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Using Rotational Resistance Measures to Thoroughly Assess Shoulder Flexibility in Baseball Pitchers

University of Florida Institutional Repository
Permanent Link: http://ufdc.ufl.edu/UFE0021038/00001

Material Information

Title: Using Rotational Resistance Measures to Thoroughly Assess Shoulder Flexibility in Baseball Pitchers Implications for Throwing Arm Adaptations and Injuries
Physical Description: 1 online resource (89 p.)
Language: english
Creator: Wight, Jeffrey Thomas
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: baseball, biomechanics, external, flexibility, internal, pitching, shoulder
Applied Physiology and Kinesiology -- Dissertations, Academic -- UF
Genre: Health and Human Performance thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Throwing arm injuries are extremely prevalent in baseball pitchers. The flexibility of the throwing shoulder is thought to be relevant to the incidences of throwing arm injuries and injury mechanisms. Previous flexibility studies have assessed a single shoulder variable: the range of motion (ROM). In this study, a custom device was built to measure shoulder flexibility and a new and more thorough manner. The device assesses the amount of torque (or effort) required to passively rotate the shoulder. This novel analysis provides a measure of how stiff or loose the shoulder is as it is rotated to the end ROM. The two shoulder motions that are considered the most relevant to injury were analyzed (internal rotation and external rotation). Two major findings were revealed in this study. First, for both ER and IR the end ROM and stiffness of the shoulder are not related. This means that two pitchers can have similar ROM but drastically different shoulder stiffness. This data suggests that both ROM and stiffness are required to describe the flexibility of the pitching shoulder. Second, pitching alters the flexibility of the throwing shoulder. This was discovered by comparing the flexibility of the throwing shoulder to that of the non-throwing shoulder. Variables that were significantly different bilaterally were the ROM, the resistance onset angle (angle where the soft tissue begins to stretch), and shoulder stiffness. These bilateral differences were large (20-40%). The magnitude and direction of these bilateral differences are likely relevant to throwing arm injuries. We recommend the incorporation of this new shoulder analysis into clinical and rehabilitation settings and believe future research should strive to better understand the relevance of shoulder flexibility to throwing arm injuries.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Jeffrey Thomas Wight.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Tillman, Mark D.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021038:00001

Permanent Link: http://ufdc.ufl.edu/UFE0021038/00001

Material Information

Title: Using Rotational Resistance Measures to Thoroughly Assess Shoulder Flexibility in Baseball Pitchers Implications for Throwing Arm Adaptations and Injuries
Physical Description: 1 online resource (89 p.)
Language: english
Creator: Wight, Jeffrey Thomas
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: baseball, biomechanics, external, flexibility, internal, pitching, shoulder
Applied Physiology and Kinesiology -- Dissertations, Academic -- UF
Genre: Health and Human Performance thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Throwing arm injuries are extremely prevalent in baseball pitchers. The flexibility of the throwing shoulder is thought to be relevant to the incidences of throwing arm injuries and injury mechanisms. Previous flexibility studies have assessed a single shoulder variable: the range of motion (ROM). In this study, a custom device was built to measure shoulder flexibility and a new and more thorough manner. The device assesses the amount of torque (or effort) required to passively rotate the shoulder. This novel analysis provides a measure of how stiff or loose the shoulder is as it is rotated to the end ROM. The two shoulder motions that are considered the most relevant to injury were analyzed (internal rotation and external rotation). Two major findings were revealed in this study. First, for both ER and IR the end ROM and stiffness of the shoulder are not related. This means that two pitchers can have similar ROM but drastically different shoulder stiffness. This data suggests that both ROM and stiffness are required to describe the flexibility of the pitching shoulder. Second, pitching alters the flexibility of the throwing shoulder. This was discovered by comparing the flexibility of the throwing shoulder to that of the non-throwing shoulder. Variables that were significantly different bilaterally were the ROM, the resistance onset angle (angle where the soft tissue begins to stretch), and shoulder stiffness. These bilateral differences were large (20-40%). The magnitude and direction of these bilateral differences are likely relevant to throwing arm injuries. We recommend the incorporation of this new shoulder analysis into clinical and rehabilitation settings and believe future research should strive to better understand the relevance of shoulder flexibility to throwing arm injuries.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Jeffrey Thomas Wight.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Tillman, Mark D.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021038:00001


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USING ROTATIONAL RESISTANCE MEASURES TO THOROUGHLY ASSESS
SHOULDER FLEXIBILITY IN BASEBALL PITCHERS: IMPLICATIONS FOR THROWING
ARM ADAPTATIONS AND INJURIES




















By

JEFFREY T. WIGHT


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2007



























O 2007 Jeffrey T. Wight









ACKNOWLEDGMENTS

I would first like to thank my advisor, Dr. Mark Tillman. I am particularly thankful for his

unselfishness and ability to make things happen at crunch time. His abilities to quickly assess

new ideas and clarify unpolished thoughts are unmatched. He was the perfect advisor for me and

this project. I am also grateful to my remaining committee members: Dr. John Chow, Dr. Paul

Borsa, and Dr. Anthony Falsetti. I would like to thank Dr. Chow for providing me with many

research opportunities. I am particularly thankful for his guidance and support on the USTA

proj ect which laid the foundation for this proj ect. I will always remember his open office door

and his generosity and leadership at conferences. I would like to thank Dr. Borsa for steering me

in the right direction. His experience, knowledge, and enthusiasm have been crucial to this

proj ect, my development, and this line of research. I would like to thank Dr. Falsetti for his

incredible sacrifice, support, and contributions. I would also like to thank my fellow graduate

student, Guy Grover, for his involvement at every step along the way. I am particularly grateful

for his friendship and sacrifice at the crucial points in this proj ect. I am thankful for our

teamwork and ability to combine ideas and efforts to fulfill a common vision.

Next, I would like to thank my family for their incredible support. I am thankful to have

completed this journey with my wife, Erin. Enrolling in graduate school together six years ago

was one of the best decisions we ever made. I am proud of her accomplishments and thankful for

her contributions to this proj ect. Everyday with her is a blessing. I would like to thank baby

Largo Wight for motivating me and putting things in perspective. I would like to thank my

parents and sister for their unconditional support. I am thankful for their love and I appreciate the

freedom and confidence they instilled in me to explore my thoughts and follow my dreams. I

would also like to thank my in-laws for their friendship, love, and support. Having them in

Florida has been wonderful. I would also like to thank Gary Nave, Kelly Larkin, Curtis Weldon,










Dr. Geoff Dover, Dr. Chris Hass, J.D. Garbrecht, John Barrett, Richard Stark, Ross Jones, Pat

Dougherty, the Fightin' Blue Hens, the USTA, and MLB.

In closing, I would like to dedicate this proj ect to the baseball community. I am grateful to

all of the coaches and players I have worked with over the years and I am happy that I can give a

little back with this proj ect. Finally, I would like to thank the sport of baseball for teaching me

that, "sometimes you win, sometimes you lose, and sometimes it rains".












TABLE OF CONTENTS

page

ACKNOWLEDGMENT S ................. ...............3.......... ......


LIST OF TABLES ................ ...............8............ ....


LI ST OF FIGURE S .............. ...............9.....


AB S TRAC T ............._. .......... ..............._ 10...


CHAPTER


1 INTRODUCTION TO STUDY .............. ...............12....


General Introduction ................... ............ ...............12.......
Shoulder Mobility and Stability ................ ...............14...
Assessing Shoulder Mobility and Stability .............. ...............15....
Specific Aims............... ...............15..

2 REVIEW OF THE LITERATURE .............. ...............22....


Analyzing the Shoulder IR/ER Passive Motion .............. ...............22....
Important Methodological Considerations ....._._._ .......__. ...._._ ............2
Arm position............... ...............23
Scapular stabilization .............. ...............23....
Novotny' s Approach .............. ...............24....
Reliability of Traditional Measures ........._. ....___ ........_. ..........2
The Shifted Motion............... ...............25.
Other Shoulder Motions .............. ...............25....

Sport Specific Findings .............. ...............26....
Age and the Motion Shift ............... ...............27....
Biomechanics of the Baseball Pitch ..........._.._. ...............28....._._. ....
Alterations to the Throwing Arm .............. ...............29....
Humeral retroversion............... ..............2
Soft Tissue Theories .........._.... ........___ ...............31....
Horizontal Adduction Tightness Tests ......__....._.__._ ......._._. ............3
A ctive IR ............... ...............32....
Glenohumeral Stiffness .............. ...............32....
Glenohumeral Translation ........._.._.. ...._... ...............33....
Conclusions .............. ...............33....


3 MATERIALS AND METHODS .............. ...............34....


Participants .............. ...............34....
Equipment ........._..... ...._... ...............34.....
Arm Position............... ...............36

Scapular Stabilization ........._..... ...._... ...............36.....












Data Collection .............. ...............37....
RR Device Collection ............. ...... .__ ...............39..
Data Reduction ................. ...............39...
Reduce To Best-Fit Line .............. ..... ...............39.

Definiti on of Rotational Re si stance Group s ...._ ......_____ .......___ .........4
Angle Conventions .............. ...............42....
Data Analysis............... ...............42
General Analysis .............. ...............42....

Analysis of Specific Aims ............. ......___ ...............43...

4 RE SULT S .............. ...............47....


Specify c Aim la .............. ...............47....
Specific Aim lb .............. ...............48....
Specify c Aim 2a .............. ...............49....
Specify c Aim 2b .............. ...............50....
Specific Aim 2c .............. ...............51....
Specific Aim 3 .............. ...............52....


5 DI SCUS SSION ................. ...............5 5......... ....


Description of Pitchers .............. ...............55....

Important General Findings ........._...... ...............56.....__........
Magnitude of Rotational Resi stance ........._...... ............ .. ...............57....
High Variability in Rotational Resistance Among Subj ects ................. ........_._... .....58
Prevalence of Throwing Arm Injuries ................. ...............59........... ...

Specify c Aims............... ...............59..
A im la .............. ...............59...
A im lb .............. ...............61....
A im 2a .............. ...............62....
A im 2b .............. ...............65....
A im 2c .............. ...............66....
A im 3 .............. ...............67....

Sum m ary ................. ......... ...............68......
General Conclusions............... ......... ........6

Practical application and recommendations .............. ...............69....
Future Research ................. ...............70........ ......


APPENDIX


A SHOULDER ANATOMY AND EXAMPLE INJURIES ................ .......... ................72


B APPROVED IRB ............. ...... .__ ...............75..


C APPROVED INFORMED CONSENT ................. ...............78................


D THROWING ARM INJURY QUESTIONNAIRE ................. ...............80........... ...













LIST OF REFERENCES ................. ...............82................


BIOGRAPHICAL SKETCH .............. ...............88....










LIST OF TABLES


Table page

2-1 Summary of shoulder IR/ER range of motion studies for overhead athletes. ........._........26

2-2 Humeral retroversion in baseball pitchers. ............. ...............30.....

3-1 Means and SD of flexibility variables for repetitions 1, 2, and 3 .............. ...................41

3-2 Statistical analyses for aim la. ........._..._.._ ...............43....._.. ...

3-3 Statistical analyses for aim 1b............... ...............44...

3-4 Statistical analyses for aim 2a. ........._.__ ..... .___ ...............44..

3-5 Statistical analyses for aim 2b............... ...............44...

3-6 Statistical analyses for aim 2c ...._._. ................. ........._..._......4

3-7 Chi-square contingency table for aim 3 .............. ...............46....

4-1 ROM and resistance zones for the high and low rotational resistance groups. .................49

4-2 Bilateral comparison of flexibility variables for ER and IR. .............. ....................4

4-3 Mean moti on shifts for non-dominant shoulder rotati onal re si stance group s.........__.......52

4-4 Summary of self-reported throwing arm injuries............... ...............54










LIST OF FIGURES


Figure page

2-1 Shoulder ER during the baseball pitch ........... _.....___ ...............28

2-2 Follow-through phase of the pitch. ........... _.....__ ...............29.

3-1 RR device designed for measuring overhead athletes. ............. ...............35.....

3-2 Schematic of data collection. ............. ...............37.....

3-3 Example torque-displacement data for an ER repetition. ................... ............... 4

3-4 Defining groups based on rotational resistance variables. ......____ .... .. ..___............42

4-1 Stiffness versus end ROM for the throwing shoulder ................. ......... ................47

4-2 ROA versus end ROM for ER and IR of the throwing shoulder. ........._._..........._.......47

4-3 Formation of high and low rotational resistance (RR) groups for ER and IR. ................48

4-4 Bilateral stiffness difference versus the motion shift for the dominant shoulder.. ............50

4-5 Dominant shoulder ROA bilateral differences versus the motion shift. ................... .........50

4-6 Non-dominant ER rotational resistance measures versus the ER motion shift. ........._.....51

4-7 Non-dominant IR rotational resistance measures versus the IR motion shift. .................51

4-8 High and low rotational resistance groups for the non-dominant ER and IR. ...................52

4-9 Prevalence of shoulder and elbow injuries with respect to ER passive flexibility. ...........53

4-10 Prevalence of shoulder and elbow injuries with respect to IR passive flexibility. ............54

5-1 The ROA and ROM shifts for external rotation. ............. ...............65.....









Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

USING ROTATIONAL RESISTANCE MEASURES TO THOROUGHLY ASSESS
SHOULDER FLEXIBILITY IN BASEBALL PITCHERS: IMPLICATIONS FOR THROWING
ARM ADAPTATIONS AND INJURIES

By

Jeffrey T. Wight

August 2007

Chair: Mark Tillman
Maj or: Health and Human Performance

Throwing arm injuries are extremely prevalent in baseball pitchers. The flexibility of the

throwing shoulder is thought to be relevant to the incidences of throwing arm injuries and injury

mechanisms. Previous flexibility studies have assessed a single shoulder variable: the range of

motion (ROM). In this study, a custom device was built to measure shoulder flexibility and a

new and more thorough manner. The device assesses the amount of torque (or effort) required to

passively rotate the shoulder. This novel analysis provides a measure of how stiff or loose the

shoulder is as it is rotated to the end ROM. The two shoulder motions that are considered the

most relevant to injury were analyzed (internal rotation and external rotation). Two major

findings were revealed in this study. First, for both ER and IR the end ROM and stiffness of the

shoulder are not related. This means that two pitchers can have similar ROM but drastically

different shoulder stiffness. This data suggests that both ROM and stiffness are required to

describe the flexibility of the pitching shoulder. Second, pitching alters the flexibility of the

throwing shoulder. This was discovered by comparing the flexibility of the throwing shoulder to

that of the non-throwing shoulder. Variables that were significantly different bilaterally were the

ROM, the resistance onset angle (angle where the soft tissue begins to stretch), and shoulder









stiffness. These bilateral differences were large (20-40%). The magnitude and direction of these

bilateral differences are likely relevant to throwing arm injuries. We recommend the

incorporation of this new shoulder analysis into clinical and rehabilitation settings and believe

future research should strive to better understand the relevance of shoulder flexibility to throwing

arm injuries.









CHAPTER 1
INTRODUCTION TO STUDY

General Introduction

Evolving the ability to throw was crucial to the existence and advancement of our species

(Darlington et al., 1975; Young et al., 2003). Although the importance of throwing to daily

survival has diminished, its pervasiveness remains. Hundreds of thousands of individuals around

the world participate in recreational and organized athletics that involve throwing or throwing-

like motions (Fleisig et al., 1996; Conte et al., 2001; Escamilla et al., 2001; Janda, 2003).

Athletes that regularly throw or use throwing-like motions are referred to as overhead

athletes (Baltaci et al., 2004; Borsa et al., 2005). Example overhead actions include the baseball

pitch, football pass, javelin throw, volleyball spike, and tennis serve. Regularly performing

overhead actions places great demands on the dominant arm (Zheng et al., 2004; Mullaney et al.,

2005). Detailed, long term injury surveillance studies have yet to be completed however; injuries

to the dominant shoulder and elbow are prevalent and often severe, especially in baseball

pitchers (Fleisig et al., 1995).

Currently, Maj or League Baseball disabled list reports provide the most thorough

description of injury prevalence in baseball pitchers (Conte et al., 2001). Over 11 seasons (1989-

1999), each team, on average, had players miss 640.6 days per season. Pitchers accounted for

over half of these missed days. The maj ority of injuries were to the shoulder (27.8%) and elbow

(22.0%). The knee was a distant third at 7.3%. These findings are not unique to professionals;

high throwing arm injury rates are seen throughout all levels of play (Hang et al., 2004; Sabick et

al., 2004; Olsen et al., 2006).

Throwing arm injuries are related to repeated exposure to extreme biomechanics.

Throwing arm joint velocities, forces, and torques are approximately 25-40% greater than other









overhead actions, like the football pass (Fleisig et al., 1996), and they are thought to load elbow

and shoulder tissues at or near capacity (Fleisig et al., 1995). Also, the throwing arm is subj ected

to these loads many times and very often. Starting pitchers throw 100+ pitches every 4-6 days

and relief pitchers commonly throw 15+ pitches on consecutive days (Mullaney et al., 2005).

Finally, the seasons are long, up to 8 months in the professional leagues, with games almost

every day.

A plethora of throwing arm injuries has been documented. Most injuries are "overuse" in

nature meaning they gradually develop over the course of a season or career (Zheng et al., 2004).

Pitching overuse injuries develop in one of two ways. First, repetitive loading may weaken or

alter a bony or soft tissue to the point where the pitcher suffers laxity, dysfunction, pain, or a

severe tear. Common examples include gradual stretching of the anterior passive constraints

(Kvitne et al., 1993), humeral epiphyseal plate injuries (Sabick et al., 2004), and the gradual

weakening (and perhaps eventual tearing) of the ulnar collateral ligament (Safran et al., 2005) or

rotator cuff muscles (Mazoue et al., 2006). Second, repetitive loading may lead to throwing arm

mal-adaptations. For example, the posterior capsule may excessively tighten (Burkhart et al.,

2003) or the scapular positioning may become altered in a detrimental way (Myers et al., 2005).

These alterations may lead to clinical problems like shoulder impingement.

Baseball pitchers have now been intensely studied for approximately 30 years. The

understanding of the pitching motion and demands on the throwing arm has improved

dramatically (Feltner et al., 1986; Matsuo et al., 2006). Ability to diagnose injuries and help

injured pitchers has also improved dramatically (Nakagawa et al., 2005; Koh et al., 2006; Song

et al., 2006). Interestingly, injuries remain prevalent.









Fortunately, progress is being made in three areas. The first is pitching behavior. The

number of pitches thrown, types of pitches thrown, and tendency to throw with pain appear to be

relevant to injuries, especially in youth (Lyman et al., 2001; Olsen et al., 2006). Second, the

relevance of pitching mechanics to injuries is being discovered (Wight et al., 2004; Matsuo et al.,

2006). Last, researchers are beginning to better understand the mechanical characteristics of the

pitching arm, specifically the shoulder. These three general topics all provide great potential to

reduce injuries because they are relevant to injuries and can be controlled by players/coaches or

manipulated through interventions. This proj ect will focus on the last factor: better understanding

the mechanical characteristics of the throwing shoulder.

Shoulder Mobility and Stability

Biomechanical studies have revealed the essential requirements of the pitching shoulder.

First, the shoulder must be mobile, especially in external rotation. During the arm cocking phase,

pitchers externally rotate the shoulder as far as possible to help generate throwing velocity

(Feltner et al., 1986). The magnitude of shoulder rotation is crucial to success. High velocity

pitchers are able to achieve 175-1800 of shoulder ER (Zheng et al., 2004). This is approximately

10-150 more than low velocity pitchers (Matsuo et al., 2001; Murray et al., 2001). The second

essential requirement is shoulder stability. The shoulder must remain stable enough to prevent

injuries as it is externally rotated to 1750, rapidly internally rotated to over 70000/s (Dillman et

al., 1993), and exposed to a distraction force during the follow through phase that is near or

beyond the pitchers body weight (Fleisig et al., 1996).

Many have stressed the importance of understanding the delicate balance between shoulder

mobility and stability (Wilk et al., 2002; Ellenbecker et al., 2002; Crockett et al., 2002).

Developing a better understanding of shoulder mobility and stability is important for three

reasons. First, it is thought to influence to how vulnerable to injury the shoulder is. Second, it









may influence how vulnerable to injury the elbow is; shoulder mobility and stability may

influence the throwing arm movements that place stress upon and injure the elbow joint (Feltner

et al., 1986; Fleisig et al., 1995). Third, there is potential to improve or optimize the mobility and

stability of the shoulder since strength (Treiber et al., 1998), proprioception (Safran et al., 2001),

and flexibility (Kibler et al., 2003) can be altered via interventions.

Assessing Shoulder Mobility and Stability

Ideally, shoulder mobility and stability would be assessed during the pitch. But the ability

to do this is limited. The only kinetic analysis available is inverse dynamics and the ability to

assess the kinematics of the humeral head has yet to be established. Therefore, the most

productive way to study shoulder mobility and stability is to examine the shoulder in a controlled

clinical setting. Topics relevant to shoulder mobility and stability that have been assessed in this

manner include strength (Noffal et al., 2003), motor control (Safran et al., 2001), glenohumeral

translation (Borsa et al., 2005) and stiffness (Borsa et al., 2006), scapular mobility (Downar et

al., 2005) and shoulder ROM (Ellenbecker et al., 2002). The most important, popular, and useful

shoulder examination thus far has proven to be the shoulder internal rotation (IR) and external

rotation (ER) ROM examination. This project will focus on improving the shoulder IR/ER

examination to better understanding throwing shoulder flexibility, how pitching alters the

throwing shoulder, and throwing arm injuries.

Specific Aims

The relevance of the IR/ER motion was discovered when researchers revealed it to be

drastically altered by pitching (Brown et al., 1988; Baltaci et al., 2001). In most pitchers, this

motion is shifted back (towards ER) approximately 100. Thus, the pitcher gains 100 of ER and

loses 100 of IR. This "motion shift" is thought to be a positive adaptation that allows the pitcher

to externally rotate the shoulder to an extreme ROM during the pitch (Crockett et al., 2002;









Baltaci et al., 2004). The IR/ER motions and motion shift are relevant to throwing arm injuries.

Pitchers with limited IR often have throwing arm problems including shoulder impingement and

SLAP lesions (Burkhart et al., 2003; Myers et al., 2006). The loss of IR motion is commonly

referred to as glenohumeral internal rotation defecit or GIRD (Myers et al., 2006). GIRD is

considered excessive when it is approximately 200 or more. Relationships between the ER

motion and injuries are not as well established. However, excessive ER motion, whether it be

natural or developed from pitching, may be relevant to shoulder problems including instability

(Crockett et al., 2002; Kuhn et al., 2000).

The relevance of osseous and soft tissues to the IR/ER motions and motion shifts has been

addressed. Osseous tissues have been studied directly via CT scans (Crockett et al., 2002) and

radiographs (Osbahr et al., 2002; Reagan et al., 2002). The amount of "twist" or retroversion in

the proximal humeral physis appears to contribute to the IR/ER motions. Retroversion is also

relevant to the shifted motion. In most pitchers, the throwing arm humerus is retroverted towards

ER 5-200 more than the non-throwing arm. But retroversion does not fully explain the IR/ER

ROMs or the motion shift. Correlations with ER are conflicting among studies and correlations

with IR are non-significant or weak (Osbahr et al., 2002; Reagan et al., 2002). The lack of ability

of retroversion to explain the IR/ER motions and motion shift suggests that soft tissues may be

important. This idea is not new: over 20 years ago Pappas et al., (1985) suggested that the IR/ER

motion shift results from the stretching of anterior shoulder soft tissues and tightening of

posterior shoulder soft tissues. Surgical interventions have qualitatively verified this hypothesis

for injured pitchers; excessive laxity to the anterior capsule and/or excessive thickening of the

posterior capsule and rotator cuff muscles has been observed (Burkhart et al., 2003; Myers et al.,

2006). However, surgical interventions cannot be used to examine the shoulder soft tissues in the









vast maj ority of pitchers. A non-invasive, measure of the soft tissue' s looseness or stiffness is

needed to help better understand the IR/ER motion and the mechanisms of the motion shifts.

This gap in the literature will be addressed by examining the IR/ER passive motion in a

novel, more extensive manner. A new flexibility measure, called rotational resistance, will be

assessed along with the traditional ROM measures. Rotational resistance is measured as the

torque (N-m) required to internally and externally rotate the shoulder to the end ROM. This

measure provides information regarding how "stiff' or "loose" the shoulder is as it is rotated and

is thought to reflect the passive resistance to motion provided by the soft tissues as they stretch.

The rotational resistance of the shoulder has been reliably measured for clinical purposes once,

but it has never been measured in baseball pitchers (Novotny et al., 2000).

The ultimate goal for this line of research is to use rotational resistance and ROM measures

to assess shoulder flexibility and determine its relevance to incidence of throwing arm injuries,

injury prevention, injury mechanisms, and injury rehabilitation. In this proj ect, three studies have

been designed to help make progress towards those goals. The obj ective of the first study is to

examine important relationships among various flexibility measures. A priority will be

determining how to best measure shoulder IR/ER passive flexibility for research purposes. The

general hypothesis is that rotational resistance is needed to sufficiently evaluate shoulder

flexibility. The objective of the second study is to determine the relevance of rotational

resistance to the shifted motion. The general hypothesis is that shoulder rotational resistance is

altered by pitching and is related to the magnitude of the motions shifts. The obj ective of the

third study is to determine if incidences of throwing arm injuries vary among groups of pitchers

that have drastically different shoulder flexibility. The general hypothesis is that pitchers that

have extremely flexible or extremely inflexible shoulders will have higher incidences of









throwing arm injuries than pitchers with moderately flexible shoulders. After completing these

studies, it may be possible to determine 1) the best way to assess the IR/ER motion, 2) if a

pitcher has a flexible or inflexible throwing shoulder, 3) if pitchers with GIRD do in fact have

thickened posterior soft tissues, 4) if shoulder soft tissues are altered by pitching, and 5) if

shoulder rotational resistance influences the magnitude of the motion change, 6) if shoulder

rotational resistance is related to throwing arm injury incidence.

The first general hypothesis will be addressed with two specific aims:

Specific Aim la was to determine if ROM and rotational resistance are both necessary to

assess shoulder IR/ER flexibility. Previous shoulder passive IR/ER studies are limited to one

flexibility measure: the end ROM. This limited analysis may lead to false conclusions about a

pitcher' s flexibility. For example, it is possible for two pitchers to have similar ROM, yet

drastically different rotational resistance. Preliminary shoulder ER pilot data from 26 tennis

players revealed multiple instances where players had similar ROM but a two-fold difference for

rotational resistance (Wight et al., 2006). The player with half the rotational resistance is clearly

more flexible. Measuring rotational resistance will help to properly make these distinctions. We

hypothesize that rotational resistance variables and the end ROM will be independent. This

finding would suggest that measures of both ROM and rotational resistance are needed to make

conclusions about shoulder IR or ER flexibility.

Specific Aim lb was to determine if high rotational resistance groups have significantly

different ROM compared to low rotational resistance groups. Two basic measures will be used to

thoroughly assess shoulder rotational resistance. First, is the resistance onset angle (ROA). This

represents the angle where soft tissues begin to stretch. Second, the stiffness will be assessed.

This represents how "tight" or "loose" the shoulder is. These measures will be used to create a









high rotational resistance group and low rotational resistance group. The low group will have

two flexible characteristics: a late ROA and low rotational resistance. The high group will have

two inflexible characteristics: an early ROA and high rotational resistance. We hypothesize that

the low rotational resistance groups will have significantly greater ROMs compared to the high

rotational resistance groups. This finding would suggest that the ROA and stiffness should be

considered together when analyzing flexibility.

The second general hypothesis will be addressed with three specific aims: Specific Aim 2a

was to determine if pitching alters the soft tissue of the throwing shoulder. Previous researchers

have suggested that pitching attenuates the anterior shoulder soft tissues and tightens the

posterior shoulder soft tissues (Pappas et al., 1985). This hypothesis will be tested by comparing

the stiffness of the throwing shoulder to the stiffness of the non-throwing shoulder. Bilateral

differences are assumed to be alterations to the soft tissues of the pitching shoulder. We

hypothesize that the throwing arm IR stiffness will be significantly greater and the ER stiffness

to be significantly less stiff than the non-throwing shoulder. These findings would suggest that

pitching alters the soft tissues of the shoulder. No alterations to stiffness would suggest that

humeral retroversion is the primary factor responsible for the motion shifts.

Specific Aim 2b was to determine if the magnitude of the motion shift is related to the

magnitude of the stiffness change. The average pitcher has a 100 motion shift for both ER and

IR. But the range is quite variable; some pitchers have virtually no motion shift while others

exceed 200. Limited and/or excessive motion shifts are associated with throwing arm injuries

(Burkhart et al., 2003; Myers et al., 2006). Therefore, determining the factors that influence the

magnitude of the motion shift is crucial. We hypothesize that the motion shift will increase as

alterations to stiffness in the throwing shoulder increases. This finding would suggest that the









motion change is dependent on the extent of the attenuation or tightening of the soft tissues. This

test will only be run if bilateral differences in stiffness are found in the previous aim.

Specific Aim 2c was to determine if the rotational resistance of the non-throwing shoulder

is related to the magnitude of the motion shift. It is possible that the magnitude of the motion

shift is related to the original or "pre-altered" tightness or looseness of the soft tissue. The

rotational resistance of the non-throwing arm will be used as a control to represent the pre-

altered rotational resistance. We hypothesize that the magnitude of the motion shift will increase

with the stiffness of the non-throwing arm. If significant, this finding would help to identify

individuals that may be at risk of injury.

The third general hypothesis will be addressed with one specific aim: Specific Aim 3 was

to determine if incidence of throwing arm injuries are different among rotational resistance

groups. Previous studies have revealed associations between shoulder ROM and throwing arm

injuries (Burkhart et al., 2003; Myers et al., 2006). The general consensus is that limited IR

motion and/or excessive ER motion likely makes the throwing arm susceptible to injury

(Crockett et al., 2002; Kuhn et al., 2000). An analogous hypothesis will be tested with respect to

rotational resistance. We hypothesize that pitchers will low ER rotational resistance (i.e.,

extremely flexible) and pitchers will high IR rotational resistance (i.e., extremely inflexible) will

have higher incidences of throwing arm injuries than their peers. This preliminary analysis is

considered valuable because it may reveal general injury incidence trends and may help to better

identify pitchers at risk of injury.

This study is believed to be innovative because it will be the first to 1) thoroughly assess

shoulder IR/ER flexibility in pitchers, 2) directly test if the flexibility of soft tissues are altered

by pitching, 3) explore the magnitude of the motion shift, 4) explore whether flexibility is









relevant to the motion shift, and 5) explore the relevance of rational resistance to incidences of

throwing arm injuries. Long term benefits are also expected. This study may stimulate the

incorporation of rotational resistance into shoulder IR/ER examinations and help to determine

the most parsimonious way to examine the motion. Results from this study may help athletics

trainers, orthopedic surgeons, and sports medicine clinicians better analyze the shoulder IR/ER

passive motion to diagnose injuries, assess throwing arm adaptations, assess throwing,

stretching, and/or exercise interventions, and assess rehabilitation outcomes. This study is also

expected to stimulate future research. Researchers may be able to use findings and methods from

this study to help better determine the relevance of flexibility to the incidence of throwing arm

injuries and injury mechanisms.









CHAPTER 2
REVIEW OF THE LITERATURE

The purpose of this literature review is to demonstrate that measurement of the rotational

resistance of the shoulder IR/ER passive motion is needed. Focus will be placed on the general

methods used to assess the passive mechanical properties of the throwing shoulder thus far, the

general findings from those studies, and the gaps in the literature. Throughout the review,

shoulder anatomy and injuries will be addressed. A review of shoulder anatomy and example

pitching injuries are included as an appendix (Appendix A).

Analyzing the Shoulder IR/ER Passive Motion

Traditional measurement of the IR/ER motion is relatively simple. The investigator

internally or externally rotates the shoulder to the end ROM and then measures the angle using a

plastic or digital goniometer. Novotny et al., (2000) showed that it is possible to measure the

motion more extensively. A custom device was used to quantify rotational resistance.

Methodological considerations relevant to collecting ROM and rotational resistance will be

discussed.

Important Methodological Considerations

When analyzing the IR/ER motion, three important methodological decisions must be

made: whether motion will be passive or active, the positioning of the arm, and whether to

stabilize the scapula.

Passive vs. Active

During a passive collection, the participant is instructed to remain totally relaxed and the

joint is rotated to the "end feel" as determined by patient comfort and capsular end feel (Awan et

al., 2002). During active measurement, the athlete uses the shoulder external rotators and/or

shoulder internal rotators to actively rotate the joint as far as possible. Measurements are then









taken as the athlete maintains the end ROM (Ellenbecker et al., 2002). Both methods are

commonly used clinically (Boon et al., 2000). The maj ority of overhead athlete studies have used

the passive method (Baltaci et al., 2004). In this study, collections will be passive because

rotational resistance cannot be collected actively.

