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A Simple Exercise for the Scapula, Posterior Chain, and Posture

I am always a fan of simple exercises that get a big bang for my buck.  I want to be able to streamline my programs to have as little fluff as possible.

One exercise I often use for scapular control is called the “cheerleader exercise,” which my friend Russ Paine in Houston first showed me and has popularized over the years.  Russ included this exercise in one of his latest publications on The Role of the Scapula in the International Journal of Sports Physical Therapy.  The article is free to read and is a great adjunct to my recent webinar on Scapular Dyskinesis.

Russ teamed up with another pioneer in sports physical therapy, Mike Voight, to write the new manuscript.  The amazing part is that Russ and Mike wrote one of the landmark articles on scapular rehabilitation in JOSPT in 1993, twenty years ago!

The cheerleader exercise uses a piece of Theraband or rubber tubing to perform a series of reciprocal exercises focusing on scapular retraction.  You begin by grasping a piece of tubing between both hands with your arms raised forward at shoulder height.  Pull both hands apart into horizontal abduction.  Then, return to the starting position and pull one arm down and the other up in a diagonal pattern.  For those familiar with proprioceptive neuromuscular facilitation (PNF) drills, these are D2 flexion and D1 extension positions.  Return to the starting position again and switch the diagonals.

scapula cheerleader exercise

This is a great posterior chain drill that works on developing strength and endurance in a functional scapular patterns.  It is a great drill when working on facilitating a more posterior dominant posture, and getting out of our terrible anterior dominant sitting posture.

This one drill effectively combines several exercises that focus on scapular retraction, upward rotation, and posterior tilt.  But what I really like about the exercise is the reciprocal nature of the exercise.

scapula exercise

Think about it, running, jumping, throwing and other activities always involve a reciprocal involvement of upward arm movement and reciprocal arm extension.

I don’t use this as a replacement for pure isotonic strengthening of the scapula muscles, such as the YTWL exercises, but it is a nice drill to work on integrated patterns and endurance.  Next time you are looking for a drill to enhance scapular control, posterior chain strength, and postural awareness, try the cheerleader exercise.

 

 

 

Can Physical Therapy for Rotator Cuff Tears Prevent Surgery?

Rotator cuff repair surgery and postoperative rehabilitation continue to be some of the most debated topics on the shoulder at orthopedic and physical therapy conferences.  Numerous studies have been published showing the failure rate of rotator cuff repair surgery ranges anywhere from 25-90%.

rotator cuff tearWhile this failure rate is certainly alarming, the term “failure” must be defined.  In traditional study models, success is defined as an intact rotator cuff, which makes sense.  However, one of the more interesting findings in most of these studies is that despite the “failed” repair, most patients are quite satisfied with their functional status and outcome.  This really does have to make you question how we define “failure” as patient outcomes and satisfaction seems more important than radiological findings.

These studies have sparked debate over the role of postoperative physical therapy follow rotator cuff repair surgery, with many physicians becoming more conservative and slowing down their protocols.  This obviously implies that some physicians believe that early physical therapy is the reason why failures occur.  This thinking may be flawed and factors such as tissue quality, tear severity, patient selection, surgical technique, and others may be more likely related to ultimate failure rates.

Another perspective to consider is that despite having a failed rotator cuff repair, patient satisfactions were good.  From experience, I can tell you that patients are satisfied when they:

  1. Have less pain
  2. Regain their mobility
  3. Return to functional activities

So the question really should be asked – if there is up to a 90% surgical failure rate but significant increase in satisfaction and outcomes, can physical therapy for rotator cuff tears alone without surgery be just as beneficial at helping patients reduce pain, regain mobility, and return to their activities?

Can Physical Therapy for Rotator Cuff Tears Prevent the Need for Surgery?

A recent study in the Journal of Shoulder and Elbow Surgery looked at this exact question.  The MOON Shoulder Group, which is a multi-center network of research teams around the country, followed a group of 381 patients with atraumatic full-thickness tears of the rotator cuff for a minimum of two tears.  The mean age of the patients was 62 years with a range of 31-90 years.

The patients performed 6-12 weeks of nonoperative physical therapy focusing on basic rotator cuff strengthening, soft tissue mobilization, and joint mobilizations.

