Does Reaching Behind the Back Reflect the Actual Internal Rotation of the Shoulder?

image It is no secret that I am not a big fan of stretching the shoulder behind the back to gain internal rotation.  I have written about this in the past and even included it in my list of the 5 least favorite exercises.  I received a lot of feedback for this opinion, both positively and negatively. 

Many people agree with me that this is an aggressive stretch and puts the rotator cuff in an extremely disadvantageous position while many argued that it is still a position of function for their patients.

Apparently I am not the only one who has questioned this in the past as I have come across some research studies that assess if reaching behind the back (BTB) is an accurate measurement of internal rotation.  This isn’t exactly the stretch that I dislike, but more of using the hand-behind-the-back technique to measure range of motion.

 

What Does the Research Say?

image Wakabayashi et al (JSES 2006) used electromagnetic tracking to assess the amount of shoulder internal rotation, extension, abduction, and elbow extension during this BTB movement.  The authors report that the majority of internal rotation at the shoulder occurs before the patient reaches the sacrum.  There is also a significant increase in shoulder extension and abduction to reach the sacrum.   After the hand passes the sacrum, the majority of motion is achieved by flexing the elbow.  After the hand passes T12, there is no significant increase in internal rotation.  So it appears that getting to the sacrum is the key to this motion and that shoulder internal rotation, abduction, and extension can all limit the ability to get to the sacrum.

Mallon et al (JSES 1996) uses radiographs in healthy individuals to assess contributing motions and concluded that 35% of the BTB motion actually occurs at the scapulothoracic joint.  They also agreed that elbow flexion was an important component of this motion and considered the BTB position invalid. 

More recently, Ginn et al (JSES 2006) assess the validity of the BTB motion in assessing a loss of internal rotation in a group of 137 subjects with shoulder pain.  The measured the BTB motion as well as standard goniometer of the shoulder IR at 45 and 90 degrees of abduction.  The results showed only a low to moderate correlation between the motions, the ability to reach behind the back did not correlate to loss of active IR of the shoulder.

 

Clinical Implications

Ok so what does all of this mean?  Here are my thoughts:

  • Reaching behind the back is not a valid measurement for internal rotation.  The motion is created by the combination of scapula tilt, shoulder internal rotation, abduction, extension, and elbow flexion.  Any combination of these factors will influence this motion.
  • Be careful when using a shoulder outcome scale that uses the BTB motion to quantify shoulder internal rotation.  Unfortunately some do, including the Constant scale and the American Shoulder Elbow Surgeons (ASES) scale.
  • If you want to measure internal rotation of the shoulder, actually measure internal rotation of the shoulder.  Grab that old goniometer out of the dusty drawer, it is actually pretty handy!
  • Don’t make treatment implications based on the BTB motion.  For example, don’t perform posterior capsule joint mobilizations on a person just because they can’t reach behind their back.

Based on all of this, what about the person that has a limitation with this movement, what should we do?

  • I understand and agree that this is a position of function.
  • I still recommend avoiding this as a stretch.  I have never had good outcomes and I really believe you are putting the shoulder joint and rotator cuff in a terrible position.  I talk about this in more detail in these past two posts on my 5 least favorite exercise here and here.
  • Use the information from these studies to explore why a person doesn’t have good BTB motion.  Assess the scapula, shoulder extension, abduction, and elbow flexion.  Don’t just assume it is all IR. 

If you are interested in more information about how I treat the shoulder, check out my Optimal Shoulder Performance DVD with Eric Cressey and some of my DVDs at AdvancedCEU.com.

I am sure there are a lot of people that have more thoughts, what do you think?  Agree with me?  Disagree?  Why?

 

 

 

Wakabayashi, I., Itoi, E., Minagawa, H., Kobayashi, M., Seki, N., Shimada, Y., & Okada, K. (2006). Does reaching the back reflect the actual internal rotation of the shoulder? Journal of Shoulder and Elbow Surgery, 15 (3), 306-310 DOI: 10.1016/j.jse.2005.08.022

11 replies
  1. Kereen Wallace
    Kereen Wallace says:

    I think there are two sides to this story. There is a place for functional screening with BTB testing as it does give you an idea of some of the restrictions that may exist. You may also use it as a position to do ” a quick lift off test”. Secondly, once I note the restrictions and I still go ahead and check isolated IR and ER to find out the specific limits of the movement. But in all cases clinical reasoning dictates what is done in each case, no one test is absolute in all cases.

