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Shoulder Impingement

Keys Shoulder Impingement

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

Shoulder Impingement

This month’s Inner Circle webinars discussed keys to shoulder impingement.  We talked about several topics, including:

  • Is shoulder impingement normal?
  • How to assess the different types of impingement
  • The three keys to treatment
  • The 5 “don’ts” of training around shoulder impingement
  • And more

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

How to Pick the Best Shoulder Exercises and Know Why

shoulder programI can’t tell you how many times people ask me for a copy of my shoulder program.  You’ve been reading my website for a while now, have you found my shoulder program?  I bet you haven’t!  That is because not one shoulder program is appropriate for everyone.

Rather than rely on one simple shoulder program for everyone, I always try to customize my programs based on each person and their presentation.

Things I will customize:

  1. Emphasis on muscle groups that are weak or inhibited
  2. Sets and reps to emphasize specific muscle groups
  3. Weights for each individual exercise

Pretty basic concepts, huh?  Yet for some reason, everyone is looking for a shoulder program.  There are a lot of exercises out there that you can choose from, think of them like your tool kit and pick certain exercises you want to use to work on a certain deficiency.  This is probably why things like “patellofemoral programs” don’t work, you can’t just have a vague and standardized program for everyone.

Sure, I have a core set of exercises that I like to use, and if you have seen me speak, gone through my online course, or viewed any of my DVDs, you know what they are, but more importantly, you know WHY I picked them.

 

You can learn to choose the best shoulder program exercises too

In my mind, we need to pick exercises that have been shown to be effective in recruiting muscle activity of the muscles specific to the activity you are training or rehabbing.

shoulder exercise EMGIn essence you need to understand:

  1. The biomechanics of the joint.  You need to know how the entire joint interacts with itself and the surrounding joints.
  2. The biomehcanics and EMG of the muscle.  You need to know the arthrokinematics and influence of muscle anatomy, moment arms, and EMG response to different positioning and movements.
  3. The biomechanics of the activity you are training.  You need to know how the joint and muscles you are training are going to work in the real world.

I know a lot of people tend to think that I place too much emphasis on EMG studies, and maybe I do, but EMG is a piece of the puzzle.  For me, it is most important when comparing muscle activity between two different exercises.  It is one of the factors I consider when choosing exercises.  But there are many more.

 

How to Build Your Own Shoulder Program and Know Why

Go back and read my article on the rationale behind shoulder exercises, which includes a link to download a free copy of my JOSPT articles on the Current Concepts in the Scientific and Clinical Rationale Behind Exercises for the Glenohumeral and Scapulothoracic Musculature.  This article will help you a ton when designing your next shoulder program, but more importantly will help you understand why you choose certain exercises based on many factors.

For those highly motivated, I go over this ton more in my online shoulder CEU program at ShoulderSeminar.com and on my DVD with Eric Cressey Optimal Shoulder Performance.

In this day and age of “functional exercise,” which is ultimately important, isolated strengthening exercises are still needed to address deficiencies and imbalances BEFORE we get functional.  This is one of the many principles I emphasize in my upcoming Functional Stability Training program (just to wet your appetite, but this is in it’s infancy, perhaps early 2012).  But for now, I hope this information helps you build your own shoulder program!

Why I Do Not Like YTWL Shoulder Exercises

I remember when the YTWL shoulder exercises started to become popular.  Using the “YTWL” letters was is a pretty good description and easy way for people to remember the shoulder exercises.  I even joined the bandwagon and started training everyone bilaterally, even injured people rehabilitating from a shoulder injury.  Because the YTWL shoulder exercises are performed bilateral, you can get more work done in a shorter amount of time and work on symmetry. But I was never really pleased with the exercises, trying a bunch of difference variations.

First was standing and bent over – A good place to start, seems simple, right?  Well I quickly found out that most people don’t get into a good position to perform these exercises.  Most people do not perform this parallel to the ground, but more at a 45 degree angle to the ground.  I don’t like that, this increases deltoid involvement, which is the last thing I want when performing rotator cuff and scapular exercises

YTWL Shoulder ExercisesNext I tried lying prone on a physioball – what a great idea, right?  Train the shoulder and scapular muscles while stabilizing the core!  Well, not exactly.  Research on this topic has been conflicting, but in general studies have not shown that EMG of the shoulder or core muscles is increased consistently when performing exercises on a physioball, but one trend emerges from the research – force output is reduced.  We’ll assume this is similar to the difference between back squats and leg press, you can lift more weight on a leg press because you don’t have to stabilize as much.  OK, this might not be that bad, specifically for healthy people or athletes training for function.  But remember why we are performing the YTWL shoulder exercises – to enhance shoulder and scapular function, which does not seem to be the emphasis when performing YTWL exercises on an unstable surface.