Arm position

Nearly all IR/ER studies have assessed shoulder motion with the participant lying supine

on a training table with the arm in the standard throwing relevant position. This arm position is

900 of shoulder adduction, 900 of elbow flexion, and neutral shoulder horizontal ab/adduction

meaning the upper arm points lateral (Awan et al., 2002; Ellenbecker et al., 2002; Meister et al.,

2005). Alterations in adduction have a drastic influence on the ROM. For 19 pitchers, Osbahr et

al., (2002) revealed that the ER end ROM at 900 of shoulder adduction to exceed the 00

adduction position (126.80 vs. 90. 10, respectively, p<0.05). The influence of horizontal

adduction has not been tested directly. However, Borsa et al., (2005) made a slight alteration to

the standard position to place the upper arm in the plane of the scapula (approximately 150

anterior to the coronal plane). This adjustment appeared to have minimal effects on the IR and

ER end ROMs; Borsa's findings were comparable to those of other investigators (Table 2-2). In

this study, the arm will be assessed in the standard throwing relevant position.

Scapular stabilization

The scapula if often stabilized by manually applying an anterior force to the anterior

shoulder. This helps to isolate glenohumeral motion (Boon et al., 2000; Awan et al., 2002). Boon

found scapular stabilization to significantly reduce (p < 0.05) end ROMs in 50 high school

athletes. The eROM reduced approximately 90. The IR end ROM was reduced far more,

approximately 260. Nearly all researchers have stabilized the scapula when analyzing overhead









athletes. The scapula will be stabilized for this proj ect to isolate glenohumeral motion and to

allow for comparison of results to previous research.

Novotny's Approach

Novotny successfully evaluated the rotational resistance of the shoulder. A load cell was

used to quantify the torque required to passively internally and externally rotate the shoulder.

Angular displacement was continually collected using an electromagnetic motion system. A

similar approach will be used in this study; however, angular displacement will be monitored

with a potentiometer. There are two other differences between Novotny's approach and the

approach used in this study. The first is participant positioning. Novotny had the participant

seated with the arm abducted 450 from the side of the body. Participants in this study will lay

supine and have the arm in the previously mentioned throwing relevant position. This will allow

for better comparison of results to those in the literature. Second, Novotny ceased shoulder

rotation once a pre-set torque was achieved (4 N-m). This pre-set torque limited the ROM such

that participants were unable to obtain the end ROM. In this study, the shoulder will be rotated to

the true end ROM (since the end ROM is a variable of interest).

Reliability of Traditional Measures

Using a goniometer to measure the end ROM is subj ective by nature. The investigator

must align the device with the participant' s arm. The investigator must also maintain the

alignment of the participant' s upper arm. Not surprisingly, inter and intra-tester reliability scores

are often low and variable. Boon et al., (2000) summarized reliability for 9 shoulder ROM

studies. Five of the 9 studies had ICC score below 0.60. This craft appears to be highly

dependent on the skill of the investigator. Variability may also be related to the accuracy of the

device, which is +10 (Awan et al., 2002), and the ability to line up the device with the forearm.










Using a custom device that secures the arm and uses an electrogoniometer to continuously

measure the ROM can improve the accuracy and obj activity of measurement. Not surprisingly,

custom devices have produced good to excellent reliability: Novotny had no significant

differences between same-day or cross-day measures and the device that will be used in this

proj ect produced inter and intra-tester ICC values ranging from 0.79-0.95 for all ROM and

rotational resistance measures (Grover et al., 2006).

The Shifted Motion

Shoulder IR/ER passive motion in baseball pitchers became a "hot topic" when bilateral

differences were discovered (Brown et al., 1988; Baltaci et al., 2001). Average bilateral

differences were calculated for six recent studies that measured pitchers (Table 2-1). The

throwing arm had 8.50 more ER and 11.60 less IR and than the non-throwing arm. These Eindings

contrast control groups (Crockett et al., 2002) in which non-throwers have no, or very limited

bilateral differences.

The increased ER and decreased IR are commonly referred to as external rotation gain, or

ERG, and glenohumeral internal rotation deficit, or GIRD (Myers et al., 2006). For most

pitchers, the ERG is quite similar to GIRD. Wilk et al., (2002) used the phrase "total motion

concept" to describe this phenomenon since the total motion of the throwing arm changes little.

Other Shoulder Motions

Other passive shoulder motions (extension, abduction, horizontal adduction) have no

significant or minimal (1-20) bilateral differences (Meister et al., 2005; Reagan et al., 2002;

Baltaci et al., 2001; Baltaci et al., 2004). This makes the IR/ER motion unique and likely the

most relevant to throwing arm injuries.












Table 2-1. Summary of shoulder IR/ER range of motion studies for overhead athletes.
ER
Total Total ROM
Author Year Participants ER nn R I o- ROM non- Atv A
dominant domina dominant dominant Passive (P)
nt dominant dominant

Borsa 2006 bebe a13.7 59.7 (7.0) 68.2 (8.6) 11 1) 198.6 (26.6) P

Levine 2006 baeb laes (10) (9) 38 (9.5) 54 (12.3) 147 148 P
11 baseball ivith 125.8 117.5 42.5 62.2
Myers 2006 168.3 179.7 P
impingement (13.1) (16.7) (12.1) (16.9)
Myer 200 baseball 121.1 116.0 51.1 62.2 122 182P
controls (8.7) (10.3) (14.4) (13.7)
Ruotolo 2006 37clee 117.6 108.8 23.7 32.6 140.7 141.6 4
baseball players
43 professional 134.8 125.8 78.3 203.4
Borsa 2005 baseball pitchers (10.2) (8.7) 686(.) (10.6) (9.7) 20.(97P
Dower 005 27 pros (20 were 108.9 101.9 56.6 68.6 165.5 104(05
pitchers) (9.0) (5.9) (12.5) (12.6) (14.4)
Blai 2004 2prfsoa 11.8 109 59.2 (6.9) 70.3 (5.8) 11 7) 186.4 (11.1) P
20 controls 97.3 172.2
Baltaci 2004 98.5 (6.8) (.) 74.4 (9.2) 83.1 (9.1) (1.) 180.1 (9.2) P
Schmidt- 204 27 professional 89.1 81.2 43.8 608(.) 132.9 120(19
Wiethoff tennis players (13.7) (10.2) (11.0) (15.0)
Schmidt- 84.0 146.9
Witof 2004 20 controls 85.4 (7.6) (.) 61.6 (8.1) 59.3 (8.3) (.) 143.3 (7.5) P

Sethi 2004 37poad 110 (14) 14 68 (16) 82 (11) 178 (23) 186 (15) P
college pitchers (14)
Sethi 2004 1poion 100 (11) 10 69 (11) 75 (10) 169 (10) 174 (10) P
players (12)
Crcet 2002 2prfsinl 128 (9.2) 19 62 (7.4) 71 (9.3) 189 (12.6) 189 (12.7) P
pitchers (7.2)
Crockett 2002 25nntrlig 13 12 65(8.9) 69 (7. 1) 179(17.7) 181(15.3) P
controls (14.6) (13.9)
Ellenbecker 2002 4prfsinl 132 94.5 42.4 52.4 145.7 146.9 4
pitchers (9.1)
Ellenbecker 202 117elite junior 103.7 10. 45463 191 182
tennis players (10.9)
19 college 126.8(12. 114. 5(9
Osbahr 2002 .79.3(13.3) 91.4(13.6) 206.1 205.9 P
pitchers 0) .1)
Reagan 2002 ba l es (113 1 ) 43.0 (7.4) 51.2 (7.3) 155 157.8 (11.5) P


Baltaci 2001 1pclee 13.5 1 ) 55.8 (7. 1) 69.2 (4.8) 187.3 185.8 P


Baltaci 2001 2poion 1.4 114.6 58.2 (7. 1) 68.7 (6.8) 180.6 183.3 P
players (10.9)
Meas or 124.8 116.3 61.8 72.9 186.4 189.0
pitchers



Sport Specific Findings


Ellenbecker attempted to determine if there are IR and ER ROM differences between


tennis players and baseball pitchers. The 46 professional baseball (22.6 & 2.0 years) pitchers


were compared to 1 17 elite junior tennis players (16.4 & 1.6 years). Identical methods were used


to assess the athletes. Both groups lost approximately 100 of IR in the dominant arm.









Interestingly, the baseball pitchers had a significant ER bilateral difference (8.70) but the tennis

players did not. This may be related to the more extreme biomechanics of the baseball pitch

during the arm-cocking phase (Feltner et al., 1986; Elliot et al., 2003). Pitchers also show

significantly greater bilateral differences than non-pitching baseball players (Baltaci et al., 2001;

Sethi et al., 2004).

Age and the Motion Shift

Levine examined 298 youth baseball players (age 8-28 years) with hopes of establishing

the onset of the motion shift. Participants were divided into three age groups based on skeletal

growth: immature group (n = 100, 8-12 years), period of maximal growth (n = 100, 13-14

years), and at or near skeletal maturity (n = 98, 15-28 years). ER and IR bilateral differences

were minimal in the youngest group (40) and then increased significantly with age. By age 13-14

years the ER bilateral difference was 100 and the IR bilateral differences 90. Bilateral differences

further increased in the oldest group to 150 in ER and 160 in IR.

Meister reported that IR and ER bilateral differences remain relatively constant from 8-12

years of age. Throughout these 4 years, bilateral differences were significant, but minimal (ER =

approximately 3-50, IR = 2-40). At 13 years of age, both ER and IR began to reduce

dramatically. From age 8 to 16 years, ER reduced in the dominant shoulder and non-dominant

shoulder by 20.50 and 23.30, respectively. IR also reduced significantly from age 8 to 16 years,

but the dominant arm showed a more dramatic reduction (17.70) compared to the non-dominant

(9. 10). These reductions in ER and IR resulted in significant total range of motion loss of 32.50

Interestingly, the total range of motion was never different in the dominant and non-dominant

shoulders. The IR and ER motions appear to be dynamic in children and adolescents. The shifted

motion appears to develop as other changes related to physical maturity become established. It

remains unclear if these changes result from osseous change, soft tissue, or both.









Biomechanics of the Baseball Pitch

The biomechanics of the baseball pitch are thought to be extreme enough to alter the

tissues of the throwing arm. Feltner et al., (1986) presented the first thorough kinematic and

kinetic analysis of the baseball pitch. Eight college pitchers were analyzed. For each pitcher, 3

maximum effort pitches were captured with 2 LOCAM cameras at 200 frames per second. The

following injury relevant biomechanics were reported:

* The most extreme motion was reported to be shoulder external rotation. The shoulder was
externally rotated over 1700 to develop high throwing velocity (Figure 2-1).

* The average time from the instant the stride foot contacted the mound to ball release was
just 283 milliseconds. In addition, arm acceleration (instant of shoulder maximum ER to
ball release) was only 32 milliseconds.

* At the approximate instant of ball release, shoulder internal rotation angular velocity
peaked at 61000/s + 17000/s.

* Torques required to externally rotate and accelerate the arm were high. Peak values were
reported to be 110 N-m (horizontal adduction), 70N-m (abduction) and 90 N-m (internal
rotation). The highest shoulder load was the shoulder distraction force (Figure 2-2)
attempting to dislodge the humeral head at ball release. It was near, or even beyond the
pitcher' s body weight (860 N).



















Figure 2-1. Shoulder ER during the baseball pitch. Repeated exposure to extreme ER during the
pitch is thought to increase the shoulder passive ER motion.


























Figure 2-2. Follow-through phase of the pitch. Shoulder loads are extremely high at the instant
of ball release. The shoulder distraction force is near or beyond the pitcher' s body
weight. The shoulder posterior soft tissues are thought to develop tightness from
repeated exposure to the follow-through loads. Posterior tightness is thought to
decrease the shoulder IR passive motion.

Similarly extreme pitching biomechanics have been reported by others (Fleisig et al., 1995;

Werner at al., 2001; Wight et al., 2004; Zheng et al., 2004). These biomechanics are thought to

be responsible for altering the tissues of the throwing arm that cause the IR/ER motion shift

(Baltaci et al., 2001; Osbahr et al., 2002).

Alterations to the Throwing Arm

Strong evidence exists to show that osseous change occurs in the form of humeral

retroversion. However, the extent of the contribution to the IR/ER shifted motion remains

unclear. Alterations to soft tissues have been verified surgically in injured pitchers (Burkhart et

al., 2003). However, it remains unclear if soft tissue alterations significantly contribute to the

shifted motion in asymptomatic pitchers. Changes to soft tissue are not as obvious since they

have not been tested directly. Osseous and soft tissue studies will now be discussed.

Humeral retroversion

Humeral retroversion refers to the amount of axial "twist" in the bone. Three studies have

explored retroversion in baseball pitchers (Table 2-2). Crockett completed the most thorough










study: pitchers and a control group of non-throwers were examined. Non-throwers had

approximately 200 of retroversion in each humerus (the bone is retroverted towards ER).

Pitchers had a 170 bilateral difference. The throwing arm had 400 of retroversion. The difference

between controls and pitchers suggests that retroversion developed from pitching.

Table 2-2. Humeral retroversion in baseball pitchers.
Retroversion Retroversion Bilateral
Author Participants Method
dominant non-dominant difference
54 college
Reaanetbaseball 36.6 (9.8) 26.0 (9.4) 10.6 x-ray
al., 2002
players
Osbahr et 19 college
33.2 (11.4) 23.1 (9.1) 10.1 x-ray
al., 2002 pitchers
Crockett et 25 professional
40 (9.9) 23 (10.4) 17 Multiple CT scans
al., 2002 pitchers
25 non-
Crockett et
al. 202 throwing 18 (12.9) 19 (13.5) -1 Multiple CT scans
controls


Crockett postulated that humeral retroversion is a protective adaptation that allows the

pitcher to more effectively externally rotate the shoulder. Retroversion is thought to occur from

repeated exposure to the biomechanics of the cocking phase of the pitch (Osbahr et al., 2002;

Reagan et al., 2002). Large forces and torques associated with externally rotating the shoulder

and rapidly internally rotating the shoulder are thought to alter the proximal physis in a way that

leads to excessive retroversion. The humerus is thought to be particular susceptible to being

retroverted during adolescence, before bones have fully matured.

Retroversion does not fully explain the shifted IR/ER motion. Both Osbahr and Reagan

tested whether the amount of retroversion was related to the shifted motion. For ER, Osbahr

found a strong relationship (R2 = 0.71, p < 0.05) in 19 college pitchers, but Reagan found a

weaker relationship (R2 = 0.21, p < 0.05) in 25 college pitchers. Relationships with IR were weak









and non-significant. The amount of variation explained is conflicting for ER and weak for IR.

This suggests that soft tissue alterations likely contribute to the shifted motion.

Soft Tissue Theories

For years, researchers have theorized that alterations to the soft tissues of the shoulder

contribute to the motion shift. The large follow-through loads are thought to place heavy loads

upon the posterior soft tissues. Over time, the posterior capsule is thought to develop tightness

that contributes to the loss of internal rotation (Pappas et al., 1985). This has been surgically

verified in injured players that suffer from severe internal rotation loss (Burkhart et al., 2003).

Asymptomatic pitchers may suffer similar posterior tissue tightness, but to a lesser degree.

Increases in ER have been attributed to the attenuation of anterior soft tissues over time (Jobe et

al., 1991). Attenuation may occur from the accumulation of microtrauma associated with the

arm cocking phase of pitching (Baltaci et al., 2001).

Horizontal Adduction Tightness Tests

Tyler et al., (2000) developed a horizontal adduction test that, in theory, tests for tightness

of the posterior capsule and/or rotator cuff muscles. Tightness is identified when the dominant

shoulder passive horizontal adduction end ROM is significantly farther from the treatment table

than the non-dominant arm. Downar et al., (2005) reported no significant bilateral difference

between the dominant (30.2 cm & 4.6 cm) and non-dominant arms (28.0 cm & 4.8 cm) in a group

of healthy professional baseball players (N = 27, 20 of which were pitchers). Myers similarly

reported no bilateral differences in a group of 11 competitive asymptomatic baseball players

(dominant = 21.1 cm & 6.2 cm, non-dominant = 21.9 cm & 6.2 cm). However, a significant

deficit occurred in a group of 11 baseball players suffering from pathologic internal impingement

in the throwing shoulder (throwing arm = -4.2 cm & 4.4, non-throwing arm = 2.8 cm & 4.4). This









test suggests these pitchers suffer from posterior tightness, however, the measure is considered

limited because it is subjective by nature and only assesses ROM.

Active IR

Active IR is another theoretical test of posterior shoulder tightness that was recommended

by the Amerian Academy of Orthopedic Surgeons and the Shoulder and Elbow Surgeons

(Baltaci et al., 2001; Baltaci et al., 2004). For the active IR test, the participant places the

posterior surface of the hand on the back and reaches vertically. The goal is to reach the highest

vertebral level possible. Active internal rotation is measured as the vertical distance the thumb

rests from spinous process TS. Two different groups of college baseball pitchers (N = 38 and N =

54) had significant bilateral differences of 7 cm and 10 cm, respectively (Baltaci et al., 2001;

Baltaci et al., 2004). This measure suggests pitchers have posterior tightness but the measure is

again considered limited because it only assesses ROM.

Glenohumeral Stiffness

Borsa et al., (2006) and Crawford et al., (2006) measured glenohumeral stiffness which is a

reflection of the static structures resisting humeral head displacement from the glenoid cavity.

Using a Ligmaster device, a 15-dN force is applied to the proximal humerus with the shoulder at

900 of abduction and 600 of ER. The force displacement curve is divided into two distinct

regions: the initial slope and the final slope. The final slope was used to model the passive joint

stiffness. The ICCs ranged from poor to excellent depending on side and direction. No bilateral

differences were found. The main effect for direction was significant; anterior j oint stiffness was

significantly greater than posterior j oint stiffness (16.4 & 1.6 N/mm vs. 15.2 & 3.2 N/mm,

respectively). Pitching does not appear to compromise the joint' s passive restraining quality but

it may alter the rotational resistance.









Glenohumeral Translation

Glenohumeral translation of the shoulder is a measure of the mobility of the humeral head.

Glenohumeral translation has been measured bilaterally as well (Borsa et al., 2005; Sethi et al.,

2004). Borsa again applied a 15-dN anterior or posterior force to the proximal humerus. A

portable ultrasound scanner was used to dynamically track the translation of the humeral head in

relation to the scapula. No bilateral differences were found. No significant relationships were

found between rotational and translational ROM. There was less than a millimeter of difference

between sides for anterior/posterior translation. Sethi measured laxity in 56 college and

professional baseball players (19 baseball position players, 37 pitchers). Electromagnetic sensors

were placed under the thumb of the examiner over the bicipital groove region of the athlete' s

humerus. The investigator applied a manual force to produce anterior and posterior translation.

Five percent (1/19) of the position players had significant bilateral translation difference greater

than 3 mm. Fifty nine percent of college pitchers (10/17) and 60% of professional pitchers

(12/20) had significant bilateral differences greater than 3 mm. Correlation revealed a significant

moderate positive relationship (r2 = 0.20) between bilateral ER differences and translation in all

players. Translational measures do not appear to be strongly related to the IR/ER passive ROM

shift in baseball pitchers.

Conclusions

These studies have demonstrated the importance of assessing the passive mechanical

properties of the pitching shoulder. They have established the importance of the IR/ER motion

and revealed that a thorough assessment, using rotational resistance measures, is warranted.

Finally, these studies have identified appropriate methodological considerations that will guide

data collection and analysis in this proj ect.









CHAPTER 3
MATERIALS AND METHODS

Participants

Thirty elite baseball pitchers participated in the study (age = 22.1 & 3.3 years; height = 1.89

& 0.06 m; mass = 93.2 & 6.6 kg). Thirteen were pitchers from the University of Florida team and

17 were professional minor league pitchers from the Cincinnati Reds. To participate, pitchers

had to be at least 18 years of age, active with their team at the time of testing, and injury free at

the time of testing (currently pitching at 100% effort). Individuals that had throwing arm surgery

within the past year were excluded.

Equipment

Novotny et al., (2000) demonstrated that it is possible to reliably analyze the rotational

resistance of the shoulder throughout the IR/ER passive motion using a custom device. However,

Novotny's device was not specific to overhead athletes: the arm was abducted only 450. Grover

et al., (2006) developed a similar device to analyze overhead athletes. The arm was analyzed in a

throwing relevant position with the shoulder abducted 900 and elbow flexed 900 (Ellenbecker et

al., 2002; Borsa et al., 2006; Myers et al., 2006). Inter and intra-rater reliability was extensively

tested on 22 participants and found to be good to excellent for all IR and ER rotational resistance

and ROM measures (ICCs = 0.79-0.95). This device and associated methods were used in the

current study. The device is called the rotational resistance device (RR device).

The RR device was built to internally and externally rotate the shoulder in an obj ective,

controlled, and safe manner. More specifically, rotational resistance (torque required to passively

rotate the arm) and angular displacement are continuously monitored as the shoulder is slowly

rotated to the end ROM. A detailed description of the RR device is included (Figure 3-1).











































Figure 3-1. RR device designed for measuring overhead athletes. The pitchers laid supine on an
athletic training table. The arm rotation assembly was attached to an aluminum pipe
(#1) that could be adjusted by inserting a metal pin into holes that were drilled in 1
cm increments. The bottom of the aluminum pipe was secured to a plywood
platform. The arm rotation assembly consisted of a wheel-chair wheel, an arm support
(#2), and a wrist mount (#3). A cable (#4) runs around the rim of the wheel. The arm
is rotated by slowly pulling on the free end of the cable. The cable goes through a
pulley (#5) that is mounted to the top of a 50-pound load cell (SBO-50, Transducer
Techniques, Temecula, CA). A potentiometer (#6) was mounted to the wheel to
continuously monitor angular displacement (Clarostat 73JB 100). Analog data from
the load cell and potentiometer were collected using an amplifier (#7) (BioAmp 215
Bridged Amplifier, Biocomunication Electronics, Madison, WI), a laptop (HP
Pavilion 7020, Palo Alto, CA), and an 11-bit USB-based data acquisition device (#8)
(miniLAB 1008, Measurement Computing, Middelboro, MA). Data were recorded at
a rate of 100 Hz using LabVIEW software version 7.1 (Austin, TX).









For this proj ect, several improvements were made to the RR device and data collection

procedure:

* The participant played supine on an athletic training table when analyzed, instead of sitting
in a reclined chair. This helped to better control and maintain the orientation of the torso,
provided the opportunity to stabilize the scapula, and allowed for better comparison of
results to studies in the literature (nearly all relevant studies have examined overhead
athletes in the supine position).

* One rotation complex measured the right arm and a second measured the left arm. This
allowed the participant to remain nearly stationary throughout the data collection. Only one
slight position adjustment occurred. After the first shoulder was examined the participant
slid laterally approximately 20 cm to have the second shoulder analyzed. Previously, with
only one rotation complex, the participant had to stand up and turn around to have the
second shoulder assessed. Minimal position adjustment is crucial for accurate bilateral
comparisons.

* A new, more optimal 50 lb (222.5 N) load cell (SBO-50, Transducer Techniques,
Temecula, CA) replaced the previously used 150 lb (667.5 N) load cell. This provided a
higher resolution signal that requires less amplification. Two high quality wheel chair
wheels replaced the single bicycle wheel. These new wheels allowed for a better wrist
mounts and more optimal potentiometer attachments. Finally, a new and improved cable
and pulley was installed, and new potentiometers were used.

Arm Position

IR/ER measures were again collected with the arm in the following throwing relevant

position: 900 of shoulder abduction and 900 of elbow flexion. The lateral edge of the acromion

process was lined up with the edge of the training table. The RR device was adjusted such that

the upper arm was in a neutral position (parallel with the floor). The center of the wheel on the

rotation assembly was lined up with the long axis of the upper arm.

Scapular Stabilization

The scapula was stabilized (Figure 3-1) by applying a manual antero-posterior force to the

subj ect' s coracoid process and clavicle (Boon et al., 2000; Awon et al., 2002). This helped to

islolate glenohumeral motion. The applied force was kept low enough to ensure that the

participant felt no discomfort.














































Custom Device Collection
One of the following four orders were used randomly.

Left ER Left IR Right ER Right IR
Left IR Left ER Right IRRight ER
Right ER Right IRLeft ER Left IR
Right IRRight ER Left IR Left ER

Collect entire left side then entire right side (or vice versa).
Collect ER before IR for both arms (or vice versa).
Collect 3 consecutive repetitions for each combination.


Figure 3-2. Schematic of data collection.


Data Collection


A schematic of the five step data collection process is included (Figure 3-2).


Sign informed consent





Participant information
Age
Height and weight
Handedness
Years played
Injury questionnaire
*Contact information






Familiarity session
Warm-up, light stretching
Fit to RR device
Successive stretches for each direction
1 practice repetition to end ROM


Prior to the data collection, each participant signed an informed consent that was approved

by the University of Florida Institutional Review Board. An brief throwing arm injury

questionnaire was then filled out (Appendix D). Height and weight were recorded by one









investigator. Age, handedness, years played, and contact information were recorded on a data

collection sheet. Another investigator, who performed the shoulder analysis data collections,

remained blind to the handedness of the participant until after the collection. Each pitcher

participated in a brief familiarization period just prior to the data collection. The purpose was to

familiarize the participant with the RR device, instructions, protocol, and their end ROMs (for

both arms, IR and ER). For a brief warm-up, participants actively internally and externally

rotated each shoulder five consecutive repetitions, or as much as necessary, to feel warmed-up.

The end ROM test was described to the participant. He was told that: 1) this examination is

similar to a "sit-and-reach test", 2) the end ROM should be slightly uncomfortable but not

painful, and 3) the end ROM should be able to be repeated three consecutive times. Both arms

were appropriately fit in the device according to the previously described guidelines.

Two successive stretches were performed on each arm, for both IR and ER. For the first

stretch, the participant was instructed to actively rotate the arm until a light stretch was felt. The

participant then completely relaxed the shoulder and the investigator held the stretch for 3

seconds. The arm was then slowly returned to the neutral position (forearm pointing anterior to

the chest) by the investigator. The participant was instructed to keep the shoulder completely

relaxed (passive) for the second stretch. The second stretch was moderately farther

(approximately 5-100 beyond the first stretch) and again held for 3 seconds before being

returned to the neutral position. Next, the investigator slowly rotated the participant' s shoulder

to the end ROM. Rotation ceased when a firm endpoint was felt by the investigator (Borsa et al.,

2006) or when the subj ect said "stop", whichever came first. The arm was then returned to the

neutral position by the investigator.









RR Device Collection

For each arm, and each direction (IR and ER), three consecutive repetitions were collected

to the end ROM. To prevent any unwanted torso movement, IR and ER were collected

consecutively for each arm. The order of IR and ER was randomized for the first arm. The

second arm followed the same order as the first arm (for optimal bilateral comparison). The arm

was rotated very slowly. Pilot data revealed the average angular velocity to be approximately 2

o/sec for 27 previous participants. Rotation was kept this slow to eliminate any possible

confounding effects associated with rotating the shoulder quickly.

Data Reduction

Reduce To Best-Fit Line

Custom programs, written in LabVIEW software, were used to reduce the displacement

and force data from the potentiometer and load cell, respectively. Force was converted to torque

by multiplying by the moment arm of the rotation complex (the distance from the center of the

wheel to the wrist support was 0.26 m). Since the arm was rotated manually, the velocity of the

rotation was slightly variable. To correct for any minor differences in velocity, all ROM values

(and their associated torque) were averaged in 1/20 degree increments. The average torque data

was then graphed against angular displacement.

Qualitative analysis revealed the torque to be relatively stable and below 5 N-m in the

laxity zone (Figure 3-3). The torque sharply increased and became linear once approximately 5

N-m of torque was achieved. This sharp increase occurred approximately 25o before the end

ROM. The first step to modeling the data was fitting each repetition with a best-fit line from the

angle where 7 N-m of torque was achieved to the end ROM. R2 ValUeS for each best-fit line were

then checked. If R2 WaS lower than 0.95, the data was refit with best-fit lines starting at 5 Nm and

6 Nm. The best-fit line with the highest R2 ValUe WaS then identified and used to model the data.










Seven N-m was used for 81% of the repetitions. The R2 for the best-fit lines were high. For ER,

the R2 ValUeS were > 0.93 for all repetitions. For IR, the R2 ValUeS were lower for 4 repetitions

(0.83-0.87) but very high (> 0.92) for the remaining maj ority of the repetitions.


50 75 100 125 150 170
External rotation ()


Figure 3-3. Example torque-displacement data for an ER repetition. These data were collected
with the RR device and reduced using a custom program written in LabVIEW
software. The experimental data and best-fit modeled data (green) are shown for one
repetition of shoulder ER. Velocity is controlled for by averaging data into 1/20 slots..
Passive rotational stiffness is defined as the slope of the best-fit line and the ROA is
the angle where 5 N-m of torque is first achieved. The end ROM and end torque
(torque at the end ROM) were also calculated from the best-fit line.

Variables of Interest

For both arms and both directions (IR and ER), five flexibility variables were calculated.

Bilateral differences were also calculated for each variable as the difference between the pitching

arm and non-pitching arm (Osbahr et al., 2002)..

* The ROA is defined as the angle on the best fit line where 5 N-m of torque is achieved.
The ROA is a measure of the angle where the shoulder soft tissues begin to provide
substantial resistance to motion due to stretching.

* Stiffness is defined as the slope of the best-fit line. Stiffness is a measure of how tight or
loose the shoulder is when it is passively rotated.

* The end ROM is defined as the farthest degree achieved on the best-fit line.










*The end torque is defined as the torque at the end ROM. It is calculated from the best-fit
line.

*The resistance zone is the total displacement from the ROA to the end ROM. It is
calculated by subtracting the ROA from the end ROM.

Repeated measures ANOVA were used to determine if subj ects became more flexible

across repetitions 1, 2, and 3. No differences among the repetitions were expected because all

pitchers participated in the warm-up session. However, significant main effects were detected

and follow-up tests (dependent T-tests with Bonferroni adjustments) revealed significant

differences between the first and second repetitions for the ROA and stiffness suggesting that the

shoulder did become more flexible (Table 3-1). Since the mechanical properties were altered

between repetitions 1 and 2, data from the first repetition were not used; data from repetitions 2

and 3 were averaged for all flexibility variables.

Table 3-1. Means and SD of flexibility variables for repetitions 1, 2, and 3*
ROA (o) Stiffness (N-m/o) End ROM (o) End Torque (N-m)
1 2 3 1 2 3 1 2 3 1 2 3
122.2 126.4 127.5 0.49 0.57 0.57 147.8 149.4 150.4 17.4 17.9 17.9
D ER
(11.6) (13.2) (12.5) (0.10) (0.12) (0.11) (12.2) (12.3) (11.8) (3.7) (3.2) (3.1)
1-2 1-2 1-2 2-1 3-1
2-1 3-1 2-1 3-1
1-3 1-3 1-3 2-3 3-2
D IR 60.2 62.9 63.7 0.46 0.53 0.54 80.5 81.8 83.7 14.5 15.1 15.8
(7.7) (8.1) (8.9) (0.12) (0.14) (0.17) (10.9) (11.4) (12.0) (4.2) (4.1) (4.5)
1-2 1-2 1-2 2-1 3-1 1-2 2-1 3-1
2-1 3-1 2-1 3-1
1-3 1-3 1-3 2-3 3-2 1-3 2-3 3-2
*Signficant differences are show in the boxes below the means and standard deviations. For
example, 1-2 means a significant difference between repetitions 1 and 2. For both ER and IR, the
mechanical properties of the shoulder (ROA and stiffness) were not different between reps 2 and
3. This suggests that the subj ects were successfully warmed-up by rep 2. Interestingly, ROM
increased each consecutive repetition despite no change in mechanical properties between reps 2
and 3.

Definition of Rotational Resistance Groups

The two rotational resistance variables (ROA and rotational stiffness) were used to

categorize pitchers as having high, low, or moderate rotational resistance (Figure 3-4). This was

performed for both ER and IR. The average ROA and average rotational stiffness were used to

define groups. The low rotational resistance group had two flexible characteristics: an above

























-* Moderate RR*
-High RR *



Moderate RR Low RR


average ROA and below average rotational stiffness. The high rotational resistance group had

two inflexible characteristics: a below average ROA and above average rotational stiffness. The

moderate group had one flexible characteristic and one inflexible characteristic: a below average

ROA and below average rotational stiffness or an above average ROA and above average

rotational stiffness.


Dominant Arm Internal Rotation


40 50 60 70 80
ROA (")

Figure 3-4. Defining groups based on rotational resistance variables. The resistance onset angle
(ROA) and rotational stiffness were used to categorize pitchers as into low, moderate,
and high rotational resistance groups. The vertical and horizontal lines are the
average ROA and rotational stiffness, respectively.