  2. Christopher Johnson
    Christopher Johnson says:

    Behind the back internal rotation looks at several items. I like to use this as a screening/assessment technique but I discourage clinicians form using this for stretching the posterior shoulder elements especially after rotator cuff repair. Clinicians should also be aware that the ribs must be able to internally torsion on the ipsilateral side of the movement while the vertebral segments must flex open. If there is a restriction or limitation in this movement, one must then consider if we are dealing with the dominant or nondominant arm and know if the individual is a unilaterally dominant overhead athlete. Other items I like to look at in conjunction with active internal rotation behind the back is ER/IR ROM at 90, the Tyler test, horizontal adduction, asymmetric pect minor tightness posterior glenohumeral glide, and clavicular arthrokinematics. If no major impairments are found I then start to consider the potential restrictions at the level of the costal cage. This is a great discussion topic. I would also encourage people to check out Mark Bookhout's presentation from CSM (I believe 2006).

  3. Matt Hayre
    Matt Hayre says:

    Mike, does this have implications for the Hand-to-hand assessment test? I have very little congenital laxity (can barely lift my pinky 40 degrees and score a 0 out of 5) and the hand to hand rocks me. Still, my shoulders aren't internally rotated and my total motion is balanced.

  4. Jess Barsotti, DPT, ATC
    Jess Barsotti, DPT, ATC says:

    Sam,

    Assessing the specific ("exact") impairments is important. However I prefer to observe the functional pattern first when examining someone. This allows me to streamline my evaluation (save time) and prioritize hypotheses and treatments, focusing on the key impairments.

    I can find almost infinite "impairments" in anyone, but each person may or may not have pain/difficulty in functional patterns because of those limitations. Stretching someone's posterior capsule because I found it to be hypomobile may or may not improve his or her function. Whereas if I see lack of motion at a joint or atrophy or poor control/timing of a muscle in their function, I know where to focus my treatments first.

    I hope this helps answer your question.

  5. Jason H, DPT, CSCS
    Jason H, DPT, CSCS says:

    Definitely agree with you on this Mike.

    The BTB position just perpetuates the excessive anterior glide of the humeral head resulting/contributing to the laxity which is present in a large majority of the shoulder patients I treat.

    Shirley Sahrmann would definitely disapprove of using the BTB as a stretch!

  6. Preston Collins SDPT
    Preston Collins SDPT says:

    Mike, I love the topic. I hadn't really put much thought into how many motions are actually occurring in the BTB movement.

    As a current DPT student, we are being taught to look at the BTB motion from a more functional standpoint, as has been discussed here. Our faculty always emphasize the importance to measure IR/ER in the most fundamental way we know – with the goniometer. I do agree, however, that by looking not only at how far the patient can move in BTB but also the way in which they go about completing the task, can tell you a lot as far as their impairments/functional limitations, and consequent disabilities.

    Also as an aside, Mike (or others), do you have specific stretches you like to use for either the posterior cuff and/or capsule? We have been shown one or two in school but I am curious as to any you have found to give the best clinical outcomes, mainly among the athletic population.

  7. Mike Reinold
    Mike Reinold says:

    Good points Jess, thanks for writing. The scap repositioning sounds like a good idea. I really still wont use this stretch, though, as there are better ways to achieve this without putting the joint in a disadvantageous position.

    Sam, i think what you are looking for is that you can look OK when you test the shoulder, scap, elbow, etc but when asking a person to perform a task they dont perform well. This is more along the lines of neuromuscular control, proprioception, dynamic stability, etc.

  8. mitchdcba
    mitchdcba says:

    I forgot a key point. I have been getting deep tissue massage every week for the past 8 weeks and this really helps accelerate the healing. I tired Professional Physical Therapist, and I heard it works.
    Shoulder Pain Treatment

  9. Sam
    Sam says:

    Could we possibly have a discussion as to WHY the "functional" approach via Gray Cook is inferior to the, what i call, the "exact" approach where we break it down to find out exactly which muslce or joint is the culprit.

    I can remember Gray talking about something along the lines of "you can asses each joint and they test ok but when you coordinate it into functional movement then it looks bad". Why is that then?

    I'm not a DPT or anything, just a college student trying to find the answer to this question. . .

  10. Jess Barsotti, DPT, ATC
    Jess Barsotti, DPT, ATC says:

    This is a great topic for discussion, Mike.

    Even though the BTB motion is one of function, I feel it should never be performed as a stretch.

    My reason is because, as with any stretch, you need to stabilize both ends of the muscle/joint capsule/etc that you intend to stetch.

    The posterior shoulder muscles and joint capsule should be the goal of this stretch. However in the BRB position, those muscles rarely get stretched. Instead the scapula will protract and anteriorly tip (winging out), and the anterior shoulder and rotator cuff end up taking the most stress.

    Ask one of your patients to perform a BRB and then manually assist them in retracting and posteriorly tipping the scapula. This should get them to feel the stretch in the correct tissue(s).

    It is somewhat ironic that "healthy" people in the Mallon et al study performed the BRB motion with 35% of the scapulothoracic joint. While this may be the norm, I'm quite certain it is not ideal.

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