Home Posts tagged "Rotator Cuff Exercises"

Optimizing and Progressing Arm Care

The prone horizontal abduction - also known as a "T" - is well known as a popular arm care exercise that has been around for decades. Unfortunately, it's commonly performed incorrectly. In today's video, I cover the most common mistakes - and then add a progression I like to use with folks once they've mastered the technique. Check it out:

Keep in mind that these cues also apply to "T" drills you perform with bands, TRX, or any other implements as well.  

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Random Thoughts on Sports Performance Training – Installment 29

I didn't get in a May installment of this series, but the good news is that it gave me two months to gather my thoughts for a big June! Here goes...

1. Athleticism is doesn't have to be max effort if you have a strength and power "reserve."

Cressey Sports Performance athlete Logan Morrison is currently second in Major League Baseball in homeruns. I came across this video of #22 on Twitter and it immediately got me thinking:

Hitting bombs in the big leagues - particularly on 95mph sinkers - is really challenging, but that looked absurdly easy. He put some force into the ground, got himself in a good position to succeed, and athleticism "happened."

The only reason this is possible is that he's developed a strength and power "reserve." LoMo is strong - and more importantly, he's a powerful dude. When he throws a medicine ball, in many cases, the entire gym stops and watches because it sounds like he's going to knock the wall down. When you've got a foundation of strength and know how to use it quickly, this kind of easy athleticism happens. It does not, however, happen if you're a) weak or b) strong and not powerful. I'd call LoMo a nice blend on the absolute strength-to-speed continuum.

2. If you're struggling to feel external rotation exercises in the right place, try this quick and easy fix.

One of the reason some throwers struggle to "keep the biceps" quiet during external rotation drills is that they start too close to the end-range for external rotation. A quick strategy to improve this is to simply build a little success in a more internally rotated position. This video goes into more depth:

3. Be cautiously optimistic with new surgical advances.

On a pretty regular basis, we hear about remarkable sports medicine breakthroughs that will revolutionize the way we prevent and treat both acute and chronic diseases and injuries/conditions. Unfortunately, they usually don't live up to the hype. Most of the time, we're talking about a "miracle" supplement or drug, but sometimes, we have to ponder the benefits of a new surgical procedure.

In the mid 1990s, the thermal capsulorrhaphy procedure was introduced to attempt to treat shoulder instability. It gained some momentum in the few years that followed, but the outcomes didn't match the hype in spite of the fact that the initial theory seemed decent (heat can shorten capsular tissues, which would theoretically increase shoulder stability). Failure rates were just too high.

Conversely, in 1974, Dr. Frank Jobe revolutionized the way elbow pain was treated in baseball pitchers - and saved a lot of careers - when he performed the first successful ulnar collateral ligament reconstruction (better known as Tommy John Surgery). More than 1/4 of MLB pitchers have had Tommy John, so you could say that this procedure revolutionized sports medicine even though it's taken decades to fine-tune it.

More recently, a new surgery - the UCL repair with internal brace -  has been gaining some steam as an alternative to Tommy John surgery. The initial results have been very promising, particularly in situations where the patient is a good match (depending on age, activity level, and location and extent of the UCL tear). I've actually seen two of these surgeries in the past week myself. One pitcher (Seth Maness) was able to successfully return to the Major Leagues after having it - but we still have a long way to go to determine if it might someday dramatically reduce the number of Tommy John surgeries that take place. Why? 

Right now, we only have statistics on a limited number of these cases, and they're usually in the high school and college realms. All that is reported on is return to previous level of competition (e.g., varsity baseball). We don't know whether a kid that has it at age 16 is still thriving with a healthy elbow at age 22 during his senior year of college.

Additionally, Seth Maness has really been an 88-90mph pitcher throughout his MLB career. We don't know if this same level of success will be seen with 95-100mph flamethrowers. 

Dr. Jeffrey Dugas has become known as "the guy" when it comes to these procedures, and I loved the fact that he reiterated "cautious optimism" in his webinar at the American Sports Medicine Institute Injuries in Baseball course earlier this year. If this gets rolled out too quickly and in the wrong populations, the failure rate could be significantly higher and give an otherwise effective surgery a bad name.  I think it's important for all of us to stay on top of sports medicine research to make sure we don't miss out on these advancements, but also so that we know to be informed consumers so that we don't jump behind new innovations without having all the information we need.

Speaking of the ASMI Injuries in Baseball Course, it's on sale for $100 off through this Sunday, June 24, at midnight. I've enjoyed going through this collection of webinars, and I'm sure you will, too. You can check it out HERE.

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Washington, DC Seminar Announcement: September 17, 2017

I just wanted to give you a heads-up on one-day seminar with me in Washington, DC on Sunday, September 17, 2017.

Cressey scapula

We’ll be spending the day geeking out on shoulders, as the event will cover Shoulder Assessment, Corrective Exercise, and Programming.  The event will be geared toward personal trainers, strength and conditioning professionals, rehabilitation specialists, and fitness enthusiasts alike.