At the six-week mark, patients were assessed and 9% chose to have rotator cuff repair surgery.  Patients were again assessed and the 12-week mark.  At 12-weeks, an additional 6% chose to have surgery.  In total, 26% of patients decided to have surgery by the 2-year follow-up mark.  Statistical analysis revealed that if a patient does not choose to have surgery within the first 12-weeks of nonoperative rehabilitation, they are unlikely to need to surgery.

Nearly 75% of patients avoided rotator cuff repair surgery by performing physical therapy despite having full thickness cuff tears. [Click to Tweet]

That is a pretty significant finding.

Keys to Nonoperative Rotator Cuff Rehabilitation

The results of this study could have a large impact on how we treat rotator cuff tears.  Physical therapy should be attempted prior to surgery, even in the case of a full thickness tear.  To maxmize these outcomes, a comprehensive rehabilitation program should be developed.  When working on patients with rotator cuff tears, I tend to focus on 3 key areas.

Restore Shoulder Mobility

This includes both passive and active mobility.  For passive mobility, it seems to me that shoulder range of motion is gradually lost as the rotator cuff symptoms increase.   Perhaps it is a pain avoidance strategy, disuse, or some other factor.  You’ll often find glenohumeral joint capsule hypomobility and soft tissue restrictions.  Soft tissue mobilization, joint mobilizations, and range of motion exercises should be designed based on the specific loss of motion exhibited by the patient.

Restore The Ability of the Rotator Cuff to Dynamically Stabilize

This is essentially the same as restoring active mobility of the shoulder.  The rotator cuff has to function properly to allow active mobility without restrictions.  In a previous article, I discussed the suspension bridge concept and how you can have a rotator cuff tear without symptoms.  You can see in this diagram that if you have properly functioning anterior and posterior rotator cuff muscles, you can often still elevate the arm despite a tear to the supraspinatus.

rotator cuff suspension bridge concept

Exercises designed to enhance strength and dynamic stability of the shoulder should be incorporated.  In my experience external rotation strength tends to be the most limited and needs to most attention.

Reduce the Impact of the Kinetic Chain

In addition to restore mobility and stability of the shoulder, you should also consider the impact of the kinetic chain on shoulder function.  Read my past article on the different types of shoulder impingement to understand some of these concepts.  Any dysfunctions of the scapulothoracic joint, cervical spine, thoracic spine, and lumbopelvic complex should be assessed.  These areas all have a significant impact on the alignment, mobility, and stability of the glenohumeral joint.

If you want to learn more about how I perform nonoperative rehabilitation for rotator cuff tears, I have a past webinar on shoulder impingement that discusses many of the same keys to treatment.

Using these principles, you can formulate a rehabilitation program that could potentially save 75% of people with rotator cuff tears from needed rotator cuff repair surgery.  Hopefully studies like this will continue to shed light on the impact physical therapy can have on the satisfaction and outcomes of patients with rotator cuff tears, with or without surgery.

What You Need to Know About GIRD: What It Is and What it Isn’t

GIRD Mike ReinoldGlenohumeral internal rotation deficit, or GIRD, continues to be one of the most polarizing topics in baseball sports medicine.  It has become so popular that even athletes and the general public know about GIRD, often exhibiting fear and anxiety with just the mention of GIRD.

How many times has a baseball player come back from the doctor with their head down saying, “I have GIRD,” as if the world has just ended?

I do not feel that everyone truly understands GIRD, how to assess GIRD, or how to treat GIRD.  There are a lot of theories and assumptions out there that may or may not be true.

Here is my take on GIRD, and it is not exactly how everyone would describe GIRD.

 

What is normal range of motion in an overhead athlete?

Before we can have any discussion on what is considered abnormal range of motion in the thrower’s shoulder, we should make sure we understand what is considered “normal” in overhead athletes.

Throwers have very unique adaptations from the demands of throwing. Numerous articles over the past 15 years have consistently shown that the dominant shoulder in overhead athletes exhibits an increase of external rotation and a subsequent decrease in internal rotation.  However, if you take the total rotation motion and combine ER and IR measurements the numbers are almost identical.

I remember when we first started discovering this phenomenon many years ago and it is uncanny how you find essentially the exact same total motion arc on both sides.

Here is an illustration of what this looks like.  In this figure.  You see the nondominant shoulder on the left and the dominant shoulder on the right.  You see the shift in the arc of total rotational motion, however if you break down the components of ER and IR, you see that both sides total 180 degrees.

