Case Study: More than Just Rotator Cuff Exercises
Written on August 5, 2010 at 6:30 am, by Eric Cressey
I had a one-time consultation client at Cressey Performance yesterday, and when I noticed that he had some interesting stuff going on, it made me realize that I need to do more “case studies” here in the blog.
This guy had a history of on-and-off right-sided lower back and left shoulder pain. Basically, it would act up every once in a while, then calm down when he cut out exercising. Then, he’d return to training for a bit – only to have another set-back. It has been one step forward, and one step back for years.
Now, if you’d seen this guy move, you’d realize that the lower back and shoulder stuff were clearly closely related. If you’re at all familiar with the Postural Restoration Institute, he was a classic Left AIC pattern: adducted/internally rotated right hip and abducted/externally rotated left hip – and the compensations working their way up to lead to a low right shoulder and prominent left rib flair. Everything was definitely related.
Not surprisingly, he’d been told he had scoliosis previously – but the “interesting” thing about it is that this was an acquired posture. He hadn’t had these when he was a kid; he developed them when he was a rower who was always on the right side of the boat. If you can acquire them, you can “unacquire” them – but it takes time.
We’re getting him started on some drills to iron out his hip imbalances, but for the sake of this blog, I wanted to highlight what we saw with his shoulder, as I think it includes some great take-home messages on how to manage shoulder function – both in the presence and absence of pain.
If you look at the research, if you look at shoulder total motion (internal rotation + external rotation with the scapula stabilized at 90 degrees of abduction), you should see symmetry between right and left in a healthy shoulder. The internal and external components may be different between sides (e.g., more external rotation and less internal rotation in a throwing shoulder), but the total motion should be the same. When it’s not, “normalizing” total motion should be a primary goal, whether you’re trying to address or prevent shoulder issues.
In our case study’s situation, here is what we measured with the goniometer:
Left: 39° (IR) + 98° (ER) = 137° (TM)
Right: 58° (IR) + 109° (ER) = 167° (TM)
In other words, it was a 30° total motion deficit, with most of that deficit coming from internal rotation.
The logical next step would be to manually stretch the shoulder girdle, right? Well, certainly, it may be justified. However, before I go having an athlete crank on a somewhat “delicate” joint, I like to see what we can do to get that area to relax without even touching it.
The first thing we did was simply close down that left rib cage flair a bit while flexing his left hip and flexing his left arm overhead. And, we just left him there to breath for 30 seconds or so. Then, we remeasured:
Left: 44° (IR) + 104° (ER) = 148° (TM)
In other words, we got 11° of total motion without ever touching his shoulder. His body did that work just by getting air in with a new posture (no left rib flair).
Next, I simply had him get on all fours and go through a pretty low-key thoracic spine mobilization with his arm gently positioned behind his back so that it was on absolutely no stretch. He did eight reps on each side, using cervical motion to drive a bit of thoracic extension and rotation and scapular movement. Then, we remeasured:
Left: 46° (IR) + 107° (ER) = 153° (TM)
There’s another 5° of total motion, and it got us a lot closer to where he needs to be – without ever touching his shoulder. And, the coolest part was that when he stood up, the low right shoulder was markedly less prominent – and it was a positioning that “stuck around” for the rest of his session.
Sure, manual stretching of the shoulder is probably warranted for him to get those last 14 degrees, and I don’t expect him to maintain all this range indefinitely after this session. He’ll need to be consistent with the movements to regain range bit-by-bit and use his strength training to ingrain it in his movement patterns, but the point is that the less aggressive, seemingly indirect, and self-applied interventions are often the best way to get lasting results. And, when they work, it makes you realize just how “synced up” our entire body is from head-to-toe.
For more information on the best assessments and corrective exercises for the shoulder, check out our Optimal Shoulder Performance DVD Set.
Related Posts
Shoulder Range-of-Motion Norms
Mobilizing the Throwing Shoulder: The Do and Don’t
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August 5th, 2010 at 8:23 am
Yeah, please do more of these. I think this will turn out to be one of the best features on your site.
August 5th, 2010 at 10:33 am
Agreed with Rog – this was informative and had me researching off site to learn even more.
August 5th, 2010 at 10:50 am
Well done Eric. A “CP Case Reports” section of your site would be a welcome addition. I actually think it would explode!
August 5th, 2010 at 11:14 am
PRI is a powerful system when used appropriately. Glad to see you’re starting to integrate the stuff from Myokin. I look forward to seeing more.
Regards
Carson Boddicker
August 5th, 2010 at 11:16 am
How bout fixing Scapular Winging as a case study? While I don’t have an extreme case of this, I find it very difficult to correct for myself!
