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Journal of Orthopaedic & Sports Physical Therapy Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association
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Name _______________________________________________________________________________________________ Address _____________________________________________________________________________________________ sport-specific activities. An athlete can begin an ISP INTRODUCTION Address _____________________________________________________________________________________________ following a satisfactory clinical exam demonstrating Rehabilitation specialists commonly observe upper- full ROM, minimal pain or tenderness, adequate dyCity _______________________________State/Province __________________Zip/Postal Code _____________________ extremity injuries in golfers, baseball players, and namic stabilization, and sufficient strength and mustennis Traditional nonoperative and postopPhoneplayers. _____________________________Fax____________________________Email _____________________________ cular endurance.7,8 The ISP is initiated upon clearerative rehabilitation programs for these athletes inance by the athlete’s physician to resume sport Would you like to receive JOSPT email of updates and renewal notices? Yes No volve a gradual restoration of range motion activities and performed under the supervision of (ROM), strength, muscular endurance, dynamic stathe rehabilitation team (physician, physical therapist, bilization, and neuromuscular control.9,10 Upon sucand athletic trainer). Several guidelines are considcessful completion of the early phases of the rehabili- ered in the development of an ISP: (1) return-toPayment Information tation program, a gradual and controlled return to sport activities after injury that include attention to Check enclosed payable to the JOSPT).ausport activities has (made been advocated by several the entire body; (2) a gradual progression of applied thors.1,2,3,6,9,10,11 The term ‘‘interval sport programs’’ forces to lessen the chance of reinjury; (3) proper Credit Card (circle one) MasterCard VISA American Express has been used to refer to functional rehabilitation warm-up and maintenance exercises; and (4) proper guidelines that simulate sport activities. These probiomechanics to minimize the incidence of reinjury. Card Number ___________________________________Expiration Date _________________________________________ grams are designed to progressively apply forces to The ISP is set up to minimize the chance of the healing______________________________________Date structures and are intended to gradually reinjury and emphasizes warm-up and stretching. Signature __________________________________________________ return the athlete to full athletic competition as Because there is an individual variability in all athquickly and safely as possible. The purpose of this letes, there is no set timetable for completion of the paper is to describe specific interval sport programs program. Variability is based on each athlete’s skill To order email or mail to: currently utilized at our center to return golfers,call, fax, level, goals, and injury. It is recommended that the 1111 North Fairfax Street, Suiteathlete 100, Alexandria, 22314-1436 baseball players, and tennis players to competition follow theVA program rigidly, as this will permit following an injury or surgery. Phone 877-766-3450 • Fax 703-836-2210 • Email: [email protected] the safest return to competition. Highly competitive individuals who wish to return to competition quickly Principles of Interval Sport Programs Thank you for maysubscribing! have the tendency to increase the intensity of Interval sport programs (ISP) are designed to the ISP. This may increase the incidence of reinjury gradually return upper-extremity function after injury and may retard the rehabilitation process. or surgery by slowly progressing through graduated During the recovery process, the athlete may experience soreness and a dull, diffuse, aching sensation 1 Physical therapist, HealthSouth Rehabilitation, Birmingham, AL. in the muscles and tendons. If sharp pain is experi2 Physical therapist, American Sports Medicine Institute, Birmingham, AL. 3 enced, particularly in the joint or point of injury, the Rehabilitation consultant, Tampa Bay Devil Rays Baseball Organization, Tamp Bay, FL. athlete is instructed to stop all sport activity until the 4 Athletic trainer, Tampa Bay Devil Rays Baseball Organization, Tampa pain ceases. If pain persists, the athlete needs to unBay, FL. 5 dergo a physical assessment. Orthopaedic surgeon, Alabama Sports Medicine and Orthopedic Center, Birmingham, AL. 6 Medical director, Tamp Bay Devil Rays Baseball Organization, Tampa Bay, FL. Send correspondence to Michael M. Reinold, HealthSouth Sports Medicine and Rehabilitation Center, 1201 11th Avenue South, Suite 100, Birmingham, AL 35205. E-mail: [email protected] Journal of Orthopaedic & Sports Physical Therapy
Rehabilitation Program The athlete should supplement the ISP with a high-repetition, low-weight exercise program such as 293
Interval Sport Programs: Guidelines for Baseball, Tennis, and Golf
the Throwers Ten Program.6,10,11 While the strengthening program should achieve a balance between anterior and posterior shoulder musculature, special emphasis should be given to the posterior rotator cuff and scapular musculature for any strengthening program.9,10 The rehabilitation program should follow a sequential order of alternating days.6 All strengthening, plyometric, and neuromuscular control drills should be performed 3 times per week (with a day off in between) on the same day as the ISP (Table 1). The athlete should warm up, stretch, and perform 1 set of each exercise before the ISP, followed by 2 sets of each exercise after the ISP. This provides an adequate warm-up but also ensures maintenance of necessary ROM and flexibility of the upper extremity. Cryotherapy may be used following the completion of the rehabilitation program to minimize pain and inflammation. The alternate days are used for lower-extremity, cardiovascular, and core-stability training. In addition, the athlete performs ROM and light strengthening exercises that emphasize the posterior rotator cuff and scapular muscles.6 The cycle is repeated throughout the week and the seventh day is designated for rest and light ROM and stretching exercises.
