This past Friday we thought we’d have a little fun and treat out Shannon’s shoulder pain as part of our weekly in service. This is a great way for all of us to put our heads together and solve some of our more challenging cases.
Check out the video below to see how we did:
It’s always cool to see significant improvements in range of motion and decreased shoulder pain – especially when the changes are immediate!
There is quite a bit more work to do here to get that shoulder moving right again but dry needling in combination with electrical stimulation can be the kick start that’s needed.
If you’ve been struggling with shoulder pain – and wondering if there is anything that can be done about it – give us a call (231 421-5805). We’ve been able to help numerous clients with acute and chronic cases of shoulder pain (including those that have had PT elsewhere without success).
Or email questions to Joe@elitepttc.com
If you’re interested – check out the muscles/trigger points with their corresponding referral patterns below:
Teres Minor Trigger Point
For more information on shoulder pain and trigger points, please refer to a couple previous articles on our blog:
I’ve made it a practice to have my PT students contribute to the Elite PT blog and SportsRehabExpert.com so without further delay this is my most recent student, and ridiculously good runner, Scott McKeel, demonstrating some of our favorite dynamic warm-up drills. In this episode, Scott will hit on the upper body warm-ups and then in subsequent episodes we’ll work through lower body warm-ups, running technique, and ankle mobility drills.
Finding new ways to unload an athlete but still get in a good amount of work is always a challenge. Finding lifts the athlete can do in a single leg stance position would be one way to do that.
I’m not claiming that I’m going to create any monsters (as Charlie Weingroff would say) with lighter weights here, but I am looking for ways to incorporate an injured limb with increased demands for trunk control and an expression of upper body strength. This is a great way to bridge the gap in rehab back to the weight room. It can also be a great way to unload an athlete from time to time to prevent over training.
Check out the video below for tips and progressions of the single leg overhead press:
full shoulder range of motion – you should be able to lie on your back with knees bent, low back flat on the floor, and arms should lie flat on the floor overhead.
hold single leg balance with a level pelvis 20-30 seconds statically
This article was originally posted on SportsRehabExpert.com by Andy Barker – head physiotherapist for Leeds Rhinos Rugby team in the U.K. This article is about preventing shoulder pain, but also would fit right in with our series on preventing back pain. Cheating with the spine to create more shoulder mobility is a great way to get hurt.
In this article, Andy shows a great way to assess shoulder mobility with the spine locked out of the equation. Enjoy!
by Andy Barker PT
A great quick and easy test to use to clear overhead lifting in rehab/training. Begin seated on the floor, tuck your thumb into your hand, keeping your elbows straight and lower back and head against the wall take your arms overhead to touch the wall behind you.
From this video you can clearly see the subject is able to touch the wall whilst being able to keep the head and lower back in contact with the wall. As a result this would constitute a pass and as a result the subject would be cleared to lift overhead in the gym.
A fail would include inability to touch the wall overhead and/or any visible compensation (usually lumbar extension) needed to allow increased shoulder flexion to occur.
I wrote a similar article on wall posture shoulder mobility exercises here: http://www.elitepttc.com/blog/?p=362. These are standing exercises meant to address deficiencies in the test above, but they may be a challenge to start with. Probably should use a supine version like the one below first. Once your arms hit the floor with good spinal control, then move to the standing versions.
This article was originally written for physical therapists and other clinicians dealing with shoulder pain and loss of motion so excuse some of the medical terminology. I know a number of them read this blog so I’m leaving the article as is.
The jist of this article is as follows: most of us have too much extension (arch) in our lower spines, and we go into even more extension any time we try to raise our arms overhead. Over time this can lead to shoulder pain and low back pain. The article below describes a great warm-up exercise to improve shoulder mobility while controlling spinal posture.
As always if you have any questions feel free to email me: firstname.lastname@example.org
Joe Heiler PT, CSCS
This is a great correction for the shoulder mobility movement patterns and also for the shoulder flexion component of the MS Extension pattern. The lumbar spine frequently contributes excessive extension to the shoulder patterns when the shoulder itself is limited. Mobility work is required to free up the shoulder, but this pattern will continue if motor control is not imparted to lock in the new range of motion.
I would not want to be her low back right about now!
The ‘wall posture’ as I describe it to the patient is an attempt to get the entire spine to touch the wall. By having the feet out in front and knees slightly flexed it makes it easier to get the lumbar spine flat onto the wall which is really just a less extended, and probably more neutral position, for most folks. If you’re concerned that it is too much flexion, or if it is not well tolerated due to back pain, and towel roll/lumbar support could be used but contact must be kept at all times.
