Today's guest post comes from my good friend and Elite Baseball Mentorships colleague, Eric Schoenberg. Enjoy! -EC
It is well documented that shoulder pain/injury is a primary reason for lost time in the gym and on the baseball field. Often times, the culprit is not poor exercise selection, but instead poor exercise execution. Most high level performers are going to do the work that we ask them to do, the issue is whether they are practicing getting better or practicing getting worse.
The following three tips will be useful for any strength coach or physical therapist to help ensure optimal function of the shoulder.
1. Understand and Appreciate Relative Stiffness.
There are several examples of relative stiffness around the shoulder that can result in faulty movement, pain and/or decreased performance.
A primary culprit occurs when the relative stiffness of the deltoid is greater than the rotator cuff. The result of this will be superior translation of the humeral head.
This can lead to undersurface rotator cuff tears, biceps tendon irritation, cyst formation, inferior glenohumeral ligament tears, or humeral head abnormalities – all of which are common to throwers.
Consider this when attempting to strengthen the cuff. Check to see if the humerus is in extension, as demonstrated in this photo. This faulty "elbow behind the body" pattern will lead to over-recruitment of the posterior deltoid:
You also want to cue the athlete away from excessive horizontal abduction, as demonstrated in the next photo. Prone external rotation with no support results in increased use of deltoid to support the arm against gravity:
Here it is corrected with support:
More times than not, we see athletes doing the correct exercise with the wrong execution and getting poor results. We want to avoid allowing an athlete to practice getting better at moving incorrectly.
2. Stop rowing so much, especially if your rowing technique is incorrect!
Rowing variations are generally the safest and easiest upper body exercises to program. However, even though a row is usually pain free, it can sometimes lead to patterns that result in injury down the road.
For example: If the rhomboids and lats are too stiff, you will see limited upward rotation of the scapula. Regardless of how much you strengthen the serratus anterior and lower trapezius, these smaller muscles will never match the force production of the lats and rhomboids.
With this in mind, the best “fix” is to increase stiffness and muscle performance of serratus and lower trapezius while simultaneously decreasing the stiffness and use of the lats/rhomboids.
This can be done by modifying the way we row. In this great video, EC discusses how to correct the row and ensure the scapula is moving properly on the ribcage with both phases of the rowing pattern.
In addition, we should program pressing or reaching exercises such as landmines, kettlebell presses, overhead carry variations.
3. Don’t let good lower body days double as “bad” upper body days.
We sometimes see athletes come in complaining about an increase in symptoms following lower body days. They will report something like “I don’t know what I did to my shoulder; I lifted lower body yesterday.”
By now we know that a common cause of shoulder pain is the scapula being too depressed and downwardly rotated.
If an athlete performed deadlifts, back squats, or any lower body exercise where the weight was held by their sides (DB reverse lunges, step ups, RDLs, Bulgarian split squats, etc.), chances are they were feeding the pattern of depression and downward rotation.
Taking this a step further, we commonly see these exercises resulting in postures and stabilization strategies that present with increased lumbar lordosis and anterior pelvic tilt. When this goes uncorrected, scapular alignment suffers. Here’s a look at a reverse lunge with excessive hip extension, lumbar extension, and anterior pelvic tilt:
Remember, there is no “corrective’ in the world that will counteract the stress of carrying 120-pound DBs by your side while training on a lower body day. This does not mean that you shouldn’t program it; instead, it means that we should just be aware of the consequences.
The solution to this is to consider alternate loading strategies (such as a Safety Squat Bar, KB Goblet set-up, or weight vests) that will allow the shoulder girdle to be freed up and positioned more optimally. If we pair this with consistent attention to proper alignment and movement strategies, we can use lower body days as another opportunity to enhance shoulder function.
About the Author
Eric Schoenberg (@PTMomentum) is a physical therapist and strength coach located in Milford, MA where he is co-owner of Momentum Physical Therapy. Eric is addicted to baseball and plays a part in the Elite Baseball Mentorship Seminars at Cressey Sports Performance. He can be reached at eric@momentumpt.com.