I should also mention that I wasn’t in love with the positioning most people got into when doing these exercises on a physioball.  Again, most people were not parallel to the ground and most people can’t perform the exercises through full range of motion as their arms are longer than the physioball.  So again, more sacrifices for maximizing benefits of the shoulder and scapular muscles.  Plus, seemed to me people probably didn’t have the best core stability and were rocking back into hyperextension of the lumbar spine to complete the movement pattern.

Next, I tried taking away the unstable surface and just performing the YTWL exercises prone on a table.  Doing this requires that you pretty much have your head and shoulders out over the edge of the table or bench.  Not bad, doing the YTWL shoulder exercises in this position actually seemed to be decent – you can still use your normal weight and you actually had to stabilize the lumbar spine in neutral (if you cue the person to stay flat on the table and not hyperextend).  I finally reached the “body parallel to the ground position” I had been searching for with the previous positions.

upper trapeziusUh-oh, now that I got there, I don’t like it.  To have your head out off the edge of the table and perform bilateral shoulder exercises you really need a lot of upper trapezius and levator activity.  We all know how I feel about reducing upper trapezius activity and getting out of our upper trap dominant posture.  In addition, again, we are performing these exercises to enhance shoulder and scapular function.  Anything that enhances upper trapezius and deltoid activity is probably working against our main goal, especially when we know that the ratio of upper trapezius to lower trapezius activity is correlated to shoulder impingement.  So again, seems counterproductive to me.

Why I Don’t Like the YTWL Shoulder Exercises

As you can see, there are some limitations when performing the YTWL shoulder exercises.  To summarize, here are some of the limitations of the YTWL exercises that concern me:

  • If not performed parallel to the ground, it changes the muscle angle and recruits more deltoid
  • Easy to hyperextend the lumbar spine
  • Performing on an unstable surface potentially reduces force output and reduces the emphasis of the shoulder and scapular muscles
  • Performing on a physioball does not allow for full range of motion
  • If performed off the front of a table or bench, recruits too much upper trapezius and levator to help hold the head up.

What I Would Recommend When Using the YTWL Shoulder Exercises

To me, if the primary goal is to increase the strength of the rotator cuff and scapular muscles, I am not a fan of the YTWL exercises.  I will perform them all but I really think we need to simplify things and just perform them unilaterally on a stable and parallel to the ground surface (like a treatment table).  Yes, you have to turn your head and not stay neutral, but at least the neck muscles are relaxed.  You can still perform the shoulder W exercise bilaterally (click the link to see my past post and video demonstration of the shoulder W exercise technique), but I would perform the Y’s, T’s, and L’s unilateral.

YTWL Exercise

If you are not rehabilitating from a specific injury or surgery, or if your primary goal isn’t to maximize shoulder and scapular strength, then performing the YTWL shoulder exercises may be OK especially if your goals are to maximize symmetry or movement function.  Just realize that if you have specific deficits you are working on you may be better suited to just perform the exercise the plain old boring way.  Perhaps that is your starting point and then when strength is restored, your progress to these other positions.  For the rehabilitation and fitness specialists out there, you really need to coach and cue during the bilateral YTWL exercises to make sure some of the compensatory patterns discussed above are not present.

There is a time and place for bilateral YTWL shoulder exercises, but the majority of time I am trying to enhance shoulder and scapular strength and function.  I see the bilateral YTWL exercises as a progression once you have adequate strength and stability of the shoulder and scapula.  I think performing the YTWL shoulder exercises bilaterally may take away from that goal a little bit, what do you think?

Rotator Cuff Fatigue Increases Superior Humeral Head Migration

shoulder impingementIf there is one thing that I would say is the most important concept to understand regarding the shoulder, it is simply that you can not work the rotator cuff to failure as rotator cuff fatigue causes superior humeral head migration and subacromial impingement.  That is it, I just summarized the role of the rotator cuff in one sentence, albeit a long sentence!

I talk about this concept all the time including a past post on humeral head biomechanics after rotator cuff fatigue, my Optimal Shoulder Performance DVD with Eric Cressey, as well as an entire week on rotator cuff injuries in my online shoulder CEU program.  Yet, I still read and see people performing exercises designed to “burn out” the cuff, or build endurance my “working the cuff to failure.”

This doesn’t work.  You can not work the rotator cuff to failure.

