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6 Keys to Shoulder Instability Rehabilitation

Shoulder instability is a common pathology encountered in the orthopedic and sports medicine setting.

But “shoulder instability” itself isn’t that simple to understand.

Would you treat a high school baseball player that feels like their shoulder is loose when throwing the same as a 35 year old that fell on ice onto an outstretched arm and dislocated their shoulder?  They’re both “shoulder instability,” right?

There exists a wide range of symptomatic shoulder instabilities from subtle recurrent subluxations to traumatic dislocations. Nonoperative rehabilitation is commonly utilized for shoulder instability to regain previous functional activities through specific strengthening exercises, dynamic stabilization drills, neuromuscular training, proprioception drills, scapular muscle strengthening program and a gradual return to their desired activities.

I’ve had great success rehabilitating dislocated shoulders and helping people return back to full activities without surgery.  But to truly understand shoulder instability, there are several key factors that you must consider.

 

Key Factors When Designing Rehabilitation Programs for Shoulder Instability

Because there are so many different variations of shoulder instability, it is extremely important to understand several factors that will impact the rehabilitation program.  This will allow us to individualize programs and enhance recovery.

There are 6 main factors that I consider when designing my rehabilitation programs for nonoperative shoulder instability rehabilitation.  I’m going to cover each in detail.

 

Factor #1 – Chronicity of Shoulder Instability

The first factor to consider in the rehabilitation of a patient with shoulder instability is the onset of the pathology.

Pathological shoulder instability may result from an acute, traumatic event or chronic, recurrent instability. The goal of the rehabilitation program may vary greatly based on the onset and mechanism of injury.

Following a traumatic subluxation or dislocation, the patient typically presents with significant tissue trauma, pain and apprehension. The patient who has sustained a dislocation often exhibits more pain due to muscle spasm than a patient who has subluxed their shoulder. Furthermore, a first time episode of dislocation is generally more painful than the repeat event.

Rehabilitation will be progressed based on the patient’s symptoms with emphasis on early controlled range of motion, reduction of muscle spasms and guarding and relief of pain.

The primary traumatic dislocation is most often treated conservatively with immobilization in a sling and early controlled passive range of motion (ROM) exercises especially with first time dislocations. The incidence of recurrent dislocation ranges from 17-96% with a mean of 67% in patient populations between the ages of 21-30 years old. Therefore, the rehabilitation program should progress cautiously in young athletic individuals. It should be noted that Hovelius et al has demonstrated that the rate of recurrent dislocations is based on the patient’s age and not affected by the length of post-injury immobilization. Individuals between the ages of 19 and 29 years are the most likely to experience multiple episodes of instability. Hovelius et al also noted patients in their 20’s exhibited a recurrence rate of 60% whereas patients in their 30’s to 40’s had less than a 20% recurrence rate. In adolescents, the recurrence rate is as high as 92% and 100% with an open physes.

Conversely, a patient presenting with atraumatic instability often presents with a history of repetitive injuries and symptomatic complaints. Often the patient does not complain of a single instability episode but rather a feeling of shoulder laxity or an inability to perform specific tasks.

Rehabilitation for this patient should focus on early proprioception training, dynamic stabilization drills, neuromuscular control, scapular muscle exercises and muscle strengthening exercises to enhance dynamic stability due to the unique characteristic of excessive capsular laxity and capsular redundancy in this type of patient.

Chronic subluxations, as seen in the atraumatic, unstable shoulder may be treated more aggressively due to the lack of acute tissue damage and less muscular guarding and inflammation. Rotator cuff and periscapular strengthening activities should be initiated while ROM exercises are progressed. Caution is placed on avoiding excessive stretching of the joint capsule through aggressive ROM activities.

The goal is to enhance strength, proprioception, dynamic stability and neuromuscular control especially in the specific points of motion or direction which results in instability complaints.

 

Factor #2 – Degree of Shoulder Instability

Bankart LesionThe second factor is the degree of instability present in the patient and its effect on their function.