The cervical spine is a little trickier when it comes to proper positioning. I will cue to get the spine to the wall, but to a point. That cue will usually bring the chin down and back (into cervical retraction) which again will bring most folks to a more neutral posture. Too ‘straight’ is not a normal position either and could affect the shoulder mobility component of this corrective so don’t force it. If their forward head posture is so severe that their head won’t touch the wall without going into extension, then place a towel roll behind the head and require them to hold the towel in place as the arms go overhead.
Maintaining the proper positioning throughout the movement is the most important factor here. The shoulder motions in the video are a challenge to that positioning. When posture is lost, the movement is done.
Breathing is critical here as well. My preferred way of cuing the breathing is to inhale at the bottom and slowly exhale during the overhead motion. The more the ribs stay down in the front the better. This can be incredibly hard for many people, and especially so for many overhead athletes, weight lifters, dancers, and gymnasts.
The order in which the motions are presented in the video go from easier to most challenging:
If following the SFMA’s 4×4 matrix, this would be considered a level 4 posture, unloaded but with assistance (the wall as the positional cue) so 4:1. Competency must be attained in each of the previous postural levels: 1) supine/prone, 2) quadruped, 3) tall or half kneeling.
Progressions per the matrix:
4:2 – shoulder mobility work without the postural cuing or any activation 4:3 – loaded with cuing or activation. Shoulder Flexion/Extension (reciprocal patterning) or pressing overhead with the spine against the wall or a corner (I prefer a corner to allow the shoulders to move more freely). 4:4 – loaded without cuing or activation – Shoulder Flexion/Extension in standing, any type of pressing.
This is an article I originally posted on SportsRehabExpert.com, and thought it would be a great piece for the blog audience as well so I apologize ahead of time if some of the terminology is a bit too ‘medical’.
I’m constantly on the lookout for ways to challenge my patients and athletes, but without overloading their joints and tissues. Many of them want to really push themselves, but sometimes they are at that point in their lives or careers where it’s just not appropriate for longevity sake. In this article I’ll discuss some of the strategies I use to get the most out of strength training without overloading the weakest link.
There are 4 basic ‘solutions’ to this problem that I will use. I think the best way to cover these would be to describe a couple cases for the lower body and upper body:
Case 1: Active military gentleman with 2 episodes of disc hernation and radicular symptoms within a two year period. Both episodes were brought about with heavy lifting, but he also spends quite a bit of time sitting in the back of a helicopter in a seat that’s about 6″ off the ground (his knees are practically in his face).
I worked with him after the first incident, cleared his movement and had no symptoms. He resumed weightlifting and all other previous activities. After 6 months in the clear he went back to heavy squats and deadlifts, and after 2-3 months of that began noticing the radiating pain into his left leg again.
This guy is an absolute beast when it comes to his fitness level and his form has always been very good. But because of his past and his work demands, this is a guy that I want to limit the load he is using, as well as the positions he puts himself in.
Solution #1 – Move from bilateral stance to split or single leg stance
This one is pretty obvious in that there is no way he is going to load single leg activities the way he can load a traditional squat or deadlift. Single leg deadlifts and squats are great options here because of the extra stabilization needed just to balance and control the trunk. There is only so much weight you’re going to pull with these single leg movements.
Solution #2 – Asymmetrical loading
An example of this would be a single leg deadlift in which the weight is held in the opposite hand (of the stance leg) so the trunk must work in an anti-rotation manner as well as anti-flexion (see video above). Another great example would be a front squat with a kettlebell in one hand (see picture below) using either the traditional grip or bottoms up. The demands on the core can be quite high loading in this manner so the athlete gets a great workout with less overall load.
Single Arm Kettlebell Squat
Solution #3 – Postural Assist
Split squats or rear foot elevated split squats (REESS) are ideal for this type of athlete because the positioning makes it easy to maintain an upright spine and therefore decrease the shearing type loads you would see with a traditional squat where the trunk is angled forward. Mike Boyle (one of the top strength coaches in the world) has talked extensively about this and thus his programs have moved from back squats to front squats to RFESS over time. This type of squat can easily be asymmetrically loaded as well (different weighted dumbbells in each hand).
Rear Foot Elevated Split Squat
Solution #4 – Bottoms Up
There are many reasons I like kettlebells, and the ability to go bottoms up is another one of those reasons. I can instantly make any kettlebell exercise much more challenging to the athlete’s grip and stability. The video above showing the KB front squat is a great example, plus I will frequently use this with Turkish Get-Ups, various carries, and presses.
