Optimal Shoulder Performance From Rehabilittaion to High Performance ShoulderPerformance.com
Eric Cressey, MA, CSCS is the president of Cressey Performance in Hudson, MA. Cressey is a highly soughtafter coach for healthy and injured athletes alike from youth sports to the Olympic and professional ranks, with baseball development as his greatest focus. Behind Eric’s expertise, Cressey Performance has rapidly established itself as a go-to high-performance facility among Boston athletes – and those that come from abroad to experience CP’s cutting-edge methods. Eric has lectured in four countries and more than one dozen U.S. states; written over 200 articles and four books; contributed on scientific journal articles and book chapters; and co-created four DVD sets. He publishes a free weekly newsletter and daily blog at http://www.EricCressey.com. A record-setting competitive powerlifter, Cressey has deadlifted 650 pounds at a body weight of 174 and is recognized as an athlete who can jump, sprint, and lift alongside his best athletes to push them to higher levels.
Michael M. Reinold, PT, DPT, SCS, ATC, CSCS is considered a leader in orthopedic and sports rehabilitation as a clinician, educator, and researcher, with specific emphasis on the shoulder and the treatment of overhead athletes. Mike is currently the Head Athletic Trainer of the Boston Red Sox and Coordinator of Rehabilitation Research & Education for the Sports Medicine Division of Massachusetts General Hospital. Mike has lectured extensively throughout the nation, published over 50 scientific journal articles and book chapters, and is the author of the textbook, The Athlete’s Shoulder, 2nd Edition. Mike’s contributions to sports medicine have earned recognition by groups such as the APTA, ESPN, Sports Illustrated, The Sporting News, Men’s Health, The Boston Globe, and The Boston Herald. For more information, visit Mike’s free educational website at http://www.MikeReinold.com.
This DVD and the following guidelines have been provided as general information for exercise and rehabilitation and are intended for educational purposes. Any individual beginning exercises
contained in this video, or beginning any other exercise program, should first consult with a qualified health professional. Discontinue any exercise that causes discomfort and/or dysfunction and consult with a qualified medical professional. Please consult with a physician prior to implementing any rehabilitation or exercise protocol. This DVD does not contain medical advice. The instructions and advice presented are in no way a substitute for professional testing, instruction, or training. The creator, producer, and distributor of this DVD and program disclaim any liabilities or loss, personal or otherwise, in connection with the exercises and advice herein.
Inefficiency vs. Pathology Eric Cressey www EricCressey com www.EricCressey.com www.CresseyPerformance.com
Miniaci A. et al. Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. Am J Sports Med. 2002 Jan-Feb;30(1):66-73. • 79% of professional pitchers (28/40) had “abnormal labrum” features g resonance imaging g g • …“magnetic of the shoulder in asymptomatic high performance throwing athletes reveals abnormalities that may encompass a spectrum of ‘nonclinical’ findings”
What would you think if a coach/trainer had… • 82% of his athletes with disc bulges or herniations at one level, and 38% at more than one level? • 27% of his athletes with vertebral fractures? • 34% of his athletes with rotator cuff tears? • 79% of his overhead throwing athletes with labral tears? • 26% of his jumpers with patellar tendinopathy?
Jost B et al. MRI findings in throwing shoulders: abnormalities in professional handball players. Clin Orthop Relat Res. 2005 May;(434):130-7. • Researchers looked at throwing and non-throwing shoulders of 30 handball players and non-athletes w/MRI • More abnormalities seen in throwing shoulders • “Although 93% of the throwing shoulders had abnormal magnetic resonance imaging findings, only 37% were symptomatic.” • “Symptoms correlated poorly with abnormalities seen on magnetic resonance imaging scans and findings from clinical tests. This suggests that the evaluation of an athlete's throwing shoulder should be done very thoroughly and should not be based mainly on abnormalities seen on magnetic resonance imaging scans.” • Not just about throwers, though! Has been demonstrated with swimmers, volleyball players, AND non-athlete controls…
*There are people out there – myself included – that think that you may very well need a SLAP lesion to throw hard in the first place!
Rotator Cuff Fun… • Sher et al. (1995): MRIs of 96 asymptomatic subjects, RTC tears in 34% of cases, and 54% of those older than 60. • Miniaci et al. (1995): MRIs of 30 shoulders under age 50 with “no completely ‘normal’ rotator cuffs.” 23% had evidence of partialthickness tears. • Connor et al. (2003): eight of 20 (40%) dominant shoulders in asymptomatic tennis/baseball players had evidence of partial or full-thickness cuff tears. Five of 20 had MRI evidence of Bennett’s lesions.