Varying degrees of shoulder instability exist such as a subtle subluxation or gross instability. The term subluxation refers to the complete separation of the articular surfaces with spontaneous reduction. Conversely, a dislocation is a complete separation of the articular surfaces and requires a specific movement or manual reduction to relocate the joint. This will result in underlying capsular tissue trauma. Thus, with shoulder dislocations the degree of trauma to the glenohumeral joint’s soft tissue is much more extensive.

Speer et al have reported that in order for a shoulder dislocation to occur, a Bankart lesion must be present and also soft tissue trauma must be present on both sides of the glenohumeral joint capsule.

Thus, in the situation of an acute traumatic dislocation, the anterior capsule may be avulsed off the glenoid (this is called a Bankart lesion – see pictures to the right) and the posterior capsule may be stretched, allowing the humeral head to dislocate. This has been referred to as the “circle stability concept.”

The rate of progression will vary based upon the degree of instability and persistence of symptoms. For example, a patient with mild subluxations and muscle guarding may initially tolerate strengthening exercises and neuromuscular control drills more than a patient with a significant amount of muscular guarding.

 

Factor #3 – Concomitant Pathology

Hill Sachs LesionThe third factor involves considering other tissues that may have been affected and the premorbid status of the tissue.

As we previously discussed, disruption of the anterior capsulolabral complex from the glenoid commonly occurs during a traumatic injury resulting in an anterior Bankart lesion. But other tissues may also be involved.

Often osseous lesions may be present such as a concomitant Hill Sach’s lesion caused by an impaction of the posterolateral aspect of the humeral head as it compresses against the anterior glenoid rim during relocation. This has been reported in up to 80% of dislocations. Conversely, a reverse Hill Sach’s lesion may be present on the anterior aspect of the humeral head due to a posterior dislocation.

Occasionally, a bone bruise may be present in individuals who have sustained a shoulder dislocation as well as pathology to the rotator cuff. In rare cases of extreme trauma, the brachial plexus may become involved as well. Other common injuries in the unstable shoulder may involve the superior labrum (SLAP lesion) such as a type V SLAP lesion characterized by a Bankart lesion of the anterior capsule extending into the anterior superior labrum. These concomitant lesions will affect the rehabilitation significantly in order to protect the healing tissue.

 

 

Factor # 4 – Direction of Shoulder Instability

Shoulder Multidirectional InstabilityThe next factor to consider is the direction of shoulder instability present. The three most common forms include anterior, posterior and multidirectional.

Anterior shoulder instability is the most common traumatic type of instability seen in the general orthopedic population. It has been reported that this type of instability represents approximately 95% of all traumatic shoulder instabilities. However, the incidence of posterior instabilities appears to be dependent on the patient population. For example, in professional or collegiate football, the incidence of posterior shoulder instability appears higher than the general population. This is especially true in linemen. Often, these posterior instability patients require surgery as Mair et al reported 75% required surgical stabilization.

Following a traumatic event in which the humeral head is forced into extremes of abduction and external rotation, or horizontal abduction, the glenolabral complex and capsule may become detached from the glenoid rim resulting in anterior instability, or a Bankart lesion as discussed above.

Conversely, rarely will a patient with atraumatic instability due to capsular redundancy dislocate their shoulder. These individuals are more likely to repeatedly sublux the joint without complete separation of the humerus from the glenoid rim.

Posterior shoulder instability occurs less frequently, only accounting for less than 5% of traumatic shoulder dislocations.

This type of instability is often seen following a traumatic event such as falling onto an outstretched hand or from a pushing mechanism. However, patients with significant atraumatic laxity may complain of posterior instability especially with shoulder elevation, horizontal adduction and excessive internal rotation due to the strain placed on the posterior capsule in these positions.

Multidirectional instability (MDI) can be identified as shoulder instability in more than one plane of motion. Patients with MDI have a congenital predisposition and exhibit ligamentous laxity due to excessive collagen elasticity of the capsule.

