Optimal Shoulder Performance From Rehabilittaion to High Performance
ShoulderPerformance.com
Eric Cressey, MA, CSCS is the president of Cressey Performance in Hudson, MA. Cressey is a highly sought-after coach for healthy and injured athletes alike from youth sports to the Olympic and professional ranks, with baseball development as his greatest focus. Behind Erics expertise, Cressey Performance has rapidly established itself as a go-to high-performance facility among Boston
athletes and those that come from abroad to experience CPs cutting-edge methods.
Eric has lectured in four countries and more than one dozen U.S. states; written over 200 articles and four books; contributed on scientific journal articles and book chapters; and co-created four DVD sets. He publishes a free weekly newsletter and daily blog at http://www.EricCressey.com. A record-setting competitive powerlifter, Cressey has deadlifted 650 pounds at a body weight of 174 and is recognized as an athlete who can jump, sprint, and lift alongside his best athletes to push them to higher levels.
Michael M. Reinold, PT, DPT, SCS, ATC, CSCS is considered a leader in orthopedic and sports rehabilitation as a clinician, educator, and researcher, with specific emphasis on the shoulder and the treatment of overhead athletes. Mike is currently the Head Athletic Trainer of the Boston Red Sox and Coordinator of Rehabilitation Research & Education for the Sports Medicine Division of Massachusetts General Hospital.
Mike has lectured extensively throughout the nation, published over 50 scientific journal articles and book chapters, and is the
author of the textbook, The Athletes Shoulder, 2nd Edition. Mikes contributions to sports medicine have earned recognition by groups such as the APTA, ESPN, Sports Illustrated, The Sporting News, Mens Health, The Boston Globe, and The Boston Herald. For more information, visit Mikes free educational website at http://www.MikeReinold.com.
This DVD and the following guidelines have been provided as general information for exercise and
rehabilitation and are intended for educational purposes. Any individual beginning exercises contained in this video, or beginning any other exercise program, should first consult with a qualified health professional. Discontinue any exercise that causes discomfort and/or dysfunction and consult with a qualified medical professional. Please consult with a physician prior to implementing any rehabilitation or exercise protocol. This DVD does not contain medical advice. The instructions and advice presented are in no way a substitute for professional testing, instruction, or training. The creator, producer, and distributor of this DVD and program disclaim any liabilities or loss, personal or
otherwise, in connection with the exercises and advice herein.
Inefficiency vs. Pathology
Eric Cresseywww EricCressey comwww.EricCressey.com
www.CresseyPerformance.com
What would you think if a coach/trainer had
82% of his athletes with disc bulges or herniations at one level, and 38% at more than one level?
27% of his athletes with vertebral fractures?27% of his athletes with vertebral fractures? 34% of his athletes with rotator cuff tears? 79% of his overhead throwing athletes with labral
tears? 26% of his jumpers with patellar tendinopathy?
Miniaci A. et al. Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. Am J Sports Med. 2002 Jan-Feb;30(1):66-73.
79% of professional pitchers (28/40) had abnormal labrum features magnetic resonance imagingg g gof the shoulder in asymptomatic high performance throwing athletes reveals abnormalities thatmay encompass a spectrum of nonclinical findings
*There are people out there myself included that think that you may very well need a SLAP lesion to throw hard in the first place!
Jost B et al. MRI findings in throwing shoulders: abnormalities in professional handball players. Clin Orthop Relat Res. 2005 May;(434):130-7.
Researchers looked at throwing and non-throwing shoulders of 30 handball players and non-athletes w/MRI
More abnormalities seen in throwing shoulders Although 93% of the throwing shoulders had abnormal magnetic
resonance imaging findings, only 37% were symptomatic. Symptoms correlated poorly with abnormalities seen on magnetic
resonance imaging scans and findings from clinical tests. This suggests that the evaluation of an athlete's throwing shoulder should be done very thoroughly and should not be based mainly on abnormalities seen on magnetic resonance imaging scans.
Not just about throwers, though! Has been demonstrated with swimmers, volleyball players, AND non-athlete controls
Rotator Cuff Fun
Sher et al. (1995): MRIs of 96 asymptomatic subjects, RTC tearsin 34% of cases, and 54% of thoseolder than 60.
Miniaci et al. (1995): MRIs of 30shoulders under age 50 with no completely normal rotator cuffs.23% had evidence of partial-thickness tears.