Jensen MC, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med.1994 Jul 14;331(2):69-73. • MRIs of 98 asymptomatic backs • “52 percent of the subjects had a bulge at at least one level, 27 percent had a protrusion, and 1 percent had an extrusion [82% of subjects]. Thirty-eight percent had an abnormality of more than one intervertebral disk. The prevalence of bulges, but not of protrusions, increased with age. The most common nonintervertebral disk abnormalities were Schmorl's nodes (herniation of the disk into the vertebral-body end plate), found in 19 percent of the subjects; annular defects (disruption of the outer fibrous ring of the disk), in 14 percent; and facet arthropathy (degenerative disease of the posterior articular processes of the vertebrae), in 8 percent. The findings were similar in men and women.”
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Soler T, Calderon C. The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med. 2000 JanFeb;28(1):57-62. • 8% of elite Spanish athletes affected • 27% of track & field throwers, 17% of rowers, 14% of gymnasts, and 13% of weightlifters • L5 most common (84%), followed by L4 (12%). • Bilateral 78% of the time • Only 50-60% of those diagnosed actually reported low back pain • Presence of spondylolysis is estimated at 15-63%, with the highest prevalence among weightlifters. • Presence is estimated at 3-7% in the general population
You Kneed to Know… Cook JL et al. Patellar tendinopathy in junior basketball players: a controlled clinical and ultrasonographic study of 268 patellar tendons in players aged 14-18 years. Scand J Med Sci Sports. 2000 Aug;10(4):216-20. • 34 elite jjunior basketball players p y (268 ( total patellar p tendons)) • Only 19 tendons (7%) presented clinically with symptoms of tendinopathy. • However, under ultrasonographic examination, 26% of all tendons could be diagnosed with tendinopathy based on degenerative changes. • For every one diagnosed, more than three are overlooked… • This is magnified as one ages!
We’ve misinterpreted the meaning of the word “pathology.” • “any deviation from a healthy, normal, or efficient condition” (dictionary.com) • In I other th words, d “inefficiency” “i ffi i ” and d “pathology” may in fact be the same thing.
Chou R et al. Imaging strategies for low-back pain: systematic review and meta-analysis. The Lancet, 2009;373 (9662), 463-472. • Review of imaging for low back pain without significant red flags suggesting serious conditions (cancer, fracture, etc) • “Lumbar imaging for low back pain without indications of serious underlying y g conditions does not improve p clinical outcomes.” • “Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low back pain and without features suggesting a serious underlying condition.” • Some research suggests that MRI leads to poorer outcomes in back pain patients
Just to Scare You a Bit More… “Somewhere between 2 and 8 percent of the time in American hospitals, a patient havingg a genuine g heart attack gets sent home – because the doctor doing the examination thinks for some reason that the patient is healthy.” -Malcom Gladwell, in Blink
Wordplay? • My primary goal for today is to show you that if you correct the inefficiency, you’ll markedly reduce the likelihood that these “ h l i ” reach “pathologies” h threshold. h h ld • Effective screening, and an understanding of population-specific “norms” is the key. • The site of the pain isn’t always the source of the problem…
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Perhaps the Best Example… • The Tendinopathy Debate • Tendinosis – osis = degenerative – Tissue loading exceeds tissue tolerance
• Tendinitis – itis = inflammatory – Inflammation should be easily controlled with cortisone injections and/or NSAIDs
The Truth is… • Anyone who has ever dealt with a “tendinitis” diagnosis knows that it isn’t so easy to fix… • So,, traditional treatment modalities are often based on the wrong diagnosis. • Many people get healthy simply because they implement rest for the tissues – not because they address underlying inefficiencies.
Kinesio-Taping • Perfect example of the difference between tendinitis and tendinosis • It works k tto redistribute di t ib t stress appropriately • Training should do the same!!
Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy. 1998 Nov-Dec;14(8):840-3. • “In overuse clinical conditions in and around tendons, frank inflammation is infrequent, and is associated mostly with tendon ruptures. Tendinosis implies tendon degeneration without clinical or histological signs of intratendinous inflammation, and is not necessarily symptomatic. symptomatic Patients undergoing an operation for Achilles tendinopathy show similar areas of degeneration. When the term tendinitis is used in a clinical context, it does not refer to a specific histopathological entity. However, tendinitis is commonly used for conditions that are truly tendinoses, and this leads athletes and coaches to underestimate the proven chronicity of the condition.” • “The combination of pain, swelling, and impaired performance should be labeled tendinopathy.”
Waiting to Reach Threshold? • Remember Cook et al.: while 26% of tendons could be diagnosed with tendinopathy under ultrasonographic exam, only 7% presented clinically with symptoms • The other 19% are just waiting to reach threshold. • Tendinopathy is a constant “give and take” in every muscle in the body, and degeneration is population and activity-specific.
