Exercise Programs to Protect Baseball Pitchers Arm

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Information about Exercise Programs to Protect Baseball Pitchers Arm
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Published on June 27, 2008

Author: jwoodatc

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Exercise Programs to Protect Baseball Pitchers Arms From Overuse Injuries :  Exercise Programs to Protect Baseball Pitchers Arms From Overuse Injuries Jeffery D. Wood, MS. ATC, LAT Assistant Athletic Trainer University of Tennessee Knowledge:  Knowledge “Science knows many things, but the least of these things it knows is the science of man. The science of man is the least known, but the most important of all the sciences.” Learning:  Learning “If you want to improve, be content to be thought foolish and stupid.” Epictetus Greek Philosopher Baseball Pitching:  Baseball Pitching High injury pursuit, even with proper mechanics Over 40% of major league disabled list is composed of pitchers In career, over 70% of pitchers will experience injury Baseball Pitching:  Baseball Pitching Based on the NCAA Injury Surveillance System, in 2002, injuries reported by collegiate baseball players were at an all time high. Most frequently injured body parts were the shoulder and elbow. Pitching and throwing injuries accounted for 1/3 of all practice and 19% of all game injuries. Shows importance of injury prevention in baseball pitchers (Mungin, 2006) History of Baseball Pitcher Conditioning Programs:  History of Baseball Pitcher Conditioning Programs 25 years ago a pitcher’s conditioning program consisted of running poles and sprints, along w/ long tossing. In mid 80’s, work by Jobe advocated rotator cuff and scapular stabilizer exercises. Late 80’s saw the increase use of weight training for total body conditioning. History, continued:  History, continued Saw the use of heavy weights, resulting in increased bulk, lack of flexibility and many times increased injuries. Late 90’s saw more baseball specific training with lighter weights, higher repetition and increased flexibility. Coleman (1998) advocated year round conditioning programs for pitchers. More History:  More History Programs now are focusing on core stabilization with increased emphasis on legs, trunk, then upper extremity. In 2000, McMullen and Uhl designed a program that integrated the entire kinetic chain to stabilize the scapula and decrease stress at the shoulder. General body strength training now the norm. Presentation Goals:  Presentation Goals Brief overview of overhand throwing/pitch biomechanics. Identify factors that can lead to injury and injury prevention. Learn how to identify postural asymmetries that can lead to injury. Look at exercises to restore correct posture and strengthen correct patterns to reduce overuse injuries. Rotation:  Rotation Most activities of daily living require rotation throughout the body Must be symmetrical Whether it be walking … Rotation:  Rotation Running… Rotation:  Rotation Or working… Rotation:  Rotation In baseball, rotation is critical to success Again, just like ADLs, it must be symmetrical to maintain health Whether batting… Or …. Rotation:  Rotation Pitching Overhand Throwing Motion:  Overhand Throwing Motion Total body athletic skill High demand with extraordinary stresses placed on the shoulder and elbow complex Involves precise timing and coordination of body segments (proper mechanics) to produce accuracy and maximum velocity (Murray, et al 2001) Overhand Throwing:  Overhand Throwing Throwing involves sequential activation beginning with the contralateral foot and progressing through the trunk to the rapidly accelerating upper extremity. (Pappas, 1985) Overhand Throwing:  Overhand Throwing Proper throwing mechanics are critical to enable the athlete to achieve maximum performance with minimum chance of injury Improper mechanics may alter this complex chain of events that can produce additional stresses resulting in injury or dysfunction Kinetic Chain:  Kinetic Chain In coordinated human motion, energy and momentum are transferred through sequential body segments, achieving maximum magnitude in the terminal segment. Baseball Pitching:  Baseball Pitching Since pitching is a “total body activity,” dysfunction anywhere along the kinetic chain can result in injury. i.e., lower extremity or trunk dysfunction can result in shoulder or elbow injury Baseball Pitching:  Baseball Pitching Most pitching injuries occur