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Training, Prevention, and Rehabilitation/Section Articles

Rehabilitation and Prehabilitation for Upper Extremity in Throwing Sports: Emphasis on Lacrosse

Vincent, Heather K. PhD, FACSM; Vincent, Kevin R. MD, PhD, FACSM, CAQSM, FAAPMR

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Current Sports Medicine Reports: June 2019 - Volume 18 - Issue 6 - p 229-238
doi: 10.1249/JSR.0000000000000606
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Despite the rapid growth of lacrosse participation in developing players, appropriate prerehabilitation and rehabilitation training strategies to prepare these players are still in development. Lacrosse is a unique throwing sport, because it involves continuous upper-extremity use through carriage and play with a handheld crosse, physical contact (1), and high-speed lower-body motion. In this fast-paced game, athletes (10 for men, 12 for women) run distances up and down a field while carrying a ball, passing, shooting, or defending a goal or other defending other players with the crosse. Regulation game times range from 40 to 50 min, depending on the age and sex of the competitors. For club lacrosse activity, teams may play in tournaments that involve multiple games per day.

Until now, the complexities of the game, and the variations in player position among the men's and women's game have challenged sports medicine research to understand the physical demands sufficient enough to formulate prehabilitation and rehabilitation programs. Deficiencies along the kinetic chain contribute to pathomechanics in overhead throwing athletes and the use of a crosse adds stress to movement control. Prevention measures should include a well-rounded training program that optimizes mechanical sequencing with the crosse and improves endurance and prevents chronic upper-extremity injuries irrespective of age and sex. Our understanding of overhead mechanics and injuries is largely derived from baseball (2) and cricket, (3) tennis (4) and other racquet sports (5). Our laboratory and others have provided the limited evidence of lacrosse shooting and throwing (6,7). In each of these sports, there is an overhead motion where a ball is released, thrown, or returned, and there are common phases and events of the motion that place stressors on the upper extremity. Lacrosse is emerging as a sport with throwing motion similar to that of baseball pitching (8). To advance our practices in the care of lacrosse athletes, this review will: 1) describe biomechanical risks for chronic upper-extremity injury based on evidence from other overhead sports, existing lacrosse studies, and our laboratory findings; and 2) present rehabilitative methods that translate from other sports to lacrosse and propose exercise strategies that prepare these athletes for the demands of the sport.

Injury Patterns in the Upper Extremity

Newest injury synopses of evidence have found an increased risk of shoulder injuries in male collegiate compared with female overhead athletes (9,10). Most upper-extremity injuries reported in lacrosse are acute or traumatic. An estimated 5% to 12.4% of boys and men and 1.6% to 4.1% of girls and women experience shoulder injuries (6,10,11). Among professional lacrosse players, 23.3% of injuries occur in the upper extremity, and the shoulder is the second most commonly injured joint (12). Acute injuries may become sources of chronic pain, such as a shoulder subluxation that over time becomes chronically painful and unstable. Chronic upper-extremity injuries can independently develop. Common overuse injuries in throwers and racquet sport athletes include distal humeral stress fractures (13), elbow stress fractures (14), lunate stress injuries (15), elbow epicondylitis, and internal impingement (16). Due to the repetitive throwing motion, young lacrosse players also experience injury to the proximal humeral epiphysis or more commonly referred to as “Little League Shoulder,” similar to what is experienced by other overhead athletes.

An important concept is that upper-extremity pain may not be isolated from pain in other bodily areas. Sekiguchi et al. (17) found that among 2212 overhead athletes, that the odds risk of incurring shoulder/elbow pain was 2.28 to 6.13 greater in athletes who reported preexisting low back pain, hip pain, or foot pain. Moreover, deficits in the kinetic chain at the legs, hips, and trunk occur in upper-extremity athletes who have shoulder or elbow injuries (2,18). Abundant research in these other sports has demonstrated the importance of a coordinated motion sequence and optimal body positioning toward the target for performance and injury prevention (2,19). Hence, a strong, injury-free lower body and trunk foundation is critical in the protection against upper-extremity chronic injuries.