The Law of Repetitive Motion I = NF/AR • I = Insult/Injury to the tissues • N = Number of repetitions • F = Force or tension of each repetition as a percent of maximum muscle strength • A = Amplitude of each repetition • R = Relaxation time between repetitions (lack of pressure or tension on the tissue)
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The Law of Repetitive Motion I = NF/AR • Poor posture: higher forces with Lifting tasks (no change in amplitude or relaxation => high insult) • Sitting at a computer: high number of reps (constant activation) with low amplitude and lower relaxation time. • The weaker you are, the higher the percentage of maximal strength you’ll use to accomplish a task. • Resistance training can be extremely effective in correcting problems quickly. Otherwise, we’d have to sit with “more-than-perfect” posture for an equal amount of time to iron things out.
The Bigger Picture: 12 Shoulder Health Factors
Building Blocks to Dysfunction: Soft Tissue Restrictions Pec Minor Inferior Capsule Subscapularis p Teres Minor Infraspinatus
For more information, check out Dr. William Brady at www.integrativediagnosis.com.
Quantify what you can, and video/photo whatever you can’t!
Overuse Rotator Cuff Weakness Scapular Stability Poor Glenohumeral ROM Soft Tissue Restrictions Poor Thoracic Spine Mobility Type 3 Acromion Poor Exercise Technique Poor Cervical Spine Function Opposite Hip/Ankle Restrictions Poor Structural Balance in Programming Faulty Breathing Patterns
We need to look at all of them to be comprehensive.
Things We Quantify: • Glenohumeral internal rotation, external rotation, and total motion • Thoracic spine mobility • Hip internal rotation, external rotation, and flexion • Knee flexion • Combined Tests (fist-to-fist)
Case Studies!
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16-year old Pitcher
Glenohumeral Internal Rotation Deficit (GIRD)
• Medial Elbow Pain • Previous treatments included forearm exercises,, ultrasound,, rotator cuff strength/endurance, and scapular stability • Cleared for a full return to play • No assessment of glenohumeral range of motion or front hip ROM.
The “Perfect” GIRD? Right Shoulder: 19°IR, 103°ER, 122° Total Motion Left Shoulder: 53°IR 90°ER 143° Total Motion Asymptomatic, and cleared for a full return to play with a 21° total motion deficit and 34° GIRD.
Same Deficits, Slightly Different Problem • 23 year-old Professional Pitcher • Medial Elbow Stress Fracture • 28° GIRD, 16° Total Motion Deficit • 35° Hip IR on Front Leg (goal = >40°) • 124° Knee Flexion on Front Leg (goal = >135°)
GIRD “Threshold?” • Burkhart et al. reported that all of a 124-thrower sample size with Type II SLAP lesions presented with an internal rotation deficit of greater than 25°. • Myers et al. al pinned that “don’t don t cross this line line” number at a 19.7° deficit. • The research on non-symptomatic throwing shoulders was in the 12-17° range. • Every little bit matters – and this applies to elbows, too!
Treatment? • 16-year old got ultrasound • 23-year old got a bone stimulator • Neither of them fixed their shoulder or hip ROM deficit!
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• This is like banging your head against the wall. • Does the wall or your head break first? • Incorrect Approach: patch the wall or take some ibuprofen for your head • The Correct Approach: Stop banging your head against the wall.
Wow… • Fractured Right Hip Three Years Earlier • 23° of Hip Internal Rotation (goal = >40°) 40 ) • You can “cheat” on your hip motion with long toss, but you can’t cheat when on the mound, when stress is higher.
17-year-old Left-Handed Pitcher • Chronic Left Shoulder Pain • Positive SLAP tests • Tried rotator cuff and scapular stability exercises • Could long-toss pain free, but had significant pain with throwing off the mound • What gives?
Another 17-year-old Pitcher • Both posterior shoulder pain and medial elbow pain • Addressed cuff weakness, hip ROM issues, soft tissue quality – and pretty much did everything right! i h! • But, athlete jumped the gun on his throwing program – and didn’t integrate the new hip mobility into his movements. • You can lead a horse to water, but you can’t make him drink…
Lessons…
I know, I know…
• Similar injuries, different causes! • Different injuries, similar causes! • Each hit threshold for different reasons. This may be age-specific. • Your assessment and corrective approach must be thorough – and specific to the sport. • Look at multiple joints – both strength and flexibility – as well as tissue quality • Follow-up exercise selection and overall programming must be appropriate – and the exercises must be performed correctly.
• Most of you aren’t rehabilitation specialists – and I wouldn’t consider that my realm, either! • In reality, though, this is because less black and white – and a lot more gray nowadays. • Why? W y? – Insurance companies are more and more stingy. – As I showed earlier, pretty much everyone is messed up – and even those who aren’t usually don’t move well. • And let’s be honest…
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Active vs. Passive Restraints • Active: muscles, tendons, and (to a lesser degree) bone • Passive: meniscus, labrum, discs • Poor active restraint function (strength, tissue quality, or ROM) leads to increased stress on the passive restraints, or issues with the active restraints themselves.