because of some form of imbalance during pitch delivery When delivery is synchronized and arm and body are working together there is less stress on throwing arm Not Made To Pitch???:  Not Made To Pitch??? Have always heard that the human body is not made to throw a baseball. I strongly DISAGREE!! I think God is a huge baseball fan and has designed the perfect mechanism for throwing a baseball. Sacrificed stability for performance, with a perfect integration of all body parts. However…:  However… I do agree that a pitcher only has so many throws in an arm. Analogous to tires on a car. If we keep the suspension aligned properly and keep the right amount of air in the tires, then we can maximize mileage and parts don’t wear out. Our goal is to maximize mileage! Phases of Pitching:  Phases of Pitching Broken down into six phases: Wind-up Stride Arm Cocking Arm Acceleration Arm Deceleration Follow-Through Phases:  Phases Injury Potential:  Injury Potential Critical phases of the throwing motion: Cocking phase(late) Injury Potential :  Injury Potential Deceleration Phase Proper Mechanics:  Proper Mechanics The keys to proper mechanics are: Equal opposites Symmetry Balance Athleticism Injury Risk:  Injury Risk Factors that can lead to poor performance and heighten a pitcher’s injury risk: Improper mechanics Poor dynamic stability Muscle fatigue Injury Risk :  Injury Risk Another factor that can lead to injury is Biomechanical Adaptation Patterns (BAPs) A termed coined by Ron Hruska, PT founder of the Postural Restoration Institute in Lincoln, NE. Biomechanical Adaptation Patterns :  Biomechanical Adaptation Patterns BAPs exist in all of us to a certain degree and are even desirable to a degree in a pitcher. Problems occur when an athlete performs the same movement patterns day after day, month after month and in some cases year after year resulting in strong BAPs and undesirable asymmetrical activity. Biomechanical Adaptation Patterns :  Biomechanical Adaptation Patterns Most likely joint affected in the baseball pitcher is the acetabular-femoral or femoral-acetabular joint depending on your myokinematic perspective. Biomechanical Adaptation Patterns :  Biomechanical Adaptation Patterns Can adversely effect lumbo-pelvic-femoral symmetry and stability which is the foundation for proper trunk rotation, scapulo-humeral rotation and humeral-glenoid rotation. Biomechanical Adaptation Patterns :  Biomechanical Adaptation Patterns With a strong, undesirable BAPs that can not be inhibited, a pitcher who has a lack a left femoral IR may exhibit a lack of right shoulder IR due to the myokinematic processes occur in the athlete’s body. (will be discussed later) Biomechanical Adaptation Patterns :  Biomechanical Adaptation Patterns Previous generations of American children, boys and girls, got better training and were better all around athletes. We rode bicycles, waded in streams, played each sport in its season, climbed trees . . we didn't call it cross training but that's what it was. High-end coaches I talked to were consistent in telling me that the athletes they encounter -- even the high-achieving ones -- are often skilled in their sport but surprisingly poor at a basic athletic level. This "one-trick pony" athleticism is an injury risk, Michael Sokolove “Warrior Girls” 2008 Injury Prevention:  Injury Prevention Ensure proper pitch mechanics - excellent pitching coach Ensure dynamic stability - trunk, pelvis and shoulder girdle Prevent fatigue - properly designed total-body strength and conditioning programs designed to increase strength and endurance of lower and upper extremities Injury prevention:  Injury prevention Reduce postural asymmetries that can result in misuse or overuse of interactive and interdependent muscles and joints above and below the lumbo-pelvic-femoral complex (i.e., inhibit the undesirable BAPs). These postural asymmetries need to be reduced prior to initiating a regular strength and conditioning program. Postural asymmetries:  Postural asymmetries “He is called into this room for the purpose of comparing engines that have been strained from being thrown off track, or run against other bodies with such force as to bend journals, pipes, break or loosen bolts; or otherwise deranged so as to render it useless until repaired. To repair signifies to readjust from the abnormal condition in which the machinist finds it, … Postural asymmetries (cont.):  Postural asymmetries (cont.) …to the condition of normal engines which