Here is a Deltoid injection done intramuscular.
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When refering to evidence in academic writing, you should always try to reference the primary original source. That is usually the journal article where the information was first stated. In most cases Physiopedia articles are a secondary source and so should not be used as references.
Physiopedia articles are best used to find the original sources of information see the references list at the bottom of the article. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Original Editors - Samuel Jacob Melnick.
Wilk et al describes the throwing athletes' predicament by defining The thrower's paradox: The thrower's shoulder must be lax enough to allow excessive external rotation but stable enough to prevent symptomatic humeral head subluxations, thus requiring a delicate balance between mobility and functional stability.
This balance is frequently compromised and believed to lead to various types of injuries to the surrounding tissues. While many sports involve overhead throwing, baseball pitchers compromise a plurality of those throws and over half of the throws made in a baseball game. The etiology behind a throwing injury can be analyzed by looking at the different phases of an overhead throw.
The phases of an overhead throw consist of a wind up, stride, cocking, acceleration, and deceleration phase. They are as follows: The wind up phase is defined as the initial movement to maximum knee lift of stride leg. During these simple movements consider the muscles proximally to distally. During this phase the muscle activity is quite low and for these reasons risk of injury is low as well.
The picture below depicts an overhead view of the alignment of the body during the acceleration phase of throwing. Note the 15 degree angle of the foot away from the center of the mound. During the cocking phase, Fleisig reports a 3. Please note that decreasing the distance away from center or decreasing the angle did not result in increased anterior force on the shoulder.
So, because of the increased anterior force on the shoulder, it can be assumed that over time the anterior ligamentous structures to the glenohumeral joint may be compromised. This finding is consistent with the anterior glenohumeral instability found in many throwing athletes and emphasizes the importance of proper mechanics throughout the entire kinematic chain.
The arm cocking phase can be defined as the beginning of lead foot contact and ends at maximum shoulder external rotation. Due to the circumstances the scapula and shoulder muscles are highly activated to promote and sustain movements of the shoulder, especially external rotation. Special focus to anterior instability in this phase is vital due to the high ranges of external rotation reached in this phase. The biceps brachii and supraspinatus are shown to be initiated or excited by these mechanoreceptors and assist with prevention of anterior instability.
Overtime the excessive utilization of the biceps brachii could lead to a superior labrum anterior to posterior SLAP tear. Simultaneously the pectoralis major, subscapularis, and serratus anterior are inhibited. These muscles decelerate shoulder external rotation in this phase. When these actions cannot be preformed there is increase likelihood of anterior instability of the glenohumeral joint.
The arm acceleration phase begins at maximum shoulder external rotation and ends at ball release. Improper stabilization of the scapula may be the cause of increased risk of shoulder impingement in this phase.
Coupled with the arm cocking phase this phase has also been hypothesized to be at increase risk of various shoulder injuries due to the high kinetic energy generated from the lower extremities.
The arm deceleration phase begins at ball release and ends at maximum shoulder internal rotation. Due to the high forces generated in this phase, the posterior muscles are highly susceptible to tensile overload, undersurface cuff tears, labrum and bicep pathologies, capsule injuries, and internal impingement. Olsen et al surveyed year old baseball players to determine possible risk factors for surgery among adolescent baseball pitchers.
Compared with the control group, the shoulder injury group pitched significantly more months of the year, innings per game, pitches per game, pitches per year, and warm-up pitches before a game. These pitchers were more frequently used as starting pitchers and pitched in more showcases. They pitched with higher velocity despite fatigue. They also used anti-inflammatory drugs more frequently to prevent an injury.
This section will mostly pertain to the upper extremity's influence on throwing. There is inconclusive evidence as to whether or not glenohumeral external rotation during the earlier phases of throwing such as stride foot contact has a positive or negative impact on throwing kinematics or injury occurrence. Athletes with throwing injuries typically present with an increase in shoulder external rotation and a decrease in shoulder internal rotation.
External Rotation can range actively at 90 o abduction from o to o and passively at Internal rotation was commonly found at Total motion, which is the combination of external and internal rotation, was found to be approximately equal on both the throwing and non-throwing shoulder of professional baseball pitchers.
This indicates that although motion was lost in one direction it was gained in the opposite direction. Changes in the tissue structure of the anterior capsule of the GH joint is theorized to be the greatest contributor to increase in shoulder external rotation. Controversially, research has also shown posterior capsule laxity in throwing athletes without anterior capsule issues and mixed deficits in range of motion.
Due to the circumstances there is no definitive conclusion that anterior capsule laxity is the exclusive reason for hypermobility at the shoulder.
The osseous adaption most notably seen in a throwing athlete is an increase in retroversion of the humeral head in the glenoid. The retroversion angle of the humeral head can be configured by subtracting the angle of the transepicondylar axis, with respect to the horizontal, from the angle of the humeral head axis, with respect to the horizontal.
Chant et al theorized that a larger angle in retroversion of the humeral head would constitute an increase in shoulder external rotation prior to the anterior capsule and GH ligaments.