Later on, we’ll go through how to assess the function of all these active restraints…
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This Presentation
Testing, Treating, & Training the Shoulder
Clinical Examination of the Shoulder
• Discuss some general concepts behind shoulder examination • Where we are with evidence-based exams • How to use evidence & experience! • Some differential diagnosis tests • When to refer out • When to treat & correct • Clips from DVD on shoulder exam from AdvancedCEU.com
Michael M. Reinold, PT, DPT, SCS, ATC, CSCS Boston Red Sox / MGH Sports Medicine MikeReinold.com
Evidence • Unfortunately the evidence is still a work in progress • But getting closer every day • The problem –
Experience • • • •
What your past experience has shown you Important component Put the pieces of the puzzle together Algorithm approach – each portion of exam leads the next portion
– Can’t completely base your exam on evidence alone – Not enough studies – Conflicting information in the literature – Different patient populations
Expertise – Combining Experience and Evidence • How does a recent graduate conduct a shoulder examination? • How does the expert conduct a shoulder examination?
The True Use of the Exam • To determine where to start with the patient and when to send out to more qualified discipline – Secondary purpose to refer out as needed!
• What to perform and what to avoid • Make list of objective goals and plan to improve
• Be careful! Don’t get stuck in your ways!
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Impingement Vs. Cuff Tear
Assess Active Motion
• Progressive cuff pathology • Irritation Æ inflammation Æ fraying Æ tearing • Identifying where in the process the person is currently
AC joint or subacromial Impingement
Rotator cuff tear vs. inflammation
Impingement Tests
The Thrower’s Shoulder Motion and Laxity • Common findings – Excessive ER – Limited IR
• Anterior laxity • Posterior tightness
Internal Impingement
Wilk,Reinold,Crenshaw,et al: ‘‘99 99--09 • Examined ROM in 1400+ professional baseball players • ER @ 90 deg abduction: – Dominant: 129 + 10 deg – Non-Dom: 121 + 9 deg. deg
• IR @ 90 abduction: – Dominant: – Non-Dom.
61 + 9 deg 68 + 8 deg
• Total Motion: 190 + 14 Total Motion Equal Bilateral !!!
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Total Motion Concept Wilk et al AJSM 2002
Range of Motion After Throwing Loss of Total Motion • Pitching with loss of total motion results in greater chance of injury – Ruotolo: JSES ’06 06 – Myers: AJSM ‘06
ER + IR = Total Motion
Range of Motion After Throwing Loss of Total Motion • Loss of IR normal adaptation • Injury occurs when loss of TM • Cumulative microtrauma due to eccentric and tensile forces
Causes of Loss of IR Motion Humeral Retroversion • Several studies have shown retroversion of the humerus – Crocket AJSM 2002 – Reagan AJSM 2002
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Causes of Loss of IR Motion Not Posterior Capsule Contracture • Borsa, Wilk, Reinold: AJSM 2005 • Examined GH translation in 43 professional baseball pitchers – Anterior: 2.81 mm – Posterior: 5.38 mm • Significantly greater posterior translation • No differences between D and ND
– No correlation between IR ROM and posterior translation
Causes of Loss of IR Motion Posterior Muscular Contracture • Reinold: AJSM ‘08 • ROM Before & After Throwing • Measure PROM before and after pitching in 117 professional baseball players • Significant decrease in: – IR: -8.5° – TM: -9.5° – elbow extension: -2.4°
• Changes still present at 24 hours
Tomiya:: AJSM ‘04 Tomiya
Tomiya:: AJSM ‘04 Tomiya
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Range of Motion After Season Reinold & Gill: 2006 2006--2009 • ROM changes over course of season • Subjects stretched daily
Flexion ER IR TM E Flex E Ext
Beginning 175 133 46 179 135 -4
End 176 138 47 185 136 -6
Change +5 +6 -2
What is a Shrug???
• I am not sure that the posterior capsule is the cause of the changes in IR in overhead athletes – I have not seen this to be common in the healthy or the injured athlete
• IR is supposed to be less in the throwing arm, amount depends on retroversion – Throwing causes acute loss of IR, can become cumulative
• Assess, DON’T ASSUME!
What a Cuff Tear Looks Like
Assess cuff vs. capsule
DO NOT work through a shoulder shrug arc of motion !!!
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What About Instability?
Traumatic Dislocation
• Different types of instability • Acute first time dislocation vs. congenital laxity MDI • Actual capsulolabral tear vs just looseness • Laxity L it vs. IInstability t bilit
Torn Posterior Capsule
Voluntary Subluxation
Congenital Laxity
CONGENITAL LAXITY!
