CB CB Athletic Consulting, Inc. Training Report
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ISSUE #116

1 - Shoulder Injury Prevention & Rehabilitation: Part II

Bill Hartman is a physical therapist and strength & conditioning coach in Indianapolis, IN. A lifetime athlete, Bill was a top ten finisher in the National Junior Olympics in the javelin, which he continued along with football at the collegiate level. He was a graduate with distinction at Purdue University and received his degree in physical therapy from Indiana University.

Bill has worked with athletes at all levels in a number of sports and is probably best known for his athletic approach to the physical preparation for golf. He is also an Active Release Techniques Practitioner, a cutting-edge soft-tissue treatment technique, with certification in spine, upper extremity, and lower extremity treatment. Bill has certifications with the National Strength and Conditioning Association as a Certified Strength and Conditioning Specialist and with USA Weightlifting as a Sports Performance Coach. Bill provides seminars on sports training and fitness, writes for national publications and websites, and is the author of the upcoming The Golf Swing Unleashed.

CB: Bill, why do the shoulders get injured so often in athletes, lifters, and everyday people?

Well, for starters it's a naturally unstable joint. For a joint to have the ability to circumduct (move the arm in a large circle) like the shoulder does, it has to be unstable. The shoulder is not like a ball that's surrounded by a socket like the hip. It's actually more like a golf ball sitting on a tee. So the shoulder joint relies heavily on the connective tissues to maintain stability.

There's also a very limited space between the humeral head and the acromion called the subacromial space. In this subacromial space are the rotator cuff tendons, biceps tendon, and the subacromial bursae. During movements that involve the elevation of the arm and external rotation of the arm this space gets even smaller (i.e. throwing).

Movements that involve high force, high speed, "unsafe" motions, and repetitive movements, as well as postural adaptations can result in altered muscle recruitment patterns and/or abnormal amounts of instability which, in turn, result in impingement of the subacromial structures. Repetitive impingement can then result in pain, tendonitis, tendonosis, bursitis, and at worst a tear.

These things rarely produce pain immediately but changes in joint position and function occur over time. It's pretty common to hear a client or a patient say, "I've done this for years and never had any problems before." Most incidents that seem to be the cause are more like the "straw that broke the camel's back" in that enough "wear 'n' tear" has taken place to finally produce symptoms and injury.

CB: The rotator cuff gets hurt in a lot of people. So what should people avoid and what methods are most useful in rehabilitating this injury?

I think we've hit on a number of things to avoid. Let's talk about rehabilitation.

The biggest tool I have in my toolbox other than exercise is Active Release Techniques. This is a manual soft-tissue treatment technique developed by a chiropractor, Dr. Mike Leahy. This technique has been so effective for me, I can't tell you how many times a patient or client comes to me literally unable to reach overhead because of pain and leaves with full range of motion of the shoulder in only 1 treatment. Yes, I said one. Many times they can get full resolution of pain in 3 treatments. For more information, go to www.activereleasetechniques.com.

Like I mentioned above, exercise is the key to rehabilitation. We can certainly do a lot with manual techniques, but it's the exercise that will restore ultimate function back to the shoulder. If I had to pick only one form of exercise, it would be PNF. These are diagonal movement patterns that include all the major motions of the upper extremity.

The great thing about the PNF patterns is that we can work on flexibility and strength at the same time. We can load them with manual resistance, with bands, with dumbbells, or with cables. The adaptability fits right along with the philosophy of getting the most for your time and efforts.

The symptoms will ultimately determine what course of action to take. Sometimes pain is so great that I have to initiate rehab with simple single plane shoulder exercises or isometrics.

CB: Is it better to use traditional isolation exercises (i.e. external rotations) or multi-muscle exercises such as wide-grip rowing and other rowing variations? And are external rotations done with tubing ineffective because of the problems with the strength curve?

