Distal to proximal segmental sequencing, all right? So it's 1,000, 2,000, 3,000, 5,000, 6,000, starting from the lower leg through the forearm pronation. So it's a summation of speed, and you have to have that summation. It's all about the kinetic chain, and we're gonna talk about that. It's from the toes to the fingertips, and you gotta examine the whole way through. The weak link will get you every time. I gotta talk to Ben Kibler. This is his slide, actually. Alterations in interactive motions in one area creates change throughout the system, and it alters the forces in the distal segment. So this is the injury cause, and it's all you're always trying to catch up. The problem is once a distal segment goes, you're always trying to catch up above. Historically, thrower's shoulder in the 70s was outlet impingement. Then the 80s, it was subtle instability. Then it's internal impingement in the 90s. 2000s, scapular dyskinesias, sick scapula syndrome, GERD, and SLAPS, and then there's biceps tunnel disease. Well, here's the thing. So what's next? My next question is why aren't our outcomes any better if we know more about it? What are we missing? We're constantly worrying about what are we missing? This is the potpourri of suspected culprits for disabled throwing shoulder. These are all in your handouts. The most common things we talk about now are scapular weakness and dyskinesia, posterior inferior capsular contracture, dynamic posterior instability, internal impingement, SLAP lesions, partial cup tears, GERD, and then biceps tunnel syndrome. So there's a lot to them. Here's the problem. If something goes wrong with your kinetic chain, it affects every one of those things, all right? Once you get scapular dyskinesias, it affects every one of those things. And then in the end, you got this spaghetti soup looking stuff that it affects everything. So it's a pretty complicated problem. So the big list, this is the big list. What do you look for? Okay, number one, landing leg or quad weakness, landing hip internal rotation loss, stance leg hip extension loss, hamstring tightness, pelvic obliquity and rotational issues, poor posture, poor core, scapular malposition and dyskinesis, motion loss of any type, especially total range of motion, shoulder weakness of any type, especially dynamic instability, pec major, latissimus dorsi mismatches, which give you posterior instability, or any muscle inactivation from C5 to thoracic outlet. Here's the real list of problems, the small list. Posture balance, lower extremity flexibility and strength, lumbopelvic hip complex motion, core flexibility, scapular position, shoulder stability, and kinesis. All right, posture. Posture affects everything. No matter what you do, you gotta fix their posture, number one. If they have bad posture, you're gonna have a bad problem with the thrower. Number two is balance. So you're gonna do open and closed chain dynamic and functional stability testing. I like this thing called the iBalance. The iBalance will tell you pretty quickly how their balance is. And if you don't think it's important, if you fix someone's UCL that's a thrower, you actually improve their balance. What about lumbopelvic, you know, I have trouble with hips, I don't know about you, but hips are hard for me. But if you look at the literature, it's replete with scapular position, scapular kinematics, range of motion, external rotation, torque, shoulder eccentric loads, those are all affected by your hips, your lumbopelvic hip mobility. And it's really important. Sometimes you can fix an athlete by just getting rid of their internal rotation contracture of their left hip in a thrower. So what about hip rotation? Well, is it like shoulder rotation? Should you do it in extension and inflection? Well, your stance leg, you should do in extension. And your landing leg, you should do in about 45 degrees of flexion to see what their motion is to make sure they don't have any contractures. What about core stability? Well, it's been well published that many athletic appearing baseball players fail to maintain a neutral position performing the simplest of spine stabilization exercises. How do you expect them to throw well if they have a weak core? I take over a lot of professional golfers and that's the first thing we look at. We look at their core. They go bad when their core goes bad. During inspection, you gotta take their shirt off. Start from the top. How many times does a fellow not take the shirt off? They're looking, I say, how can you figure out what's wrong if you don't take his shirt off? Anyway, you wanna look for any type of postural problems, muscle problems, especially atrophy of the infraspinatus, which we see a lot in throwers. The next is, the scapula to me is the essential link. It's the base between the trunk and the arm. It maintains a dynamic, stable, reproducibly producing platform for the glenohumeral joint. You have to have a good scapula. It maximizes both glenohumeral joint stability and transfer of motion to the arm. You got a bad scapula, you can't throw well. And Craig Morgan and Ben Kibler and Steve Burkhart did us a great service by explaining what sixth scapula syndrome is and what to look for. That's scapular malposition. It's inferior, the medial border is prominent, coracoid and AC pain, and then you get dyskinesis. So now, this is a typical