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Acquired Laxity
Instability • Apprehension sign
Congenital Laxity
Sulcus
• Sulcus sign • > 10 mm positive
Sulcus
Beighton Laxity Score
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SLAP Lesions • SLAP’s are trendy right now • Likely a little over diagnosed • Well over 20 published “tests” to detect a SLAP lesion • Several variations of SLAPs • Different tests for different types of SLAPs
Compression Injuries
Traction Injuries
Peel Back Lesions
Reinold & Gill: Sports Health ‘09 Wilk, Reinold, Andrews: JOSPT ‘05 Myers, Andrews: AJSM ‘06
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Shoulder Examination Key Points • We are still evolving into evidence based examination • Challenging progression • Understand how the shoulder functions • Determine – – – –
Specific structures involved When to refer out Where to begin What to avoid
• Look at causative factors • The complete picture
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Training the Injured Shoulder During and Post-Rehabiliation Eric Cressey www.EricCressey.com Ei C www.CresseyPerformance.com
External Impingement • The Sedentary/Stationary Shoulder Problem • Pain with: – Overhead motion – Approximation – Periods of inactivity (night, morning) – Internal Rotation – Scapular Protraction • Bursal-sided cuff issues
External Impingement • Eliminate overhead activities • Modify/Eliminate Horizontal Pressing • More horizontal p pulling, g, asymptomatic y p cuff exercises, scapular stabilization exercises (improve upward rotation function) • Gentle stretching for the internal rotators and pec minor • Optimize thoracic spine mobility
Important Prerequisites… • Primary goal should always be to fix what’s wrong, not just keep things “fun.” • When applicable, you can always train the uninjured limb with great benefits. • Know when to refer out. Two minds and skill sets are better than one! • Make the athlete feel like an athlete, not a patient. • Look to soft tissue quality early-on…
External Impingement • Primary vs. Secondary • Scapulohumeral Rhythm • Populations p most commonlyy affected: lifters,, desk jockeys, elderly • Tendinosis? Tendinitis? Bursitis? • Supraspinatus? Infraspinatus? Biceps Tendon? Labrum?
External Impingement • Soft tissue work: pec minor/major, upper traps, levator scap, scalenes, rhomboids, RTC,, lats • Thoracic Extension and Rotation • Avoid “at-risk” position: front squat in place of back squat
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External Impingement Once symptomatic with ADLs: (Feet-Elevated) Push-up Isometric Holds > (Feet-
Elevated) Body Weight Push-up > Stability Ball Push-up > Weighted Push-up > Neutral Grip DB Floor Press > Neutral Grip Decline DB Press > Pronated Grip Decline DB Press > Barbell Board Press (gradual lowering) > Barbell Floor Press > Neutral Grip DB Bench Press > Low Incline DB Press > Close-Grip Bench Press > Bench Press > Barbell Incline Press > ???Overhead Pressing???
Internal Impingement • AKA posterior-superior glenoid impingement • Supra- and infraspinatus against P-S glenoid and labrum (articular-sided cuff issues) • High-speed, overhead activities: swimmers, tennis players, baseball players • Encompasses a broad spectrum of more specific diagnoses and pain presentation patterns
The Demands of Throwing • Shoulder stability is sacrificed for mobility • Highly reliant on soft tissue function for stability • Some numbers to consider during acceleration: – 7,200+°/second internal rotation ((20 full revolutions pper second) – 2,300°/second elbow extension – 650°/second horizontal abduction
Why? • • • • • • •
Limited ROM before full ROM Adducted before abducted Unstable before stable Cl d h i before Closed-chain b f open-chain h i Dumbbells before barbells Isometrics before “regular” speeds Traction before approximation (e.g., pull-ups would come before overhead pressing)
Why is baseball an at-risk sport? • Very Long Competitive Season – >200 games as a pro? – >100 College/HS? • Unilateral Dominance/Handedness Patterns – Asymmetry is a big predictor of injury – Switch hitters – but no “switch throwers!” • The best pitchers – with a few exceptions – are the tallest ones. The longer the spine, the tougher it is to stabilize. • Short off-season + Long in-season w/daily games = tough to build/maintain strength, power, flexibility, and optimal soft tissue quality
Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Med. 2006;36(3):189-98.
• 49% of athletes with posterior-superior labral tears also had a hip rotation ROM d fi i or abduction deficit bd i weakness k
• Requires a collaborative effort of DOZENS of muscles, not just the rotator cuff!
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Symptomatic Internal Impingement • Glenohumeral Internal Rotation Deficit (GIRD) • Why does it happen? • Role in SLAP lesions • Almost everybody has labral fraying and partial thickness cuff issues, but not necessarily w/symptoms • Possible elbow complications
Eccentric Stress Dictates Dysfunction • Reinold et al. Changes in shoulder and elbow passive range of motion after pitching in professional baseball players. Am J Sports Med. 2008 Mar;36(3):523 Mar;36(3):523-77. • “A significant decrease in shoulder internal rotation (-9.5 degrees), total motion (-10.7 degrees), and elbow extension (-3.2 degrees) occurred immediately after baseball pitching in the dominant shoulder (P<.001). These changes continued to exist 24 hours after pitching.”