August 5th, 2010 at 11:23 am
Very interesting. I have also been diagnosed with scoliosis and it is pretty obvious on X-Ray but now I wonder if there might be something else going on that contributed to the spinal curvature and whether it can be corrected.
August 5th, 2010 at 11:37 am
I vote for more case studies.
A few questions
1. Left rib flair?, is this when a single rib sticks out, or when the entire lower left ribcage ‘sticks out’
2. Your description of first stretch left me wondering what that stretch actually looks like. Does it have a name I can google, or look up in my Access and Correct manual.
Jarred Blount
August 5th, 2010 at 11:54 am
Cressey-good post-video of your manual manipulations would be an awesome follow-up!
August 5th, 2010 at 1:15 pm
I really enjoyed this article! It’s nice to get an, “In your head,” view of things, as you work with a client. Would appreciate more :-].
August 5th, 2010 at 1:20 pm
Definitely more case studies, and a bad winging would be great. Quick question: you said “get on all fours and go through a pretty low-key thoracic spine mobilization with his arm gently positioned behind his back” … how can you be on all fours with your hands behind your back??? Can you provide a little better explaination of the thoracic mob?
August 5th, 2010 at 2:45 pm
What kind of exercises he had to do for his hip imbalances?
August 5th, 2010 at 3:39 pm
It’s nice to see you expanding out of the norm in treating your clients. The whole body approach is great. We have used the PRI method in our clinic for a while now and it still amazes me how well it work. I word of caution though it’s not for the untrained. We have a therapist that is going through the training and she still struggles with the concepts/treatments. I really like the case study concept for the site as well as the links.
August 5th, 2010 at 4:06 pm
I agree with Roger & Carson, EC – I think this post was a fantastic idea.
August 5th, 2010 at 6:20 pm
Carson – definitely using it a ton, especially with our right-handed baseball guys. Very powerful stuff, indeed.
August 5th, 2010 at 6:21 pm
Could be a detailed blog post, Brandon. I’m on it.
August 5th, 2010 at 6:21 pm
Ben, did you always have it?
August 5th, 2010 at 6:23 pm
Jarred,
1. It’s the entire lower left rib cage.
2. Supine position, flex left hip and knee, and flex left arm (overhead). Then “close down” left rib (toward right hip) with partner assistance or the opposite arm. Breath for a bit and see what happens.
Normally, your left AIC folks are going to have the limitations on the right shoulder, but this guy presented a bit different – but benefited nonetheless.
August 5th, 2010 at 6:24 pm
They weren’t even manual manipulations, Nic. Didn’t really ever touch him – except to measure shoulder ROM.
August 5th, 2010 at 6:25 pm
Dave, the all-fours position was just set up. He then went to a three-point stance and basically did a quadruped extension-rotation with the moving side arm behind the back. Sorry about the confusion.
August 5th, 2010 at 8:59 pm
Eric,
I’m currently going into 3rd yr physiotherapy and I think I’ve learned more useful/practical info reading your articles than all of my rediculously expensive textbooks! Keep it coming! Do you accept Canadian interns?!
August 5th, 2010 at 9:22 pm
Hi Eric….
I enjoyed your case….
I am a PT (graduated from BU 🙂 and I’ve been looking at the myokin stuff….did you take the courses? What did you think?
Thanks for any input.
c.
August 5th, 2010 at 10:52 pm
Very informative…I like the case study, “real-world” approach.
August 6th, 2010 at 8:04 am
Very intersting. Like these case studies 😉
August 6th, 2010 at 9:34 am
Eric,
Great post! I would love to see more of the case study posts. Which one of the classes did you attend at PRI?
August 6th, 2010 at 3:46 pm
Postural Restoration is the real deal. I was skeptical at first, but mostly because I’m always skeptical of a “system” that some guy “invented.” But it’s based on science, using a total-body approach to function and movement. I have had amazing results. It’s not a quick, over-night fix, especially if you’ve ingrained bad behavior (like me). But, with time, I’ve come back even stronger than before.
August 7th, 2010 at 12:50 am
Great post.
Totally agree with the scapular winging case study. i myself have some definite issues. Neanderthal no more has helped but i really need more.
Please do more “case studies” Thanks Eric.
August 7th, 2010 at 5:33 am
More of these! Great post and reminder how it’s all related. My chiro often surprises me with what he works on based on the issue I showed up with.
August 9th, 2010 at 5:40 am
I work out five days a week, and I have had a nagging shoulder pinch, this is great info, keep it up.