Case 2: This is more of a general example here as I work with a number of adult athletes post rotator cuff repair looking to return to their sport and the gym. Unless they are competing in powerlifting or weightlifting events, I really don’t need them putting a whole bunch of weight on the bar to bench or shoulder press any longer.
My #1 job is to protect the repair while they are seeing me in PT, but also when they are beyond my care. Job #2 is to give them tools to enhance performance and get them back to the sports they enjoy. Again I believe this can be done using the ‘Solutions’ mentioned above. Here are some examples for the upper body (although in the clinical or performance setting I would never really divide them up this way).
Solution #1 – Move from bilateral to single arm exercises.
The same idea applies to upper body as lower. The amount of stabilization and balance needed to perform single arm presses (horizontal and vertical) is going to make it quite difficult to really load up with weight.
The single arm bench press is one of my favorites. I have the athlete scoot their hip and shoulder off the bench so they really have to fight the weight pulling them off the bench. I usually have to start athletes at about 50% of what they could dumbbell bench using the traditional two arm method. Athletes are not always happy about going down in weight but they feel right away this is going to make them work.
Solution #2 – Asymmetrical loading
In the case of upper body pushing and pulling, the ‘solution’ of asymmetrical loading is usually just a version of ‘Solution #1’. Another way to inject greater asymmetrical loading into singe arm lifts would be to have the athlete lift from a single leg stance position. This isn’t something I use real often but there have been times I’ve had to be cautious with someone’s shoulder and wanted to increase intensity without increasing load. Single leg/single arm kettlebell presses fall into this category, as well as single leg rows (hamstring killer!).
Can’t believe I couldn’t find a better picture than this!
Solution #3 – Postural Assist
In this instance, requiring the athlete to stand to overhead press (or go tall or half kneeling) brings a lot of postural and stability requirements to the table. It makes it more difficult again to really load up the lift when they don’t have a bench to press into.
Solution #4 – Bottoms Up
Same thing again using the kettlebell bottoms up to work the grip harder and force great stability from the upper quarter.
Single Arm Press – Now that’s a picture! That KB is 55 KG by the way
Now don’t get me wrong, I still love to see big lifts. There are just times when the person in front of you needs less loading so be creative and use these techniques to help create an optimal environment to make gains without risking injury.
In part I of this series I discussed how traditional physical therapy exercises for the rotator cuff often miss the mark, and then in part II how dysfunction and a lack of motor control in other areas of the body can significantly affect the shoulder and cause pain. Be sure to read those, if you haven’t already, as this article will make much more sense.
In part III I want to talk about another concept that has taken the therapy world by storm – Scapular Retraction.
In a nutshell, scapular retraction means pulling the scapula (shoulder blade) closer to the spine, and often times the cuing from the therapist or physician is to pull the shoulder blades down and back (or “put your shoulder blades in your back pockets”). Check out the picture below:
“Shoulder Blades down and back”
Now I’m not going to sit here and say that good things can’t happen from doing this, or deny that I used to buy this approach. Some folks are just stuck with their shoulder girdle forward and scapulae protracted (spread apart) so far that they create a shoulder impingement with that faulty posture. Working on scapular retraction can work in the short term in these cases, but I certainly don’t think it’s a permanent fix. There are many therapists and physicians that feel this strategy will help in all cases. Here are some reasons why it will not:
1) The scapula is most cases just needs to be posteriorly tilted (or tipped). Check out the photo below to get the visual, but the jist of it is that this creates more space in the glenohumeral (shoulder) joint to decrease impingement while also allowing for greater freedom of movement at the shoulder.
Try lifting your arm overhead maintaining your scapulae down and back like in the picture above. It isn’t going to happen. The scapulae are meant to upwardly rotate when going overhead to maintain the joint space and prevent impingement. Too much ‘down and back’ will actually create more downward rotation and greater impingement (see picture above in the upper left). Strike 1!
Scapular Reduction Test – the scapula is gently posteriorly tilted. This will often clear an impingement with shoulder elevation. Notice he is not pulling the scapula closer to the spine!
2) Too much scapular retraction with common exercises like rows and pull-downs can result in an anterior glide of the humeral head. Fancy term for the ‘ball’ of the shoulder sitting too far forward in the socket. This can also lead to greater impingement, and for someone with the very common condition of bicipital tendinosis can be quite painful.