GIRD glenohumeral internal rotation deficit

This adaptation has been shown in too many publications to list here, but I’ll add a few:

GIRD total rotational motion

This is a brief list but you can see that the total rotation motion on both the dominant and nondominant shoulders is almost identical in every study.  Statistical analysis revealed no significant differences in range of motion side to side.

 

Why the Adaptation in Shoulder Range of Motion?

Since the first discovery of this loss of internal rotation on the throwing arm, there have been several theories as to the specific reason for the adaptation.

The first theory centered around the fact that since there was a loss of internal rotation, there must be a subsequent tightness of the posterior capsule.  In actuality, this is really a long shot of being the isolated reason for the loss of IR, assuming a very specific cause for GIRD.

With so many potential factors contributing to the altered range of motion, it is surprising to me how popular this theory became.  If IR is less on the thrower shoulder, we now jump straight to recommending aggressive internal rotation and posterior capsular stretching.  I guess whatever theory comes out first gets the most traction and popularity!

The major flaw of the posterior capsule tightness theory is that it does not take into consideration the very specific increase in ER that is also seen in overhead athletes, let alone the fact that total rotational motion is still the same side-to-side.  If the posterior capsule was the cause of the loss of IR, would we then assume that the anterior capsule has loosened precisely the exact same amount to allow the exact same increase in ER as the posterior capsule does to restrict IR?

That sounds pretty unrealistic to me.

Shortly after the posterior capsule tightness theory was presented, many researchers took a more scientific look at what could be causing this very precise shift in the arc of motion in baseball pitchers and other overhead athletes. Several studies have now been published that have assessed boney changes that could be associated with GIRD.  Using both MRI and CT scans, it is now well documented that the humerus of the throwing arm is more retroverted than the nondominant arm.

What this means is that the actual bone of your upper arm torques and adapts.

Imagine twisting and wringing out a towel.  This is exactly what happens to the humerus during throwing while your growth plates are open.  The body, bones especially, do a great job of adapting to stress.  Essentially, the humerus bone of your upper arm twists at the growth plate and causes permanent adaptations to your bones.  Newer research is also now showing that the other end of the socket, the glenoid, also shows retroversion.

Based on these studies, the exact amount of retroversion observed appears to be approximately 10 degrees on average.  Now go back up and look at the table above.  Notice how the loss of IR is approximately 10 degrees and the gain of ER is approximately 10 degrees?  This boney adaptation makes the very specific shift in range of motion make more sense.  I have shown a simple and fairly effective way of measuring humeral retroversion in the clinic.  Try it in your throwers and you’ll see.

Pretty cool, right?  Still think the posterior capsule is the cause of loss of IR?

I was also a part of two studies that looked at glenohumeral translation in the baseball pitcher that both showed that posterior translation was twice that of anterior translation.  This was even present in baseball pitchers with as little as 10 degrees of IR.  They still had a large amount of posterior translation, not posterior capsular tightness.

Taking all of this into consideration, if there is one thing you take away from this article, it should be:

[quote]The thrower’s shoulder is supposed to have less IR on the dominant side.  This is normal.[/quote]

 

Determining What is Clinically Significant GIRD

A threshold to determine what can be considered a clinically significant loss of IR is vitally important to the implementation of programs designed to prevent and treat GIRD.  As previously discussed, a loss of IR itself can be considered a normal anatomical variation observed in overhead athletes.

Despite this finding, the term GIRD has continued to have a negative connotation, implying that any side-to-side loss of IR may be pathological.  This has resulted in a trend towards assuming many of the hypothesized theories of why loss of IR occurs are present in each person.

This unfortunately leads to a standardized prescription of stretches and exercises based on assumption and not a thorough assessment.

After reviewing the literature, it appears that most authors have been arbitrarily defining GIRD as a loss of IR greater than 15-20 degrees in comparison to the nonthrowing arm.  Some authors have even published studies showing that your chance of getting injured is increased if you have GIRD of more than 15-20 degrees.

Correlating GIRD to injury is too simplistic at best and again has too many flaws to consider this valid.

You can not accurately state why an increase in injury was observed.  Was it the loss of 17 degrees of IR?  Or perhaps the subsequent gain of 17 degrees of ER?  You can’t make a definitive conclusion either way.

[quote]Perhaps the increase of injuries in baseball pitchers is due to the gain in shoulder ER, not GIRD and the loss of IR?[/quote]

I am thinking this more and more everyday.