Warm-Up An adequate warm-up is essential before beginning the ISP. The amount of warm-up will vary from person to person; therefore, the athlete should jog or cycle until developing a light sweat, then progress to the flexibility exercises. Because most sport motions involve the entire body, all muscle groups should be stretched prior to the ISP. Capsular stretches and shoulder ROM exercises6,9,10,11 should be performed as needed before beginning the ISP. TABLE 1. Rehabilitation program commonly used for golfers, baseball players, and tennis players.* Mon, Wed, Fri †
Tue, Thu, Sat
• LE strengthening
• Light ROM
• Neuromuscular control drills
• Core stability
• Posterior RTC and scapula strengthening‡
• Throwers Ten
* ISP = interval sport program; LE = lower extremity; RTC = rotator cuff; ROM = range of motion. † Consists of a set of specific exercises designed to increase strength and flexibility of the upper extremity.6,10,11 ‡ Strengthening of the posterior rotator cuff and scapular muscles are incorporated on alternating days during the early phases of rehabilitation. As the athlete progresses to more of a maintenance program, these exercises are discontinued on these days. 294
SPECIFIC INTERVAL SPORT PROGRAMS Interval Throwing Program An interval throwing program is used to gradually return baseball pitchers and positional players to competition. The interval throwing program is used for high school, college, and professional baseball players and is divided into 2 phases. Our interval throwing program has been developed based on research conducted in our laboratory quantifying the biomechanics of flat-ground, long-toss, and partialeffort throwing.4,5 The interval throwing program is initiated with throwing on flat-ground for approximately 4 to 6 weeks (Table 2). The athlete begins throwing at 13.7 m (45 ft) and gradually progresses to 18.3, 27.4, 36.6, 45.7, and 54.8 m (60, 90, 120, 150, and 180 ft, respectively). A critical aspect of the interval throwing program is the use of proper throwing mechanics. The use of the ‘‘crow hop’’ method simulates the throwing act, emphasizing proper body mechanics. A pitching coach and sports biomechanist may be valuable allies to the rehabilitation team to ensure the use of proper throwing mechanics. Components of the crow hop method are first a hop, then a skip, followed by the throw. The velocity of the throw is determined by the distance, whereas the ball should be thrown with an arc and have only enough momentum to travel the desired distance. Using the crow hop method, the athlete should begin warm-up throws at a comfortable distance of approximately 9.1 to 13.7 m (30 to 45 ft) and then progress to the distance indicated for each step of the interval throwing program. The program consists of throwing at each step 2 to 3 times on separate days without pain or symptoms before progressing to the next step. Initially, the athlete will perform 2 sets of 25 throws at the specified distance. Adequate warm-up before each set and a rest of 5 to 10 minutes is encouraged. The amount of throws is then increased to 3 sets of 25 throws at each distance, and finally to the next distance in the sequence. If pain exists at a particular step, the athlete is instructed to return to the previous asymptomatic step and attempt to progress again when symptoms subside. Positional players are instructed to progress through the entire interval throwing program before beginning position-specific drills. However, pitchers are instructed to progress through 36.6 m (120 ft) of long-toss throwing (phase 1, step 8). At this time, they may opt to continue the normal progression or they may advance to step 14 of phase 1. This step is intended specifically for pitchers and involves 10 to 15 throws at progressive distances of 18.3, 27.4, and 36.6 m (60, 90, and 120 ft, respectively), followed by flat-ground throwing from 18.3 m (60 ft) using norJ Orthop Sports Phys Ther • Volume 32 • Number 6 • June 2002
TABLE 2. Interval throwing program for baseball players: phase 1.* 45-Ft Phase
Warm-up throwing 180 ft, 25 throws Rest 5–10 min Warm-up throwing 180 ft, 25 throws Rest 5–10 min Warm-up throwing 180 ft, 20 throws Rest 5–10 min Warm-up throwing 15 throws, progressing from 120 to 90 ft
Note: All throws should be on an arc with a crow hop. Warm-up throws consist of 10 to 20 throws at approximately 30 ft. Throwing program should be performed every other day, 3 times per week unless otherwise specified by a physician or rehabilitation specialist. Perform each step times before progressing to next step.