Upper-Extremity Biomechanical Stresses in Lacrosse

Throwing and shooting in lacrosse have several biomechanical characteristics that are similar to other activities, such as pitching (20,21). There is a typical motion sequence that involves a stride (with lead foot plant), anterior pelvis rotation, trunk rotation (trunk-to-pelvis crossover), arm cocking, shoulder internal rotation, elbow extension, and flexion of the wrist (20–22). At the upper extremity, an intricate relationship exists between the dynamic stabilizers (pectoralis major, latissimus dorsi, rotator cuff) and the static stabilizers to simultaneously permit glenohumeral range of motion, stability, and force to throw (20). Scapular motion during a throw depends on trapeziums, rhomboids, serratus anterior, and levator scapulae muscles. Ball release is followed by additional trunk rotation and forward bending, and weight shift over the lead leg. After ball release, the throwing shoulder crosses anteriorly and transversely over the pelvis. During the entire throw, the finger forces that are used for gripping (as in a baseball pitching fastballs) can exceed 80% of the maximum finger strength measured (23). In sports that use lever arms while performing overhead motion like tennis or lacrosse, there are similar events in the motion sequence of a serve, including the shoulder and arm cocking, the separation between the shoulders and pelvis as the trunk rotates over the pelvis in the transverse plane, lateral trunk tilt, and elbow extension (24,25). A difference between overhead ball throwing and racquet serving may include greater wrist flexion and shear forces and grip force with a heavier racquet. Thus, inclusion of strengthening the distal muscles of the forearm and hand is important in injury prevention programs (23).

Proper kinetic chain sequencing (timing of peak angular velocities, joint positions, and excursions of body segments or joints) optimizes energy transfer from the lower body to the upper body (20). The lower-extremity muscles (quadriceps, internal-external hip rotators, hamstrings) and trunk muscles (abdominals, lumbar extensors, gluteals) are critical in providing power and a stable base of support. Coordination of these muscle actions reduces motion variance (26). Control of motion can increase efficiency of the task, and the joint moments can integrate to protect joints from high loads (26,27). Some sports initiate throwing from a two-footed standing or relatively stable position (such as football quarterbacking or pitching) (22,28,29). Lacrosse players can throw at high velocities from a two-footed position but also while running or jumping (such as a hip-over shot). Athletes must modify throwing biomechanics based on the field situation. For example, midfield “sniper” shooters who throw from distances farther away from the goal must produce greater lower and upper body joint excursions and sequentially activate more muscle mass to generate at fast shot than positions closer to the goal. Attack who are positioned closer to the goal may catch a pass and shoot on the run and use fast upper body joint excursions to throw around a defender. Shots can be overhead, sidearm, or underhand. In all cases, mechanical stresses occur at the upper extremity but likely by different mechanisms.

During a throwing motion with a ball, shoulder forces, torques, and muscle activity are typically highest during the preparatory arm cocking (crank back) and deceleration (after ball release, or follow through) phases (30). The magnitude and sequencing of muscle activity can impact the quality and magnitude of energy transfer from the lower body to ball release and modify forces acting at joints (31). This concept is critical with respect to musculoskeletal injury during similar overhead throwing repetitive activity. Injuries can occur when mechanical energy is absorbed by, or transferred to, joints at magnitudes or rates that overwhelm the ability of tissues to respond to it (32). There also are variations in the style of overhead throwing motion that impart different mechanical stressors on the upper extremity. In baseball pitching, for example, the arm moves in several paths before ball release or return, including true overhead (arm near vertical), three quarter (hallway between overhead and sidearm), sidearm (arm near horizontal) (29), and underhand (arm positioned below horizontal). Scapular and arm motion are exposed to different mechanical stresses, where at the time of peak cocking, the elbow varus torque and internal shoulder rotation torque are highest in overhead throws, and shoulder anterior and proximal forces are highest in three quarter throws and elbow flexion and proximal force are highest with sidearm motion (29). Near ball release, the sidearm pitch produces 15% higher elbow flexion torque and 5% more shoulder external rotation — thus excessively loading the structures about the shoulder (29). During follow through, the throwing arm decelerates and the deltoid and rotator cuff muscles eccentrically contract and the serratus anterior, trapezius, and rhomboids eccentrically contract to decelerate the scapula. The elbow and forearm are decelerated by the biceps (33). For baseball, softball, and cricket bowlers, there are large distraction forces (0.80 to 1.08 body weights) during follow through, that if not resisted by muscles about the shoulder, can lead to pain onset and overuse injury (34).

