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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.
*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!
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 reach
pathologies
h threshold.
h h ld
Effective screening, and an understanding
of population-specific norms is the key.
The site of the pain isnt always the source
of the problem
Tendinitis
itis = inflammatory
Inflammation should be easily
controlled with cortisone
injections and/or NSAIDs
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.
Kinesio-Taping
Perfect example of the
difference between
tendinitis and
tendinosis
It works
k tto redistribute
di t ib t
stress appropriately
Training should do
the same!!
Overuse
Rotator Cuff Weakness
Scapular Stability
Poor Glenohumeral ROM
Soft Tissue Restrictions
Poor Thoracic Spine Mobility
Type 3 Acromion
Poor Exercise Technique
Poor Cervical Spine Function
Opposite Hip/Ankle Restrictions
Poor Structural Balance in Programming
Faulty Breathing Patterns
Things We Quantify:
Glenohumeral internal rotation, external
rotation, and total motion
Thoracic spine mobility
Hip internal rotation, external rotation, and
flexion
Knee flexion
Combined Tests (fist-to-fist)
Case Studies!
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.
al pinned that dont
don t cross this line
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!
Treatment?
16-year old got
ultrasound
23-year old got a
bone stimulator
Neither of them
fixed their shoulder
or hip ROM deficit!
Wow
Fractured Right Hip
Three Years Earlier
23 of Hip Internal
Rotation (goal = >40)
40 )
You can cheat on
your hip motion with
long toss, but you cant
cheat when on the mound, when stress is higher.
Lessons
I know, I know
This Presentation
Evidence
Unfortunately the evidence is still a
work in progress
But getting closer every day
The problem
Experience
AC joint or subacromial
Impingement
Impingement Tests
Anterior laxity
Posterior tightness
Internal Impingement
Wilk,Reinold,Crenshaw,et al: 99
99--09
Examined ROM in 1400+
professional baseball players
ER @ 90 deg abduction:
Dominant: 129 + 10 deg
Non-Dom: 121 + 9 deg.
deg
IR @ 90 abduction:
Dominant:
Non-Dom.
61 + 9 deg
68 + 8 deg
ER + IR = Total Motion
10
Tomiya:: AJSM 04
Tomiya
Tomiya:: AJSM 04
Tomiya
11
Flexion
ER
IR
TM
E Flex
E Ext
Beginning
175
133
46
179
135
-4
End
176
138
47
185
136
-6
Change
+5
+6
-2
What is a Shrug???
12
Traumatic Dislocation
Voluntary Subluxation
Congenital Laxity
CONGENITAL LAXITY!
13
Acquired Laxity
Instability
Apprehension sign
Congenital Laxity
Sulcus
Sulcus sign
> 10 mm positive
Sulcus
14
SLAP 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
Different tests for different
types of SLAPs
Compression Injuries
Traction Injuries
15
Shoulder Examination
Key Points
We are still evolving into
evidence based examination
Challenging progression
Understand how the shoulder
functions
Determine
16
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
Eliminate overhead activities
Modify/Eliminate Horizontal Pressing
More horizontal p
pulling,
g, asymptomatic
y p
cuff
exercises, scapular stabilization exercises
(improve upward rotation function)
Gentle stretching for the internal rotators
and pec minor
Optimize thoracic spine mobility
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
Primary vs. Secondary
Scapulohumeral Rhythm
Populations
p
most commonlyy affected: lifters,, desk
jockeys, elderly
Tendinosis? Tendinitis? Bursitis?
Supraspinatus? Infraspinatus? Biceps Tendon?
Labrum?
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
17
External Impingement
Once symptomatic with ADLs:
(Feet-Elevated) Push-up Isometric Holds > (Feet-
Internal Impingement
AKA posterior-superior
glenoid impingement
Supra- and infraspinatus
against P-S glenoid and
labrum (articular-sided cuff
issues)
High-speed, overhead
activities: swimmers, tennis
players, baseball players
Encompasses a broad
spectrum of more specific
diagnoses and pain
presentation patterns
Why?
18
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
Mar;36(3):523-77.
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<.001). These changes
continued to exist 24 hours after pitching.
External:
Physiological norm
Primary (acromion
spurring) and
secondary (muscular
weakness)
RTC/biceps tendon
impingement under
acromion
Bursal sided cuff
issues
Posterosuperior
Impingement
Specific to throwing
athletes
Humeral head impinges on
posterior labrum and
glenoid
Multiple pathologies can
result
Articular-sided cuff issues
Internal Impingement
Optimize upward rotation function
Avoid stretching into external rotation,
horizontal abduction,
abduction and full extension!
Rest and NSAIDs wont cut it!
Optimize GH ROM symmetry.
Posterior cuff strength, t-spine mobility,
scapular stability
Internal:
Overhead
O
h d lifti
lifting (not
( t chin-ups,
hi
th
though)
h)
Straight-bar benching
One-Arm Medicine Ball Work
Upright rows
Front/Side raises (especially empty can)
Olympic lifts
Back squats
19
A few reasons
Why dont you do overhead work?