Another major flaw with defining GIRD using an arbitrary number is that the published amounts of range of motion have a very large standard deviation.  If you look through the published studies on GIRD, you’ll see that the standard deviation of measurements is large, ranging from 8 degrees to over 15 degrees.  That means the “normal” amount of internal rotation on a shoulder is approximately 50 degrees, but plus or minus 15 degrees.  Thus both 35 degrees and 65 degrees of internal rotation should be considered “normal.”

I can say that I have observed this first hand in professional baseball pitchers.  I have seen just as many players with 140 degrees of total rotational motion than I have with 200 degrees of total rotational motion.  Sure, this averages out to 170 degrees.  But not all baseball pitchers have 170 degrees of total rotational motion.

With such a large standard deviation and variability in measurements, assigning an arbitrary number to define GIRD is too simplistic.

 

A New Definition of GIRD

These findings have caused me to alter the way I define GIRD and stimulated me to propose a new definition of GIRD based on total rotational motion.

Previous definitions of GIRD based on arbitrary numbers have resulted in generalized treatment programs that are not specific or individualized enough to be utilized in clinical practice.

I propose that a loss of side-to-side IR is actually a normal anatomical variation in overhead athletes and should not be considered pathological GIRD unless there is a subsequent loss of total rotational motion in the dominant arm as well.  

This definition essentially takes the large variability in ROM that has been observed in athletes into consideration and allows for a more individualized approach to treating GIRD. So:

[quote]GIRD is a loss of internal rotation range of motion in the presence of a loss of total rotational motion.[/quote]

In this new definition of GIRD, a pathological condition of GIRD is defined as a loss of IR in the presence of loss of total rotational motion.

Lets looks at this as both an illustration and an equation.  In the figure below, you see the normal arc of motion in an overhead athlete, and to the right, an altered total rotational range of motion due to a loss of IR.

a new definition of GIRD

You can observe this yourself by assessing the specific range of motion measurements.  To calculate GIRD, use this equation:

GIRD = (Side-to-side difference in ER) + (Side-to-side difference in IR)

Here is an example of two baseball pitchers with a loss of IR:

  • Player 1 = (D ER 120 deg – ND ER 100 deg = +20 deg ER) + (D IR 60 deg – ND IR 80 deg = -20 deg IR) = 0 deg – Despite a loss of 20 degrees this is not pathological GIRD because total motion is the same bilaterally
  • Player 2 = (D ER 120 deg – ND ER 100 deg = +20 deg ER) + (D IR 35  deg – ND IR 80 deg = -45 deg IR) = -25 deg GIRD – This represents a pathological GIRD because both IR and total rotational motion are limited

I would suggest that the first player above should not be considered or even called GIRD, despite the fact that there is 20 degrees less IR on the throwing shoulder.  Because the total motion is the same, this is a normal adaptation in this athlete.

In fact, I would comfortably say in my experience that if you tried to reduce that 20 degrees loss of IR when total motion is symmetrical, you would essentially be increasing the total rotation motion and creating instability in an already vulnerable joint.

I believe this causes more injuries than it helps.

Because of the negative association that we have established with the word GIRD, I would propose that we stop calling everything GIRD and reserve GIRD for when it is truly pathological.  This helps clear up confusion.

I strongly feel that this new definition of GIRD takes the individual variability of range of motion as well as the total rotation motion into consideration and is a much more accurate calculation to base treatment recommendations.

 

Why is this important?

The goal of this article is to share my experience treating baseball pitchers.  I have rehabilitated 1000’s of injured baseball pitchers and managed 1000’s of healthy baseball pitchers.  This unique experience really opened my eyes to what is “normal” in baseball players.

When I first started working in Major League Baseball, I quickly found out that much of what I believe to be “facts” were not always accurate.  I’ll be the first to admit this.  If you only treat injured baseball pitchers, you start to assume that some normal adaptations may be pathological.

While my experience has been with baseball pitchers, this information can be extrapolated to all overhead athletes as these findings have all been established in other sports, such as tennis and handball.

There are far too many people who see a loss of IR and immediately label it GIRD.  Furthermore, there are far too many people who label any loss of IR as GIRD and blindly treat the posterior capsule.  I’m not saying that posterior capsular tightness does not exist, I am just saying it exists far less than we are diagnosing it and there are many other reasons that we need to consider before we start challenging the integrity of the stabilizing structures of the thrower’s shoulder.  I even dedicated an entire webinar to showing you 5 ways to gain IR without stretching the posterior capsule.