External vs. Internal Impingement
Important Note: Some GIRD is Normal! • GIRD is a measurement, not a pathology • If you throw, you're going to have retroversion even if you throw the soft tissue and capsular issues out the window. • I typically use 12° as our cut-off of what is acceptable, and the number tends to get a little larger as guys get older and accumulate more mileage on their arms. • We are very IR focused with our stretching in-season and during the early offguys y come back from longg seasons (or ( we get g kids with messed season as our g up shoulders and elbows for the first time) • Some guys never need it - particularly the multi-sport athletes. • Obviously, total motion plays into this as well. • Don’t just look at IR; look at posterior cuff strength, scap stability, t-spine mobility, hip mobility, ankle mobility, soft tissue quality • My general rules: <12° through age 18, <15° for 18-22, <18° for 22+ • ¾ arm slot guys tend to be more pronounced that over the top guys
• External: – Physiological norm – Primary (acromion spurring) and secondary (muscular weakness) – RTC/biceps tendon impingement under acromion – Bursal sided cuff issues
– Posterosuperior Impingement – Specific to throwing athletes – Humeral head impinges on posterior labrum and glenoid – Multiple pathologies can result – Articular-sided cuff issues
The beauty of working with internal impingement cases…
Internal Impingement • Optimize upward rotation function • Avoid stretching into external rotation, horizontal abduction, abduction and full extension! • Rest and NSAIDs won’t cut it! • Optimize GH ROM symmetry. • Posterior cuff strength, t-spine mobility, scapular stability…
• Internal:
• Generally, almost anything you do in the weightroom is fair game. • Excluding: – – – – – – –
Overhead O h d lifti lifting (not ( t chin-ups, hi th though) h) Straight-bar benching One-Arm Medicine Ball Work Upright rows Front/Side raises (especially empty can) Olympic lifts Back squats
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A few reasons… Why don’t you do overhead work? It’ss part of their sport It sport, so you need to expose them to it…
• • • • • •
Labral fraying: less mechanical stability GIRD: non-neutral humeral positioning Approximation is not traction! Subscapularis microtrauma Cervical spine hyperextension tendency O-Lifts: UCL and wrist/forearm/hand stress
Retro-what?
Congenital Factors? Huh?
• Throwing shoulders have more humeral and glenoid retroversion (may occur when pre-pubescent athletes throw when the proximal humeral epiphysis isn’t closed yet) • Retroversion gives rise to a greater arc of total rotation range of motion (total motion concept = IR + ER) range-of-motion • NO EXERCISE WILL CHANGE BONE STRUCTURE!!! • Warp bones to throw heat? • Retroversion may actually spare the anterior-inferior capsule from excessive stress during external rotation
• Bigliani et al. found that 67% of pitchers and 47% of position players at the professional level have a positive sulcus sign in their throwing shoulder • Adaptation to imposed to demand? Yes, but… • Those researchers also found that 89% of the pitchers and 100% of the position players with that positive sulcus sign also came up positive in their non-throwing shoulder. • Natural selection!
Laudner KG, Stanek JM, Meister K. Differences in Scapular Upward Rotation Between Baseball Pitchers and Position Players. Am J Sports Med. 2007 Dec;35(12):2091-5.
“CONCLUSION: Baseball pitchers have less scapular upward rotation than do position players, specifically at humeral elevation angles of 60 degrees and 90 degrees.” “CLINICAL RELEVANCE: This decrease in scapular upward rotation may compromise the integrity of the glenohumeral joint and place pitchers at an increased risk of developing shoulder injuries compared with position players. As such, pitchers may benefit from periscapular stretching and strengthening exercises to assist with increasing scapular upward rotation.”
Things we like… • • • •
Push-up variations Multi-purpose bar Neutral grip DB pressing variations E Every row andd chin-up hi you can imagine i i (excluding upright rows) • Loads of thick handle/grip training • Medicine Ball Work: Rotational and Overhead • Specialty bars: Giant Cambered, Safety Squat
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Acromioclavicular Joint Pain • • • •
Traumatic vs. Insidious Piano key sign? Osteolysis Pain with: – – – –
Direct Palpation Horizontal adduction Full extension Approximation?