Connor et al. (2003): eight of20 (40%) dominant shoulders in asymptomatic tennis/baseball players had evidence of partial or full-thickness cuff tears. Five of 20 had MRI evidence of Bennetts lesions.
Jensen MC, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med.1994 Jul 14;331(2):69-73.
MRIs of 98 asymptomatic backs
52 percent of the subjects had a bulge at at least one level, 27 percent had a protrusion, and 1 percent had an extrusion [82% of subjects]. Thirty-eight percent had an abnormality of more than one intervertebral disk. The prevalence of bulges, but not of protrusions, increased with age. The most common nonintervertebral disk abnormalities were Schmorl's nodes (herniation of the disk into the vertebral-body end plate), found in 19 percent of the subjects; annular defects (disruption of the outer fibrous ring of the disk), in 14 percent; and facet arthropathy (degenerative disease of the posterior articular processes of the vertebrae), in 8 percent. The findings were similar in men and women.
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Soler T, Calderon C. The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med. 2000 Jan-Feb;28(1):57-62.
8% of elite Spanish athletes affected 27% of track & field throwers, 17% of rowers, 14% of
gymnasts, and 13% of weightlifters L5 most common (84%), followed by L4 (12%). Bilateral 78% of the time Only 50-60% of those diagnosed actually reported low back
pain Presence of spondylolysis is estimated at 15-63%, with the
highest prevalence among weightlifters. Presence is estimated at 3-7% in the general population
Chou R et al. Imaging strategies for low-back pain: systematic review and meta-analysis. The Lancet, 2009;373 (9662), 463-472.
Review of imaging for low back pain without significant red flags suggesting serious conditions (cancer, fracture, etc)
Lumbar imaging for low back pain without indications of serious underlying conditions does not improve clinical y g poutcomes.
Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low back pain and without features suggesting a serious underlying condition.
Some research suggests that MRI leads to poorer outcomes in back pain patients
You Kneed to KnowCook JL et al. Patellar tendinopathy in junior basketball players: a controlled clinical and ultrasonographic study of 268 patellar tendons in players aged 14-18 years. Scand J Med Sci Sports. 2000 Aug;10(4):216-20.
34 elite junior basketball players (268 total patellar tendons)j p y ( p ) Only 19 tendons (7%) presented clinically with symptoms of
tendinopathy. However, under ultrasonographic examination, 26% of all tendons
could be diagnosed with tendinopathy based on degenerative changes. For every one diagnosed, more than three are overlooked This is magnified as one ages!
Just to Scare You a Bit More
Somewhere between 2and 8 percent of the time inAmerican hospitals, a patienthaving a genuine heart g gattack gets sent home because the doctor doingthe examination thinks for some reason that thepatient is healthy.
-Malcom Gladwell, in Blink
Weve misinterpreted the meaning of the word pathology.
any deviation from a healthy, normal, or efficient condition (dictionary.com)I th d i ffi i d In other words, inefficiency and pathology may in fact be the same thing.
Wordplay?
My primary goal for today is to show you that if you correct the inefficiency, youll markedly reduce the likelihood that these h l i h h h ldpathologies reach threshold.
Effective screening, and an understanding of population-specific norms is the key.
The site of the pain isnt always the source of the problem
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Perhaps the Best Example
The Tendinopathy Debate Tendinosis
osis = degenerative Tissue loading exceeds tissueTissue loading exceeds tissue
tolerance Tendinitis
itis = inflammatory Inflammation should be easily
controlled with cortisone injections and/or NSAIDs
Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy. 1998 Nov-Dec;14(8):840-3.
In overuse clinical conditions in and around tendons, frank inflammation is infrequent, and is associated mostly with tendon ruptures. Tendinosis implies tendon degeneration without clinical or histological signs of intratendinous inflammation, and is not necessarily symptomatic Patients undergoing anis not necessarily symptomatic. Patients undergoing an operation for Achilles tendinopathy show similar areas of degeneration. When the term tendinitis is used in a clinical context, it does not refer to a specific histopathological entity. However, tendinitis is commonly used for conditions that are truly tendinoses, and this leads athletes and coaches to underestimate the proven chronicity of the condition.
The combination of pain, swelling, and impaired performance should be labeled tendinopathy.
The Truth is
Anyone who has ever dealt with a tendinitis diagnosis knows that it isnt so easy to fix
So, traditional treatment modalities are often ,based on the wrong diagnosis.
Many people get healthy simply because they implement rest for the tissues not because they address underlying inefficiencies.
