Training the Injured Shoulder During and Post-Rehabiliation

Eric Cressey

www.EricCressey.com

www.CresseyPerformance.com

Important Prerequisites…

• Primary goal should always be to fix what’s wrong, not just keep things “fun.”

• When applicable, you can always train the uninjured limb with great benefits.

• Know when to refer out. Two minds and skill sets are better than one!

• Make the athlete feel like an athlete, not a patient. • Look to soft tissue quality early-on…

External Impingement

• The Sedentary/Stationary Shoulder Problem

• Pain with:– Overhead motion– Approximation– Periods of inactivity

(night, morning)– Internal Rotation– Scapular Protraction

• Bursal-sided cuff issues

External Impingement

• Primary vs. Secondary• Scapulohumeral Rhythm• Populations most commonly affected: lifters, desk

jockeys, elderly• Tendinosis? Tendinitis? Bursitis?• Supraspinatus? Infraspinatus? Biceps Tendon?

Labrum?

External Impingement

• Eliminate overhead activities

• Modify/Eliminate Horizontal Pressing

• More horizontal pulling, asymptomatic cuff exercises, scapular stabilization exercises (improve upward rotation function)

• Gentle stretching for the internal rotators and pec minor

• Optimize thoracic spine mobility

External Impingement

• Soft tissue work: pec minor/major, upper traps, levator scap, scalenes, rhomboids, RTC, lats

• Thoracic Extension and Rotation

• Avoid “at-risk” position: front squat in place of back squat

External ImpingementOnce symptomatic with ADLs:

(Feet-Elevated) Push-up Isometric Holds > (Feet-Elevated) Body Weight Push-up > Stability Ball Push-up > Weighted Push-up > Neutral Grip DB Floor Press > Neutral Grip Decline DB Press > Pronated Grip Decline DB Press > Barbell Board Press (gradual lowering) > Barbell Floor Press > Neutral Grip DB Bench Press > Low Incline DB Press > Close-Grip Bench Press > Bench Press > Barbell Incline Press > ???Overhead Pressing???

Why?• Limited ROM before full ROM• Adducted before abducted• Unstable before stable• Closed-chain before open-chain• Dumbbells before barbells• Isometrics before “regular” speeds• Traction before approximation (e.g., pull-ups

would come before overhead pressing)

Internal Impingement

• AKA posterior-superior glenoid impingement

• Supra- and infraspinatus against P-S glenoid and labrum (articular-sided cuff issues)

• High-speed, overhead activities: swimmers, tennis players, baseball players

• Encompasses a broad spectrum of more specific diagnoses and pain presentation patterns

Why is baseball an at-risk sport?• Very Long Competitive Season

– >200 games as a pro?– >100 College/HS?

• Unilateral Dominance/Handedness Patterns– Asymmetry is a big predictor of injury– Switch hitters – but no “switch throwers!”

• The best pitchers – with a few exceptions – are the tallest ones. The longer the spine, the tougher it is to stabilize.

• Short off-season + Long in-season w/daily games = tough to build/maintain strength, power, flexibility, and optimal soft tissue quality

The Demands of Throwing

• Shoulder stability is sacrificed for mobility• Highly reliant on soft tissue function for stability• Some numbers to consider during acceleration:

– 7,200+°/second internal rotation (20 full revolutions per second)

– 2,300°/second elbow extension– 650°/second horizontal abduction

• Requires a collaborative effort of DOZENS of muscles, not just the rotator cuff!

Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Med.

2006;36(3):189-98.

• 49% of athletes with posterior-superior labral tears also had a hip rotation ROM deficit or abduction weakness

Symptomatic Internal Impingement• Glenohumeral Internal

Rotation Deficit (GIRD)• Why does it happen?• Role in SLAP lesions• Almost everybody has

labral fraying and partial thickness cuff issues, but not necessarily w/symptoms

• Possible elbow complications

Eccentric Stress Dictates Dysfunction

• Reinold et al. Changes in shoulder and elbow passive range of motion after pitching in professional baseball players. Am J Sports Med. 2008 Mar;36(3):523-7.

• “A significant decrease in shoulder internal rotation (-9.5 degrees), total motion (-10.7 degrees), and elbow extension (-3.2 degrees) occurred immediately after baseball pitching in the dominant shoulder (P<.001). These changes continued to exist 24 hours after pitching.”

Important Note: Some GIRD is Normal!