Interestingly, for racquet sports like tennis, different serve motions (kick, flat, and slice serves) impart less impact on mechanics of the upper extremity. Specifically, while maximal posterior shoulder force was highest in the kick serve, anterior and overall shoulder forces, maximal elbow force, and wrist forces were not different among serve types (35). In lacrosse, evidence on different shooting motions is lacking. However, the throw motion characteristics are going to be dependent on the purpose of the motion and stick to attempt a score or to move the ball around offensively setting up a play or to clear the ball downfield. The phases and events of the throw may be similar, but speculate that the amount of segmental motion, angular velocities, and joint forces will vary considerably for each throwing motion. Figure 1 provides an overview of the key forces acting on the lacrosse player when shooting a ball.

Figure 1
Figure 1:
Key upper-extremity mechanical stresses acting on a lacrosse player during a typical overhead throwing motion during crank back and follow through.

Suboptimal mechanics also elevate forces along the upper extremity. During baseball overhead throwing, the muscles of the legs and core normally produce 51% to 55% of the kinetic energy that is ultimately transferred to the hand during a throw (22). Less force production by the lower body with inefficient motion means that the upper extremity needs to generate more force for a fast throw. Inadequate knee flexion at lead foot contact, inappropriate timing of trunk rotation, or decoupling of shoulder-to-pelvis rotation with repetitive throws could change shoulder angulation during arm cocking and transfer high aberrant forces along the upper extremity and change the muscle activation patterns. Fatigue worsens mechanical energy transfer (36). An end result in all these scenarios is elevation in elbow valgus torques (2,36–38). In lacrosse, the volume of shots during competition is not as high as baseball pitches during a game, but 1) the starting body position and orientation of each shot is variable depending on field situation and 2) players can throw and shoot with both arms from a range of field locations relative to the goal. Hence, the stresses transferred to the upper-extremity joints and tissues will vary for each shot and are likely different between the dominant and nondominant arms.

Throwing Velocity and Volume

Throwing velocity is related to upper-extremity pain (39). Our preliminary, unpublished data have shown that high school players with any mild-to-moderate shoulder pain (1 to 6 out of a 10-point numerical pain rating scale) were shooting an average of 19.6% faster and had 33% higher maximal pelvis and shoulder angular velocities than players with no shoulder pain. The volume of play also may change the risk for upper-extremity injury. The number of repetitive throwing actions, especially with fatigue, can compromise joint positions and timing of mechanics and lead to chronic injury (2). Among adolescent baseball pitchers, higher seasonal pitching volumes were correlated to severity of arm soreness (correlation coefficient r = 0.748) (40). In tennis players, prolonged play reduces the shoulder internal rotation and total shoulder rotation arc in tennis (41). Moreover, scapulothoracic and humerothoracic kinematics (less humeral abduction and external rotation, more scapular upward rotation) contributes to chronic shoulder pain (42). Less glenohumeral rotational range of motion is associated with elbow valgus loading (38), ulnar collateral ligament tears (43), and superior labral anterior posterior tears (44). While evidence is not yet available, lacrosse players who participate in extended play may experience similar changes to glenohumeral range of motion. With respect to injury prevention in high velocity throwing, a prehabilitation program should include core training, balance training, and functional movements for the shoulder and upper extremity to increase upper-extremity durability under high-velocity motion. This approach has been used in other sports, like javelin (45), and will be discussed later.

Sex Difference in Lacrosse Throwing Motion

Upper-extremity mechanical stresses with lacrosse may be different between sexes. For girls and women, the lacrosse head pocket shape is shallow and requires the athlete to carry it with less positional variation to prevent it from falling from the pocket. For boys and men, the crosse head is relatively deep, allowing the athlete to draw the arm far back behind body, close to the trunk, out in front of body without losing the ball. Our laboratory quantified sex differences in the pelvis interaction during a shot motion (46). We found that women did not follow through with as much shoulder-to-pelvis crossover as men (55.8° ± 23.8° men and 42.3° ± 13.5° women). This difference was exaggerated during shots from the nondominant side, and the trunk was suboptimally positioned to the target (46). To produce similar fast shot speeds on both sides, the shoulder, chest, and upper-extremity musculature must compensate and produce more force before ball release. A secondary result could be elevation of shoulder or elbow torque stresses. To help protect against overreliance on the upper extremity for throwing, core, hip, and back exercises should be performed to strengthen these muscles and improve muscle activation during rotation.