The top hand is palpating the borders of the scapula, while the bottom hand is palpating the front and back of the humeral head. Her humerus is seated anterior in the socket on both sides, but much more pronounced on the L shoulder. This is actually very common.
I’ve seen quite a few patients with this type of shoulder positioning fail miserably with scapular retraction programs. You’re literally pulling the scapulae back and leaving the humeral head protruding even more to the front creating great impingement. Strike 2!
3) Remember in part II when I talked about regional interdependence? Anything you do to the scapula could create a reaction somewhere else. In the majority of cases the patient will overdo it, and you’ll end up with negative compensations elsewhere in the body. Check out the picture below. This is one of my all-time favorites, and I use this as a teaching tool with my students.
I know they say the picture on the right is ‘correct’, but look at what he had to do to his neck and back to get there (the arrows are mine). He had to jack his neck and back into more extension, and over recruit his upper traps just to get there. Nothing like creating a neck and back problem while trying to fix the shoulder. It’s easy enough to do and I’ve seen many a therapist and trainer let this go. Strike 3!
So what to do about this?
There is nothing wrong with a little scapular retraction to reposition the scapula on the thorax, but if some other issues are cleared up first this may just happen naturally.
1) Cervical mobility – the neck should move freely and without pain. I gave a great example of this in part II. There are a number of muscles running between the neck and shoulder girdle so any tension resulting in cervical restrictions can alter scapular position.
2) Thoracic mobility – the scapulae sit on the thorax so positioning and movement of the thoracic spine will definitely affect scapular positioning. Poor mobility creates an inability to adjust the posture to the activity, and poor scapular mechanics result.
3) Poor motor control – once mobility issues have been corrected (and it’s not just the cervical and thoracic spines), then scapular and spinal motor control often improve automatically. Scapular retraction exercises aim to strengthen the scapular muscles, but motor control basically means the muscles are positioning and moving the scapula the right way at the right time. See part 2 again for a more in-depth explanation.
This is by no means an exhaustive list of possible solutions, but it’s a start.
I plan on posting a couple videos next week showing how to perform pushing and pulling exercises correctly. I’m on my way to Chicago right now for a Graston Technique training so those will have to wait until I get back. Keep an eye out for those and part 4 – correcting scapular winging.
As always feel free to email any questions to me: email@example.com
In Part I, I discussed how physical therapy of the shoulder using traditional rotator cuff exercises really gets me fired up. Traditional methods of shoulder rehab often train the muscles of the shoulder in a way that they are not really used in normal everyday function. If you haven’t caught that article yet, I suggest you read that one first.
In this article I want to address a couple other pieces of the puzzle: motor control and regional interdependence.
There are many cases in which a certain movement may look dysfunctional in a standing position, but may actually be completely functional in other positions where the patient is more unloaded like lying on their back or stomach, side lying, on hands and knees, or even in kneeling. In these positions there are fewer joints and segments to control and in most of these cases less gravity to deal with.
Unless the movement pattern is tested in multiple positions, it is not possible to know with any certainty that the movement is limited because of a true mobility issue (think joint restriction or ‘tight’ muscle) or if it is because of a lack of motor control.
Here is a great example looking at a functional reaching pattern behind the back. In standing, you should be able to reach up behind your back and touch the bottom of the opposite shoulder blade as in the picture below:
So this past week I had a patient come in that could only reach to just below her belt line. She had been given stretches to increase that movement but they really hurt her shoulder to perform. If you’ve ever had a shoulder problem or therapy after a shoulder surgery then this exercise will look very familiar:
Shoulder Internal Rotation Stretch
When I had her lie down on her left side, she could reach all the way up her back and touch the opposite shoulder blade! So why could she not do it in standing but had no pain and no difficulty lying on her side?
By going to a more unloaded position in side lying, the other joints of the body are taken out of the equation, and there is much less to have to control. In this position she could be successful. This is a great example of poor motor control, not a loss of shoulder range of motion. So of course the first question she asked me is why did she spend the last 4 weeks in therapy and at home trying to stretch out her shoulder?
During the evaluation is was also discovered that she had some loss of mobility in her neck. Because the neck movements were not painful, these were addressed first using cervical manipulation and then I followed that up with some soft tissue work using the Graston Technique through her upper trapezius, levator, and rhomboids.