Agenda

9:00AM-9:30AM – Inefficiency vs. Pathology (Lecture)
9:30AM-10:15AM – Understanding Common Shoulder Injuries and Conditions (Lecture)
10:15AM-10:30AM – Break
10:30AM-12:30PM – Upper Extremity Assessment (Lab)
12:30PM-1:30PM – Lunch
1:30PM-3:30PM – Upper Extremity Mobility/Activation/Strength Drills (Lab)
3:30PM-3:45PM – Break
3:45PM-4:45PM – Upper Extremity Strength and Conditioning Programming: What Really Is Appropriate? (Lecture)
4:45PM-5:00PM – Q&A to Wrap Up

Location

Beyond Strength Performance NOVA
21620 Ridgetop Circle
Suite 100
Dulles, VA 20166  

Continuing Education Credits

The event has been approved for 0.7 CEUs (7 contact hours) through the National Strength and Conditioning Association (NSCA).

Cost:

SOLD OUT! Please email ec@ericcressey.com if you'd like to be added to the waiting list in case a spot opens up.

Note: we'll be capping the number of participants to ensure that there is a lot of presenter/attendee interaction - particularly during the hands-on workshop portion - so be sure to register early, as the previous offering sold out well in advance of the early-bird registration deadline.

Looking forward to seeing you there!

Questions? Please email ec@ericcressey.com.

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New York Seminar Announcement: August 20, 2017

I just wanted to give you a heads-up on one-day seminar with me in New York on Sunday, August 20, 2017.

Cressey scapula

We’ll be spending the day geeking out on shoulders, as the event will cover Shoulder Assessment, Corrective Exercise, and Programming.  The event will be geared toward personal trainers, strength and conditioning professionals, rehabilitation specialists, and fitness enthusiasts alike.

Agenda

9:00AM-9:30AM – Inefficiency vs. Pathology (Lecture)
9:30AM-10:15AM – Understanding Common Shoulder Injuries and Conditions (Lecture)
10:15AM-10:30AM – Break
10:30AM-12:30PM – Upper Extremity Assessment (Lab)
12:30PM-1:30PM – Lunch
1:30PM-3:30PM – Upper Extremity Mobility/Activation/Strength Drills (Lab)
3:30PM-3:45PM – Break
3:45PM-4:45PM – Upper Extremity Strength and Conditioning Programming: What Really Is Appropriate? (Lecture)
4:45PM-5:00PM – Q&A to Wrap Up

Location

Solace NY
38 East 32nd St.
New York, NY 10016

Continuing Education Credits

0.7 CEUs (7 contact hours) through the National Strength and Conditioning Association (NSCA)

Cost:

SOLD OUT! Please email ec@ericcressey.com to get on the waiting list.

Note: we'll be capping the number of participants to ensure that there is a lot of presenter/attendee interaction - particularly during the hands-on workshop portion - so be sure to register early, as the previous offering sold out well in advance of the early-bird registration deadline.

Registration

SOLD OUT!

Looking forward to seeing you there!

Questions? Please email ec@ericcressey.com.

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Making Sense of Exercise Contraindications

I've got a wonky shoulder. Actually, the term "wonky" probably doesn't do it justice. As of a MRI in 2014, here's what I've got:

"There is a high-grade partial thickness articular surface tear of the posterior fibers of the supraspinatus that measures 15 mm AP x 15 mm RL. The undersurface tendon fibers are delaminated and retracted 15
mm.

"There is a high-grade partial-thickness cartilage defect over the posterior medial aspect of the humeral head
(near the posterior-superior labrum) with cartilage flap formation that measures 8 mm SI x 5 mm AP."

That was about three years ago, and it may be worse now. The truth is that it started with internal impingement during my high school tennis career, and gradually progressed over the years. In comparing the 2014 MRI to one I'd had in 2003, you see that the damage has progressed (as expected), but the symptoms have actually gotten substantially better.

My (occasional) pain is your gain, though. You see, the symptoms (or lack thereof) can actually teach us a lot about how we view contraindicating exercises.

I can bench press as heavy as I want with zero issues. Pull-ups, rows, pullovers, overhead carries, landmine presses, Turkish get-ups are all completely asymptomatic. They're in my safe exercise repertoire.

And, as long as I don't go crazy with volume or intensity, I can throw a baseball just fine. I long-tossed out well over 200 feet with my pro guys consistently this offseason and it wasn't a problem.

Overhead pressing is weird for me, though. If I tried to push press 135 pounds, my shoulder would hate me for the next 6-8 weeks. Interestingly, though, if I keep the weight lighter, stick to dumbbells in the scapular plane, control the tempo, focus on perfect technique, and don't go crazy with volume, overhead pressing actually makes my shoulder feel better. I'll work it in as an assistance exercise every other month.