The decrease in shoulder internal rotation could be attributed to contacting the posterior capsule sooner. Common strength deficits demonstrated by throwing athletes are weak shoulder external rotators and strong shoulder internal rotators and adductors. Unilateral muscle ratio at the shoulder and more specifically antagonist-agonist muscle strength ratio have been utilized to assess muscle balance necessary at the shoulder to maintain dynamic stabilization.
These muscle groups have shown the greatest muscle activity in EMG studies during all phases of throwing and contribute to mobility and stability of both the humerus and scapula. Studies have shown an increase in scapula protractors, elevators, and depressors in throwing position baseball players as compared to non-throwing positions.
The scapula plays an important role throughout any movement of the arm especially with overhead throwing. A common issue faced with throwing athletes is scapular dyskinesis which is the alteration in motion of the scapula during coupled scapulohumeral movements.
The signs and symptoms are as follows, most notably is the asymmetrical dropped scapula, an inferior medial border prominence, coracoid pain and mal-position, and dyskinesis of scapular movement such as anterior tilting of the scapula causing a decrease in shoulder internal rotation. The physical examination of an overhead throwing athlete should involve a thorough upper quarter examination that includes the joints above and below the shoulder.
The injuries incurred by these athletes are wide-ranging, requiring an in depth evaluation to tease out the pathology. The basis of the examniation should involve: The anterior, inferior, and posterior portions of the joint capsule must be evaluated to determine whether a hyper or hypomobility is present. The following chart gives an itemized examination of the key points of the physical examination.
A lower quarter examination is imperative for these athletes as well. Decreased knee flexion from stride foot contact through the release phase has been correlated with higher pitching velocities, so adequate knee strength and stability should be addressed.
While preventative and conservative treatments are the most critical components of rehabilitation for common injuries affecting the throwing athlete, concomitant medical management is indicated for certain conditions. The following medical recommendations should be considered: These pharmacotherapies are utilized mainly in the initial periods of shoulder pathology in order to decrease pain and inflammation.
Corticosteroids have been shown to be effective for short-term pain reduction for sub-acromial impingement and rotator cuff tendonitis but demonstrate poor long-term pain reduction and continued function.
Therapeutic consideration of the involved tissues should lead treatment and decisions of return to play as ROM and strength are properly restored. Failure to demonstrate marked progress by 3 months or return to asymptomatic competition by 6 months necessitates imaging if not already obtained. Additionally, if suspicion of a more notable dysfunction or mechanical abnormality presents then clear imaging is warranted.
Of the four main categories of SLAP lesions, throwing athletes typically present with a Type II tear which includes a full or partial detachment of the biceps brachii tendon from the superior labral attachment in addition to labrum involvement. This injury results from repeated tensile and torsion forces from external rotation in the late cocking phase as well as the eccentric biceps brachii contraction through deceleration.
Injury to the rotator cuff muscles or the bicipital tendon may be due to primary or secondary impingement of the subacromial structures. Although primary impingement is rare in throwing athletes, both conditions typically respond well to conservative therapy. The most common mechanisms for secondary impingement of rotator cuff muscles is joint instability and laxity, most often involving lack of adequate scapular control. Surgical examination and debridement of the involved tissues for this condition is indicated only after failed attempts at proper conservative therapy as there is not strong evidence to support surgery for this condition.
Full or partial thickness tears of the rotator cuff should attempt no less than two bouts of physical therapy to the complete shoulder complex followed by an interval throwing program. Current research demonstrates very poor return to play outcomes for throwing athletes who undergo surgical intervention for full rotator cuff tears, especially baseball pitchers.
Although the majority of pathologies related to the dominant shoulder in the throwing athlete are categorized as overuse or damage resultant from repetitive trauma, the occurrence of acute traumatic instability or dislocation most often indicates surgical management. Recurrent dislocation rates have been found as high has Please refer to this Physiopedia link for surgical information on shoulder Internal Impingement. Pitchers have the option of throwing from "The Stretch" or "The Wind-up" positions.
It is important for them to be comfortable with both deliveries and for both to be mechanically similar during the follow-through phase. The throwers ten exercise programme is a long sanding series of exercises designed to prepare the shoulder for throwing related videos and PDFs. An extension to the standard thrower's ten exercise programme has been proposed by Wilk et al .
Youtube video demonstrating the Throwers Ten exercise programme. Lyman et al established the following recommendations for adolescent pitchers :. Ballistic Six Exercise Progression . The ballistic six exercises were developed to reproduce the conditions under which the shoulder girdle musculature must act to control the head of the humerus on the glenoid during the overhead throwing motion.
The sets, reps, and progression of the ballistic six training regimen was developed to follow the SAID principle of progressive resistance exercise and also to tax the anaerobic and aerobic systems of the pitcher in a similar pattern to that of a baseball game.
Exercises 1,2,4,5,6 are performed unilaterally while exercise 3 is to be performed with both hands. Identification of these factors can help little league coaches and associations determine rules and regulations to further protect adolescent pitchers. The purpose of the article: They determined frequently, injuries can be successfully treated with a well-structured and carefully implemented non-operative rehabilitation program.
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