• Active vs. Passive Restraints
It might explain why… • …soft tissue work on the levator scap, pec minor, and infraspinatus/teres minor have worked. • Subscap activation work has been key. • Michael Hope, PT: manual depressions of the clavicle have helped. • As always, optimizing upward rotation is key. • Supine Test of the Coracoid Process Muscles
Anecdotally… • Lifting-specific population w/insidious onset • Most have significant scapular anterior tilt, and marked GIRD is common • Lower L resting i posture off the scapula allows acromion to slip anteriorly and inferiorly relative to clavicle. • Thoracic outlet? SC joint issues?
Acromioclavicular Joint Pain • Active vs. Passive Restraints • Training Modifications – Front Squat Harness, GCB, SSB, Back Squats – Never do another dip! – Push-up holds > Board Presses/Floor Presses>FullROM benches – Overhead pressing is sometimes okay – Pulling exercises may need to be modified to avoid full extension
Important Takeaways • Work hand-in-hand with rehabilitation specialists to formulate an appropriate return-to-action plan • Remember that different shoulder conditions mandate different training modifications • Understanding the causes, symptoms, and exacerbating exercises for each condition not only makes it easier to recover from the problem, but to prevent its recurrence.
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Treating the Athlete’s Shoulder Testing, Treating, and Training the Shoulder
The Athlete’s Shoulder Introduction • Common site of injury » Repetitive forces / stresses • Tremendous joint forces » Anterior shear forces 11-1.5 X BW » Distraction forces 75 75--100% X BW
• High velocities (7,265 0/sec) Michael M. Reinold, PT, DPT, SCS, ATC ATC,, CSCS
• Tremendous mobility » Repetition & fatigue » Arm fatigue & injury patterns » Number of pitches
The Athlete’s Shoulder
The Athlete’s Shoulder
Introduction
Introduction
• Injuries to the rotator cuff are common • Range from minor to severe • Specific pathologies » » » »
Internal impingement Rotator cuff tensile overload Subacromial impingement Partial thickness Æ full thickness tear
Function of the Rotator Cuff • Let’s take a step back… • What is the function of the rotator cuff? » ER/IR the arm? » Elevate arm in the scapula plane? » Initiate arm elevation?
• To treat the athlete you must understand: » The shoulder » The unique characteristics of the overhead athlete » The specific pathology
The function of the rotator cuff is to simply center the humeral head within the glenoid fossa
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Principles of RTC Rehab • • • • • •
Need adequate strength Need muscular balance Need stable base of support Need endurance Need dynamic stability Can’t work the cuff to failure!!!
Rotator Cuff Strength • Based on scientific evidence » Reinold, Escamilla, Wilk: JOSPT ’09 » Wilk, Reinold, Andrews: The Athlete’s Shoulder ‘09
• EMG studies showing what muscles are active in athletics » Jobe: Jobe: AJSM ‘83, ’84 » Digiovine: Digiovine: JSES ‘92
• EMG studies showing the safest and most effective exercise » Reinold et al: JOSPT ‘06 » Reinold et al: J Athl Train ‘08
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EMG of Posterior Rotator Cuff Reinold: JOSPT ‘04
EMG of Posterior Rotator Cuff
EMG of Supraspinatus
Reinold: JOSPT ‘04
Reinold: J Athl Train ‘07
• Placing a towel between the arm and the body increases muscular activity • Balance between the superior shoulder muscles that ER the arm and the inferior shoulder muscles that adduct the arm to hold the towel • 23% increase in EMG
Rotator Cuff Balance • Balance net forces • Focus on posterior dominant shoulder » At least 22-3:1 ratio of posterior:anterior
• ER strength is key to the shoulder
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Goal: Improve “muscular b balance” l ” “Posterior dominant shoulder”
Infra, teres
Lat, pec pec,, subscap, ant. subscap, delt
Stable Base of Support • Scapula posture, strength, and balance • Upper body cross • Thoracic spine
Scapular Position • Static resting position of scapula is protracted and anterior tilted » Bastan Bastan,, Reinold, Wilk: APTA ’06 » Macrina, Wilk: ‘08 08 » 71 Professional baseball pitchers
• These positions have strong correlation with decreased serratus and lower trapezius strength » Thigpen, Reinold, Gill: APTA ‘08 » 50 Professional baseball pitchers
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Endurance of Cuff • Fatigue contributing factor of injury » Lyman: MSSE ‘01 » Lyman: AJSM ‘02 02
• Endurance of cuff is extremely important • Need adequate base of strength before emphasizing • Remember, can not work cuff to failure!