• GIRD is a measurement, not a pathology• If you throw, you're going to have retroversion even if you throw the soft tissue

and capsular issues out the window.  • I typically use 12° as our cut-off of what is acceptable, and the number tends to

get a little larger as guys get older and accumulate more mileage on their arms.  • We are very IR focused with our stretching in-season and during the early off-

season as our guys come back from long seasons (or we get kids with messed up shoulders and elbows for the first time)

• Some guys never need it - particularly the multi-sport athletes.  • Obviously, total motion plays into this as well.• Don’t just look at IR; look at posterior cuff strength, scap stability, t-spine

mobility, hip mobility, ankle mobility, soft tissue quality• My general rules: <12° through age 18, <15° for 18-22, <18° for 22+• ¾ arm slot guys tend to be more pronounced that over the top guys

External vs. Internal Impingement

• External:– Physiological norm– Primary (acromion

spurring) and secondary (muscular weakness)

– RTC/biceps tendon impingement under acromion

– Bursal sided cuff issues

• Internal:– Posterosuperior

Impingement

– Specific to throwing athletes

– Humeral head impinges on posterior labrum and glenoid

– Multiple pathologies can result

– Articular-sided cuff issues

Internal Impingement

• Optimize upward rotation function

• Avoid stretching into external rotation, horizontal abduction, and full extension!

• Rest and NSAIDs won’t cut it!

• Optimize GH ROM symmetry.

• Posterior cuff strength, t-spine mobility, scapular stability…

The beauty of working with internal impingement cases…

• Generally, almost anything you do in the weight-room is fair game.

• Excluding:– Overhead lifting (not chin-ups, though)– Straight-bar benching– One-Arm Medicine Ball Work– Upright rows– Front/Side raises (especially empty can)– Olympic lifts– Back squats

Why don’t you do overhead work?

It’s part of their sport, so you need to expose them to it…

A few reasons…

• Labral fraying: less mechanical stability

• GIRD: non-neutral humeral positioning

• Approximation is not traction!

• Subscapularis microtrauma

• Cervical spine hyperextension tendency

• O-Lifts: UCL and wrist/forearm/hand stress

Retro-what?

• Throwing shoulders have more humeral and glenoid retroversion (may occur when pre-pubescent athletes throw when the proximal humeral epiphysis isn’t closed yet)

• Retroversion gives rise to a greater arc of total rotation range-of-motion (total motion concept = IR + ER)

• NO EXERCISE WILL CHANGE BONE STRUCTURE!!!

• Warp bones to throw heat?

• Retroversion may actually spare the anterior-inferior capsule from excessive stress during external rotation

Congenital Factors? Huh?

• Bigliani et al. found that 67% of pitchers and 47% of position players at the professional level have a positive sulcus sign in their throwing shoulder

• Adaptation to imposed to demand? Yes, but…• Those researchers also found that 89% of the

pitchers and 100% of the position players with that positive sulcus sign also came up positive in their non-throwing shoulder.

• Natural selection!

Laudner KG, Stanek JM, Meister K. Differences in Scapular Upward Rotation Between Baseball Pitchers and Position Players. Am J Sports Med. 2007 Dec;35(12):2091-5.

“CONCLUSION: Baseball pitchers have less scapular upward rotation than do position players, specifically at humeral elevation angles of 60 degrees and 90 degrees.”

“CLINICAL RELEVANCE: This decrease in scapular upward rotation may compromise the integrity of the glenohumeral joint and place pitchers at an increased risk of developing shoulder injuries compared with position players. As such, pitchers may benefit from periscapular stretching and strengthening exercises to assist with increasing scapular upward rotation.”

Things we like…• Push-up variations• Multi-purpose bar• Neutral grip DB pressing variations• Every row and chin-up you can imagine

(excluding upright rows)• Loads of thick handle/grip training• Medicine Ball Work: Rotational and Overhead• Specialty bars: Giant Cambered, Safety Squat

Acromioclavicular Joint Pain

• Traumatic vs. Insidious• Piano key sign?• Osteolysis• Pain with:

– Direct Palpation

– Horizontal adduction

– Full extension

– Approximation?

• Active vs. Passive Restraints

Anecdotally…

• Lifting-specific population w/insidious onset

• Most have significant scapular anterior tilt, and marked GIRD is common

• Lower resting posture of the scapula allows acromion to slip anteriorly and inferiorly relative to clavicle.

• Thoracic outlet? SC joint issues?

It might explain why…• …soft tissue work on the levator scap, pec minor,

and infraspinatus/teres minor have worked. • Subscap activation work has been key.• Michael Hope, PT: manual depressions of the

clavicle have helped.• As always, optimizing upward rotation is key.• Supine Test of the Coracoid Process Muscles

Acromioclavicular Joint Pain

• Active vs. Passive Restraints• Training Modifications

– Front Squat Harness, GCB, SSB, Back Squats

– Never do another dip!

– Push-up holds > Board Presses/Floor Presses>Full-ROM benches

– Overhead pressing is sometimes okay

– Pulling exercises may need to be modified to avoid full extension

Important Takeaways

• Work hand-in-hand with rehabilitation specialists to formulate an appropriate return-to-action plan

• Remember that different shoulder conditions mandate different training modifications

• Understanding the causes, symptoms, and exacerbating exercises for each condition not only makes it easier to recover from the problem, but to prevent its recurrence.