HC: Softball Player with R Frozen Shoulder Underlying Labral Tear (In office patient) 8-20-18

12-17 Follow Up
- Exam revealed limitation in R shoulder IR, limitation in R shoulder overhead flexion, slight limitation in reach behind the back on the right compared to the left
- We discussed the importance of maintaining shoulder IR ROM with the sleeper stretch position
  - Isometric resisting the back of the hand/wrist 5x5sec
  - Then passive IR stretch, if no pain can hold 10-15sec and repeat 5 -10x 2x/day
  - Keep some awareness that you are not starting to lose IR by checking the reach behind the back position
    - Check how well you can get your fists to touch behind your back
    - Look in a mirror a look at overhead motion to make sure you are able to keep elbow straight and move through similar motion
- Strengthening:
  - Ideally can be done 2-3x per week
  - We discussed the importance of shoulder blade position
  - Hold off on dips
  - push ups can be done but keep them shallow
  - Shoulder impingement general information:
10-26 Updates
- Added some new concepts to your strength and warm up sequence…look for them below
10-12 Updates
- We focused on band positions that challenge the shoulder in various throwing positions
- Also band postions the move across the body
- Look for them below in your strength circuit
10-5
- Reviewed throwing progression
- Allowed to initiate hitting (Phase 1 follow the levels below at 50% effort swings/Slaps, Phase 2: follow levels below but do 1/2 of the swing amount at max swing and 1/2 at 50%/slaps, for example phase 2 level 1 would be 10 swings at 50% effort or done as more of a slap and 10 swings at normal effort
  - level 1: 20 swings
  - level 2: 30 swings
  - Level 3: 40 swings
  - Level 4: 50 swings
- Ideal week should look like this
- Day 1: Mobility routine and hitting/throwing
- Day 2: Mobility routine and strength
- Day 3 Mobility routine
- Day 4: Mobility routine and throwing/hitting
- Day 5: Mobility routine and strength
- Day 6 Mobility routine
- Day 7: rest/ optional hitting and throwing/optional strength
- Day 7 as you get more into softball training will be more hitting and throwing and strength only the other 2 days….If it is more off season you are better off keeping the 3 strength days and only 2 hitting/throwing
9-28 Initiated return to throwing program and hitting specific movements in the strength program
- See updates to strength program below in bold
- Ideally, you do not want to throw and strengthen on the same day
- Throwing Program
  - Positions:
    - (SA) Short Arm throw from one knee
    - (SFT) Standing FULL Throw from specified distance
    - (UHPP) Under Hand Pre Pitch (Under hand throw without full arc motion)
    - (FPWU) Full Pitch Wind Up throw: Use the distance from the mound to home
  - FOLLOW THE SORENESS RULES
    - These rules are meant to guide you in regards to the amount of rest necessary between sessions and how to progress in the level of difficulty
  - ALWAYS ICE 10-20 MINUTES AFTER THROWING SESSION
  - LEVELS
    1. SA: 10x 30feet, UHPP: 10x 30feet, repeat 3x
    2. SA: 10x 30feet, UHPP: 10x 30feet, repeat 4x
    3. SA: 10x 30feet, UHPP: 10x 30feet, repeat 5x
    4. SA: 10x 30feet, UHPP: 10x 30feet, repeat 3x
    5. SA: 10x30feet, UHPP: 10x30feet, SFT: 10x30feet, repeat 3x
      1. We were here on 10-5-18 but only did 2 rounds
    6. SA: 10x30feet, UHPP: 10x30feet, SFT: 10x30feet, SFT: 10x40feet, repeat 3x
    7. SA: 10x30feet, UHPP: 10x30feet, SFT: 10x30feet, 10x40feet, 10x50feet, repeat 3x
    8. SA: 10x30feet, UHPP: 10x30feet, SFT: 10x30feet, 10x40feet, 10x50feet, 10x 60feet repeat 3x
    9. Repeat above 4x
    10. SFT: 10x45feet, UHPP: 10x from the mound, FPWU: 10x 25-50% effort, repeat 3x
    11. Repeat above 4x
    12. Repeat above 5x
    13. SFT: 10x45feet, UHPP: 10x from the mound, FPWU: 10x 25-50% effort,FPWU: 10x 50-75% effort, repeat 3x
    14. Repeat above 4x
    15. Repeat above 5x
    16. SFT: 10x45feet, UHPP: 10x from the mound, FPWU: 10x 25-50% effort, FPWU: 10x 50-75% effort, FPWU: 10x 75%-Max effort, repeat 3x
    17. Repeat above 4x
    18. Repeat above 5x
FIFTH VISIT: 9-7: Overhead shoulder motion only a slight deficit with difficulty actively lifting arm and difficulty coming through the wind up of the pitching motion. We progressed overhead strength in the circuits below
Fourth Visit
- Active overhead motion continues to improve but is still limited in comparison to the left
- Reorganized program into the following
- Daily Movements/warm up
  - 11.3) Pillow Case Active Shoulder Extension Hands Progress Closer VIDEO
    - 8-15x
  - 31.1) Hands Elevated Variation VIDEO
    - In and out 8-15x
  - 27.1) Cane ER AAROM to Long Duration Stretch VIDEO
    - 10x in and out, followed by 10sec, 20sec, 30sec
    - This is done in 2 positions, closer to side and at 90deg where elbow is closer to shoulder height
    - No Longer necessary
  - Lying on your back, we used a cane to do the clock positions VIDEO
    - We used a cane to go into 12….11….and 10 0’clock positions
    - Once you reproduced tightness or pain, you pressed down into the cane as you moved back to the starting position
    - 5x through
    - Overhead only
    - NO LONGER NECESSARY
    - REPLACE WITH THE WEIGHTED SOFTBALL GOING THROUGH THE PITCHING MOTION
  - 46) Side Lying Thoracolumbar Rotation Stretch VIDEO
    - 10-15x
  - 12.3) Standing Behind the Back Self Stretch VIDEO
    - 10sec, 20sec, 30sec
    - Change to:
      - 23) Combined Flexion and Reach Behind Back Thoracic Mobility Bind Progression VIDEO
  - Holding Post, wide grip, standing overhead and try to roll all the way through to behind your back
    - 10 reps
- Strength Circuits: 2 sets of each second set 1/2 as many reps/time, Complete Every other Day
  - #1
    - 100.1) Ball Rollout Wall Block VIDEO
      - 8-20 reps
      - Do the harder version where your body follows the ball
        
