3 Keys to Restoring Shoulder Function

Y ExerciseEach day I treat many shoulder and elbow injuries in all types of athletes. Whether it’s a Crossfit athlete, a professional baseball pitcher, or just someone looking to improve their overall shoulder function, I often see many overlapping similarities.

No matter the situation, the key is to restore their functional range of motion and strength through a well-designed program targeting the implicated tissues.

Each case presents a new challenge for me but there are definitely many overlapping issues that I see on a regular basis. Typically, if we can address these and introduce an evidence-based exercise program, then the athlete can quickly return to their sport at the same, if not higher level.

Common Issues We See

I wrote about Restoring Shoulder Soft Tissue Mobility In Baseball Pitchers on some of the ways I use manual therapy to help restore shoulder soft tissue mobility. Mike and I also published a study on Changes in shoulder and elbow passive range of motion after pitching in professional baseball players  showing the acute effects of throwing on shoulder motion. We know these acute changes need to be addressed to restore normal movements and allow the athlete to perform as needed.

Knowing this, I always insist on empowering the client to do most of their exercises at home with the goal of having complete control.

3 Keys to Restoring Shoulder Function

If I had to target 3 key areas to improve a client’s overhead function, it would definitely be:

  1. Thoracic spine mobility
  2. Shoulder soft tissue mobility
  3. Rotator cuff and scapula strength

 

Thoracic Mobility

Foam RollMost people lack adequate thoracic mobility and have to compensate with lumbar spine extension or push their shoulder into a position that may be symptomatic.

By improving thoracic mobility, we can potentially take stress off of the lumbar spine and shoulder joint. This can also help to restore improved scapula position, as the scapular is highly influenced by the thoracic spine.

Someone with a more flexed thoracic spine will have excessive scapular protraction and anterior tilt. This often leads to a decrease in the joint space where the rotator cuff tendon sits and can potentially lead to issues of pain or dysfunction if not addressed.


Shoulder Soft Tissue Mobility

Lax Ball Post CuffWe briefly talked about the importance of maintaining good shoulder motion and the issues we often see in our athletes. There are specific movements, that we use daily, to help the client regain or maintain their motion.

The soft tissue restrictions, if not treated on a regular basis, can lead to adaptive changes that may put the shoulder in a disadvantageous position. Often times, we can address these issues with some simple drills which can help restore or improve the athlete’s range of motion.


Cuff and Scapula Strength Exercises

Shoulder ROMAnd finally, we definitely would be remiss if we didn’t address any strengthening activities for our clients. It’s easy to work on shoulder and thoracic mobility but all may be lost if we don’t attempt to lock in these gains with a good rotator cuff and scapula stabilization program.

We often see that our clients have been working on the bigger, sexier muscle groups but ignoring the smaller, stabilizing muscles. Remember, you’re only as strong as your base of support so we’ll maintain that your rotator cuff and scapular stabilizers are as important.

Download Our Home Exercise Program

Combining the 3 key factors above can often unlock lost potential and allow the athlete to return to their sport at a higher level. Careful consideration to improve thoracic spine mobility, shoulder soft tissue mobility and rotator cuff/scapula strength will lead to improved shoulder function.

Click below to download an example of a home program we often use for people with these needs:

 

 

The Power of Touch

Lately, I’ve interacted with clients looking to take their game to the next level. Their previous physical therapy was inadequate and they found us through many avenues, whether it be word of mouth, Google search or from another health professional.  The common theme for most of them was an inadequate experience in which they would have minimal interaction with the PT or just head straight to the exercise equipment for a ‘workout.’

My background, coming from a busy sports medicine clinic, made some client interactions difficult in the past. I, however, always made time to at least do 10-20 minutes of hands-on manual therapy with each one. All too often, we get complacent and take for granted that patients can do many of their exercises on their own. I then ask, why do they come to PT to do heel slides for self knee range of motion or just some ankle pumps and towel stretching for an Achilles repair?