Shoulder Sulcus SignOne of the most simple tests you can perform to assess MDI is the sulcus sign.

I would consider an inferior displacement of greater than 8-10mm during the sulcus maneuver with the arm adducted to the side as significant hypermobility, thus suggesting significant congenital laxity.  You can see this pretty good in this photo to the right, the sulcus is clearly larger than my finger width.

Due to the atraumatic mechanism and lack of acute tissue damage with MDI, ROM is often normal to excessive.

Patients with recurrent shoulder instability due to MDI generally have weakness in the rotator cuff, deltoid and scapular stabilizers with poor dynamic stabilization and inadequate static stabilizers. Initially, the focus is on maximizing dynamic stability, scapula positioning, proprioception and improving neuromuscular control in mid ROM.

Also, rehabilitation should focus on improving the efficiency and effectiveness of glenohumeral joint force couples through co-contraction exercises, rhythmic stabilization and neuromuscular control drills. Isotonic strengthening exercises for the rotator cuff, deltoid and scapular muscles are also emphasized to enhance dynamic stability.

 

Factor #5 – Neuromuscular Control

neuromuscular controlThe fifth factor to consider is the patient’s level of neuromuscular control, particularly at end range.

Injury with resultant insufficient neuromuscular control could result in deleterious effects to the patient. As a result, the humeral head may not center itself within the glenoid, thereby compromising the surrounding static stabilizers. The patient with poor neuromuscular control may exhibit excessive humeral head migration with the potential for injury, an inflammatory response, and reflexive inhibition of the dynamic stabilizers.

Several authors have reported that neuromuscular control of the glenohumeral joint may be negatively affected by joint instability.

Lephart et al compared the ability to detect passive motion and the ability to reproduce joint positions in normal, unstable and surgically repaired shoulders. The authors reported a significant decrease in proprioception and kinesthesia in the shoulders with instability when compared to both normal shoulders and shoulders undergoing surgical stabilization procedures.

Smith and Brunoli reported a significant decrease in proprioception following a shoulder dislocation.

Blasier et al reported that individuals with significant capsular laxity exhibited a decrease in proprioception compared to patients with normal laxity.

Zuckerman et al noted that proprioception is affected by the patient’s age with older subjects exhibiting diminished proprioception than a comparably younger population.

Thus, the patient presenting with traumatic or acquired instability may present with poor neuromuscular control that must be addressed.

 

Factor # 6 – Pre-Injury Activity Level

The final factor to consider in the nonoperative rehabilitation of the unstable shoulder is the arm dominance and the desired activity level of the patient.

If the patient frequently performs an overhead motion or sporting activities such as a tennis, volleyball or a throwing sport, then the rehabilitation program should include sport specific dynamic stabilization exercises, neuromuscular control drills and plyometric exercises in the overhead position once full, pain free ROM and adequate strength has been achieved.

Patients whose functional demands involve below shoulder level activities will follow a progressive exercise program to return full ROM and strength. The success rates of patients returning to overhead sports after a traumatic dislocation of their dominant arm are often low, but possible.

Arm dominance can also significantly influence the successful outcome. The recurrence rates of instabilities vary based on age, activity level and arm dominance. In athletes involved in collision sports, the recurrence rates have been reported between 86-94%.

 

Keys to Shoulder Instability Rehabilitation

To summarize, nonoperative rehabilitation of shoulder instability has many subtle variations.  To simplify my thought process, I always think of these 6 key factors before I decide what I want to do.  I hope these factors help you too.  What other factors do you consider when designing rehabilitation programs for shoulder instability?

 

Learn How I Evaluate and Treat the Shoulder

shoulder seminarWant to learn exactly how I rehabilitate shoulder instability?

I have a whole lesson on this as part of my comprehensive online program on the Evidence Based Evaluation and Treatment of the Shoulder at ShoulderSeminar.com.  If you want to learn exactly how I evaluate and treat the shoulder, including shoulder instability, this course is for you.  You’ll be an expert on shoulders!