 

Rotator Cuff Fatigue Increases Superior Humeral Head Migration

Another recent study by Jaclyn Chopp from the Journal of Shoulder Elbow Surgery again contributes evidence to this concept.  The study examined the amount of superior humeral head migration during arm elevation in the scapular plane before and after fatiguing the rotator cuff.  The examiners fatigued the rotator cuff by performing a repetitive overhead lifting task that involved lifting an object in the following fashion:

  • Lifting an object from 45 degrees to 135 degrees of sagittal plane elevation
  • Then, slowly lowering the object in the same plane
  • Then, externally rotating the arm and lifting in the coronal plane
  • Then, slowly lowering the object again and internally rotating back into the original start position
  • Lastly, they also performed 5 second static holds at 90 degrees abduction with the same weight every minute.

As you can see, I like their fatigue protocol as it combines flexion, abduction, external rotation, and internal rotation of the shoulder, plus they threw in the commonly performed static hold at 90 degrees abduction.  The weight they lifted was 15% of their maximal lift, so certainly not that heavy and a good replication of a functional activity.

In the pre-fatigued state, the shoulder demonstrated normal biomechanics of a mild amount of superior humeral head migration that eventually stopped and centered the humeral head within the glenoid fossa.  This is normal, as the humeral head actually sits inferior to the center of the glenoid in the resting position, likely due to gravity.  So, you can see in the table below that the humeral head rises up a little and then actually migrated inferiorly as the arm is elevated.

In the fatigued state, the humeral head continued to migrated superiorly and never started to move inferiorly, effectively decreasing the subacromial space and potentially leading to shoulder impingement.

rotator cuff fatigue

 

superior humeral head migration

 

More evidence indeed to support the concept that the rotator cuff is so important in providing dynamic stability of the shoulder, even during simple tasks, that you can not work it to failure.  So think of this next time you want to attempt to work the cuff to failure. Doing so will increase superior humeral head migration and increase subacromial impingement.  So after that exercise, every time you pick up your arm for the rest of the day, you are causing some subacromial impingement.

So consider this a call to action, stop working the cuff to failure or performing burn out sets for the rotator cuff (and the back too, but that is another post…).  These muscles don’t work this way.  I continue to stick to sets of 10 repetitions for shoulder exercises.  I am also very careful when trying to build endurance in the rotator cuff, assuring that the person’s overall shoulder workload is not too high when focusing on endurance.

The last thing you want to do is cause rotator cuff fatigue, superior humeral head migration, or subacromial impingement.

The Shoulder W Exercise

Shoulder W ExerciseLast week I wrote an article on what I considered essential exercises to add to every program, which included the shoulder W exercise for external rotation.  I received a lot of feedback from that article and many requests to post a video describing the technique.  Although, this is a pretty simple exercise, there are some tips I can share to help you maximize the exercise.

Why I Like the Shoulder W Exercise

Like I mentioned in my previous article, I have been a fan of the shoulder W exercise for some time now.  If you’ve taken my Evaluation and Treatment of the Shoulder online course, you know what I mean.  The exercise combines shoulder external rotation with scapular retraction and posterior tilt, definitely a great combo and advantageous for many people as it recruits the posterior rotator cuff (infraspinatus and teres minor) and the lower trapezius.

A study by McCabe et al (NAJSPT 2007) demonstrated that the shoulder W exercise exhibited a moderate amount of posterior rotator cuff and lower trapezius EMG activity.  But more notable for me was the finding that this exercise produced minimal upper trapezius activity and the highest ration of lower trapezius to upper trapezius activity.  I’ve written about how the upper trapezius can affect shoulder function and how upper trapezius and lower trapezius imbalances may cause shoulder impingement, so you know how much I am going to like an exercise that really emphasizes the lower trap and posterior rotator cuff!

Shoulder W Exercise Video Demonstration

In the video demonstration of the shoulder W exercise below, notice that I grasp a good piece of Theraband about shoulder width apart and hold with my thumbs up.  I’ve seen many people recommend that you point your thumbs back, I don’t really think that supinating your forearm changes the exercise so I’d rather keep the forearm in neutral and really just focus on the shoulder and scapula.

The other tidbit I would recommend, and the origin of the name “W” exercise, is that I like to keep a 90 degree angle at the elbow, which ends up form a “W” when you reach end range of external rotation.  This happens because the lat muscle mass causes your arms to abduct a little bit of your body.  I wouldn’t recommend trying to keep your forearms parallel to the ground.