Angle Conventions

Standard shoulder IR/ER angle conventions were used (Ellenbecker et al., 2002; Borsa et

al., 2006; Myers et al., 2006). Zero degrees means the forearm is pointed anterior to the pitcher' s

chest. Ninety degrees of ER means the forearm is pointed superior, towards the head. Ninety

degrees of IR means the forearm is pointed inferior, towards the feet.

Data Analysis

General Analysis

For most statistical tests, a conventional level of significance was used (a=0.05). When

multiple T-tests were performed within a specific aim, a Bonferroni correction was used to


0.8


S0.6
~0.5
S0.4
S0.3
02









reduce the chance of committing a type I error. Descriptive statistics (mean and standard

deviation) were calculated for all variables of interest.

Analysis of Specific Aims

Specific Aim la was to determine if ROM and rotational resistance are both necessary to

assess shoulder IR/ER flexibility. Pearson correlations were used to determine if significant

relationships exist among the following three flexibility variables: ROA, rotational stiffness, and

end ROM. These tests were performed for both ER and IR of the throwing arm.

Table 3-2. Statistical analyses for aim la.
Test Arm Direction Variables
Pearson Throwing ER ROA and stiffness
Pearson Throwing IR ROA and stiffness
Pearson Throwing ER ROA and ROM
Pearson Throwing IR ROA and ROM
Pearson Throwing ER stiffness and ROM
Pearson Throwing IR stiffness and ROM

Specific Aim lb was to determine if high rotational resistance groups have significantly

different ROM compared to low rotational resistance groups. Independent T-tests were used to

determine if the high and low rotational resistance groups have significantly different end ROMs

and/or resistance zones (a=0.05/2). These tests were completed for the throwing shoulder for

both directions (IR and ER).










Table 3-3. Statistical analyses for aim lb.
Test Arm Direction Variables
Independent T-test Throwing ER ROM
Independent T-test Throwing IR ROM
Independent T-test Throwing ER RZ
Independent T-test Throwing IR RZ


Specific Aim 2a was to determine if pitching alters the soft tissue of the throwing shoulder.

For both ER and IR, independent T-tests were performed to determine if the rotational resistance

variables (ROA and stiffness) of the throwing shoulder are significantly different from the non-

throwing shoulder (a=0.05/2).

Table 3-4. Statistical analyses for aim 2a.
Test Arm Direction Variables
Independent T-test Bilateral comparison ER stiffness
Independent T-test Bilateral comparison ER ROA
Independent T-test Bilateral comparison IR stiffness
Independent T-test Bilateral comparison IR ROA


Specific Aim 2b was to determine if the magnitude of the motion shift is related to the

magnitude of the stiffness change. For both ER and IR, Pearson correlations were used to

determine if the ROM bilateral differences were significantly predicted by the rotational stiffness

and ROA bilateral differences.

Table 3-5. Statistical analyses for aim 2b.
Test Arm Direction Variables
Stiffness bilateral difference and
Pearson Bilateral difference ER
ROM bilateral difference
ROA bilateral difference and
Pearson Bilateral difference ER
ROM bilateral difference
Stiffness bilateral difference and
Pearson Bilateral difference IR
ROM bilateral difference
ROA bilateral difference and
Pearson Bilateral difference IR
ROM bilateral difference








































Specific Aim 3 was to determine if incidences of throwing arm injuries are different among

rotational resistance groups. Incidence of injury was compared among the previously described

groups (the low, moderate, and high rotational resistance pitchers from aim lb). Chi-square

analysis was used to determine if significant differences in frequencies throwing arm injuries

occurred. This test was performed for both IR and ER (a=0.05/2). A questionnaire was

developed and used to determine incidences of throwing arm injuries over the past year

(Appendix D).


Specific Aim 2c was to determine if the rotational resistance of the non-throwing shoulder

is related to the magnitude of the motion shift. For both ER and IR, Pearson correlations were

used to determine if the ROA and/or rotational stiffness of the non-throwing arm significantly

predicts the motion shift (bilateral ROM difference) of the throwing arm. Independent T-tests

were also used to determine if the low rotational resistance groups and high rotational resistance

groups (based on the non-throwing arm) have significantly different motion shifts (a=0.05/2).

Table 3-6. Statistical analyses for aim 2c.
Test Arm Direction Variables


ER

ER

IR

IR
ER
IR


Non-throwing arm stiffness and
throwing arm ROM bilateral difference
Non-throwing arm ROA and
throwing arm ROM bilateral difference
Non-throwing arm stiffness and
throwing arm ROM bilateral difference
Non-throwing arm ROA and
throwing arm ROM bilateral difference
ROM bilateral difference
ROM bilateral difference


Pearson

Pearson

Pearson

Pearson

Independent T-test
Independent T-test


Both

Both

Both

Both

Throwing
Throwing









Table 3-7. Chi-square contingency table for aim 3.
Low RR Moderate RR
Inj ured
Healthy


High RR











CHAPTER 4
RESULTS


Specific Aim la

To determine if end ROM and rotational stiffness are both needed to assess shoulder


IR/ER passive flexibility. For both ER and IR, Pearson correlation analysis revealed no


significant relationship between stiffness and end ROM in the throwing shoulder (Figure 4-1).

The ROA and end ROM were positively correlated for both ER and IR (Figure 4-2). For ER, the


ROA occurred 23.00 & 5.90 before the end ROM. For IR, the ROA occurred 19.40 & 5.60 before

the end ROM.


Dominant Arm External Rotation Dominant Arm Internal Rotation
180 110
170 *# 100
e 160 f' 90 + *


m130 m
120 60 1 *
110 50
0.2 0.4 0.6 0.8 0.2 0.4 0.6 0.8
Stiffness (N~m/*) Stiffness (N~m/*)

r = 0. 11, R2=0.01, p=0.55 r = 0.15, R2=0.02, p=0.42
Figure 4-1. Stiffness versus end ROM for the throwing shoulder. As hypothesized, stiffness and
end ROM were not related for both ER and IR.


Dominant Arm External Rotation Dominant Arm Internal Rotation
180 110
170 4 4** 100-
8 160 +1 E 90 *
150 + ***
140, p 80 -
oH 2 70- *
m130 m
120-1 60-
110 50
90 110 130 150 40 50 60 70 80
ROA (*) ROA (*)

r = 0.89, R2=0.79, p<0.001* r = 0.90, R2=0.80, p<0.001*
Figure 4-2. ROA versus end ROM for ER and IR of the throwing shoulder.




































High RR* -
t



Low RR


Hinh RR I* 1



Low RR


Specific Aim lb

To determine if high rotational resistance groups have a significantly different end ROM


compared to low rotational resistance groups. As expected, comparable numbers of pitchers were

in the high and low rotational resistance groups (Figure 4-3). For IR, 5 pitchers had high


rotational resistance (ROA = 54.9 & 4.70; stiffness = 0.68 & 0. 11 N-m/o) and 7 pitchers had low


rotational resistance (ROA = 70.5 & 3.20; stiffness = 0.43 & 0.07 N-m/o). For ER, 8 pitchers had


high rotational resistance (ROA = 116.0 & 10.10; stiffness = 0.67 & 0.05 N-m/o) and 7 pitchers

had low rotational resistance (ROA = 138.8 & 8.80; stiffness = 0.50 + 0.03 N-m/o)


Dominant Arm External Rotation Dominant Arm Internal Rotation


90 110 130 150 40 50 60 70 80
ROA (a) ROA (*)

r = 0.15, R2=0.01, p=0.61 r = 0.09, R2=0.02, p=0.42


Figure 4-3. Formation of high and low rotational resistance (RR) groups for ER and IR. Vertical
lines are at the mean ROA and horizontal lines are drawn at the mean stiffness. High
RR pitchers have a below average ROA and above average stiffness. Low RR
pitchers have an above average ROA and below average stiffness.

As hypothesized, the high rotational resistance groups had significantly limited ROM


compared to the low rotational resistance groups for both IR and ER (Table 4-1). The difference

was approximately 200 for both IR and ER. The resistance zones (difference between end ROM


and ROA) were not significantly different between the high and low rotational resistance groups.


However, the 50 difference between the low and high IR groups approached significance


(p=0.06).


0.8
S0.7
10.6
v,0.5
S0.4
v,0.3
0 2


V.
S0.7-
S0.6 -
u,0.5-
S0.4-
E 0.3 -
02










Table 4-1. ROM and resistance zones for the high and low rotational resistance groups.
High rotational resistance Low rotational resistance
p-value
group group
IR end ROM 73.20 (4.10) 93.80 (7.60) p<0.001*
ER end ROM 137.30 (10.50) 161.10 (10.60) p=0.001*
IR resistance zone 18.30 (0.90) 23.30 (5.00) p=0.06
ER resistance zone 21.30 (4.40) 22.30 (4.40) p=0.66

Specific Aim 2a

To determine if pitching alters the soft tissues of the throwing shoulder. The dominant

shoulder had significantly greater ER stiffness (approximately 20%) than the non-dominant

shoulder (Table 4-2). This finding did not support the original hypothesis; the dominant shoulder

was expected to be less stiff than the non-dominant shoulder. For IR, the dominant shoulder was

significantly stiffer (approximately 39%) than the non-dominant shoulder, as expected. The

dominant shoulder had a significantly later ROA than the non-dominant shoulder (approximately

100) for ER. For IR, the ROA bilateral difference approached significance (p=0.03); the

dominant arm had an earlier ROA than the non-dominant shoulder (approximately 50)

Significant bilateral differences were revealed for the ER end ROM: the dominant shoulder had

approximately 120 more motion. The dominant shoulder had a limited IR end ROM compared to

the non-dominant, but the difference was not significant. The dominant shoulder required

significantly more torque (approximately 22%) to be externally rotated to end ROM. The

dominant shoulder also had a significantly larger ER resistance zone (approximately 20%).

Table 4-2. Bilateral comparison of flexibility variables for ER and IR.
Pitching shoulder Non-pitching shoulder p-value
ER ROA 127.40 (13.00) 118.10 (10.70) p<0.01*
ER stiffness 0.57 N-m/o (0.11 N-m/o) 0.48 N-m/o (0.09 N-m/o) p<0.01*
ER ROM 150.60 (12.10) 137.90 (10.80) p<0.001*
ER resistance zone 23.10 (6.00) 19.20 (17.20) p<0.025*
ER torque at end ROM 17.9 N-m (3.1 N-m) 14.7 N-m (3.0 N-m) p<0.01*
IR ROA 62.70 (8.30) 67.90 (9.70) p=0.03
IR stiffness 0.54 N-m/o (0.16 N-m/o) 0.39 N-m/o (0.07 N-m/o) p<0.001*
IR ROM 81.90 (11.30) 85.10 (14.00) p=0.34
IR resistance zone 19.20 (5.30) 17.20 (8.20) p=0.27
IR torque at end ROM 15.2, 4.3 11.8, 3.7 p<0.001*












Specific Aim 2b

To determine if the magnitude of the motion shift is related to the magnitude of the


stiffness change. Bilateral stiffness differences did not predict the IR and ER motion shifts as


hypothesized (Figure 4-4). However, bilateral ROA differences significantly predicted the


motion shifts for ER and IR (Figure 4-5). Pearson correlation analysis revealed strong positive


correlations between the motion shifts and their respective bilateral ROA differences.




Dominant Arm External Rotation Dominant Arm Internal Rotation
30 40
25* 30-
+ o *
e 20- + 20 *
15 10 -*
c10 0- *
0 -0- *
-5 -30 -*
-10 -40
-0.2 0 0.2 0.4 -0.2 0 0.2 0.4 0.6
Stiffness bilateral difference (N~m/*) Stiffness bilateral difference (N~m/*)

r = 0.34, R2=0. 11, p=0.07 r = 0.14, R2=0.02, p=0.46


Figure 4-4. Bilateral stiffness difference versus the motion shift for the dominant shoulder. For
both ER and IR, the motion shift is not predicted by the bilateral stiffness difference.




Dominant Arm External Rotation Dominant Arm Internal Rotation
30 40
25 30-
e 20- *~ 20 -1 *
15 10 -*
~10 0 0-*
.2 5 .2,* -10 "
0* -2 *
-5 -30-
-10 -40
-30 -10 10 30 -30 -10 10 30
ROA bilateral difference (*) ROA bilateral difference (*)

r = 0.85, R2=0.72, p<0.001* r = 0.89, R2=0.79, p<0.001*


Figure 4-5. Dominant shoulder ROA bilateral differences versus the motion shift. Pearson
correlation analysis revealed strong positive correlations for ER and IR.












Specific Aim 2c

To determine if the rotational resistance of the non-throwing shoulder is related to the


magnitude of the motion shift. Non-dominant shoulder rotational resistance variables did not


predict the motion shift for ER (Figure 4-6). However, for IR, the non-dominant ROA was


significantly negatively correlated to the motion shift (Figure 4-7). Non-dominant IR stiffness

was not related to the motion shift.




Dominant Arm External Rotation Dominant Arm External Rotation
40 40
+I *
S30 30-

20 -* ** 20 -*

o 10o
E 0- + 0- **

-10 -10
0.3 0.4 0.5 0.6 90 110 130 150
Non-throwing stiffness (N~m/*) Non-throwing ROA (*)

r = 0.16, R2=0.02, p=0.40 r = 0.24, R2=0.06, p=0.18


Figure 4-6. Non-dominant ER rotational resistance measures versus the ER motion shift. ROA
and stiffness did not predict the motion shift.







Dominant Arm Internal Rotation Dominant Arm Internal Rotation
40 40
30 -30
S20 ; 20 .
-10 10

-0 9 -0**
-30~2 3
-40 -40 *
0.2 0.3 0.4 0.5 0.6 40 50 60 70 80 90
Non-throwing stiffness (N~m/*) Non-throwing ROA (*)

r = 0.25, R2=0.06, p=0.19 r = 0.65, R2=0.41, p<0.001*


Figure 4-7. Non-dominant IR rotational resistance measures versus the IR motion shift. Stiffness
did not predict the motion shift but the ROA was a significant moderate predictor.





Low and high rotational resistance groups were formed for the non-dominant arm (Figure


4-8). For IR, 6 pitchers had high rotational resistance (ROA= 57.2 & 8.40; stiffness = 0.55 & 0.08

N-m/o) and 6 pitchers had low rotational resistance (ROA= 75.3 & 4.30; stiffness = 0.34 & 0.03


N-m/o). For ER, 8 pitchers had high rotational resistance (ROA=106.5 & 6.50; stiffness = 0.55 &


0.08 N-m/o) and 8 pitchers had low rotational resistance (ROA=127.1 8.20; stiffness = 0.40 +


0.05 N-m/o)


Non-dominant Arm External Rotation
0.8

S0.7
S0.6 -1 HighRP*

0j 0.3-
Low RR
0 2


Non-dominant Arm Internal Rotation
0.6
,0.55-
0 -High RR. .
S0.45 -

0.3-
0.25 Low RR
02


90 110 130 150 40 60 80 100
ROA (*) ROA (*)


Figure 4-8. High and low rotational resistance groups for the non-dominant ER and IR.




For both IR and ER, the high rotational resistance groups were hypothesized to have


significantly greater motion shifts than the low rotational resistance groups. However, no

significant differences were revealed (Table 4-3).

Table 4-3. Mean motion shifts for non-dominant shoulder rotational resistance groups.
High rotational resistance Low rotational resistance
p-value
group group
ER motion shift 12.80 (14.30) 8.10 (7.60) p=0.43
IR motion shift 0.90 (13.20) -12.30(14.20) p=0.13


Specific Aim 3

To determine if incidence of throwing arm injuries are different among rotational


resistance groups. Throwing arm injuries were prevalent in this group of elite pitchers. Fourteen



































- High RR s




Low RR

-


of the 30 pitchers had a throwing arm injury that made them unable to pitch for at least one week

of practice or games over the past year. Six (43%) were elbow injuries and 8 (57%) were

shoulder injuries. The injured pitchers missed an average of 10.5 + 16.7 weeks over the previous

year. Ten of the 14 (71%) injured pitchers visited a physician for their injury. A summary of the

self-reported injuries are included (Table 4-4). The injured pitchers were dispersed among the

low, moderate, and high rotational resistance groups for both ER (Figure 4-10) and IR (Figure 4-

11). Chi-square analysis revealed no significant differences in incidence of injury among the

groups for both ER (p=0.90) and IR (p=0.41).


Dominant Arm External Rotation


0.8

S0.7
S0.6

u,0.5

S0.4
(n0.3
02


*Healthy
a Injured shoulder
a Injured elbow


90 110 130 150

ROA (")

Figure 4-9. Prevalence of shoulder and elbow injuries with respect to ER passive flexibility. A
vertical line is drawn at the mean ROA and a horizontal line is drawn at the mean
stiffness. Shoulder and elbow injuries were dispersed among the low, moderate, and
high rotational resistance groups for ER.

















-High RR_ .*


a *I Low RR
-a a


Dominant Arm Internal Rotation


0.8

0.7

S0.6

- ,


0.3


*Healthy
a Injured shoulder
a Injured elbow


40 50 60
ROA (O)


70 80


Figure 4-10. Prevalence of shoulder and elbow injuries with respect to IR passive flexibility. A
vertical line is drawn at the mean ROA and a horizontal line is drawn at the mean
stiffness. Shoulder and elbow injuries were dispersed among the low, moderate, and
high rotational resistance groups.


Table 4-4. Summary of self-reported throwing arm injuries.
Elbow (E) or Was a physician
Self-reported injury
Shoulder (S) seen?
S Lateral shoulder pain No
S Posterior shoulder tightness Yes
S Shoulder bursitis Yes
S Partial tear of supraspinatus Yes
Subluxation which caused No (worked with
bicep tendonitis athletic trainers)
S Proximal tricep tendon pain Yes
E Distal bicep tendon pain Yes
E UCL tomn 2 years ago Yes
E UCL partially tomn 2 years ago Yes
Recently recovered from UCL
E Yes
that was tomn 2 years ago
E Medial elbow pain No
Recently recovered from a
E stitch put inUCL yearr ago) e
E Tore UCL 2 years ago Yes
E Medial elbow pain No


College (C) or
Time missed
Professional (P)
2 weeks C
3 weeks C
10 days P
10 days P
1 month P
1 month P
1 week C
2 weeks C
6 months C
11 months C
2 weeks C
11 months P
1 month P
1 week P









CHAPTER 5
DISCUSSION

This discussion is composed of four sections. First, this sub-population of pitchers is

addressed. Second, descriptive statistics are highlighted to reveal important general findings.

Focus is placed upon the variability of rotational resistance and injury rates in this group of

pitchers. Third, the specific research aims are addressed individually. Fourth, a summary of the

relevance of this study is provided by sharing general conclusions, practical applications, and

future research recommendations. When appropriate, relations between results from this study

and those in the literature are discussed. However, the ability to do so is limited since this is the

first analysis of shoulder rotational resistance in overhead athletes. Therefore, the maj ority of the

discussion is focused on the interpretation and meaning of the results and future research.

Description of Pitchers

This first analysis of rotational resistance was performed on a relatively homogenous

group of pitchers. All pitchers were elite (University of Florida or professional minor league

pitchers) and the maj ority were young (22. 1 & 3.3 years), tall (1.89 & 0.06 m) and had large body

mass (93.2 & 6.6 kg).

Methods in this study were designed to be similar to those used in studies that analyzed

similar groups of elite pitchers (Borsa et al., 2005, Borsa et al., 2006, and Crockett et al., 2002).

During analysis, the pitchers laid supine on an athletic training table, the scapula was stabilized,

and the elbow remained flexed at 900. Interestingly, mean ER and IR ROM values in this study

are 5-150 greater than those previously reported for similar groups of pitchers. Two factors may

have contributed to this discrepancy. First, ROM values are highly dependent on the analyzer(s)

and/or the group of pitchers so variation can be expected (Table 2-2 for a review). Second, when

assessing the motion manually, it may be difficult for a single analyst, or uncomfortable for the










participant, to hold the shoulder at the end ROM while measures are being taken. In this study

the shoulder did not have to be held at the end ROM; the shoulder was rotated to the end ROM

and then immediately taken back to the neutral position. Future studies could explore this issue

by having the same analyst assess shoulders manually and with a custom device.

This data set is considered to be a good representation of elite pitchers since the ROM

values are relatively close to those reported in the previously mentioned studies. Also, the ER

and IR bilateral differences in this study were comparable to those of Borsa and Crockett: the

dominant shoulder had greater ER (130) and limited IR (40) compared to the non-dominant arm.

Important General Findings

One analysis of shoulder IR and ER stiffness was completed seven years ago (Novotny et

al., 2000) on a healthy, non-throwing population (N=10). Some methods used by Novotny

drastically differed from those used in this study. For example, Novotny ceased shoulder rotation

at 5 N-m of torque, therefore, only a fraction of the total shoulder ROM was analyzed (139.4o 4

40.50). In the current study, the entire shoulder ROM was analyzed; torque was applied as

necessary to achieve the end ROM for both IR and ER. We found the true total ROM to be

232.50 which was nearly 1000 greater than the total ROM reported by Novotny. Rotating the

shoulder to the end ROM required over three times as much torque for ER (17.9 N-m) and IR

(15.2 N-m).

Pitchers in this study had far greater shoulder stiffness than the non-throwers studied by

Novotny. For ER, the stiffness was approximately 11 times greater (0.05 N-m/o vs. 0.57 N-m/o)

and for IR the stiffness was approximately 3 times greater (0.17 N-m/o vs. 0.54 N-m/o). These

large differences may be related to the arm positions analyzed. Novotny assessed the shoulder

with the arm close to the torso (shoulder abducted 450) while we assessed the shoulder with the

arm in a throwing-relevant position (shoulder abducted 900). It is possible that in the 900









abducted position the shoulder soft tissues are stretched more than the 45o abducted. This

discrepancy may help to explain the stiffness differences between the studies. Future studies

should compare shoulder stiffness at various shoulder position to clarify. Methods used to

calculate stiffness also varied between the two studies. Novotny analyzed shoulder stiffness from

the angle where 1 Nm of torque was applied to the angle where 5 Nm of torque was applied. We

analyzed shoulder stiffness from the angle where 5 N-m of torque was applied to the end ROM.

Presumably, Novotny analyzed the shoulder as the soft tissues began to stretch while we

analyzed the shoulder as the soft tissues approached their maximum stretch. This discrepancy

may also contribute to the different stiffness values between the studies. Future studies shoulder

compare throwers and non-throwers at various shoulder positions to better understand the unique

characteristics of the throwing shoulder.

Magnitude of Rotational Resistance

A potential contribution of this line of research is determining the relevance of passive soft

tissue stretching to joint moments during various activities. Silder et al., (2007) addressed this

issue for the hip. The hip joint was passively extended to the end ROM (150) in 20 healthy young

adults. The torque generated by the stretching of hip soft tissues was approximately 20 N-m. This

passive torque was approximately 50% of the hip flexor moment reported at toe-off during gait.

Silder concluded that "passive mechanisms may contribute substantially to the hip flexor

moment seen during normal gait".

The torque required to passively externally rotate the dominant shoulder to the end ROM

was high (17 N-m) and relatively similar to the passive hip flexor moment reported by Silder (20

N-m). It seems reasonable to conclude that pitchers likely overcome more than 17 N-m of passive

torque when externally rotating the shoulder during the pitch because the pitching end ROM

(1800) exceeds the passive end ROM by approximately 500 (Zheng et al., 2004). Regardless, the









magnitude of the passive external rotation torque reported in this study suggests that externally

rotating shoulder during the pitch is challenging and it may help to explain why pitchers rotate

the torso at such high velocities during the arm-cocking phase of the pitch (Matsuo et al., 2001).

Interestingly, the passive ER shoulder torque in this study is approximately 33% of the

maximum internal rotation torque reported for the arm cocking phase of the pitch (Zheng et al.,

2004). This finding suggests that shoulder passive mechanisms may greatly contribute to the

shoulder moments generated during the pitch and therefore may be relevant to throwing arm

injuries and performance. Future studies should assess whether the shoulder ER passive

properties influence pitching kinematics and kinetics used to externally rotate the shoulder

during the pitch. Future studies should also attempt to determine if shoulder passive ER

properties are related to pitching performance.

The torque required to passively internally rotate the shoulder in this study was also high

(approximately 14 N-m). Interestingly, during the pitch, shoulder IR is ceased at 00 (Zheng et al.,

2004) which is well short of the passive end ROM (810). The IR rotational resistance is therefore

not likely directly relevant to the IR motion during the pitch. Instead, it is likely indirectly

relevant to other shoulder motions during the follow-through such as distraction, adduction, and

horizontal adduction. The relevance of IR rotational resistance to kinematics and kinetics of the

follow-through phase should also be assessed.

High Variability in Rotational Resistance Among Subjects

This apparently homogenous group of pitchers had drastically different rotational

resistance. For example, the angle where the soft tissues first provided substantial resistance (the

ROA) varied drastically. Nine pitchers had an IR ROA less than 1200 while 6 exceeded 1400

Similar patterns were revealed for ER. The stiffness of the dominant shoulder was also highly

variable. Seven pitchers had extremely low ER stiffness (< 0.4 N-m/o) while 6 pitchers exceeded









0.7 N-m/o. This finding revealed that some pitchers have "stiff" shoulders while others have

"loose" shoulders. Similar patterns were found for IR stiffness. This drastic variation may help to

better identify pitchers at risk of injury.

Prevalence of Throwing Arm Injuries

Fourteen of the 30 pitchers had a throwing arm injury serious enough to cause at least one

week of missed practice or games (Table 4-5). This data further illustrates the high incidence of

throwing arm injuries in baseball pitchers and is considered valuable since very few studies have

addressed this issue.

Specific Aims

Aim la

Aim la to determine if ROM and rotational stiffness are both necessary to assess shoulder

IR/ER flexibility. A maj or goal of this proj ect was to determine if stiffness is a useful measure

that can help to better assess shoulder flexibility in baseball pitchers. Stiffness, in this study, is a

measure of how "tight" or "loose" the shoulder is as it is rotated to the end ROM. This is the first

study to measure rotational stiffness in baseball pitchers. Results from aim la suggest that

stiffness does indeed provide new and important information about the flexibility of the throwing

shoulder. The most important finding may be that ROM and stiffness are not related, as

hypothesized. This means that two players can have similar ROM but drastically different

stiffness (or vice versa). Extreme examples were revealed for both IR and ER. For example, two

pitchers with similarly low IR stiffness (approximately 0.45 N-m/o) had IR end ROMs that

differed by 300 (Figure 4-1). Large ROM discrepancies (1300) were also found among pitchers

with similar stiffness at moderate and high levels (approximately 0.6 N-m/o and 0.7 N-m/o,

respectively). Similar patterns occurred for ER. These findings suggest that the addition of









rotational stiffness is valuable because it can help to better assess shoulder flexibility (as opposed

to analyzing ROM alone).

Previous studies have addressed how tight or loose the pitching shoulder is in a static

situation. Borsa et al., (2005) accomplished this by applying a 15-dN anterior or posterior force

to the proximal humerus and measuring how far the humeral head translated. Interestingly, the

amount of humeral humeral head translation did not predict the end ROM for IR or ER. From

this study and Borsa et al., (2006), it is quite clear that rotation and translation measures of

shoulder looseness or tightness measures do not predict the absolute ROM. What remains

unclear is if rotational or translation stiffness can be altered (via stretching, exercise, or throwing

interventions) and if alterations to stiffness influence the end ROM. For example, resistance

training may increase rotational or translational stiffness (which may decrease the ROM) and/or

stretching interventions may decrease stiffness (which may increase the ROM).

The ROA was also analyzed for the first time in this study. The ROA is a measure of the

angle where the soft tissues begin to provide substantial resistance to stretching. The ROA was

highly variable among pitchers; for both ER and IR the ROA range exceeded 300. The ROA is

also relevant to study because it determines the beginning of the resistance zone. The resistance

zone represents the portion of the motion (ER or IR) where the soft tissue is providing resistance

because it is being stretched. The resistance zone begins at the ROA and ends at the end ROM.

For IR, the resistance zone was 19.4 & 5.60. For ER, the resistance zone was 23.9 & 5.90.

Interestingly, the ROA strongly predicts the end ROM for both IR and ER. This strong

correlation suggests that most pitchers have a resistance zone of similar size. To simplify, an

analyst can expect approximately 200 of passive motion once the soft tissue begins to provide

substantial resistance from stretching. Future research should focus on the relevance of the









resistance zone to throwing arm injuries. Pitchers who have abnormal resistance zones (limited

or excessive) may be more susceptible to injuries than pitchers with average resistance zones.

Aim lb

To determine if high rotational resistance groups have significantly different ROM

compared to low rotational resistance groups. A maj or focus of this study was identifying and

further analyzing pitchers that had high rotational resistance and low rotational resistance.

Pitchers with high rotational resistance were defined as those that had two inflexible

characteristics: an early ROA and a stiff shoulder. Pitchers with low rotational resistance were

defined as those that had two flexible characteristics: a late ROA and loose shoulder. As

hypothesized, pitchers with low rotational resistance had significantly greater ROMs compared

to pitchers with high rotational resistance. For ER, the low rotational resistance group had a

ROM approximately 24o greater than the high rotational resistance group. For IR, the low

rotational resistance group had a ROM approximately 200 greater than the high rotational

resistance group. The data suggest that pitchers with high rotational resistance are "inflexible"

and that pitchers with low rotational resistance are "flexible".

High rotational resistance pitchers were expected to have limited resistance zones since

they have stiff shoulders. Interestingly, there was no difference between stiff and loose pitchers;

the resistance zone was between 18-23o for all groups. Stiffness had no apparent affect on the

motion acquired. But stiffness did demonstrate kinetic relevance. Stiff shoulders appear to

require more applied torque to achieve the end ROM. For example, the stiff shoulders of the high

rotational resistance group required approximately 20% more applied torque to achieve the ER

end ROM than the loose shoulders of the low rotational resistance group. This difference

approached significance (p = 0.05). The differences in these passive mechanical properties










among pitchers should be further explored because they may make some pitchers more

susceptible to throwing arm injuries than others.

Aim 2a

To determine if pitching alters the soft tissue of the throwing shoulder. Results for aim 2a

demonstrate that the passive ER and IR flexibility of the throwing shoulder is indeed different

from that of the non-throwing shoulder. Previous researchers have hypothesized that the anterior

soft tissues of the shoulder become more flexible from repeatedly exposure to extreme external

rotation during pitching (Pappas et al., 1985). Unexpected results were revealed; the passive ER

rotational stiffness of the throwing shoulder was significantly greater (20%) than the non-

throwing shoulder. This finding is important because it demonstrates that the soft tissues of the

throwing shoulder are different from that of the non-throwing shoulder. Future studies should

strive to better understanding the relevance of this difference between the throwing and non-

throwing shoulder as it may help to better identify players at risk for injury and improve injury

rehabilitation.

The meaning and limitations of the passive rotational resistance measures are important to

address. It is possible that the increased ER stiffness of the throwing shoulder results from the

tightening of anterior shoulder soft tissues. However, other potential hypotheses exist because

the passive torque collected in this study is a measure of the collective resistance of the shoulder.

For example, the stiffness increase may result from hypertrophy of the throwing shoulder

internal rotators. Hypertrophy may be associated with the increased internal rotation strength of

the throwing arm reported in professional pitchers; Ellenbecker et al., (1997) revealed that the

throwing arm produced significantly greater internal rotation isokineitc torques than the non-

throwing arm. Future research should attempt to better understand why the ER stiffness is greater









in the throwing shoulder. Examining stiffness bilaterally in non-throwers would help to reveal if

pitchers develop increased ER stiffness or if the dominant shoulder is "naturally" stiffer.

The ROA is a measure of the angle where the soft tissue begins providing substantial

resistance to rotation (due to stretching). ER ROA analysis revealed the throwing shoulder soft

tissues to provide substantial resistance 90 later than the non-throwing shoulder. Both bony

and/or soft tissue alterations to the throwing arm may be responsible for this "shift". A bony

alteration that may contribute to the 90 ROA shift is humeral retroversion. Three studies have

shown the pitching arm humerus to be retroverted ("twisted" along its axis) 11-17o back towards

ER. Pitching is thought to cause retroversion because non-throwers have no bilateral difference.

Future studies should address the relationship between humeral retroversion and the increased

ROA of the throwing shoulder.

The ROA "shift" is also important to study because it may influence the resistance zone. In

this study, the throwing shoulder ER resistance zone was 4o larger than the non-throwing

shoulder. This difference occurred because the ROA bilateral difference was less than the ROM

bilateral difference (Figure 5-1).

The importance of the size of the resistance zone, alterations to the resistance zone, and

mechanisms should be addressed. Finally, it is important to note that a significantly higher torque

was applied to externally rotate the torque to the end ROM. It is unclear if this is due to

differences in the passive mechanical properties of the throwing and non-throwing shoulders or

differences in discomfort as the end ROM is approached.