Blindly assuming GIRD is pathological, stretching the heck out of IR, and treating the posterior capsule is harmful.

 

Assess, Don’t Assume

Even with a pathological GIRD using the above equation, you can not assume you know why they have a loss of IR.

I have previously published a study showing that there is an immediate loss of IR after pitching.  We theorized that this was too acute to represent any changes in the capsule and most likely represented muscular stiffness from the eccentric trauma associated with pitching.  This was even more apparent when we also noticed that there was a loss of elbow extension, which is also subject to extreme eccentric forces during throwing.

You can’t assume they need to be stretched to gain more IR or that the posterior capsule is tight.  Maybe it is.  Maybe it isn’t.  Regardless:

Assess, don’t assume.

There is a specific way to assess the posterior capsule, which I will share in an upcoming post.  In fact I am going to write a series on how to more accurately assess GIRD, internal rotation, and the posterior capsule.

By changing the way we assess and define GIRD, we can start to more accurately understand what is happening to these overhead athletes and provide the best care possible.

How to Treat Internal Impingement of the Shoulder

Internal Impingement

The latest webinar recording for Inner Circle members is now available below.

How to Treat Internal Impingement of the Shoulder

This month’s Inner Circle webinar is part 2 of my series on internal impingement of the shoulder.  I thought this was such a large subject that I wanted to separate them into two different webinars, one discussing what internal impingement is and how to make an accurate diagnosis.  Click here to view part 1 on the Diagnosis of Internal Impingement.

Once you understand that, you can develop a treatment strategy for internal impingement, which is part 2 of this webinar series.  Here is just a few of the things we covered:

  • The principles of treating the overhead athlete with internal impingement
  • What to do initially and what to focus on before progressing their program
  • What to do instead of aggressively stretching the shoulder
  • The one key are to focus on when treating internal impingement
  • When to know when to begin throwing and when to begin pitching

 

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

The Effect of Reactive Neuromuscular Training on Pitchers

It’s no question that the shoulder is a troublesome area for a great number of folks out there.  Most of you that read Mike’s website on a regular basis are looking to treat the shoulder in some capacity—either physical therapy or performance based.  Throughout my career as an Athletic Trainer and Strength Coach, I have worked predominantly with baseball players, or clients dealing with shoulder issues.

In regards to assessing and training for “good” shoulder function, I know Mike is a big advocate for determining what a muscle’s true “role” is beyond just direction(s) of movement and I couldn’t agree more.  The rotator cuff may abduct, internally and externally rotate the shoulder, but its true role is to center the humerus in the glenoid during these movements to maintain proper joint congruency.

Reactive Neuromuscular Training on PitchersRhythmic Stabilizations are great exercise variations that train rotator cuff timing and control in varying positions of instability. While I was completing my Master’s degree at Springfield College and working with their baseball program, I incorporated these exercises with everyone probably 2-3 times a week.  I loved that they were a good way to train rotator cuff control/timing in various positions without excessively loading up the shoulder—this was especially true as throwing volumes increased later in the off season and in season.

However, I always wondered what the efficacy of these drills had in the sense of shoulder performance.

Relative to baseball, this meant throwing velocity.  So I put this to the test!  I conducted my thesis research on the “Effect of Reactive Neuromuscular Training on Pitchers.”  In this study, I investigated how velocity was impacted immediately after performing rhythmic stabilization drills. My initial hypothesis was that velocity would improve.  Theoretically, these drills are intended to promote proximal joint control, therefore should improve the overall function of the shoulder.  Seemed simple enough, but let’s take a closer look at the study.

 

The Effect of Reactive Neuromuscular Training on Pitchers

Participants were 13 collegiate male baseball pitchers between the ages of 18-22.  Participants were free of any shoulder or elbow injury that withheld them from playing activity within the previous 6 weeks.

Test Day 1:

  • All participants were measured for total shoulder range of motion (Internal Rotation + External Rotation) with a goniometer. Total ROM ranged from (155-237 degrees).
  • Each participant threw 10 warm up pitches.
  • Each participant threw 10 four seam fastballs from the windup and pitching velocity was recorded with a radar gun.