 

The Need for Hands-On Therapy

Improve Overhead ROMWith most of these people that would come to me feeling behind in their rehab process, they were disheartened that they didn’t get the one-on-one or ‘hands-on’ PT that they were expecting.  Most would further comment that they ‘could do all of this on their own at home’ and would discontinue their PT.  Down the road, their function wasn’t what they expected because they never achieved their full potential and had to seek more PT.

We, as PT’s, have so much power and influence on a patient’s return to function after an injury or surgery. Taking the time to get into the mind of your client and connect on their issues and goals is a skill that most young PT’s need to work on. And for that matter, some veteran PT’s as well.

Beyond that, once you can get a handle on the patient’s presentation and their goals, there’s a sense that the patient is coming to you to ‘fix’ them.  There are very few clients that don’t need some form of manual therapy, whether it is simple range of motion, soft tissue work, dry needling or manual resistance exercises. The power of touch that a PT can impart on a patient is often taken for granted. It’s during this time that many interactions, beyond that of the initial evaluation, can reveal so much more about the patient’s issues.  Never mind the benefits that the tactile cueing and sensory input can potentially unlock for the patient.

Soft Tissue CompressedTheir sense of well-being, and a feeling that the PT really cares about and is guiding  their recovery, is immeasurable. Some may say this is hocus-pocus, but I respectfully disagree. I have 12+ years of patient interactions and not one has ever told me that the hands-on approach was not helpful or warranted.  Absolutely all of them are thankful that I took the time to listen to them and convey my knowledge and skills to help their recovery.

So please, don’t take for granted the power of touch with your patients. It’s what sets us apart from many other professions and is a key variable that can help unleash the endless potential that your patient has inside.

 

 

 

Is Physical Therapy as Effective as Rotator Cuff Surgery?

Injuries to the shoulder and rotator cuff are ever presenting to me for physical therapy at Champion.  As I assess and treat these clients, I maintain a firm stance that surgery may not be required and that PT is a logical and cost saving way to return function. I wrote about how physical therapy can help avoid rotator cuff repair surgery a while back in a blog post and continue to believe that PT is way under utilized.

Studies continually show the benefits of conservative management of rotator cuff tears versus operative treatment. Don’t get me wrong, many rotator cuff tears require surgical intervention but I feel as if a select population of patients are having surgery when they could easily benefit from PT alone, at a fraction of the cost.

 

Can Physical Therapy Help Avoid Shoulder Surgery?

On a weekly basis, I scour the literature looking for the latest and greatest findings. Of note, I see more research stating that PT may be just as effective as surgery for patients with a rotator cuff tear. Because of that, I felt like I needed to follow up with a recent article out of Finland in The Bone and Joint Journal.

In this randomized controlled trial, the authors seek the outcomes of 3 groups with symptomatic and atraumatic rotator cuff tears documented on MRI. The 3 groups consisted of

  1. Those that received physical therapy alone
  2. Those that had an acromioplasty surgery plus physical therapy
  3. Those that had rotator cuff repair surgery plus physical therapy

The results of a 1 year follow up were pretty eye opening, suggesting that operative management of symptomatic rotator cuff tears was no better than conservative management involving physical therapy alone.

 

Study Details

Let’s dive a little deeper…

Patients were included in the study if they were >55 years old, had full range of motion and had a supraspinatus tear < 75% of the tendon insertion.  A total of 167 shoulder were available for follow up 1 year after the interventions.  Isolated supraspinatus tears with a mean size of less than 1 cm were observed.

Is Physical Therapy as Effective as Rotator Cuff Surgery?The PT group consisted of range of motion and scapula retraction for 6 weeks (which seemed way too conservative) then they were progressed to ‘dynamic exercises’ from 6 weeks to 12 weeks and further progressed to resistance and strength training up to 6 months.  Again, I would’ve initiated this immediately after being seen, considering full ROM was part of the inclusion criteria so working on this early on seemed like a waste of time and may have made the PT group’s results inferior to what they actually achieved.

The same rehab concept was used for the acromioplasty group however they were allowed to progress the rehab at 3 weeks post-op. Again, being relatively ‘aggressive’ compared to the PT group may have skewed this group’s outcomes to look better.