Experience-Related Motion Differences in Throwing or Shooting

Throwing motion can change with athlete experience and age (47). We found that younger players demonstrate less transfer of energy from the start of the motion to ball release (25). While the peak pelvic angular rotational velocities of young players (middle and high school) are similar to collegiate and professional players (582°·s−1 vs 594°·s−1 and 562°·s−1 respectively), there is less progressive increase in angular velocities from the trunk and shoulder. Moreover, there is less symmetry of angular velocities between dominant and nondominant sides in younger players than more experienced players (13.5% to 17% high school vs 0.1% 12.5% in professionals) (25). Experienced players may rely on strong wrist flexion to create a fast whip before ball release. Younger players may rely on a “pushing” movement by the shoulders and arms on the nondominant side to move the crosse quickly and may experience different mechanical stresses. These findings are of direct relevance to the design of prehabilitation and rehabilitation programs for lacrosse athletes, whereby inclusion of multisegmental exercises that require coordination of whole kinematic chain sequencing on both sides of the body and reinforce reliance on the nondominant limb.

Experience level impacts motion in other overhead sports. Among baseball pitchers, professionals demonstrate kinematic patterns, such as later onset and more maximum trunk rotation (48), more back hip and pelvis rotation early in the throw compared with high school players. Normalized elbow varus torques were higher in high school players, and shoulder rotation torques, elbow anterior shear forces, and shoulder proximal shoulder forces are similar between experience levels (49). Thus, younger overhead athletes may not be leveraging the ability of the hips, pelvis, and trunk to optimize safe energy transfer to the upper extremity. In tennis players, novice players use different wrist motion when doing back hand stroke, which includes increased wrist flexion and sustained eccentric contraction during the stroke compared with expert players who hold their wrists more in extension (50). This can differentially change the stresses applied at the elbow especially at ball contact and place novice players at greater risk for lateral elbow epicondylitis.

Positional Differences in Throwing Motion and Crosse Use

The crosse equipment and position roles differ among offense, defense, and goalie positions. The stick acts as an extension of the upper extremity and increases the physical demand of ball carry, passing, and shooting (51). Men's stick lengths for offense and defense range from 100 cm to 105 cm and 130 cm to 180 cm, respectively. Girls and women's sticks range in length from 90 cm to 100 cm goalie stick lengths range from 92.5 cm to 180 cm and 88.8 cm to 120 cm. The overall weight of this lever arm averages around 0.59 kg to 0.85 kg. Among positions, the throwing motion demands are not equal. Offensive players may shoot or pass frequently from far distances or close range, whereas defensive players and goalies clear the ball or make long passes less often. Defensive players must hold the crosse out in front of their bodies for sustained periods during defensive play. Heavier, longer lever arms require adequate strength and movement coordination to produce high joint torques and ball speed. Younger, developing players may be more challenged to wield relatively heavier defensive poles or goalie sticks for sustained periods. Thus, part of the prehabilitation strategy should include exercises and flexibility training for the hand and fingers to increase grip strength.

Each position is characterized by unique variations in the throwing motion, and an understanding of these nuances is important for preparatory prehabilitation against upper-extremity injury. Using data that we pooled from our previous and ongoing lacrosse research (25,52), we provide here a first look at the amount of segmental excursion key segmental kinematics and segmental angular velocities among player field positions grouped by sex. Figures 2A-B illustrate the amount of rotational and anterior movement of males and females of each field position type. High school male and female midfielders and female goalies demonstrate the most transverse rotation in the pelvis and shoulders during a throw compared with defensive players or attack. Female midfielders and goalies also produce greater anterior trunk lean excursions than the remaining positions. Midfielders produced the highest average ball speeds among all field positions (110 to 120 km·h−1 males, 65 to 80 km·h−1 females). These findings suggest that midfielders, in general, and female goalies may experience more mechanical stress at the shoulder when trying to shoot fast from father away from the goal or clearing the ball. Among professional players shooting on an actual lacrosse field, we found that midfielders produced higher maximal angular velocities of the pelvis and shoulder than attack by 17.3% to 31.8%, and rotated the shoulders to pelvis more in the transverse plane at follow through; mean ball speeds were 149.7 km·h−1 in midfielders and 134.2 km·h−1 in attack (52). Thus, specific positions may benefit from additional multisegment coordinated exercise that improves the lower body to shoulder sequencing and reduces stress on the upper extremity.

