3 Ways to Improve Your Overhead Position

improve your overhead positionIn our practice at Champion, one of our areas of expertise is helping people get the most out of their bodies and improve their performance.  One of the more common areas of performance we work on with people is improving their overhead position.

It’s great to see so many people wanting to work overhead again, however, this is a more challenging position to achieve than most realize.  I’m not going to lie, I’m worried that we’re pushing people during their workouts and causing more harm than good for many.  I’ve seen a bunch of people in for physical therapy recently with shoulder pain and an angry rotator cuff because they’re working beyond fatigue while trying to maintain a quality overhead position.

Before we get into a few ways to improve your ability to work overhead, let’s briefly discuss some of the reasons this position can be compromised.

 

Why The Overhead Position is Challenging

The overhead position, although commonly utilized in workouts, can be more of a challenge than most think.  Not only does the bony anatomy offer an inherent obstacle on some, but efficient dynamic stability of the shoulder joint and endurance of the muscles are often compromised. This can lead to subtle positional changes that often go undetected by the athlete or the strength coach.

The bony anatomy of the glenohumeral joint affords only a small amount of space for the rotator cuff tendons, bursal tissue and biceps tendon.  If the humeral head (the ball) rides up in the glenoid (the socket) because of fatigue, poor control or even encroached upon by a small bone spur, then pain and poor function may result.

Working through these deficits will not help improve the overhead position.  This isn’t one of those areas you can just force through and hope it gets better.  Over time, this can lead to tissue wear, impingement (tendonitis) or even a rotator cuff tear over time..

Let’s look at the anatomy and what is involved.  As you can see, there’s only a small amount of space in the shoulder, about 1 cm in a normal joint.  This space isn’t empty, it’s filled with your rotator cuff tendons and a bursa.  We have little room for error, especially in an athlete doing repetitive overhead activities like throwing a baseball, pressing or even a snatch.

In the photo below, I’ve highlighted the subacromial space in red (photo credit).  This is where the rotator cuff and bursa are located:

subacromial space - overhead position

 

As a result, you may present with shoulder pain along the outside aspect that is almost felt midway down the arm (where the deltoid muscle attaches).

This is typically referred pain from the rotator cuff or bursal tissue (bursitis).  If this is the case, the athlete needs to stop the overhead position and be assessed by a physical therapist to determine the extent of the injury and potentially make changes to their workout routines.  I’ve seen this a bunch recently and there’s a common theme with most of them:.

  1. They have subtle laxity in their shoulders, meaning the joint capsule is just slightly looser than the ‘normal’ shoulder. They can’t do anything about this as this is most likely a genetic predisposition.  This is probably a good thing in the long run and common in athletic people.
  2. They also have poor dynamic stability and weakness of the shoulder and scapula musculature but have never really had a rehab program to address the ‘little’ muscles and get a good base of control.  Combine this with #1 above and we are starting to see the problem…
  3. Finally, their overhead position has been compromised by a lack of mobility.   These mobility restrictions are usually tightness in their soft tissue, particularly their lats, and poor thoracic mobility.  These mobility issues usually come from a society that is biased toward sitting at a desk for many hours or being on a smartphone and having our neck and spine in a forward flexed position.  This can be made worse in athletes as a result of overhead workouts that are focused on creating a powerful acceleration forces (ie throwing a baseball or swimming).

 

3 Ways to Improve Your Overhead Position

Based on these three common findings, here are some techniques I often use to improve overhead position.  These 3 exercises can help address the above mentioned issues and help return the athlete to their workouts.

 

Latissimus Foam Rolling

Recent studies have the shown the efficacy of foam rolling on muscles to aid in performance recovery and soreness.  I don’t think we completely understand the exact mechanism behind this but I definitely see client’s recover faster if they foam roll between workouts or after a big athletic event. I’ll take it!!

The foam roll is used on the area of tightness, which is usually the latissimus, or lat, muscle.  We instruct people to roll over the area of tightness for ~30 seconds and to hold on tender spots for an additional 10 seconds.  This often results in relaxation of the muscle and improved mobility.

Latissimus foam rolling

 

Thoracic Spine Extension on Foam Roller

Another pre-workout activity I like to add into a shoulder program is a thoracic spine extension over a foam roller.   This will improve thoracic extension and result in more greater overhead shoulder mobility.