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This is the second half of my collection of take-home points from reviewing The Complete Shoulder and Hip Blueprint from Tony Gentilcore and Dean Somerset. In case you missed the first half, you can check out Part 1 here. Additionally, I should offer a friendly reminder that the introductory $60 off discount on this great resource ends tonight at midnight; you can learn more here.
6. Shifting low threshold exercises to a high threshold strategy may yield faster results.
Dean goes to great lengths to discuss how proximal (core) stability affects distal (extremity) mobility. In doing so, he cites four examples:
a. Doing front planks may help one to gain hip external rotation.
b. Doing side planks may help one to gain hip internal rotation.
c. Doing dead bugs may help to improve your deep squat.
d. Training active hip flexion (one joint) may help one to to improve a straight leg raise (multiple joints).
With that said, there is a HUGE clarification that must be made: these exercises are all performed with HIGH TENSION. In other words, if you can do eight reps of dead bugs, you aren’t bracing hard enough.
To some degree, this flies in the face of the conventional wisdom that there are high-threshold exercises and low-threshold exercises – and most folks would assume the aforementioned four drills would fall in the low-threshold category. That said, I think a better classification scheme would be high- and low-threshold STRATEGIES. In other words, there is a time to treat a plank or dead bug as a low threshold drill, but also scenarios under which bracing like crazy is appropriate. Trying to create distal mobility is one such example.
That said, don't go and turn everything you do into a high-threshold strategy! This leads me to...
7. Improving mobility is a combination of sympathetic and parasympathetic activity.
I loved this quote from Dean so much that I replayed it a few times so that I could type up this quote:
"If you hold your breath, you're going to limit your mobility. If you breath through the stretch, you're going to access a greater range of motion than you had before. So, it's kind of a dance between parasympathetic and sympathetic and neural activation. You want to be able to use high-threshold sympathetic type stuff to fire up the nervous system and produce that stability, but you want to use parasympathetic stimulation - that long inhale, long exhale - to be able to use that range of motion after you've built the stability."
That's pure gold right there, folks.
8. The term “scapular stability” is a bit of a misnomer.
Nothing about the scapula is meant to be stable. If it were meant to be stable, it would have so many different muscular attachments (17, in fact) with a variety of movement possibilities. A better term would be something originally popularized by physical therapist Sue Falsone: controlled mobility.
9. Don’t assume someone’s "aberrant" posture means an individual will be in pain.
Posture is a complex topic, and the relationship between resting posture and pain measures is surprisingly very poorly established in the research world. We can walk away from this recognition with two considerations:
a. It's important to assess movement quality, and not just resting posture.
b. Use posture as information that guides program design and coaching cues rather than something that tries to explain or predict injuries.
10. Teach movements from the position where relative stiffness principles are challenged the most - but cue high-threshold tension.
During one of his presentations, Dean was coaching a hip flexor stretch in the lunge position, and it immediately got me to thinking about the principle of relative stiffness. In this position, if there isn't adequate anterior core control, lumbar extension will occur instead of hip extension. And, if there isn't solid glute recruitment, there will be a tendency of the head of the femur to glide forward in the socket during the hip extension that does occur.In other words, being able to brace the core and have solid glute activation is key to making sure that the individual is in a good place at this position where movement is challenged the most.
In this instance, Dean cued a high-threshold strategy that allowed him to effectively coach the movement from the most challenging position - which is somewhat counterintuitive to what we've always assumed as coaches ("win the easy battles" first by owning the simple ranges-of-motion). However, if you can get to the appropriate position (adequate passive ROM) and educate a trainee on how to establish a bracing strategy, chances are that you can speed up the learning process.
As I thought about it, this is something we do quite commonly with our end-range rotator cuff strengthening exercises, but I simply haven't applied it nearly as much at the hip as we do at the shoulder. It's definitely something I'll be playing around with more moving forward.
Last, but certainly not least, just a friendly reminder that today is the last day to get the introductory $60 off discount on The Complete Shoulder and Hip Blueprint. As you can probably tell from these posts, I've really enjoyed going through it myself, and would highly recommend it to any fitness professionals and rehabilitation specialists out there. Click here to learn more.
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I've spent the past week going through Tony Gentilcore and Dean Somerset's awesome new resource, The Complete Shoulder and Hip Blueprint. With that in mind, Cressey Sports Performance staff member Tim Geromini and I pulled together ten solid takeaway points from the resource that we thought you'd like. Here are the first five, in no particular order...