 

 

 

 

Shoulder Impingement – 3 Keys to Assessment and Treatment

Shoulder impingement really is a pretty broad term that most of us likely take for granted.  It has become such a junk term, such as “patellofemoral pain,” especially with physicians.  It seems as if any pain originated from around the shoulder could be labeled as “shoulder impingement” for some reason, as if that diagnosis is helpful to determine the treatment process.

Unfortunately, There is no magical “shoulder impingement protocol” that you can pull out of your notebook and apply to a specific person. [Click to Tweet]

I wish it were the simple.

A thorough examination is still needed.  Each person will likely present differently, which will require a variations on how you approach their rehabilitation.

But the real challenge when working with someone with shoulder impingement isn’t figuring out they have shoulder pain, that’s fairly obviously.  It’s figuring out why they have shoulder pain.

 

 

Shoulder Impingement: 3 Keys to Assessment and Treatment

To make the treatment process a little more simple, there are three things that I typically consider to classify and differentiate shoulder impingement.

  1. Location of impingement
  2. Structures involved
  3. Cause of impingement

Each of these can significantly vary the treatment approach and how successful you are helping each person.

 

Location of Impingement

The first thing to consider when evaluating someone with shoulder impingement is the location of impingement.  This is generally in reference to the side of the rotator cuff that the impingement is located, either the bursal side or articular side.

shoulder impingement assessment and treatment

See the photo of a shoulder MRI above.  The bursal side is the outside of the rotator cuff, shown with the red arrow.  This is probably your “standard” subacromial impingement that everyone refers to when simply stating “shoulder impingement.”  The green arrow shows the inside, or articular surface, of the rotator cuff.  Impingement on this side is termed “internal impingement.”

The two are different in terms of cause, evaluation, and treatment, so this first distinction is important.  More about these later when we get into the evaluation and treatment treatment.

 

Impinging Structures

To me, this is more for the bursal sided, or subacromial, impingement and refers to what structure the rotator cuff is impinging against.  As you can see in the pictures below (both side views), your subacromial space is pretty small without a lot if room for error.  In fact, there really isn’t a “space”, there are many structures running in this area including your rotator cuff and subacromial bursa.

Shoulder impingement

You actually “impinge” every time you move your arm.  Impingement itself is normal and happens in all of us, it is when it becomes excessive or abnormal that pathology occurs.

I try to differentiate between acromial and coracoacromial arch impingement, which can happen in combination or isolation.  There are fairly similar in regard to assessment and treatment, but I would make a couple of mild modifications for coracoacromial impingement, which we will discuss below.

 

Cause of Impingement

The next thing to look at is the actual reason why the person is experiencing shoulder impingement.  There are two main classifications of causes, that I refer to as “primary” or “secondary”shoulder  impingement.

Primary impingement means that the impingement is the main problem with the person.  A good example of this is someone that has impingement due to anatomical considerations, with a hooked tip of the acromion like this in the picture below.  Many acromions are flat or curved, but some have a hook or even a spur attached to the tip (drawn in red):

shoulder impingement

 

Secondary impingement means that something is causing impingement, perhaps their activities, posture, lack of dynamic stability, or muscle imbalances are causing the humeral head to shift in it’s center of rotation and cause impingement.  The most simply example of this is weakness of the rotator cuff.

The rotator cuff and larger muscle groups, like the deltoid, work together to move your arm in space.  The rotator cuff works to steer the ship by keeping the humeral head centered within the glenoid.  The deltoid and larger muscles power the ship and move the arm.

