Optimal Shoulder Performance - Cressey Reinold

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 sought-after coach for healthy and injured athletes alike from youth sports to the Olympic and professional ranks, with baseball development as his greatest focus. Behind Erics 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 CPs 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 Athletes Shoulder, 2nd Edition. Mikes contributions to sports medicine have earned recognition by groups such as the APTA, ESPN, Sports Illustrated, The Sporting News, Mens Health, The Boston Globe, and The Boston Herald. For more information, visit Mikes 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 Cresseywww EricCressey comwww.EricCressey.com

www.CresseyPerformance.com

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?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?

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 magnetic resonance imagingg g gof the shoulder in asymptomatic high performance throwing athletes reveals abnormalities thatmay encompass a spectrum of nonclinical findings

*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!

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

Rotator Cuff Fun

Sher et al. (1995): MRIs of 96 asymptomatic subjects, RTC tearsin 34% of cases, and 54% of thoseolder than 60.

Miniaci et al. (1995): MRIs of 30shoulders under age 50 with no completely normal rotator cuffs.23% had evidence of partial-thickness tears.

Connor et al. (2003): eight of20 (40%) dominant shoulders in asymptomatic tennis/baseball players had evidence of partial or full-thickness cuff tears. Five of 20 had MRI evidence of Bennetts 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 Jan-Feb;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

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 conditions does not improve clinical y g poutcomes.

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

You Kneed to KnowCook 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 junior basketball players (268 total patellar tendons)j p y ( p ) 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!

Just to Scare You a Bit More

Somewhere between 2and 8 percent of the time inAmerican hospitals, a patienthaving a genuine heart g gattack gets sent home because the doctor doingthe examination thinks for some reason that thepatient is healthy.

-Malcom Gladwell, in Blink

Weve misinterpreted the meaning of the word pathology.

any deviation from a healthy, normal, or efficient condition (dictionary.com)I th d i ffi i d In other words, inefficiency and pathology may in fact be the same thing.

Wordplay?

My primary goal for today is to show you that if you correct the inefficiency, youll markedly reduce the likelihood that these h l i h h h ldpathologies reach threshold.

Effective screening, and an understanding of population-specific norms is the key.

The site of the pain isnt always the source of the problem

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Perhaps the Best Example

The Tendinopathy Debate Tendinosis

osis = degenerative Tissue loading exceeds tissueTissue loading exceeds tissue

tolerance Tendinitis

itis = inflammatory Inflammation should be easily

controlled with cortisone injections and/or NSAIDs

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 Patients undergoing anis not necessarily 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.

The Truth is

Anyone who has ever dealt with a tendinitis diagnosis knows that it isnt 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.

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 symptomswith 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.

Kinesio-Taping Perfect example of the

difference between tendinitis and tendinosisIt k t di t ib t It works to redistribute stress appropriately

Training should do the same!!

The Law of Repetitive MotionI = 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

Poor posture: higher forces with Lifting tasks (no change in amplitudeor relaxation => high insult) Sitting at a computer: high number

I = NF/AR

Sitting at a computer: high numberof reps (constant activation) with lowamplitude and lower relaxation time. The weaker you are, the higher the percentage of maximal

strength youll use to accomplish a task. Resistance training can be extremely effective in correcting

problems quickly. Otherwise, wed have to sit with more-than-perfect posture for an equal amount of time to iron things out.

Building Blocks to Dysfunction: Soft Tissue Restrictions

Pec MinorInferior CapsuleSubscapularis

For more information, check out Dr. William Bradyat www.integrativediagnosis.com.

pTeres MinorInfraspinatus

The Bigger Picture: 12 Shoulder Health Factors

OveruseRotator Cuff WeaknessScapular StabilityPoor Glenohumeral ROMSoft Tissue Restrictions

We need to look at all of them to be comprehensive.

Poor Thoracic Spine MobilityType 3 AcromionPoor Exercise TechniquePoor Cervical Spine FunctionOpposite Hip/Ankle RestrictionsPoor Structural Balance in ProgrammingFaulty Breathing Patterns

Quantify what you can, and video/photo whatever you cant!

Things We Quantify:

Glenohumeral internal rotation, external rotation, and total motion

Thoracic spine mobilityThoracic 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

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.