Previous studies have examined posterior shoulder tightness indirectly using bilateral

ROM tests. Significant bilateral differences have been reported for tests including passive IR

(Borsa et al., 2005), active IR (Ellenbecker et al., 2002), horizontal adduction (Myers et al.,









2006), and reaching to the highest vertebra behind the back (Baltaci et al., 2001). Passive IR was

the only ROM measure analyzed in this study. Previous passive IR ROM studies on comparable

groups of pitchers have reported the throwing shoulder to have an internal rotation deficit of

approximately 10o. As stated previously, this group of pitchers did not have a significant internal

rotation deficit. Therefore, if this group of pitchers would have been analyzed with ROM alone,

no evidence of posterior tightness would have been revealed. Interestingly, the preliminary

rotational resistance analysis did find evidence for posterior tightness, despite the lack of a IR

deficit. The throwing shoulder was 38% stiffer than the non-throwing shoulder the earlier ROA

(5o) approached significance (p = 0.03), and 29% more torque was required to internally rotate

the throwing shoulder to the end ROM (with no differences in the size of the resistance zone). It

is important to repeat a similar analysis in pitchers with a significant IR deficit (approximately

10o) like the aforementioned studies. Doing so would help to determine if rotational resistance

bilateral differences increase even more in pitchers with a large deficit. Also, future studies

should be completed on a population of pitchers with shoulder impingement since they are

known to suffer from severe IR deficits (Myers et al., 2006). Finally, the relationship between IR

rotational resistance and humeral retroversion should be explored. Previous studies have revealed

no relationship or a weak relationship between humeral retroversion and the IR loss (Osbahr et

al., 2002; Reagan et al., 2002). Exploring relationships between humeral retroversion and IR

rotational resistance may help to better understand if humeral retroversion at least partially

contributes to this loss of IR motion. This is important because limited IR motion is associated

with throwing arm injuries including SLAP lesions (Burkhart et al., 2003) and shoulder

impingement (Myers et al., 2006).






















No~n-dom~nina nt ER
res i sta~ne zojne

.....Dommiant ER
fe515tanCOe Z~ne


118o


1.270


1380


151o


Figure 5-1. The ROA and ROM shifts for external rotation. The ROM shift is 4o larger than the
ROA shift for ER. This discrepancy increases the ER resistance zone for the throwing
shoulder.

Aim 2b

Aim 2b was to determine if the magnitude of the motion shift is related to the magnitude of

the stiffness change. The ER motion shift was hypothesized to be associated with a decrease in

ER stiffness and the IR motion shift was also hypothesized be associated with an increase in IR

stiffness. Neither motion was significantly correlated with their respective stiffness bilateral

difference. It is still possible that alterations to soft tissues contribute to the motion shift; the

passive mechanical properties of soft tissue structures (such as rotator cuff muscles or the

capsule) may play an important role. But the passive rotational stiffness measure, which is a

reflection of all soft tissues, clearly did not predict the motion change in this study.

The magnitude of ER and IR motion shifts were strongly related to their respective ROA

bilateral differences. For most pitchers, the ROM bilateral difference was similar to the ROA

bilateral difference (both the direction and magnitude). It is important to note that this trend









remained even for the pitchers that had unexpected motion shifts (i.e., loss of ER or gain in IR).

These strong correlations between 1) the absolute ROA and the end ROM and 2) the ROA

bilateral differences and their respective motion shifts suggest important interaction between

these two variables. Analyzing these two variables in unison may help to identify pitchers who

are particularly susceptible to throwing arm injuries. This idea has previously been used for

ROM analysis. Pitchers with "unbalanced" motion shifts (IR deficit is 10o more than the ER

gain) are thought to be particularly susceptible to injury or showing signs of injury (Wilk et al.,

2002). Bilateral differences may be good indicators of pitching arm health. For example, having

a ROA shift and motion shift of similar magnitude may be a sign of throwing arm health or

having drastically different ROA and ROM shifts may be cause for concern. Future research

should explore these topics.

Aim 2c

Aim 2c was to determine if the rotational resistance of the non-throwing shoulder is related

to the magnitude of the motion shift. For aim 2c the non-throwing shoulder served as a control

and was assumed to represent the pre-altered pitching shoulder. For ER, pitchers with stiff non-

throwing shoulders and/or an early ROA were hypothesized to have the greatest motion shifts

(they were thought to have great potential to "loosen-up"). For IR, pitchers with stiff non-

throwing shoulders were hypothesized to have a minimal motion shift (since they were already

"tight"). One significant correlation related to these hypotheses was revealed: for IR, a moderate

negative correlation was revealed between the non-throwing ROA and the IR motion shift.

Interestingly, pitchers that had an early non-throwing ROA gained IR motion. This gain in IR

may be important and has yet to be discussed in the literature. This IR finding suggests that

pitchers that start with a "tight" shoulder become "looser". Pitchers with an average IR ROA had

no or a minimal motion shift. Pitchers with a late IR ROA had the greatest loss of motion; they









started out extremely loose and became tighter. As previously stated, this correlation is moderate,

but it is considered important because it is preliminary evidence that helps to explain the IR

motion shift. This aim also further highlights the potential for using the ROA as an indicator of

pitching health.

Aim 2c should be repeated on a population of adolescent pitchers. This would be useful

because two studies have shown that ER and IR motion shifts become established in pitchers as

young as 12-14 years (Meister et al., 2005). The non-dominant rotational resistance measures

should also be correlated to humeral retroversion. This analysis may help to determine which

pitchers have significant bony alterations.

Aim 3

Aim 3 was to determine if incidence of throwing arm injuries are different among

rotational resistance groups. The purpose of this preliminary injury analysis was to determine if

any general trends existed. Therefore, the number of pitchers analyzed was limited (N=30), the

analysis was retrospective in nature, all injuries were analyzed collectively, and the severity and

location of injury were not considered. The primary goal was to determine if the maj ority of

injured pitchers belonged to a specific rotational resistance group. Chi-square analysis revealed

no significant differences for the ER or IR groups. Interestingly, both healthy and injured

pitchers were dispersed quite evenly. This finding is important because it reveals that no obvious

injury trends exist.

With no obvious trends revealed, additional steps should now be taken to more thoroughly

analyze the relevance of rotational resistance measures to throwing arm injuries. First, rotational

resistance bilateral differences should be assessed in a similar fashion. It is possible that

alterations to rotational resistance are more important than absolute rotational resistance. Second,

greater numbers of pitchers should be analyzed. Injuries were very prevalent in this group of










pitchers, but analyzing additional pitchers would help to improve statistical power and the

strength of conclusions. Third, pitchers should be followed prospectively. It is possible that

rotational resistance changed after the throwing arm was injured. Last, each type of injury should

be analyzed individually. In this study, all injuries were analyzed collectively.

Analyzing injuries individually is important because injuries may be "direction specific".

Medial elbow injuries can be used to illustrate this point. The medial elbow is critically loaded as

the shoulder is maximally externally rotated at the end of the arm cocking phase of the pitch. The

ER rotational resistance is likely relevant at this point in the pitch since the anterior soft tissues

are being stretched maximally (Fleisig et al., 1995). The IR rotational resistance is likely not

relevant at this point in the pitch since posterior shoulder soft tissues are not being stretched.

Therefore, it seems appropriate to focus attention on ER rotational resistance when analyzing

elbow injuries.

Interestingly, a high number of pitchers suffered medial elbow injuries in this study (n=7).

Qualitative analysis revealed findings to support the relevance of ER rotational resistance to this

specific injury. The ER rotational resistance of these 7 pitchers was relatively similar. The ROA

measures were within 15o and their stiffness was within 11 N-m/o. This contrasts the disparate

findings for IR (the "irrelevant" direction). For IR, the ROA range was greater (7o) and the

stiffness range was approximately twice as large. Analyzing larger numbers of specific injuries

in this manner could help to identify the direction (IR vs. ER).and group (low, moderate, or high

rotational resistance) of greatest concern for each type of injury.

Summary

General Conclusions

*Throwing arm injuries are prevalent and severe in elite baseball pitchers. Forty-seven
percent of the pitchers in this study had a serious throwing arm injury that made them unable to
participate in practice or a game (for a week or more) during the previous year.










* The torque required to passively rotate the shoulder to the end ROM was 14 N-m for
internal rotation and 17 N-m for external rotation. These large passive torques may be extremely
relevant to shoulder and elbow loads generated during the pitch that cause throwing arm injuries.

* Shoulder internal and external rotation passive flexibility was highly variable in this
relatively homogenous group of elite pitchers. For both IR and ER, the resistance onset angle
range exceeded 30o and some pitchers shoulders were twice as stiff as others.

* Aim la showed that ROM and stiffness were not correlated. This finding suggests that
both measures are needed to make clear conclusions about shoulder flexibility.

* Aim la also showed that the resistance onset angle strongly predicted the end ROM. For
both ER and IR, the end ROM occurred approximately 20o beyond the resistance onset angle.
This was true for pitchers that had a limited ROM and pitchers that had an excessive ROM.

* Aim lb classified pitchers as having low, moderate, or high rotational resistance. As
expected, low rotational resistance pitchers had a significantly greater ROM than high rotational
resistance pitchers. The difference was approximately 200 for ER and IR.

* Aim 2a addressed bilateral differences. Results provide strong evidence to suggest that
pitching alters the soft tissues of the throwing shoulder. The throwing shoulder was 20% stiffer
for ER and 40% stiffer for IR. The ROA was 100 later for ER and 5o earlier for IR.

* Aim 2b addressed the magnitude of the motion shifts. Bilateral stiffness differences did not
predict the motion shifts but the ROA shifted similarly to the ROM for ER and IR (the direction
and magnitudes of the bilateral differences were similar).

* Aim 2c used the non-throwing shoulder as a model of the original (or pre-altered)
flexibility of the throwing arm. The non-throwing ROA predicted the IR motion shift. This
finding helps to identify who is having motion shifts and why. Pitchers with an early ROA
gained motion, pitchers with an average ROA had no motion shift, and pitchers with a late ROA
lost motion.

* Aim 3 was a preliminary retrospective injury analysis that compared incidence of throwing
arm injuries among a low, moderate, and high rotational resistance groups. No general trends
were revealed. Future efforts should focus on analyzing larger groups of pitchers and groups of
pitchers with similar injuries (rather than assessing all throwing arm injuries collectively).

Practical application and recommendations

* Rotational resistance should be developed to analyze the shoulder in clinical and
rehabilitation settings. Athletic trainers, orthopedic surgeons, and sports medicine
clinicians should consistently monitor the passive ER and IR flexibility of both shoulders
in overhead athletes.

* Measures and methods from this study may help to better guide and assess exercise and
rehabilitation interventions in overhead athletics.










Future Research

* Determine the relevance of rotational resistance to throwing arm loads during the pitch.

* Determine the relevance of rotational resistance to pitching performance (pitching
accuracy and pitching velocity).

* Examine the relationships between rotational resistance the humeral retroversion to better
understand the motion shift and causes of the motion shift.

* Analyze rotational resistance in adolescent populations when the motion shifts first
become established.

* Perform longitudinal studies to monitor relationships between rotational resistance and
throwing arm injuries prospectively.

* Determine the relevance of rotational resistance bilateral differences to incidence of
throwing arm injuries.

* Analyze the relevance of rotational resistance to specific throwing arm injuries.

* Determine influence of stretching and resistance training interventions on rotational
resistance.

* Assess rotational resistance in baseball position players and other overhead athletes.

* Determine influence of warm-up and fatigue on rotational resistance.

* Determine influence of specific soft tissues on rotational resistance by completing cadaver
studies.

In conclusion, this study demonstrated the importance of assessing shoulder passive IR and

ER rotational resistance in baseball pitchers. The most important novel finding may be that

rotational stiffness and end ROM are not related. This finding suggests that both measures are

required to thoroughly assess IR or ER passive flexibility of the throwing shoulder. This study

also demonstrated that rotational resistance varies dramatically bilaterally and that rotational

resistance is relevant to the motion shift. We believe that rotational resistance shoulder

assessments could help athletic trainers, orthopedic surgeons, and sports medicine clinicians to

prevent, diagnose, and rehabilitate throwing arm injuries; we recommend the assimilation of










shoulder rotational resistance assessments into practice. Future research should continue to focus

on determining the relevance of rotational resistance measures to incidences of throwing arm

injuries and injury prevention. We believe throwing arm injuries may be reduced by focusing on

injury mechanisms, the motion shifts, and throwing arm interventions. Injury mechanism

research should focus on examining associations between rotational resistance and the throwing

arm loads experienced during the pitch. Motion shift research should explore the relationship

between rotational resistance and humeral retroversion. Finally, throwing arm intervention

research should focus on the influence of stretching interventions and resistance training

interventions on rotational resistance.









APPENDIX A
SHOULDER ANATOMY AND EXAMPLE INJURIES

Articulations of the Shoulder Joint

The shoulder complex has four articulations: acromioclavicular, sternoclavicular,

scapulothoracic, and glenohumeral. Pitching researchers are most concerned with the

glenohumeral joint due to the high incidence of injuries (Baltaci et al., 2001). The glenohumeral

j oint is a ball and socket j oint. Pitchers are able to achieve a tremendous shoulder ROM during

the pitch because the socket, or glenoid, is extremely shallow (Pink et al., 1995). "Little League

Shoulder" is a common bony injury in adolescents (Fleming et al., 2004). Young pitchers suffer

from little league shoulder when the growth plate, or physis, at the proximal end of the humerus

gradually separates. This injury is known to occur in pitchers age 11-16 years (Carson et al.,

1998). Little league shoulder is thought to develop from repeated exposure to external rotation

torque at the end of the arm-cocking phase of the pitch (Sabick et al., 2004).


Soft Tissue Stabilizers

The shallow nature of the glenoid forces the soft tissues of the shoulder to be the primary

stabilizers. Shoulder soft tissues are categorized as "static stabilizers" or "dynamic stabilizers"

(Donatelli, 2004). The static stabilizers are the cartilages and ligaments that surround the joint.

The two main static stabilizers, the labrum and capsule, are commonly injured in baseball

pitchers. Many dynamic stabilizers, or muscles, also surround the joint. Primary attention is give

to the rotator cuff muscles due to their important role in providing shoulder stability and their

high susceptibility to injury.

The labrum

The labrum is a ring of fibrous tissue that surrounds the glenoid. The labrum helps to

provide stability by forming a "socket" for the humeral head. It also serves as an attachment site









for ligaments and tendons. The labrum helps to secure the humeral head by forming a ring

around the glenoid. The biceps tendon attaches to the superior labrum. "SLAP lesions" are

injuries to the labrum that baseball pitchers suffer from (Park et al., 2002). SLAP stands for

"superior labrum anterior to posterior" and is used to describe tears to the labrum. There are four

basic types of SLAP lesions that baseball pitchers suffer from. SLAP lesions may be caused by

impingement or large bicep tendon forces that act to "peel" the labrum off the glenoid during the

arm cocking and/or arm deceleration phase of the pitch (Park et al., 2002).

The capsule

The capsule completely surrounds the humeral head and provides stability near the limits

of motion. At the scapular end it attaches along the rim of the glenoid, just beyond the labrum.

At the humeral end it attaches along the anatomical neck. Capsular thickenings occur on the

anterior, middle, and inferior surfaces. The role of the capsule as a stabilizer varies with the arm

position and the shoulder biomechanics. The capsule remains lax in most shoulder positions

(Jobe, 1995). It becomes tense, and an important stabilizer, at extreme shoulder positions. The

anterior capsule can become attenuated from repeated exposure to extreme ER and the posterior

capsule can become tightened from repeated exposure to the follow through loads. These

problems are thought to be highly preventable (Jobe, 1995) and often addressed with surgical

interventions. The "capsular shift" surgical intervention is used to eliminate excessive anterior

instability (Glousman et al., 1995). Another procedure, thermal capsulorrhaphy, can similarly

eliminate excessive instability by shrinking the capsule with a heated probe (Enad et al., 2004).

The rotator cuff muscles

Four rotator cuff muscles originate from the scapula (Figure A-10). The rotator cuff

tendons blend with the capsule as they approach the humeral tuberosities. The rotator cuff










muscles are important stabilizers since the capsule is lax at most arm positions (Jobe 1995).

Primary roles include stabilizing the humeral head within the glenoid, precisely positioning the

humeral head within the glenoid, and rotating the humerus (Yocum et al., 1995). Tears to the

rotator cuff are common (Mazoue et al., 2006). Rotator cuff muscles are greatly responsible for

decelerating the arm after ball release. Tears are thought to be associated repeated exposure to

the large distraction force at ball release that is equal to or greater than the pitchers body weight

(Fleisig et al., 1995). Tears occur most commonly in the posterior half of surprspinatus and

superior half of infraspinatus (Mazoue et al., 2006). This serious injury requires surgical

intervention. Rotator cuff tendons also commonly get impinged between the glenoid and humeral

head.










APPENDIX B
APPROVED IRB

1. TITLE OF PROTOCOL:

Shoulder Intemnal and External Rotational Stiffness in Baseball Pitchers

2. PRINCIPAL INVESTIGATOR(s): (Name, degree, title, dept., address, phone #, e-
mail & fax)

Jeff T. Wight, B.S., M.S., PHD candidate, Department of Applied Physiology &
Kinesiology, PO Box 118206, 150 Florida Gym, 392-0584 ext. 1400,
jwight@ufl.edu, 392-5262 (fax)

Guy B. Grover, B.S., M. S. candidate, Department of Applied Physiology &
Kinesiology, PO Box 118206, 152 Florida Gym, 392-9575 ext. 1401,
ggrover@ufl.edu, 392-5262 (fax)

3. SUPERVISOR (IF PI IS STUDENT): (Name, campus address, phone #, e-mail &
fax)

Mark D. Tillman, Ph.D., Assistant Professor, Department of Applied Physiology
& Kinesiology, PO Box 118205, 118 Florida Gym, 392-0584 ext. 1237,
mtillman@hhp.ufl. edu, 392-5262 (fax)

4. DATES OF PROPOSED PROTOCOL:

October 15, 2006 to October 15, 2007

5. SOURCE OF FUNDING FOR THE PROTOCOL:
(As indicated to the Office of Research, Technology and Graduate Education)

None.

6. SCIENTIFIC PURPOSE OF THE INVESTIGATION:

The purposes of this study are to 1) measure the passive flexibility characteristics
of the shoulder in intemal/extemal rotation in baseball pitchers, 2) determine if
relationships exist among various passive internal and external rotation variables,
and 3) determine if bilateral differences exist in passive flexibility characteristics
of the shoulder.


-75-











7. DESCRIBE THE RESEARCH METHODOLOGY IN NON-TECHNICAL
LANGUAGE: The UFIRB needs to know what will be done with or to the research
participants) .

Protocol and methods. Bilateral shoulder flexibility measurements will be taken with the
participant lying supine on an athletic training table. The upper arm will be secured to a
rotational device with the elbow bent at 900. To prevent shoulder and scapular
movement, the investigator will push lightly on the participant's anterior shoulder. The
whole arm will be internally and externally rotated to the end range of motion. The end
range of motion will be determined by the participant. The participant will say "stop"
when he believes that further rotation of the arm would become uncomfortable. The
participant will be instructed to keep the upper body muscles relaxed (no musclular
effort) while the measures are taken. Surface electromyography (Konigsburg Instruments,
inc., Pasadena, CA) will be used to monitor the shoulder area muscle activity. Both the
force required to rotate the arm and the resulting displacement will be recorded into a
laptop computer via a load cell (Tansducer Techniques, Temecula, CA) in line with the
force applicator and an electrogoniometer (Model 536 Precision Potentiometer),
respectively .

There will be a 20 minute Familiarization Session and a 20 minute Data Collection
Session (total of 40 minutes). These two sessions may be performed on the same day or
different days (depending on convenience).

Familiarization Session.
First, the participant will read (and sign) the informed consent. The custom device will
then be adjusted to properly fit the participant the arm support will be lowered or raised
as necessary). The device settings will be recorded (to use in the Data Collection
Session). The participant will then be familiarized with the protocol using five sub-
maximal repetitions (both internally and externally, for both the right and left arm). The
shoulder will be rotated very slowly for all repetitions. The first rotation will cease when
the subj ect first feels a light stretch in the shoulder. That stretch will then be held for
approximately five seconds. The only difference in the next four repetitions will be the
magnitude of the rotation; each rotation will be slightly further than the previous (but all
will be short of the end range of motion). Finally, the subj ect' s shoulder will be rotated
once to the comfortable end range of motion.

Next, three simple shoulder range of motion measures will be taken on each shoulder.
First, the participant will be asked to reach the highest vertebra possible behind his back.
Second, maximum passive adduction will be measured with the subj ect lying on his side.
Third, the internal and external end range of motion will be measured with a plastic
gomiometer.

Data collection session. The device will be adjusted to the proper settings (recorded in
the Familiarization Session). EMG electrodes will be placed over the shoulder area
muscles. Five consecutive repetitions (to the comfortable passive end range of motion)
will be collected for shoulder internal and external rotation for both shoulders. There will









be two consecutive collections: once with the shoulder stabilized by the investigator and
once without.


8. POTENTIAL BENEFITS AND ANTICIPATED RISKS: (If risk of physical,
psychological or economic harm may be involved, describe the steps taken to protect participant.)

The anticipated risks associated with this study would be no more than those associated
with self stretching of the shoulder under normal conditions. To avoid muscle injury due
to overexertion, the subj ects will be required not to engage in strenuous exercise during
the day of the test and to warm-up properly before the testing session. In the unlikely
event that an injury does occur, a certified athletic trainer will be present at the collection,
or on call, to provide treatment.

9. DESCRIBE HOW PARTICIPANTS) WILL BE RECRUITED, THE NUMBER
AND AGE OF THE PARTICIPANTS, AND PROPOSED COMPENSATION (if
any) :

Sixty-five male baseball pitchers (age 18-40 years) will be recruited from college and
professional teams in Florida. No compensation will be provided by the investigators.

10. DESCRIBE THE INFORMED CONSENT PROCESS. INCLUDE A COPY OF

THE INFORMED CONSENT DOCUMENT (if applicable).



Written informed consent (see attached) will be obtained from each participant prior to his
participation.

Please use attachments sparingly.


Principal Investigator's Signature


Co-Principal Investigator's Signature


Supervisor's Signature


I approve this protocol for submission to the UFIRB:



Dept. Chair/Center Director Date










APPENDIX C
APPROVED INFORMED CONSENT

INFORMED CONSENT AGREEMENT

PROJECT TITLE: Shoulder Internal and External Rotational Stiffness in Baseball Pitchers

INVESTIGATORS: Jeff T. Wight and Guy B. Grover

Please read this consent agreement carefully before
you decide to participate in this study

PURPOSE OF THIS PROJECT:

The purpose of this study is to measure the passive internal and external rotation flexibility characteristics of both
shoulders in baseball pitchers.

WHAT YOU WILL BE ASKED TO DO:

The flexibility tests will be conducted with you lying on an athletic training table. Small sensors (EMG electrodes)
will be place over your shoulder area muscles to monitor muscle activity. We will ask you to hold your arm in a
throwing position (elbow bent at 900). We will then secure your arm to a wheel that can rotate. During the test, one
investigator will lightly push against the front of your shoulder to prevent unwanted movement. The other
investigator will slowly rotate your arm internally (moving the forearm downward) or externally (moving the
forearm upward). You will be asked to keep your shoulder totally relaxed during the testing. You will also be asked
to say "stop" when you believe that further rotation of the arm would become uncomfortable. Both the force
required to rotate the arm and the resulting displacement will be recorded.

The Familiarization Period We want to make sure that you are comfortable with our flexibility measuring
protocol. To do this we will perform six practice repetitions for each arm (for internal and external rotation).
During these practice repetitions we will ask you to completely relax your shoulder. During the first repetition, we
will cease rotation when you first feel a light stretch in your shoulder. We will hold that stretch for approximately
five seconds. Four more stretches will be performed, and each time we will rotate your arm a little farther. After the
five stretches have been completed, we will rotate your arm to the comfortable end range of motion twice. The first
time, we will use a device that we built to measure your shoulder. The second time, we will use a simple plastic
goniometer to measure your shoulder.

The data collection.

We will start with two simple shoulder measures. First, you will be asked to place your hand behind your back and
reach the highest vertebra possible. Second, we will measure how far you can reach across your body.

Next, we will collect five consecutive repetitions to the passive end range of motion. We will do this for both
shoulders and both directions internall and external rotation). For each repetition you will be asked to say "stop"
when you achieve your comfortable end range of motion. Throughout the collections, we would like you to remain
still and relaxed. We will complete this test twice.

TIME REQUIRED:

Approximately 40 minutes. Familiarization and testing sessions may occur on consecutive days.

RISKS AND BENEFITS:











The anticipated risks associated with this study would be no more than those associated with self stretching of the
shoulder under normal conditions. In the unlikely event that an injury does occur, a certified athletic trainer will be
present at the collection, or on call, to provide treatment.

There is no direct benefit to you for participating in this study. However, the findings of this study may help us to
better understand performance and injuries in overhand athletics.

COMPENSATION:

No compensation will be provided by the investigators.

CONFIDENTIALITY:

Your identity will be kept confidential to the extent provided by law. The records of your participation will be kept
confidentially. Only the investigators of this study will have access to your records and data files. Video recordings
will be destroyed when the study is completed. Your name will not be used in any report.

VOLUNTARY PARTICIPATION:

Your participation in this study is completely voluntary. All data collection will be performed by graduate research
assistants.

RIGHT TO WITHDRAW:

You have the right to withdraw from the study at anytime without penalty.

WHOM TO CONTACT IF YOU HAVE QUESTIONS ABOUT THIS STUDY:

Jeff T. Wight, M.S., Ph.D. candidate, 150 Florida Gym, 392-0584 ext. 1400, jwight~ufl.edu
Guy B. Grover. B.S., 152 Florida Gym, 392-9575 ext. 1401, ggrover~ufl.edu
Mark D. Tillman, Ph.D., 118 Florida Gym, 392-0584 ext. 1237, mtillman~hhp.ufl.edu

WHOM TO CONTACT ABOUT YOUR RIGHTS AS A RESEARCH PARTICIPANT INT THE
STUDY:

UFIRB Office, Box 1 12250, University of Florida, Gainesville, FL 32611-2250; Tel.:3 92-043 3.


AGREEMENT:

I, have read the procedure described above and I voluntarily
(participant's name)
agree to participate in the procedure. I also understand that I will receive a copy of this form upon
request.

Participant: Date:
Principal Investigator: Date:









APPENDIX D
THROWING ARM INJURY QUESTIONNAIRE


This questionnaire will ask you about the frequency and location
of throwing arm inj uries over the past year.



Please feel free to ask questions.


GENERAL INFORMATION


DATE


TEAM


Right-handed or Left-


NAME
handed


Height_


Weight


In the past year, were you a starting pitcher or relief pitcher?


How many years have you pitched competitively?










1. In the past year, did you suffer from any throwing arm injuries/pain that made you unable to fully
participate in throwing activities during practice, unable to practice at all, or unable to compete in
a game?

YES Please answer questions la-1d below. NO Please move on to #2.

la. In the past year, how many days/weeks were you unable to participate in throwing
activities during practice, unable practice at all, or unable to compete in a game because
of throwing arm injuries/pain?

days weeks

lb. When did the symptoms begin?

Ic. Circle the general area of the throwing arm where the injury/pain occurred.

Shoulder Elbow Both Other

10. Circle any specific locations) of the shoulder and/or elbow where the injury/pain
occurred.

Shoulder: anterior, posterior, superior, lateral

Elbow: medial, lateral, internal, anterior, posterior

Id. Did you see a physician about your throwing arm injury/pain?

YES What was your doctor's diagnosis? NO

2. Currently, are you experiencing any throwing arm pain during practice and/or games?

YES Please answer questions 2a-2d below. NO Thank you for your
time .

2a. Circle the general area of the injury/pain.

Shoulder Elbow Both Other

2b. Circle any specific locations) of injury/pain on the shoulder and/or elbow.

Shoulder: anterior, posterior, superior, lateral

Elbow: medial, lateral, internal, anterior, posterior

2c. Is the pain severe enough to negatively influence your pitching performance (velocity or
control)?
YES NO

2d. Do you feel that you have altered your pitching mechanics because of the pain?

YES NO










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BIOGRAPHICAL SKETCH

Jeffrey T. Wight was born in Grand Rapids, Michigan in 1977. He was raised in Plover,

Wisconsin and graduated from Stevens Point Area Senior High in 1995. Jeff has enjoyed

participating in athletics, the outdoors, and fishing throughout his life. His undergraduate studies

were completed at the University of Wisconsin-Madison where he received a Bachelor of

Science in Zoology and completed extensive studies in mathematics.

After receiving his bachelor' s degree, Jeff worked for the Center for Limnology at the

University of Wisconsin. Jeff married Erin Largo in the summer of 2001 and they began

graduate studies at the University of Delaware in the Department of Health, Exercise Science,

and Nutrition in August of 2001. Two years later, Jeff graduated from the University of

Delaware with his Master of Science in Exercise Science. He completed and published a thesis

titled "Influence of pelvis rotation styles on overall baseball pitching kinematics and Irinctics;

under the supervision and guidance of his advisor, Dr. James Richards. Jeff was also a volunteer

baseball coach at the high-school and college level for 8 years during his undergraduate years

and time in Delaware.

He and his wife started their doctoral studies at the University of Florida in the College of

Health and Human Performance in August of 2003. During his years of graduate studies, Jeff

taught a total of nine different courses at the University of Delaware, University of Florida, and

Stetson University. He also gave many guest lectures at the University of Florida in a variety of

courses: In addition to teaching, Jeff has been actively involved with research projects during his

doctoral studies at the University of Florida. He was an investigator on awarded grants,

published in peer-reviewed journals, and presented research at various national conferences. Jeff









is a member of professional organizations including the American Society ofBiomechanics and

the American College of Sports M~edicine .

Jeff was active and involved with the University and College throughout his doctoral

tenure. Jeff and his wife were selected as recipients of the College of Health and Human

Performance German Scholarship Exchange Program to the University of Darmstadt in

Darmstadt, Germany, where they gave a joint research presentation. He has also been actively

involved with the College' s informal co-ed Ultimate Frisbee league and has enjoyed learning

about Florida' s natural ecosystems by kayaking many waters from the Florida Keys to Cedar

Key with his wife.

Jeff and his wife are graduating with their doctorates from the University of Florida,

College of Health and Human Performance, in the summer of 2007. They will also welcome

their first child into the world in June of 2007.