Both muscles groups need to work together.  If rotator cuff weakness is present, the cuff may lose it’s ability to keep the humeral head centered.  In this scenario, the deltoid will overpower the cuff and cause the humeral head to migrate superiorly, thus impinging the cuff between the humeral head and the acromion:

evaluation and treatment of shoulder impingement

 

Other common reasons for secondary impingement include mobility restrictions of the shoulder, scapula, and even thoracic spine.  We see this a lot at Champion.  In the person below, you can see that they do not have full overhead mobility, yet they are trying to overhead press and other activities in the gym, flaring up their shoulder.

shoulder impingement mobility

If all we did with this person was treat the location of the pain in his anterior shoulder, our success will be limited.  He’ll return to gym and start the process all over if we don’t restore this mobility restriction.

The funny thing about this is that people are almost never aware that they even have this limitation until you show them.

 

 

Differentiating Between the Types of Shoulder Impingement

In my online program on the Evidence Based Evaluation and Treatment of the Shoulder, I talk about different ways to assess shoulder impingement that may impact your rehab or training.  There are specific tests to assess each type of impingement we discussed above.

The two most popular tests for shoulder impingement are the Neer test and the Hawkins test.  In the Neer test (below left), the examiner stabilizes the scapula while passively elevating the shoulder, in effect jamming the humeral head into the acromion.  In the Hawkins test (below right) the examiner elevates the arm to 90 degrees of abduction and forces the shoulder into internal rotation, grinding the cuff under the subacromial arch.

Shoulder impingement tests

You can alter these tests slightly to see if they elicit different symptoms that would be more indicative to the coracoacromial arch type of subacromial impingement.  This would involve the cuff impingement more anteriorly so the tests below attempt to simulate this area of vulnerability.

The Hawkins test (below left) can be modified and performed in a more horizontally adducted position.  Another shoulder impingement test (below right) can be performed by asking the patient to grasp their opposite shoulder and to actively elevate the shoulder.

how to assess shoulder impingement

There is a good chance that many patients with subacromial impingement may be symptomatic with all of the above tests, but you may be able to detect the location of subacromial impingement (acromial versus coracoacromial arch) by watching for subtle changes in symptoms with the above four tests.

Internal impingement is a different beast.

This type of impingement, which is most commonly seen in overhead athletes, is typically the result of some hyperlaxity in the anterior direction.  As the athlete comes into full external rotation, such as the position of baseball pitch, tennis serve, etc., the humeral head slides anterior slightly causing the undersurface of the cuff to impingement on the inside against the posterior-superior glenoid rim and labrum.  This is what you hear of when baseball players have “partial thickness rotator cuff tears” the majority of time.

shoulder internal impingement

 

 

The test for this is simple and is exactly the same as an anterior apprehension test.  The examiner externally rotates the arm at 90 degrees abduction and watches for symptoms.  Unlike the shoulder instability patient, someone with internal impingement will not feel apprehension or anterior symptoms.  Rather, they will have a very specific point of tenderness in the posterosuperior aspect of the shoulder (below left).  Ween the examiner relocates the shoulder by giving a slight posterior glide of the humeral head, the posterosuperior pain diminishes (below right).

how to assess shoulder internal impingement

 

3 Keys to Treating Shoulder Impingement – How Does Treatment Vary?

There are three main keys from the above information that you can use to alter your treatment and training programs based on the type of impingement exhibited:

Subacromial Impingement Treatment

To properly treat, you should differentiate between acromial and coracoacromial impingement.  Treatment is essentially the same between these two types of subacromial impingement, however, with coracoacromial arch impingement, you need to be cautious with horizontal adduction movements and stretching.  This is unfortunate as the posterior soft tissue typically needs to be stretched in these patients, but you can not work through a pinch with impingement!

A “pinch” is impingement of an inflamed structure!

Also, I would avoid elevation in the sagittal plane or horizontal adduction exercises.

 

Primary Versus Secondary Shoulder Impingement

This is an important one and often a source of frustration in young clinicians.  If you are dealing with secondary impingement, you can treat the persons symptoms all you want, but they will come back if you do not address the route of the pathology!

I do treat their symptoms, that is why they have come to see me.  I want to reduce inflammation.  However, this should not be the primary focus if you want longer term success.

