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Pad the Shoulder

I was talking with one of our athlete’s fathers the other day discussing his son’s health and performance. We were talking about the usual weight gain for adolescent athletes and then began talking about shoulder health. In talking we stumbled onto a term or phrase that I have heard before and admit to using when I was younger. Tying into our weight gain conversation, “padding the shoulder” came up. Paraphrasing “we want to pad his shoulder in order to avoid injury.” Like I mentioned, I remember using that term in high school and its still out there today.

 

What does “pad the shoulder” mean?

The definition that you would hear from most people would be along the lines of: to add weight or muscle around your shoulder so that it’s able to withstand more stress placed upon it during play. Or adding muscle around the shoulder so it can act like a cushion in helping take the beating from pitching and throwing.

My translation of that definition would be to increase the size of your deltoid muscle and muscles in close proximity in an effort to almost encase the shoulder joint to keep it safe.

Now lets clarify and debunk this statement. Injuries that occur at the shoulder, rotator cuff injuries, impingement, or labral tears, happen within the glenohumeral joint (shoulder) or result from dysfunction at the joint. That means that we could lock our shoulders in a bulletproof safe, yet that does nothing for keeping your shoulder joint healthy. The term padding the shoulder with muscle and weight around the joint doesn’t do anything for us when referring to the muscles you can see – the deltoid. Sure adding strength and muscle can be good, but it carries no merit without addressing mechanics at the glenohumeral joint.

Think of it as if you put layers of steal and concrete around your car so that you could drive as fast as you wanted and if you hit anything you will be fine. Sure the car will be fine, but if you aren’t strapped in, as soon as you hit something, your body is going through the windshield or going flying in any other direction inside that car. The “padding” is the steal and concrete. The person driving the car represents your humeral head and the interior of the car represents the glenoid (shoulder socket) and surrounding tissue structures.

How Your Shoulder Joint Functions

One of the main functions of the rotator cuff that is often overlooked is its ability to keep the humeral head centered inside of the glenoid. When muscles are unbalanced, the humeral head at rest can be out of alignment. Which is going to lead to some issues.

All over our body at different joints we present with what are called force couples. A force couple is the relationship between 2 or more muscles acting on the same joint. Your muscles each have actions and lines of pull. A muscles line of pull refers to the direction of its fibers and how it exerts force on its attachment site. A muscle action is the movement, function or how it stabilizes a surrounding joint.

Sticking with the shoulder joint, surrounding muscles have jobs to pull in one direction while other muscles at the same joint are meant to pull in an opposite direction. When certain force couples are unbalanced, where one muscle isn’t contributing the right amount of pull, we again start to have issues. The shoulder becomes so complicated because the scapula has 17 different muscles that attach there. All 17 have their jobs to pull on the scapula in different directions.

Pad the Shoulder

Lets look at one force couple, the rotator cuff and deltoid. Remember, the deltoid is our “pad” in our example phrase. One of the actions of the deltoid is to flex the humerus, or lift your arm over your head. We can say that the deltoid works to elevate the humerus. One of the actions of the 4 rotator cuff muscles works to depress the humerus. The deltoid is a much bigger and stronger muscle than the rotator cuff muscles. With a weak rotator cuff, the deltoid can easily win this force battle and begin to elevate the humeral head too far.

When we have humeral head elevation, we are now talking about an impingement syndrome. You now run the risk of that humeral head rubbing up against your supraspinatus tendon, superior labrum, bursa, and the long head of the biceps tendon. There are quite a few soft tissue, tendons, and bursa that all share space above where you humerus sits to make up your shoulder joint. Having a misaligned humeral head can also play a role in the function of the glenohumeral ligaments, which work to create anterior stability in the joint.

Baseball players and specifically pitchers need a tremendous amount of anterior shoulder stability. Due to the extreme forces present in throwing a baseball, the anterior portion of the shoulder joint is tested. If we put all this “padding” on our shoulder, we would be continuing to feed into this problem of impingement no matter how strong our rotator cuffs are.

The moral of the story is that its not about just adding bulk around your shoulder. It’s about having proper rotator cuff strength and function as well as proper mechanics in sport.  Rotator cuff strength is the key.

If we want to pad something to protect the shoulder, do it in the lower body. The lower body is responsible for generating strength and power to your arm. We want our much larger and stronger muscles in our lower body to take the load off of the shoulder. With a weak lower half and core, we put the arm and shoulder on overtime to create all the force needed to throw or hit a baseball. But that’s a whole other topic.

Am I saying not to do any deltoid work? Yes and no.

We do posterior deltoid work with our baseball players at Champion. That’s used in conjuncture with direct rotator cuff work or in an effort to pull certain athletes out a rounded shoulder position. With upper body pressing exercises, the anterior deltoid is firing as well. Dumbbell Y’s and T’s are options but notice how there is no overhead pressing or any other meaty deltoid exercises. We aren’t talking bodybuilding, this is baseball.

This of course is just one example and a look at one aspect of obtaining optimal shoulder health, and working to clarify a misconception that’s still out there.

Keep those cuffs strong and if you are going to “pad” up anything, make it your legs.

 

 

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.

 

 

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.