Q: I'm a baseball pitcher who was diagnosed with a posterior labral tear. Since I was young and the doctor didn't feel that the tear was too extensive, he recommended physical therapy and not surgery. I'm still training the rest of my body hard, but am finding that I can't back squat because it causes pain in the shoulder. Any idea why and what I can do to work around this?
A: It isn't surprising at all, given the typical SLAP injury mechanism in overhead throwing athletes. If there is posterior cuff tightness (and possibly capsule tightness, depending on who you ask), the humeral head will translate upward in that abducted/externally rotated position. In other words, the extreme cocking position and back squat bar position readily provoke labral problems once they are in place. The apprehension test is often used to check for issues like this, as they are commonly associated with anterior instability. Not surprisingly, it's a test that involves maximal external rotation to provoke pain:
The relocation aspect of the test involves the clinician pushing the humeral head posteriorly to relieve pain. If that relocation relieves pain, the test is positive, and you're dealing with someone who has anterior instability. So, you can see why back squatting can irritate a shoulder with a posterior labrum problem: it may be the associated anterior instability, the labrum itself, or a combination of those two factors (and others!).
On a related note, most pitchers report that when they feel their SLAP lesion occur on a specific pitch, it takes place right as they transition from maximal external rotation to forward acceleration. This is where the peel-back mechanism (via the biceps tendon on the labrum) is most prominent. That's one more knock against back squatting overhead athletes.
If you're interested in reading further, Mike Reinold has some excellent information on SLAP lesions in overhead throwing athletes in two great blog posts:
Top 5 Things You Need to Know about a Superior Labral TearClinical Examination of Superior Labral Tears
The solutions are pretty simple: work with front squats, single-leg work (dumbbells or front squat grip), and deadlift variations. If you have access to specialty bars like the giant cambered bar and/or safety squat bar, feel free to incorporate work with them.
And, alongside that, work in a solid rehabilitation program that focuses not only on the glenohumeral joint, but also scapular stability and thoracic spine mobility.
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In Part I, I went into some detail on why I really didn’t like the catch-all term “shoulder impingement.” This week, I’m going to talk about the different kinds of shoulder impingement: external and internal.
External impingement, also known as outlet impingement, is the one we hear about the most. Here, we’re dealing with compression of the rotator cuff – usually the supraspinatus, and over time, the infraspinatus (and biceps tendon) – by the undersurface of the acromion. This impingement can lead to bursal-sided rotator cuff tears - and happens a lot more with ordinary weekend warriors and very common in lifters (not to mention much more prevalent in older populations.
External impingement can be further subdivided into primary and secondary classifications. In primary impingement, the cause is related to the acromion – either due to bone spurring or congenital shape. As you can see in the photo below, hook (II) and beak (III) are worst than flat (I), as there are marked difference in “clearance” under the acromion.
Secondary impingement, on the other hand, is usually related to poor scapular stability (related to both tightness and weakness, as described in last week’s newsletter), which alters the position of the scapula. In both cases, pain is at the front and/or side of the shoulder and is irritated with overhead activity, scapular protraction, and several other activities (depending on the severity of the tissue problems). You’ll also generally see a lack of external rotation range-of-motion, as these are folks who do too much bench pressing and computer work (both of which shorten the internal rotators).
Conversely, internal impingement, also known as posterosuperior impingement, really wasn’t proposed until the early 1990s. This form of impingement is more common in younger individuals who are involved in overhead sports, making it more of an “athletic impingement.” Adaptive shortening and scarring of the posterior rotator cuff in these athletes causes a loss of internal rotation and an upward translation of the humeral head during the late cocking phase of throwing (or swimming): external rotation and abduction. These issues are magnified by poor scapular control, insufficient thoracic rotation, and weakness of the rotator cuff.
When the humeral head translates superiorly excessively in this position, it impinges on the posterior labrum and glenoid (socket), irritating the rotator cuff and biceps tendon along the way. So, pain usually starts in the back of the shoulder, as you are seeing irritation of the posterior fibers of the supraspinatus and anterior fibers of the infraspinatus tendons. Gradually, this pain may “shift” toward the front as the biceps tendon, and that implies labral involvement. At least initially, the pain is purely mechanical in nature; it won't bother an athlete unless the "apprehension" position (full external rotation at 90 degrees of abduction) is created.