malposition that you typically see. Ben also came out with a composite 3D scapular motion during throwing has been established and deviation from the established patterns are associated with injury. What about shoulder motion, which I think is very important? You got to do it actively, passively. You need to have true abduction and true flexion. And then you want to do internal extra rotation, both at the side and overhead. Here's the skinny on the shoulder at rest. This is kind of the take home message. This is what you want to look for. So side to side, anything that's greater or less than five degrees. So you got a 10 degree window versus the opposite shoulder. So you should be equal to your opposite shoulder if you're five more than five less. If you're more than five more, that's an issue. If you have a GERD difference between 18 and 20, that's a problem. That's a glenohumeral internal rotation deficit. If you have a side to side glenohumeral external rotation loss of less than five degrees, that's an issue. If your humeral torsion is greater than 17 degrees, you're going to have problems. Now you got to remember, when am I going to examine this or when am I going to look at it? Well, if you do it post throwing, they're going to have eight to 12 degrees of internal rotation loss. 24 hours, it's 12 to 15. 48 hours, it's 15. At 72 hours, they return to baseline if they're late in the season. But if they're early in the season, it takes 96 hours. So you got to decide when are you going to examine them. You get them a baseline and then you've got to do it again to see if they truly have it. Then there's this slap problem. We have way too many slap tests. I mean, there's not one test, single maneuver that can accurately diagnose a slap lesion. This is what we do in Pittsburgh. It's called the Pit Slap 3-Pack. You have an active compression that's positive and you have a D-PIT, a dynamic posterior instability test and a modified D-PIT, and you have a positive whipple and a positive modified whipple. You have a 98% chance of having a symptomatic slap. This is John Conway doing that. This is a dynamic posterior instability test. We call it the D-PIT. He asked the player to, this is a left-handed player, he's asking him to throw, and the arm goes right out the back there and it really bothers him, he'll point to that area. And the modification is to put your finger over it and block him from going out, and if it goes away, you have a pretty good chance. This is unpublished data, we just finished this. But for posterior instability in slaps, if just the dynamic posterior instability test is positive and the modified's positive, you have a sensitivity of 92, specificity of 95, and a positive predictive value of 98%. Now there's another test that we like to do if there's a hidden tunnel lesion, that's O'Brien's test, and he called it the three-pack. So if you have a positive O'Brien's test or an active compression and positive palpation in the groove, that's the best way to find biceps tunnel disease. Stability, you wanna do apprehension, anterior-inferior posterior translation, jerk and circumduction tests. So what about good slap, bad slap? You gotta have a hypermobile segment, you gotta have a mobile segment to throw well. So that's a good slap, it's a purposeful, beneficial, allowing greater labor mobility, humor elevation, external rotation, velocity and performance. But then there's the bad slap. That's when performance, it's a pathologic process causing translational and rotational micro-instability, loss of, or pain and loss of performance. So a good slap, you get pain relieved by a subacromial injection, it's a type one, or posterior, type two, chronic, it has good tissue, it rolls back on ABER, biceps tendon is stable on ABER, and there's no rotator cuff tear. There's an easy way to remember it, it's in your handout, it's called STAMP-BR, that's how I can always remember them. Bad slaps, the pain's not relieved. Anterior, or type three or four, it's an acute onset, bad tissue, unstable in ABER, and you have a rotator cuff tear. So imaging, if you wanna operate on a thrower's shoulder, get an MRI, but if you get one, don't treat the MRI, because they always have something wrong with them. 48% of asymptomatic Major League Baseball pitchers had a slap lesion, that's Lesniak's study. 80% of asymptomatic mature pitchers had MRI changes, and 45% of them had a labral tear, and there was nothing wrong with them. But sometimes it is, like it is on the right, that's a true pathologic slap tear. So in summary, thrower's shoulder is a pathologic continuum. It's a breakdown of sound mechanics, and thus, we lose the protection of the kinetic chain. Physical exam, you start at the ground, work your way up to the fingertips. You must understand and reestablish the kinetic chain at every level, function and synchrony. You need to try to identify the shoulder at risk. As the continuum progresses, pathology can occur at any level of the kinetic chain, and the components of the restraint system, and when any pathology prevents reestablishment of this kinetic chain, you must be able to surgically address that pathologic event. Thank you very much. I don't see prevention, but Pittsburgh is the real city of champions.

kinetic chain

thrower's shoulder injuries

scapular weakness

dyskinesis

surgical intervention