stand in the shop of repairs. His inspection would commence, by first lining up the wheels with straight journals; then he would naturally be conducted to the boiler, steam chest, shafts and every part that belongs to a completed engine.” A.T. Still (Founder of Osteopathy – 1899) Postural asymmetries:  Postural asymmetries There are underlying patterns of postural asymmetry existing to some degree in all humans regardless of hand dominance. Lower Body - Left Anterior Interior Chain Pattern (LAIC) (Hruska) Left Anterior Interior Chain Pattern:  Left Anterior Interior Chain Pattern Involves the following muscles: Diaphragm Iliacus Psoas Tensor Fascia Latae Vastus Lateralis Biceps Femoris Left Anterior Interior Chain Pattern:  Left Anterior Interior Chain Pattern The left hemi-pelvis will be anteriorly tilted and forward rotated compared to the right side. Left acetabular-femoral external rotation (AFER) Left Anterior Interior Chain Pattern:  Left Anterior Interior Chain Pattern Shifting your weight over the right hip will result in relative adduction and internal rotation of right hip (AFIR) and abduction and external rotation of the left hip (AFER). To return to normal you need an active contraction of the right hip abductors and left hip adductors. Left Anterior Interior Chain Pattern:  Left Anterior Interior Chain Pattern Anterior rotation of left pelvis results in weakness of left femoral internal rotation due to passive internal orientation of femur or as a result of compensation of external rotators to orient femur towards midline. Left Anterior Interior Chain Pattern:  Left Anterior Interior Chain Pattern A left anterior tilted and forward rotated hemi-pelvis will result in a L)ASIS “outflare” with a sacrum and lumbar spine that is oriented to the right. May lead to upper extremity pathomechanics. Left Anterior Interior Chain Pattern:  Left Anterior Interior Chain Pattern If there is an inability to establish left AF IR due to weakness of thrower’s left FA/AF internal rotators and/or hypertonicity of right FA/AF external rotators then the body must adjust and the thrower cannot achieve maximum velocity. Masek, 2007 Left Anterior Interior Chain Pattern:  Left Anterior Interior Chain Pattern With lumbar spine rotated to the right, compensations occur in the thoracic spine, i.e. upper trunk (thorax) rotation left These compensations will affect the position of the scapula on the rib cage of the thoracic spine. Causing dysfunction of proper scapular-thoracic/thoracic-scapular mechanics. Why does it always affect the left side?:  Why does it always affect the left side? Everyone favors right leg, no matter whether left or right handed 3 lobes of lung on right and only 2 on left Heart lays more on left Liver on right side (3-4#) maintains larger right diaphragm. Only spleen on left w/ smaller diaphragm. Diaphragm:  Diaphragm Why does it always affect the left side?:  Why does it always affect the left side? This organ asymmetry, coupled with gravity and environmental factors result in tendency to stand on right leg and rotate upper body to left. Reinforced w/ daily activities. Run around track clockwise RHP always pushing off w/ right and rotating upper body left. Kinetic Chain:  Kinetic Chain If pitcher has a left anterior interior chain, what is the dysfunctional progression up the kinetic chain? Progress up to the thorax, including the thoracic spine and rib cage. Large muscles of hip/trunk help position thorax to accommodate appropriate scapular motion (McMullen, Uhl 2000) Concave surface of scapula lies on the convex rib cage. Thorax / Shoulder Girdle:  Thorax / Shoulder Girdle Brachial Chain:  Brachial Chain The upper body polyarticular chain identified by Ron Hruska, PT Involves the following muscles: Intercostals (anterior/lateral), pectorals/deltoid, Sibson’s fascia, triangularis sterni, sternocleidomastoid, scalenes and diaphragm. Right BC opposed by: right lower trapezius, serratus anterior, external rib rotators and left internal oblique. A LAIC will usually result in a Right BC. Right Brachial Chain:  Right Brachial Chain Indicates the upper body compensation for an anteriorly rotated left ilium w/ concomitant sacrum, lumbar spine and diaphragm rotation to right (LAIC). Body compensates by rotating thoracic spine and rib cage back to the left. Right Brachial Chain:  Right Brachial Chain Thorax and lumbar spine will be sidebent right w/ concavity right and convexity left. Right ribs will be internally rotated and