Glenohumeral Internal Rotation Deficit (GIRD)

The Perfect GIRD?Right Shoulder: 19IR,

103ER, 122 Total Motion

Left Shoulder: 53IR90ER143 Total Motion

Asymptomatic, and cleared for a full return to play with a 21 total motion deficit and 34 GIRD.

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 pinned that dont cross this lineMyers et al. pinned that don t cross this 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!

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)

Treatment?

16-year old got ultrasound

23-year old got a bone stimulatorbone 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 headtake some ibuprofen for your head The Correct Approach: Stop banging

your head against the wall.

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?

Wow Fractured Right Hip Three Years Earlier 23 of Hip InternalRotation (goal = >40)Rotation (goal 40 ) You can cheat on your hip motion withlong toss, but you cant cheat when on the mound, when stress is higher.

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 i h !right!

But, athlete jumped the gun on his throwing program and didnt integrate the new hip mobility into his movements.

You can lead a horse to water, but you cant make him drink

Lessons 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 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.

I know, I know Most of you arent rehabilitation specialists and

I wouldnt 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 arent usually dont move well.

And lets 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, well go through how to assess the function of all these

active restraints

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Testing, Treating, & Training the ShoulderTesting, Treating, & Training the Shoulder

Clinical Examination of the Shoulder

Michael M. Reinold, PT, DPT, SCS, ATC, CSCSBoston Red Sox / MGH Sports Medicine

MikeReinold.com

This This PresentationPresentation

Discuss some general concepts behind shoulder examination

Where we are with evidence-based exams How to use evidence & experience! Some differential diagnosis tests Some differential diagnosis tests When to refer out When to treat & correct Clips from DVD on shoulder exam

from AdvancedCEU.com

EvidenceEvidence

Unfortunately the evidence is still a work in progress

But getting closer every day

The problem The problem Cant completely base your exam on

evidence alone Not enough studies Conflicting information in the literature Different patient populations

ExperienceExperience

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

portionportion

Expertise Expertise Combining Experience and EvidenceCombining Experience and Evidence

How does a recent graduate conduct a shoulder examination?

How does the expert conduct a shoulder examination?

Be careful! Dont get stuck in your ways!

The True Use of the ExamThe 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 improveMake list of objective goals and plan to improve

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Impingement Vs. Cuff TearImpingement Vs. Cuff Tear

Progressive cuff pathology Irritation inflammation fraying tearing Identifying where in the process the person is currently

Assess Active MotionAssess Active Motion

AC joint or subacromialImpingement

Rotator cuff tear vs. inflammation

Impingement TestsImpingement Tests Internal ImpingementInternal Impingement

The Throwers ShoulderThe Throwers ShoulderMotion and LaxityMotion and Laxity

Common findings Excessive ER Limited IR

Anterior laxity Posterior tightness

Wilk,Reinold,Crenshaw,etWilk,Reinold,Crenshaw,et al: al: 9999--0909

Examined ROM in 1400+ professional baseball players

ER @ 90 deg abduction: Dominant: 129 + 10 deg Non-Dom: 121 + 9 deg Non-Dom: 121 + 9 deg.

IR @ 90 abduction: Dominant: 61 + 9 deg Non-Dom. 68 + 8 deg

Total Motion: 190 + 14

Total Motion Equal Bilateral !!!

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Total Motion ConceptTotal Motion ConceptWilk et al AJSM 2002Wilk et al AJSM 2002

ER + IR = Total Motion

Range of Motion After ThrowingRange of Motion After ThrowingLoss of Total MotionLoss of Total Motion

Pitching with loss of total motion results in greater chance of injury Ruotolo: JSES 06Ruotolo: JSES 06 Myers: AJSM 06

Range of Motion After ThrowingRange of Motion After ThrowingLoss of Total MotionLoss of Total Motion

Loss of IR normal adaptation

Injury occurs when loss of TMof TM

Cumulative microtraumadue to eccentric and tensile forces

Causes of Loss of IR MotionCauses of Loss of IR MotionHumeral RetroversionHumeral Retroversion

Several studies have shown retroversion of the humerus Crocket AJSM 2002 Reagan AJSM 2002