Itss part of their sport
It
sport, so you need to
expose them to it
Retro-what?
Things we like
Push-up variations
Multi-purpose bar
Neutral grip DB pressing variations
E
Every
row andd chin-up
hi
you can imagine
i
i
(excluding upright rows)
Loads of thick handle/grip training
Medicine Ball Work: Rotational and Overhead
Specialty bars: Giant Cambered, Safety Squat
20
Direct Palpation
Horizontal adduction
Full extension
Approximation?
Anecdotally
Lifting-specific population
w/insidious onset
Most have significant
scapular anterior tilt, and
marked GIRD is common
Lower
L
resting
i posture off
the scapula allows
acromion to slip anteriorly
and inferiorly relative to
clavicle.
Thoracic outlet? SC joint
issues?
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.
21
Tremendous mobility
Repetition & fatigue
Arm fatigue & injury patterns
Number of pitches
Introduction
Introduction
Internal impingement
Rotator cuff tensile overload
Subacromial impingement
Partial thickness full
thickness tear
The function of
the rotator cuff is
to simply center
the humeral head
within the glenoid
fossa
22
23
EMG of Supraspinatus
Reinold: JOSPT 04
ER strength is key to
the shoulder
24
Goal:
Improve
muscular
b
balance
l
Posterior
dominant
shoulder
Infra, teres
Lat, pec
pec,,
subscap, ant.
subscap,
delt
Scapular Position
Static resting position of
scapula is protracted and
anterior tilted
Bastan
Bastan,, Reinold, Wilk: APTA 06
Macrina, Wilk: 08
08
71 Professional baseball pitchers
25
Endurance of Cuff
Fatigue contributing factor of injury
Lyman: MSSE 01
Lyman: AJSM 02
02
Dynamic Stability
Video 9, 10, 11
26
The KEY to
treating the athlete
Train the rotator cuff to be strong &
SMART
Require precise
interaction of the
dynamic
stabilizers
27
Subacromial Impingement
Internal Impingement
DO:
DO:
DONT:
Work the cuff to failure
Work through pinches
DONT:
Force into ER
Mobilize the posterior capsule
Instability
Congenital Laxity
DO:
Allow healing
Strengthen in stable range
DONT:
Force motion
Progress to aggressive exercises too early
DO:
Focus on strength of entire shoulder
Dynamic stability
Fatigue
Fatigue--resistant
DONT:
Stretch
Put in disadvantageous positions
Focus on big muscle groups
28
DON
DONT:
T:
Stretch into excessive ER
Aggressive closed chain too early
Biceps
Key Points
Understand:
Shoulder Athlete Pathology
Principles of Treatment
Strength, balance, base of
support
Posterior dominant
Dynamic stability
Specific pathology
Remember the Dos and
Donts
29
Total Motion
Scapular
ER
Humeral
IR
Side-Lying
Extension
Rotation
Side-Lying
Internal
External
Extension
Rotation
Manual
Stretching
Sleeper
Stretch
Side-Lying
Cross Body
Stretch
Prone
Internal
Rotation
Dynamic
Blackburns
Shoulder
Flexion
(supine)
T-Spine
Standing Chin
Tucks
Supine
Coracoid
Process
Doorway
Slides
Forward Head
Posture
Fist-to-Fist
Supine Pec
Minor
Corner Pec
Minor
Wall
Triceps
Reach, Roll,
Lift
Scapular
Wall Slides
No Money
Drill
Scapular
Pushups
Forearm
Wall Slides
Abduction
Wall
Pushups
T-Spine Ext.
w/roller
Quadruped
Chin Tucks
Breathing
Patterns
Quadruped
Ext.
Rotation
Static
Posture
3-Point Ext.
Rotation
Lumbar
Locked
Rotation
Bent Over
T-Spine
Rotation
Prone Belly
Breathing
Side-Lying
Ext.
Rotation
Squat-toStand
w/Ext.
Rotation
30
ExaminationLab
Impingement
NeerSign
HawkinsSign
InternalImpingement
BeightonScore
Laxity
SulcusSign
31
Instability
ApprehensionSign
SLAPTests
PronatedLoad
ResistedSupinationERTest
32
Board Pressing
Very similar cues as bench pressing
Important to sink the bar into the board, not
just bounce off it.
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;
oo ; therefore,
t e e o e, its
t s good to use a pad
beneath the body.
I tend to favor board pressing initially for
impingement-type cases, and floor pressing
for AC joint type issues.
Push-ups
33
Push-ups (cont.)
Dont let hips sag.
Keep arms at 45 angle to body.
While 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).
34
TreatmentLab
RhythmicStabilizations
ClosedKineticChain
35
ManualResistance
ReactiveNeuromuscularControl
36
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