the left ribs will be externally rotated. Right Brachial Chain:  Right Brachial Chain Right scapula will be adducted and depressed due to right internally rotated ribs. Scapula will also appear to be upwardly rotated and “winging” (vertebral border posteriorly displaced). Scapular malpositioning:  Scapular malpositioning This depressed, upwardly rotated and winged position corresponds to what Burkhart, et al described in 2003. Termed the “SICK” scapula. Scapular malpositioning:  Scapular malpositioning Masek contends that this observed scapular pattern is due to compensatory thoracic/ scapular motion. Scapula appears depressed and adducted due to resting position of scapula on ribcage. Scapular malpositioning:  Scapular malpositioning Scapula upward rotation is due to compensatory activity of upper trapezius and levator scapula to restore frontal plane motion of head and neck due to depressed right shoulder. Scapular malpositioning:  Scapular malpositioning “Winging brings glenoid fossa anteriorly to correct scapular position so humeral-glenoid motion can occur. Compensation also includes elevation and abduction to allow increased H-G motion Scapular malpositioning:  Scapular malpositioning Increased abduction and elevation results in increased HG ER w/ a tight posterior capsule and external rotators of the rotator cuff as described by Burkhart, et al. Injury Implications:  Injury Implications “SICK” Scapula and tight posterior capsule have been implicated in a multitude of shoulder maladies including anterior instability, SLAP tears, rotator cuff tendinitis, tears and impingement, posterior impingement, bicipital tendinitis. It has also been felt by some physician’s to increase risk of UCL tears in pitchers. LAIC w/ Right BC:  LAIC w/ Right BC From front R) shoulder lower than L) and “towards” you Sidebent right Rib flare L), chest looks “fuller” L) ASIS closer to you and “outflare” and lower compared to R) LAIC w/ Right BC:  LAIC w/ Right BC From back R) shoulder lower, scapula depressed and adducted. Medial border winging Classic LAIC w/ Right BC:  Classic LAIC w/ Right BC Moving On …:  Moving On … Have reviewed pitch mechanics. Have reviewed pelvic asymmetry that can occur due to uninhibited BAPS (LAIC). Have reviewed thoracic and thoraco-scapular compensations due to LAIC (BC). Now … Identify and correct LAIC and BC patterns before moving on to our general exercise program to prevent pitchers’ arm injuries. Left Anterior Interior Chain (LAIC) Identification:  Left Anterior Interior Chain (LAIC) Identification Four principle tests: Supine Passive Straight Leg Raise Supine Trunk Rotation Sidelying Hip Adduction Drop Test Seated Passive Femoral Internal Rotation / External Rotation Test Supine Passive Straight Leg Raise:  Supine Passive Straight Leg Raise Sagittal Plane Patient supine w/ legs extended Examiner passively lifts LE, maintaining knee extension Positive test indicated by inability to SLR to 90 degrees Supine Passive Straight Leg Raise:  Supine Passive Straight Leg Raise w/ LAIC, usually positive left side due to anterior rotation of left hemi-pelvis causing tension on hamstrings Supine Trunk Rotation:  Supine Trunk Rotation Transverse plane test Athlete supine, examiner stabilizes rib cage. Allow knees to rotate to either side. Positive test indicated by knees not dropping to one side as far as the other. Supine Trunk Rotation:  Supine Trunk Rotation w/LAIC knees don’t go as far left indicating a right rotation of lumbar spine rotational bias right Hip Adduction Drop Test:  Hip Adduction Drop Test Frontal plane test Athlete sidelying w/ bottom knee bent to stabilize pelvis Examiner stabilizes pelvis w/ proximal hand Flex, abduct, ER femur w/ distal hand, return to neutral and allow knee to drop to table Hip Adduction Drop Test:  Hip Adduction Drop Test Do not let femur IR Positive when one leg does not drop to table due to bony block of pelvis. In LAIC left side does not drop Seated Femoral IR / ER :  Seated Femoral IR / ER Frontal plane test Athlete seated w/ legs over edge of table. Examiner places forearm underneath (B) femurs to relax psoas. Seated Femoral IR / ER:  Seated Femoral IR / ER Passively internally rotate and externally rotate femurs Can measure or visualize. w/ LAIC, tight posterior capsule due to compensatory femoral ER. Will lack femoral IR Seated Femoral IR / ER:  Seated Femoral IR / ER Interesting side note: athlete will be weak on L) resisted IR (gluteus medius) and R) resisted ER (gluteus maximus) due to compensatory patterns thru pelvis But, this is what is needed to stabilize pelvis LAIC corrective exercises:  LAIC corrective exercises Have identified a Left anterior interior chain. Based on a positive test: Passive SLR (sagittal) Supine Trunk Rotation (transverse) Sidelying Hip Adduction Drop (frontal) Seated Femoral IR/ER (frontal) Need to prescribe exercises to correct LAIC. 90 / 90 Hip Lift w/ Hemibridge:  90 / 90 Hip Lift w/ Hemibridge Developed by Ron Hruska, PT, founder Postural Restoration Institute. Activates L) biceps femoris to correct a L) anterior hemi-pelvis in sagittal plane. 