This question was answered in a recent journal. Multiple joint, multiple muscle exercises win hands down for strengthening the entire shoulder girdle including the rotator cuff. That's not to say that isolation exercise should never be utilized. There's no such thing as a perfect program. Sometimes you have to plug the holes with an isolation exercise or two.

External rotations with tubing have a place, but you do have to understand how it loads the muscles. Because the tension increases as the tubing is stretched, the highest tension will be where the external rotators are already shortened and can't produce maximum force.

There are a couple of tricks to get around this issue: One trick is to put the tubing under tension and hold the arm fixed while you actively change the position of the body to produce the rotation of the shoulder.

The other is to perform partial range of motion exercises at a relatively narrow range of band tension. For instance, you only move the arm 2-3 inches at end range at a certain tension, then shift the body so that the same tension occurs at the mid range of motion, and then shift again so that the same tension occurs at the beginning of the range of motion. This method isn't terribly efficient, but it does have a place in rehab.

I really like to use tubing or bands at the end of rehab to perform faster activities to restore elasticity and to train the stretch-shortening cycle. I do this with my healthy throwing or overhead athletes as well.

CB: What strength training adjustments or "pre-hab" techniques can the average athlete or lifter use to avoid shoulder injury?

Most athletes or lifters just don't know how to train or program properly. It seems that everyone thinks they're doing things correctly, but I'm sure you've noticed that you typically spend an entire training cycle just teaching a client how to perform even the simplest of exercises. So the number one prevention technique is to learn the proper execution of the exercises.

The next most common cause of shoulder pain in lifters is training too much, too heavy, and too often. I blame the muscle magazines for this one. I appreciate all the bravado that goes with the whole bodybuilding thing, but seems that each guy has to try to outdo the next guy in training intensiveness to prove his manhood. The unfortunate result is that you have generation after generation of lifters who think that if you don't take every set to failure, every workout, and then train every day, you won't make progress.

A simple plan for most lifters is to progressively increase intensity and reduce volume over a period of 3 or 4 weeks and then reduce both for a week. Most lifters are amazed at how much stronger and how much more muscle they gain simply by reducing volume, modulating intensity, and programming a little recovery into their programs. Folks need to understand the delayed training effect. And guess what…no shoulder pain to boot!

If you can balance training volumes of pushing and pulling exercises, you'll actually need very little "pre-hab" (see the answer above about basic exercises and cuff strength). Again the primary areas that I see with shoulders even in decent training programs are relatively weak lower traps and internal shoulder rotation range of motion issues.

CB: Can you give some more information on basic prehab exercises?

These are pretty standard for emphasis of scapular muscles. Very rehab/prehab. If you've got someone with "normal" shoulder mobility who can do some limited overhead work, these may not be necessary. You find that Olympic lifters who do overhead squats and snatch grip overhead work have very strong scapular muscles. The problem is that most folks sit on their asses to much or have postural issues that preclude the overhead stuff. Thus, you need to do these. Are you doing any directed at serratus anterior?

CB: So what are your thoughts on overhead pressing?

After talking with Dale Buchberger who does a great deal of lecturing on shoulder issues (good video at www.swis.ca BTW) and doing a bit of follow-up, I've started to shift away from a great deal of true overhead pressing for my clients(maybe I'm just getting old?). It certainly puts a great deal of repetitive strain on the weakest structures of the gleno-humeral joint.

Obviously, if you have a competitive weightlifter or strongman competitor, you have to do them in training.

The drawback for not doing them I've found is the necessity to do more direct work to the scapular stabilizers like low traps and serratus anterior and the trunk. I do use a lot of PNF patterns which does require an overhead reach, but the direction of loading is more directly into the G-H joint rather than on the anterior-inferior capsule.

Another way around the issue a bit is to use jerks rather than true presses. You still have issues with the loading of weaker structures overhead but you bypass some of the loading through the mid range of motion. I still have a couple of guys and a gal that do jerks and power snatches, but they have never had any shoulder problems and the loads are nowhere near maximal.