If you perform the shoulder W exercise with thumbs back and keep your forearms parallel to the ground (and thus don’t form a “W”) I feel that you are really missing out on the scapula retraction and more importantly, the scapular posterior tilt that you achieve when forming a “W.”  Try it yourself, you’ll feel what I mean.

Realize that this isn’t rocket science here, there are several variations of bilateral shoulder external rotation exercises, but I wanted to share my thoughts on performing the shoulder W exercise and why I prefer it, what do you think?

Evolution of the Human Shoulder and Throwing

image Have you ever considered that the clavicle is the “key” to shoulder function and our ability to throw?  I haven’t either, but it is in a way!  Scientist studying the evolution of the human shoulder point to the development of the human clavicle as the key development in the evolution of the shoulder.

In a nice little article by NPR, Anthropologists, anatomists, and archaeologists all comment on the evolution of the shoulder and the development of the ability to throw.  They describe the transition from the clavicle position of ape’s, which is great to hang from a tree, to the current human clavicle that excels at allowing extreme motion and the ability to throw objects.

Pretty interesting and something I thought would be good to share.  Click the link below to read the whole article or watch the podcast below to learn more.

Evolution of the Human Shoulder

 

Photo from Wikipedia

Subscapularis Release for Loss of External Rotation

image We have a great guest post today from my friend Trevor Winnegge.  Trevor wrote a nice article last year on complications following distal radius fractures that ranked as my number 1 guest post in 2009!  This time, he presents the results of really nice case series on restoring external rotation ROM using subscapularis release massage techniques.  Great idea and some common manual techniques that I use as well with all of my patients.  Thanks Trevor!

The Role of Soft Tissue Mobilization to Subscapularis to Improve External Rotation in a Type II SLAP Repair-A Case Series

Our clinic is a smaller clinic and doesn’t have the time or resources for a full research study but we did have the opportunity to perform a very small pilot study/case series. I decided to contribute this information because I think it is an underutilized technique and is valuable in assisting our post operative shoulder patients.

We looked at the role that subscapularis has on limiting external rotation (ER) in a post operative shoulder patient. Given that subscapularis is an internal rotator and also assists with some adduction, it is stretched with abduction and ER of the shoulder[1]. Many shoulder surgeries place the patient in a sling in the internally rotated position to some degree. Standard Type II SLAP repair protocols limit the passive range of motion (PROM) into ER to anywhere from 0-30 degrees for the first four weeks, limiting the ability of the subscapularis to stretch[2]. Therefore, we felt if we could perform soft tissue mobilization to the subscapularis in the initial post operative period while range of motion is limited, then they would be less stiff once they were allowed to progress into ER. To my knowledge there has been only one study to date looking at the role of soft tissue mobilization to subscapularis on improving ER and that was published in JOSPT in December of 2003[3]. In that study, conducted by Godges et al, they excluded any patient that was in the immediate four week post operative healing phase. We felt that this immediate healing phase is when we can be most successful at preventing excessive subscapularis tightness by performing soft tissue mobilization, thereby improving ER ROM once they are allowed to progress past 30 degrees of ER.

Research Design

We took four patients (two males, two females) between the ages of 17 and 26 who had undergone primary Type II SLAP repair and randomly assigned them into two groups. The first group received standard ROM treatment for all motions and had ER ranged only to 30 degrees per the doctors protocol. The second group had the same exact treatment, however also received five minutes of subscapularis soft tissue mobilization[4]. Soft tissue mobilization was performed while the patient was in sidelying for the first one or two treatment sessions until the patient had enough abduction ROM to allow for good access to subscapularis in a supine position. The technique was using thumb or fingertips to hook inside the lateral border of the scapula and dig deep down between the scapula and ribs. A combination of deep pressure and soft tissue mobilization were performed for a total of five minutes. Every patient in each group was seen at the one week post operative timeframe and was seen twice a week for the next three weeks.

Video Demonstration

I do have two videos of the soft tissue techniques. The first is for the immediate post op patient while patient is in sidelying. The second video is while the patient is in supine. This video also incorporates the soft tissue technique with some elevation ROM.

Results

The results were as we had expected. The group that received the soft tissue mobilization had about twenty five more degrees of ER ROM (measured with goniometer in 45 degrees of abduction while supine) at the four week mark than did the group that did not receive the treatment.