        then 5-10x easier version
        
        REPLACE WITH
        
        103.3) Band Chop to Baseball Swing VIDEO
        
        DOUBLE GREEN BAND
        
        8-20 REPS
    - 123.1) TRX Reverse SidePlank VIDEO
      - 8-20x slow
      - REPLACE THIS WITH
        
        134.2) Bar Hang March VIDEO
        
        CAN START WITH THE SCAPULA PULL DOWN 5 SEC AND THE FREE HANG 5 SEC…PROGRESS TO KEEPING SCAPULA PULL AND DOING THE MARCH LIKE IN THE VIDEO
    - 105.2) 1/2 Kneel Overhead Kettlebell Press VIDEO
      - 5lbs 8-15reps
  - #2
    - 126) Supine to Wall Sit Wide Pull Down VIDEO
      - Red band on your back
      - REPLACE WITH
        
        163.1) Single Leg Deadlift Band Extension VIDEO
        
        GREEN/BLUE BAND
    - 74) Table Top Progression VIDEO
      - REPLACE WITH
        
        90.1) Band Bicep Loading into End Range Extension VIDEO
        
        BLUE
        
        8-20 REPS
        
        THIS CAN INCORPORATE THE 3 DIFFERENT POSITIONS WE USED TO MIMIC YOUR VARIOUS PITCHES
        
        REMEMBER, THE ARM MOVES IN THE SAME DIRECTION AND YOU TURN YOUR BODY AWAY OR TOWARDS THE ARM
    - 96.3) Lying on Weight Bench Pullover VIDEO
      - 10lbs
  - #3
    - 97) Band Pull Down 3 Planes VIDEO
      - only at a 90deg angle
    - 92.2) Full Can Fly Endurance VIDEO
      - 2lbs
      - REPLACE WITH
        