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Borsa, Wilk, Reinold: AJSM 2005 Examined GH translation in 43

professional baseball pitchers Anterior: 2.81 mm

Causes of Loss of IR MotionCauses of Loss of IR MotionNotNot Posterior Posterior Capsule ContractureCapsule Contracture

Posterior: 5.38 mm Significantly greater posterior translation No differences between D and ND

No correlation between IR ROM and posterior translation

Reinold: AJSM 08 ROM Before & After Throwing Measure PROM before and

after pitching in 117 professional baseball players

Causes of Loss of IR MotionCauses of Loss of IR MotionPosterior Muscular ContracturePosterior Muscular Contracture

professional baseball players Significant decrease in:

IR: -8.5 TM: -9.5 elbow extension: -2.4

Changes still present at 24 hours

TomiyaTomiya: AJSM 04: AJSM 04 TomiyaTomiya: AJSM 04: AJSM 04

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Range of Motion After SeasonRange of Motion After SeasonReinold & Gill: Reinold & Gill: 20062006--20092009

ROM changes over course of season Subjects stretched daily

Beginning End ChangeBeginning End ChangeFlexion 175 176 -ER 133133 138138 +5+5IR 46 47 -TM 179179 185185 +6+6E Flex 135 136 -E Ext --44 --66 --22

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, DONT ASSUME!

What is a Shrug???What is a Shrug???

Assess cuff vs. capsule

What a Cuff Tear Looks LikeWhat a Cuff Tear Looks Like

DODO NOTNOT work throughwork througha shoulder shrug arc of motion !!!a shoulder shrug arc of motion !!!

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What About Instability?What About Instability?

Different types of instability Acute first time dislocation vs. congenital laxity MDI Actual capsulolabral tear vs just looseness

L it I t bilit Laxity vs. Instability

Traumatic DislocationTraumatic Dislocation

Torn Posterior CapsuleTorn Posterior Capsule Voluntary Voluntary SubluxationSubluxation

Congenital LaxityCongenital Laxity CONGENITAL LAXITY!CONGENITAL LAXITY!

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Acquired LaxityAcquired Laxity InstabilityInstability

Apprehension sign

Congenital LaxityCongenital Laxity

Sulcus sign > 10 mm positive

SulcusSulcus

SulcusSulcus BeightonBeighton Laxity ScoreLaxity Score

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SLAP LesionsSLAP Lesions

SLAPs are trendy right now Likely a little over diagnosed Well over 20 published tests

to detect a SLAP lesion Several variations of SLAPs Several variations of SLAPs Different tests for different

types of SLAPs

Compression InjuriesCompression Injuries Traction InjuriesTraction Injuries

Reinold & Gill: Sports Health 09Wilk, Reinold, Andrews: JOSPT 05Myers, Andrews: AJSM 06

Peel Back LesionsPeel Back Lesions

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Shoulder ExaminationShoulder ExaminationKey PointsKey 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 CresseyE i Cwww.EricCressey.com

www.CresseyPerformance.com

Important Prerequisites

Primary goal should always be to fix whats 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

The Sedentary/Stationary Shoulder Problem

Pain with: Overhead motion Approximation Periods of inactivity

(night, morning) Internal Rotation Scapular Protraction

Bursal-sided cuff issues


Primary vs. Secondary Scapulohumeral Rhythm Populations most commonly affected: lifters, desk p y ,

jockeys, elderly Tendinosis? Tendinitis? Bursitis? Supraspinatus? Infraspinatus? Biceps Tendon?

Labrum?


Eliminate overhead activities Modify/Eliminate Horizontal Pressing More horizontal pulling, asymptomatic cuff p g, y p

exercises, scapular stabilization exercises (improve upward rotation function)

Gentle stretching for the internal rotators and pec minor

Optimize thoracic spine mobility


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 ImpingementOnce 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 >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???

Why? Limited ROM before full ROM Adducted before abducted Unstable before stable

Cl d h i b f h i Closed-chain before open-chain Dumbbells before barbells Isometrics before regular speeds Traction before approximation (e.g., pull-ups

would come before overhead pressing)

Internal Impingement AKA posterior-superior

glenoid impingement Supra- and infraspinatus

against P-S glenoid and labrum (articular-sided cuff issues)issues)

High-speed, overhead activities: swimmers, tennis players, baseball players

Encompasses a broad spectrum of more specific diagnoses and pain presentation patterns

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 injuryAsymmetry 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

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 per ( psecond)

2,300/second elbow extension 650/second horizontal abduction

Requires a collaborative effort of DOZENS of muscles, not just the rotator cuff!