We often hear about SLAP lesions in the news. This refers to a superior labrum, anterior-posterior injury. In reality, when we are talking about labral injuries in overhead athletes as they relate to internal impingement, it’s mostly just posterior (although serious cases can eventually affect the anterior labrum, too). There are different kinds of SLAP lesions (1-4). Every baseball pitcher you’ll meet has a SLAP 1, which is just fraying. SLAP 2 lesions are far more serious and often require surgical intervention. SLAP 1 issues become SLAP 2 lesions when poor mobility and dynamic stability aren't established.
So, just to bring you up to speed, we’ve got two different kinds of impingement, one of which (external) has two subcategories that mandate different treatment strategies (primary = surgery, secondary = corrective exercise). We also have two separate areas where pain presents (external = front/side, internal = back). That’s just the tip of the iceberg, though, as we have two more considerations…
First, symptomatic internal impingement tends to be "mechanical pain." Unless you’re dealing with a more advanced case, athletes with symptomatic internal impingement only have pain when they get into the late cocking phase (and sometimes follow-through). It usually isn’t present when they’re just sitting around – and for this reason, they can usually be more aggressive in the weight room with upper body training. Keep in mind that I use the term “symptomatic” because I think that internal impingement is a physiological norm, just like I observed last week with external impingement. You're essentially just going to go out of your way to avoid this "apprehension" position in the weight room by omitting exercises like back squats. An apprehension test - illustrated in the most enthusiastic video in internet history - is a quick and easy assessment many doctors and rehabilitation specialists use to check for symptomatic internal impingement, as it reproduces the injury mechanism.
Second, and perhaps more importantly, you are dealing with two rotator cuff tears that are fundamentally different. It’s these differences that make me think doctors need to get rid of the term “impingement.” Here’s the scoop:
Let’s say that we have two guys with partial thickness tears of the supraspinatus – one from external impingement and one from internal impingement.
With external impingement, we’re usually dealing with a bursal-sided tear, as the rubbing comes from the top (acromion). These issues will generally heal more quickly because the bursa actually has a decent blood supply.
With internal impingement, on the other hand, we’ve got an articular-sided tear, meaning that the wear on the tendon comes from underneath (glenoid). The tear is more interstitial in nature. Blood supply isn’t quite as good in this area, so healing is slower (or non-existent).
Traditionally, articular has been an athletic injury, and bursal has been a general population issue. This is not always the case, though.
Factor in the activity demands of overhead throwers, and they have more challenging tears and greater functional demands. Fortunately, they also typically have age and tissue quality on their sides, so things tend to even out.
With all these factors in mind, if a doctor ever tells you that you have "shoulder impingement," ask:
1. Internal or external?
2. If external, is it primary or secondary? (It’ll probably be both)
3. If internal, is there labral involvement? Biceps tendon?
4. If internal, what is the internal rotation deficit? (They should measure it, as this will begin to dictate the rehabilitation plan)
5. Given my age, activity level, and the nature of the tear, do you feel that surgical or conservative treatment is best?
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EricCressey.com Subscriber-only Q&A
Q: Could you please explain the rationale for the wall triceps stretch you used in a previous blog post?
A: Here’s a photo of that stretch, for those who missed it:
We find that this stretch can relieve shoulder issue in a lot of the guys who come to us with typical pitcher problems – particularly posterior/superior shoulder pain (and sometimes medial elbow pain – but no glenohumeral internal rotation deficit (GIRD).
Posterior cuff/capsule stiffness will cause the humeral head to translate superiorly and posteriorly during the late cocking phase of throwing. And, this stiffness also has huge implications on humeral head position during the deceleration and follow-through phases of throwing.
Most throwers with shoulder problems will have the most pain at:
a. maximal external rotation/late cocking phase (usually the worst type of problems, SLAP 2 lesions, that warrant a great consideration of surgery)
or
b. follow-through/deceleration (usually something that’s more easily fixed with good posterior cuff/capsule stretching and good scapular stability work, so conservative treatment is the name of the game)
Of course, all this depends on symptoms, degree of mechanical pain, and what the MRI says.
Sometimes, though, if the stiffness isn't present posteriorly, but you're still seeing these kind of symptoms, you have to look to the inferior capsule. The shoulder capsule is large and relatively “loose” to allow for the wide range of shoulder movements present. When tightness kicks in somewhere, you can see some noteworthy problems.
So, the roundabout answer to your question is that the truth is that this is as much an inferior capsular mobilization/stretch as it is a triceps stretch.
As a general rule of thumb, you always migrate opposite capsular tightness. Inferior tightness leads to superior migration. Inferior tightness is the big problem in regular ol' weekend warriors, and definitely moreso in those who have had surgery and been immobilized with the arm at the side
As an aside to this, rarely will someone need JUST inferior capsule mobilizations; they usually need other attention to areas such as
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