Waiting to Reach Threshold? Remember Cook et al.: while
26% of tendons could be diagnosed with tendinopathy under ultrasonographic exam, only 7% presented clinically with symptomswith symptoms
The other 19% are just waiting to reach threshold.
Tendinopathy is a constant give and take in every muscle in the body, and degeneration is population and activity-specific.
Kinesio-Taping Perfect example of the
difference between tendinitis and tendinosisIt k t di t ib t It works to redistribute stress appropriately
Training should do the same!!
The Law of Repetitive MotionI = NF/AR
I = Insult/Injury to the tissues N = Number of repetitions F = Force or tension of each repetition as a percent
of maximum muscle strength A = Amplitude of each repetition R = Relaxation time between repetitions (lack of
pressure or tension on the tissue)
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The Law of Repetitive Motion
Poor posture: higher forces with Lifting tasks (no change in amplitudeor relaxation => high insult) Sitting at a computer: high number
I = NF/AR
Sitting at a computer: high numberof reps (constant activation) with lowamplitude and lower relaxation time. The weaker you are, the higher the percentage of maximal
strength youll use to accomplish a task. Resistance training can be extremely effective in correcting
problems quickly. Otherwise, wed have to sit with more-than-perfect posture for an equal amount of time to iron things out.
Building Blocks to Dysfunction: Soft Tissue Restrictions
Pec MinorInferior CapsuleSubscapularis
For more information, check out Dr. William Bradyat www.integrativediagnosis.com.
pTeres MinorInfraspinatus
The Bigger Picture: 12 Shoulder Health Factors
OveruseRotator Cuff WeaknessScapular StabilityPoor Glenohumeral ROMSoft Tissue Restrictions
We need to look at all of them to be comprehensive.
Poor Thoracic Spine MobilityType 3 AcromionPoor Exercise TechniquePoor Cervical Spine FunctionOpposite Hip/Ankle RestrictionsPoor Structural Balance in ProgrammingFaulty Breathing Patterns
Quantify what you can, and video/photo whatever you cant!
Things We Quantify:
Glenohumeral internal rotation, external rotation, and total motion
Thoracic spine mobilityThoracic spine mobility Hip internal rotation, external rotation, and
flexion Knee flexion Combined Tests (fist-to-fist)
Case Studies!
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16-year old Pitcher
Medial Elbow Pain Previous treatments included forearm
exercises, ultrasound, rotator cuff , ,strength/endurance, and scapular stability
Cleared for a full return to play No assessment of glenohumeral range of
motion or front hip ROM.
Glenohumeral Internal Rotation Deficit (GIRD)
The Perfect GIRD?Right Shoulder: 19IR,
103ER, 122 Total Motion
Left Shoulder: 53IR90ER143 Total Motion
Asymptomatic, and cleared for a full return to play with a 21 total motion deficit and 34 GIRD.
GIRD Threshold? Burkhart et al. reported that all of a 124-thrower
sample size with Type II SLAP lesions presented with an internal rotation deficit of greater than 25.
Myers et al pinned that dont cross this lineMyers et al. pinned that don t cross this line number at a 19.7 deficit.
The research on non-symptomatic throwing shoulders was in the 12-17 range.
Every little bit matters and this applies to elbows, too!
Same Deficits, Slightly Different Problem
23 year-old Professional Pitcher Medial Elbow Stress Fracture 28 GIRD, 16 Total Motion
Deficit 35 Hip IR on Front Leg (goal =
>40) 124 Knee Flexion on Front Leg
(goal = >135)
Treatment?
16-year old got ultrasound
23-year old got a bone stimulatorbone stimulator
Neither of them fixed their shoulder or hip ROM deficit!
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This is like banging your head against the wall.
Does the wall or your head break first? Incorrect Approach: patch the wall or
take some ibuprofen for your headtake some ibuprofen for your head The Correct Approach: Stop banging
your head against the wall.
17-year-old Left-Handed Pitcher Chronic Left Shoulder Pain Positive SLAP tests Tried rotator cuff and scapular stability
exercises Could long-toss pain free, but had
significant pain with throwing off the mound
What gives?
Wow Fractured Right Hip Three Years Earlier 23 of Hip InternalRotation (goal = >40)Rotation (goal 40 ) You can cheat on your hip motion withlong toss, but you cant cheat when on the mound, when stress is higher.
Another 17-year-old Pitcher Both posterior shoulder pain and medial elbow
pain Addressed cuff weakness, hip ROM issues, soft
tissue quality and pretty much did everything i h !right!