Step 14: Return to respective position or progress to step 14 below. Flat-Ground Throwing for Baseball Pitchers Step 14: A) B) C) D) E)
Warm-up throwing 60 ft, 10–15 throws 90 ft, 10 throws 120 ft, 10 throws 60 ft (flat-ground) using pitching mechanics, 20–30 throws F) 60–90 ft, 10–15 throws G) 60 ft (flat-ground) using pitching mechanics, 20 throws Progress to phase 2: throwing off the mound
* 45 ft = 13.7 m; 60 ft = 18.3 m; 90 ft = 27.4 m; 120 ft = 36.6 m; 150 ft = 45.7 m; 180 ft = 54.8 m.
mal pitching mechanics, thereby initiating throws on a straight line without an arc and crow hop. After the pitcher can perform phase 1 without symptoms, he is ready to progress to phase 2: throwing off the mound (Table 3). Just as the advancement to this phase was gradual and progressive, so must the return to unrestricted pitching follow the same principles. The length of phase 2 is determined specifically for each athlete. A pitcher should first throw only fastballs at 50% effort, and progress to 75% and 100% effort. The use of a radar gun may be helpful to assist in effort control. Phase 2 of the interval throwing program begins by using the 36.6-m (120-ft) step of phase 1 as a warm-up. The pitcher then throws 15 throws off the mound using full wind-up pitching mechanics at 50% effort. As the player progresses through phase J Orthop Sports Phys Ther • Volume 32 • Number 6 • June 2002
2, the number of pitches as well as the percent effort of throwing is gradually advanced until the athlete is allowed to pitch light batting practice. At this time, the player may start more stressful pitches such as breaking balls, as well as the initiation of simulated games. In the event that an injury occurs during the competitive season, an abbreviated interval throwing program is used in conjunction with a rehabilitation program (Table 4). The program is designed to expediently return the athlete to competition within 21 days.
Little League Interval Throwing Program The little league interval throwing program (Table 5) parallels the previously outlined interval throwing program in providing the youth baseball player with 295
TABLE 4. Short-duration interval throwing program.* Day 1: A) 45 ft, 30 throws B) 60 ft, 30 throws
Day 11: A) B) C) D)
Day 2: A) 45 ft, 45 throws B) 60 ft, 45 throws
Day 12: A) Rest
Day 3: A) 60 ft, 125 throws
Day 13: A) 60 ft, 100 throws B) Bullpen pitching, fastballs only, 25 pitches, 75% effort
Day 4: A) 60 ft, 85 throws B) 90 ft, 30 throws C) 60 ft, 20 throws
Day 14: A) B) C) D)
Day 5: A) Rest
Day 15: A) 60 ft, 100 throws B) Bullpen pitching, fastballs and change-ups, 35 pitches, 80% effort
Day 6: A) 60 ft, 100 throws B) 90 ft, 30 throws C) 60 ft, 20 throws
Day 16: A) Rest
Day 7: A) 60 ft, 50 throws B) 90 ft, 50 throws C) 60 ft, 50 throws
Day 17: A) 60 ft, 100 throws B) Bullpen pitching, all pitches, 45 pitches, 100% effort
Day 8: A) B) C) D)
Day 18: A) B) C) D)
Stage 2: Fastballs Only Step 9:
A) B) Step 10: A) B) Step 11: A) B)
60 throws, 75% 15 throws, batting practice 50–60 throws, 75% 30 throws, batting practice 45–50 throws, 75% 45 throws, batting practice Stage 3
Step 12: A) B) C) Step 13: A) B) C) Step 14: A) B)
30 throws, 75% 15 throws, 50%, begin breaking balls 45–60 throws, batting practice, fastball only 30 throws, 75% 30 breaking balls, 75% 30 throws, batting practice 30 throws, 75% 60–90 throws, batting practice, gradually increase breaking balls Step 15: A) Simulated game: progressing by 15 throws per workout (pitch count) * Represents percentage effort. † All throwing off the mound should be done in the presence of a pitching coach or sport biomechanist to stress proper throwing mechanics (use speed gun to aid in effort control). ‡ Use interval throwing 120-ft (36.6-m) phase as warm-up.