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USING ROTATIONAL RESISTANCE ME ASURES TO THOROUGHLY ASSESS SHOULDER FLEXIBILITY IN BASEBALL PI TCHERS: IMPLICATIONS FOR THROWING ARM ADAPTATIONS AND INJURIES By JEFFREY T. WIGHT A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2007 1

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2007 Jeffrey T. Wight 2

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ACKNOWLEDGMENTS I would first like to thank my advisor, Dr. Mark Tillman. I am particularly thankful for his unselfishness and ability to make things happen at crunch time. His abilities to quickly assess new ideas and clarify unpolished th oughts are unmatched. He was th e perfect advisor for me and this project. I am also grateful to my rema ining committee members: Dr. John Chow, Dr. Paul Borsa, and Dr. Anthony Falsetti. I would like to thank Dr. Chow for providing me with many research opportunities. I am pa rticularly thankful for his gui dance and support on the USTA project which laid the foundation for this projec t. I will always remember his open office door and his generosity and leadership at conferences. I w ould like to thank Dr. Borsa for steering me in the right direction. His expe rience, knowledge, and enthusiasm have been crucial to this project, my development, and this line of res earch. I would like to th ank Dr. Falsetti for his incredible sacrifice, support, and contributions. I would also li ke to thank my fellow graduate student, Guy Grover, for his involvement at every step along the way. I am particularly grateful for his friendship and sacrifice at the crucial points in this project. I am thankful for our teamwork and ability to combine ideas and efforts to fulfill a common vision. Next, I would like to thank my family for their incredible support. I am thankful to have completed this journey with my wife, Erin. Enro lling in graduate school together six years ago was one of the best decisions we ever made. I am proud of her accomplishments and thankful for her contributions to this projec t. Everyday with her is a bles sing. I would like to thank baby Largo Wight for motivating me and putting things in perspective. I w ould like to thank my parents and sister for their uncond itional support. I am thankful for their love and I appreciate the freedom and confidence they instilled in me to explore my thoughts and follow my dreams. I would also like to thank my in-laws for thei r friendship, love, and support. Having them in Florida has been wonderful. I would also like to thank Gary Nave, Kelly Larkin, Curtis Weldon, 3

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Dr. Geoff Dover, Dr. Chris Hass, J.D. Garbrech t, John Barrett, Richard Stark, Ross Jones, Pat Dougherty, the Fightin Blue Hens, the USTA, and MLB. In closing, I would like to dedica te this project to the baseba ll community. I am grateful to all of the coaches and players I have worked with over the years and I am happy that I can give a little back with this project. Finally, I would lik e to thank the sport of baseball for teaching me that, sometimes you win, sometimes you lose, and sometimes it rains. 4

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TABLE OF CONTENTS page ACKNOWLEDGMENTS ...............................................................................................................3 LIST OF TABLES ...........................................................................................................................8 LIST OF FIGURES .........................................................................................................................9 ABSTRACT ...................................................................................................................................10 CHAPTER 1 INTRODUCTION TO STUDY.............................................................................................12 General Introduction ...............................................................................................................12 Shoulder Mobility and Stability ......................................................................................14 Assessing Shoulder Mobility and Stability .....................................................................15 Specific Aims..........................................................................................................................15 2 REVIEW OF THE LITERATURE........................................................................................22 Analyzing the Shoulder IR/ER Passive Motion .....................................................................22 Important Methodological Considerations ......................................................................22 Arm position .............................................................................................................23 Scapular stabilization ...............................................................................................23 Novotnys Approach .......................................................................................................24 Reliability of Traditional Measures .................................................................................24 The Shifted Motion .................................................................................................................25 Other Shoulder Motions ..................................................................................................25 Sport Specific Findings ...................................................................................................26 Age and the Motion Shift .......................................................................................................27 Biomechanics of the Baseball Pitch .......................................................................................28 Alterations to the Throwing Arm ...........................................................................................29 Humeral retroversion .......................................................................................................29 Soft Tissue Theories ........................................................................................................31 Horizontal Adduction Tightness Tests ............................................................................31 Active IR .........................................................................................................................32 Glenohumeral Stiffness ...................................................................................................32 Glenohumeral Translation ...............................................................................................33 Conclusions .....................................................................................................................33 3 MATERIALS AND METHODS...........................................................................................34 Participants .............................................................................................................................34 Equipment ...............................................................................................................................34 Arm Position ....................................................................................................................36 Scapular Stabilization ......................................................................................................36 5

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Data Collection .......................................................................................................................37 RR Device Collection .............................................................................................................39 Data Reduction .......................................................................................................................39 Reduce To Best-Fit Line .................................................................................................39 Definition of Rotational Resistance Groups ....................................................................41 Angle Conventions ..........................................................................................................42 Data Analysis ..........................................................................................................................42 General Analysis .............................................................................................................42 Analysis of Specific Aims ...............................................................................................43 4 RESULTS...................................................................................................................... .........47 Specific Aim 1a ......................................................................................................................47 Specific Aim 1b ......................................................................................................................48 Specific Aim 2a ......................................................................................................................49 Specific Aim 2b ......................................................................................................................50 Specific Aim 2c ......................................................................................................................51 Specific Aim 3 ........................................................................................................................52 5 DISCUSSION................................................................................................................... ......55 Description of Pitchers ...........................................................................................................55 Important General Findings ....................................................................................................56 Magnitude of Rotational Resistance ................................................................................57 High Variability in Rotational Resistance Among Subjects ...........................................58 Prevalence of Throwing Arm Injuries .............................................................................59 Specific Aims..........................................................................................................................59 Aim 1a .............................................................................................................................59 Aim 1b .............................................................................................................................61 Aim 2a .............................................................................................................................62 Aim 2b .............................................................................................................................65 Aim 2c .............................................................................................................................66 Aim 3 ...............................................................................................................................67 Summary .................................................................................................................................68 General Conclusions ........................................................................................................68 Practical application and recommendations ....................................................................69 Future Research ...............................................................................................................70 APPENDIX A SHOULDER ANATOMY AND EXAMPLE INJURIES......................................................72 B APPROVED IRB................................................................................................................. ...75 C APPROVED INFORMED CONSENT..................................................................................78 D THROWING ARM INJURY QUESTIONNAIRE................................................................80 6

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LIST OF REFERENCES ...............................................................................................................82 BIOGRAPHICAL SKETCH .........................................................................................................88 7

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LIST OF TABLES Table page 2-1 Summary of shoulder IR/ER range of motion studies for overhead athletes. ...................26 2-2 Humeral retroversion in baseball pitchers. ........................................................................30 3-1 Means and SD of flexibility va riables for repetitions 1, 2, and 3 ......................................41 3-2 Statistical analyses for aim 1a. ...........................................................................................43 3-3 Statistical analyses for aim 1b. ...........................................................................................44 3-4 Statistical analyses for aim 2a. ...........................................................................................44 3-5 Statistical analyses for aim 2b. ...........................................................................................44 3-6 Statistical analyses for aim 2c. ...........................................................................................45 3-7 Chi-square contingency table for aim 3 .............................................................................46 4-1 ROM and resistance zones for the hi gh and low rotational resistance groups. .................49 4-2 Bilateral comparison of flexib ility variables for ER and IR. .............................................49 4-3 Mean motion shifts for non-dominant shoulder rotational resistance groups. ..................52 4-4 Summary of self-reported throwing arm injuries. ..............................................................54 8

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LIST OF FIGURES Figure page 2-1 Shoulder ER during the baseball pitch ...............................................................................28 2-2 Follow-through phase of the pitch. ....................................................................................29 3-1 RR device designed for m easuring overhead athletes. ......................................................35 3-2 Schematic of data collection. .............................................................................................37 3-3 Example torque-displacement data for an ER repetition. ..................................................40 3-4 Defining groups based on rota tional resistance variables..................................................42 4-1 Stiffness versus end ROM for the throwing shoulder. .......................................................47 4-2 ROA versus end ROM for ER and IR of the throwing shoulder. ......................................47 4-3 Formation of high and low rotational resistance (RR) groups for ER and IR...................48 4-4 Bilateral stiffness difference versus th e motion shift for the dominant shoulder.. ............50 4-5 Dominant shoulder ROA bilateral differences versus the motion shift. ............................50 4-6 Non-dominant ER rotational resistan ce measures versus the ER motion shift. ................51 4-7 Non-dominant IR rotational resistance measures versus the IR motion shift. ...................51 4-8 High and low rotational resistance groups for the non-dominant ER and IR. ...................52 4-9 Prevalence of shoulder and elbow injuries with respect to ER passive flexibility. ...........53 4-10 Prevalence of shoulder and elbow injuries with respect to IR passive flexibility. ............54 5-1 The ROA and ROM shifts for external rotation. ...............................................................65 9

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Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy USING ROTATIONAL RESISTANCE ME ASURES TO THOROUGHLY ASSESS SHOULDER FLEXIBILITY IN BASEBALL PI TCHERS: IMPLICATIONS FOR THROWING ARM ADAPTATIONS AND INJURIES By Jeffrey T. Wight August 2007 Chair: Mark Tillman Major: Health and Human Performance Throwing arm injuries are extremely prevalent in baseball pitchers. Th e flexibility of the throwing shoulder is thought to be relevant to the incidences of throwing arm injuries and injury mechanisms. Previous flexibility studies have as sessed a single shoulder variable: the range of motion (ROM). In this study, a custom device was built to measure shoulder flexibility and a new and more thorough manner. The device assesses th e amount of torque (or effort) required to passively rotate the shoulder. Th is novel analysis provides a measure of how stiff or loose the shoulder is as it is rotated to the end ROM. Th e two shoulder motions that are considered the most relevant to injury were analyzed (int ernal rotation and extern al rotation). Two major findings were revealed in this study. First, for both ER and IR the end ROM and stiffness of the shoulder are not related. This means that two pi tchers can have similar ROM but drastically different shoulder stiffness. This data sugge sts that both ROM and s tiffness are required to describe the flexibility of the pitching shoulde r. Second, pitching alters the flexibility of the throwing shoulder. This was discovered by compari ng the flexibility of th e throwing shoulder to that of the non-throwing shoulder. Variables that were significantly different bilaterally were the ROM, the resistance onset angle (angle where th e soft tissue begins to stretch), and shoulder 10

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stiffness. These bilateral differences were larg e (20%). The magnitude and direction of these bilateral differences are likely relevant to throwing arm injuries. We recommend the incorporation of this new shoulder analysis into clinical and reha bilitation settings and believe future research should strive to better understand the relevance of shoulder flexibility to throwing arm injuries. 11

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CHAPTER 1 INTRODUCTION TO STUDY General Introduction Evolving the ability to throw was crucial to the existence and advancement of our species (Darlington et al., 1975; Young et al., 2003). Although the importance of throwing to daily survival has diminished, its pervasiveness rema ins. Hundreds of thousands of individuals around the world participate in recrea tional and organized athletics that involve throwing or throwinglike motions (Fleisig et al., 1996; Conte et al., 2001; Escamilla et al., 2001; Janda, 2003). Athletes that regularly throw or use throwing-like motions are referred to as overhead athletes (Baltaci et al ., 2004; Borsa et al., 2005). Example ov erhead actions include the baseball pitch, football pass, javelin thro w, volleyball spike, and tennis serve. Regularly performing overhead actions places great demands on the domi nant arm (Zheng et al., 2004; Mullaney et al., 2005). Detailed, long term injury surveillance studies have yet to be completed however; injuries to the dominant shoulder and elbow are prevalen t and often severe, es pecially in baseball pitchers (Fleisig et al., 1995). Currently, Major League Baseball disabled list reports provide the most thorough description of injury prevalence in baseball pitchers (Conte et al., 2001). Over 11 seasons (19891999), each team, on average, had players miss 640.6 days per season. Pitchers accounted for over half of these missed days. The majority of injuries were to the s houlder (27.8%) and elbow (22.0%). The knee was a distant third at 7.3%. Th ese findings are not uniq ue to professionals; high throwing arm injury rates are s een throughout all levels of play (Hang et al., 2004; Sabick et al., 2004; Olsen et al., 2006). Throwing arm injuries are related to repeated exposure to extreme biomechanics. Throwing arm joint velocities, forces, and tor ques are approximately 25% greater than other 12

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overhead actions, like the football pass (Fleisig et al., 1996), and they are thought to load elbow and shoulder tissues at or near capacity (Fleisig et al., 1995). Als o, the throwing arm is subjected to these loads many times and very often. Starti ng pitchers throw 100+ pitches every 4 days and relief pitchers commonly throw 15+ pitches on consecutive days (M ullaney et al., 2005). Finally, the seasons are long, up to 8 months in the professional league s, with games almost every day. A plethora of throwing arm injuries has been documented. Most injuries are overuse in nature meaning they gradually develop over the c ourse of a season or car eer (Zheng et al., 2004). Pitching overuse injuries develop in one of two ways. First, repe titive loading may weaken or alter a bony or soft tissue to th e point where the pitcher suffers laxity, dysfunction, pain, or a severe tear. Common examples in clude gradual stretching of the anterior passive constraints (Kvitne et al., 1993), humeral epiphyseal plate in juries (Sabick et al., 2004), and the gradual weakening (and perhaps eventual tearing) of the ulnar collateral ligament (Safran et al., 2005) or rotator cuff muscles (Mazou et al., 2006). Second, repetitive loading may lead to throwing arm mal-adaptations. For example, the posterior caps ule may excessively tighten (Burkhart et al., 2003) or the scapular positioning may become alte red in a detrimental way (Myers et al., 2005). These alterations may lead to clini cal problems like shoulder impingement. Baseball pitchers have now been intensel y studied for approximately 30 years. The understanding of the pitching motion and demands on the throwing arm has improved dramatically (Feltner et al., 1986; Matsuo et al., 2006). Ability to diagnose injuries and help injured pitchers has also improved dramatically (Nakagawa et al., 2005; Koh et al., 2006; Song et al., 2006). Interestingly, in juries remain prevalent. 13

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Fortunately, progress is being made in three areas. The first is pitching behavior. The number of pitches thrown, types of pitches throw n, and tendency to throw with pain appear to be relevant to injuries, especial ly in youth (Lyman et al., 2001 ; Olsen et al., 2006). Second, the relevance of pitching mechanics to injuries is being discovered (Wight et al., 2004; Matsuo et al., 2006). Last, researchers are beginning to better understand the mechanical characteristics of the pitching arm, specifically the shoul der. These three gene ral topics all provid e great potential to reduce injuries because they are relevant to injuries and can be controlled by players/coaches or manipulated through interventions. This project will focus on the last factor: better understanding the mechanical characteristics of the throwing shoulder. Shoulder Mobility and Stability Biomechanical studies have revealed the esse ntial requirements of the pitching shoulder. First, the shoulder must be mobile, especially in external rotation. During the arm cocking phase, pitchers externally rota te the shoulder as far as possible to help generate throwing velocity (Feltner et al., 1986). The magnitude of shoulder rotation is crucial to success. High velocity pitchers are able to achieve 175 of shoulder ER (Zheng et al ., 2004). This is approximately 10 more than low velocity pitchers (Mat suo et al., 2001; Murray et al., 2001). The second essential requirement is shoulde r stability. The shoulder must re main stable enough to prevent injuries as it is externally rotated to 175, rapi dly internally rotated to over 7000/s (Dillman et al., 1993), and exposed to a distraction force dur ing the follow through phase that is near or beyond the pitchers body weight (Fleisig et al., 1996). Many have stressed the importance of understa nding the delicate bala nce between shoulder mobility and stability (Wilk et al., 2002; Elle nbecker et al., 2002; Crockett et al., 2002). Developing a better understanding of shoulder m obility and stability is important for three reasons. First, it is thought to influence to how vulnerable to injury the shoulder is. Second, it 14

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may influence how vulnerable to injury the elbow is; shoulder mobility and stability may influence the throwing arm movements that place stress upon and injure the elbow joint (Feltner et al., 1986; Fleisig et al., 1995). Third, there is potential to impr ove or optimize the mobility and stability of the shoulder since st rength (Treiber et al., 1998), pr oprioception (Safran et al., 2001), and flexibility (Kibler et al., 2003) ca n be altered via interventions. Assessing Shoulder Mobility and Stability Ideally, shoulder mobility and stability woul d be assessed during the pitch. But the ability to do this is limited. The only kinetic analysis av ailable is inverse dynami cs and the ability to assess the kinematics of the humeral head has yet to be established. Therefore, the most productive way to study shoulder mobility and stab ility is to examine the shoulder in a controlled clinical setting. Topics relevant to shoulder mobility and stability that have been assessed in this manner include strength (Noffal et al., 2003), mo tor control (Safran et al., 2001), glenohumeral translation (Borsa et al., 2005) and stiffness (Borsa et al., 2006) scapular mobility (Downar et al., 2005) and shoulder ROM (Ellenbecker et al., 2002). The most important, popular, and useful shoulder examination thus far has proven to be the shoulder internal ro tation (IR) and external rotation (ER) ROM examination. This project will focus on improving the shoulder IR/ER examination to better understanding throwing shoulder flexibility, how pitching alters the throwing shoulder, and throwing arm injuries. Specific Aims The relevance of the IR/ER motion was discove red when researchers revealed it to be drastically altered by pitching (Brown et al., 1988; Baltaci et al., 2001). In most pitchers, this motion is shifted back (towards ER) approximate ly 10. Thus, the pitcher gains 10 of ER and loses 10 of IR. This motion shift is thought to be a positive adaptation that allows the pitcher to externally rotate the shoulder to an extreme ROM duri ng the pitch (Crockett et al., 2002; 15

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Baltaci et al., 2004). The IR/ER motions and moti on shift are relevant to throwing arm injuries. Pitchers with limited IR often have throwing arm problems including shoulder impingement and SLAP lesions (Burkhart et al ., 2003; Myers et al., 2006). The loss of IR motion is commonly referred to as glenohumeral internal rotation defecit or GIRD (Myers et al., 2006). GIRD is considered excessive when it is approximately 20 or more. Relationships between the ER motion and injuries are not as well established. However, excessive ER motion, whether it be natural or developed from pitching, may be releva nt to shoulder proble ms including instability (Crockett et al., 2002; Kuhn et al., 2000). The relevance of osseous and soft tissues to the IR/ER motions and motion shifts has been addressed. Osseous tissues have be en studied directly via CT scans (Crockett et al., 2002) and radiographs (Osbahr et al., 2002; Reagan et al., 2002). The amount of twist or retroversion in the proximal humeral physis appears to contri bute to the IR/ER motions. Retroversion is also relevant to the shifted motion. In most pitchers the throwing arm humerus is retroverted towards ER 5 more than the non-throwing arm. But retroversion does not fu lly explain the IR/ER ROMs or the motion shift. Correlations with ER are conflicting among studies and correlations with IR are non-significant or w eak (Osbahr et al., 2002; Reagan et al., 2002). The lack of ability of retroversion to explain the IR/ER motions and motion shift suggests that soft tissues may be important. This idea is not new: over 20 years ag o Pappas et al., (1985) s uggested that the IR/ER motion shift results from the stretching of anterior shoulder soft ti ssues and tightening of posterior shoulder soft tissues. Su rgical interventions have qualit atively verified this hypothesis for injured pitchers; excessive laxity to the ante rior capsule and/or excessive thickening of the posterior capsule and rotator cuff muscles has been observed (Burkha rt et al., 2003; Myers et al., 2006). However, surgical interventions cannot be used to examine the shoulder soft tissues in the 16

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vast majority of pitchers. A non-invasive, measure of the soft tissues looseness or stiffness is needed to help better underst and the IR/ER motion and the mechanisms of the motion shifts. This gap in the literature will be addresse d by examining the IR/ER passive motion in a novel, more extensive manner. A new flexibility measure, called rotational resistance, will be assessed along with the traditional ROM measures. Rotational re sistance is measured as the torque (Nm) required to internally and externally rotate the shoulder to the end ROM. This measure provides information regarding how stiff or loose the shoulder is as it is rotated and is thought to reflect the passive resistance to motion provided by the soft tissues as they stretch. The rotational resistance of the shoulder has been reliably measured for clinical purposes once, but it has never been measured in base ball pitchers (Novot ny et al., 2000). The ultimate goal for this line of research is to use rotational resistance and ROM measures to assess shoulder flexibility and determine its relevance to incidence of throwing arm injuries, injury prevention, injury mechanisms and injury rehabilita tion. In this project, three studies have been designed to help make progress towards th ose goals. The objective of the first study is to examine important relationships among various flexibility measures. A priority will be determining how to best measure shoulder IR/ER passive flexibility for research purposes. The general hypothesis is th at rotational resistance is needed to sufficiently evaluate shoulder flexibility. The objective of the second study is to determine the relevance of rotational resistance to the shifted motion. The general hypothesis is that shoulder rotational resistance is altered by pitching and is related to the magnitude of the motions shifts. The objective of the third study is to determine if incidences of th rowing arm injuries vary among groups of pitchers that have drastically different shoulder flexibili ty. The general hypothesis is that pitchers that have extremely flexible or extremely inflexible shoulders will have higher incidences of 17

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throwing arm injuries than pitchers with modera tely flexible shoulders. After completing these studies, it may be possible to determine 1) the best way to assess the IR/ER motion, 2) if a pitcher has a flexible or inflexible throwing shoulde r, 3) if pitchers with GIRD do in fact have thickened posterior soft tissues, 4) if shoulder soft tissues ar e altered by pitching, and 5) if shoulder rotational resistance infl uences the magnitude of the motion change, 6) if shoulder rotational resistance is related to throwing arm injury incidence. The first general hypothesis will be addressed with two specific aims: Specific Aim 1a was to determine if ROM a nd rotational resistance are both necessary to assess shoulder IR/ER flexibility. Previous shoulder passive IR/ER studies are limited to one flexibility measure: the end ROM. This limited analysis may lead to fa lse conclusions about a pitchers flexibility. For example, it is possibl e for two pitchers to have similar ROM, yet drastically different rotational re sistance. Preliminary shoulder ER pilot data from 26 tennis players revealed multiple instances where player s had similar ROM but a two-fold difference for rotational resistance (Wight et al., 2006). The player with half the ro tational resistance is clearly more flexible. Measuring rotational resistance will help to properly make these distinctions. We hypothesize that rotational resist ance variables and the end ROM will be independent. This finding would suggest that measur es of both ROM and rotational re sistance are needed to make conclusions about shoulder IR or ER flexibility. Specific Aim 1b was to determine if high rotational resistance groups have significantly different ROM compared to low rotational resistance groups. Two basic measures will be used to thoroughly assess shoulder rotationa l resistance. First, is the re sistance onset angle (ROA). This represents the angle where soft tissues begin to stretch. Second, the stiffness will be assessed. This represents how tight or loose the shoulder is. These measures will be used to create a 18

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high rotational resistance group and low rotational resistance group. The low group will have two flexible characteristics: a late ROA and lo w rotational resistance. The high group will have two inflexible characteristics: an early ROA a nd high rotational resistan ce. We hypothesize that the low rotational resistance groups will have significantly greater ROMs compared to the high rotational resistance gro ups. This finding would suggest that the ROA and stiffness should be considered together when analyzing flexibility. The second general hypothesis wi ll be addressed with three sp ecific aims: Specific Aim 2a was to determine if pitching alters the soft tissue of the throwing shoulder. Previous researchers have suggested that pitching attenuates the an terior shoulder soft ti ssues and tightens the posterior shoulder soft tissues (P appas et al., 1985). This hypothe sis will be tested by comparing the stiffness of the throwing shoulder to the stiffness of the non-throwing shoulder. Bilateral differences are assumed to be alterations to th e soft tissues of the pitching shoulder. We hypothesize that the throwing arm IR stiffness will be signific antly greater and the ER stiffness to be significantly less stiff th an the non-throwing shoulder. Th ese findings would suggest that pitching alters the soft tissues of the shoulder. No alterations to stiffness would suggest that humeral retroversion is the primary fact or responsible for the motion shifts. Specific Aim 2b was to determine if the magnitude of the motion shift is related to the magnitude of the stiffness change. The average pitcher has a 10 motion shift for both ER and IR. But the range is quite variable; some pitche rs have virtually no motion shift while others exceed 20. Limited and/or excessive motion shifts are associated with throwing arm injuries (Burkhart et al., 2003; Myer s et al., 2006). Therefore, determin ing the factors that influence the magnitude of the motion shift is crucial. We hypothesize that the motion shift will increase as alterations to stiffness in the throwing shoulde r increases. This finding would suggest that the 19

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motion change is dependent on the ex tent of the attenuation or tight ening of the soft tissues. This test will only be run if bila teral differences in stiffness are found in the previous aim. Specific Aim 2c was to determine if the rota tional resistance of the non-throwing shoulder is related to the magnitude of the motion shift. It is possible that the magnitude of the motion shift is related to the original or pre-altered tightness or looseness of the soft tissue. The rotational resistance of the non-throwing arm will be used as a control to represent the prealtered rotational resistance. We hypothesize that the magnitude of the motion shift will increase with the stiffness of the non-th rowing arm. If significant, th is finding would help to identify individuals that may be at risk of injury. The third general hypothesis will be addresse d with one specific aim: Specific Aim 3 was to determine if incidence of throwing arm injuries are different among rotational resistance groups. Previous studies have revealed associ ations between shoulder ROM and throwing arm injuries (Burkhart et al., 2003; Myers et al., 2006). The general consensus is that limited IR motion and/or excessive ER motion likely make s the throwing arm susceptible to injury (Crockett et al., 2002; Kuhn et al., 2000). An anal ogous hypothesis will be tested with respect to rotational resistance. We hypothesi ze that pitchers will low ER rotational resistance (i.e., extremely flexible) and pitchers will high IR rotational resistance (i.e., extremely inflexible) will have higher incidences of throwing arm injuries th an their peers. This preliminary analysis is considered valuable because it may reveal general injury incidence trends and may help to better identify pitchers at risk of injury. This study is believed to be innovative because it will be the first to 1) thoroughly assess shoulder IR/ER flexibility in pitchers 2) directly test if the flexib ility of soft tissues are altered by pitching, 3) explore the magnitude of the moti on shift, 4) explore whether flexibility is 20

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relevant to the motion shift, and 5) explore the relevance of rational resi stance to incidences of throwing arm injuries. Long term benefits are also expected. This study may stimulate the incorporation of rotational resistance into shoulder IR/ER examinations and help to determine the most parsimonious way to examine the motion. Results from this study may help athletics trainers, orthopedic surgeons, and sports medici ne clinicians better analyze the shoulder IR/ER passive motion to diagnose injuries, asse ss throwing arm adaptations, assess throwing, stretching, and/or exercise inte rventions, and assess rehabilitation outcomes. This study is also expected to stimulate future re search. Researchers may be able to use findings and methods from this study to help better determine the relevance of flexibility to the in cidence of throwing arm injuries and injury mechanisms. 21

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CHAPTER 2 REVIEW OF THE LITERATURE The purpose of this literature review is to demonstrate that measurement of the rotational resistance of the shoulder IR/ER passive motion is needed. Focus will be placed on the general methods used to assess the passive mechanical properties of the throwing shoulder thus far, the general findings from those studies, and the ga ps in the literature. Throughout the review, shoulder anatomy and injuries will be addresse d. A review of shoulder anatomy and example pitching injuries are included as an appendix (Appendix A). Analyzing the Shoulder IR/ER Passive Motion Traditional measurement of the IR/ER moti on is relatively simple. The investigator internally or externally rotates the shoulder to the end ROM and then measures the angle using a plastic or digital goniometer. Novot ny et al., (2000) showed that it is possible to measure the motion more extensively. A custom device wa s used to quantify rotational resistance. Methodological considerations relevant to co llecting ROM and rotationa l resistance will be discussed. Important Methodological Considerations When analyzing the IR/ER motion, three im portant methodological decisions must be made: whether motion will be passive or active, the positioning of the arm, and whether to stabilize the scapula. Passive vs. Active During a passive collection, the participant is in structed to remain totally relaxed and the joint is rotated to the end feel as determined by patient comfort and capsular end feel (Awan et al., 2002). During active measurement, the athlete uses the shoulder external rota tors and/or shoulder internal rotators to activ ely rotate the joint as far as possible. Measurements are then 22

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taken as the athlete maintains the end ROM (Ellenbecker et al., 2002). Both methods are commonly used clinically (Boon et al., 2000). The ma jority of overhead athlete studies have used the passive method (Baltaci et al., 2004). In this study, collecti ons will be passive because rotational resistance cannot be collected actively. Arm position Nearly all IR/ER studies have assessed shoul der motion with the participant lying supine on a training table with the arm in the standard throwing relevant position. This arm position is 90 of shoulder adduction, 90 of elbow flexi on, and neutral shoulder horizontal ab/adduction meaning the upper arm points lateral (Awan et al., 2002; Ellenbecker et al., 2002; Meister et al., 2005). Alterations in adduction have a drastic influence on the ROM. For 19 pitchers, Osbahr et al., (2002) revealed that the ER end ROM at 90 of shoulde r adduction to exceed the 0 adduction position (126.8 vs. 90.1, respectiv ely, p<0.05). The influence of horizontal adduction has not been tested dire ctly. However, Borsa et al., ( 2005) made a slight alteration to the standard position to place the upper arm in the plane of the scapula (approximately 15 anterior to the coronal plane). This adjustment appeared to have minimal effects on the IR and ER end ROMs; Borsas findings were comparable to those of other investig ators (Table 2-2). In this study, the arm will be assessed in the standard throwing relevant position. Scapular stabilization The scapula if often stabilized by manually ap plying an anterior force to the anterior shoulder. This helps to isolat e glenohumeral motion (Boon et al ., 2000; Awan et al., 2002). Boon found scapular stabilization to significantly reduce (p < 0.05) end ROMs in 50 high school athletes. The eROM reduced approximately 9. The IR end ROM was reduced far more, approximately 26. Nearly all researchers have stabilized the scapula when analyzing overhead 23

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athletes. The scapula will be stabilized for this project to isolate gl enohumeral motion and to allow for comparison of results to previous research. Novotnys Approach Novotny successfully evaluated the rotational re sistance of the shoulder. A load cell was used to quantify the torque requi red to passively internally and externally rotate the shoulder. Angular displacement was continually collected using an electromagnetic motion system. A similar approach will be used in this study; however, angular displacement will be monitored with a potentiometer. There are two other differences between Novotnys approach and the approach used in this study. The first is pa rticipant positioning. N ovotny had the participant seated with the arm abducted 45 from the side of the body. Participants in this study will lay supine and have the arm in the previously mentioned throwing relevant position. This will allow for better comparison of results to those in the literature. Second, Novotny ceased shoulder rotation once a pre-set torque wa s achieved (4 Nm). This pre-set torque limited the ROM such that participants were unable to obtain the end ROM. In this st udy, the shoulder will be rotated to the true end ROM (since the end RO M is a variable of interest). Reliability of Traditional Measures Using a goniometer to measure the end ROM is subjective by nature. The investigator must align the device with the participants arm. The investigator must also maintain the alignment of the participants upper arm. Not surprisingly, inter and intra-tester reliability scores are often low and variable. Boon et al., (2000) summarized reliabil ity for 9 shoulder ROM studies. Five of the 9 studies had ICC score below 0.60. This craft appears to be highly dependent on the skill of the investigator. Variability may also be related to the accuracy of the device, which is (Awan et al., 2002), and the ability to line up the devi ce with the forearm. 24

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Using a custom device that secures the arm a nd uses an electrogoniometer to continuously measure the ROM can improve the accuracy and objectivity of measurement. Not surprisingly, custom devices have produced good to exce llent reliability: Novotny had no significant differences between same-day or cross-day measur es and the device that will be used in this project produced inter and in tra-tester ICC values ranging from 0.79.95 for all ROM and rotational resistance measures (Grover et al., 2006). The Shifted Motion Shoulder IR/ER passive motion in baseball pitchers became a hot topic when bilateral differences were discovered (Brown et al ., 1988; Baltaci et al., 2001). Average bilateral differences were calculated for six recent studies that measured pitchers (Table 2-1). The throwing arm had 8.5 more ER and 11.6 less IR and than the non-throwing arm. These findings contrast control groups (Crockett et al., 2002) in which non-throwers have no, or very limited bilateral differences. The increased ER and decreased IR are commonl y referred to as extern al rotation gain, or ERG, and glenohumeral internal rotation defic it, or GIRD (Myers et al., 2006). For most pitchers, the ERG is quite similar to GIRD. Wilk et al., (2002) used th e phrase total motion concept to describe this phenom enon since the total motion of the throwing arm changes little. Other Shoulder Motions Other passive shoulder motions (extension, a bduction, horizontal adduction) have no significant or minimal (1) bilateral differences (Meister et al., 2005; Reagan et al., 2002; Baltaci et al., 2001; Baltaci et al., 2004). This makes the IR/ER motion unique and likely the most relevant to throwing arm injuries. 25

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Table 2-1. Summary of shoulde r IR/ER range of motion stud ies for overhead athletes. Author Year Participants ER dominant ER nondomina nt IR dominant IR nondominant Total ROM dominant Total ROM nondominant Active (A) Passive (P) Borsa 2006 34 professional baseball pitchers 135.5 (9.5) 130.4 (10.7) 59.7 (7.0) 68.2 (8.6) 195.2 (12.1) 198.6 (26.6) P Levine 2006 98 amateur baseball players 109 (12.1) 94 (6.9) 38 (9.5) 54 (12.3) 147 148 P Myers 2006 11 baseball with impingement 125.8 (13.1) 117.5 (16.7) 42.5 (12.1) 62.2 (16.9) 168.3 179.7 P Myers 2006 11 baseball controls 121.1 (8.7) 116.0 (10.3) 51.1 (14.4) 62.2 (13.7) 172.2 178.2 Pe Ruotolo 2006 37 college baseball players 117.6 108.8 23.7 32.6 140.7 141.6 A Borsa 2005 43 professional baseball pitchers 134.8 (10.2) 125.8 (8.7) 68.6 (9.2) 78.3 (10.6) 203.4 (9.7) 204.1 (9.7) P Downer 2005 27 pros (20 were pitchers) 108.9 (9.0) 101.9 (5.9) 56.6 (12.5) 68.6 (12.6) 165.5 (14.4) 170.4 (10.5) P Baltaci 2004 20 professional baseball 126.5 (10.8) 115.9 (10.6) 59.2 (6.9) 70.3 (5.8) 185.7 (12.7) 186.4 (11.1) P Baltaci 2004 20 controls 98.5 (6.8) 97.3 (9.5) 74.4 (9.2) 83.1 (9.1) 172.2 (12.4) 180.1 (9.2) P SchmidtWiethoff 2004 27 professional tennis players 89.1 (13.7) 81.2 (10.2) 43.8 (11.0) 60.8 (7.4) 132.9 (15.0) 142.0 (11.9) P SchmidtWiethoff 2004 20 controls 85.4 (7.6) 84.0 (7.3) 61.6 (8.1) 59.3 (8.3) 146.9 (8.7) 143.3 (7.5) P Sethi 2004 37 pro and college pitchers 110 (14) 104 (14) 68 (16) 82 (11) 178 (23) 186 (15) P Sethi 2004 19 position players 100 (11) 100 (12) 69 (11) 75 (10) 169 (10) 174 (10) P Crockett 2002 25 professional pitchers 128 (9.2) 119 (7.2) 62 (7.4) 71 (9.3) 189 (12.6) 189 (12.7) P Crockett 2002 25 non-throwing controls 113 (14.6) 112 (13.9) 65(8.9) 69 (7.1) 179(17.7) 181(15.3) P Ellenbecker 2002 46 professional pitchers 103.2 (9.1) 94.5 42.4 52.4 145.7 146.9 A Ellenbecker 2002 117 elite junior tennis players 103.7 (10.9) 101.8 45.4 56.3 149.1 158.2 A Osbahr 2002 19 college pitchers 126.8(12. 0) 114.5(9 .1) 79.3(13.3) 91.4(13.6) 206.1 205.9 P Reagan 2002 54 college baseball players 116.3 (11.4) 106.6 (11.2) 43.0 (7.4) 51.2 (7.3) 159.5 (12.4) 157.8 (11.5) P Baltaci 2001 15 college pitchers 131.5 (11.5) 116.6 (11.3) 55.8 (7.1) 69.2 (4.8) 187.3 185.8 P Baltaci 2001 23 position players 122.4 (10.9) 114.6 58.2 (7.1) 68.7 (6.8) 180.6 183.3 P Means for pitchers 124.8 116.3 61.8 72.9 186.4 189.0 Sport Specific Findings Ellenbecker attempted to determine if ther e are IR and ER ROM differences between tennis players and baseball pitchers. The 46 pr ofessional baseball (22.6 2.0 years) pitchers were compared to 117 elite junior tennis players (16.4 1.6 years) Identical methods were used to assess the athletes. Both groups lost appr oximately 10 of IR in the dominant arm. 26

