Shoulder pain is a common complaint among baseball pitchers and is one of the top causes of missed participation, which results in an average of 527 days missed.1 Through a routine shoulder examination, pain may present with other dysfunctions, such as weak rotator cuff muscles or inhibition of the scapular muscles. During a traditional rehabilitation program, clinicians commonly prescribe scapular stabilization and proprioceptive and closed kinetic chain exercises.2 However, these exercise regimens tend to isolate the involved tissue and neglect the contributions of the trunk and lower extremity.2 Evaluating patients from a regional interdependence approach may allow clinicians to identify underlying causes of decreased hip mobility and/or dysfunction. Decreased hip mobility has been linked to lateral elbow pain, poor shoulder kinematics, shoulder impingement, or an inhibition of scapular muscles.3
The regional interdependence model refers to the concept that identifies unrelated impairments in a remote anatomical region that may contribute to, or be associated with, the patient's primary complaint.4
Although pain in the shoulder is present, it may not be the origin of the dysfunction. It has been determined that limited hip mobility can alter biomechanics and lead to both hip and shoulder pathologies.3–5 Limited hip mobility can affect an upper or lower extremity when normal pitching biomechanics are altered, and force the torso, scapulothoracic joint, and shoulder to compensate.6,7 It is important to use a regional interdependence approach during the evaluation and to assess hip mobility in patients presenting with upper extremity pain.
Neurodynamics is a regional interdependence assessment and treatment approach to address neuromuscular dysfunction that is commonly overlooked, and can contribute to musculoskeletal dysfunction or pain.8 A common neurodynamic assessment includes evaluating eight unique movements (four upper extremity, four lower extremity). A positive finding would include any reproduction of symptoms, neurological symptoms that may radiate, and/or perceived musculoskeletal tightness. A positive test result may indicate a dysfunction in the neuromuscular interface, and prompt treatment is necessary.8 Neurodynamic sliders are a treatment method that can modulate pain and/or the symptoms through the central and peripheral nervous system.9 With the use of neurodynamic sliders, optimal function may be restored between the nervous and musculoskeletal systems, resulting in normal fluid movement.9
A 22-year-old left-handed male pitcher presented with complaints of shoulder and elbow pain while throwing. He stated the pain started 1 week prior. The patient reported his pain 2 days after it began and started a traditional rehabilitation plan that focused on shoulder stabilization and wrist flexor stretching. After reevaulation, it was noted that his pain was sharp during activity and achy after. He also stated the pain woke him up at night and radiated into the middle of his hand. The patient identified his shoulder pain to be a 5 of 10 on the Numeric Pain Rating Scale (NRS) at rest and an 8 of 10 on the NRS during activity. He had a history of infra-spinatus strain and low back pain, which occurred 1 year prior. Activities that elicited symptoms were excluded, but the patient stated he did not feel that he was improving. There were no medical “red flags” noted.
The patient was tender to palpation over the origin of the wrist flexor mass, but not tender over the glenohumeral or scapulothoracic structures. He was not tender to palpation over the cervical spine. Cervical spine range of motion (ROM) and upper thoracic spine ROM were within normal limits.10,11 The patient had decreased glenohumeral and hip joint ROM compared bilaterally, measured with the clinometer app (Table 1). Manual muscle tests of glenohumeral motion were rated a 5 of 5, with the exception of a 4 of 5 for the external rotation at 90 degrees of abduction.12
Shoulder and Hip Range of Motion Measurements
The Patient-Specific Functional Scale, Disablement in the Physically Active Scale, and Global Rate of Change were also assessed (Table 2). Patient outcomes were less than desired (eg, NRS score of 3 of 10, persistent night symptoms), and a new course of assessment and treatment was warranted. A neurodynamic assessment was used to identify whether an underlying neuromuscular pathology was present. The assessment revealed positive results on peroneal and median nerve testing (Figure 1), which could indicate neural tension. Median and peroneal neurodynamic sliders were added to the patient's intervention plan and were administered as a treatment on day 5. This neurodynamic treatment was administered by the clinician passively, which included three sets of 10 repetitions. During this treatment, the clinician provided a slow and gentle movement so the patient did not have any increase of symptoms. The patient then completed actively three sets of 10 repetitions of the peroneal and median nerve neurodynamic sliders at home. After three treatments of incorporating neurodynamic sliders, the patient reported a score of 0 of 10 on the NRS.