Test Day 2:

  • 2-3 days later (depending if they were a starter or reliever)
  • Each participant threw 10 warm up pitches.
  • Each participant performed 2 separate drills.
  • Each participant threw 10 four seam fastballs from the windup while pitching velocity was measured with a radar gun.

Here are videos of the 2 reactive neuromuscular training drills:

Supine Rhythmic Stabilization

Half-Kneeling Rhythmic Stabilization

 

Key Findings

I am going to be honest; I was surprised by the results of this study! Most pitchers actually threw the ball slower than before!

Significant differences were noted in pre- and posttest Maximum (p < .004) and Average (p < .002) velocity.  This equated to a 1.56 MPH decrease in average velocity and 1.62 MPH decrease in maximal velocity!

Another key finding was that greater Total ROM was highly correlated (r= .61) with posttest Maximum velocity.  This means that those with greater shoulder ROM responded more favorably to these drills when compared to those with less shoulder ROM.  Also, players that possessed the greatest amount of shoulder ROM—loose shoulders—threw the hardest overall.

 

Clinical Implications

Like I said before, I was quite surprised by the results that I observed in this study, but after looking further into WHY I may have gotten those results, it made a bit more sense.  First, with any sort of isometric exercise, we are facilitating slow twitch type 1 muscle fibers that are in charge of posture and control.  Pitching is the fastest motion in all of sports, so this acute activation in slow twitch fibers may have had a negative impact on improving maximal pitching velocity, contrary to what I previously would have suspected.

Possibly the most interesting and re-affirming point that was drawn out of this particular study was that some pitchers responded more favorably to the exercise protocol than others! The big takeaway from this: there is no “secret program” or “one-size-fits-all” program that will make you throw harder, or make your shoulder feel better. IT ALL DEPENDS ON THE INDIVIDUAL.  There is a continuum: those who are “tight” (i.e. less total ROM), “loose” (i.e. more total ROM), and all those in between.  Based on this particular research, and concepts like joint centration and the core pendulum theory, it seems that if you are “tight” it may be best to improve joint mobility, address soft tissue concerns, or joint positioning to see improvements in joint function and performance.  If you are “loose”, it may behoove you to improve your overall joint control and just get stronger. This is why constantly assessing and individualizing programs for your athletes, clients, and patients is so crucial.  Otherwise, folks will fall through the cracks and you won’t maximize your results with those you work with regardless of what population it is.

 

Mike’s Thoughts

Great article Sam!  This is a nice research study looking at a topic very important to me.  I outlined how I incorporate rhythmic stabilizations into some of my programmin in my Optimal Shoulder Performance DVD with Eric Cressey.  Since that time, I am thrilled to see so many strength and conditioning coaches and personal trainers incorporating this into their programming.

I couldn’t agree more with Sam’s overall conclusion – each program must be individualized.  This is important as not every needs the same program or should have the same emphasis.  Based on this study it looks like performing rhythmic stabilizations prior to pitching should be included in pitchers that have been assessed and determined to be “loose.”  This makes sense to me.

In regard to the overall lose of velocity in the tight players, I think there may be many other factors that should be considered, including what happened in the 2-3 days between testing sessions.  Perhaps tight players bounce back differently?  More importantly, we don’t know if the lose of velocity was a normal occurrence in this group of subjects throwing 2-3 days later.  Future studies should randomize the groups and have half of the subjects perform rhythmic stabilizations before their first throwing session.

Another thing I would add is that the subjects were all college-aged pitchers.  I am a big believer that older pitchers may need more preperation work prior to throwing to get the rotator cuff firing and prepared to throw.  Perhaps these findings would be different in other age groups.

I’m not sure I am ready to stop performing rhythmic stabilizations before a game in those that are tight, however I will certainly keep this knowledge in mind when individualizing someone’s programs in the future, especially loose athletes.

Great research and article by Sam!  Thanks for contributing to our knowledge of how to treat baseball pitchers!

 

About The Author

Sam SturgisSam Sturgis holds a Bachelor’s Degree in Athletic Training from Quinnipiac University (2010) and Master’s Degree in Strength and Conditioning from Springfield College (2012).  A skilled Strength Coach and Athletic Trainer at Pure Performance Training in Needham, MA, Sam works primarily with baseball athletes and clients rehabilitating from injury.  Sam has developed a successful off-season baseball Strength & Conditioning program in which many athletes utilize.  Sam has also been a regular contributor to the Pure Performance Training website.