Figure 2
Figure 2:
(A-B) Mean body segment or joint excursion during a lacrosse shot motion in men (A) and women (B). Pelvis and shoulder rotation occur in the transverse plane. Pelvis and trunk tilt are anterior in the sagittal plane with vertical at the starting point.

How do these differential position mechanics impact the upper extremity? From the kinetic chain perspective, the energy produced in the lower body and trunk in the transverse and sagittal planes contribute to fast angular velocities in the arm. This energy is transferred to the throwing arm as it rotates forward toward the target for ball release. The weight of the lever arm coupled with the transferred energy contribute to high torques about the glenohumeral joint and large distraction forces on the shoulder and elbow ligaments. In youth baseball pitchers, maximal shoulder distraction forces reach 49.8% of body weight (53), and this distraction may be more with players carrying crosses who throw a ball. Players who shoot more or stay on the field for a prolonged time will be exposed to a greater overall mechanical load at the upper extremity. Thus, offensive players may experience higher repetitive mechanical stress, particularly if the shooting motions are “nonideal.” For example, when lead foot and trunk orientation is not optimally positioned relative to the target (body closed off or open facing the target), the kinetic sequence is disrupted, and the upper extremity becomes a main source for power generation. This situation can occur when shooting on the run, when challenged by a defender during a shot, pass or a clear, or attempting a shot on the goal from a small angle. High-volume shooters may be more likely to develop overuse upper-extremity issues. Thus, incorporation of exercises into the prehabilitation or rehabilitation programs that challenge throwing motions in off-balance situations on both sides might help optimize pelvic and truncal mechanics and reduce reliance on upper extremity during the throw.

Upper-Extremity Prehabilitation and Rehabilitation for Lacrosse Athletes

There are not yet formal lacrosse recommendations specific to upper-extremity injury prevention and rehabilitation training. Sufficient evidence is not yet available for meta-analyses on injury prevention in overhead sports or on return-to-sport after injury (54). As such, we relied on the training methods discussed in several reviews and most relevant intervention studies in other overhead athlete populations that can be applied to lacrosse (55–57). A major limitation to the state of the science on athletic shoulder exercise prescription is the lack of study of the global demands from the lower body and trunk on the overall throwing motion (56). The following rehabilitation evidence particularly in baseball is overall well developed and accepted by clinicians but other sports provide evidence of varying quality and design (tennis, javelin). Given that our laboratory found similar kinematics between baseball pitching and lacrosse (8), we will apply many concepts in prehabilitation and rehabilitation to lacrosse.

We translate here available evidence of different exercises and provide additional exercises that are relevant to upper-extremity health in lacrosse players. The main goals for these programs are to maintain appropriate function of the upper-limb joints and correct musculoskeletal deficiencies and asymmetries that interfere with the normal throwing motion sequence and energy transfer along the kinetic chain. We acknowledge that resources for lacrosse programs may be limited (small or no strength and conditioning staff, athletic trainers, or assistant coaches). As such, we provide key exercises that can increase upper-extremity durability in all player positions.

A well-rounded prehabilitation program for the upper extremity should be comprised of exercises that: 1) develop lower body, back and core strength, and movement control in the three planes of movement; and 2) optimize upper-extremity dynamic muscle strength, endurance, and flexibility in real-life playing conditions. Deficiencies in shoulder flexibility, shoulder-back-leg muscle strength and endurance, hip joint flexibility, and motion sequencing have potential to disrupt normal throwing motion. For other throwing sports like javelin (45), programs contain core and power exercise and sport-specific exercises that improve upper-extremity strength and shoulder mobility. Similarly, we recently proposed a comprehensive core and back strengthening program for lacrosse (58) that can be used in combination with upper-extremity exercises we present here. These exercises described are critical in developing the lower-body strength and core-back coordination to protect against excessive stress on upper extremity. In brief, core and back stability can be improved through the use of dynamic balance activity (single-legged squats, balance or lunges, core synergistic movements (medicine ball throws, stem engine, woodchoppers, up-run-and-shoot), plyometrics (side-to-side lateral jumps, jump lunges, plyo push-ups, box jumps), planking and trunk flexion-extension actions (V-ups, bow-to-boat) (58). The complexity and difficulty of exercises can be increased through the use of unstable surfaces, such as wobble boards or rehabilitation pads.