But, athlete jumped the gun on his throwing program and didnt integrate the new hip mobility into his movements.
You can lead a horse to water, but you cant make him drink
Lessons Similar injuries, different causes! Different injuries, similar causes! Each hit threshold for different reasons. This may
be age-specific. Your assessment and corrective approach must be Your assessment and corrective approach must be
thorough and specific to the sport. Look at multiple joints both strength and
flexibility as well as tissue quality Follow-up exercise selection and overall
programming must be appropriate and the exercises must be performed correctly.
I know, I know Most of you arent rehabilitation specialists and
I wouldnt consider that my realm, either! In reality, though, this is because less black and
white and a lot more gray nowadays. Why?W y?
Insurance companies are more and more stingy. As I showed earlier, pretty much everyone is
messed up and even those who arent usually dont move well.
And lets be honest
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Active vs. Passive Restraints Active: muscles, tendons, and (to a lesser
degree) bone Passive: meniscus, labrum, discs Poor active restraint function (strength,
tissue quality, or ROM) leads to increased stress on the passive restraints, or issues with the active restraints themselves.
Later on, well go through how to assess the function of all these
active restraints
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Testing, Treating, & Training the ShoulderTesting, Treating, & Training the Shoulder
Clinical Examination of the Shoulder
Michael M. Reinold, PT, DPT, SCS, ATC, CSCSBoston Red Sox / MGH Sports Medicine
MikeReinold.com
This This PresentationPresentation
Discuss some general concepts behind shoulder examination
Where we are with evidence-based exams How to use evidence & experience! Some differential diagnosis tests Some differential diagnosis tests When to refer out When to treat & correct Clips from DVD on shoulder exam
from AdvancedCEU.com
EvidenceEvidence
Unfortunately the evidence is still a work in progress
But getting closer every day
The problem The problem Cant completely base your exam on
evidence alone Not enough studies Conflicting information in the literature Different patient populations
ExperienceExperience
What your past experience has shown you Important component Put the pieces of the puzzle together Algorithm approach each portion of exam leads the next
portionportion
Expertise Expertise Combining Experience and EvidenceCombining Experience and Evidence
How does a recent graduate conduct a shoulder examination?
How does the expert conduct a shoulder examination?
Be careful! Dont get stuck in your ways!
The True Use of the ExamThe True Use of the Exam
To determine where to start with the patient and when to send out to more qualified discipline Secondary purpose to refer out as needed!
What to perform and what to avoid Make list of objective goals and plan to improveMake list of objective goals and plan to improve
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Impingement Vs. Cuff TearImpingement Vs. Cuff Tear
Progressive cuff pathology Irritation inflammation fraying tearing Identifying where in the process the person is currently
Assess Active MotionAssess Active Motion
AC joint or subacromialImpingement
Rotator cuff tear vs. inflammation
Impingement TestsImpingement Tests Internal ImpingementInternal Impingement
The Throwers ShoulderThe Throwers ShoulderMotion and LaxityMotion and Laxity
Common findings Excessive ER Limited IR
Anterior laxity Posterior tightness
Wilk,Reinold,Crenshaw,etWilk,Reinold,Crenshaw,et al: al: 9999--0909
Examined ROM in 1400+ professional baseball players
ER @ 90 deg abduction: Dominant: 129 + 10 deg Non-Dom: 121 + 9 deg Non-Dom: 121 + 9 deg.
IR @ 90 abduction: Dominant: 61 + 9 deg Non-Dom. 68 + 8 deg
Total Motion: 190 + 14
Total Motion Equal Bilateral !!!