 

 

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Internal Impingement – What it is and How to Diagnose

The latest webinar recording for Inner Circle members is now available below.

Internal Impingement – What it is and How to Diagnose

This month’s Inner Circle webinars discussed a one of the most requested topics to date and featured a TON of people online live!  We’ll cover:

  • What is internal impingement?
  • The difference between internal and subacromial impingement
  • Anatomical, biomechanical, and pathological reasons for developing internal impingement
  • What do athlete’s that have internal impingement feel?
  • The #1 test to perform to diagnose internal impingement
  • What else you should look for on examination to develop the best treatment program

The topic is so big, I need to break it down into 2 parts.  This first part will cover the etiology and diagnosis.  I will follow this up in the upcoming months with an entire webinar dedicated to how to treat internal impingement.

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

Can You Have a Rotator Cuff Tear and No Symptoms?

Over the years, our knowledge and ability to treat rotator cuff tears have really advanced significantly.  rotator cuff tearThis includes advances in surgical technique, rehabilitation processes, and even training modifications.  photo from Wikipedia

I see a lot of clients that report shoulder pain that appears to be coming from rotator cuff pathology.  Notice that I just simple say “rotator cuff pathology.”  To me, it doesn’t really matter if it’s torn, partially torn, impinged, inflamed, or anything else.  Shoulder impingement is sort of a junk term.  The only thing that matters to me is how well you function.  Can you lift your arm?  Can you work or play sports without difficulty?  Are you happy with your shoulder?

Still, when people come to see me, all they care about is if their rotator cuff is torn.

Over the years, we have learned that diagnostic tests, like x-rays and MRIs, often don’t correlate with the level of pathology.  This has been shown for injuries such as arthritis and disc pathology.  I have seen films of people with really nasty looking backs and knees and minimal complaints.  Conversely, I have seen films of people with minimal findings but debilitating symptoms.

I was recently asked by a client, “is it possible to have a rotator cuff tear and no symptoms.”  I thought this was a great question and worth sharing my answer.

We know in elite level overhead athletes that Conner et al showed that 40% of asymptomatic shoulders had rotator cuff tears.  I always say that throwing a baseball isn’t good for your body!  But what about everyone else?

One of the nicer articles on the subject was publish back in 1999 by Tempelhof et al.  They studied 411 asymptomatic shoulders using ultrasound and noted that 23% of subjects had a rotator cuff tear.   That’s 1 in 4!  Pretty big number in my mind, but take a look at the breakdown by age:

  • 13% of people aged 50 to 59
  • 20% of people aged 60 to 69
  • 31% of people aged 70-79
  • 51% of people aged 80 or above

As you can see, there is a linear increase in the presence of rotator cuff tears as we age.  So the answer to my clients question was a pretty clear “absolutely!”

How Can You Have a Rotator Cuff Tear and No Symptoms?

rotator cuff tear symptomsI really put symptoms and function together.  If you have symptoms you probably aren’t functioning well (lifting your arm etc.), and if you aren’t functioning well, that is essentially a symptom itself.  So the question is, how can you have a rotator cuff tear and no symptoms?  photo by verygreen

The answer has to do with a suspension bridge!

Burkhart et al described what is called the suspension bridge concept of rotator cuff anatomy.  If you look at the shoulder from overhead, you can imagine a suspension bridge surrounding the humeral head.  In this model, imagine that there is a tear of the supraspinatus muscle on the top of the bridge.  If the anterior and posterior rotator cuff (the two suspension towers) are intact and functioning well, shoulder function may be maintained.  photo from Burhart et al

rotator cuff tear symptoms

This explains the massive irreparable rotator cuff tears that we see and can eventually rehabilitate them back to lifting their shoulder again.  This also explains why so many rotator cuff repairs fail after surgery, but patients are still satisfied with their outcome.  Essentially if we enhance the anterior and posterior cuff’s ability to dynamically stabilize, you can still maintain function with a supraspinatus tear.

So, you can have a rotator cuff tear and no symptoms, you just need a strong and stable cuff around the tear to help dynamically stabilize.

4 Myths of Rotator Cuff Exercises

Rotator cuff exercises are some of the most commonly performed exercises for both rehabilitation and corrective exercises. Considering the excessive mobility of the shoulder joint and crazy demands we place on the shoulder, it is no wonder that over 20% of the adult population has been shown to have some degree of rotator cuff tears!  Furthermore, as we age and the stresses applied become cumulative, the prevalence of rotator cuff tears increases.  That’s not even to mention all the people that may have shoulder impingement symptoms.