The rotator cuff repair group was placed in a sling for 3 weeks then allowed to progress per the PT group. Again, this seems more aggressive than the way the PT group was treated. I believe the treatment was appropriate to initiate passive range of motion and scapula work early on but may have contributed to a more positive outcome when compared to the relatively conservative ‘PT only group’.

Functional score comparing outcomes at 12 months displayed no significant differences in mean Constant score, patient satisfaction, range of motion or strength. The only significant differences were pain ratings between the groups and activities of daily living however they do not say where the differences were detected.

 

What About the Cost?

Finally, if not the most eye-opening of the study was the mean cost of treatment for the 3 groups.  How about these stats:

  • Physical therapy group cost = $2664
  • Acromioplasty surgery group cost = $5252
  • Rotator cuff repair group cost = $6293

The indirect societal costs were also significantly different when comparing the PT group to the surgical groups.  The money saved to patients, health care companies and society is staggering and should not be ignored.

Symptomatic patients with an atraumatic rotator cuff tears should try a course of physical therapy prior to surgical intervention as the time, cost savings and 1 year outcomes definitely benefit the physical therapy group in this study.

 

 

Restoring Shoulder Soft Tissue Mobility in Baseball Pitchers

Shoulder and elbow injuries, especially Tommy John surgery, have been all the rage the past few years and continues to be a pain for baseball pitchers of all ages. Trust me, my 10+ years working alongside Dr. James Andrews in Birmingham were eye opening. Many kids and parents would show up expecting to have surgery, only to be told that physical therapy was their best bet to return to pitching. I applaud a surgeon who thinks physical therapy is worth a shot before going under the knife. There’s no guarantee that surgery will fix the issue and there’s no guarantee that your fastball will get any faster.

Knowing this, what can we as PT’s do to help these athletes return to their sport and prevent future episodes?  My last blog post dealt with ways to improve overhead mobility and stability.

We know that the overhead athlete’s shoulder become adapted to the stresses placed upon it, especially when an adolescent is throwing around the ages of 11-14 years old.

After a pitcher throws, particularly in a game, they lose shoulder ROM. We think this is due to the eccentric forces on the back of the shoulder, causing loss of shoulder internal rotation. We showed this in a study in the American Journal of Sports Medicine.

If these soft tissue restrictions are not resolved, then the pitcher may be setting themselves up for future injury. The more I practice and research, the more I think the whole glenohumeral internal rotation deficit (GIRD) phenomenon is not as significant as we original thought. Loss of internal rotation is normal, however if they begin to lose too much and their total range of motion is reduced, the bigger risk they may have for shoulder injury. We showed this in a study back in 2011 and continue to see the trend if a pitcher’s total motion is not equal side to side when measuring the way we recommended.

 

Restoring Soft Tissue Mobility in Baseball Pitchers

I continue to use the supine horizontal adduction stretch with the lateral border of the shoulder blade stabilized. I find this elicits the best stretch to the back of the shoulder as long as they don’t feel a pinch in the front or the top. If so, you need to reposition and try a new angle. This is critical!

While internal rotation and GIRD get all the attention, another issue that we have noticed is loss of flexion mobility, both passive and active.

Recently, we published a study in AJSM that showed a higher elbow injury rate in the group that didn’t have full flexion range of motion. We believed ‘the correlation between shoulder flexion deficit and elbow injury in the current study may represent lack of tissue mobility and overall flexibility in injury-prone subjects.

As you can see, the dominant shoulder cannot elevate as high as the non-dominant one.

Limited shoulder flexion

 

We again attribute this to soft tissue restrictions and have noticed that manual therapy on the subscapularis, pec minor, latissimus, and teres major aids in returning this motion back to normal.

Again and again I am seeing this and believe that it is critical to regain this mobility in order to continue throwing at such a high level.

Don’t rush into surgery until you have optimized your body.  Significant mobility restrictions have been correlated to injury and may be the underlying cause of your actual shoulder or elbow injury.  Address the true “cause” of your injury and return to throwing without surgery.