90 / 90 Hip Lift w/ Hemibridge:  90 / 90 Hip Lift w/ Hemibridge Patient supine w/ feet on wall, hips 90 and knees 90. Deep breath, blow out as raise pelvis off table, keep back on. Maintain hip lift w/ left leg on wall, maintain L) knee position and straighten R) leg. 90 / 90 Hip Lift w/ Hemibridge:  90 / 90 Hip Lift w/ Hemibridge Slowly take right leg on and off wall as you breath in through nose and out through mouth. Should feel back of L) thigh engage. Repeat 5 sets of 10 reps. Right Sidelying Adductor Pullbacks:  Right Sidelying Adductor Pullbacks Restoration in transverse plane. Activates L) gluteus medius and ischiocondylar adductor to promote femoral control. Patient lying on R) side w/ hips 90, knees 90 and back rounded. Right Sidelying Adductor Pullbacks:  Right Sidelying Adductor Pullbacks Place a bolster between feet to make L) knee lower than foot and towel between knees. Place exercise band around lower leg, just below knee for resistance. Another person holds for resistance. Push bottom foot into wall. Right Sidelying Adductor Pullbacks:  Right Sidelying Adductor Pullbacks Breath through your nose as you “pull back” your L) leg. Exhale for 3 seconds as you squeeze L) knee into the right. Inhale and pullback further. Feel inner thigh. Exhale and squeeze down again. Right Sidelying Adductor Pullbacks:  Right Sidelying Adductor Pullbacks Continue this sequence until you have completed 4 – 5 breaths. Relax. Return to start position and repeat this sequence 4 more times. Left Sidelying Right Glute Max:  Left Sidelying Right Glute Max Transverse plane. Activates R) glute max to ER femoral-acetabular jt. In a AFER position. Orients sacrum to (L) Athlete laying on left side w/ hips and knees bent 60-90 degrees. Left Sidelying Right Glute Max:  Left Sidelying Right Glute Max Ankles on top of 3 – 5” bolster w/ feet firmly against wall. Exercise band around thighs, just above knees. Shift R) knee forward until you feel a pull in your L) outside hip. Left Sidelying Right Glute Max:  Left Sidelying Right Glute Max Keep toes on wall, raise your right knee up, while keeping hip shifted forward. Should feel outside of R) hip engage. Hold for 4 – 5 breaths. Relax and repeat 4 more times. Left Sidelying Left Flexed Adduction with Concomitant Right Extended Abduction:  Left Sidelying Left Flexed Adduction with Concomitant Right Extended Abduction Frontal plane activity. Returns pelvis to neutral state by activation of right hip abductors and left hip adductors. Athlete lying on left side w/ R) leg straight and L) knee bent 60 degrees Left Sidelying Left Flexed Adduction with Concomitant Right Extended Abduction:  Left Sidelying Left Flexed Adduction with Concomitant Right Extended Abduction Right shoulder, hip, knee and ankle lined up. Bolster under head so head is slightly side-bent right. Left foot on 2-3” bolster, toes pressing into wall and small bolster under left side. Left Sidelying Left Flexed Adduction with Concomitant Right Extended Abduction:  Left Sidelying Left Flexed Adduction with Concomitant Right Extended Abduction Slightly raise left knee off table by turning thigh “in.” Feel inside left thigh engage. Keep left knee up and turn right toes down. Left Sidelying Left Flexed Adduction with Concomitant Right Extended Abduction:  Left Sidelying Left Flexed Adduction with Concomitant Right Extended Abduction Attempt to take right foot off wall. You should feel right outside hip engage. Hold while taking 4 – 5 deep breaths in through nose and out through mouth. Relax and repeat 4 more times. Right Brachial Chain Identification:  Right Brachial Chain Identification Supine Left Rib Flare. Secondary to elevated left ribs. Horizontal Abduction Test. Decreased left side due to rotation of sternum/rib cage to right. Decreased shoulder flexion. Usually on left, again due to malpositioned rib cage/scapula. Decreased right HG