My past article on 3 Myths of Scapular Exercises was so popular, that I thought a similar article on myths of rotator cuff exercises was in order.

Below are some of my favorite myths of rotator cuff exercises, there are probably more than 4, but this is a start!

4 Myths of Rotator Cuff Exercises

Rotator Cuff Exercises Are Not Functional

Rotator Cuff Exercise - Mike Reinold

A very popular trend right now is an emphasis on “functional” training, and rightfully so in my mind. However, I have heard many people imply that performing isolated rotator cuff exercises is not functional, and even worthless! Oh, how I couldn’t disagree more.

I have mentioned this recently in presentations, but our shift to “functional” training may be swaying too far in one direction, which tends to happen in a cyclical fashion. If you’ve been out in the real world for more than a decade, you know what I mean. We appear to be in a very “functional movement” cycle right now.

I think this is awesome. Our professions have made really exciting progress in our understanding of how the human body functions. By understanding and applying concepts of functional movement patterns, we truly can help people move better and perform better.

However, we can’t forget the basics. I often comment on some of the many studies that have been published on ACL rehabilitation that compare a traditional strength program with a program that emphasizes neuromuscular control. These studies always tend to show that BOTH groups do well and improve their functional status. But I always say, why choose one? If both work well in isolation, imagine what a combined approach would yield!

Saying that rotator cuff exercises are worthless is a bold statement. I understand that the cuff’s main role is to stabilize, I have taught this endlessly throughout my career. But, I can’t help but think that a weak muscle can’t stabilize. How are we going to efficiently perform a functional movement pattern if we have underlying weakness and muscle imbalances?

Stick with the rotator cuff exercises when weakness is present. Get strong, then get functional, otherwise you may just be creating disadvantageous compensatory patterns.

You Get Enough Rotator Cuff Work During Other Exercises

While it is certainly true that the rotator cuff fires during all upper body strengthening exercises, how the cuff functions during different activities is important to understand. The cuff is active during activities to maintain stability of the shoulder joint. This does involve activity of the cuff, but not at levels that will produce strength gains.

I have seen very strong and powerful weightlifters and athletes have terribly weak rotator cuffs. It always catches up to them.

If You Use Heavy Weights Your Cuff Shuts Off and Larger Muscles Take Over

Myths of Rotator Cuff ExercisesThis is one of my favorites. You’ve probably heard this one before. The magic number seems to be 5, right? If you lift any weight over 5 pounds, your rotator cuff magically shuts off and your big muscles like your deltoid take over.

Have you ever taken a step back and thought about that?

I think I know where this came from. Imagine you had a pretty weak rotator cuff during an exercises such as side lying external rotation. You can comfortably perform the exercise with 3 pounds. If I were to give you a 15 pound weight, I bet your form would be awful and you would just sling your arm back using your posterior deltoid and trapezius muscles. That is obviously not good, any time you overload a weak muscle you will get compensation. That applies to every muscle in the body.

But that doesn’t mean that you can’t slowly work your weight up to over 5 pounds as you get stronger. Why would you stop at 5 pounds? What if that isn’t challenging anymore? What is the point of that? Would you stop loading your squat at a certain weight and just sit there forever?

I routinely get patients into weight over 5 pounds when working the rotator cuff, some even in double digits. If you are compensating and using larger muscle groups, you may just not be strong enough for that weight.

Use the Same Weight During All Rotator Cuff Exercises

This one cracks me up and I am absolutely guilty of this myself! When we give someone a shoulder program to perform, why do we tell them to use the same weight for every exercise? Would you do this anywhere else in your body?  Today we are going to squat, lunge, and deadlift with the same weight… Sounds funny, right?

Challenge each muscle during each exercise. If a weight is too light for one exercise, go up. Don’t get stuck in the habit of using the same weight for every exercise or you will almost certainly not be maximizing your gains for each muscle group. Remember, the goal is to get stronger.

So there are 4 myths of rotator cuff exercises that you should consider.  What do you think about these myths?  Do you think there are more?  Like I said, there are probably more, but these at least came to my mind when I think about rotator cuff exercises.

Learn Exactly How I Evaluate and Treat the Shoulder

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  • Rotator cuff injuries
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