Home Posts tagged "Thoracic Outlet Syndrome" (Page 2)

6 Saturday Shoulder Strategies

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 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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Register Now for the 3rd Annual Cressey Sports Performance Fall Seminar!

I’m psyched to announce that on Sunday, September 28, we’ll be hosting our third annual fall seminar at Cressey Sports Performance.  As was the case with our extremely popular fall event over the past two years, this event will showcase both the great staff we're fortunate to have as part of our team.  Also like last year, we want to make this an affordable event for everyone and create a great forum for industry professionals and fitness enthusiasts alike to interact, exchange ideas, and learn.

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Here are the presentation topics:

Thoracic Outlet Syndrome: A "New" Diagnosis for the Same Old Problems - Presented by Eric Cressey

More and more individuals - both athletes and non-athletes alike - are being diagnosed with thoracic outlet syndrome. In this presentation, Eric will explain what it is, how it's treated, and - most importantly - what fitness professionals and rehabilitation specialists can do to prevent it from occurring in the first place.

Making Bad Movement Better – Presented by Tony Gentilcore

Tony will cover the most common technique flaws he sees on a daily basis, outlining both coaching cues and programming strategies one can utilize to improve exercise technique. He'll also cover progressions and regressions, and when to apply them.

Paleo: The Good, The Bad, and The Ugly – Presented by Brian St. Pierre

Paleo: possibly the most hyped nutritional approach to come along since Atkins. This, of course, begs the question: do the results match the hype? Is it right for everybody? Do we really need to avoid dairy, legumes and grains to achieve optimal health? Do all clients need to take their nutrition to this level? In this presentation, Brian explores the pros and the cons, the insights and the fallacies of the Paleo movement. And, he'll discuss the accumulated wisdom from coaching over 30,000 individuals, and what that teaches us about which nutritional camp to which should really "belong."

Trigger Points 101:  – Presented by Chris Howard

In this presentation, massage therapist Chris Howard will discuss what trigger points are, why they develop, where you'll find them, and - of course - how to get rid of them! He'll pay special attention to how certain trigger points commonly line up with certain issues clients face, and how soft tissue work can play an integral in improving movement quality while preventing and elimination symptoms.

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How Bad Do You Want It? – Presented by Greg Robins

In this presentation, Greg will discuss the factors that govern how individuals stick to (or abandon) their training and nutrition goals. He'll introduce real strategies to help people make changes by focusing on the most important variable: themselves.

Finding the Training Potential in Injury – Presented by Andrew Zomberg

Don't let a setback set you or your clients back in the weight room. Injuries happen, but that doesn’t mean that you can’t still achieve a great training effect. Andrew will discuss the most common injuries/conditions individuals encounter, and how the fitness professional can aid in sustaining a training stimulus during the recovery phase. This will include exercise selection tips, coaching cue recommendations, and programming examples.

Location:

Cressey Sports Performance
577 Main St.
Suite 310
Hudson, MA 01749

Cost:

Regular Rate – $149.99
Student Rate (must have student ID at door) – $129.99

Date/Time:

Sunday, September 28, 2014
Registration 8:30AM
Seminar 9AM-5PM

Continuing Education:

0.6 NSCA CEUs pending (six contact hours)

Click Here to Sign-up (Regular)

or

Click Here to Sign-up (Students)

We’re really excited about this event, and would love to have you join us! However, space is limited and each seminar we’ve hosted in the past has sold out quickly, so don’t delay on signing up!

If you have additional questions, please direct them to cspmass@gmail.com. Looking forward to seeing you there!

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Assessments You Might Be Overlooking: Installment 4

I always tell up-and-comers in the strength and conditioning field, "If you aren't assessing, you're just guessing."  It's not as simple as just doing a sit-and-reach test and having someone hop on the scale for you, though. This series is devoted to highlighting some of the most commonly overlooked components of the assessment process - and here are three more evaluations you might be missing:

1. Previous Athletic/Training Workload - If you're trying to help a client get to where they want to be, it's important to realize where they've been.  For example, someone who has a history of overworking themselves might respond really well to a lower volume program.  Or, an athlete looking to gain muscle mass who has never trained with much lifting volume might be well-served to add some "backoff" sets and additional assistance work.