C1-2 Thrust Manipulation
GT to the Upper Trapezius
Here is where that term – Regional Interdependence – comes into play. In simple terms, regional interdependence is the interplay between different regions of the body. In this case its easy to see how limitations in the neck can affect the shoulder since there are a number of muscles that run between the spine and shoulder girdle. In other cases it could be dysfunction even further down the spine, the pelvis, hip, and beyond that could affect alignment and function at the shoulder. Without the proper evaluation, it would be nearly impossible to find these relationships.
Once her cervical mobility was restored, we immediately went to corrective exercises to improve motor control of the neck and shoulder girdle. These were fairly simple non-painful exercises that allowed her to successfully work through her neck limitations in a more unloaded position (hands and knees in this case).
Following that first treatment she could reach behind her back and nearly touch her opposite shoulder blade!
When the patient returned for her next visit, she had maintained her neck mobility and behind the back reach without shoulder pain. We progressed to kneeling and standing motor control exercises, and by the end of the treatment she could touch her opposite shoulder blade without difficulty.
Half kneeling chops and lifts are a great way to improve stability and motor control through the spine and hips.
Needless to say, this patient was quite happy with the results. Sometimes it is as simple as being in the right place at the right time with your treatment. We’ll see how the rest of her treatment goes but for now we’ve knocked out a major limitation in her shoulder function without directly targeting her sore shoulder.
Part III coming soon
If you have any questions, feel free to contact me: firstname.lastname@example.org
Physical therapy of the shoulder using traditional rotator cuff exercises really gets me fired up, so I should probably warn any physical therapists, chiropractors, or physicians reading this to buckle up! Actually I’m not going to try to offend anyone, I just like to challenge conventional thinking and ask questions – especially when it comes to dogma like rotator cuff exercises.
If you’ve ever been to physical therapy for a shoulder rehab then you’ve probably seen this one:
Shoulder External Rotation
Shoulder Internal Rotation
These are just 2 of many exercises that supposedly target the rotator cuff that are commonly provided by your health care provider. In fact, many of you have probably been handed 2-3 pages of these and told to do 3 sets of 15 up to 3x daily. Ever heard of the shotgun approach? Your health care provider is hoping and praying that one of these might just work and make you feel better.
Now here is the reality of the rotator cuff: It’s job is to stabilize the humeral head (the ‘ball’ of the shoulder) in the glenoid fossa (the socket)
The 4 Muscles of the Rotator Cuff
What most health care providers are going on are EMG studies that measure how hard a muscle can fire in isolation during a specific activity. There is certainly great evidence that the rotator cuff muscles are firing during these exercises. The problem as I alluded to before is that these muscles do not function in this way in real life.
These smaller rotator cuff muscles are stabilizers, not movers(like the larger deltoids, pecs, lats, etc). The traditional rotator cuff exercises train the muscles like ‘movers’ which is not their true function. I’m not going to argue that someone can’t show increased strength over time within these exercises, but I will argue is that there is no transfer to improved function (i.e. lifting, reaching, carrying, pushing/pulling, etc).
The reality of the rotator cuff again is to stabilize the humeral head (the ‘ball’ of the shoulder) in the glenoid fossa (the socket). It performs this task reflexively meaning it happens without you having to think about it. All four muscles quickly fire and relax in a specific sequence (depending on the activity) to stabilize the shoulder joint. They never work in isolation like you have been trained in the past.
So what are the best ways to fire the rotator cuff reflexively?
Compression – this means putting weight through the arm. Examples would include exercises that involve hands or forearms on the ground holding your body weight, any type of pressing, holding a weight (on your back with the shoulder flexed 90 deg. – think top of a bench press position; or with a weight overhead) just to name a few.
Distraction – this would include anything that pulls downward or outward on the shoulder (think traction). This would include carrying weight by your side, pull-ups, horizontal rows, lifting from the floor, etc.
In any of the above activities, the brain immediately recognizes the need for stability and reflexively fires the cuff to prevent bad things from happening like dislocating your shoulder or falling on your face. Now obviously I’m not trying to actually do these things to you, but forcing muscles to fire reflexively always works better when there is some sense of urgency.
I’ll leave you with a few of my favorites below, and in part 2 I’ll tackle more of the dogma of shoulder rehab.
Arm/Leg Diagonals – a.k.a. the Bird Dog – Shoulder Compression for Reflex Stabilization
Farmer’s Walk – Shoulder Distraction to elicit reflex stabilization
Kettlebell Arm Bar – The goal is reflex stabilization of the glenohumeral joint through compression (using a kettlebell) while performing thoracic rotation. Lots of great things happening here!
Feel free to email any comments or questions to me: email@example.com