IR. Due to humerus impinging on abducted/depressed (protracted) scapula when attempting IR (posterior impingement) Supine Rib Flare:  Supine Rib Flare Athlete supine. Considered positive when you see left rib cage elevated compared to right. Indicates left ribs externally rotated with right ribs internally rotated. Horizontal Abduction Test:  Horizontal Abduction Test Patient supine with knees bent. Arm to be tested off edge of table. Lower arm, at shoulder level with palm up. Positive test indicated by a decreased horizontal abduction compared to other side. Supine Shoulder Flexion :  Supine Shoulder Flexion Athlete supine, knees bent. Examiner places one hand on lower rib cage and guides arm over head as far as it will go. Repeat on other side. Shoulder Internal Rotation:  Shoulder Internal Rotation Athlete lies on back w/ knees bent. Bring bent arm to shoulder level. Stabilize shoulder w/ firm pressure on top of shoulder. Rotate forearm toward table as far as it will go w/o letting shoulder come up. Right Brachial Chain Corrective Exercises:  Right Brachial Chain Corrective Exercises 90/90 Hip Lift with Right Arm Reach and Balloon PRI Squat with Balloon Left Sidelying Swiss Ball Stretch w/ Apical Expansion and Balloon 90/90 Hip Lift with Right Arm Reach and Balloon :  90/90 Hip Lift with Right Arm Reach and Balloon Lie on your back with feet flat on wall, hips 90 and knees 90. 4 – 6” ball between knees. Right arm above head and balloon in left hand. 90/90 Hip Lift with Right Arm Reach and Balloon :  90/90 Hip Lift with Right Arm Reach and Balloon Take deep breath in through nose, exhale through open mouth as you do a pelvic tilt and lift tailbone off table, while keeping back flat. Dig down into wall with heels. 90/90 Hip Lift with Right Arm Reach and Balloon :  90/90 Hip Lift with Right Arm Reach and Balloon Place right hand straight up in air , balloon in mouth w/ left hand. Take a deep breath in through nose and as you blow into balloon reach towards ceiling with right hand. 90/90 Hip Lift with Right Arm Reach and Balloon :  90/90 Hip Lift with Right Arm Reach and Balloon Hold this position for 3 seconds using tongue in roof of mouth to prevent air-flow out of balloon. Again inhale through nose and exhale into balloon while reaching further towards ceiling w/ right hand 90/90 Hip Lift with Right Arm Reach and Balloon :  90/90 Hip Lift with Right Arm Reach and Balloon Hold this position for 3 seconds. After 4th breath in, pinch balloon and remove from mouth. Let air out. Relax and repeat sequence 4 more times. PRI Wall Squat with Balloon:  PRI Wall Squat with Balloon Stand w/ feet 7 – 10” away from wall. 4 – 6” ball between knees and balloon in left hand. Keep back rounded, begin to squat until bottom touches wall. PRI Wall Squat with Balloon:  PRI Wall Squat with Balloon Shift left hip back. Left knee will be slightly behind right and you will feel outside left hip engage. Squeeze ball and inhale through nose. As you exhale reach forward and across midline w/ right hand. PRI Wall Squat with Balloon:  PRI Wall Squat with Balloon Maintaining this position, inhale again and this time exhale into balloon. Pause 3 seconds keeping air in balloon w/ tongue in roof of mouth. PRI Wall Squat with Balloon:  PRI Wall Squat with Balloon Inhale again through nose and exhale into balloon while reaching across midline w/ right arm Do not strain. Inhale again and reach and exhale again. PRI Wall Squat with Balloon:  PRI Wall Squat with Balloon Should feel stretch across right chest wall, along w/ engagement of left abdominal wall and outside hip. After 4th inhalation, remove balloon and release air. Relax, repeat 4 more times Left Sidelying Swiss Ball Stretch w/ Apical Expansion and Balloon :  Left Sidelying Swiss Ball Stretch w/ Apical Expansion and Balloon Place a Swiss ball against wall. Lie on left side w/ left forearm on ground, balloon in right hand. Right leg in front and left heel against wall. Turn left toes up to ceiling and lift left foot off ground. Left Sidelying Swiss Ball Stretch w/ Apical Expansion and Balloon:  Left Sidelying Swiss Ball Stretch w/ Apical Expansion and Balloon Keeping left leg up, inhale through nose and exhale into balloon. Pause 3 seconds, tongue in roof of mouth to block air out of balloon. Inhale again through nose Left Sidelying Swiss Ball Stretch w/ Apical Expansion and Balloon:  Left Sidelying Swiss Ball Stretch w/ Apical Expansion and Balloon Slowly exhale again into balloon. Do not strain. After 