In this exercise you use the foam roller as a fulcrum places at the thoracic spine.  Focus is on extended the upper back and keeping the lower back stable.  Perform this for 1-2 sets of 10 reps.

thoracic extension foam roll

Shoulder ER Press

Finally, in order to help maintain these soft tissue and range of motion gains, we need to work on dynamic stability in the newly gained overhead position.  One that I like to use involves simple elastic tubing, in which the athlete pulls into scapula retraction at shoulder height, then presses overhead in a pain free range of motion.

We call this the Shoulder ER Press, as it combines shoulder external rotation and overhead pressing.

The tubing is pulling the shoulder forward so it takes a lot of effort (more than you think) by the back of the shoulder and rotator cuff to maintain a good position.  This requires strength but also works on muscular endurance overhead.

As the athlete progresses, a manual rhythmic stabilization may be incorporated to further challenge the dynamic stabilizers in an overhead position.

 

 

I’ve seen this a bunch recently and have employed these 3 techniques with pretty excellent outcomes in a relatively short period of time.

So, remember to address any soft tissue and mobility issues that may be contributing to the overhead position and work to progressively strengthen the dynamic stabilizers.  Working through these restrictions is only going to maket the situation worse. You should see some improvement in your overhead position in a few visits, once you get the underlying inflammation under control.

 

The Number One Way You Are Killing Your Posture

The Washington Post published an interesting article last week on how cellphones are changing our posture.  Cell phones, and more importantly, smart phones and texting, are making a significant impact on our posture and overall health.  We spend a large portion of our day starring at a tiny little screen, causing us to strain and position our head forward.

Ready to be amazed?  How about these for statistics:

Cell phone text messaging neck pain

(Photo Source)

 

Cell Phones Are Killing Our Posture

The Washington Post article goes on to discuss that the forward head posture that is caused by looking at a small screen close to your face, such as when texting, places an enormous amount of strain on your neck.

The human head weighs about 12 pounds on average, but the more forward your head in your posture can cause this to increase 5X.  Imagine walking around with a 60 pound weight tied to your head!

cell phone text messaging posture

(Photo Source)

 

This causes the muscles and joints in your neck to be stretched to their end range, which causes muscles tightness, muscle soreness, neck pain, and even headaches.  Overtime, the results are cumulative and cause lose of motion of the vertebra in your spine and stress on your discs and nerves.

It isn’t that simple, however, this is impacting more than just neck pain.

We talk about this a lot at Champion, but the body is really great at compensation and finding the path of least resistance.  So, anytime you have increased flexion of your neck, it’s going to have an impact elsewhere on your body.  In my experience, I see these frequently together:

  • Forward head posture
  • Limited arm elevation
  • Tightness in your thoracic spine
  • Excessive extended posture of your low back
  • Anterior tilting of your pelvic

These can cause problems all over your body, including neck pain, shoulder impingement, rotator cuff injuries, low back pain, tight hip flexors, and tight hamstrings, just to name a few.  What amazes me the most is that young kids these days, including athletes, can’t even touch their toes anymore!  I blame this on this phenomenon and postural adaptations that occur from our cell phone usage.

 

What To Do About It

So, I know you aren’t going to stop text messaging as much, I get it.  Neither am I.  But there are things we can do to minimize the effect of our phones on our posture.  I think there are two really easy tips to implement:

1. Bring your cell phone to your eyes, not your eyes to your phone

Taking a huge step back, cell phones don’t actually cause any of these issues.  You do when you strain to see the screen and move your head (and eyes) closer to the screen.  This causes forward head posture and the ripple effect discussed above.  Instead, try bringing your phone closer to you eyes.

2. Reverse your posture frequently throughout the day

Probably the most important strategy is to reverse your posture frequently throughout the day.  The body adapts to the positions you place it in and needs to reminded to not to lose your normal posture.  For people sitting at a desk all day, we tell them to get up and walk around frequently.  For those texting, you need to reverse your forward head posture.

There is one easy exercise we use all the time, the shoulder W with a chin tuck that I discussed on my website at MikeReinold.com:

This is an easy exercise to work in throughout the day when your neck starts getting tired.  We try to incorporate exercises like this into all of our strength programs at Champion PT and Performance.

Cell phones and text messaging are killing our posture and causing many problems, keep these statistics in mind and try to be proactive with your posture throughout the day.