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Interestingly, the baseball pitchers had a signi ficant ER bilateral differe nce (8.7) but the tennis players did not. This may be related to the more extreme biomechanics of the baseball pitch during the arm-cocking phase (Feltner et al., 1986 ; Elliot et al., 2003). Pitchers also show significantly greater bilateral differences than non -pitching baseball player s (Baltaci et al., 2001; Sethi et al., 2004). Age and the Motion Shift Levine examined 298 youth baseball players (age 8 years) with hopes of establishing the onset of the motion shift. Participants were divided into three age groups based on skeletal growth: immature group (n = 100, 8 years) period of maximal growth (n = 100, 13 years), and at or near skeletal maturity (n = 98, 15-28 year s). ER and IR bilateral differences were minimal in the youngest group (4) and then increased significantly with age. By age 13-14 years the ER bilateral difference was 10 and the IR bilateral diffe rences 9. Bilateral differences further increased in the oldest group to 15 in ER and 16 in IR. Meister reported that IR and ER bilateral differences remain relatively constant from 8 years of age. Throughout these 4 years, bilateral differences were significant, but minimal (ER = approximately 3, IR = 2). At 13 years of age, both ER and IR began to reduce dramatically. From age 8 to 16 years, ER re duced in the dominant shoulder and non-dominant shoulder by 20.5 and 23.3, respective ly. IR also reduced significantly from age 8 to 16 years, but the dominant arm showed a more dramatic reduction (17.7) compared to the non-dominant (9.1). These reductions in ER a nd IR resulted in significant tota l range of motion loss of 32.5. Interestingly, the total range of motion was never different in the dominant and non-dominant shoulders. The IR and ER motions appear to be dynamic in children and adolescents. The shifted motion appears to develop as other changes related to physical maturity become established. It remains unclear if these changes result from osseous change, soft tissue, or both. 27

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Biomechanics of the Baseball Pitch The biomechanics of the baseball pitch are thought to be extr eme enough to alter the tissues of the throwing arm. Feltner et al., (1986) presented the first thorough kinematic and kinetic analysis of the baseball pitch. Eight co llege pitchers were analyzed. For each pitcher, 3 maximum effort pitches were captured with 2 LOCAM cameras at 200 frames per second. The following injury relevant biomechanics were reported: The most extreme motion was reported to be shoulder external ro tation. The shoulder was externally rotated over 1 70 to develop high throwing velocity (Figure 2-1). The average time from the instant the stride foot contacted the m ound to ball release was just 283 milliseconds. In addition, arm acceleration (instant of shoulder maximum ER to ball release) was only 32 milliseconds. At the approximate instant of ball release, shoulder internal rotation angular velocity peaked at 6100/s 1700/s. Torques required to externally rotate and acce lerate the arm were high. Peak values were reported to be 110 Nm (horizontal adduction) 70Nm (abduction) and 90 Nm (internal rotation). The highest shoulder load was th e shoulder distraction force (Figure 2-2) attempting to dislodge the humeral head at ball release. It was near, or even beyond the pitchers body weight (860 N). Figure 2-1. Shoulder ER during th e baseball pitch. Repeated exposure to extreme ER during the pitch is thought to increase the shoulder passive ER motion. 28

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Figure 2-2. Follow-through phase of the pitch. S houlder loads are extremel y high at the instant of ball release. The shoulder distraction force is near or beyond the pitchers body weight. The shoulder posterior soft tissues are thought to develop tightness from repeated exposure to the follow-through loads. Posterior tight ness is thought to decrease the shoulder IR passive motion. Similarly extreme pitching biomechanics have b een reported by others (Fleisig et al., 1995; Werner at al., 2001; Wight et al., 2004; Zheng et al., 2004). These biomechanics are thought to be responsible for altering th e tissues of the throwing arm th at cause the IR/ER motion shift (Baltaci et al., 2001; Os bahr et al., 2002). Alterations to the Throwing Arm Strong evidence exists to show that osseous change occurs in the form of humeral retroversion. However, the extent of the c ontribution to the IR/ER shifted motion remains unclear. Alterations to soft tissues have been verified surgically in injured pitchers (Burkhart et al., 2003). However, it remains unclear if soft tiss ue alterations significantly contribute to the shifted motion in asymptomatic pitchers. Changes to soft tissue are not as obvious since they have not been tested directly. Osseous and soft tissue studies will now be discussed. Humeral retroversion Humeral retroversion refers to the amount of axial twist in the bone Three studies have explored retroversion in baseba ll pitchers (Table 2-2). Croc kett completed the most thorough 29

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study: pitchers and a con trol group of non-th rowers were examined. Non-throwers had appro ce Retroversion Retroversion Bilateral 54 college players al pi 1 x-ray Crockett et 25 professional 40 (9.9) 23 (10.4) 17 Multiple CT scans t al., 2002 18 (12.9) 19 (13.5) -1 Multiple CT scans k a l retrove protecdaptatio ively ex otate thr. Retr oversion is thought to occur from repeated exposure to the biomechanics of the cocking phase of the pi tch (Osbahr et al., 2002; Reaga ers, but Reagan found a weak ak ximately 20 of retroversion in each humer us (the bone is retroverted towards ER). Pitchers had a 17 bilateral difference. The throwing arm had 40 of retroversion. The differen between controls and pitchers suggests that retroversion developed from pitching. Table 2-2. Humeral retroversi on in baseball pitchers. Author Participants dominant non-dominant difference Method Reagan et al., 2002 baseball 36.6 (9.8) 26.0 (9.4) 10.6 x-ray Osbahr et 19 college 3 2 ., 2002 tchers 3.2 (11.4) 3.1 (9.1) 0.1 al., 2002 Crockett e pitchers 25 nonthrowing controls Croc ett postulated th t hume ra rsion is a tive a n that allows the pitcher to m ore effect te rnally r e shoulde n et al., 2002). Large forces and torques as sociated with externa lly rotating the shoulder and rapidly internally rotating the shoulder are thought to alter th e proximal physis in a way that leads to excessive retroversion. The humerus is thought to be pa rticulary susceptible to being retroverted during adolescence, be fore bones have fully matured. Retroversion does not fully explain the shif ted IR/ER motion. Both Osbahr and Reagan tested whether the amount of retroversion was related to the shifted motion. For ER, Osbahr found a strong relationship (R = 0.71, p < 0.05) in 19 college pitch er relationship (R = 0.21, p < 0.05) in 25 college pitchers. Relationships with IR were we 30

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and non-significant. The amount of variation expl ained is conflicting for ER and weak for IR This suggests that soft tis sue alterations likely contri bute to the shifted motion. Soft Tissue Theories For years, researchers have theorized that alterati ons to the soft tissues of the shoulder shift. The large follo w-through loads are thought to place heavy loads upon s t e tion test that, in theory, tests for tightness f muscles. Tightness is identified when the dominant shoul ent This contribute to the motion the posterior soft tissues. Over time, the posterior capsule is t hought to develop tightnes that contributes to the loss of internal rotation (Pappas et al., 1985). This has been surgically verified in injured players that suffer from seve re internal rotation loss (Burkhart et al., 2003). Asymptomatic pitchers may suffer similar poste rior tissue tightness, but to a lesser degree. Increases in ER have been attributed to the atte nuation of anterior soft tissues over time (Jobe e al., 1991). Attenuation may occur from the accumu lation of microtrauma associated with th arm cocking phase of pitching (Baltaci et al., 2001). Horizontal Adduction Tightness Tests Tyler et al., (2000) developed a horizontal adduc of the posterior capsule and/or rotator cuf der passive horizontal adduc tion end ROM is significantly fa rther from the treatment table than the non-dominant arm. Downar et al., ( 2005) reported no significan t bilateral difference between the dominant (30.2 cm 4.6 cm) and non-dominant arms (28.0 cm 4.8 cm) in a group of healthy professional baseball players (N = 27, 20 of which were pitchers). Myers similarly reported no bilateral differences in a group of 11 competitive asymptomatic baseball players (dominant = 21.1 cm 6.2 cm, non-dominant = 2 1.9 cm 6.2 cm). However, a significant deficit occurred in a group of 11 baseball player s suffering from pathologi c internal impingem in the throwing shoulder (throwing arm = -4.2 cm 4.4, non-throwing arm = 2.8 cm 4.4). 31

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test suggests these pitchers su ffer from posterior tightness, howe ver, the measure is considered limited because it is subjective by nature and only assesses ROM. Active IR Activ e IR is another theoretical test of posterior shoulder tightness that was recommended by the ghest = s nd Crawford et al., (2006) measured gle nohumeral stiffness which is a reflec t joint y but Amerian Academy of Orthopedic Surgeons and the Shoulder and Elbow Surgeons (Baltaci et al., 2001; Baltaci et al., 2004). For the active IR test, the participant places the posterior surface of the hand on the back and reache s vertically. The goal is to reach the hi vertebral level possible. Active internal rotation is measured as the vertical distance the thumb rests from spinous process T5. Two different groups of college baseball p itchers (N = 38 and N 54) had significant bilate ral differences of 7 cm and 10 cm, respectively (Baltaci et al., 2001; Baltaci et al., 2004). This measur e suggests pitchers have posteri or tightness but the measure i again considered limited because it only assesses ROM. Glenohumeral Stiffness Borsa et al., (2006) a tion of the static structur es resisting humeral head disp lacement from the glenoid cavity. Using a Ligmaster device, a 15-dN force is applied to the proximal humerus with the shoulder a 90 of abduction and 60 of ER. The force disp lacement curve is divided into two distinct regions: the initial slope and the final slope. The final slope was used to model the passive stiffness. The ICCs ranged from poor to excell ent depending on side and direction. No bilateral differences were found. The main effect for direction was significant; anterior joint stiffness was significantly greater than posterior joint stiffne ss (16.4 1.6 N/mm vs. 15.2 3.2 N/mm, respectively). Pitching does not appear to compro mise the joints passive restraining qualit it may alter the rotational resistance. 32

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Glenohumeral Translation Glenohumeral translation of the shoulder is a measure of the mobility of the humeral head. Glenohumeral translation has been measured bilate rally as well (Borsa et al., 2005; Sethi et al., 2004). Borsa again applied a 15-dN anterior or posterior force to the proximal humerus. A portable ultrasound scanner was used to dynamically track the translation of the humeral head in relation to the scapula. No b ilateral differences were found. No significant relationships were found between rotational and translational ROM. There was less than a millimeter of difference between sides for anterior/posterior translation. Sethi measur ed laxity in 56 college and professional baseball players (19 baseball position players, 37 p itchers). Electromagnetic sensors were placed under the thumb of the examiner over the bicipital groove region of the athletes humerus. The investigator applied a manual force to produce anterior an d posterior translation. Five percent (1/19) of the position players had significant bilateral translation difference greater than 3 mm. Fifty nine percent of college pitc hers (10/17) and 60% of professional pitchers (12/20) had significant bila teral differences greater than 3 mm. Correlation revealed a significant moderate positive relationship (r = 0.20) between bilateral ER di fferences and translation in all players. Translational measures do not appear to be strongly related to the IR/ER passive ROM shift in baseball pitchers. Conclusions These studies have demonstrated the impor tance of assessing the passive mechanical properties of the pitching shoulder. They have established the importance of the IR/ER motion and revealed that a thorough assessment, usi ng rotational resistance m easures, is warranted. Finally, these studies have identified appropria te methodological considerations that will guide data collection and analysis in this project. 33

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CHAPTER 3 MATERIALS AND METHODS Participants Thirty elite baseball pitchers participated in the study (age = 22.1 3.3 years; height = 1.89 0.06 m; mass = 93.2 6.6 kg). Thirteen were pitchers from the University of Florida team and 17 were professional minor league pitchers from the Cincinnati Reds. To participate, pitchers had to be at least 18 years of age, active with th eir team at the time of testing, and injury free at the time of testing (currently pi tching at 100% effort). Individuals that ha d throwing arm surgery within the past year were excluded. Equipment Novotny et al., (2000) demonstrat ed that it is possible to re liably analyze the rotational resistance of the shoulder throughout the IR/ER passive motion using a custom device. However, Novotnys device was not specific to overhead athletes: the arm was abducted only 45. Grover et al., (2006) developed a similar device to analyz e overhead athletes. The arm was analyzed in a throwing relevant position with th e shoulder abducted 90 and elbow flexed 90 (Ellenbecker et al., 2002; Borsa et al., 2006; Myers et al., 2006). Inter a nd intra-rater reliabil ity was extensively tested on 22 participants and found to be good to excellent for all IR and ER rotational resistance and ROM measures (ICCs = 0.79.95). This device a nd associated methods were used in the current study. The device is called the rotational resistance device (RR device). The RR device was built to internally and exte rnally rotate the shoulder in an objective, controlled, and safe manner. More specifically, rotational resistance (torque require d to passively rotate the arm) and angular disp lacement are continuously monitored as the shoulder is slowly rotated to the end ROM. A detailed description of the RR device is included (Figure 3-1). 34

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Figure 3-1. RR device designed for measuring overhead athletes. The pitchers laid supine on an athletic training table. The arm rotation assembly was attached to an aluminum pipe (#1) that could be adjusted by inserting a me tal pin into holes that were drilled in 1 cm increments. The bottom of the alum inum pipe was secured to a plywood platform. The arm rotation assembly consisted of a wheel-chair wheel, an arm support (#2), and a wrist mount (#3). A cable (#4) runs around the rim of the wheel. The arm is rotated by slowly pulling on the free end of the cable. The cable goes through a pulley (#5) that is mounted to the top of a 50-pound load cell (SBO-50, Transducer Techniques, Temecula, CA). A potentiomet er (#6) was mounted to the wheel to continuously monitor angular displacement (Clarostat 73JB100). Analog data from the load cell and potentiometer were collect ed using an amplifier (#7) (BioAmp 215 Bridged Amplifier, Biocomunication Electronics, Madison, WI), a laptop (HP Pavilion 7020, Palo Alto, CA), and an 11-b it USB-based data acquisition device (#8) (miniLAB 1008, Measurement Computing, Midd elboro, MA). Data were recorded at a rate of 100 Hz using LabVIEW so ftware version 7.1 (Austin, TX). 35

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For this project, several improvements were made to the RR device and data collection procedure: The participant layed supine on an athletic training table when analyzed, instead of sitting in a reclined chair. This helped to better c ontrol and maintain the or ientation of the torso, provided the opportunity to stab ilize the scapula, and allo wed for better comparison of results to studies in the literature (nearly all relevant studies have examined overhead athletes in the supine position). One rotation complex measured the right arm and a second measured the left arm. This allowed the participant to rema in nearly stationary throughout the data collection. Only one slight position adjustment occu rred. After the first shoulder was examined the participant slid laterally approximately 20 cm to have the second shoulder analyzed. Previously, with only one rotation complex, the participant had to stand up and turn around to have the second shoulder assessed. Minimal position adjust ment is crucial for accurate bilateral comparisons. A new, more optimal 50 lb (222.5 N) load cell (SBO-50, Transducer Techniques, Temecula, CA) replaced the pr eviously used 150 lb (667.5 N) load cell. This provided a higher resolution signal that requires less amplification. Two high quality wheel chair wheels replaced the single bicycle wheel. Th ese new wheels allowed for a better wrist mounts and more optimal potentiometer attach ments. Finally, a new and improved cable and pulley was installed, and ne w potentiometers were used. Arm Position IR/ER measures were again collected with the arm in the following throwing relevant position: 90 of shoulder abduction and 90 of elbow flexion. The lateral edge of the acromion process was lined up with the edge of the traini ng table. The RR device was adjusted such that the upper arm was in a neutral position (parallel with the floor). The center of the wheel on the rotation assembly was lined up with the long axis of the upper arm. Scapular Stabilization The scapula was stabilized (Figure 3-1) by a pplying a manual antero-posterior force to the subjects coracoid pro cess and clavicle (Boon et al., 2000; Awon et al., 2002). This helped to islolate glenohumeral motion. The applied for ce was kept low enough to ensure that the participant felt no discomfort. 36

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Data Collection A schematic of the five step data coll ection process is included (Figure 3-2). Sign informed consent Participant information Age Height and weight Handedness Years played Injury questionnaire Contact information Familiarity session Warm-up, light stretching Fit to RR device Successive stretches for each direction 1 practice repetition to end ROM Figure 3-2. Schematic of data collection. Custom Device Collection One of the following four orders were used randomly. Left ER Left IR Right ER Right IR Left IR Left ER Right IR Right ER Right ER Right IR Left ER Left IR Right IR Right ER Le ft IR Left ER Collect entire left side then entire right side (or vice versa). Collect ER before IR for both arms (or vice versa). Collect 3 consecutive repetitions for each combination. Prior to the data collection, each participant signed an inform ed consent that was approved by the University of Florida Institutional Review Board. An brief throwing arm injury questionnaire was then filled out (Appendix D) Height and weight we re recorded by one 37

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investigator. Age, handedness, years played, and contact information were recorded on a data collection sheet. Another inves tigator, who performed the shoulder analysis data collections, remained blind to the handedness of the participant until after the collection. Each pitcher participated in a brief familiari zation period just prior to the da ta collection. The purpose was to familiarize the participant with the RR device, in structions, protocol, and their end ROMs (for both arms, IR and ER). For a brief warm-up, part icipants actively intern ally and externally rotated each shoulder five consecutiv e repetitions, or as much as necessary, to feel warmed-up. The end ROM test was described to the participant. He was told that: 1) this examination is similar to a sit-and-reach test, 2) the end ROM should be slightly uncomfortable but not painful, and 3) the end ROM should be able to be repeated three consecutive times. Both arms were appropriately fit in the device according to the previous ly described guidelines. Two successive stretches were performed on each arm, for both IR and ER. For the first stretch, the participant was instructed to actively rotate the arm until a light stretch was felt. The participant then completely re laxed the shoulder and the inves tigator held the stretch for 3 seconds. The arm was then slowly returned to the neutral position (forearm pointing anterior to the chest) by the inves tigator. The participant wa s instructed to keep the shoulder completely relaxed (passive) for the second stretch. Th e second stretch was moderately farther (approximately 5 beyond the first stretch) an d again held for 3 seconds before being returned to the neutral position. Next, the inves tigator slowly rotated the participants shoulder to the end ROM. Rotation ceased when a firm e ndpoint was felt by the inves tigator (Borsa et al., 2006) or when the subject said stop, whichever came first. The arm was then returned to the neutral position by the investigator. 38

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RR Device Collection For each arm, and each direction (IR and ER), three consecutive repetitions were collected to the end ROM. To prevent any unwanted torso movement, IR and ER were collected consecutively for each arm. The order of IR and ER was randomized for the first arm. The second arm followed the same order as the first arm (for optimal bilateral comparison). The arm was rotated very slowly. Pilot data revealed the average angular velocity to be approximately 2 /sec for 27 previous participan ts. Rotation was kept this slow to eliminate any possible confounding effects associated with rotating the shoulder quickly. Data Reduction Reduce To Best-Fit Line Custom programs, written in LabVIEW softwa re, were used to reduce the displacement and force data from the potentiometer and load ce ll, respectively. Force was converted to torque by multiplying by the moment arm of the rotation co mplex (the distance from the center of the wheel to the wrist support was 0.26 m). Since the arm was rotated manually, the velocity of the rotation was slightly variable. To correct for a ny minor differences in velocity, all ROM values (and their associated torque) were averaged in 1/ 2 degree increments. The average torque data was then graphed against angular displacement. Qualitative analysis revealed the torque to be relatively stable and below 5 Nm in the laxity zone (Figure 3-3). The to rque sharply increased and beca me linear once approximately 5 Nm of torque was achieved. This sharp increas e occurred approximately 25 before the end ROM. The first step to modeling the data was fitting each repetition with a best-fit line from the angle where 7 Nm of torque was achieved to the end ROM. R values for each best-fit line were then checked. If R was lower than 0.95, the data was refit with be st-fit lines starting at 5 Nm and 6 Nm. The best-fit line with the highest R value was then identified and used to model the data. 39

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Seven Nm was used for 81% of th e repetitions. The R for the best -fit lines were high. For ER, the R values were 0.93 for all repetitions. For IR, the R values were lower for 4 repetitions (0.83.87) but very high ( 0.92) for the remaining majority of the repetitions. Figure 3-3. Example torque-displacement data fo r an ER repetition. These data were collected with the RR device and reduced using a custom program written in LabVIEW software. The experimental data and best-f it modeled data (green) are shown for one repetition of shoulder ER. Velocity is controll ed for by averaging data into 1/2 slots.. Passive rotational stiffness is defined as th e slope of the best-fit line and the ROA is the angle where 5 Nm of torque is fi rst achieved. The end ROM and end torque (torque at the end ROM) were also calculated from the best-fit line. Variables of Interest For both arms and both directions (IR and ER), five flexibility vari ables were calculated. Bilateral differences were also calculated for eac h variable as the differe nce between the pitching arm and non-pitching arm (Osbahr et al., 2002).. The ROA is defined as the angle on the best fit line where 5 Nm of torque is achieved. The ROA is a measure of the angle where th e shoulder soft tissues begin to provide substantial resistance to motion due to stretching. Stiffness is defined as the slope of the best-fit line. Stiffne ss is a measure of how tight or loose the shoulder is when it is passively rotated. The end ROM is defined as the farthest degree achieved on the best-fit line. 40

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The end torque is defined as the torque at the end ROM. It is calculated from the best-fit line. The resistance zone is the total displacemen t from the ROA to the end ROM. It is calculated by subtracting the ROA from the end ROM. Repeated measures ANOVA were used to de termine if subjects became more flexible across repetitions 1, 2, and 3. No differences am ong the repetitions were expected because all pitchers participated in the warm-up session. Ho wever, significant main effects were detected and follow-up tests (dependent T-tests with B onferroni adjustments) revealed significant differences between the first and second repetitions for the ROA and stiffness suggesting that the shoulder did become more flexible (Table 3-1) Since the mechanical properties were altered between repetitions 1 and 2, data from the first re petition were not used; da ta from repetitions 2 and 3 were averaged for all flexibility variables. Table 3-1. Means and SD of flexibility variables for repetitions 1, 2, and 3* ROA () Stiffness (Nm/) End ROM () End Torque (Nm) 1 2 3 1 2 3 1 2 3 1 2 3 D_ER 122.2 (11.6) 126.4 (13.2) 127.5 (12.5) 0.49 (0.10) 0.57 (0.12) 0.57 (0.11) 147.8 (12.2) 149.4 (12.3) 150.4 (11.8) 17.4 (3.7) 17.9 (3.2) 17.9 (3.1) 1-2 1-3 2-1 3-1 1-2 1-3 2-1 3-1 1-2 1-3 2-1 2-3 3-1 3-2 D_IR 60.2 (7.7) 62.9 (8.1) 63.7 (8.9) 0.46 (0.12) 0.53 (0.14) 0.54 (0.17) 80.5 (10.9) 81.8 (11.4) 83.7 (12.0) 14.5 (4.2) 15.1 (4.1) 15.8 (4.5) 1-2 1-3 2-1 3-1 1-2 1-3 2-1 3-1 1-2 1-3 2-1 2-3 3-1 3-2 1-2 1-3 2-1 2-3 3-1 3-2 *Signficant differences are show in the boxes below the means and standard deviations. For example, 1-2 means a significant difference between repetitions 1 and 2. For both ER and IR, the mechanical properties of the shoulder (ROA and sti ffness) were not differe nt between reps 2 and 3. This suggests that the subj ects were successfully warmed-up by rep 2. Interestingly, ROM increased each consecutive repetit ion despite no change in mechanical properties between reps 2 and 3. Definition of Rotational Resistance Groups The two rotational resistance variables (ROA and rotational stiffness) were used to categorize pitchers as having high, low, or moderate rotational resi stance (Figure 3-4). This was performed for both ER and IR. The average ROA and average rotational stiffness were used to define groups. The low rotationa l resistance group had two flexib le characteristics: an above 41

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average ROA and below average rotational stiffn ess. The high rotational resistance group had two inflexible characteristics: a below average ROA and above average rotational stiffness. The moderate group had one flexible ch aracteristic and one inflexible characteristic: a below average ROA and below average rotational stiffness or an above average ROA and above average rotational stiffness. Dominant Arm Internal Rotation0.2 0.3 0.4 0.5 0.6 0.7 0.8 4050607080 ROA ()Stiffness (Nm/) High RR Low RR Moderate RR Moderate RR Figure 3-4. Defining groups based on rotational resistance variable s. The resistance onset angle (ROA) and rotational stiffness were used to categorize pitchers as into low, moderate, and high rotational resistance groups. The vertical and horizontal lines are the average ROA and rotational stiffness, respectively. Angle Conventions Standard shoulder IR/ER angle conventions we re used (Ellenbecker et al., 2002; Borsa et al., 2006; Myers et al., 2006). Zero degrees means the forearm is poi nted anterior to the pitchers chest. Ninety degrees of ER means the forearm is pointed superior, towards the head. Ninety degrees of IR means the forearm is point ed inferior, towards the feet. Data Analysis General Analysis For most statistical tests, a conve ntional level of significance was used ( =0.05). When multiple T-tests were performed within a specific aim, a Bonferroni correction was used to 42

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reduce the chance of committing a type I error. Descriptive statistics (mean and standard deviation) were calculated fo r all variables of interest. Analysis of Specific Aims Specific Aim 1a was to determine if ROM a nd rotational resistance are both necessary to assess shoulder IR/ER flexibility. Pearson correlations were used to determine if significant relationships exist among the following three flexibility variables: ROA, rotational stiffness, and end ROM. These tests were performed for both ER and IR of the throwing arm. Table 3-2. Statistical analyses for aim 1a. Test Arm Direction Variables Pearson Throwing ER ROA and stiffness Pearson Throwing IR ROA and stiffness Pearson Throwing ER ROA and ROM Pearson Throwing IR ROA and ROM Pearson Throwing ER stiffness and ROM Pearson Throwing IR stiffness and ROM Specific Aim 1b was to determine if high rotational resistance groups have significantly different ROM compared to low rotational resistance groups. Independent T-tests were used to determine if the high and low rotational resistan ce groups have significan tly different end ROMs and/or resistance zones ( =0.05/2). These tests were completed for the throwing shoulder for both directions (IR and ER). 43

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Table 3-3. Statistical analyses for aim 1b. Test Arm Direction Variables Independent T-test Throwing ER ROM Independent T-test Throwing IR ROM Independent T-test Throwing ER RZ Independent T-test Throwing IR RZ Specific Aim 2a was to determine if pitching alte rs the soft tissue of the throwing shoulder. For both ER and IR, independent T-tests were perf ormed to determine if the rotational resistance variables (ROA and stiffness) of the throwing shoulder are signi ficantly different from the nonthrowing shoulder ( =0.05/2). Table 3-4. Statistical analyses for aim 2a. Test Arm Direction Variables Independent T-test Bilateral comparison ER stiffness Independent T-test Bila teral comparison ER ROA Independent T-test Bilateral comparison IR stiffness Independent T-test Bila teral comparison IR ROA Specific Aim 2b was to determine if the magnitude of the motion shift is related to the magnitude of the stiffness change. For both ER and IR, Pearson correla tions were used to determine if the ROM bilateral differences were significantly predicted by the rotational stiffness and ROA bilateral differences. Table 3-5. Statistical analyses for aim 2b. Test Arm Direction Variables Pearson Bilateral difference ER Stiffness bilateral difference and ROM bilateral difference Pearson Bilateral difference ER ROA bilateral difference and ROM bilateral difference Pearson Bilateral difference IR Stiffness bilateral difference and ROM bilateral difference Pearson Bilateral difference IR ROA bilateral difference and ROM bilateral difference 44

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Specific Aim 2c was to determine if the rota tional resistance of the non-throwing shoulder is related to the magnitude of the motion shift. For both ER and IR, Pearson correlations were used to determine if the ROA and/or rotationa l stiffness of the non-throwing arm significantly predicts the motion shift (bilateral ROM differe nce) of the throwing arm. Independent T-tests were also used to determine if the low rotational resistance groups and high rotational resistance groups (based on the non-throwing arm) have significantly different motion shifts ( =0.05/2). Table 3-6. Statistical analyses for aim 2c. Test Arm Direction Variables Pearson Both ER Non-throwing arm stiffness and throwing arm ROM bilateral difference Pearson Both ER Non-throwing arm ROA and throwing arm ROM bilateral difference Pearson Both IR Non-throwing arm stiffness and throwing arm ROM bilateral difference Pearson Both IR Non-throwing arm ROA and throwing arm ROM bilateral difference Independent T-test Throwing ER ROM bilateral difference Independent T-test Throwing IR ROM bilateral difference Specific Aim 3 was to determine if incidences of throwing arm injuries are different among rotational resistance gro ups. Incidence of injury was compar ed among the previously described groups (the low, moderate, and high rotational resistance pitchers from aim 1b). Chi-square analysis was used to determine if significant di fferences in frequencies throwing arm injuries occurred. This test was performed for both IR and ER ( =0.05/2). A questionnaire was developed and used to determine incidences of throwing arm injuries over the past year (Appendix D). 45

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Table 3-7. Chi-square contingency table for aim 3 Low RR Moderate RR High RR Injured Healthy 46

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CHAPTER 4 RESULTS Specific Aim 1a To determine if end ROM and rotational st iffness are both needed to assess shoulder IR/ER passive flexibility. For both ER and IR, Pearson correlation analysis revealed no significant relationship between stiffness and end ROM in the throwing shoulder (Figure 4-1). The ROA and end ROM were positively correlated for both ER and IR (Figure 4-2). For ER, the ROA occurred 23.0 5.9 before the end ROM. For IR, the ROA occurred 19.4 5.6 before the end ROM. Dominant Arm External Rotation110 120 130 140 150 160 170 180 0.2 0.4 0.6 0.8 Stiffness (Nm/)End ROM () Dominant Arm Internal Rotation50 60 70 80 90 100 110 0.2 0.4 0.6 0.8 Stiffness (Nm/)End ROM () r = 0.11, R=0.01, p=0.55 r = 0.15, R=0.02, p=0.42 Figure 4-1. Stiffness versus end ROM for the th rowing shoulder. As hypothesized, stiffness and end ROM were not related for both ER and IR. Dominant Arm External Rotation110 120 130 140 150 160 170 180 90 110 130 150 ROA ()End ROM () Dominant Arm Internal Rotation50 60 70 80 90 100 110 4050607080 ROA ()End ROM () r = 0.89, R=0.79, p<0.001* r = 0.90, R=0.80, p<0.001* Figure 4-2. ROA versus end ROM for ER and IR of the throwing shoulder. 47

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Specific Aim 1b To determine if high rotational resistance gr oups have a significan tly different end ROM compared to low rotational resistance groups. As expected, comparable numbers of pitchers were in the high and low rotational resistance groups (Figure 4-3). For IR, 5 pitchers had high rotational resistance (ROA = 54.9 4.7; stiffness = 0.68 0.11 Nm/) and 7 pitchers had low rotational resistance (ROA = 70.5 3.2; stiffness = 0.43 0.07 Nm/). For ER, 8 pitchers had high rotational resistance (ROA = 116.0 10.1; s tiffness = 0.67 0.05 Nm/) and 7 pitchers had low rotational resistance (ROA = 138.8 8.8; stiffness = 0.50 0.03 Nm/). sistance (RR) groups for ER and IR. Vertical ean ROA and horizontal lin es are drawn at the mean stiffness. High ers have a below average ROA and above average stiffness. Low RR pitchers have an above average ROA and below average stiffness. As hypothesized, the high rotational resistan ce groups had significantly limited ROM compared to the low rotational resistance groups for both IR and ER (Table 4-1). The difference nce between end ROM However, t (p=0. r = 0.15, R=0.01, p=0.61 r = 0.09, R=0.02, p=0.42 Figure 4-3. Formation of high and low rotational re lines are at the m RR pitch was approximately 20 for both IR and ER. The resistance zones (differe and ROA) were not significantly different betw een the high and low rotational resistance groups. he 5 difference between the low and high IR groups approached significance 06). Dominant Arm Internal Rotation0.2 0.3 0.4 0.5 0.6 0.7 0.8 4050607080 ROA ()Stiffness (Nm/) Dominant Arm External Rotation0.2 0.3 0.4 0.5 0.6 0.7 0.8 90 110 130 150 ROA ()Stiffness (Nm/) High RR Hi g hR R Low RR Low R R 48