Dynamic Stability • Video 9, 10, 11
• By far the most important aspect of RTC rehab in the athlete • Center the humeral head • Stabilize the joint during sport
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Static Shoulder Stabilization • Athletes inherently have poor static stability y
The KEY to treating the athlete • Train the rotator cuff to be strong & SMART
» Require precise interaction of the dynamic stabilizers
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• 3 position stab video
Do’s and Don’t’s
Do’s and Don’t’s
Subacromial Impingement
Internal Impingement
• DO:
• DO:
» Focus on posture, posterior strength » Soft tissue » Shoulder – scapula interaction
• DON’T: » Work the cuff to failure » Work through “pinches”
» Restore posterior flexibility » Maximize strength AND dynamic stability
• DON’T: » Force into ER » Mobilize the posterior capsule
Do’s and Don’t’s
Do’s and Don’t’s
Instability
Congenital Laxity
• DO: » Allow healing » Strengthen in stable range
• DON’T: » Force motion » Progress to aggressive exercises too early
• DO: » Focus on strength of entire shoulder » Dynamic stability » Fatigue Fatigue--resistant
• DON’T: » Stretch » Put in disadvantageous positions » Focus on big muscle groups
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Do’s and Don’t’s SLAP Lesions • DO: » Focus on strength & dynamic stability
• DON DON’T: T: » Stretch into excessive ER » Aggressive closed chain too early » Biceps
Key Points • Understand: » Shoulder – Athlete Pathology
• Principles of Treatment » Strength, balance, base of support » Posterior dominant » Dynamic stability
• Specific pathology » Remember the Do’s and Don’t’s
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Total Motion Scapular ER
Humeral
IR
Side-Lying Extension Rotation Side-Lying Internal – External Extension Rotation
Manual Stretching Sleeper Stretch Side-Lying Cross Body Stretch Prone Internal Rotation Dynamic Blackburns
Shoulder Flexion (supine)
T-Spine Standing Chin Tucks
Supine Coracoid Process
Doorway Slides
Forward Head Posture
Fist-to-Fist
Supine Pec Minor
Corner Pec Minor Wall Triceps Reach, Roll, Lift Scapular Wall Slides No Money Drill Scapular Pushups Forearm Wall Slides
Abduction Wall Pushups
T-Spine Ext. w/roller
Quadruped Chin Tucks
Breathing Patterns
Quadruped Ext. Rotation
Static Posture
3-Point Ext. Rotation
Lumbar Locked Rotation
Bent Over T-Spine Rotation
Prone Belly Breathing
Side-Lying Ext. Rotation Squat-toStand w/Ext. Rotation
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Examination Lab Impingement Neer Sign
Hawkins Sign
Internal Impingement
Beighton Score
Laxity
Sulcus Sign
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Instability Apprehension Sign
SLAP Tests Pronated Load
Resisted Supination ER Test
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Bench Pressing Variations • Narrower grip is generally less stressful (although many post-AC joint injuries will handle wider grips better) • Feet directly under or slightly behind knees, not up on bench! • Retract and depress scaps, then position eyes 4-6 inches down the bench from the bar. • Slide back to the starting position with your eyes under the bar.
Bench Pressing Variations (cont.) • Use your handoff! • Ease the bar over the pins; think of it as a “slide-over.” • Count: C t “1 “1, 22, G Gulp!” l !” • Belly up, chest up: go get the bar. • Pull the bar down to your lower sternum • Keep the upper arms at 45° angle to torso
Bench Pressing Variations (cont.) • Don’t let the scaps “roll” forward. • Think of pushing yourself away from the bar. • If your ffeett lleave the th floor, fl you are a tool. t l • Never, ever, ever, ever, EVER let your spotter say, “All you, man.”
Board Pressing • Very similar cues as bench pressing • Important to sink the bar into the board, not just bounce off it. it • Set-up options – Partner (preferred) – Band-Assisted – Under shirt
Floor Pressing • Similar cues as benching • Less overall loading needed • Less scapular stability possible because of firm floor; oo ; therefore, t e e o e, it’s t s good to use a pad beneath the body. • I tend to favor board pressing initially for impingement-type cases, and floor pressing for AC joint type issues.
Push-ups • • • •
Ensure appropriate hand position Glutes tight Brace core “Pull” torso to floor: – preactivates scapular stabilizers – ensures that chest gets to floor before face (eliminates forward head posture)
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Push-ups (cont.) • Don’t let hips sag. • Keep arms at 45° angle to body. • While it takes a bit more strength and core stability, many individuals will do better initially with feet-elevated push-ups. Increasing the amount of shoulder elevation increases serratus anterior recruitment (Lear and Gross, 1998).
Push-up Iso Holds • Great for teaching ideal posture, sequencing, and activation patterns. • Excellent for females in conjunction with elevated push-ups off pins/benches. • You can add in perturbations to challenge both dynamic shoulder stability and core stability.
Standing 1-arm Cable Rows • My personal favorite • Avoid forcing humeral extension/horizontal abduction on a fixed scapula • Pull the shoulder blade down and back toward opposite hip • If possible, use non-working hand to feel scapular movement.
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Treatment Lab Rhythmic Stabilizations
Closed Kinetic Chain
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Manual Resistance
Reactive Neuromuscular Control
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