Athletic Training and Sports Health Care

Pearls of Practice 

Joint Mobilization Technique for Flexor-Pronator Mass Tightness in the Throwing Athlete

Kallie N. Hannon, ATC, CSCS; Sarah Sherman, PT, DPT, ATC; Neal R. Glaviano, PhD, ATC

Abstract

Flexor-pronator mass tightness is a common pathology in throwing athletes. Between the 2010 and 2014 minor and major league baseball seasons, there were 763 forearm flexor injuries that placed athletes on the disabled list.1 In major league baseball alone, it has been found that 22% to 26% of all injuries involve the elbow.2

It is widely accepted that there are changes in the range of motion (ROM) of the elbow following a pitching outing. These changes are observed immediately after pitching and are present for 24 hours after pitching.3 The greatest changes in ROM are in shoulder internal rotation, total shoulder motion, and elbow extension.3 Although the ulnar collateral ligament (UCL) is the primary stabilizer against valgus forces, the demands on the medial elbow sometimes meet, if not exceed, the capacity of the UCL. In these cases, such as in the baseball throwing motion, the flexor-pronator mass provides dynamic stability to the medial elbow and serves to protect the UCL.1 These forces can lead to injury of the flexor-pronator mass, but also commonly lead to general elbow pain and tightness. Addressing decreased ROM after throwing is crucial to the prevention of motion adaptations that may lead to injury. We present a mobilization technique to address the decreased elbow ROM that results from pitching, specifically extension, due to tightness of the flexor-pronator mass.

Several types of joint mobilizations have been shown to increase range of motion and decrease pain.4 This particular joint mobilization is a sustained mobilization or traction.4 Traction movements typically have global effects as they take the slack off soft tissue around the joint and decrease compressive forces on the joint.4 Current literature regarding joint mobilization of the upper extremity focuses on the shoulder, and the little evidence that does exist regarding the elbow predominantly addresses lateral epicondylalgia.4

The patient is positioned supine on the table for mobilization of the elbow. The clinician will sit or stand to the side of the patient's affected limb. The patient's elbow is flexed to 90 degrees, the forearm is fully supinated, and the shoulder is slightly abducted (Figure 1A). A belt is placed around the proximal forearm distal to the elbow and around the back of the clinician (Figure 1B). The clinician leans back into the belt to create tension on the belt and distraction at the elbow. The distraction force should be perpendicular to the axis of the humeroulnar joint. Throughout the distraction, the clinician uses both hands to stabilize the forearm while applying over-pressure into supination (Figure 2). The clinician uses the thenar eminence of one hand to stabilize the ulna and uses the pads of the fingers on the other hand to stabilize the patient's thenar eminence, to place the patient in supination. The clinician holds this position for 15 to 30 seconds5 and then releases tension so the patient is in a rest position. General parameters for sustained mobilizations recommend three to five repetitions. The time and number of repetitions will be determined by tissue response to the mobilization.6

A recent systematic review investigated the existing literature regarding the use of joint mobilizations to improve clinical outcomes in the treatment of disorders affecting the elbow, wrist, and hand.4 The systematic review found 16 articles using various joint mobilizations at the elbow. The majority of these studies refer to Mulligan's Mobilization With Movement treating lateral epicondylalgia.4 Although these effects do not speak to the patient described in our example, there is promising evidence that joint mobilizations have led to improved pain-free grip strength, decreased pain, improved function, and increased ROM.4 Benefits of using this treatment include low time demand…

Flexor-pronator mass tightness is a common pathology in throwing athletes. Between the 2010 and 2014 minor and major league baseball seasons, there were 763 forearm flexor injuries that placed athletes on the disabled list.1 In major league baseball alone, it has been found that 22% to 26% of all injuries involve the elbow.2

It is widely accepted that there are changes in the range of motion (ROM) of the elbow following a pitching outing. These changes are observed immediately after pitching and are present for 24 hours after pitching.3 The greatest changes in ROM are in shoulder internal rotation, total shoulder motion, and elbow extension.3 Although the ulnar collateral ligament (UCL) is the primary stabilizer against valgus forces, the demands on the medial elbow sometimes meet, if not exceed, the capacity of the UCL. In these cases, such as in the baseball throwing motion, the flexor-pronator mass provides dynamic stability to the medial elbow and serves to protect the UCL.1 These forces can lead to injury of the flexor-pronator mass, but also commonly lead to general elbow pain and tightness. Addressing decreased ROM after throwing is crucial to the prevention of motion adaptations that may lead to injury. We present a mobilization technique to address the decreased elbow ROM that results from pitching, specifically extension, due to tightness of the flexor-pronator mass.