4th breath in, remove balloon, let air out and relax. Repeat this entire sequence 2 more times. Exercise Progression:  Exercise Progression After restoring proper body position, now we can progress onto exercises designed to integrate diaphragm activity with scapulothoracic activity utilizing the serratus anterior, lower trapezius and triceps needed for scapular stabilization. Also need to work on shoulder IR/ER motions utilizing the subscapularis w/ proper scapular positioning. PRI Exercises:  PRI Exercises Standing Resisted Trunk Around w/ Left AFIR and Left Trunk Rotation. Sidelying Resisted Right Serratus Punch with Right Trunk Rotation. Sidelying Trunk Lift All Four Belly Lift Reach Standing Resisted Right Diagonal Flexion in PRI Right AIC Single Leg Vertical Balance Paraspinal Release w/ Hamstrings Supine Resisted Right HG IR Standing Resisted Trunk Around with Left AFIR and Left Trunk Rotation:  Standing Resisted Trunk Around with Left AFIR and Left Trunk Rotation Stand w/ tubing in right hand facing away from door. Shift hips to left and slightly bend both knees. Keep hip shifted left, begin to turn trunk to left by reaching across midline w/ right hand. Standing Resisted Trunk Around with Left AFIR and Left Trunk Rotation:  Standing Resisted Trunk Around with Left AFIR and Left Trunk Rotation Should feel right abdominal wall engage. Keeping trunk turned to left, raise right foot off ground. Feel left hip/thigh working. Standing Resisted Trunk Around with Left AFIR and Left Trunk Rotation:  Standing Resisted Trunk Around with Left AFIR and Left Trunk Rotation Balance, while taking 4 – 5 deep breaths in through nose and out through mouth. Relax and repeat 4 more times. Sidelying Resisted Serratus Punch with Right Trunk Rotation:  Sidelying Resisted Serratus Punch with Right Trunk Rotation Place a piece of tubing in each hand w/ tubing wrapped behind back. Lie on your left side with knees bent and head supported by bolster and small bolster under left side. Standing Resisted Trunk Around with Left AFIR and Left Trunk Rotation:  Standing Resisted Trunk Around with Left AFIR and Left Trunk Rotation Shift right knee ahead of left. Reach forward with right hand by straightening elbow. Keeping right knee forward and right elbow straight, inhale through nose… Standing Resisted Trunk Around with Left AFIR and Left Trunk Rotation:  Standing Resisted Trunk Around with Left AFIR and Left Trunk Rotation …as you exhale through mouth turn right knee and right arm up towards ceiling. Maintain this position while inhaling through nose. Standing Resisted Trunk Around with Left AFIR and Left Trunk Rotation:  Standing Resisted Trunk Around with Left AFIR and Left Trunk Rotation Exhale and reach upward with right hand. Should feel outside right hip and back of shoulder. From here, inhale again and as you exhale lower right arm and knee. Relax, repeat 4 more times. Sidelying Trunk Lift:  Sidelying Trunk Lift Lie on right side with hips and knees bent 90 degrees. Prop trunk up on your right forearm, keeping elbow directly under shoulder. Press left knee into right and pull scapula down and back Sidelying Trunk Lift:  Sidelying Trunk Lift Keeping scapula pulled back, slowly raise right hip up and off mat. You should feel muscles in the back of right scapula engage. Maintain this position, raise left arm above head … Sidelying Trunk Lift:  Sidelying Trunk Lift … and take 4 – 5 deep breaths in through your nose and out through mouth. Slowly return to the start position and repeat 4 more times. All Four Belly Lift Reach:  All Four Belly Lift Reach Position yourself on your hands and knees w/ hands on a 2 – 6” block. Place knees shoulder width or wider and round back. Keeping back rounded, raise knees off floor until legs are straight. All Four Belly Lift Reach:  All Four Belly Lift Reach Shift weight to right and reach towards floor w/ left hand w/o bending right elbow. Feel scapular muscles engage. Inhale through nose filling up the back of your right chest wall with air. All Four Belly Lift Reach:  All Four Belly Lift Reach Exhale through mouth and reach with your left hand. Place L)hand back on block and shift weight left. Reach towards floor with right hand with-out bending left elbow. All Four Belly Lift Reach:  All Four Belly Lift Reach Inhale filling back of left chest with air. Exhale and push with right hand. Continue this sequence of breathing taking 4-5 deep breaths in through the nose and out through mouth holding one position at