Neurodynamic assessment and treatment of the median nerve.
The patient was reevaluated on day 12 and had a negative neurodynamic assessment and increased ROM in the glenohumeral and hip joints. Not only did the patient have an increase of ROM from the beginning of the treatment, but his ROM became symmetrical throughout the treatment. The patient reported a scale of 6 on the Patient-Specific Functional Scale, for which the minimal clinically important difference is 2 to 3 points.13 The patient was discharged on day 12 with a total of three neurodynamic treatments. At his 1-week follow-up visit, on day 26, the patient reported no pain on the NRS at rest, with activity, or at night. A neurodynamic reassessment was conducted to determine lasting effects and nerve test results were all negative. The patient also maintained glenohumeral and hip joint ROM.
Baseball players report that at least 47% of injuries occur at the upper extremity.1 However, without including a regional interdependence approach in the assessment and treatment, regional dysfunction and/or compensatory patterns may be missed, which may limit the patient from reporting positive outcomes and developing ideal biomechanics.1,5,6 It is important that clinicians evaluate patients initially using a regional interdependence approach to correct the underlying dysfunction that has possibly led to the problematic pathology.
Within this specific case study, there was potential neural involvement and neurodynamic sliders were indicated. Because the peroneal and median nerves both had positive findings in the assessment, the administered treatment was the upper limb nerve test for the median nerve and the peroneal nerve (Figure 1) as described by Butler.14 Sliders were chosen as a treatment over tensioners because they were less likely to increase the patient's symptoms while also decreasing the neural dysfunction and pain associated with the neural dysfunction.9 Because neurodynamic sliders create little tension or compression on the nerve, a neurodynamic tensioner produces and increases pressure or tension on the nerve relative to the surrounding tissue.8,9,14 When tensioners are administered, they may produce an increased risk of symptom provocation.8,9,14 Therefore, if the clinician administering neurodynamic sliders is not knowledgeable of neurodynamic tensioners, the tensioners are contraindicated.9,14
Neurodynamic sliders gained recent attention within the literature as a paradigm to successfully treat neuromuscular pain and dysfunction with neural involvement.8 Neurodynamic sliders have been identified as a successful treatment for carpal tunnel syndrome, lateral epicondylitis, perceived hamstring tightness, and medial tibial stress syndrome.8,9,10,15 The current case review is unique in that it provides evidence for incorporating neurodynamic median sliders in the treatment of shoulder and elbow pain and peroneal sliders to increase hip ROM without symptomatic hip pain.
Implications for Clinical Practice
The use of neurodynamic sliders may provide alternative approaches to successfully treating shoulder and elbow pain and decreased ROM. By incorporating neurodynamic sliders into a rehabilitation program, the interface between the neuromuscular system may be restored to a more optimal function.8,9,13 Clinicians should not only assess a patient at the location of symptoms, but also through a regional interdependence lens to identify underlying dysfunctions.
Assessment of patients through the regional interdependence lens is important to identify a possible underlying dysfunction that led to musculoskeletal pain in a remote anatomical region. Also, an initial assessment of patient outcomes is important to determine the patient's progression throughout rehabilitation. Incorporating a neurodynamic assessment to identify the neural system as an underlying cause of the pain is necessary because this may lead to musculoskeletal pain and/or dysfunction. This case review examined an overhead thrower with complaints of shoulder and elbow pain who had an underlying hip dysfunction and responded positively to treatment with neurodynamic sliders. Future research is needed to assess the use of neurodynamic sliders in the treatment of shoulder and elbow pain. Further research related to similar patients who have hip dysfunction and are treated with neurodynamics should be evaluated to determine the benefits of neurodynamic sliders for the treatment of hip asymmetries when neuromusculature involvement is indicated.
