Home Posts tagged "Shoulder Surgery"

6 Saturday Shoulder Strategies

In light of the recent announcement of my upcoming shoulder course in Colorado, 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.

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.

Gray112thoracicoutlet

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.

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 June 24 seminar in Colorado, please click here.

Have a great weekend!

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Lose Fat, Gain Muscle, Get Strong: Eric Cressey’s Best Articles of 2010

Show and Go: High Performance Training to Look, Feel, and Move Better - This was obviously my biggest project of 2010.  I actually began writing the strength and conditioning programs and filming the exercise demonstration videos in 2009, and put all the "guinea pigs" through the four-month program beginning in February.  When they completed it as the start of the summer rolled around, I made some modifications based on their feedback and then got cracking on writing up all the tag along resources.  Finally, in September, Show and Go was ready to roll.  So, in effect, it took 10-11 months to take this product from start to finish - a lot of hard work, to say the least.  My reward has been well worth it, though, as the feedback has been awesome.  Thanks so much to everyone who has picked up a copy.

Optimal Shoulder Performance - This was a seminar that Mike Reinold and I filmed in November of 2009, and our goal was to create a resource that brought together concepts from both the shoulder rehabilitation and shoulder performance training fields to effectively bridge the gap for those looking to prevent and/or treat shoulder pain.  In the process, I learned a lot from Mike, and I think that together, we brought rehabilitation specialists and fitness professionals closer to being on the same page.

Why President Obama Throws Like a Girl - A lot of people took this as a political commentary, but to be honest, it was really just me talking about the concept of retroversion as it applies to a throwing shoulder - with a little humor thrown in, of course!

Overbearing Dads and Kids Who Throw Cheddar - This one was remarkably easy to write because I've received a lot of emails from overbearing Dads asking about increasing throwing velocity in their kids.

What I Learned in 2009 - I wrote this article for T-Nation back at the beginning of the year, and always enjoy these yearly pieces.  In fact, I'm working on my 2010 one for them now!

What a Stressed Out Bride Can Teach You About Training Success - I wrote this less than a month out from my wedding, so you could say that I had a good frame of reference.

Baseball Showcases: A Great Way to Waste Money and Get Injured - In case the title didn't tip you off, I'm not much of a fan of baseball showcases.

Cueing: Just One Piece of Semi-Private Training Success - Part 1 and Part 2 - These articles were featured at fitbusinessinsider.com.  I enjoy writing about not only the training side of things, but some of the things we've done well to build up our business.

Three Years of Cressey Performance: The Right Reasons and the Right Way - This might have been the top post of the year, in my eyes. My job is very cool.

How to Attack Continuing Education in the Fitness Industry - Here's another fitness business post.

Want to Be a Personal Trainer or Strength Coach?  Start Here. - And another!

The Skinny on Strasburg's Injury - I hate to make blog content out of someone else's misfortune, but it was a good opportunity to make some points that I think are very valid to the discussion of not only Stephen Strasburg's elbow injury, but a lot of the pitching injuries we see in youth baseball.

Surely, there are many more to list, but I don't want this to run too long!  Have a safe and happy new year, and keep an eye out for the first content of 2011, which is coming very soon!

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Weight Training For Baseball: Best Videos of 2010

I made an effort to get more videos up on the site this year, as I know a lot of folks are visual learners and/or just enjoy being able to listen to a blog, as opposed to reading it.  Here are some highlights from the past year: The Absolute Speed to Absolute Strength Continuum - Regardless of your sport, there are valuable take-home messages.  I just used throwing velocity in baseball pitchers as an example, as it's my frame of reference.

Should Pitchers Overhead Press? - This was an excerpt from Mike Reinold and my Optimal Shoulder Performance seminar (which became a popular DVD set for the year).

Shoulder Impingement vs. Rotator Cuff Tears - Speaking of Mike, here's a bit from the man himself from that seminar DVD set.

Thoracic and Glenohumeral Joint Mobility Drills - The folks at Men's Health tracked me down in the lobby at Perform Better in Providence and asked if I could take them through a few shoulder mobility drills we commonly use - and this was the result.

Cressey West - This kicks off the funny videos from the past year. A few pro baseball players that I program for in a distance-based format created this spoof video as a way of saying thank you.

Tank Nap - My puppy taking a nap in a provocative position.  What's more cute?

Matt Blake Draft Tracker - CP's resident court jester and pitching instructor airs his frustrations on draft day.

1RM Cable Horizontal Abduction - More from the man, the myth, the legend.

You can find a lot more videos on my YouTube page HERE and the Cressey Performance YouTube page HERE.