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Total Motion ConceptTotal Motion ConceptWilk et al AJSM 2002Wilk et al AJSM 2002
ER + IR = Total Motion
Range of Motion After ThrowingRange of Motion After ThrowingLoss of Total MotionLoss of Total Motion
Pitching with loss of total motion results in greater chance of injury Ruotolo: JSES 06Ruotolo: JSES 06 Myers: AJSM 06
Range of Motion After ThrowingRange of Motion After ThrowingLoss of Total MotionLoss of Total Motion
Loss of IR normal adaptation
Injury occurs when loss of TMof TM
Cumulative microtraumadue to eccentric and tensile forces
Causes of Loss of IR MotionCauses of Loss of IR MotionHumeral RetroversionHumeral Retroversion
Several studies have shown retroversion of the humerus Crocket AJSM 2002 Reagan AJSM 2002
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Borsa, Wilk, Reinold: AJSM 2005 Examined GH translation in 43
professional baseball pitchers Anterior: 2.81 mm
Causes of Loss of IR MotionCauses of Loss of IR MotionNotNot Posterior Posterior Capsule ContractureCapsule Contracture
Posterior: 5.38 mm Significantly greater posterior translation No differences between D and ND
No correlation between IR ROM and posterior translation
Reinold: AJSM 08 ROM Before & After Throwing Measure PROM before and
after pitching in 117 professional baseball players
Causes of Loss of IR MotionCauses of Loss of IR MotionPosterior Muscular ContracturePosterior Muscular Contracture
professional baseball players Significant decrease in:
IR: -8.5 TM: -9.5 elbow extension: -2.4
Changes still present at 24 hours
TomiyaTomiya: AJSM 04: AJSM 04 TomiyaTomiya: AJSM 04: AJSM 04
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Range of Motion After SeasonRange of Motion After SeasonReinold & Gill: Reinold & Gill: 20062006--20092009
ROM changes over course of season Subjects stretched daily
Beginning End ChangeBeginning End ChangeFlexion 175 176 -ER 133133 138138 +5+5IR 46 47 -TM 179179 185185 +6+6E Flex 135 136 -E Ext --44 --66 --22
I am not sure that the posterior capsule is the cause of the changes in IR in overhead athletes I have not seen this to be common in the healthy
or the injured athlete IR is supposed to be less in the throwing arm,
amount depends on retroversion Throwing causes acute loss of IR, can become
cumulative Assess, DONT ASSUME!
What is a Shrug???What is a Shrug???
Assess cuff vs. capsule
What a Cuff Tear Looks LikeWhat a Cuff Tear Looks Like
DODO NOTNOT work throughwork througha shoulder shrug arc of motion !!!a shoulder shrug arc of motion !!!
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What About Instability?What About Instability?
Different types of instability Acute first time dislocation vs. congenital laxity MDI Actual capsulolabral tear vs just looseness
L it I t bilit Laxity vs. Instability
Traumatic DislocationTraumatic Dislocation
Torn Posterior CapsuleTorn Posterior Capsule Voluntary Voluntary SubluxationSubluxation
Congenital LaxityCongenital Laxity CONGENITAL LAXITY!CONGENITAL LAXITY!
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Acquired LaxityAcquired Laxity InstabilityInstability
Apprehension sign
Congenital LaxityCongenital Laxity
Sulcus sign > 10 mm positive
SulcusSulcus
SulcusSulcus BeightonBeighton Laxity ScoreLaxity Score
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SLAP LesionsSLAP Lesions
SLAPs are trendy right now Likely a little over diagnosed Well over 20 published tests
to detect a SLAP lesion Several variations of SLAPs Several variations of SLAPs Different tests for different
types of SLAPs
Compression InjuriesCompression Injuries Traction InjuriesTraction Injuries
Reinold & Gill: Sports Health 09Wilk, Reinold, Andrews: JOSPT 05Myers, Andrews: AJSM 06
Peel Back LesionsPeel Back Lesions
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Shoulder ExaminationShoulder ExaminationKey PointsKey Points
We are still evolving into evidence based examination
Challenging progression Understand how the shoulder
functions Determine
Specific structures involved When to refer out Where to begin What to avoid
Look at causative factors The complete picture
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Training the Injured Shoulder During and Post-Rehabiliation
Eric CresseyE i Cwww.EricCressey.com
www.CresseyPerformance.com
Important Prerequisites
Primary goal should always be to fix whats 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 p y ,
jockeys, elderly Tendinosis? Tendinitis? Bursitis? Supraspinatus? Infraspinatus? Biceps Tendon?
Labrum?
External Impingement
Eliminate overhead activities Modify/Eliminate Horizontal Pressing More horizontal pulling, asymptomatic cuff p g, y p
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
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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 >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
Cl d h i b f h i 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)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 injuryAsymmetry 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 ( psecond)
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 d fi i bd i kdeficit or abduction weakness
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Symptomatic Internal Impingement Glenohumeral Internal
Rotation Deficit (GIRD) Why does it happen? Role in SLAP lesions Almost everybody has 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):523-72008 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
Why dont you do overhead work?