Upper extremity-specific exercises should enhance player safety by challenging muscles that strengthen the shoulder, the elbow, wrist, and hand that are necessary to progress to whole body coordinated movements. Shoulder stability (scapular stabilization) is an important aspect of throwing that involves integration of upper trapezius, serratus anterior, and lower trapezius activity which posteriorly tilts, elevates, and anteriorly rotates the scapula during a throw (57). The challenge for athletes is to develop a balance between shoulder mobility and stability sufficient to prevent damage from repetitive high-speed, high force motions (57). The Table provides specific exercises that increase shoulder strength, mobility, and stability. Some exercises are not mutually exclusive in one category but can cross over to other categories.

Upper-extremity exercises for lacrosse players. Note that some exercises can cross into more than one category.

Shoulder Strengthening and Stabilization Exercise

In contrast to single-arm throwing (pitching, cricket, bowling), where shoulder flexibility asymmetry is the norm (55), lacrosse athletes who use both arms should have symmetric joint function and flexibility. Strong shoulder stabilizers also are critical for sustained stick holds in defensive posture and for the goalie. Posterior shoulder muscle strength and endurance are both important in crank back and follow through phases (30) and in sustained front-of-body stick holds in defensive players. Players of any age, sex, and player position can benefit from exercises that do not require heavy resistance but can effectively strengthen and stabilize the scapular position. These exercises include lateral raises or shoulder flyes, or Y-T-W, and include internal and external rotations from a standing position as described in the Thrower's Ten Program. While these 10 exercises were developed for baseball players, these can be effective also for The Advanced Thrower's Ten Program directs athletes to perform exercises on an unstable base (e.g., stability ball or while performing a side plank) (59). Diagonal shoulder flexion and upright shoulder rows can challenge posterior shoulder muscles from other movement planes. Single-arm stabilization exercises can be done one side at a time and include latissimus pulldown, diagonal flyes, or squat aways. Squat away posterior chain holds can be used to activate posterior shoulder muscles using an isometric hold; the athlete can squat against a wall, one arm abducted at 90° from the body and presses the back of one hand against the wall and slide it along the wall during the squat. Exercises that involve heavier resistance loads can be incorporated when age-appropriate. For example, maneuvers such as shoulder press, incline/decline shoulder press, barbell shrugs, and swimmers press activate the large muscle groups that support the shoulder girdle and prepare athletes for holding a crosse for sustained periods or pushing defensively.

Shoulder Mobility and Flexibility

Improving or restoring shoulder mobility is vital for performance, injury prevention, and rehabilitation. The mechanisms underlying shoulder mobility and pain remain unclear, but could include stiffness of the pectoralis muscles (60,61), glenoid capsule tightness, or neuromuscular pathways. Awareness of underlying hypermobility syndromes is important, and the goals to increase range of motion about the shoulder could be deemphasized with more focus on muscle strengthening about the shoulder girdle. We suggest that the use of dynamic mobility and passive mobility exercise is prudent to maximize range of motion gains acutely before play and over time as players develop. For any player of any age, shoulder mobility can be accomplished by including low-resistance actions, such as push-ups, increased range of motion push-ups using a suspension trainer. Intervention studies have shown that self-administered standing stretches with the arm held abducted at 90° against a wall corner (6 wk; four 1-min stretches with 30-s rest intervals) can reduce muscle pain (62). Even one bout of stretching the pectoralis minor shoulder at maximal horizontal abduction and external rotation with arm elevation at 150° (10 intervals of 30 s of stretch, 10 s of rest) can increase external rotation, posterior tilt of the scapula, and decrease pectoralis muscle stiffness by 12.7% (61). Other comparative studies have found that self-administered sleeper stretches that mobilize the glenohumeral joint can acutely increase the total arc of shoulder internal-external rotation by 6.2% in baseball players (63). Inclusion of these mobility exercises before practice or competition may help prepare athletes for passing, clearing, shooting, and defense. Emerging evidence shows that the preemptive use of shoulder capsule stretching exercises two times a week can improve scapular motion among asymptomatic baseball pitchers over one month. The authors reported that inclusion of these stretching exercises (see the Table) can help increase internal rotation excursion and overall total arc of shoulder motion, and potentially prevent the cascade of events leading to shoulder and upper-extremity injury (64). These same stretches may be beneficial to lacrosse athletes looking to improve shoulder range of motion.