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Weight Training for Baseball: Featured Articles

I really enjoy writing multi-part features here at EricCressey.com because it really affords me more time to dig deep into a topic of interest to both my readers and me.  In many ways, it's like writing a book.  Here were three noteworthy features I published in 2010: Understanding Elbow Pain - Whether you were a baseball pitcher trying to prevent a Tommy John surgery or recreational weightlifter with "tennis elbow," this series had something for you. Part 1: Functional Anatomy Part 2: Pathology Part 3: Throwing Injuries Part 4: Protecting Pitchers Part 5: The Truth About Tennis Elbow Part 6: Elbow Pain in Lifters

Strategies for Correcting Bad Posture - This series was published more recently, and was extremely well received.  It's a combination of both quick programming tips and long-term modifications you can use to eliminate poor posture. Strategies for Correcting Bad Posture: Part 1 Strategies for Correcting Bad Posture: Part 2 Strategies for Correcting Bad Posture: Part 3 Strategies for Correcting Bad Posture: Part 4

A New Paradigm for Performance Testing - This two-part feature was actually an interview with Bioletic founder, Dr. Rick Cohen.  In it, we discuss the importance of testing athletes for deficiencies and strategically correcting them.  We've begun to use Bioletics more and more with our athletes, and I highly recommend their thorough and forward thinking services. A New Paradigm for Performance Testing: Part 1 A New Paradigm for Performance Testing: Part 2 I already have a few series planned for 2011, so keep an eye out for them!  In the meantime, we have two more "Best of 2010" features in store before Friday at midnight. Sign-up Today for our FREE Newsletter:
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Cressey Performance Athletes Excel, Reporters Write About It, Villagers Rejoice

I don't know if there is something in the water that the reporters around the country (and particularly the Massachusetts sports scene) have been drinking, but Cressey Performance's Elite Baseball Development Program has gotten a lot of love in the news this weekend. Last week, CP athlete Tim Collins was part of a blockbuster trade, as he went from the Toronto Blue Jays to the Atlanta Braves.  Tim didn't disappoint in his debut, striking out five batters in two innings pitched without allowing a walk, hit, or run.  In a recent posting about Collins in the Atlanta-Journal Constitution, beat writer David O'Brien wrote the following: "I asked [Braves Manager] Bobby Cox if he knew anything about him, and Cox started talking about seeing video of him. Said he's extremely athletic, a muscular little guy who's real aggressive. Apparently the video showed him pitching and also working out, because he made quite an impression on Cox and others with the workout portion." Apparently, Bobby Cox is quite a fan of the EricCressey.com and Cressey Performance YouTube pages.  Hello, Bobby!

The AJC followed it up with a feature on Tim where my business partner, Pete Dupuis, was interviewed: Pitcher in Escobar Trade is 5-7 Fireballer.

Saturday night, CP athlete Kevin Youkilis had the game-tying and game winning RBIs for the Red Sox in a come-from-behind win at home against the Rangers. These features were followed shortly by another one - this time on a talented pitching prospect from Worcester, MA, Louisville pitcher Keith Landers.  The Worcester Telegram just did this feature on Keith and the training he started up about eight weeks ago at Cressey Performance as he works his way back from a shoulder surgery.

Landers Rehabbing Repaired Shoulder

landers

(yes, Keith is really almost as tall as I am, even though he's kneeling)

And, last, but certainly not least, the Daily New Tribue published this feature on CP athlete Travis Dean, who was drafted in the 14th round by the New York Yankees this year: Newton's Travis Dean Weighs Options as Yankees' Pitching Draftee.

Finally, here's a blog post from ESPN.com's Brendan Hall that features a boatload of CP studs who have had great summer showings: Tyler Beede, Adam Ravenelle, Carl Anderson, Barrett O'Neill, John Gorman, Jordan Cote, Ben Smith, Matt Luppi, AJ Zarozny, and David St. Lawrence.

Click here for more information on Cressey Performance's Elite Baseball Development Program.

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Great Feedback on Optimal Shoulder Performance

We just received this great feedback on Optimal Shoulder Performance: "I just recently finished the Optimal Shoulder Performance DVD's.  Without a doubt, that was the best $100 I've spent on a home based CEU opportunity. The material was very well presented, the talks cut to the chase, and provided tons of practical ideas that I have already put into practice with my baseball and softball players. "In addition to the downloadable PowerPoint slides PDF, I took tons of notes because both of you offered up such great information. "I would highly recommend this to anyone who wants a quality shoulder DVD to add to their professional library. "Thanks, guys, for a very high quality practical product!" -Kevin Collins, MS, ATC

Click here to pick up your own copy of Optimal Shoulder Performance!

shoulder-performance-dvdcover

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Cressey/Reinold Week at RobertsonTrainingSystems.com