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Table 4-1. ROM and resistance zones for the high and low rotational resistance groups. group group p-value IR end ROM 73.2 (4.1) 93.8 (7.6) p<0.001* ER end ROM 137.3 (10.5) 161.1 (10.6) p=0.001* IR resistance zone 18.3 (0 .9) 23.3 (5.0) p=0.06 High rotational resistance Low rotational resistance ER resistance zone 21.3 (4 .4) 22.3 (4.4) p=0.66 Specific Aim 2a To determine if pitching alters the soft ti ssues of the throwing shoulder. The dominant ble 4-2). T did not suppinal hypothesis; the dominant shoulder e lesthe non-domi er. For IR, thnant shoulder was significantly stiffer (approxima tely 39%) than the non-dominant shoulder, as expected. The domin d to ). Pitching shoulder Non-pitching shoulder p-value shoulder hd significan an the minant a tly greater ER stiffne ss (approximately 20%) th non-do shoulder (Ta his finding ort the orig was expected to b s stiff than nan t should e domi ant shoulder had a significan tly later ROA than the non-dom inant shoulder (approximately 10) for ER. For IR, the ROA bilateral diffe rence approached significance (p=0.03); the dominant arm had an earlier ROA than the non-dominant shoulder (approximately 5). Significant bilateral differences were revealed for the ER end ROM: the dominant shoulder had approximately 12 more motion. The dominant s houlder had a limited IR end ROM compare the non-dominant, but the difference was not si gnificant. The domina nt shoulder required significantly more torque (appr oximately 22%) to be externa lly rotated to end ROM. The dominant shoulder also had a si gnificantly larger ER resistan ce zone (approximately 20% Table 4-2. Bilateral comparison of flexibility variables for ER and IR. ER ROA 127.4 (13.0) 118.1 (10.7) p<0.01* ER stiffness 0.57 Nm/ (0.11 Nm/) 0.48 Nm/ (0.09 Nm/) p<0.01* ER ROM 150.6 (12.1) 137.9 (10.8) p<0.001* ER resistance zone 23.1 (6.0) 19.2 (17.2) p<0.025* ER torque at end ROM 17.9 Nm (3.1 Nm) 14.7 Nm (3.0 Nm) p<0.01* IR ROA 62.7 (8.3) 67.9 (9.7) p=0.03 IR stiffness 0.54 Nm/ (0.16 Nm/) 0.39 Nm/ (0.07 Nm/) p<0.001* IR ROM 81.9 (11.3) 85.1 (14.0) p=0.34 IR resistance zone 19.2 (5 .3) 17.2 (8.2) p=0.27 IR torque at end ROM 15.2, 4.3 11.8, 3.7 p<0.001* 49

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Specif ine if of the mo lated to thede of the at rences e IR a nd ER motion shifts as ized (Figure 4er, bilateral ROA differences signif icantly predicted the agure 4-5). Pear slation analysis rtrong positive correlations between the motion shifts a bilateral ROA differences. ic Aim 2b To determ the magnitude tion shift is re magnitu stiffness change. Bil eral stiffnes s diffe did not pre dict th hypothes -4). Howev m otion shifts for ER nd IR (Fi on corre evealed s nd thei r respective Dominant Arm External Rotation-5 0 5 10 15 20 25Moon shift () -10 30 -0.2 0 0.2 0.4 Stiffness bilateral difference (Nm/)ti Dominant Arm Internal Rotation-30 -20 -10 -40 0 40 -0.200.20.40.6 Stiffness bilateral difference (Nm/)ti 10 20 30Moon shift () r = 0.34, R=0.11, p=0.07 r = 0.14, R=0.02, p=0.46 Figure 4-4. Bilateral stiffness difference versus the motion shift for the dominant shoulder. For both ER and IR, the motion shift is not predicte d by the bilateral stiffness difference. Dominant Arm External Rotation-10 -5 0 5Motio 10 25 30 -30 -10 10 30 ROA bilateral difference ()n s) 15 20hift ( Dominant Arm Internal Rotation-40 -30 -20 -10Motio 0 30 40 -30 -10 10 30 ROA bilateral difference ()n) 10 20 shift ( r = 0.85, R=0.72, p<0.001* r = 0.89, R=0.79, p<0.001* Figure 4-5. Dominant shoulder R OA bilateral differences versus the motion shift. Pearson correlation analysis revealed strong pos itive correlations for ER and IR. 50

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Specific Aim 2c To determine if the rotational resistance of the non-throwing shoulder is related to the magnitude of the motion shift. Non-dominant sh oulder rotational resistance variables did not predict the motion shift for ER (Figure 4-6). However, for IR, the non-dominant ROA was significantly negatively correlated to the motion shift (Figure 4-7) Non-dominant IR stiffness was not related to the motion shift. Dom inant Arm External Rotation -10 10 30 40 Non-throwing stiffness (Nm/)tion shift () 0 20 0.3 0.4 0.5 0.6Mo Dominant Arm External Rotation -10 40 Non-throwing ROA ()tio 0 10 20 90 110 130 150Mon shi 30ft () r = 0.16, R=0.02, p=0.40 r = 0.24, R=0.06, p=0.18 Figure 4-6. Non-dominant ER rotatio nal resistance measures vers us the ER motion shift. ROA and stiffness did not predict the motion shift. Dominant Arm Internal Rotation -40 0.6 -30 -20 -10 0 10 20 30 40Motion shift () 0.20.30.40.5 Non-throwing stiffness (Nm/) Dominant Arm Internal Rotation -40 405060 -30 -20 -10 0 10 20 30 40 708090Motion shift () Non-throwing ROA () r = 0.25, R=0.06, p=0.19 r = 0.65, R=0.41, p<0.001* igure 4-7. Non-dominant IR rotatio nal resistance measures versus the IR motion shift. Stiffness did not predict the motion shift but the ROA was a significant moderate predictor. F 51

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Low and high rotational resistance groups we re formed for the non-dominant arm (Figure 4-8). For IR, 6 pitchers had high rotational resistance (ROA= 57.2 8.4; stiffness = 0.55 0.08 Nm/) and 6 pitchers had low rotational resistance (ROA= 75.3 4.3; stiffness = 0.34 0.03 Nm/). For ER, 8 pitchers had high rotati onal resistance (ROA=106.5 6.5; stiffness = 0.55 0.08 Nm/) and 8 pitchers had low rotationa l resistance (ROA=127.1 8.2; stiffness = 0.40 Figure 4-8. High and low rotati onal resistance groups for the non-dominant ER and IR. For both IR and ER, the high rotational resi stance groups were hypothesized to have significantly greater motion shifts than the low rotational resistance groups. However, no significant differences were revealed (Table 4-3). Table 4-3. Mean motion shifts for non-domin ant shoulder rotational resistance groups. High rotational resistance group Low rotational resistance group p-value ER motion shift 12.8 (14.3) 8.1 (7.6) p=0.43 IR motion shift 0.9 (13.2) -12.3(14.2) p=0.13 Specific Aim 3 To determine if incidence of throwing arm injuries are different among rotational resistance groups. Throwing arm injuries were prev alent in this group of e lite pitchers. Fourteen 0.05 Nm/). Non-dominant Arm Internal Rotation0.2 0.35 ROA ()ffnm 0.25 0.3 0.4 0.45 0.5 0.55 0.6 40 60 80 100Stiess (N/) Non-dominant Arm External Rotation0.2 0.4 0.6 0. 0. ROA ()nm/) 0.3 0.5 7 8 90 110 130 150Stiffess (N Hi g h R R Low R R Hi g hR R Low R R 52

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of the 30 pitchers had a throwing arm injury that made them unable to pitch for at least one week of practice or games over the past year. Six (43%) were elbow injuries and 8 (57%) were shoulder injuries. The injured p itchers missed an average of 1 0.5 16.7 weeks over the previous year. Ten of the 14 (71%) injured pitchers visite d a physician for their in jury. A summary of the self-reported injuries are incl uded (Table 4-4). The injured p itchers were dispersed among the w, moderate, and high rotationa l resistance groups for both ER (Figure 4-10) and IR (Figure 4g the vertical line is drawn at the mean ROA a nd a horizontal line is drawn at the mean high rotational resistance groups for ER. lo 11). Chi-square analysis revealed no significan t differences in incidence of injury amon groups for both ER (p=0.90) and IR (p=0.41). Dominant Arm External Rotation0.7) 0.2 0.5 0.8 90 110130150ess/ 0.3Sti 0.4ffn 0.6 (Nm Healthy Injured shoulde r Injure Figure 4-9. Prevalence of shoulder and elbow injuries with respec t to ER passive flexibility. A stiffness. Shoulder and elbow injuries we re dispersed among the low, moderate, and ROA () d elbow High RR Low RR 53

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Figure 4-10. Prevalence of shoulder and elbow injuries with respect to IR passive flexibility. A vertical line is drawn at the mean ROA a nd a horizontal line is drawn at the mean stiffness. Shoulder and elbow injuries we re dispersed among the low, moderate, and high rotational resistance groups. Table 4-4. Summary of self-reported throwing arm injuries. Elbow (E) or Was a physician College (C) or S S S 10 days P Subluxation which caused bicep tendonitis No (worked with athletic trainers) 1 month P P C C C hs C C hs P P P Dominant Arm Internal Rotation0.8 0.3 0.4 0.5 0.6 0.7 4050607080 ROA ()Stiffness (Nm/) Healthy Shoulder (S) Self-reported injury seen? Time missed Professional (P) S Lateral shoulder pain No 2 weeks C Posterior shoulder tightness Yes 3 weeks C Shoulder bursitis Yes 10 days P Partial tear of supraspinatus Yes S S Proximal tricep tendon pain Yes 1 month E Distal bicep tendon pain Yes 1 week E UCL torn 2 years ago Yes 2 weeks E UCL partially torn 2 years ago Yes 6 months E Recently recovered from UCL that was torn 2 years ago Yes 11mont E Medial elbow pain No 2 weeks E Recently recovered from a stitch put in UCL (1 year ago) Yes 11mont E Tore UCL 2 years ago Yes 1 month E Medial elbow pain No 1 week Injured shoulder Injured elbow Hi g h R R Low R R 54

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CHA PTER 5 D This dis ourions First, this sub-population of pitchers is dressed. Se rhlighted to portant general findings. resistance and injury ra tes in this group of chers. Third s ary of the evance of t ded by shar general conclusions, practical applications, and ture research recommendations. When appropria te, relations between results from this study and those in the literature are di scussed. However, the ability to do so is limited since this is the first analysis of shoulder rotationa l resistance in overhead athletes. Therefore, the majority of the discussion is focused on the interpretation and m eaning of the results and future research. Description of Pitchers This first analysis of ro tational resistance was perfor med on a relatively homogenous group of pitchers. All pitchers we re elite (University of Florid a or professional minor league pitchers) and the majority were young (22.1 3.3 years), tall ( 1.89 0.06 m) and had large body mass (93.2 6.6 kg). Methods in this study were designed to be sim ilar to those used in studies that analyzed similar groups of elite pitchers (Borsa et al., 2005, Borsa et al., 2006, and Crockett et al., 2002). During analysis, the pitchers laid supine on an athl etic training table, the scapula was stabilized, and the elbow remained flexed at 90. Interest ingly, mean ER and IR ROM values in this study are 5-15 greater than those prev iously reported for similar groups of pitchers. Two factors may have contributed to this discre pancy. First, ROM values are hi ghly dependent on the analyzer(s) and/or the group of pitchers so variation can be expected (Table 2-2 for a review). Second, when assessing the motion manually, it may be difficult fo r a single analyst, or uncomfortable for the ISCUSSION cussion is composed of f sect ad cond, descriptive sta tistics a e hig rev eal im Focus is placed upon the variability of rotational pit the specific research aim are addressed individually. Fourth, a summ rel his study is provi ing fu 55

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participant, to hold the shoulder at the end easures are being taken. In this study the shoulder did not have to be held at the end ROM; the shoulder was rotated to the end ROM and then immediately taken back to the neutral position. Future studies co uld explore this issue by having the same analyst assess shoulders manually and with a custom device. This data set is considered to be a good re presentation of elite p itchers since the ROM values are relatively close to those reported in the previously mentioned studies. Also, the ER and IR bilateral differences in this study were comparable to those of Borsa and Crockett: the dominant shoulder had greater ER (13) and lim ited IR (4) compared to the non-dominant arm. Important General Findings One analysis of shoulder IR and ER stiffne ss was completed seven years ago (Novotny et al., 2000) on a healthy, non-throwing populat ion (N=10). Some methods used by Novotny drastically differed from those used in this study. For example, Novotny ceased shoulder rotation at 5 Nm of torque, therefore, only a fraction of the total shoulder RO M was analyzed (139.4 40.5). In the current study, the entire shoulder ROM was analyzed; torque was applied as necessary to achieve the end ROM for both IR and ER. We found the true total ROM to be 232.5 which was nearly 100 greater than th e total ROM reported by Novotny. Rotating the shoulder to the end ROM required over three times as much torque for ER (17.9 Nm) and IR (15.2 Nm). Pitchers in this study had far greater shoulde r stiffness than the non-throwers studied by Novotny. For ER, the stiffness was approximately 11 times greater (0.05 Nm/ vs. 0.57 Nm/) and for IR the stiffness was approximately 3 times greater (0.17 Nm/ vs. 0.54 Nm/). These large differences may be related to the arm positions analyzed. Novotny assessed the shoulder with the arm close to the torso (shoulder abducted 45) while we assessed the shoulder with the arm in a throwing-relevant position (shoulder ab ducted 90). It is possible that in the 90 RO M while m 56

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abducted position the shoulder soft tissues are stretched more than the 45 abducted. This discrepancy may help to explain the stiffness differences between the studies. Future studies should compare shoulder stiffness at various shou lder position to clarif y. Methods used to calculate stiffness also varied between the two studies. Novotny an alyzed shoulder stiffness from the an We may also contribute to the differe compar his oung his t. ded that passive mechanisms ma y contribute substantiall y to the hip flexor momen 20 ve ss, the gle where 1 Nm of torque was applied to the angle where 5 Nm of torque was applied. analyzed shoulder stiffness from the angle where 5 Nm of torque was ap plied to the end ROM Presumably, Novotny analyzed the shoulder as th e soft tissues began to stretch while we analyzed the shoulder as the so ft tissues approached their ma ximum stretch. This discrepancy nt stiffness values between the studies. Future studies shoulder e throwers and non-throwers at various shoulder positions to be tter understand the unique characteristics of the throwing shoulder. Magnitude of Rotational Resistance A potential contribution of this line of research is determining the rele vance of passive soft tissue stretching to joint moments during various activities. Silder et al., (2007) addressed t issue for the hip. The hip joint was passively extended to the end ROM (15) in 20 healthy y adults. The torque generated by the stretching of hip soft tissues was approximately 20 Nm. T passive torque was approximately 50% of the hip flexor moment reported at toe-off during gai Silder conclu t seen during normal gait. The torque required to passively externally rotate the dominant shoulder to the end ROM was high (17 Nm) and relatively similar to the pa ssive hip flexor moment reported by Silder ( Nm). It seems reasonable to conclude that pitche rs likely overcome more than 17 Nm of passi torque when externally rotating the shoulder during the pitch because the pitching end ROM (180) exceeds the passive end ROM by approxima tely 50 (Zheng et al., 2004). Regardle 57

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magnitude of the passive external rotation torque reported in this study suggests that extern rotating shoulder during the pitch is challenging a nd it may help to explain why pitchers rotat the torso at such high velocities during the armcocking phase of the p itch (Matsuo et al., 20 Interestingly, the passive ER shoulder torque in this study is approximately 33% of the maximum internal rotation torque reported for th e arm cocking phase of the pitch (Zheng et al., 2004). This finding suggests that shoulder passiv e mechanisms may greatly contribute to the shoulder moments generated during the pitch and therefore may be relevant to throwing a injuries and performance. Future studies should assess whether the shoulder ER passive properties influence pitching kine matics and kinetics used to externally rotate the shoulder during the pitch. Future studies should also attempt to determine if shoulder passive ER properties are related to pitching performance. ally e 01). rm ternally rotate the shoulde r in this study was also high (appr re istance Among Subjects The torque required to passively in oximately 14 Nm). Interestingly, during the pitc h, shoulder IR is ceased at 0 (Zheng et al., 2004) which is well short of the passive end ROM ( 81). The IR rotational resistance is therefo not likely directly releva nt to the IR motion during the pitc h. Instead, it is likely indirectly relevant to other shoulder motions during the follow-through such as di straction, adduction, and horizontal adduction. The relevance of IR rotational resistance to kinematics and kinetics of the follow-through phase should also be assessed. High Variability in Rotational Res This apparently homogenous group of pitche rs had drastically different rotational resistance. For example, the angle where the soft tissues first provided substantial resistance (the ROA) varied drastically. Nine pitchers had an IR ROA less than 120 while 6 exceeded 140. Similar patterns were revealed for ER. The sti ffness of the dominant shoulder was also highly variable. Seven pitchers had extremely low ER stiffness (< 0.4 Nm/) while 6 pitchers exceeded 58

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0.7 Nm/. This finding revealed th at some pitchers have stiff shoulders while others have loose shoulders. Similar patterns were found for IR stiffness. This drastic variation may help t better identify pitchers at risk of injury. Prevalence of Throwing Arm Injuries Fourteen of the 30 pitchers had a throwing ar m injury serious enough to cause at least one week of missed practice or games (Table 4-5). This data furt her illustrates the high incidence throwing arm injuries in baseball pitchers and is considered valuab le since very few studies ha addressed this issue. Specific Aims Aim 1a Aim 1a to determine if ROM and rotation o of ve al sti ffness are both necessary to assess shoulder IR/ER ilar ROM but drastically different oth IR and ER. For example, two pitche at flexibility. A major goal of this project was to dete rmine if stiffness is a useful measure that can help to better assess shoul der flexibility in baseball pitche rs. Stiffness, in this study, is a measure of how tight or loose the shoulder is as it is rotated to the end RO M. This is the first study to measure rotational stiffness in baseball pitchers. Results from aim 1a suggest that stiffness does indeed provide new and important information about the flexibility of the throwing shoulder. The most important finding may be that ROM and stiffness are not related, as hypothesized. This means that two players can have sim stiffness (or vice versa). Extreme examples were revealed for b rs with similarly low IR stiffness (approximately 0.45 Nm/) had IR end ROMs th differed by 30 (Figure 4-1). Large ROM discrepancies ( 30) were also found among pitchers with similar stiffness at moderate and high levels (approximately 0.6 Nm/ and 0.7 Nm/, respectively). Similar patterns o ccurred for ER. These findings s uggest that the addition of 59

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rotational stiffness is valuable because it can help to better assess should er flexibility (as oppo to analyzing ROM alone). Previous studies have addresse d ho sed w tight or loose the pitching shoulder is in a static d this by applying a 15-dN anterior or posterior force to the ightness measures do not predict the absolute ROM. What remains unclear is if rotational or translation stiffn ed (via stretchi ng, exercise, or throwing ions) and if alterations to stiffness influence the end ROM. For example, resistance traini is sistance M. e situation. Borsa et al., (2005) accomplishe proximal humerus and measuring how far th e humeral head translated. Interestingly, the amount of humeral humeral head translation did not predict the end ROM for IR or ER. From this study and Borsa et al., (2006), it is quite cl ear that rotation and tr anslation measures of shoulder looseness or t ess can be alter intervent ng may increase rotational or translational stiffness (which may decrease the ROM) and/or stretching interventions ma y decrease stiffness (which may increase the ROM). The ROA was also analyzed for the first time in this study. The ROA is a measure of the angle where the soft tissues be gin to provide substantial resi stance to stretching. The ROA was highly variable among pitchers; for both ER a nd IR the ROA range exceeded 30. The ROA also relevant to study because it determines the beginning of the resistance zone. The resistance zone represents the portion of the motion (ER or IR) where the soft tissue is providing re because it is being stretched. The resistance zone begins at the ROA and ends at the end RO For IR, the resistance zone was 19.4 5.6. Fo r ER, the resistance zone was 23.9 5.9. Interestingly, the ROA strongly predicts th e end ROM for both IR and ER. This strong correlation suggests that most pitc hers have a resistance zone of similar size. To simplify, an analyst can expect approximately 20 of passive motion once the so ft tissue begi ns to provid substantial resistance from stretching. Future research should focus on the relevance of the 60

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resistance zone to throwing arm injuries. Pitchers who have abnormal resistance zones (limited or excessive) may be more susceptib le to injuries than pitchers w ith average resistance zones. Aim ere d the low rotati f the high 1b To determine if high rotational resistance groups have significantly different ROM compared to low rotational resistance groups. A major focus of this study was identifying and further analyzing pitchers that had high rota tional resistance and low rotational resistance. Pitchers with high rotational resistance were defined as those that had two inflexible characteristics: an early ROA a nd a stiff shoulder. Pitchers with low rotational resistance w defined as those that had two flexible charac teristics: a late ROA and loose shoulder. As hypothesized, pitchers with low rotational resistance had significantly greater ROMs compare to pitchers with high rotational resistance. For ER, the low rotational resistance group had a ROM approximately 24 greater than the hi gh rotational resistance group. For IR onal resistance gr oup had a ROM approximately 20 greater than the high rotational resistance group. The data suggest that pitchers with high rotati onal resistance are inflexible and that pitchers with low rotati onal resistance are flexible. High rotational resistance pitchers were expect ed to have limited resistance zones since they have stiff shoulders. Interestingly, there wa s no difference between stiff and loose pitchers; the resistance zone was between 18-23 for all groups. Stiffness had no apparent affect on the motion acquired. But stiffness did demonstrate ki netic relevance. Stiff shoulders appear to require more applied torque to achieve the end ROM. For example, the stiff shoulders o rotational resistance gro up required approximately 20% more a pplied torque to achieve the ER end ROM than the loose shoulders of the lo w rotational resistance group. This difference approached significance (p = 0.05) The differences in these passive mechanical properties 61

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among pitchers should be further explored be cause they may make some pitchers more susceptible to throwing arm in juries than others. Aim 2a To determine if pitching alters the soft tissue of the throwi ng shoulder. Results for a demonstrate that the passive ER and IR flexibil ity of the throwing shoulde r is indeed different from that of the non-throwing shoulder. Previous researchers have hypothesi zed that the an soft tissues of the shoulder become more flexible from repeatedly exposure to extrem rotation during pitching (Pappas et al., 1985). Une xpected results were re vealed; the passive ER rotational stiffness of the throwing shoulder was significantly greater (20%) than the nonthrowing shoulder. This finding is important becaus e it demonstrates that the soft tissues of the throwing shoulder are different from that of th e non-throwing shoulder. Future studies should strive to better understanding the relevance of this differe nce between the throwing and no throwing shoulder as it may help to better identify players at risk for injury and improve in rehabilitation. The meaning and limitations of the passive rota tional resi im 2a terior e external njury stance measures are important to addre er. nreater ss. It is possible that the increased ER stiffness of the throwing shoulder results from the tightening of anterior shoulder soft tissues. However, other potential hypotheses exist because the passive torque collected in this study is a m easure of the collective re sistance of the should For example, the stiffness increase may resu lt from hypertrophy of the throwing shoulder internal rotators. Hypertrophy may be associated with the increased internal rota tion strength of the throwing arm reported in prof essional pitchers; Ellenbecker et al., (1997) revealed that the throwing arm produced significantly greater internal rotation is okineitc torques than the no throwing arm. Future research should attempt to better understand why the ER stiffness is g 62

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in the throwing shoulder. Examining stiffness bilate rally in non-throwers w ould help to pitchers develop increased ER stiffness or if the dom reveal if inant shoulder is naturally stiffer. e ROA is a measure of the angle where th e soft tissue begins providing substantial resist ence. In difference occurred because the ROA bilateral difference was less than the ROM bilate ue rs or Th ance to rotation (due to stretching). ER RO A analysis revealed the throwing shoulder soft tissues to provide substantial resistance 9 later than the non-throwing shoulder. Both bony and/or soft tissue alterations to the throwing arm may be res ponsible for this shift. A bony alteration that may contribute to the 9 ROA shift is humeral re troversion. Three studies have shown the pitching arm humerus to be retroverted (twisted along its ax is) 11-17 back towards ER. Pitching is thought to cause retroversion beca use non-throwers have no bilateral differ Future studies should address the relationship between humeral retroversion and the increased ROA of the throwing shoulder. The ROA shift is also important to study b ecause it may influence the resistance zone this study, the throwing shoulder ER resistance zone was 4 larger than the non-throwing shoulder. This ral difference (Figure 5-1). The importance of the size of the resistance z one, alterations to th e resistance zone, and mechanisms should be addressed. Finally, it is impor tant to note that a signi ficantly higher torq was applied to externally rotate the torque to the end ROM. It is uncl ear if this is due to differences in the passive mechanical properties of the throwing and non-throwing shoulde differences in discomfort as the end ROM is approached. Previous studies have examined posterior shoulder tightness indirectly us ing bilateral ROM tests. Significant bilateral di fferences have been reported for tests including passive IR (Borsa et al., 2005), act ive IR (Ellenbecker et al., 2002), horizontal addu ction (Myers et al., 63

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2006), and reaching to the highest vertebra behind the back (Baltaci et al., 2001). Passive IR was the only ROM measure analyzed in this study. Previous passive IR ROM studies on comp arable group l ne, t alysis in pitc hers with a significant IR deficit (approximately 10) l s ficits (Myers et al., 2006). Finally, the relationship between IR rotati led IR ause limited IR motion is associated with t s of pitchers have reported the throwing shoulder to have an internal rotation deficit of approximately 10. As stated previously, this group of pitchers did not have a significant interna rotation deficit. Therefore, if th is group of pitchers would have been analyzed with ROM alo no evidence of posterior tightness would have be en revealed. Interestingly, the preliminary rotational resistance analysis did find evidence fo r posterior tightness, desp ite the lack of a IR deficit. The throwing shoulder was 38% stiffer than the non-throwing shou lder the earlier ROA (5) approached significance (p = 0.03), and 29% more torque was required to internally rotate the throwing shoulder to the end ROM (with no differences in the si ze of the resistance zone). I is important to repeat a similar an ike the aforementioned studies Doing so would help to dete rmine if rotational resistance bilateral differences increase even more in pitchers with a large deficit. Also, future studie should be completed on a population of pitchers with shoulder impingement since they are known to suffer from severe IR de onal resistance and humeral retroversion should be expl ored. Previous studies have revea no relationship or a weak relationship between hu meral retroversion and th e IR loss (Osbahr et al., 2002; Reagan et al., 2002). Exploring relati onships between humera l retroversion and rotational resistance may help to better understand if humeral re troversion at le ast partially contributes to this loss of IR motion. This is important bec hrowing arm injuries including SLAP lesions (Burkhart et al., 2003) and shoulder impingement (Myers et al., 2006). 64

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ROA shift for ER. This discrepancy increase s the ER resistance zone for the throwin Figure 5-1. The ROA and ROM shifts for external rotation. The ROM shift is 4 larger than the g shoulder. Aim 2b Aim 2b was to determine if the magnitude of th e motion shift is related to the magnitude of the stiffness change. The ER motion shift was hypothe sized to be associated with a decrease in ER stiffness and the IR motion sh ift was also hypothesized be asso ciated with an increase in IR stiffness. Neither motion was significantly correla ted with their respective stiffness bilateral difference. It is still possible th at alterations to soft tissues contribute to the motion shift; the passive mechanical properties of soft tissue st ructures (such as rotator cuff muscles or the capsule) may play an important role. But the pass ive rotational stiffness measure, which is a reflection of all soft tissues clearly did not predict the motion change in this study. The magnitude of ER and IR motion shifts we re strongly related to their respective ROA bilateral differences. For most pitchers, the ROM bilateral difference was similar to the ROA bilateral difference (both the dir ection and magnitude). It is important to note that this trend 65

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remained even for the pitchers that had unexpected motion shifts (i.e., loss of ER or gain in IR). These strong correlations between 1) the ab solute ROA and the end ROM and 2) the ROA bilateral differences and their respective motion shifts suggest important interaction between these two variables. Analyzing these two variable s in unison may help to identify pitchers who are particularly susceptible to throwing arm inju ries. This idea has previously been used for ROM analysis. Pitchers with unbalanced motion shifts (IR deficit is 10 more than the ER gain) are thought to be particularly susceptible to injury or showing signs of injury (Wilk et al., 2002). Bilateral differences may be good indicators of pitching arm health. For example, having a ROA shift and motion shift of similar magnit ude may be a sign of throwing arm health or having drastically different ROA and ROM shifts may be cause for concern. Future research should exp Aim 2c Aim 2c was to determine if the rotational resi stance of the non-throwi ng shoulder is related to the magnitude of the motion shift. For aim 2c the non-throwing s houlder served as a control and was assumed to represent the pre-altered p itching shoulder. For ER, pitchers with stiff nonthrowing shoulders and/or an early ROA were hypothesized to have the greatest motion shifts (they were thought to have great potential to loosen-up). For IR, pitchers with stiff nonthrowing shoulders were hypothesized to have a minimal motion shift (since they were already tight). One significant correla tion related to these hypotheses wa s revealed: for IR, a moderate negative correlation was revealed between th e non-throwing ROA and the IR motion shift. Interestingly, pitchers that had an early non-th rowing ROA gained IR motion. This gain in IR may be important and has yet to be discussed in the literature. This IR finding suggests that pitchers that start with a tight shoulder become looser. Pitchers with an average IR ROA had no or a minimal motion shift. Pitchers with a late IR ROA had the greatest loss of motion; they lore these topics. 66

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started out extremely loose and b ecame tighter. As previously stat ed, this correlation is moderate but it is considered important because it is pre liminary evidence that helps to explain the IR motion shift. This aim also furt her highlights the potential for us ing the ROA as an indicator o pitching health. Aim 2c should be repeated on a population of adolescent pitchers. This would be usefu because two studies have shown that ER and IR mo tion shifts become established in pitchers young as 12-14 years (Meister et al., 2005). Th e non-dominant rotational resistance measures should also be correlated to hum eral retroversion. This analysis may help to determine which pitchers have significant bony alterations. Aim 3 Aim 3 was to determine f l as if incidence of throwing arm injuries are different among l resistance groups. The purpose of this preliminary injury analysis was to determine if any g s ghly l rotationa eneral trends exis ted. Therefore, the number of pitche rs analyzed was limited (N=30), the analysis was retrospective in nature, all injuries were analyzed collectively, and the severity and location of injury were not considered. The prim ary goal was to determine if the majority of injured pitchers belonged to a specific rotationa l resistance group. Chi-squa re analysis revealed no significant differences for the ER or IR groups. Interestingly, both healthy and injured pitchers were dispersed quite evenly. This finding is important because it reveals that no obviou injury trends exist. With no obvious trends revealed, additional st eps should now be taken to more thorou analyze the relevance of rotationa l resistance measures to throwing arm injuries. First, rotationa resistance bilateral differences should be assess ed in a similar fashion. It is possible that alterations to rotational resistan ce are more important than abso lute rotational resistance. Second, greater numbers of pitchers should be analyzed. Injuries were very prev alent in this group of 67

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pitchers, but analyzing additional pitchers woul d help to improve statistical power and the strength of conclusions. Third, pitchers should be followed prospectively. It is possible that rotational resistance changed after the throwing arm was injure d. Last, each type of injury should be analyzed individ ually. In this study, all injuries were analyzed collectively. e ., 1995). The IR rotational resistance is likely not at this point in the pitch since posterior shoulder soft tissues are not being stretched. There zing A help to identify the direct ion (IR vs. ER).and group (low, moderate, or high rotati percent of the pitchers in this study had a serious throwing arm injury that made them unable to Analyzing injuries individuall y is important because injuries may be direction specific Medial elbow injuries can be used to illustrate this point. The medial elbow is critically loaded as the shoulder is maximally externally rotated at th e end of the arm cocking phase of the pitch. Th ER rotational resistance is likely relevant at this point in the pitch since th e anterior soft tissues are being stretched maximally (Fleisig et al relevant fore, it seems appropriate to focus attent ion on ER rotational resistance when analy elbow injuries. Interestingly, a high number of pitchers suffere d medial elbow injuries in this study (n=7). Qualitative analysis revealed findings to support th e relevance of ER rotati onal resistance to this specific injury. The ER rotational resistance of th ese 7 pitchers was relatively similar. The RO measures were within 15 and their stiffness wa s within 11 Nm/. This contrasts the disparate findings for IR (the irrelevan t direction). For IR, the ROA range was greater (7) and the stiffness range was approximately twice as large. Analyzing larger numbers of specific injuries in this manner could onal resistance) of greatest concern for each type of injury. Summary General Conclusions Throwing arm injuries are prevalent and severe in elite baseball pitchers. Forty-seven participate in practice or a game (for a week or more) during the previous year. 68