a time. All Four Belly Lift Reach:  All Four Belly Lift Reach Relax and repeat 4 more times. Standing Resisted Right Diagonal Flexion in PRI Right AIC Single Leg Vertical Balance:  Standing Resisted Right Diagonal Flexion in PRI Right AIC Single Leg Vertical Balance Place a piece of tubing underneath your left foot and loop other end around right hand. Shift hips left and sidebend trunk left. Pull scapula down and together. Standing Resisted Right Diagonal Flexion in PRI Right AIC Single Leg Vertical Balance:  Standing Resisted Right Diagonal Flexion in PRI Right AIC Single Leg Vertical Balance Begin to raise right hand up and out as you rotate palm up. You should feel back of right scapula engage. Lift right foot in front of you. Try to balance on left leg as you reach … Standing Resisted Right Diagonal Flexion in PRI Right AIC Single Leg Vertical Balance:  Standing Resisted Right Diagonal Flexion in PRI Right AIC Single Leg Vertical Balance … across midline of your body with left hand. Hold this position while you take 4 – 5 deep breaths in through nose and out through mouth. Relax and repeat 4 more times. Paraspinal Release with Left Hamstrings:  Paraspinal Release with Left Hamstrings Place both palms on a 3-4” block and place feet directly in front of you. Pull shoulder blades down and together. Dig both heels into floor and push down with arms lifting hips off floor. Paraspinal Release with Left Hamstrings:  Paraspinal Release with Left Hamstrings You should feel your hamstrings and scapular muscles engage. Once your hips are up in the air, round your back, by tucking your bottom up. Continue digging both heels into ground as you move your hips forward or away from the block. Paraspinal Release with Left Hamstrings:  Paraspinal Release with Left Hamstrings Keeping hips forward and shoulders pulled together, lift your right foot off floor. You should feel your left hamstrings engage. Hold this for 4-5 breaths. In nose/out mouth. Repeat 4 more times. Supine Resisted Right HG IR:  Supine Resisted Right HG IR Lie on your back with knees bent. Bring your arms to shoulder level and rest on bolsters. Bend both arms at a 90 degree angle. Anchor a piece of tubing around a post directly above right hand. Supine Resisted Right HG IR:  Supine Resisted Right HG IR Place both ends of tubing in each hand. Keep left hand stable with thumb toward body and turn right hand so palm is towards body. Pull shoulder blades down and together. Supine Resisted Right HG IR:  Supine Resisted Right HG IR Keeping shoulder blades pressed down and together, straighten right elbow against tubing resistance. Should feel muscles in back of shoulder and arm engage. Supine Resisted Right HG IR:  Supine Resisted Right HG IR Maintaining this position, turn right hand downs toward mat. Should feel anterior shoulder muscles engage. Hold position while taking 4 – 5 deep breaths. (in nose/out mouth). Supine Resisted Right HG IR:  Supine Resisted Right HG IR Relax and repeat 4 more times. Where to now?:  Where to now? Corrected pelvic and thoracic asymmetries. Utilized exercises to maintain pelvic position while integrating exercises designed to recruit diaphragm and scapular stabilizers. Now can move on to traditional strength and conditioning programs. General Guidelines:  General Guidelines Utilize total-body exercise. Utilize plyometrics and medicine ball work to train UE and LE strength and explosiveness. Emphasize hamstring, glutes, obliques and scapular stabilizers. Avoid straight bar bench press. No overhead work, i.e. no behind neck lat pull downs. Review:  Review Brief overview of pitch mechanics. Overview of postural asymmetries / Biomechanical Adaptation Processes (BAPs). Left Anterior Interior Chain and influence on thorax and scapula. Right Brachial Chain and influence on scapulothoracic mechanics. Assessment techniques and corrective exercises for LAIC and Right BC. Exercises to strengthen polyarticular chains and decrease influence of BAPs. Reviewed general strength guidelines. Special Thanks:  Special Thanks Postural Restoration Institute, Lincoln NE. PRI Staff: Ron Hruska, PT Jason Masek, MSPT, ATC, CSCS, PRC Lisa Bartels, DPT Jane Ebmeier, Clinical Coordinator For more information: www.posturalrestoration.com Brian Gearity, MS, ATC, CSCS Baseball Strength and Conditioning Coach UT Remember: more important things:  Remember: more important things THANK YOU!:  THANK YOU! QUESTIONS?:  QUESTIONS?

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