This is an incredibly important discussion with our professional pitchers, too.  Starting pitchers who have a high workload (some in excess of 200 innings pitched in the previous 8-9 months) need to wait longer to start throwing than relief pitchers who may not have thrown more than 40 innings in a season.  The former group might not start an off-season throwing program until January 1, whereas the latter group might already have eight weeks of work in by that point.

600px-Corey_Kluber_on_June_27,_2013

Discussions of building work capacity get a lot of love in the strength and conditioning field, but I think we often lose sight of the fact that sporting coaches are also looking to build work capacity in the context of the athletes' actual sports.  Now, these two things don't have to be mutually exclusive, but if everyone is always pushing high volume all the time, things can go downhill fast.

2. Quad and Adductor Length - Let's face it: a huge chunk of the population doesn't exercise enough, and even most of those who do exercise regularly don't pay attention to mobility needs. As a result, their entire exercise program takes place in a very small amplitude; they never get through significent joint ranges of motion. Two areas in which you see this probably rearing its ugly head the most are quad and adductor length. 

Your quads are maximally lengthened when your heel is on your butt.  How often do you see someone encounter this position in their daily lives?

IMG_8805

Adductors are stretched when the hips are abducted.  When was the last time you hit this pose in your daily activities - outside of a fall on the ice?

NeutralRockBack

If you want to do a quick and easy assessment of where you stand on these, try these two (borrowed from Assess and Correct):

Prone Knee Flexion: you should have at least 120 degrees of active knee flexion without the pelvis or lower back moving.

pronekneeflexion

Supine Abduction: you should have at least 45 degrees of abduction without lumbar or pelvis compensation, or any hip rotation.

supineabduction

I generally just check these up on the training table when people get started up, but these should provide good do-it-yourself options for my readers who aren't fitness professionals.  Also, if you find that you come up short on these tests, get to work on the two stretches pictures at the start of this bulletpoint.

3. Taking the Shirt Off - This is a tricky one, as you obviously can't do it with female clients, and even when male clients, you have to be sensitize to the fact that it might not be something in which they'd like to partake.  That said, you'd be amazed at how many upper extremity dysfunctions can be obscured by a simple t-shirt.  As an example, this left-handed pitcher's medial elbow pain was diagnosed with ulnar neuritis, and he was prescribed anti-inflammatories for it and sent on his way without the doctor even having him take his shirt off to evaluate the shoulder and neck.

lowleftshoulder

Needless to say, he sits in heavy scapular depression on the left side, and it wouldn't be a "stretch" (pun intended) at all to suspect that his ulnar nerve symptoms would be originating further up the chain.  Take note on how the brachial plexus/ulnar nerve runs right under the clavicle as it courses down toward the elbow.

Gray523

Crank the scapula and clavicle down, and you can easily compress the nerve (and vascular structures) to wind up with thoracic outlet syndrome, a very common, but under-diagnosed condition in overhead throwing athletes.  The more forward-thinking upper extremity orthopedic surgeons are diagnosing this more and more frequently nowadays; elbow problems aren't always elbow problems!

The lesson is that you can see a lot when you take a shirt off.  If it's the right fit for your client/athlete, work it in.

I'll be back soon with more commonly overlooked assessments.  In the meantime, I want to give you a quick heads-up that to celebrate National Multiple Sclerosis Awareness week and help the cause, Mike Reinold and I have put both Functional Stability Training of the Core and Lower Body on sale for 25% off through tonight (Saturday) at midnight - with 25% of proceeds going to MS charities. Just use the coupon code msawareness to apply the discount at the following link: www.FunctionalStability.com.

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