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The torque required to passive ly rotate the shoulder to the end ROM was 14 Nm for relevant to shoulder and elbow loads generated during the pitch that cause throwing arm inju Shoulder internal and external rotation passive flexibility was highl y variable in this range exceeded 30 and some pitchers shoul ders were twice as stiff as others. internal rotation and 17 Nm for external rotation. These large passive torques may be extremely ries. relatively homogenous group of e lite pitchers. For both IR and ER, the resistance onset angle both measures are needed to make clear conclusions about shoulder flexibility. Aim 1a also showed that the resistance onset angle strongly predicted the end ROM. For This was true for pitchers that had a limited ROM and pitchers that had an excessive ROM. Aim 1b classified pitchers as having low, moderate, or high rotational resistance. As al resistance pitchers. The difference wa s approximately 20 for ER and IR. r agnitude of the motion sh ifts. Bilateral stiffness differences did not predic and m wing Rotational resistance should be developed to e shoulder in clinical and rehabilitation settings. Athletic trainers, orthopedic su rgeons, and sports medicine consistently monitor the pass ive ER and IR flexibility of both shoulders tes. Aim 1a showed that ROM and stiffness were not correlated. This finding suggests that both ER and IR, the end ROM occurred approxi mately 20 beyond the resistance onset angle. expected, low rotational resistance pitchers had a significantly greater ROM than high rotation Aim 2a addressed bilateral differences. Results provide strong eviden ce to suggest that pitching alters the soft tissues of the throwi ng shoulder. The throwing shoulder was 20% stiffe for ER and 40% stiffer for IR. The ROA was 10 later for ER and 5 earlier for IR. Aim 2b addressed the m t the motion shifts but the ROA shifted sim ilarly to the ROM for ER and IR (the direction agnitudes of the bilateral differences were similar). Aim 2c used the non-throwing shoulder as a model of the original (or pre-altered) flexibility of the throwing arm. The non-thro wing ROA predicted the IR motion shift. This finding helps to identify who is having motion shifts and why. Pitchers with an early ROA gained motion, pitchers with an average ROA had no motion shift, and pitchers with a late ROA lost motion. Aim 3 was a preliminary retrospective injury an alysis that compared incidence of thro arm injuries among a low, moderate, and high ro tational resistance groups. No general trends were revealed. Future efforts should focus on an alyzing larger groups of pitchers and groups of pitchers with similar injuries (rather than assessing all throwing arm injuries collectively). Practical application and recommendations analyze th clinicians should in overhead athle Measures and methods from this study may he lp to better guide and assess exercise and rehabilitation interventions in overhead athletics. 69

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Future Research Determine the relevance of rotational resistance to throwing arm loads during the pitch. Determine the relevance of rotational resistance to pitching performance (pitching accuracy and pitching velocity). Examine the relationships between rotational re sistance the humeral retroversion to better Analyze rotational resistance in adolescent populations when the motion shifts first throwing arm injuries prospectively. tional l resistance. aver es dramatically bilaterally and that rotational resist assess tic tr ainers, orthopedic surgeons, and sports medicine clinicians to understand the motion shift and causes of the motion shift. become established. Perform longitudinal studies to monitor rela tionships between rota tional resistance and Determine the relevance of rotational resistance bilateral differences to incidence of throwing arm injuries. Analyze the relevance of ro tational resistance to specific throwing arm injuries. Determine influence of stretching and resist ance training interventions on rota resistance. Assess rotational resistance in baseball posi tion players and other overhead athletes. Determine influence of warm-up and fatigue on rotationa Determine influence of specific soft tissues on rotational resistan ce by completing cad studies. In conclusion, this study demonstrated the im portance of assessing shoulder passive IR and ER rotational resistance in baseball pitchers. The most important novel finding may be that rotational stiffness and end ROM are not related. This finding suggests that both measures are required to thoroughly assess IR or ER passive flexibility of th e throwing shoulder. This study also demonstrated that rotational resistance vari ance is relevant to the motion shift. We believe that rotational resistance shoulder ments could help athle prevent, diagnose, and rehabilitate throwing arm injuries; we recommend the assimilation of 70

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shoulder rotational resistance assess ments into practice. Future research should continue to focus ing on injury mechanisms, the motion shifts, and throwing arm interventions. Injury mechanism resear al resi stance and the throwing lo ip resear tching interventions and resistance training erv on determining the relevance of rotational resistance measures to incidences of throwing arm injuries and injury prevention. We believe throwing arm injuries may be reduced by focus ch should focus on examining associations between rotation armads experienced during the pitch. Motion sh ift research should e xplore the relationsh between rotational resistance a nd humeral retroversion. Finally, throwing arm intervention ch should focus on the influence of st re intentions on rotational resistance. 71

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APPENDIX A SHOULDER ANATOMY AND EXAMPLE INJURIES Articulations of the Shoulder Joint The shoulder complex has four articulations: acromioclavicular, sternoclavicular, scapulothoracic, and glenohumeral. Pitching researchers are most concerned with the glenohumeral joint due to the high incidence of injuries (Baltaci et al., 2001). The glenohumeral joint is a ball and socket joint. Pitchers ar e able to achieve a trem endous shoulder ROM during the pitch because the socket, or glenoid, is extr emely shallow (Pink et al., 1995). Little League Shoulder is a common bony injury in adolescents (Fleming et al., 2004). Young pitchers suffer from little league shoulder when the growth plate, or physis, at the proximal end of the humerus radually separates. This injury is known to occur in pitchers age 11-16 years (Carson et al., 998). Little league shoulder is thought to develop from repeated exposure to external rotation torque at the end of the arm-cocking pha se of the pitch (Sab ick et al., 2004). Soft Tissue Stabilizers The shallow nature of the glenoid forces the so ft tissues of the shoulder to be the primary stabilizers. Shoulder soft tissues are categorized as static stab ilizers or dynamic stabilizers (Donatelli, 2004). The static stab ilizers are the cartilages and lig aments that surround the joint. The two main static stabilizers, the labrum and capsule, are commonly injured in baseball pitchers. Many dynamic stabilizers, or muscles, also surround the join t. Primary attention is give to the rotator cuff muscles due to their important role in provi ding shoulder stability and their high susceptibility to injury. The labrum The labrum is a ring of fibrous tissue that surrounds the glenoid. The labrum helps to provide stability by forming a socke t for the humeral head. It also serves as an attachment site g 1 72

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for ligaments and tendons. The labrum h humeral head by forming a ring around the glenoid. The biceps tendon attaches to the superior labrum. SLAP lesions are injuries to the labrum that baseball pitchers suffer from (Park et al., 2002). SLAP stands for superior labrum anterior to posterior and is used to describe tears to the labrum. There are four basic types of SLAP lesions that baseball pitchers suffer from. SLAP lesions may be caused by impingement or large bicep tendon forces that act to peel the labrum off the glenoid during the arm cocking and/or arm deceleration pha se of the pitch (Park et al., 2002). The capsule The capsule completely surrounds the humeral head and provides stab ility near the limits of motion. At the scapular end it attaches along the rim of the glenoid, just beyond the labrum. At the humeral end it attaches along the anatom ical neck. Capsular thickenings occur on the anterior, middle, and inferior surfaces. The role of the capsule as a stabilizer varies with the arm position and the shoulder biomechanics. The capsule remains lax in most shoulder positions tense, and an important stabilizer, at extreme shoulder positions. The rior tator cuff muscles originate from th e scapula (Figure A-10). The rotator cuff tendons elps to secure the (Jobe, 1995). It becomes anterior capsule can become attenuated from repeated exposure to extreme ER and the posterior capsule can become tightened from repeated exposure to the follow through loads. These problems are thought to be highl y preventable (Jobe, 1995) and of ten addressed with surgical interventions. The capsular shift surgical interv ention is used to eliminate excessive ante instability (Glousman et al., 1995). Another pr ocedure, thermal capsulorrhaphy, can similarly eliminate excessive instability by shrinking the capsu le with a heated prob e (Enad et al., 2004) The rotator cuff muscles Four ro blend with the capsule as they approach the humeral tuberosities. The rotator cuff 73

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muscles are important stabilizer s since the capsule is lax at most arm positions (Jobe 1995). Primary roles include stabilizing the humeral head within the glenoid, precisely positioning humeral head within the glenoid, and rotating the humerus (Yocum et al., 1995). Tears to the rotator cuff are common (Mazou et al., 2006). Rotator cuff muscle s are greatly responsible for decelerating the arm after ball release. Tears are thought to be associated repeated exposure to the large distraction force at ball release that is equal to or greater than the pitchers body weight (Fleisig et al., 1995). Tears occur most commonly in the posterior half of su the rprspinatus and f infraspinatus (Mazou et al ., 2006). This serious in jury requires surgical interve superior half o ntion. Rotator cuff tendons also commonly get impinged between the glenoid and humeral head. 74

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APPENDIX B mail & fax) Jeff T. Wight, B.S., M.S., PHD candidate Department of Applied Physiology & jwight@ufl.edu, 392-5262 (fax) Guy B. Grover, B.S., M.S. candidate, Department of Applied Physiology & ggrover@ufl.edu, 392-5262 (fax) 3. APPROVED IRB 1. TITLE OF PROTOCOL: Shoulder Internal and External Rotati onal Stiffness in Baseball Pitchers 2. PRINCIPAL INVESTIGATOR(s): (Name, degree, title, dept., address, phone #, eKinesiology, PO Box 118206, 150 Florida Gym, 392-0584 ext. 1400, Kinesiology, PO Box 118206, 152 Florida Gym, 392-9575 ext. 1401, SUPERVISOR (IF PI IS STUDENT): (Name, campus address, phone #, e-mail & fax) Mark D. Tillman, Ph.D., Assi stant Professor, Departme nt of Applied Physiology & Kinesiology, PO Box 118205, 118 Florida Gym, 392-0584 ext.1237, mtillman@hhp.ufl.edu, 392-5262 (fax) 4. DATES OF PROPOSED PROTOCOL: October 15, 2006 to October 15, 2007 5. SOURCE OF FUNDING FOR THE PROTOCOL: (As indicated to the Office of Research, Technology and Graduate Education) None. 6. SCIENTIFIC PURPOSE OF THE INVESTIGATION: The purposes of this study are to 1) meas ure the passive flexibility characteristics of the shoulder in internal/external rotati on in baseball pitchers, 2) determine if relationships exist among various passive in ternal and external rotation variables, and 3) determine if bilateral differences exist in passive flexibility characteristics of the shoulder. -75-

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7. DESCRIBE THE RESEARCH METHODOLOGY IN NON-TECHNICAL LANGUAGE: The UFIRB needs to know what will be done with or to the research Pro participant(s). tocol and methods. Bilateral shoulder flexibility measurements will be ta ken with the participant lying supine on an athletic traini ng table. The upper arm will be secured to a moinvestigator will push lightly on the participants anterior shoulder. The whole arm will be internally a nd externally rotated to the end range of motion. The end ran when h The particip upper body muscles relaxed (no musclular effort) while the measures are taken. Surf ace electromyography (Konigsburg Instruments, inc. th the force re into a laptop r Techniques, Temecula, CA) in line with the an electrogoniometer (Model 536 Precision Potentiometer), resp There will be a 20 minute Familiarization Session and a 20 minute Data Collection Ses or differen Familiarization Session. rotational device with the elbow bent at 90. To prevent shoulder and scapular vement, the ge of motion will be determined by the participant. The participant will say stop e believes that further rotation of the arm would become uncomfortable ant will be instructed to keep the Pasadena, CA) will be used to monito r the shoulder area muscle activity. Bo quired to rotate the arm and the resu lting displacement will be recorded computer via a load cell (Tansduce force applicator and ectively. sion (total of 40 minutes). These two se ssions may be performed on the same day t days (depending on convenience). Firs rmed consent. The custom device will then be adjusted to properly fit the participant th e arm support will be lowered or raised as n ecorded (to use in the Data Collection Session). T l using five subma th e right and left arm). The sho l cease when houlder. That stretch will then be held for e seconds. The only differen ce in the next four repetitions will be the magnitude of the rota revious (but all wil s houlder will be rotated once to the com Nex Firs Sec de. Thi d external end range of motion will be measured with a plastic goniometer. Data collection session. t, the participant will read (and sign) th e info ecessary). The device settings will be r he participant will then be fam iliarized with the protoco ximal repetitions (both internally and externally, for both ulder will be rotated very slowly for all repetitions. The first rotation wil the subject first feels a light stretch in the s approximately fiv tion; each rotation will be slightly further than the p l be short of the end range of motion). Fi nally, the subjects fortable end range of motion. t, three simple shoulder range of motion me asures will be taken on each shoulder. t, the participant will be asked to reach the highest vertebra possible behind his back. ond, maximum passive adduction will be meas ured with the subject lying on his si rd, the internal an The device will be adjusted to the proper settings (recorded in the Familiarization Session). EMG electr odes will be placed over the shoulder area muscles. Five consecutive repetitions (to the comfortable passive end range of motion) will be collected for shoulder internal and external rotation for both shoulders. There will 76

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be two consecutive collections: once with the shoulder stabil ized by the investigator and POTENTIAL BENEFITS AND ANTICIPATED RISKS: (If risk of physical, ociated e tion, 9. baseball pitchers (age 18-40 years) will be recruited from college and rofessional teams in Florida. No compensation will be provided by the investigators. 10. HE INFORMED CONSENT DO CUMENT (if applicable). W o his pa Please ______ Princip ______ Superv I approve this protocol for submission to the UFIRB: ______ Dept. C once without. 8 psychological or economic harm may be involved, describe the steps taken to protect participant.) The anticipated risks associated with this study would be no more than those ass with self stretching of the s houlder under normal conditions. To avoid muscle injury du to overexertion, the subjects will be require d not to engage in st renuous exercise during the day of the test and to warm-up properly before the testing session. In the unlikely event that an injury do es occur, a certified athletic trai ner will be present at the collec or on call, to provide treatment. DESCRIBE HOW PARTICIPANT(S) WILL BE RECRUITED, THE NUMBER AND AGE OF THE PARTICIPANTS, A ND PROPOSED COMPENSATION (if any): Sixty-five male p DESCRIBE THE INFORMED CONSENT PROCESS. INCLUDE A COPY OF T ritten informed consent (see attached) will be obtained from each participant prior t rticipation. use attachments sparingly. ____________________ ______________________________ al Investigator's Signature Co-Principal Invest igators Signature ___________________ isor's Signature ______________________ hair/Center Director Date 77

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-78INFORMED CONSENT AGREEMENT APPENDIX C APPROVED INFORMED CONSENT PROJECT TITLE: Shoulder Internal and External Rotati onal Stiffness in Baseball Pitchers INVES TIGATORS: Jeff T. Wight and Guy B. Grover Please read this consent agreement carefully before you decide to participate in this study PURPO purp ulder E ASKED TO DO: The flex will be p rowing position (elbow bent at 90). We will then secure your arm to a wheel that can rotate. During the test, one a a forearm u g. You will also be asked to say s table. Both the force required to rotate the arm and the resulting displ acement will be recorded. The Familiarization Period SE OF THIS PROJECT: The ose of this study is to measure the passive inte rnal and external rotation flexibility characteristics of both shos in baseball pitchers. WHAT YOU WILL B ibility tests will be conducted with you lying on an athletic training table. Small sensors (EMG electrodes) lace over your shoulder area muscles to monitor muscle activity. We will ask you to ho ld your arm in a th investigtor will lightly push against the front of your shoulder to prevent unwanted movement. The other investigtor will slowly rotate your arm internally (moving the forearm downward) or externally (moving the pward). You will be asked to k eep your shoulder totally relaxed during the testin top when you believe that further rotation of the arm would become uncomfor We want to make sure that you are comfortable with our flexibility measuring proto Durin ill c n you first feel a light stretch in your shoulder. We w ill hold that stretch for approximately performed, an d each time we will rotate your arm a little farther. After the ll rotate your ar m to the comfortable end range of motion twice. The first me, we will use a device that we built to measure your s houlder. The second time, we will use a simple plastic oniometer to measure your shoulder. col. To do this we will perform six practice repe titions for each arm (for internal and external rotation). g these practice repetitions we will ask you to complete ly relax your shoulder. During the first repetition, we ease rotation whe w five seconds. Four more stretches will be five stretches have been completed, we wi ti g The data collection. W e will start with two simple shoulder measures. First, you will be aske d to place your hand behind your back and cond, we will measure how far you can reach across your body. nsecutive repetitions to the passive end range of motion. We will do this for both oulders and both directions (internal and external rotatio n). For each repetition you will be asked to say stop hen you achieve your comfortable end range of motion. Throughout the collections, we would like you to remain IME REQUIRED: and testing sessions may occur on consecutive days. RISKS AND BENEFITS: reach the highest vertebra possible. Se Next, we will collect five co sh w still and relaxed. We will complete this test twice. T Approximately 40 minutes. Familiarization

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The anticipated risks associated wi ated with self stretching of the shoulder under normal conditions. tified athletic trainer will be present at the collection, or on c C No compensation will be p CONFIDENTIALITY: Your identity will be kept confidential to the extent provided by law. The records of your participation will be kept c w is completed. Your name will not be used in any report. V Y a R Y WHOM TO CONTACT IF YOU HAVE J th this study would be no more than those associ In the unlikely event that an injury does occur, a cer all, to provide treatment. There is no direct benefit to you for participating in this study. However, the findings of this study may help us to etter understand performance and injuries in overhand athletics. b OMPENSATION: rovided by the investigators. onfidentially. Only the inves tigators of this study will have access to your records and data files. Video recordings ill be destroyed when the study OLUNTARY PARTICIPATION: our participation in this study is completely voluntary. All data collection will be performed by graduate research ssistants. IGHT TO WITHDRAW: ou have the right to withdraw from the study at anytime without penalty. QUESTIONS ABOUT THIS STUDY: eff T. Wight M.S., Ph.D. candidate, 150 Florida Gym, 392-0584 ext. 1400, jwight@ufl.edu uy B. Grover, B.S. G 152 Florida Gym, 392-9575 ext. 1401, ggrover@ufl.edu ark D. Tillman M Ph.D., 118 Florida Gym, 392-0584 ext.1237, mtillman@hhp.ufl.edu HOM TO CONTACT ABOUT Y OUR RIGHTS AS A RESEARCH PARTICIPANT IN THE TUDY: W S UIRB Office, Box 112250, University of Flor ida, Gainesville, FL 32611-2250; Tel.:392-0433. ______________________________________________________________________________ A I F GREEMENT: have read the procedure de scribed above and I voluntarily (participant's name) gree to participate in the procedure. I also understand that I will receive a copy of this form upon equest. a r Participant:_____________________________________ Date: ___________ Principal Investig ator:____________________________ Date: ___________ -79

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APPENDIX D THROWING ARM INJURY QUESTIONNAIRE This questionnaire will ask you about the freq uency and location of throwing arm injuries ov er the past year. o ask questions. ____________ Right-handed or Lefthanded In the past year, were you a st arting pitcher or relief pitcher? Please feel free t GENERAL INFORMATION DATE________________________ TEAM________________________ NAME____________ Height__________ Weight ____________ How many years have you pitched competitively? 80

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1. In the past year, did you suffer from injuries/pain that made you unable to fully participate in thro or unable to compete in a game? 1a. In th in throwing activities during practice, unable practice at all, or unable to compete in a game because of throwing arm injuries/pain? __________ 1b. When did the symptoms begin? 1c. Circle the gen ain occurred. Shoulder Elbow Bot Other__________________ /or elbow where the injury/pain Shoulder: anterior, posterior, superior, lateral terna anterr, post d. Did you see a physician about your throwing arm injury/pain? _______________ NO Currently, are you experiencing any throwing arm pain during practice and/or games? O Thank you for your 2a. Circle the general area of the injury/pain. Shoulder Elbow Both Other__________________ 2b. Circle any specific location(s) of injuy/pain on the shoulder and/or elbow. Shoulder: anterior, posterior, superior, lateral Elbow: medial, lateral, internal, anterior, posterior 2c. Is the pain severe enough to negatively infl uence your pitching performance (velocity or control)? YES NO 2d. Do you feel that you have altered your pitching mechanics because of the pain? YES NO any throwing arm wing activities during practice, unabl e to practice at all, YES Please answer questions 1a-1d below. NO Please move on to #2. e past year, how many days/weeks were you unable to participate days ____________ weeks eral area of the throwi ng arm where the injury/p h 1c. Circle any specific location(s) of th e shoulder and occurred. Elbow: medial, lateral, inl,ioerior 1 YES What was your doctors diagnosis?____ 2 YES Please answer questions 2a-2d below. N ime. t r 81

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LIST OF REFERENCES R., Smith Awan, J., and Boon, A. J. (2002). Meas uring shoulder intern al rotation range of motion: A comparison of 3 techniques. Archives of Physical Me dicine and Rehabilitation 8 Baltaciand mobility Sport 14 BaltaciG., Joh ge of motion characteristics in ciat l of Sports Medici ne and Physical Fitness 41 (2), 236-42. Boon, A. J. and Sm Borsa, W and Andrews, J., R. (2005). Correlation of range of motion and glenohumeral translation in professional baseball pitchers. American Orthopaedic Socie ty for Sports Medicine 33(9), Borsa, P., A., D, C., W enohumeral range of motion and stiffness in prof Exercise rown LP, NieL ange of m or le Burkhart, S. S., Morgan, C. D e disabled throwing shoulder. Spectrum of pathology part I: pa thoanatomy and biomechanics. The Journal of Aosc 0. S.Iittle merican Journal of Sports Medicine 26, 575-580 a, R., K., Garrick, J., G. (2001). Disability days in Major League Baseball. The Americaf Sp Crawford, S.Ders, E iffness in the functional throwing position of high school baseball pitchers. Journal of Athletic Training, 41( 1), 52 5 Crocke, H. C ara J., Reilly M. T., Ds, J d range otio 3, 1229-1234. G. Tunay, V., T. (2004). Isokinetic performance at diagonal pattern and shoulder in elite overhead athletes. Scandanavian Journal of Medicine and Science in 231. nson, R., and Kohl, H. (2001). S houlder ran ollege baseball players. The Journa ith, J., (2000). Manual scapular stabilization: its eff ect on shoulder rotational range of motion. Archives of Physical Medicine and Rehabilitation 81, 978-83. P., A.ilk, K., E., Jacobson, J., A., Scibek., J., S., Dover, G., C., Reinold, M., M., 1392-1399. over, G.ilk, K., E., and Reinold, M., M. (2006). Gl essional baseball pitchers. Medicine & Science in Sports & 38 (1), 21-26. B hues S, Harrah A, Yavorsky P, Hi rshman HP. (1988). Upper extremity r otion and isokinetic strength of the internal and external shoulder rotators in maj ague baseball players. The American Journal of Sports Medicine 16 (6), 577-585 ., and Kibler, W. B. (2003). Th rthropic and Related Surgery, 19 (4), 404-42 Carson, W.G and, Gasser,. (1998). L leaguers shoulder: A report of 23 cases. A Conte, S., Requ n Journal oorts Medicine 29(4), 431-436. and Sau.L. (2006). Glenohume ral joint laxity and st 9. tt., Gross, L. B., Wilk, K. E., Schw artz, M. L., Reed, J., OM uga. R., Meister, K., Lyman, S., Andrew s, J. R. (2002). Osseous adaptation an f mon at the glenohumeral joint in professional baseball pitchers. The American Journal of Sports Medicine 30(1), 20-26. 82

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Meister K., Day T., Horodyski M., Kaminski T.W., Wasik, M.P., and Tillman, S. (2005). Rotational motion changes in the glenohumeral joint of th e adolescent/Li ttle League baseball playe r. The American Journal of Sports Medicine 33 (5), 693-8. rican Journal of Sports Medicine, 33(1), 108-113. Murray, T. A., Cook, Werner, S. L., Schlegel, T. F., and Hawkins, R. J. (2001). The effects of extended play on professional baseball pitchers. The American Journal of Sports Medicine Myers, J. B., Laudner, K. G., Pasquale, M. R ., Bradley, J. P., and Lephart, S. M. (2005). Scapular position and orient ation in throwing athletes. The American Journal of Sports Myers, J. B., Laudner, K. G., Pasquale, M. R ., Bradley, J. P., and Lephart, S. M. (2006). for 3Meister, K., Day, T. B., Horodyski M. B., Ka minski, T. W., Wasik, M. P., and Tillman, S. e ). Novo to nematics of the human glenohumeral joint. Osbah he American Journal of Sports Medicine 30(3), 347-353. Pappa The American Journal of Sports Medicine 13, 216-222. Mullaney M.,J., McHugh, M. P., Donofrio, T. M., and Nicholas, S.J. (2005). Upper and lower extremity muscle fatigue after a baseball pitching performance. The Ame 29(2), 137-142. Medicine, 33 (2), 263-271. Glenohumeral range of motion deficits and poste rior shoulder tightness in throwers with pathologic internal impingement. The American Journal of Sports Medicine, 34(3), 385391. Olsen II, S. J., Fleisig G.S., Dun, S., Loftice, J., and Andrews, J.R. (2006). Risk factors shoulder and elbow injuries in adolescent baseball pitchers. The American Journal of Sports Medicine, 34(6), 905-912. Noffal, G. J. (2003). Isokinetic eccentric-to-con centric strength ratios of the shoulder otator muscles in throwers and nonthrowers. American Journal of Sports Medicine 31(4), 5 541. (2005). Rotational motion changes in the glenohume ral joint of the adolescent/little leagu baseball player. The American Journal of Sports Medicine 33 (5), 693-698. Nakagawa, S., Yoneda, M., Hayashida, K., Obat a, M., Fukushima, S., and Miyazaki, Y. (2005 Forced shoulder abduction and elbow fexion test: A new simple clinical test to detect superior labral injury in the throwing shoulder. The Journal of Arthroscopic and Related Surgery, 21(11), 1290-1295. tny, J. E., Woolley, C. T., Nichols, C. E ., and Beynnon, B. D. (2000). In vivo technique quantify the internal-externa l rotation ki Journal of Orthopaedic Research, 18 (2), 190-194. r, D. C., Cannon, D. L., and Speer, K. P. (2002). Retroversion of the humerus in the throwing shoulder of college baseball pitchers. T s, A. M., Zawacki, R. M., and Sullivan, T. J. (1985). Biomechanics of baseball pitching 85

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Park, S.S., Loebenburg, M.L., Rokito, A.S., Zuckerman, J.D. (2002). The shoulder in base pitching. Biomechanics and related injuries part 2. Hospital for Joint Diseases 61, 8 88. ball 0s ). players, The American Journal of Sports Medicine 30 (3), 354-360. Safran, M., Ahmad, C. S., and El attrache., N. S. (2005). Ulnar co llateral ligament of the elbow. Safra ioception in baseball pitchers. Journal of Shoulder and Elbow Surgery, 10(5), 438444. Sethi, erican Orthopaedic Socie ty for Sports Medicine 32 (7), 1711-1715. Silder e c joint moment-angle relationships in th e lower extremity. Journal of Biomechanics, doi: 10.1016/j.jbiomech.2006.12.017. Song, llege Tyler, T.F., Nicholas, S.J., Roy, T., and Gleim, G.W. (2000). Quantification of posterior capsule Werner, S.L., Gill, T.J., Murray, T.A hip s. Wight, J.T., Richards, J.R., and Hall, S.J. (2004). Influence of pelvis rotation styles on baseball Pink, M.M., Screnar, P.M., Tollefson, K.D., an d Jobe, F.W. (1995). Injury Prevention and Rehabilitation in the Upper Extremity. In Oper ative Techniques in Upper Extremity Sport Injuries. Mosby-Year Book, Inc. Reagan, K.M., Meister, K., Horodyski, M.B., Wern er D.W., Carruthers,C., and Wilk, K. (2002 Humeral retroversion and its relationship to glenohumeral rotation in the shoulder of college baseball Sabick, M.B., Torry, M.R., Kim, Y.K., and Hawkins, R.J. (2004). Humeral torque in professional baseball pitchers. The American Journal of Sports Medicine 32(4), 892-898 The Journal of Arthroscopic and Related Surgery 21(11), 1381-1395. n, M.R., Borsa, P.A., Lephart, S.M., F u, F.H., and Warner, J.J.P. (2001). Shoulder propr P., M., Tibone, J., E., Lee, T., Q. ( 2004). Quantitative assessment of glenohumeral translation in baseball players. Am A., Whittington, B., Heiderscheit, B., and Thelen, D.G. (2007). Identification of passiv elasti J.C., Lazarus, M.L., and Song, A.P. (2006). MRI findings in little leaguer s shoulder. Skeletal Radiology, 35, 107. Treiber, F.A., Lott, J., Duncan, J., Slavens, G ., and Davis, H. (1998). Effects of theraband and lightweight dumbbell training on shoulder rotation torque and serve performance in co tennis players. The American Journal of Sports Medicine 26 (4), 510-515. tightness and motion loss in pati ents with shoulder impingement. The American Journal of Sports Medicine, 28(5), 668-73. ., Cook, T. D., and Hawkins, R.J. (2001).Relations between throwing mechanics and shoulder distraction in prof essional baseball pitcher The American Journal of Sports Medicine, 29, 354-358 pitching mechanics. Sports Biomechanics 3(1), 67-84. 86

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Wight, J.T., Grover, G.B., Chow, J.W., and Tillman, M.D. (2006). Shoulder Maximum Externa Rotation in the Tennis Serve is not Relate d to Shoulder Passive External Rotation Flex l ibility. Proceedings of the 30th Annual Mee ting of the American Society of Biomechanics. Wilk, American Journal of Sports Medicine 30(1). 136-151. Young, R.W. (2003). Evolution of the human hand: the role of throwing and clubbing. Journal Zheng, N., Fleisig, G. S., Barrentine, S. W., and Andrews, J. R. Biomechanics of Pitching. In K.E., Meister, K. and Andrews, J.R. (2002) Current Concepts in th e Rehabilitation of the Overhead Throwing Athlete. The Yocum, L.A., and Conway, J.E. (1995). Rotator Cuff Tear: Clinical Assessment and Treatment. In Operative Techniques in Upper Extremity Sports Injuries. Mo sby-Year Book, Inc. of Anatomy, 202, 165-174. George Hung (ed) (2004). Biomedical Engi neering Principles in Sports Kluwer Academic/Plenum Publishers. 87

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BIOGRAPHICAL SKETCH Jeffrey T. Wight was born in Grand Rapids, Mi chigan in 1977. He was raised in P lover, Wisconsin and graduated from Stevens Point Area Senior High in 1995. Jeff has enjoyed partic s degree, Jeff worked for the Center for Limnology at the gradu elaware in the Department of H ealth, Exercise Science, and Nutrition in August of 2001. Two years late r, Jeff graduated from the University of elaware with his Master of Science in Exerci se Science. He completed and published a thesis tled Influence of pelvis rotation styles on overall baseball pitching kinematics and kinetics under the supervision and guidance of his advisor, Dr. James Richards. Je ff was also a volunteer baseball coach at the high-school and college level for 8 years during his undergraduate years and time in Delaware. He and his wife started their doc toral studies at the University of Florida in the College of Health and Human Performance in August of 2003. During his years of graduate studies, Jeff taught a total of nine different c ourses at the University of Delaware, University of Florida, and Stetson University. He also gave many guest lectures at the University of Florida in a variety of courses: In addition to teaching, Jeff has been acti vely involved with resear ch projects during his doctoral studies at the University of Florida. He was an investigat or on awarded grants, published in peer-reviewed journa ls, and presented research at various national conferences. Jeff ipating in athletics, th e outdoors, and fishing throughout hi s life. His undergraduate studies were completed at the University of Wiscons in-Madison where he received a Bachelor of Science in Zoology and completed exte nsive studies in mathematics. After receiving his bachelor University of Wisconsin. Jeff married Erin Largo in the summer of 2001 and they began ate studies at the University of D D ti 88

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is a member of professional organ n Society of Biomechanics and the A e has also been actively involv dar a, izations including the America merican College of Sports Medicine Jeff was active and involved with the Univ ersity and College throughout his doctoral tenure. Jeff and his wife were selected as re cipients of the College of Health and Human Performance German Scholarship Exchange Pr ogram to the University of Darmstadt in Darmstadt, Germany, where they gave a joint research presentation. H ed with the Colleges informal co-ed Ulti mate Frisbee league and has enjoyed learning about Floridas natural ecosystems by kayaking many waters from the Florida Keys to Ce Key with his wife. Jeff and his wife are graduating with their doc torates from the University of Florid College of Health and Human Performance, in the summer of 2007. They will also welcome their first child into the world in June of 2007. 89