1. Full scapular range of motion during push-ups often gets overlooked as a great "corrective."
Tony did an excellent job of making this point during the shoulder portion of the seminar. Push-ups (when done properly) take take the scapula from retraction during the eccentric phase of the push-up to protraction and "wrapping around" the rib cage during the concentric phase. It is usually scapula protraction that is omitted, as many people only focus on straightening their arms to finish the push-up. This creates excessive glenohumeral (ball-on-socket) motion and insufficient scapulothoracic (shoulder blade on rib cage) movement.
Learning to "fill up" the upper back and get the shoulder blades to the arm pits can be a game changer for optimizing scapular control.
2. Your hip structure impacts your likelihood of surgical success.
Citing 2015 research from Fabricant et al, Dean noted that patients with retroverted hips had saw less improvement following surgery for femoroacetabular impingement (FAI) than those with anteverted hips.
This shouldn't be surprising if you understand the implications of these hip presentations. Anteverted hips gives rise to more hip flexion and less hip extension, whereas retroverted hips will yield hips that do well with extension, but struggle getting into flexion.
FAI is a flexion-based pathology; bony overgrowth occurs because the femoral head (ball) bangs repeatedly into the acetabular rim (socket). It makes sense that a hip structure more conducive to allowing flexion would be less likely to re-develop these negative structural changes after a surgical intervention.
That said, the big takeaway from this is that the more retroverted a hip is, the more conservative the rehabilitation ought to be - and the less aggressive that "patient" ought to be with squatting, etc. in the years that follow.
3. Don't let a lack of a partner prevent you from doing rhythmic stabilization work.
The main function of the rotator cuff is to center the humeral head (ball) on the glenoid fossa (socket). Partner assisted rhythmic stabilization drills are fantastic in training this quality. Here's an example:
However, if you don’t have a partner available to help, a nice substitute would be this simple exercise you can do with a band.
The pushing and pulling on the band with your free hand serves as form of distraction that will force the rotator cuff to resist. Of course, things like the Body Blade and Shoulder Tube can be options as well. Rhythmic stabilizations will always be the best option because they are less predictable, though.
4. Full exhalations can quickly enhance mobility - but only if you FORCEFULLY exhale.
A commonly overlooked limitation to mobility is alignment issues. As an example, if the pelvis is stuck in anterior tilt, the hip will be limited in internal rotation and flexion. As such, adding core stability (in this case, the ability to hold the pelvis in posterior tilt) can often quickly make changes to hip range of motion.
A great way to do this, as Dean notes, is to perform course stability exercises with full exhalations. When you exhale fully, the anterior core is engaged, as the rectus abdominis and external obliques, in particular, help to get air out. You can do this in various positions, but the most well-known are definitely prone and side plank positions with full exhale. It can't just be a light exhale, though. You have to work very hard and blow out every last bit of air to get that cord engagement in order to really assess that positioning will change the range of motion.
We've used these strategies a lot in the past, but this video was a good reminder that we have to really push folks to get all that air out, especially if it's the first time we're cueing them to do so.
5. Make sure you're getting motion in the right places during your thoracic spine extension work.
Improving thoracic spine extension in some people is an important part of improving overhead mobility. It’s not uncommon for many to grab a foam roller and haphazardly start leaning back in an attempt to do so. Unfortunately, many individuals perform their reps with incorrect technique; check out this video to learn more.
Speaking of learning more, I strongly encourage you to check out Tony and Dean's excellent new resource, The Complete Shoulder and Hip Blueprint. It's on sale for $60 off this week at an introductory discount; click here to learn more.
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I thought I'd use today's post to throw out some thoughts on training the shoulders.
1. In the upper extremity, the assessments are often the solutions, too.
Imagine you're assessing an athlete, and their squat pattern is absolutely brutal. Usually, the last thing you're going to do is go right to a squat as part of their training. In other words, simply coaching it differently usually won't improve the pattern immediately. Rather, you typically need "rebuild" the pattern by working with everything from ankle and hip mobility to core control, ultimately progressing to movements that replicate the squatting pattern.