Day 21: A) Game, 25–35 pitches * 45 ft = 13.7 m; 60 ft = 18.3 m; 90 ft = 27.4 m; 120 ft = 36.6 m.
Interval Tennis Program a graduated progression of throwing distances. Alterations are made based on the size of little league fields and the distance from home plate to the mound, compared to high school and adult playing situations. Similar warm-up and flexibility exercises are incorporated. The little league player begins throwing with a warm-up consisting of lobbing the ball 4.6 to 6.1 m (15 to 20 ft). The player then performs 2 sets of 25 throws at 9.1 m (30 ft) with a 15-minute rest in between. As the athlete progresses, 3 sets of 25 throws are initiated. The little league player progresses from 9.1 to 13.7, 18.3, and 27.4 m (30 to 45, 60, and 90 ft, respectively), and follows with positional drills and pitching off the mound similar to phase 2 of the interval throwing program. 296
The interval tennis program (Table 6) is used for athletes returning to racquet sports such as tennis and racquetball. The same general principles of any ISP should be followed before initiating the interval tennis program. The interval tennis program is divided into approximately 4 to 6 weeks of progressive participation. Proper biomechanics should be emphasized including a full follow-through of each shot. The first 2 weeks involve a gradual progression of forehand and backhand shots, applying 50% effort during week 1 and 75% effort during week 2. If the athlete can tolerate the latter, the athlete may progress to serving the ball at 50% effort during weeks 3 through 4. At weeks 4 through 6, the athlete may progress to fullJ Orthop Sports Phys Ther • Volume 32 • Number 6 • June 2002
TABLE 5. Little league interval throwing program.* 30-Ft Phase
* 30 ft = 9.1 m; 45 ft = 13.7 m; 60 ft = 18.3 m; 90 ft = 27.4 m.
effort forehand and backhand shots and serves at 75% effort. Playing is initiated by progressing from 3 games to 1.5 sets. Upon completion of the interval tennis program, the athlete may begin playing full matches as tolerated.
Interval Golf Program (IGP) The IGP (Table 7) follows a progression of approximately 5 weeks. Shots involving full golf swings are initiated using a progression from short irons (wedges, 9-iron, and 8-iron), medium irons (7-iron, 6-iron, and 5-iron), long irons (4-iron, 3-iron, and 2-iron), fairway woods (5-wood and 3-wood), to the driver to allow the progression of force production. The golfer is encouraged to begin using each club with a tee to avoid the deleterious forces that may be produced during a divot. Swings are initiated at partial effort and progressed to full effort as tolerated. The first week begins with light putting and chipping drills and progresses to light short-iron shots by the end of the week. Medium irons are initiated during week 2 while the number of shots is increased. Putting and chipping are performed throughout to allow for an active period of rest between sets of iron J Orthop Sports Phys Ther • Volume 32 • Number 6 • June 2002
shots. Long irons are begun at the beginning of week 3, followed by the initiation of fairway woods. Again, the number of shots using each iron and wood is progressed, until the use of the driver is initiated at week 4. If the golfer progresses through the IGP without complaints, 9 holes of golf are allowed at the end of week 4 and increased to 18 holes by the end of the fifth week. As with any ISP, proper biomechanics are essential throughout the progression.