This is where a more global look at the patient, their posture, muscle imbalances, and movement dysfunction all come into play.  Break through and see patients in this light and you will see much better outcomes.

A good discussion of the activities that are causing their symptoms may also shed some light on why they are having shoulder pain.  Again, using the example above, if you don’t have full mobility and try to force the shoulder through this tightness you are going to likely cause some issues.  This is especially true if you add speed, loading, and repetition to elevation, such as during many exercises.

 

Internal Impingement

One thing to realize with internal impingement is that this is pretty much a secondary issue.  It is going to occur with any cuff weakness, fatigue, or loss of the ability to dynamically stabilize.   The athlete will show some hyperlaxity in this athletic “lay back” shoulder position.  Treat the cuff weakness and it’s ability to dynamically stabilize to relieve the impingement.  How to treat internal impingement is a huge topic that I cover in a webinar for my Inner Circle members.

 

Learn Exactly How I Evaluate and Treat the Shoulder

If you are interested in mastering your understanding of the shoulder, I have my acclaiming online program teaching you exactly how I evaluate and treat the shoulder at ShoulderSeminar.com!

The online program at takes you through an online 8-week program with new content added every week.  You can learn at your own pace in the comfort of your own home.  You’ll learn exactly how I approach:

  • shoulder seminarThe evaluation of the shoulder
  • Selecting exercises for the shoulder
  • Manual resistance and dynamic stabilization drills for the shoulder
  • Nonoperative and postoperative rehabilitation
  • Rotator cuff injuries
  • Shoulder instability
  • SLAP lesions
  • The stiff shoulder
  • Manual therapy for the shoulder

The program offers 21 CEU hours for the NATA and APTA of MA and 20 CEU hours through the NSCA.

Click below to learn more!

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How to Stabilize the Scapula During Shoulder Elevation

One of the most common compensations we see with people with limited overhead shoulder elevation is lateral winging of the scapula.  Anytime you have limited glenohumeral joint mobility, your scapulothoracic joint is going to try to pick up the slack to raise your arm overhead.

This is common in postoperative patients, but also anyone with limited shoulder elevation.

Stabilizing the scapula during range of motion is often recommended to focus your mobility more on the shoulder than the scapula.  As with everything else, as simple as this seems, there is right way, a wrong way, and a better way to stabilize the scapula during shoulder elevation.

In this video, I demonstrate the correct way to stabilize the scapula, and show some common errors that I often see.

 

How to Stabilize the Scapula During Shoulder Elevation

 

Learn Exactly How I Evaluate and Treat the Shoulder

Interested in learning more?  Join my acclaimed online program teaching you exactly how I evaluate and treat the shoulder.  It’s a comprehensive 8-week online line program that covers everything you need to know about clinical examination, dynamic stability drills, manual therapy techniques, rotator cuff injuries, labral tears, stiff shoulders, and more.
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How to Assess the Scapula

The latest Inner Circle webinar recording on How to Assess the Scapula is now available.

How to Assess the Scapula

How to assess scapular dyskinesisThis month’s Inner Circle webinar is a live demonstration of How to Assess the Scapula.  In this recording of a live student inservice from Champion, I overview everything you should (and shouldn’t) be looking for when assessing the scapula.  When someone has a big nerve injury with significant winging or scapular dyskinesis, the assessment of the scapula is pretty easy.  But how do you detect the subtle alterations in posture, position, and dynamic movement?  By being able to identify a few subtle findings, you can really enhance how you write a rehab or training program.

In this webinar, I’ll cover:

  • What to look for in regard to static posture and scapular position
  • How to check to see if static postural asymmetries really have an impact on dynamic scapular movement
  • What really is normal scapulothoracic rhythm (if there really is a such thing as normal!)?
  • How to reliably assess for scapular dyskinesis
  • How winging during the concentric and eccentric phases of movement changes my thought process
  • How to see if scapular position or movement is increasing shoulder pain
  • How to see if scapular position or movement is decreasing shoulder strength

To access this webinar:

 

 

 

A Simple Test for Scapular Dyskinesis You Must Use

A common part of my examinations includes assessing for abnormal scapular position and movement, which can simply be defined as scapular dyskinesis.  Scapular dyskinesis has long been theorized to predispose people to shoulder injuries, although the evidence has been conflicting.