Self-myofascial release for the infraspinatus and pectoralis muscles can improve glenohumeral internal range of motion (65). Tennis players incorporated this release by lying down perpendicular to the ground with the humerus abducted anterior to the trunk at 90°; the athlete rolled a lacrosse ball over the rotator cuff muscles. In a standing position, the athletes faced the wall and rolled the ball along the pectoralis muscle. Performing this release three times a week for 10 wk increased the glenohumeral internal range of motion by approximately 11°. Maintaining shoulder mobility on the lacrosse field may be possible through the “two-out drill” as was developed by Escamilla et al. (66) for baseball pitchers. Completion of the approximately 45-s drill can help throwers retain shoulder internal-external rotation range of motion and reduce the risk for elbow injuries; this drill includes cross-body stretch, wrist extension, shoulder circles, dynamic cross-body hugs, swims, field-goals and trunk rotations (66).

Elbow and Wrist Exercise

Muscles about the elbow and wrist support the final phase of a lacrosse shot where the energy is transferred from the shoulder to the crosse. Different types of resistance exercise (involving eccentric, concentric, or isometric actions) can effectively treat elbow lateral epicondylitis (67). Hence, we propose a variety of exercises next. Distal arm strength and endurance also are vital for holding heavier defensive poles or goalie crosses over sustained periods or for defending players. Muscle strength about the elbow can develop using triceps exercises, such as seated dips and triceps extensions (from a standing position, on a bench, using a cable pull-down, or on a stability ball) or triceps push-ups. For stronger or older athletes, incorporation of barbell exercises, such as close-grip chest press or dumbbell presses, may add resistance and complexity. Wrist strength is important for the snap of a throw before ball release and for maintaining grip on the crosse. Wrist flexion-extensions and pronation-supinations can be performed using light dumbbells or barbells (68). Flexion-extensions with buckets of water (eight repetitions per set, three sets per day) (69). Players also may suspend a light plate from a rope; the rope is attached to a dowel and the wrist is used to roll the weighted rope up and down around the dowel.

Hand and Fingers

Grip strength and hand dexterity are vital for sustained hold on the lacrosse stick during practice and competition. Isometric gripping with a tennis ball or fist clenching can be used to increase strength. Sport-specific maneuvers are helpful to develop this strength including ‘wall ball’, wherein partners will throw a ball quickly back and forth to each other (or a single player uses a wall), alternating arms every 30 to 50 repetitions, and then using one arm only to execute the throw on each side. This maneuver also will strengthen the wrist and forearm. Static stretching the wrist extensors and fingers can include 30-s holds of resisted wrist extension, flexion, ulnar and radial deviation, or pressing hands against a wall can increase grip strength and wrist and forearm torque and work output and reduced pain in chronic lateral epicondylitis.

Coordinated Motions

Given that lacrosse motions are complex and involve simultaneous lower and upper body muscle activity, we propose that exercises that involve complex sequences are important in injury prevention. Moreover, variation in exercises may help develop the neuromotor pathways that are challenged under field conditions. Examples of coordinated activities include discus throwers, single arm overhead presses, or walking lunges with twists. Other exercises, such as landmines, squat presses (two or single-arm), step-ups with shoulder press, can help athletes develop complex movement skill while improving shoulder strength, grip strength, and dynamic stability. Battle rope activity involves high-intensity intermittent exercise bouts. Advantages of battle rope training appear to be greater than just for the upper extremity; 8 wk of training (three sessions per week, six exercises, 20-s exercise to 40-s rest) increased upper-body power and improved standing and dynamic shooting accuracy in basketball players (70). This finding may translate to lacrosse athletes on the field for endurance and shooting accuracy. Finally, attaching a resistance band to the crosse and performing a step forward to the point of ball release can help players develop overall upper-extremity strength during an actual throwing motion.