SUMMARY In using an ISP in conjunction with a structured rehabilitation program, the athlete should be able to return to full competition status. The general guidelines and specific programs outlined are used to minimize the chance of reinjury and to facilitate the return of function and confidence in the athlete. The program and its progression should be modified to meet the specific needs of each individual athlete. A comprehensive program consisting of a proper maintenance rehabilitation program incorporating strengthening, flexibility, plyometric, dynamic stabilization, and neuromuscular controls drills, as well as appropriate warm-up procedures and biomechanics, is essential in returning athletes to competition as quickly and safely as possible. 297
20 chips 10 short irons 5-min rest 10 short irons 15 medium irons (5-iron off tee)
20 chips 15 short irons 10-min rest 15 short irons 15 chips Putting 15 medium irons
15 short irons 20 medium irons 10-min rest 20 short irons 15 chips
15 short irons 20 medium irons 10-min rest 15 short irons 15 medium irons 5 long irons 10-min rest 20 chips
15 short irons 15 medium irons 10 long irons 10-min rest 10 short irons 10 medium irons 5 long irons 5 wood
15 short irons 15 medium irons 10 long irons 10-min rest 10 short irons 10 medium irons 10 long irons 10 wood
Play 9 holes 15 short irons 15 medium irons 10 long irons 10 drives 15-min rest Repeat
Play 9 holes
Play 9 holes
Play 18 holes
Play 9 holes
* Chips = pitching wedge; short irons = wedge, 9-iron, 8-iron; medium irons = 7-iron, 6-iron, 5-iron; long irons = 4-iron, 3-iron, 2-iron; woods = 3-wood, 5-wood; drives = driver.
2. Axe MJ, Wickham R, Snyder-Mackler L. Data-based interval throwing programs for little league, high school, college, and professional baseball pitchers. Sports Med Arthrosc Rev. 2001;9:24–34. 3. Ellenbecker TS, Mattalino AJ. The Elbow in Sport: Injury, Treatment, and Rehabiliation. Champaign, IL: Human Kinetics; 1997. 4. Fleisig GS, Escamilla RF, Barrentine SW, Zheng N, Andrews JR. Kinematic and kinetic comparison of baseball pitching from a mound and throwing from flat ground. Twentieth Annual Meeting of the American Society of Biomechanics. Atlanta, GA: American Society of Biomechanics; 1996:153–154. 5. Fleisig GS, Zheng, Barrentine SW, Escamilla RF, Andrews JR, Lemak LJ. Kinematic and kinetic comparison of full-effort and partial-effort baseball pitching. Twentieth Annual Meeting of the American Society of Biomechanics. Atlanta, GA: American Society of Biomechanics; 1996:155–156. 6. Wilk KE, Andrews JR, Arrigo CA, et al. Preventive and Rehabilitative Exercises for the Shoulder and Elbow. 6th ed. Birmingham, AL: American Sports Medicine Institute; 2001. 7. Wilk KE, Andrews JR, Arrigo CA, et al. The strength characteristics of the internal and external rotator muscles in professional baseball pitchers. Am J Sports Med. 1993;21:61–69. 8. Wilk KE, Arrigo CA, Andrews JR. The abductor and adductor strength characteristics of professional baseball pitchers. Am J Sports Med. 1995;23:307–311. 9. Wilk KE, Arrigo CA. Current concepts in the rehabilitation of the athlete shoulder. J Orthop Sports Phys Ther. 1993;18:365–378. 10. Wilk KE, Reinold MM, Andrews JR. Postoperative treatment principles in the throwing athlete. Sports Med Arthrosc Rev. 2001;9:69–95. 11. Wilk KE, Reinold MM, Dugas JR, Andrews JR. Rehabilitation following thermal-assisted capsular shrinkage of the glenohumeral joint: current concepts. J Orthop Sports Phys Ther. 2002;32:268–292.
REFERENCES 1. Axe MJ, Snyder-Mackler L, Konin JG, Strube MJ. Development of a distance-based interval throwing program for little-league-aged athletes. Am J Sports Med. 1996;24:594–602.
J Orthop Sports Phys Ther • Volume 32 • Number 6 • June 2002