Its part of their sport so you need toIt 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! 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 isnt closed yet)
Retroversion gives rise to a greater arc of total rotation range of motion (total motion concept = IR + ER)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
E d hi i i 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
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Acromioclavicular Joint Pain
Traumatic vs. Insidious Piano key sign? Osteolysis Pain with: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 commonL i f 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.
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Treating the Athletes ShoulderTreating the Athletes ShoulderTesting, Treating, and Training the ShoulderTesting, Treating, and Training the Shoulder
Michael M. Reinold, PT, DPT, Michael M. Reinold, PT, DPT, SCS, ATCSCS, ATC, CSCS, CSCS
The The Athletes ShoulderAthletes ShoulderIntroductionIntroduction
Common site of injuryCommon site of injury Repetitive forces / stressesRepetitive forces / stresses
Tremendous joint forcesTremendous joint forces
High velocities (7,265 High velocities (7,265 00/sec)/sec)
Anterior shear forces 1Anterior shear forces 1--1.5 X BW1.5 X BW Distraction forces 75Distraction forces 75--100% X BW100% X BW
Tremendous mobilityTremendous mobility Repetition & fatigueRepetition & fatigue
Arm fatigue & injury patternsArm fatigue & injury patterns Number of pitchesNumber of pitches
The The Athletes ShoulderAthletes ShoulderIntroductionIntroduction
Injuries to the rotator cuff are Injuries to the rotator cuff are commoncommon
Range from minor to severeRange from minor to severe Specific pathologiesSpecific pathologies
Internal impingementInternal impingement Rotator cuff tensile overloadRotator cuff tensile overload SubacromialSubacromial impingementimpingement Partial thickness Partial thickness full full
thickness tearthickness tear
The The Athletes ShoulderAthletes ShoulderIntroductionIntroduction
To treat the athlete you To treat the athlete you must understand:must understand: The shoulderThe shoulderThe shoulderThe shoulder The unique The unique
characteristics of the characteristics of the overhead athleteoverhead athlete
The specific pathologyThe specific pathology
Function of the Rotator CuffFunction of the Rotator Cuff
Lets take a step backLets take a step back
What is the function of the rotator cuff?What is the function of the rotator cuff? What is the function of the rotator cuff?What is the function of the rotator cuff? ER/IR the arm?ER/IR the arm? Elevate arm in the scapula plane?Elevate arm in the scapula plane? Initiate arm elevation?Initiate arm elevation?
The function of The function of the rotator cuff is the rotator cuff is to simply center to simply center
the humeral headthe humeral headthe humeral head the humeral head within the within the glenoidglenoid
fossafossa
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Principles of RTC RehabPrinciples of RTC Rehab
Need adequate strengthNeed adequate strength Need muscular balanceNeed muscular balance Need stable base of supportNeed stable base of support Need stable base of supportNeed stable base of support Need enduranceNeed endurance Need dynamic stabilityNeed dynamic stability Cant work the cuff to failure!!!Cant work the cuff to failure!!!
Rotator Cuff StrengthRotator Cuff Strength
Based on scientific evidenceBased on scientific evidence Reinold, Escamilla, Wilk: JOSPT 09Reinold, Escamilla, Wilk: JOSPT 09 Wilk, Reinold, Andrews: The Wilk, Reinold, Andrews: The
Athletes Shoulder 09Athletes Shoulder 09
EMG studies showing whatEMG studies showing what EMG studies showing what EMG studies showing what muscles are active muscles are active in athleticsin athletics JobeJobe: AJSM 83, 84: AJSM 83, 84 DigiovineDigiovine: JSES 92: JSES 92
EMG studies showing the safest EMG studies showing the safest and most effective exerciseand most effective exercise Reinold et al: JOSPT 06Reinold et al: JOSPT 06 Reinold et al: J Reinold et al: J AthlAthl Train 08Train 08
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EMG of Posterior Rotator CuffEMG of Posterior Rotator CuffReinold: JOSPT 04Reinold: JOSPT 04
EMG of Posterior Rotator CuffEMG of Posterior Rotator CuffReinold: JOSPT 04Reinold: JOSPT 04
Placing a towel between the Placing a towel between the arm and the body increases arm and the body increases muscular activitymuscular activity
Balance between the superior Balance between the superior shoulder muscles that ER the shoulder muscles that ER the arm and the inferior shoulder arm and the inferior shoulder muscles that adduct the arm muscles that adduct the arm to hold the towelto hold the towel
23% increase in EMG23% increase in EMG
EMG of EMG of SupraspinatusSupraspinatusReinold: J Reinold: J AthlAthl Train 07Train 07
Rotator Cuff BalanceRotator Cuff Balance
Balance net forcesBalance net forces Focus on posterior Focus on posterior
dominant shoulderdominant shoulderdominant shoulderdominant shoulder At least 2At least 2--3:1 ratio of 3:1 ratio of
posterior:anteriorposterior:anterior ER strength is key to ER strength is key to
the shoulderthe shoulder
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Goal:Goal:
Improve Improve muscular muscular b l b l balancebalance
Posterior Posterior dominant dominant shouldershoulder
Infra, Infra, teresteres
Lat, Lat, pecpec, , subscapsubscap, ant. , ant.