Just thought you all might be interested in checking out a five-part feature Mike Robertson ran with material from Mike Reinold and I.  Here's what it included: In the Trenches Podcast with Eric Cressey and Mike Reinold The podcast that started it all!  Here we discuss how Eric and Mike got into the field, how they evaluate shoulders, and a bunch of baseball training.  You'll definitely like this one! Eric Cressey Q&A #1 - Shoulder Forces in Boxing Here, I describes the forces you're going to see during a typical punch in boxing, as well as what biomechanical factors might predispose boxers to injury. Eric Cressey Q&A #2 - Sternoclavicular Joint Dysfunction In this post, I talk about the potential causes of sternoclavicular joint issues and how to handle them. Mike Reinold Q&A #1 - Scalene Anatomy Mike discusses the scalenes, their impact on the shoulder, and why asymmetry may not be bad for baseball players. Mike Reinold Q&A #2 - Joint Capsule Surgical Techniques Mike discusses two different surgical techniques for correcting issues with the shoulder capsule, as well as what to expect post-surgery.
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Optimal Shoulder Performance Now Available!

I'm thrilled to announce that Mike Reinold and my new project, Optimal Shoulder Performance: From Rehabilitation to High Performance, is now available.  This four DVD set blends the world of rehabilitation and strength and conditioning like no other product on the market.  For more information on the product and to order, check out www.ShoulderPerformance.com. The introductory price will not last long, so don't delay!

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Optimal Shoulder Performance: From Rehabilitation to High Performance

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Lifting after Shoulder Surgery

Q: I've found your articles on T-Nation very informative, and enjoy the format you use to convey your message (with humor!). My specific interest is in the information you provide about your shoulder problems, as you've noticed in the subject line I recently had my shoulder scoped in February to repair a labral tear. I did the required PT, and then when that was finished they pretty much sent me out on my own and said only do internal and external rotations for delts/rotator cuff. Overhead pressing and upright rows will supposedly cause problems according to the therapist (but I question this). I've read in your articles that the shoulders get plenty of work from chest and back/lat exercises, and that external rotation variations may be adequate, with occasional presses and laterals. Can I do dumbbbell presses with palms facing in to reduce shoulder pain, as well as laterals for the middle/posterior heads without causing problems? I seem to be progressing fairly well with higher rep sets on my upper body, but want to make sure I do the correct things to set myself up for a lifetime of healthy lifting and stable shoulders. A: If I am you, and I have a shoulder surgery, I can the overhead pressing for good. And, I think upright rows are quite possibly the single worst exercise for shoulder health. I wrote about this HERE - but the short version is that you don't want to go through abduction (especially above 90 degrees) with the humeral head maximally internally rotated. Dumbbell bench pressing (not overhead pressing) is fine - and the lateral raises should be okay as long as you stay in the scapular plane. Check out my Shoulder Savers series at T-Nation for details on that front. And, above all else, you need to buy the Inside-Out DVD. It sounds like you are getting way too "rotator cuff-focused" and are ignoring a bunch of other factors that are incredibly important for shoulder health; these include thoracic spine range-of-motion and scapular stability (among other things). Shoulder health is about more than just getting stronger "all over;" it's about optimizing range-of-motion and muscular balance. It would definitely be a good investment - and much cheaper than another shoulder surgery!
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Active vs Passive Restraints

I’m of the belief that all stress on our systems is shared by the active restraints and passive restraints. Active restraints include muscles and tendons – the dynamic models of our bodies. Passive restraints include labrums, menisci, ligaments, and bone; some of them can get a bit stronger (particularly bone), but on the whole, they aren’t as dynamic as muscles and tendons. Now, if the stress is shared between active and passive restraints, wouldn’t it make sense that strong active restraints with good tissue quality and length would protect ligaments, menisci, and labrums (and do so through a full ROM)? The conventional medical model – whether it’s because of watered-down physical therapy due to stingy insurance companies or just a desire to do more surgeries – fixes the passive restraints first. In some cases, this is good. For instance, if you have an acromioclavicular joint separation with serious ligament laxity, you’ll likely need surgery to tighten those ligaments up, as the AC joint is an articulation without much help from active restraints. In other cases, it does a disservice to the dynamic ability of the body to protect itself with adaptation. Consider the lateral release surgery at the knee, where surgeons cut the lateral retinaculum on the outside of the knee, allowing the patella to track more medially. I’ve seen a lot of people avoid the surgeries (and, in turn, the numerous possible complications) with even just 2-3 weeks of very good physical therapy focusing on the active restraints. I’m not saying all these surgeries are contraindicated – just that we need to exhaust other options first. So, the next time you’ve got an ache or pain, consider whether it’s an active or passive restraint giving you problems – and if it’s the latter, work backward to find out which active restraint you need to bring up to par.
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