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 bd i kdeficit or abduction weakness

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Symptomatic Internal Impingement Glenohumeral Internal

Rotation Deficit (GIRD) Why does it happen? Role in SLAP lesions Almost everybody has 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):523-72008 Mar;36(3):523 7.

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

Why dont you do overhead work?

Its part of their sport so you need toIt s part of their sport, so you need to expose them to it

A few reasons

Labral fraying: less mechanical stability GIRD: non-neutral humeral positioning Approximation is not traction! Approximation is not traction! Subscapularis microtrauma Cervical spine hyperextension tendency O-Lifts: UCL and wrist/forearm/hand stress

Retro-what?

Throwing shoulders have more humeral and glenoid retroversion (may occur when pre-pubescent athletes throw when the proximal humeral epiphysis isnt closed yet)

Retroversion gives rise to a greater arc of total rotation range of motion (total motion concept = IR + ER)range-of-motion (total motion concept = IR + ER)

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

Congenital Factors? Huh?

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 d hi i i Every row and chin-up you can imagine (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:Pain with:

Direct Palpation Horizontal adduction Full extension Approximation?

Active vs. Passive Restraints

Anecdotally Lifting-specific population

w/insidious onset Most have significant

scapular anterior tilt, and marked GIRD is commonL i f Lower resting posture of the scapula allows acromion to slip anteriorly and inferiorly relative to clavicle.

Thoracic outlet? SC joint issues?

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

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>Full-

ROM 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 Athletes ShoulderTreating the Athletes ShoulderTesting, Treating, and Training the ShoulderTesting, Treating, and Training the Shoulder

Michael M. Reinold, PT, DPT, Michael M. Reinold, PT, DPT, SCS, ATCSCS, ATC, CSCS, CSCS

The The Athletes ShoulderAthletes ShoulderIntroductionIntroduction

Common site of injuryCommon site of injury Repetitive forces / stressesRepetitive forces / stresses

Tremendous joint forcesTremendous joint forces

High velocities (7,265 High velocities (7,265 00/sec)/sec)

Anterior shear forces 1Anterior shear forces 1--1.5 X BW1.5 X BW Distraction forces 75Distraction forces 75--100% X BW100% X BW

Tremendous mobilityTremendous mobility Repetition & fatigueRepetition & fatigue

Arm fatigue & injury patternsArm fatigue & injury patterns Number of pitchesNumber of pitches


Injuries to the rotator cuff are Injuries to the rotator cuff are commoncommon

Range from minor to severeRange from minor to severe Specific pathologiesSpecific pathologies

Internal impingementInternal impingement Rotator cuff tensile overloadRotator cuff tensile overload SubacromialSubacromial impingementimpingement Partial thickness Partial thickness full full

thickness tearthickness tear


To treat the athlete you To treat the athlete you must understand:must understand: The shoulderThe shoulderThe shoulderThe shoulder The unique The unique

characteristics of the characteristics of the overhead athleteoverhead athlete

The specific pathologyThe specific pathology

Function of the Rotator CuffFunction of the Rotator Cuff

Lets take a step backLets take a step back

What is the function of the rotator cuff?What is the function of the rotator cuff? What is the function of the rotator cuff?What is the function of the rotator cuff? ER/IR the arm?ER/IR the arm? Elevate arm in the scapula plane?Elevate arm in the scapula plane? Initiate arm elevation?Initiate arm elevation?

The function of The function of the rotator cuff is the rotator cuff is to simply center to simply center

the humeral headthe humeral headthe humeral head the humeral head within the within the glenoidglenoid

fossafossa

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Principles of RTC RehabPrinciples of RTC Rehab

Need adequate strengthNeed adequate strength Need muscular balanceNeed muscular balance Need stable base of supportNeed stable base of support Need stable base of supportNeed stable base of support Need enduranceNeed endurance Need dynamic stabilityNeed dynamic stability Cant work the cuff to failure!!!Cant work the cuff to failure!!!