Interestingly, the upper extremity is usually the opposite in that the assessment might also be the drill you use to correct the movement. For instance, an aberrant shoulder flexion pattern like this...
...might be quickly corrected with some of these three cues on a back to wall shoulder flexion pattern.
This is also true of push-up assessments and shoulder abduction and external rotation tests we do; funky patterns are usually cleaned up quickly with some subtle cueing. This just isn't the case as much in the lower body, though. Why the difference?
My theory is that because we're weight-bearing all day, the lower extremity is potentially less responsive to the addition of good stiffness in the right places. Conversely, a little bit of stiffness in serratus anterior, lower trap, or posterior cuff seems to go a long way in quickly improving upper extremity movement. My experience with the Postural Restoration Institute also leads me to believe that creating a good zone of apposition can have lead to a more pronounced transient movement in the upper extremity than it does in the lower extremity. This is likely because the rib cage is directly involved with the shoulder girdle, whereas the relationship with the lower extremity (ribs --> spine --> pelvis) is less direct.
These differences also seem to at least partially explain why upper extremity posture is much easier to change than lower extremity positioning. It's far more common to see a scapular anterior tilt change markedly than it is to see an anterior pelvic tilt substantially reduced.
Just thinking out loud here, though. Fun stuff.
2. Anterior shoulder pain usually isn't "biceps tendinitis."
First off, true tendinitis is actually quite rare. In this landmark paper, Maffulli et al. went to great lengths to demonstrate that the overwhelming majority of the overuse tendon conditions we see are actually tendinOSIS (degenerative) and not tendinITIS (inflammatory). It may seem like wordplay, but it's actually a very important differentiation to make: if you're dealing with a biceps issue, it's probably tendinosis.
Second, if you speak with any forward thinking orthopedic shoulder specialist or rehabilitation expert, they'll tell you that there are a lot of differential diagnoses for anterior (front) shoulder pain. It could be referred pain from further up (cervical disc issues, tissue density at scalenes/sternocleidomastoid/subclavius/pec minor, or thoracic outlet syndome), rotator cuff injury or tendinopathy, anterior capsule injury, a lat strain or tendinopathy, labral pathology, nerve irritation at the shoulder itself, arthritis, a Bankart lesion, osteolysis of the distal clavicle, AC joint injury, and a host of other factors.
3. Thoracic outlet surgery really isn't a shoulder surgery.
Over the past few years, each time a professional pitcher gets thoracic outlet surgery, you see many news outlets call it "shoulder surgery." Sorry, but that really isn't the case unless you have a very expansive definition of the word "shoulder."
With this intervention, the surgeon is removing the first (top) rib to provide "clearance" for the nerves and vascular structures to pass underneath the clavicle.
Additionally, surgeons usually opt to perform a scalenectomy, where they surgically remove a portion of the anterior scalenes, which may have hypertrophied (grown) due to chronic overuse. Again, this is not a "shoulder" procedure.
Finally, more and more surgeons are also incorporating a pec minor release as part of the surgical intervention. This is because the nerve and vascular structures that may be impinged at the scalenes or first rib can also be impinged at the coracoid process of the scapular if an individual is too anterior-tilted. While the coracobrachialis and short head of the biceps both attach here, the pec minor is likely the biggest player in creating these potential problems.
This, for me, is the only time this becomes somewhat of a "shoulder" surgery - and it's an indirect relationship that doesn't truly involve the joint. We're still nowhere near the glenohumeral (ball-and-socket) joint that most people consider the true shoulder.
All that said, many people consider the "shoulder girdle" a collection of joints that includes the sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic articulations. In this case, though, the media just doesn't have a clue what they're trying to describe. With that in mind, hopefully this turned into somewhat of an educational rant.
4. Medicine ball scoop tosses tend to be a better than shotputs for cranky shoulders.
Rotational medicine ball training is a big part of our baseball workouts, and it's something we try to include as an integral part of retraining throwing patterns even while guys may be rehabilitating shoulder issues. When you compare rotational shotputs with rotational scoop tosses...
...you can see that the scoop toss requires far less shoulder internal rotation and horizontal adduction, and distraction forces on the joint are far lower at ball release. The shotput is much more stressful to the joint, so it's better saved for much later on in the rehab process.