- Li X, Zhou H, Williams P, et al. The epidemiology of single season musculoskeletal injuries in professional baseball. Orthop Rev (Pavia). 2013;5:e3. doi:10.4081/or.2013.e3 [CrossRef]
- McMullen J, Uhl TL. A kinetic chain approach for shoulder rehabilitation. J Athl Train. 2000;35:329–337.
- Cheatham S, Kreiswirth E. The regional interdependence model: a clinical examination concept. International Journal of Athletic Therapy and Training. 2014;19:8–14. doi:10.1123/ijatt.2013-0113 [CrossRef]
- Wainner RS, Flynn TW, Whitman J. Spinal and Extremity Manipulation: The Basic Skill Set for Physical Therapists. San Antonio, TX: Manipulations; 2001.
- Scher S, Anderson K, Weber N, Bajorek J, Rand K, Bey MJ. Associations among hip and shoulder range of motion and shoulder injury in professional baseball players. J Athl Train. 2010;45:191–197. doi:10.4085/1062-6050-45.2.191 [CrossRef]
- Cheatham SW, Shimamura KK, Kolber MJ. Differences in hip range of motion among collegiate pitchers when compared to youth and professional baseball pitcher data. J Can Chiropr Assoc. 2016;60:233–240.
- Laudner KG, Moore SD, Sipes RC, Meister K. Functional hip characteristics of baseball pitchers and position players. Am J Sports Med. 2010;38:383–387. doi:10.1177/0363546509347365 [CrossRef]
- Hansberger BL, Nasypany A, Baker RT, May J. Incorporating neurodynamics in the treatment of lower leg pain: a case review. Athletic Training & Sports Health Care. 2016;8:36–39. doi:10.3928/19425864-20151207-01 [CrossRef]
- Shacklock M. Clinical Neurodynamics: A New System of Musculoskeletal Treatment, 2nd ed. New York: Elsevier Health Sciences; 2005.
- Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther. 2010;40:67–81. doi:10.2519/jospt.2010.3047 [CrossRef]
- Lewis JS. Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment?Br J Sports Med. 2009;43:259–264. doi:10.1136/bjsm.2008.052183 [CrossRef]
- Hislop H, Avers D, Brown M. Daniels and Worthingham's Muscle Testing: Techniques of Manual Examination and Performance Testing, 9th ed. New York: Elsevier Health Sciences; 2013.
- Horn KK, Jennings S, Richardson G, Vliet DV, Hefford C, Abbott JH. The patient-specific functional scale: psychometrics, clinimetrics, and application as a clinical outcome measure. J Orthop Sports Phys Ther. 2012;42:30–42. doi:10.2519/jospt.2012.3727 [CrossRef]
- Butler DS. The Sensitive Nervous System. Adelaide, Australia: Noigroup Publications; 2000.
- Castellote-Caballero Y, Valenza MC, Puentedura EJ, Fernández-de-Las-Peñas C, Alburquerque-Sendín F. Immediate effects of neurodynamic sliding versus muscle stretching on hamstring flexibility in subjects with short hamstring syndrome. J Sports Med (Hindawi Publ Corp). 2014;2014:127471.
Shoulder and Hip Range of Motion Measurementsa
|Overall change (mean ± SD)||Left||6 ± 5.24||4 ± 2.82||13 ± 9.19||13 ± 9.19|
|Right||8 ± 5.65||1 ± 0.7||30 ± 21.21||25 ± 17.67|
|Overall change (mean ± SD)||Left||8 ± 5.65||8 ± 5.65||11 ± 7.77||0 ± 0|
|Right||0 ± 0||−5 ± 3.53||6 ± 4.24||1 ± 0.7|
|Measure||Day 1||Day 5||Day 8||Day 10||Day 12||Day 26|
|NRS (at rest)||5/10||3/10||2/10||2/10||0/10||0/10|
|GRoC (11 pt)||N/A||0||0||1||3||3|