the normalised knee extension or flexion strength across age ranges. Hamstring/quadriceps strength ratios were bilaterally symmetric and remained clinically and statistically constant across age ranges for the male and female elite tennis players.
Population and age‐specific isokinetic descriptive data from elite tennis players can provide guidance in the development and monitoring of performance enhancement and rehabilitation programs for elite tennis players. The changes identified in normalised knee extension and flexion strength in elite male tennis players necessitate the use of population and age‐specific descriptive data.
PMCID: PMC2465262  PMID: 17957008
10.  Alternative Methods for Measuring Scapular Muscles Protraction and Retraction Maximal Isometric Forces 
The importance of the scapular stabilizing muscles has led to an increased interest in quantitative measurements of their strength. Few studies have measured isometric or concentric isokinetic forces. Additionally, limited reports exist on the reliability of objective measures for testing scapular protraction and retraction muscle strength or scapular testing that does not involve the glenohumeral joint.
To determine the reliability of four new methods of measuring the maximal isometric strength of key scapular stabilizing muscles for the actions of protraction and retraction, both with and without the involvement of the glenohumeral (GH) joint.
The Isobex® stationary tension dynamometer was used to measure the maximal isometric force (kg) on thirty healthy females (ages 22–26 years). Three measures were taken for each method that was sequentially randomized for three separate testing sessions on three nonconsecutive days.
Intraclass correlations (ICC2,3) for intrasession reliability and (ICC3,3) for intersession reliability ranged from 0.95 to 0.98, and 0.94 to 0.96 respectively. The standard errors of measurement (95% confidence interval [CI]) were narrow. Scatter grams for both protraction and retraction testing methods demonstrated a significant relationship, 0.92 for protraction (95% CI 0.83 to 0.96) and 0.93 for retraction (95% CI 0.87 to 0.97). Bland-Altman plots indicated good agreement between the two methods for measuring protraction strength but a weaker agreement for the two methods measuring retraction strength.
The four new methods assessed in this study indicate reliable options for measuring scapular protraction or retraction isometric strength with or without involving the GH joint for young healthy females.
PMCID: PMC2953350  PMID: 21509104
scapular stabilizing muscles; isometric strength; static tension dynamometer
11.  Current Concepts in Rehabilitation Following Ulnar Collateral Ligament Reconstruction 
Sports Health  2009;1(4):301-313.
Injuries to the ulnar collateral ligament (UCL) in throwing athletes frequently occurs from the repetitive valgus loading of the elbow during the throwing motion, which often results in surgical reconstruction of the UCL requiring a structured postoperative rehabilitation program. Several methods are currently used and recommended for UCL reconstruction using autogenous grafts in an attempt to reproduce the stabilizing function of the native UCL. Rehabilitation following surgical reconstruction of the UCL begins with range of motion and initial protection of the surgical reconstruction, along with resistive exercise for the entire upper extremity kinetic chain. Progressions for resistive exercise are followed that attempt to fully restore strength and local muscular endurance in the rotator cuff and scapular stabilizers, in addition to the distal upper extremity musculature, to allow for a return to throwing and overhead functional activities. Rehabilitation following UCL reconstruction has produced favorable outcomes, allowing for a return to throwing in competitive environments.
PMCID: PMC3445125  PMID: 23015887
elbow; ulnar collateral ligament; rehabilitation; overhead athlete; throwing; baseball
12.  Descriptive Report of Shoulder Range of Motion and Rotational Strength Six and 12 Weeks Following Arthroscopic Superior Labral Repair 
To measure short-term post surgery glenohumeral internal and external rotation strength, shoulder range of motion (ROM), and subjective self-report ratings following arthroscopic superior labral (SLAP) repair.
Physical therapists provide rehabilitation for patients following arthroscopic repair of the superior labrum. Little research has been published regarding the short-term results of this procedure while the patient is typically under the direct care of the physical therapist.
Charts from 39 patients (7 females and 32 males) with a mean age of 43.4±14.9 years following SLAP repair were reviewed. All patients underwent rehabilitation by the same therapist using a standardized protocol and were operated on and referred by the same orthopaedic surgeon. Retrospective chart review was performed to obtain descriptive profiles of shoulder ROM at 6 and 12 weeks post surgery and isokinetically documented internal and external rotation strength 12 weeks post surgery.
At 12 weeks post-surgery, involved shoulder flexion, abduction, and external rotation active ROM values were 2-6 degrees greater than the contralateral, non-involved extremity. Isokinetic internal and external rotation strength deficits of 7-11% were found as compared to the uninjured extremity. Patients completed the self-report section of the Modified American Shoulder Elbow Surgeons Rating Scale and scored a mean of 37/45 points.
The results of this study provide objective data for both glenohumeral joint ROM and rotator cuff strength following superior labral repair at time points during which the patient is under the direct care of the physical therapist. These results show a nearly complete return of active ROM and muscular strength following repair of the superior labrum and post-operative physical therapy.
PMCID: PMC2953319  PMID: 21509132
glenohumeral joint; labrum; rehabilitation
13.  The Application of Isokinetics in Testing and Rehabilitation of the Shoulder Complex 
Journal of Athletic Training  2000;35(3):338-350.
We review the application of isokinetic testing and training for the shoulder complex, the interpretation of isokinetic testing data, and the application of normative data in the rehabilitation and performance enhancement of the athlete.
Data Sources:
We searched MEDLINE for the years 1989- 1999 using the key words “isokinetics,” “shoulder,” and “upper extremity.”
Data Synthesis:
Isokinetic testing and training is an integral part of the comprehensive evaluation and treatment of the shoulder complex. This mode of exercise allows for objective, isolated joint testing and training.
Isokinetic training and testing is an important part of the comprehensive evaluation and rehabilitation of the patient with a shoulder injury. Research has demonstrated its efficacy in training and in providing clinically relevant information regarding muscular performance. When integrated with a complete history, subjective examination, and physical and functional evaluation, isokinetic exercise can be a valuable tool for the clinician in the assessment, rehabilitation, and performance enhancement of the athlete.
PMCID: PMC1323396  PMID: 16558647
glenohumeral joint; isokinetic exercise; muscle function
14.  Heat research guides current practices in professional tennis 
British Journal of Sports Medicine  2014;48(Suppl 1):i5-i6.
PMCID: PMC3995245  PMID: 24668380
Dehydration; Elite Performance; Fluid Balance; Injury Prevention

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