Whenever data is conflicting in research articles, you need to closely scrutinize the methodology.  One particular flaw that I have noticed in some studies looking at the role of scapular dyskinesis in shoulder dysfunction has involved how the assess and define scapular dyskinesis.

Like anything else, when someone has a significant issue with scapular dyskinesis it is very apparent and obvious on examination.  But being able to detect subtle alterations in the movement of the scapula may be more clinically relevant.  There’s a big difference between someone that has a large amount of winging while concentrically elevating their arm versus someone that has a mild issues with control of the scapula while eccentrically lowering their arm.

Most people will not have a large winging of their scapula while elevating their arm.  This represents a more significant issue, such as a nerve injury.  However, a mild amount of scapular muscle weakness can change the way the scapula moves and make it difficult to control while lowering.

 

A Simple Test for Scapular Dyskinesis

One of the simplest assessments you can perform for scapular dyskinesis is watching the scapula move during shoulder flexion.  Performing visual assessment of the scapula during shoulder flexion has been shown to be a reliable and valid way to assess for abnormal scapular movement.

That’s it.  Crazy, right?  That simple!  Yet, I’m still amazed at how many times people tell me no one has ever looked at how well their scapula moves with their shirt off.

However, there is one little tweak you MUST do when performing this assessment…

You have to use a weight in their hand!

Here is a great example of someone’s scapular dyskinesis when performing shoulder flexion with and without an external load.  The photo on the left uses no weight, while the photo on the right uses a 4 pound dumbbell:

scapular dyskinesis

As you can see, the image on the right shows a striking increase in scapular dyskinesis.  I was skeptical after watching him lift his arm without weight in the photo on the left, however, everything became very clear when adding a light weight to the shoulder flexion movement.  With just a light load, the ability to prevent the scapula from winging while eccentrically lowering the arm becomes much more challenging.

I should also note that there was really no significant difference in scapular control or movement during the concentric portion of the motion raising his arms overhead:

scapular winging concentric

This person doesn’t have a significant issue or nerve damage, he simply just needs some strengthening of his scapular muscles.  But if you didn’t observe his scapula with his shirt off or with a dumbbell in his hand, you may have missed it!

 

How to Assess for Scapular Dyskinesis

In this month’s Inner Circle webinar, I am going to show you a live demonstration of how I assess scapular position and movement.  I’ve had past talks on how to assess scapular position and how to treat scapular dyskinesis, however I want to put it all together with a demonstration of exactly how I perform a full scapular movement assessment and go over things I am looking for during the examination.

I’ll be filming the video and posting later this month.  Inner Circle members will get an email when it is posted.

 

 

 

How to Coach and Perform Shoulder Program Exercises

The latest Inner Circle webinar recording on How to Coach and Perform Shoulder Program Exercises is now available.

How to Coach and Perform Shoulder Program Exercises

How to Coach and Perform Shoulder Program ExercisesThis month’s Inner Circle webinar is on How to Coach and Perform Shoulder Program Exercises.  While this seems like a simple topic, the concepts discussed here are key to enhancing shoulder and scapula function.  There are many little tweaks you can perform for shoulder exercises to make them more effective.  If you perform rotator cuff or scapula exercises poorly, you can be facilitating compensatory patterns.  In this webinar, we discuss:

  • How to correctly perform rotator cuff and scapula exercises
  • Coaching cues that you can use to assure proper technique
  • How to enhance exercises by paying attention to technique
  • How to avoid compensation patterns and assure shoulder program exercises are as effective as possible

To access this webinar:

 

 

 

5 Tweaks to Make Shoulder Exercises More Effective

The latest Inner Circle webinar recording on 5 Tweaks to Make Shoulder Exercises More Effective is now available.