deltdelt
Stable Base of SupportStable Base of Support
Scapula posture, strength, and balanceScapula posture, strength, and balance Upper body crossUpper body cross Thoracic spineThoracic spine Thoracic spineThoracic spine
Scapular Position Scapular Position Static resting position of Static resting position of
scapula is protracted and scapula is protracted and anterior tiltedanterior tilted BastanBastan, Reinold, Wilk: APTA 06, Reinold, Wilk: APTA 06 Macrina, Wilk: 08Macrina, Wilk: 08Macrina, Wilk: 08Macrina, Wilk: 08 71 Professional baseball pitchers71 Professional baseball pitchers
These positions have strong These positions have strong correlation with decreased correlation with decreased serratusserratus and lower and lower trapeziustrapeziusstrengthstrength Thigpen, Reinold, Gill: APTA 08Thigpen, Reinold, Gill: APTA 08 50 Professional baseball pitchers50 Professional baseball pitchers
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Endurance of CuffEndurance of Cuff
Fatigue contributing factor of injuryFatigue contributing factor of injury Lyman: MSSE 01Lyman: MSSE 01 Lyman: AJSM 02Lyman: AJSM 02 Lyman: AJSM 02Lyman: AJSM 02
Endurance of cuff is extremely Endurance of cuff is extremely importantimportant
Need adequate base of strength before Need adequate base of strength before emphasizingemphasizing
Remember, can not work cuff to failure!Remember, can not work cuff to failure!
Video 9, 10, 11Video 9, 10, 11
Dynamic StabilityDynamic Stability By far the most important aspect of RTC By far the most important aspect of RTC
rehab in the rehab in the athleteathlete Center the humeral headCenter the humeral head Stabilize the joint during Stabilize the joint during sportsport
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Static Shoulder StabilizationStatic Shoulder Stabilization
Athletes inherently Athletes inherently have poor static have poor static stabilitystabilityyy Require precise Require precise
interaction of the interaction of the dynamic dynamic stabilizersstabilizers
The The KEYKEY to to treating treating the the athleteathlete
Train the rotator cuff to be strong & Train the rotator cuff to be strong & SMARTSMART
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3 position stab video3 position stab video
Dos and Dos and DontsDontsSSubacromialubacromial ImpingementImpingement
DO:DO: Focus on posture, posterior strengthFocus on posture, posterior strength Soft tissueSoft tissue Soft tissueSoft tissue Shoulder Shoulder scapula interactionscapula interaction
DONT:DONT: Work the cuff to failureWork the cuff to failure Work through pinchesWork through pinches
Dos and Dos and DontsDontsInternal ImpingementInternal Impingement
DO:DO: Restore posterior flexibilityRestore posterior flexibility Maximize strength AND dynamic stabilityMaximize strength AND dynamic stability Maximize strength AND dynamic stabilityMaximize strength AND dynamic stability
DONT:DONT: Force into ERForce into ER Mobilize the posterior capsuleMobilize the posterior capsule
Dos and Dos and DontsDontsInstabilityInstability
DO:DO: Allow healingAllow healing Strengthen in stable rangeStrengthen in stable range Strengthen in stable rangeStrengthen in stable range
DONT:DONT: Force motionForce motion Progress to aggressive exercises too earlyProgress to aggressive exercises too early
Dos and Dos and DontsDontsCongenital LaxityCongenital Laxity
DO:DO: Focus on strength of entire shoulderFocus on strength of entire shoulder Dynamic stabilityDynamic stability Dynamic stabilityDynamic stability FatigueFatigue--resistantresistant
DONT:DONT: StretchStretch Put in disadvantageous positionsPut in disadvantageous positions Focus on big muscle groupsFocus on big muscle groups
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Dos and Dos and DontsDontsSLAP LesionsSLAP Lesions
DO:DO: Focus on strength & dynamic stabilityFocus on strength & dynamic stability
DONT:DONT: DON T:DON T: Stretch into excessive ERStretch into excessive ER Aggressive closed chain too earlyAggressive closed chain too early BicepsBiceps
Key PointsKey Points Understand:Understand:
Shoulder Shoulder Athlete Athlete --PathologyPathology
Principles of TreatmentPrinciples of Treatment Strength, balance, base of Strength, balance, base of
supportsupport Posterior dominantPosterior dominant Dynamic stabilityDynamic stability
Specific pathologySpecific pathology Remember the Dos and Remember the Dos and
DontsDonts
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Lumbar Locked
Rotation
Wall Pushups
Supine Coracoid Process
Total Motion Fist-to-Fist
Breathing Patterns
ER IR
Humeral T-SpineScapular
Prone Belly Breathing
Doorway Slides
Side-Lying Extension Rotation
Side-Lying Internal External
Extension Rotation
Manual Stretching
Sleeper Stretch
Side-Lying Cross Body
Stretch
Prone Internal Rotation
Dynamic Blackburns
T-Spine Ext. w/roller
3-Point Ext. Rotation
Bent Over T-Spine Rotation
Quadruped Ext.