I wouldn't do any overhead pressing with anyone with a history of shoulder pain, history of repetitive throwing (pitchers and quarterbacks), someone who compensates for a lack of flexion/abduction with lumbar extension, someone who lacks sufficient upward scapular rotation(or outer depending on the way you were taught), or someone with a tight posterior capsule/tight external rotators.

There's certainly more detail we can get into if you like. There will certainly be some that can overhead press and never have any shoulder issues. They are few and far between because of the need for adequate range of motion and stability. Even the push press and jerks may cause problems depending on what condition your shoulders are in and technical issues.

Like I said before there are some who will be able to do just about anything without difficulty.

CB: What about golfers? How do they avoid shoulder injuries that otherwise keep them off the course?

Technique, technique, technique! If golfers would just take some time and work with the best teaching pro they can afford, they would experience a lot less shoulder pain. That goes for any overhead athlete, too.

It always seems the strength and conditioning coach gets the blame when someone gets injured which is rarely the case.

Well is must be the strength coaches fault because all athletes have perfect technique, right? Wrong.

Think about how many times a golfer swings a club during in a week. Then look at how many reps they perform in a week's time. One of my golfers hits no less than 1,000 full swings in week and usually more. His total reps in his strength training sessions for the week are less than a third of that. Now I'll guarantee that his strength training technique is top notch, but I can't say the every swing is perfect. Where's the greatest potential for overuse? Do I need to answer that?

Aside from technical issues, you know how I feel about flexibility. The shoulders play a very important role in generating clubhead speed much like a pitcher in baseball. The shoulders go through the largest range of motion of any joint in the body during a swing, so if there's a lack of flexibility in the shoulders, better break out the ice packs.

I've even seen some x-rays of a golf with bilateral impingement of the shoulders as a result reduced range of motion. He was banging the humerus into the acromion so hard that he had created a divot in the humeral head!

The double whammy is that if there is a lack of flexibility in the hips or spine, the shoulders tend to get overused even further in an effort to compensate for the lack of flexibility elsewhere.

The shoulder is an amazingly complex joint and we really only scratched the surface. I hope I've been able to provide a little insight to help prevent what could be a very serious injury. And remember if you've had any shoulder pain associated with training get checked by a health professional and take measure to eliminate and prevent it.

Thanks for the opportunity to share info with your readers!

CB: Thanks Bill. But we're not done yet. What impact do compound exercises and Olympic Lifts have on the shoulder joint?

I wish more therapists would see the advantage in the big muscle approach (the article just came out in JOSPT so hopefully someone will read it).

I would certainly prefer to be able to do more overhead work because it saves time and is just plain more effective, but most of my people don't have the scapular mobility and most have tight posterior capsules and tight external rotators. I just won't load shoulders like that. There's usually an anterior instability as well, so overhead work loads the anterior/inferior capsule making that worse. Then the biceps tendon is rotated posterior to the most superior aspect of the glenoid. Then you have another anterior force into the anterior/inferior capsule based on the direction of the tendon pull.

I have a kid now whose humeral head shifts forward so much that in full shoulder flexion or abduction you can see his humeral head push forward in the axilla. He's wondering why he has an impingement and pain with overhead work!?

The nice thing about Olympic lifts is that you don't load the shoulder so much in the stretch position because the leg-drive. Of course, if there are any shoulder issues, I focus on pull variations. The "pull under" can cause one helluva impingement.

CB: Thanks Bill for all this great information. Watch for more of Bill's stuff on www.grrlAthlete.com (he contributed to our fat loss book ShapeShift) and in Men's Fitness magazine.

The information on cbathletics.com is for education purposes only. It is not medical advice and is not intended to replace the advice or attention of health-care professionals. Consult your physician before beginning or making changes in your diet or exercise program, for diagnosis and treatment of illness and injuries, and for advice regarding medications.

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