 

 

Thanks to a chronic partial thickness rotator cuff tear, overhead pressing is weird for me. If I tried to push press 135 pounds, my shoulder would hate me for the next 6-8 weeks. Interestingly, though, if I keep the weight lighter, stick to dumbbells in the scapular plane, control the tempo, focus on perfect technique, and don't go crazy with volume, overhead pressing actually makes my shoulder feel better. I'll work it in as an assistance exercise every other month. This reminds us that we shouldn't just contraindicate exercises, but rather specific SCENARIOS. You won't change a person's anatomy, but you can certainly change the training stimulus to accommodate that anatomy. Check out today's post at www.EricCressey.com/blog for more info. #cspfamily #rotatorcuff #overheadpress #shoulderpain #shoulderworkout

A post shared by Eric Cressey (@ericcressey) on

Interestingly, though, back squatting is what destroys my shoulder the most. This is consistent with an internal impingement diagnosis, but doesn't make a whole lot of sense when you consider that I can throw pain-free. Even if I just try to put a 45-pound barbell on my shoulders, it lights my shoulder up in a very bad way.

This weird collection of symptoms can actually teach us three really big lessons, though.

1. Everyone's symptoms and provocative patterns are completely different.  Two people might have a very similar medical diagnosis, but dramatically different safe exercise repertoires.

2. Too often, we contraindicate simply contraindicate exercises. In reality, we should be looking much broader, considering factors such as absolute loading, tempo, volume, and exercise technique.

[bctt tweet="We should contraindicate people from exercises, not exercises for people."]

3. An individual's "safe" exercise repertoire may evolve over time due to changes in movement quality, tissue quality, recovery capacity, and structural integrity. Our programming needs to evolve to accommodate those changes, too.

Certainly, some exercises are inherently bad and not worth the risk, but it's important to evaluate each individual and situation individually to make the determinations on all those "middle of the road" exercises that deliver great training effects and make strength and conditioning fun.

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Shoulder Health: Fine-Tuning Full Can Technique

The "full can" exercise is a popular shoulder prehabilitation/rehabilitation exercise of which I'm not super fond for a number of reasons. That said, if folks are going to utilize it, I think it's important that they understand exactly how to perform the exercise and where they should feel it. Check out today's video to learn more:

Speaking of shoulder performance, I'm excited to announce that Optimal Shoulder Performance - Mike Reinold and my first collaborative product - is now available for the first time as a digital resource. To sweeten the deal, you can get 20% off by entering the coupon code 20OFF at www.ShoulderPerformance.com through the end of the day Sunday.

55-shoulder-performance-dvdcover-212x300

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The Best of 2016: Strength and Conditioning Videos

With my last post, I kicked off the "Best of 2016" series with my top articles of the year. Today, we'll highlight the top five videos of the year. These videos only include instructional videos, not quick exercise demonstrations. 

1. 1-arm TRX Row w/Offset Kettlebell Hold - Every good program includes plenty of horizontal pulling, and this is a way to incorporate a good core stability challenge at the same time.

2. Grip Width for Conventional Deadlift Technique - Getting the grip width right is one of the most important strategies for optimizing your deadlift technique.

3. Hip Extension and the Bulgarian Split Squat - The bulgarian split squat (rear foot elevated split squat) actually takes more hip mobility than you might appreciate, and this excerpt from Functional Stability Training: Optimizing Movement goes into detail on the subject. 

4. Tall Kneeling Cable Press to Overhead Lift - This is an older video, but I just uploaded it this year, as it made for a great "Exercise of the Week" inclusion. 

5. Rhythmic Stabilizations: Where Should You Feel Them? - Rhythmic stabilizations are a great way to improve rotator cuff timing - but only if they're performed correctly. In this video, I answer one of the most common questions we receive about them: "Where should you feel them?"

I'll be back soon with the top guest posts of 2016!

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3 Tips for Improving Shoulder Health and Performance

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.

55-deltoid-pull

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:

humeralextension

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:

proneer1

Here it is corrected with support:

proneercorrected

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.

ScapularDownwardRotation-300x225-2

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:

revlunge

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.

Looking to learn more about our unique approach to assessing and managing throwing athletes? Check out the upcoming Elite Baseball Mentorship Upper Extremity Course on December 18-20. For more information, click here. Don't delay, though; the early-bird registration deadline is November 18.

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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Rhythmic Stabilizations: Where Should You “Feel” Them?

Earlier this week, I received the following question, and thought it would make for some good video content:

Q: I've been training a couple college guys this month before they go back to school and I had a few questions regarding rhythmic stabilizations. I started implementing them with my pitchers recently and they say they don't feel anything. Should they be? Is there any extra coaching points I'm missing here? Thanks for your time.

A: This video!

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6 Saturday Shoulder Strategies

Tomorrow is the early-bird registration deadline for my upcoming shoulder seminar in Chicago, so 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. 

Zone-of-Apposition-300x220

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.

shoulder

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.

With Matt Harvey opting for thoracic outlet surgery this week, I've seen just about every major sporting news outlet 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.

Gray112thoracicoutlet

Additionally, surgeons may 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.

pecminor

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:

Eric-Cressey-Shoulder_OS___0-300x156

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 my July 31 seminar in Chicago, click here.

Have a great weekend!

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