Rotation
Side-Lying Ext.
Rotation
Squat-to-Stand w/Ext.
Rotation
Supine Pec Minor
Wall Triceps
Reach, Roll, Lift
Corner Pec Minor
Scapular Wall Slides
No Money Drill
Scapular Pushups
Forearm Wall Slides
Abduction
Quadruped Chin Tucks
Standing Chin Tucks
Forward Head Posture
Static Posture
Shoulder Flexion (supine)
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ExaminationLab
Impingement
NeerSign HawkinsSign InternalImpingement
Laxity
SulcusSign BeightonScore
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Instability
ApprehensionSign
SLAPTests
PronatedLoad ResistedSupinationERTest
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Bench Pressing Variations Narrower grip is generally less stressful (although
many post-AC joint injuries will handle wider grips better)
Feet directly under or slightly behind knees, not up on bench!
Retract and depress scaps, then position eyes 4-6 inches down the bench from the bar.
Slide back to the starting position with your eyes under the bar.
Bench Pressing Variations (cont.)
Use your handoff! Ease the bar over the pins; think of it as a
slide-over.C t 1 2 G l ! Count: 1, 2, Gulp!
Belly up, chest up: go get the bar. Pull the bar down to your lower sternum Keep the upper arms at 45 angle to torso
Bench Pressing Variations (cont.)
Dont let the scaps roll forward. Think of pushing yourself away from the
bar.If f t l th fl t l If your feet leave the floor, you are a tool.
Never, ever, ever, ever, EVER let your spotter say, All you, man.
Board Pressing
Very similar cues as bench pressing Important to sink the bar into the board, not
just bounce off itjust bounce off it. Set-up options
Partner (preferred) Band-Assisted Under shirt
Floor Pressing Similar cues as benching Less overall loading needed Less scapular stability possible because of
firm floor; therefore, its good to use a pad oo ; t e e o e, t s good to use a padbeneath the body.
I tend to favor board pressing initially for impingement-type cases, and floor pressing for AC joint type issues.
Push-ups
Ensure appropriate hand position Glutes tight Brace core Brace core Pull torso to floor:
preactivates scapular stabilizers ensures that chest gets to floor before face
(eliminates forward head posture)
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Push-ups (cont.)
Dont let hips sag. Keep arms at 45 angle to body. While it takes a bit more strength and coreWhile it takes a bit more strength and core
stability, many individuals will do better initially with feet-elevated push-ups. Increasing the amount of shoulder elevation increases serratus anterior recruitment (Lear and Gross, 1998).
Push-up Iso Holds
Great for teaching ideal posture, sequencing, and activation patterns.
Excellent for females in conjunction withExcellent for females in conjunction with elevated push-ups off pins/benches.
You can add in perturbations to challenge both dynamic shoulder stability and core stability.
Standing 1-arm Cable Rows
My personal favorite Avoid forcing humeral extension/horizontal
abduction on a fixed scapulaabduction on a fixed scapula Pull the shoulder blade down and back
toward opposite hip If possible, use non-working hand to feel
scapular movement.
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TreatmentLab
RhythmicStabilizations
ClosedKineticChain
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ManualResistance
ReactiveNeuromuscularControl
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