 

 

3 Ways to Avoid Loss of Motion After ACL Reconstruction

Approximately 200,000 anterior cruciate ligament, or ACL, injuries of the knee occur annually in the United States, leading to nearly 100,000 ACL reconstruction surgeries. This makes ACL reconstruction one of the most common orthopedic surgeries.

While excellent outcomes can be expected following surgery, not everyone is completely satisfied or returns to their full level of activity. However, the majority of complaints following surgery can often be avoided with proper rehabilitation.

The most common complication and cause for poorer outcomes following ACL reconstruction is motion loss, particularly loss of full knee extension. The inability to fully extend the knee results in abnormal joint motions, scar tissue formation in the front of the knee joint, and subtle changes in normal knee mobility. Thus, one of our goals is to achieve at least full extension and even some degree of hyperextension during the first few days postoperatively. As the patient progresses and the knee’s homeostasis is restored, we eventually work to restore symmetrical knee extension motion.

Many people have a certain degree of knee hyperextension, meaning it extends past a straight 0 degrees. Normal knee hyperextension is approximately 5 degrees but I’ve seen people have as much as 15-20 degrees of hyperextension.

knee hyperextension

All too often, I hear from patients that they were told that full knee extension equal to the opposite knee is not needed and that 0 degrees is good enough. Well, I’ve seen these patients a year or two out from surgery and let me tell you, it’s not good enough. Obtaining symmetrical extension (usually some form of hyperextension) is completely needed for multiple reasons.

A recent study showed that just a simple loss of 3° to 5° of knee extension resulted in worse outcomes and satisfaction after surgery.

Any loss of knee extension will cause long term issues Previous studies have shown anterior knee pain, patellofemoral pain, quadriceps weakness, and long term inability to return to daily activities and sports. I’ve also seen a 2 times increase risk of knee arthritis if the patient doesn’t obtain full ROM postoperatively. As you can see, it is critical that the patient regain full knee ROM, particularly hyperextension similar to the opposite knee.

 

How to Treat Loss of Knee Extension

The first step in treating someone with motion loss of ACL reconstruction is avoiding loss of motion during the early phases of rehabilitation. It is extremely important to find a good physical therapist and to start therapy soon after surgery. This will include specific exercises, stretches, and manual therapy to assure your knee and patellofemoral joint are progressing well.

On top of this, we educate our patients on performing multiple bouts of hamstring and calf stretches with a wedge under the heel to maintain soft tissue flexibility in the back of the knee. During both of these exercises, emphasis should be placed on moving the knee into full extension. This can be done throughout the day no matter where the patient happens to be…so no excuses!

3 Ways to Avoid Loss of Motion After ACL Reconstruction

Another technique that is really helpful is the use of a low-load, long-duration stretch, meaning a gentle stretch held for a long amount of time. This tends to help people improve mobility, especially those that are in more discomfort after surgery.

This can be performed by placing a 5-10 pound weight over the thigh with the heel propped up and gentle allowing the overpressure of the weight to stretch the knee into extension. The patient is instructed to use this stretch for 10-15 minutes, 2-4 times per day.. If someone is starting to lose motion, the frequency is often increased to total at least 60 minutes per day. We utilize this technique immediately following surgery to maintain and improve knee extension.

low load long duration stretch knee

I prefer this technique over the prone knee hang position for 3 reasons. First, the patient usually reports they feel vulnerable lying in on their stomach with their leg hanging off the table or bed. Second, it’s very difficult to control the pelvis and hamstring influence on restoring the knee’s hyperextension. Finally, I’ve shown many people the supine position after they’ve done the prone hangs with other therapists and 99% like it better than the prone hangs. That speaks volumes to me!

Finally, once motion is improving, we perform functional tasks utilizing this new mobility to lock in our gains. We have our patients perform backward walking to create an extension moment about the knee. We first do this in a controlled position while stepping over cones. We then progress to retro treadmill walking for 10-15 minutes at a time to further encourage that extension motion. I’ve had great success at improving a patient’s knee extension when they’ve been told previously that they’ll never get it to return.

retro cone walking

The literature seems to strongly show that restoring extension is imperative to a successful outcome and an asymptomatic knee long-term.  Loss of knee extension mobility will almost certainly lead to long term knee issues that will continually hamper the patients ability to return to their normal function.  Use these three techniques to avoid loss of motion following ACL reconstruction and improve your outcomes.