 

5 Tweaks to Make Shoulder Exercises More Effective

5 Tweaks to Make Shoulder Exercises More EffectiveThis month’s Inner Circle webinar is on 5 Tweaks to Make Shoulder Exercises More Effective.  Over the years, you tend to pick up on the little things that can make a big difference.  I’m always reading the latest research to find simple little tweaks that I can make to an exercise to change the desired result.  Maybe I’m trying to optimize the mechanics of the scapula, or trying to enhance EMG activity of a certain muscle, or even change the ratio of activity between two muscles.

In this webinar, we discuss:

  • Why little tweaks can make a big difference
  • Why integrating the kinetic chain into a shoulder exercise may be effective
  • How altering hip and trunk movement during exercises change the muscle activity
  • How you can put this all together and make your own functional exercises specific to each person

To access this webinar:

 

 

 

A Better Way to Perform Shoulder Exercises?

It’s pretty obvious that the shoulder is linked to the scapula, which is linked to the trunk.  So why do we so often perform isolated arm movement exercises without incorporating the trunk?  It’s a good question.  The body works as a kinetic chain that requires a precise interaction of joints and muscles throughout the body.

 

The Effect of Trunk Rotation During Shoulder Exercises

A recent study was published in the Journal of Shoulder and Elbow Surgery that examined the impact of adding trunk rotational movements to common shoulder exercises.

The authors chose overhead elevation, external rotation by the side, external rotation in the 90/90 position similar to throwing, and 3 positions of scapular retraction while lying prone (45 degrees, 90 degrees, and 145 degrees) that were similar to prone T’s and Y’s.  The essentially had subjects perform the exercise with and without rotating their trunk towards the moving arm.

A Better Way to Perform Shoulder Exercises?

EMG of the the upper trapezius, middle trapezius, lower trapezius, and serratus anterior were recorded, as well as 3D scapular biomechanics.

There were a few really interesting results.

  • Adding trunk rotation to arm elevation, external rotation at 0 degrees, and external rotation at 90 degrees significantly increased scapular external rotation and posterior tilt, and all 3 exercises increased LT activation
  • During overhead elevation, posterior tilt was 23% increased and lower trap EMG improve 67%, which in turn reduced the upper trap/lower trap ratio.
  • Adding rotation to the prone exercises reduced upper trapezius activity, and therefore enhanced the upper trap/lower trap ratio as well.

 

What Does This All Mean?

I would say these results are interesting.  While the EMG activity was fairly low throughout the study, the biggest implication is that involving the trunk during arm movements does have a significant impact on both muscle activity and scapular mechanics.  Past studies have shown that including hip movement with shoulder exercises also change muscle activity.

This makes sense.  If you think about it, traditional exercises like elevation and external rotation involve moving the shoulder on the trunk.  By adding trunk movement during the exercises you are also involving moving the trunk on the shoulder.

This is how the body works, anyway.  Most people don’t robotically just move their arm during activities, the move their entire body to position the arm in space to accomplish their goal.

It’s also been long speculated that injuries during sports like throwing and baseball pitching may be at least partially responsible for not positioning or stabilizing the scapula optimally.  I think this study supports this theory, showing that trunk movement alters shoulder function.

Isolated exercises like elevation and external rotation are always going to be important, especially when trying to enhance the strength of a weak or injured muscle.  However, adding tweaks like trunk rotation to these exercises as people advance may be advantageous when trying to work on using the body with specific scapular positions or ratio of trapezius muscle activity.

 

5 Tweaks to Make Shoulder Exercises Even More Effective

I’m a big fan of understanding how little tweaks can make a big difference on your exercise selection.  If you are interested in learning more, this month’s Inner Circle webinar will discuss 5 Tweaks to Make Shoulder Exercises Even More Effective.  The webinar will be Tuesday August 25th at 8:00 PM EST, but a recording will be up soon after.