5. Adequate rotator cuff control is about sufficient strength and proper timing - in the right positions.
To have a healthy shoulder, your cuff needs to be strong and "aware" enough to do its job in the position that matters. If you think about the most shoulder problem, there is pain at some extreme: the overhead position of a press, the lay-back phase of throwing, or the bar-on-your back position in squatting. For some reason, though, the overwhelming majority of cuff strength tests take place with the arms at the sides or right at 90 degrees of elevation. Sure, these positions might give us a glimpse at strength without provoking symptoms, but they really don't speak much to functional capacity in the positions that matter.
With that in mind, I love the idea of testing rotator cuff strength and timing in the positions that matter. Here's an example:
Obviously, you can make it even more functional by going into a half-kneeling, split-stance, or standing position. The point is that there are a lot of athletes who can test pretty well in positions that don't matter, but horribly in the postures that do.
6. Pre-operative physical therapy for the shoulder is likely really underutilized.
It's not uncommon to hear about someone with an ACL tear going through a month or so of physical therapy before the surgery actually takes place. Basically, they get a head start on range-of-motion and motor control work while swelling goes down (and, in some cases, some healing of an associated MCL injury may need to occur).
I'm surprised this approach isn't utilized as much with shoulder surgeries. It wouldn't be applicable to every situation, of course, but I think that in some cases, it can be useful to have a pre-operative baseline of range-of-motion. This is particularly true in cases of chronic throwing shoulder injuries where regaining the right amount of external rotation is crucial for return to high level function. Adding in some work on cuff strength/timing, scapular control, and thoracic mobility before hopping in a sling for 4-6 weeks probably wouldn't hurt the case, either. And, as an added bonus, if this was more common, I think we'd find quite a few people who just so happen to become asymptomatic, allowing them to cancel their surgeries. It's probably wishful thinking on my part, but that's what these random thoughts articles are all about.
For more information on approaches to evaluating, coaching, and programming for the shoulder, be sure to check out Sturdy Shoulder Solutions.
Have a great weekend!
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Call me a traditionalist, but I still love using prone (on the stomach) drills to teach good scapular (shoulder blade) control. However, we never teach these drills face-down on the floor. Check out today's video to learn why:
If you're looking for a detailed tutorial on how to perform this exercise off a table, give this a watch:
If you're looking to learn about how I assess, program, and coach at the shoulder, be sure to check out my resource, Sturdy Shoulder Solutions.
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I've often alluded to how important I think the back to wall shoulder flexion drill is as both an assessment and actual training exercise. Today, I've got three strategies for improving your performance of this exercise:
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In November of 2009, just over 40 rehabilitation specialists, fitness professionals, and athletes gathered at Cressey Performance to spend the day learning how to test, treat, and train the shoulder for health and high performance.
This seminar bridged the gap between injured athletes looking to get healthy and those performing at high levels and looking to stay healthy.
Optimal Shoulder Performance: From Rehabilitation to High Performance is a 8-hour, 4-DVD set that draws upon the expertise of two industry professionals, Mike Reinold and Eric Cressey, who have devoted countless hours to this commonly injured joint.
Today, I want to introduce you to one of the screens we do with all our throwing athletes - and what the implications of "failing" this test are. Check out this six-minute video:
If you're looking for more information along these lines, I'd encourage you to check out one of our upcoming Elite Baseball Mentorships, with events running in both October and November.
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I gave a seminar this past weekend to an awesome group of over 80 trainers, representing 10 countries.
They were an enthusiastic bunch with a lot of great questions, but none stuck out in my mind quite as prominently as when a few of them questioned some comments I made with respect to "packing the shoulder." With that in mind, I thought I'd pull together a webinar on the topic for you. Check it out:
For more detailed upper body insights like this, be sure to check out my popular resource, Sturdy Shoulder Solutions.
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In this installment of "Exercise of the Week," I have a drill that combines a few of my all-time favorite shoulder health exercises into one comprehensive approach that gives you a lot of bang for your buck. Check it out:
Also, for more exercises and coaching cues like this, don't forget to check out our Mike Reinold and my new resource, Functional Stability Training of the Upper Body. It's on sale at a big introductory discount through the end of the week.
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