 

 

3 Keys to Rotator Cuff Rehabilitation

Some of the more common shoulder injuries we see at Champion Physical Therapy and Performance in Boston are rotator cuff tears.  Luckily, we’ve discussed in the past that 74% of people with rotator cuff tears are able to avoid surgery by performing physical therapy.  Despite the optimistic outcomes, people with rotator cuff injuries often have pain with activities and loss of function.  So, what do we do with patients that have opted to begin physical therapy for a diagnosed rotator cuff tear?

To better understand, let’s first break down exactly why a rotator cuff tear causes problems.

 

Normal Function of the Rotator Cuff

The shoulder needs a combination of static and dynamic stability to functional well.

Static stability is accomplished via the joint, capsule, and labrum. These systems are typically intact in the presence of rotator cuff injuries, however joint arthritis or a chronic labral tear may cause further complications.

Dynamic stability is achieved through the interactions of the muscles of the shoulder and their precise neuromuscular control.  This is essentially the interaction of the force couples of the rotator cuff and the shoulder musculature working together to produce movement of the arm.

shoulder shrug signIn people with rotator cuff tears, we know that their dynamic stabilizers have been compromised, causing weakness, imbalances, poor movement patterns and most likely pain.  The interaction the larger prime movers (such as your deltoid, pectoralis, and latissimus) and the stabilizing rotator cuff musculature is vital for normal shoulder joint function.  This is often seen with a “shoulder shrug.”

Patients that present with a “shrug” have lost the ability to effectively activate the rotator cuff to center the humeral head within the glenoid.  The powerful deltoids overpower the ability of the rotator cuff  to keep the ball centered in the socket This can cause even more impingement-type problems and worsening of the rotator cuff tear.  It is imperative that people with rotator cuff tears perform physical therapy to improve this movement if they are trying to prevent rotator cuff repair surgery.


3 Keys to Rotator Cuff Rehabilitation

In my practice, I have had great success focusing on three things with rotator cuff rehabilitation, restore range of motion as close to normal as possible, improve muscle function, and putting the person in a position to succeed which is often the most critical.

 

Restore Range of Motion

One of the biggest complaints that people have with rotator cuff tears, in addition to pain, is loss of motion.  Losing the ability to move comfortably during your daily tasks is often what finally makes people want to address their situation.

In the rehab process, we initially focus on this mobility.  People often either avoid the range of motion that causes which results in tightness over time.  Stretching and mobility drills are initiated to promote healing, restore motion, and aid in decreasing the person’s pain.

 

Improve Muscle Function

While we are focusing on improving mobility, we also focus on improving muscle function.  Once adequate strength begins to return, motion normalizes as well.  In addition to focusing in rotator cuff strength, it is critical to focus on improving proprioception, dynamic stability, neuromuscular control, and scapular muscle strengthening.

A common basic technique I use to accomplish this is called rhythmic stabilization drills.  These rhythmic stabilization drills use alternating isometric contractions of the rotator cuff to prevent movement and enhance stability.  This is used to help enhance rotator cuff function and facilitate a muscular co-contraction of the dynamic stabilizer.  I find this is a critical component to a successful rehabilitation program.  You can see a demonstration of this in the below video.

Put in a Position to Succeed

Finally, as a physical therapist, I believe it’s critical that I put the people with a rotator cuff tear in a position to succeed.  Fighting through a shrug sign or other poor movement strategies only further propagates a poor pattern.

keys to rotator cuff rehabilitationIf the patient continues to shrug, then exercises may be adjusted to decrease stress on the shoulder.  Enhancing their ability to raise their arm may be accomplished easier in a position that does not work against gravity, such as lying on their side.  This position mimics raising their arm overhead but requires less effort from their rotator cuff when it is weak.  In my experiences, if a person can perform this exercises with good form using a 3 pound weight, then they are usually ready to lift their arm up overhead while standing.

Another trick we often use during this exercise is to utilizing electrical stimulation on the rotator cuff may help enhance the amount of rotator cuff activity during the exercise.  We have performed research showing that electrical stimulation increases the amount of rotator cuff force production.  This is great for people that are really weak and need additional help.

 

Physical therapy is often times successful for avoiding surgery in people with rotator cuff tears.  A properly designed program that takes into consideration the normal function of the shoulder joint and these three keys to rotator cuff rehabilitation should help put you in the best position to succeed.