        WEIGHTED BALL/SMALL MEDICINE BALL PALM DOWN SMALL DROP CATCHES FOR 10SEC OUT IN FRONT, 10 SEC AT 45DEG ANGLE, 10 SEC OUT TO THE SIDE AND REPEAT 2-3X FOR 60-90SEC
    - 103.1) PNF D2 Band Down and Across VIDEO
      - Blue band
      - REPLACE WITH
        
        121.1) 1/2 Kneel Band horizontal Abduction with Progression to Rotation VIDEO
        
        CAN BE DONE ON ONE KNEE OR IN A LUNGE TO PULL OUT OF THE END OF THE SWING POSITION
        
        8-20 REPS EACH ARM
    - 91) Band Horizontal Adduction VIDEO
      - WE DID THIS ON ONE KNEE WITH THE GREEN
Hannah Clunk eval
Second Visit
- Noted Improvement in shoulder extension and reaching behind her back range of motion. Her capacity for active flexion still significantly limited but was able to move through near full range in the elevated childs pose position
Third Visit (8-24)
- Progressing well with nearly symmetrical ext, ER, and combined ext with IR into reaching behind the back
- Most limited in shoulder flexion but also progressing
- Updates to program below in BOLD
Daily Movements
- 11.4) Green Strap Passive Shoulder Extension VIDEO
  - 10sec, 20sec, 30sec
  - This movement can be dropped from the program because active extension is nearly symmetrical
- 11.3) Pillow Case Active Shoulder Extension Hands Progress Closer VIDEO
  - 8-15x
- 12.3) Standing Behind the Back Self Stretch VIDEO
  - 10sec, 20sec, 30sec
- 27.1) Cane ER AAROM to Long Duration Stretch VIDEO
  - 10x in and out, followed by 10sec, 20sec, 30sec
  - This is done in 2 positions, closer to side and at 90deg where elbow is closer to shoulder height
- 31.1) Hands Elevated Variation VIDEO
  - In and out 8-15x
- Lying on your back, we used a cane to do the clock positions…video coming soon
  - We used a cane to go into 12….11….and 10 0’clock positions
  - Once you reproduced tightness or pain, you pressed down into the cane as you moved back to the starting position
  - 5x through
- 46) Side Lying Thoracolumbar Rotation Stretch VIDEO
  - 10-15x
Every Other Day Sequence Which Incorporates the Movements Above: 2 sets of each circuit
- Circuit #1
  - 11.4) Green Strap Passive Shoulder Extension VIDEO
    - 10sec, 20sec, 30sec
    - NO LONGER NECESSARY
  - 11.3) Pillow Case Active Shoulder Extension Hands Progress Closer VIDEO
    - 8-15x
  - 74) Table Top Progression VIDEO
    - 5-15 reps 5sec holds
  - Lying on your back, we used a cane to do the clock positions…video coming soon
    - We used a cane to go into 12….11….and 10 0’clock positions
    - Once you reproduced tightness or pain, you pressed down into the cane as you moved back to the starting position
    - 5x through
- Circuit #2
  - 12.3) Standing Behind the Back Self Stretch VIDEO
    - 10sec, 20sec, 30sec
  - 73.2) Band Behind the Back Ext/IR Combo VIDEO
    - green band 8-20 reps
  - 36.2) Shoulder Press at Door Frame Progression VIDEO
    - 5-15reps
    - Lifting off the door at the top as able
- Circuit #3
  - 27.1) Cane ER AAROM to Long Duration Stretch VIDEO
    - 10x in and out, followed by 10sec, 20sec, 30sec
    - This is done in 2 positions, closer to side and at 90deg where elbow is closer to shoulder height
  - 116) Laying on Back External Rotation Phase 1 VIDEO
    - red, slow 8-20 reps
  - 46) Side Lying Thoracolumbar Rotation Stretch VIDEO
    - 10-15x
- Circuit #4
  - 31.1) Hands Elevated Childs Pose Variation VIDEO
    - In and out 8-15x
  - 84) Arm Bar VIDEO
    - We started with a 5lb dumbbell
    - Hold the weight on your back for 5 sec, roll to your side and pause 5 sec…and repeat 5-15x
    - If you reach 15, add weight and start back at 5-8…work your way up to 15 then you are ready to add weight again
  - 100.1) Ball Rollout Wall Block VIDEO
    - 8-20 reps
    - Do the harder version where your body follows the ball