Control Group-ER ROM

1 week post op4 weeks post op
Subject 110 degrees40 degrees
Subject 215 degrees38 degrees

Intervention Group- ER ROM

1 week post op4 weeks post op
Subject 112 degrees64 degrees
Subject 215 degrees63 degrees

I understand that these results should be taken with a grain of salt, as strong conclusions can not be made with such a small sample size. As I previously stated we simply do not have the time or resources in our clinic to perform a large scale study. It is my hope that someone reading this who works in a much larger center can take this information and use it as a stepping stone to a full blown research study. Clinically, I use these techniques on a daily basis and achieve great results. I truly feel the results of a larger study would be quite similar. What was also interesting is that shoulder elevation was also improved in the soft tissue mobilization group. This is likely due to the close proximity of the latissimus dorsi to the subscapularis, it is hard to truly isolate the subscapularis. We focused on SLAP repairs, but Bankart repairs could also benefit from this as well as rotator cuff repair patients who require sling use for extended amounts of time, provided a subscapularis repair wasn’t performed. I think the possibilities for research in this area are endless and I would love to see it published as a large research study. Please give me any feedback if you currently use this technique, or tried it after reading this. It really works well.

clip_image001Trevor has been practicing PT for over 9 years. He graduated from Northeastern University with a bachelors in PT and a master of science degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He is currently the Clinical Coordinator of Rehabilitation at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA.


[1] Palastanga, et al. Anatomy and Human Movement. Boston MA:Butterworth Heineman; 1993.

[2] Wilk K, Reinold M, Andrews J. Postoperative Treatment Principles in the Throwing Athlete. Sports Medicine and Arthroscopy Review. 2001;9:69-95.

[3] Godges et al. The Immediate Effects of Soft Tissue Mobilization with Proprioceptive neuromuscular Facilitation on Glenohumeral External rotation and Overhead reach. JOSPT. 2003; 12: 713-718.

[4] Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore MD:Williams and Wilkins; 1983.

Rotator Cuff EMG During Daily Activities

DSC01454A frequent topic of discussion on this site involves the postoperative guidelines following rotator cuff repair.  We have had many discussions about the contrast in preference between early rehabilitation and conservative rehabilitation among clinicians.  Obviously, if you have read some of my past posts and publications (check out here and here), you know that I have always preferred to start immediate rehabilitation and have had pretty good success.

However, many, many clinicians are still progressing conservatively, even delaying the initiation of range of motion for 2 months and strengthening exercises for 3+ months!  The common justification is to avoid deleterious forces on the repair in attempt to minimize failure of the repair.  A few studies have been published showing that anywhere from 25-75% of rotator cuff repairs are torn again 1-2 years after repair.

That is why a recent study in JOSPT was of interest to me.  The study quantified the EMG activity of the infraspinatus, supraspinatus, and deltoid musculature during the pendulum exercises and three activities of daily living – typing, drinking from a glass, and brushing your teeth.  These are all activities that our rotator cuff repair patients are performing and an exercise, the pendulum, that I would say most physicians are comfortable allowing early in the rehabilitation process.

 

Results

The results of the study were very interesting, highlights include:

  • Pendulums were broken down into 4 groups and compared.  These included large circles and small circles as well as performed passively (correctly) or actively (incorrectly).
  • Large circles in general created higher EMG activity of all muscles involved.
  • Large circles performed actively produced the highest amount of supraspinatus EMG activity – about 19% MVIC
  • Small circles produced less than 10% MVIC of the deltoid and supraspinatus, and under 15% MVIC of the infraspinatus
  • Typing had relatively low EMG activity with 12% MVIC infraspinatus and 7.5% MVIC supraspinatus
  • Brushing your teeth showed 20% MVIC of the infraspinatus
  • Drinking from a glass showed over 18% MVIC of the infraspinatus and 21% MVIC of the supraspinatus

image image

 

Clinical Implications

There are a few major points I took away from this study

  1. Pendulums should be performed using small, rather than large, circles.  Furthermore, it is important to instruct the patient in proper technique, using the body to sway the shoulder passively rather than actively perform circles.  We have all seen patients just actively twirl the arm around.  This was never the true intent of the pendulum exercises.  It’s true form should be passive.  Here is a good example:
  2. Some common ADL’s, including brushing your teeth and drink from a glass, show higher EMG activity than pendulums.
  3. Furthermore, if you combine this information with past studies by McCann (CORR ’93) and Dockery (Ortho ‘98), these common ADL’s also have higher EMG activity than passive and active assisted range of motion exercises.  Thus, it again appears that we have more information to justify the use of early range of motion exercises following rotator cuff repair.

Interesting information.  How many people have physicians that will allow pendulums but will not let you start passive range of motion early after rotator cuff repair?