Rotator Cuff StrengthRotator Cuff Strength

Based on scientific evidenceBased on scientific evidence Reinold, Escamilla, Wilk: JOSPT 09Reinold, Escamilla, Wilk: JOSPT 09 Wilk, Reinold, Andrews: The Wilk, Reinold, Andrews: The

Athletes Shoulder 09Athletes Shoulder 09

EMG studies showing whatEMG studies showing what EMG studies showing what EMG studies showing what muscles are active muscles are active in athleticsin athletics JobeJobe: AJSM 83, 84: AJSM 83, 84 DigiovineDigiovine: JSES 92: JSES 92

EMG studies showing the safest EMG studies showing the safest and most effective exerciseand most effective exercise Reinold et al: JOSPT 06Reinold et al: JOSPT 06 Reinold et al: J Reinold et al: J AthlAthl Train 08Train 08

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EMG of Posterior Rotator CuffEMG of Posterior Rotator CuffReinold: JOSPT 04Reinold: JOSPT 04

EMG of Posterior Rotator CuffEMG of Posterior Rotator CuffReinold: JOSPT 04Reinold: JOSPT 04

Placing a towel between the Placing a towel between the arm and the body increases arm and the body increases muscular activitymuscular activity

Balance between the superior Balance between the superior shoulder muscles that ER the shoulder muscles that ER the arm and the inferior shoulder arm and the inferior shoulder muscles that adduct the arm muscles that adduct the arm to hold the towelto hold the towel

23% increase in EMG23% increase in EMG

EMG of EMG of SupraspinatusSupraspinatusReinold: J Reinold: J AthlAthl Train 07Train 07

Rotator Cuff BalanceRotator Cuff Balance

Balance net forcesBalance net forces Focus on posterior Focus on posterior

dominant shoulderdominant shoulderdominant shoulderdominant shoulder At least 2At least 2--3:1 ratio of 3:1 ratio of

posterior:anteriorposterior:anterior ER strength is key to ER strength is key to

the shoulderthe shoulder

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Goal:Goal:

Improve Improve muscular muscular b l b l balancebalance

Posterior Posterior dominant dominant shouldershoulder

Infra, Infra, teresteres

Lat, Lat, pecpec, , subscapsubscap, ant. , ant.

deltdelt

Stable Base of SupportStable Base of Support

Scapula posture, strength, and balanceScapula posture, strength, and balance Upper body crossUpper body cross Thoracic spineThoracic spine Thoracic spineThoracic spine

Scapular Position Scapular Position Static resting position of Static resting position of

scapula is protracted and scapula is protracted and anterior tiltedanterior tilted BastanBastan, Reinold, Wilk: APTA 06, Reinold, Wilk: APTA 06 Macrina, Wilk: 08Macrina, Wilk: 08Macrina, Wilk: 08Macrina, Wilk: 08 71 Professional baseball pitchers71 Professional baseball pitchers

These positions have strong These positions have strong correlation with decreased correlation with decreased serratusserratus and lower and lower trapeziustrapeziusstrengthstrength Thigpen, Reinold, Gill: APTA 08Thigpen, Reinold, Gill: APTA 08 50 Professional baseball pitchers50 Professional baseball pitchers

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Endurance of CuffEndurance of Cuff

Fatigue contributing factor of injuryFatigue contributing factor of injury Lyman: MSSE 01Lyman: MSSE 01 Lyman: AJSM 02Lyman: AJSM 02 Lyman: AJSM 02Lyman: AJSM 02

Endurance of cuff is extremely Endurance of cuff is extremely importantimportant

Need adequate base of strength before Need adequate base of strength before emphasizingemphasizing

Remember, can not work cuff to failure!Remember, can not work cuff to failure!

