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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 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 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 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.

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!

Weve 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, youll
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 isnt always the source
of the problem

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 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.

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)

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 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.

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 cant!

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!

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: 19IR,
103ER,
122 Total Motion
Left Shoulder: 53IR
90ER
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 dont
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!

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 cant
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 didnt integrate the new hip
mobility into his movements.
You can lead a horse to water, but you cant 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 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

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

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

Cant 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! Dont get stuck in


your ways!

Impingement Vs. Cuff Tear

Assess Active Motion

Progressive cuff pathology


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

AC joint or subacromial
Impingement

Rotator cuff tear vs.


inflammation

Impingement Tests

The Throwers 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 !!!

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

10

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

11

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, DONT ASSUME!

What a Cuff Tear Looks Like

Assess cuff vs. capsule

DO NOT work through


a shoulder shrug arc of motion !!!

12

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!

13

Acquired Laxity

Instability
Apprehension sign

Congenital Laxity

Sulcus

Sulcus sign
> 10 mm positive

Sulcus

Beighton Laxity Score

14

SLAP 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
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

15

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

16

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 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
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

17

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!

18

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.
Dont 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+
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 wont 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

19

A few reasons
Why dont you do overhead work?
Itss 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 isnt 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

20

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.

21

Treating the Athletes Shoulder


Testing, Treating, and Training the Shoulder

The Athletes 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 Athletes Shoulder

The Athletes 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 full
thickness tear

Function of the Rotator Cuff


Lets 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

22

Principles of RTC Rehab

Need adequate strength


Need muscular balance
Need stable base of support
Need endurance
Need dynamic stability
Cant work the cuff to failure!!!

Rotator Cuff Strength


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

23

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

24

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

25

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

26

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

27

3 position stab video

Dos and Donts

Dos and Donts

Subacromial Impingement

Internal Impingement

DO:

DO:

Focus on posture, posterior strength


Soft tissue
Shoulder scapula interaction

DONT:
Work the cuff to failure
Work through pinches

Restore posterior flexibility


Maximize strength AND dynamic stability

DONT:
Force into ER
Mobilize the posterior capsule

Dos and Donts

Dos and Donts

Instability

Congenital Laxity

DO:
Allow healing
Strengthen in stable range

DONT:
Force motion
Progress to aggressive exercises too early

DO:
Focus on strength of entire shoulder
Dynamic stability
Fatigue
Fatigue--resistant

DONT:
Stretch
Put in disadvantageous positions
Focus on big muscle groups

28

Dos and Donts


SLAP Lesions
DO:
Focus on strength & dynamic stability

DON
DONT:
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 Dos and
Donts

29

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

30

ExaminationLab
Impingement
NeerSign

HawkinsSign

InternalImpingement

BeightonScore

Laxity

SulcusSign

31

Instability
ApprehensionSign

SLAPTests
PronatedLoad

ResistedSupinationERTest

32

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.)


Dont 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, its
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)

33

Push-ups (cont.)
Dont 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.

34

TreatmentLab
RhythmicStabilizations

ClosedKineticChain

35

ManualResistance

ReactiveNeuromuscularControl

36

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