Rehabilitation after Injury

Given that we do not have adequate scientific evidence from which to build a formal lacrosse rehabilitation program after chronic injury, we will refer to published works in other overhead throwing sport that have direct relevance to lacrosse. Wilk et al. (57) elegantly describe comprehensive rehabilitation processes for the injured thrower, and several principles can be applied to the lacrosse athlete. Rehabilitation treatments should consider the phased-approach of first avoiding throwing while calming pain and inflammation, delaying muscle atrophy, and beginning muscle strengthening. Second, exercise progression can occur, rhythmic stabilization drills and inclusion of core-back and leg strengthening exercise can ensue. Third, advanced, coordinated exercise using whole body actions can be performed, while shooting or throwing at a lower speed and/or volume while correcting pathomechanics can be introduced (31). Finally, progression to greater volumes and speeds of throwing or shooting while strengthening, mobility, flexibility drills are continued. Progression into throwing is carefully considered based on the injury type (bone, tendon, ligament, other). During recovery for chronic shoulder injury, maintaining full range of internal and external rotation motion and improving muscular strength about the shoulder girdle are critical.

Building a Strong Foundation for Upper-Extremity Health in Lacrosse

Boys and girls may derive great benefit from inclusion of exercises that strengthen the shoulder and upper extremity early in the lacrosse career. When coupled with some exercises for core and back as we described previously (58), developing lacrosse players can build a strong physical foundation from which to enhance skills and gain understanding of the importance of injury prevention. For the younger players (10 U and under [elementary school]), the focus of the upper-extremity exercise should be on executing appropriate form and establishing good neuromotor pathways. Weight may be applied to some exercises using light dumbbells, resistance bands, medicine balls, or light plates (71). When players advance to U12 to U14 age brackets (middle school), the complexity and the load of the exercises can increase commensurate with growth and skill ability. This is important because shooting speeds increase at this age and defensive play becomes more aggressive. The musculoskeletal structures must be durable enough to handle the change in physical load. As players progress to U15-U18 brackets, players have well-developed neuromotor pathways and more muscle mass. High school players can progress to exercises that require heavier resistance loads and involve more complex coordinated motions. Dedicated efforts should be made to correct any deficits along the kinetic chain. Irrespective of player age, all players should participate in shoulder mobility stretching exercise and basic scapular stabilization exercise. These exercises can be done with no equipment, can be done anytime, and may help promote good shoulder posture during growth. For players that continue at collegiate and professional levels, the emphasis on upper-extremity prehabilitation programs should be on optimizing sequencing of segmental motion and angular velocities, increases dynamic strength, and minimizes torques acting at the upper extremity. For these highly skilled players, performing coordinated motions with greater resistance loads in unstable positions (on one leg, on BOSU ball) should be the bulk of the prehabilitation program. Participation in upper-extremity prehabilitation should occur at minimum as part of a preseasonal training period, but ideally also as part of a comprehensive off-season program. The intensity and volume of exercise would adjust as players transitioned into seasonal play, but not stop altogether.


Upper-extremity prehabilitation exercise should be part of overall musculoskeletal conditioning and injury prevention program for overhead throwing sports, including lacrosse. Passing, shooting, defense, and clearing are key motions in this lacrosse that depend on: 1) a strong, stable, and flexible upper extremity; and 2) coordinated transfer of energy from the lower body and trunk through the arm. Using the available evidence from overhead athletes with similar motion and our laboratory understanding of the mechanics of the sport, we speculate that upper-extremity preventative exercise should consist of activities that increase shoulder, elbow and wrist strength, shoulder stability and mobility, flexibility, and coordinated lower-upper body motions. Due to the significant evidence gap in prehabilitation and rehabilitation plans in lacrosse, we propose that incorporation of basic upper-extremity activities begin in the younger age brackets and progressively increase in difficulty and resistance load through older age groups.

The authors declare no conflict of interest and do not have any financial disclosures.


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