Video 9, 10, 11Video 9, 10, 11

Dynamic StabilityDynamic Stability By far the most important aspect of RTC By far the most important aspect of RTC

rehab in the rehab in the athleteathlete Center the humeral headCenter the humeral head Stabilize the joint during Stabilize the joint during sportsport

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Static Shoulder StabilizationStatic Shoulder Stabilization

Athletes inherently Athletes inherently have poor static have poor static stabilitystabilityyy Require precise Require precise

interaction of the interaction of the dynamic dynamic stabilizersstabilizers

The The KEYKEY to to treating treating the the athleteathlete

Train the rotator cuff to be strong & Train the rotator cuff to be strong & SMARTSMART

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3 position stab video3 position stab video

Dos and Dos and DontsDontsSSubacromialubacromial ImpingementImpingement

DO:DO: Focus on posture, posterior strengthFocus on posture, posterior strength Soft tissueSoft tissue Soft tissueSoft tissue Shoulder Shoulder scapula interactionscapula interaction

DONT:DONT: Work the cuff to failureWork the cuff to failure Work through pinchesWork through pinches

Dos and Dos and DontsDontsInternal ImpingementInternal Impingement

DO:DO: Restore posterior flexibilityRestore posterior flexibility Maximize strength AND dynamic stabilityMaximize strength AND dynamic stability Maximize strength AND dynamic stabilityMaximize strength AND dynamic stability

DONT:DONT: Force into ERForce into ER Mobilize the posterior capsuleMobilize the posterior capsule

Dos and Dos and DontsDontsInstabilityInstability

DO:DO: Allow healingAllow healing Strengthen in stable rangeStrengthen in stable range Strengthen in stable rangeStrengthen in stable range

DONT:DONT: Force motionForce motion Progress to aggressive exercises too earlyProgress to aggressive exercises too early

Dos and Dos and DontsDontsCongenital LaxityCongenital Laxity

DO:DO: Focus on strength of entire shoulderFocus on strength of entire shoulder Dynamic stabilityDynamic stability Dynamic stabilityDynamic stability FatigueFatigue--resistantresistant

DONT:DONT: StretchStretch Put in disadvantageous positionsPut in disadvantageous positions Focus on big muscle groupsFocus on big muscle groups

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Dos and Dos and DontsDontsSLAP LesionsSLAP Lesions

DO:DO: Focus on strength & dynamic stabilityFocus on strength & dynamic stability

DONT:DONT: DON T:DON T: Stretch into excessive ERStretch into excessive ER Aggressive closed chain too earlyAggressive closed chain too early BicepsBiceps

Key PointsKey Points Understand:Understand:

Shoulder Shoulder Athlete Athlete --PathologyPathology

Principles of TreatmentPrinciples of Treatment Strength, balance, base of Strength, balance, base of

supportsupport Posterior dominantPosterior dominant Dynamic stabilityDynamic stability

Specific pathologySpecific pathology Remember the Dos and Remember the Dos and

DontsDonts

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Lumbar Locked

Rotation

Wall Pushups

Supine Coracoid Process

Total Motion Fist-to-Fist

Breathing Patterns

ER IR

Humeral T-SpineScapular

Prone Belly Breathing

Doorway Slides

Side-Lying Extension Rotation

Side-Lying Internal External

Extension Rotation

Manual Stretching

Sleeper Stretch

Side-Lying Cross Body

Stretch

Prone Internal Rotation

Dynamic Blackburns

T-Spine Ext. w/roller

3-Point Ext. Rotation

Bent Over T-Spine Rotation

Quadruped Ext.

Rotation

Side-Lying Ext.

Rotation

Squat-to-Stand w/Ext.

Rotation

Supine Pec Minor

Wall Triceps

Reach, Roll, Lift

Corner Pec Minor

Scapular Wall Slides

No Money Drill

Scapular Pushups

Forearm Wall Slides

Abduction

Quadruped Chin Tucks

Standing Chin Tucks

Forward Head Posture

Static Posture

Shoulder Flexion (supine)

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ExaminationLab

Impingement

NeerSign HawkinsSign InternalImpingement

Laxity

SulcusSign BeightonScore

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Instability

ApprehensionSign

SLAPTests

PronatedLoad ResistedSupinationERTest

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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.C t 1 2 G l ! Count: 1, 2, Gulp!

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.)

Dont let the scaps roll forward. Think of pushing yourself away from the

bar.If f t l th fl t l If your feet leave the floor, you are a tool.

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 itjust bounce off 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; therefore, its good to use a pad oo ; t e e o e, t s good to use a padbeneath 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 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.)

Dont let hips sag. Keep arms at 45 angle to body. While it takes a bit more strength and coreWhile 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 withExcellent 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 scapulaabduction 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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TreatmentLab

RhythmicStabilizations

ClosedKineticChain

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ManualResistance

ReactiveNeuromuscularControl

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