Mobilization Technique

Several types of joint mobilizations have been shown to increase range of motion and decrease pain.4 This particular joint mobilization is a sustained mobilization or traction.4 Traction movements typically have global effects as they take the slack off soft tissue around the joint and decrease compressive forces on the joint.4 Current literature regarding joint mobilization of the upper extremity focuses on the shoulder, and the little evidence that does exist regarding the elbow predominantly addresses lateral epicondylalgia.4

The patient is positioned supine on the table for mobilization of the elbow. The clinician will sit or stand to the side of the patient's affected limb. The patient's elbow is flexed to 90 degrees, the forearm is fully supinated, and the shoulder is slightly abducted (Figure 1A). A belt is placed around the proximal forearm distal to the elbow and around the back of the clinician (Figure 1B). The clinician leans back into the belt to create tension on the belt and distraction at the elbow. The distraction force should be perpendicular to the axis of the humeroulnar joint. Throughout the distraction, the clinician uses both hands to stabilize the forearm while applying over-pressure into supination (Figure 2). The clinician uses the thenar eminence of one hand to stabilize the ulna and uses the pads of the fingers on the other hand to stabilize the patient's thenar eminence, to place the patient in supination. The clinician holds this position for 15 to 30 seconds5 and then releases tension so the patient is in a rest position. General parameters for sustained mobilizations recommend three to five repetitions. The time and number of repetitions will be determined by tissue response to the mobilization.6

Clinician (A) positioning and (B) belt placement.

Figure 1.

Clinician (A) positioning and (B) belt placement.

Hand placement.

Figure 2.

Hand placement.

Clinical Relevance

A recent systematic review investigated the existing literature regarding the use of joint mobilizations to improve clinical outcomes in the treatment of disorders affecting the elbow, wrist, and hand.4 The systematic review found 16 articles using various joint mobilizations at the elbow. The majority of these studies refer to Mulligan's Mobilization With Movement treating lateral epicondylalgia.4 Although these effects do not speak to the patient described in our example, there is promising evidence that joint mobilizations have led to improved pain-free grip strength, decreased pain, improved function, and increased ROM.4 Benefits of using this treatment include low time demand and adaptable parameters, based on patient feedback. This distraction technique is supported by experiences in clinical practice and is developed from concepts in established literature.

Additional research is needed regarding joint mobilizations for the medial elbow. Research should focus on restoration of ROM after a pitching outing and decreasing pain in the medial elbow following throwing.

References

  1. Hodgins JL, Trofa DP, Donohue S, Littlefield M, Schuk M, Ahmad CS. Forearm flexor injuries among major league baseball players: epidemiology, performance, and associated injuries. Am J Sports Med. 2018;46(9):2154–2160. doi:10.1177/0363546518778252 [CrossRef]
  2. Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Rehabilitation of the overhead athlete's elbow. Sports Health. 2012;4(5):404–414. doi:10.1177/1941738112455006 [CrossRef]
  3. Reinold MM, Wilk KE, Macrina LC, et al. Changes in shoulder and elbow passive range of motion after pitching in professional baseball players. Am J Sports Med. 2008;36(3):523–527. doi:10.1177/0363546507308935 [CrossRef]
  4. Heiser R, O'Brien VH, Schwartz DA. The use of joint mobilization to improve clinical outcomes in hand therapy: a systematic review of the literature. J Hand Ther. 2013;26(4):297–311. doi:10.1016/j.jht.2013.07.004 [CrossRef]
  5. Houglum P. Therapeutic Exercise for Musculoskeletal Injuries, 4th ed. Human Kinetics; 2016.
  6. Rivards J, Grimsby O. Science, Theory and Clinical Application in Orthopaedic Manual Physical Therapy: Scientific Therapeutic Exercise Progressions (STEP): The Back and Lower Extremity, vol. 3. The Ola Grimsby Institute; 2009.
Authors

From the Department of Sports Medicine (KNH, SS) and the School of Exercise and Rehabilitation Sciences (KNH, NRG), University of Toledo, Toledo, Ohio; and the University of Toledo Medical Center–Physical Therapy and Sports Medicine, Toledo, Ohio (SS).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Kallie N. Hannon, ATC, CSCS, School of Exercise and Rehabilitation Sciences Mail Stop 119, University of Toledo, Toledo, OH 43606. Email: Kallie.Hannon@rockets.utoledo.edu

10.3928/19425864-20200623-01

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