Share   Subscribe to RSS feed

Brian Schiff’s Blog

Injury Prevention, Sports Rehab & Performance Training Expert

Tag: shoulder rehab

For those familiar with my blog, you know I like to post research updates and exercises that prevent injury and maximize performance.  In my setting, I get to work with a very active population ranging in ages from 10-50 in most cases, including elite and professional athletes.  I am pointing this out simply because I have an opportunity to test and measure unique and challenging exercises every day with fit, athletic clients.

As part of my world, I am often faced with restoring shoulder, core and hip stability.  As clients progress through rehab and conditioning, I am always seeking advanced training options that are feasible and functional.  One training tool I like to employ, especially in upper body, core and hip training is the BOSU Balance Trainer.

Emphasizing co-contraction and scapulothoracic and glenohumeral stability is essential for optimal shoulder function.  But more importantly, addressing kinetic chain function in the shoulder, torso and hips is a must if we are to soundly address energy leaks and reduce injury risk.  To that end, I like to incorporate unstable closed kinetic chain training when my athletes are ready.  The video below demonstrates two upper body step-up progressions (forward and side-to-side) on the BOSU Balance Trainer that I utilize for higher level clientele.

Upper Body Step-ups

Regression – in place stepping (this can be used to prepare clients for the step-ups)

This regression can also be a very effective training tool especially if the client lacks sufficient strength, endurance and form to execute the full step-up patterns.  Pain and form should always guide exercise selection and progression.

Below are two links to my Functionally Fit columns describing the execution and application of these exercises:

Unstable Upper Body Step-ups (forward)

Unstable Upper Body Step-ups (lateral)

It is no secret that proper scapula alignment and muscle activation makes for a healthy shoulder.  There are many forms of dysfunction that may be present.

f1large

Generally speaking problems revolve around muscular tightness/weakness and faulty movement patterns.  The term “SICK” scapula is often used and refers to Scapula Inferior Coracoid Dyskinesis.  Common examples of a “sick”  scapula include:

  • Type I – Inferior border prominence.  This is typically related to tightness in the pec minor and weakness in the lower trapezius.  Keep in mind the upper trapezius will naturally dominate the lower trap in the force couple with the serratus anterior for upward rotation.  You may also see increased thoracic kyphosis which will inhibit the normal resting position of the scapula.
  • Type II – Medial border prominence.  In this case the scapula is internally rotated or protracted and there is liekly weakness present in the rhomboids and middle trapezius.  The serratus anterior may also likely be weak with evidence of scapular winging.  This position places the humerus in relative internal rotation and increases risk of impingement with arm elevation.
  • Type III – Superior border presence.  Here the scapula appears elevated in the face of an overactive upper trap and/or levator scapulae.  With active arm elevation, you may notice excessive shrugging or superior humeral head migration in light of the imbalance.  Again, the lower trapezius is probably weak and being overpowered.

Click here for a great graphic display from the Journal of the American Academy of Orthopaedic Surgeons of how the scapular muscles work collectively as a force couple to promote optimal movement in the shoulder.

In many of the throwers and overhead athletes I see in the clinic, they often exhibit either medial border prominence of inferior border prominence.   Additionally, I frequently observe GIRD (glenohumeral internal rotation deficit) values of 20 degrees or higher in those patients who come in with symptomatic shoulders (rotator cuff and/or labral issues).  What does this mean?

Well, in a nutshell, it means addressing posterior capsule tightness in the throwing shoulder is important for avoiding internal impingement and SLAP tears.  Tightness (or too much GIRD) can increase the load/tension in the late cocking phase of throwing thereby contributing to friction between the cuff and labrum, as well as excessive torsion on the proximal biceps tendon.  Any excessive humeral head migration with repetitive throwing is a recipe for injury over time.


Continue reading…

Research along with years of observation has taught me that the brain is inherently looking for the most efficient way (aka least effort) to execute movement in life.  In addition, it HATES pain just like you and I so it does everything possible to avoid it including ordering the body to perform dysfunctional movement patterns.

After a painful episode, the brain often needs reminded that the body can go back to the proper movement patterns once the pain is gone.  However, it often holds that painful memory and may by default lean toward a faulty movement pattern.  This protective mode then ends up perpetuating a faulty movement pattern that is no longer necessary nor efficient.  Over time, dysfunctional movement patterns can create further stress or harm to other segments in the kinetic chain.

So, I am always seeking ways to stimulate the body to work properly and exercises that facilitate proper neuromuscular patterning are instrumental in my rehab and training.  I wanted to share two exercises that I like to utilize in my rehab and training for the shoulder.  In particular, I like to employ closed chain activity to stimulate the serratus anterior as well as the other scapular stabilizers.

Below are two exercises I wrote about in my “Functionally Fit” column for PFP magazine.  The first exercise shows quadruped rocking.  Shirley Sahrmann mentions this in her work, Diagnosis and Treatment of Movement Impairment Syndromes.  I began using it after reading her book, and I agree that it works very well for scapular dysfunction.  Below is the start and finish position for the quadruped version as well as my own advanced tripod version of the exercise.

For a complete explanation of the exercise and its application, click here to read the column.

As a follow-up to this exercise, I included an unstable progression I like to employ using the BOSU trainer.  I call this the unstable tripod scapular clock.  It can be done on the knees or up on the toes.  I have included a quick video on this below. Again, I like this exercise for scapular work as well as core stability training.

Click here to read my PFP column on this exercise for the full description, application and regressions. The real beauty of this last exercise is the “big bang for your buck” attributes since it hits shoulder, core and hip stability all at once for those able to work at that level.  I hope it works as well for you as it has for me!

Shoulder impingement and scapular dysfunction are common issues that plague many clients.  Research indicates that certain muscles tend to dominate others while other muscles fatigue easily leading to faulty movement patterns and increasing the risk for impingement.  Muscle length and posture are also key factors to consider.

I like to use a mini-band retraction with clients exhibiting excessive scapular abduction.  In the video below, you will see a simple, yet effective exercise to address this faulty alignment of the scapula.  Keep in mind, you must observe the client or patient from behind with the scapula exposed to properly assess alignment and movement.

This exercise is designed to strengthen the middle trapezius and rhomboids.  In addition, it will improve scapular stability. Scapular abduction is usually more evident with elevation from 90-180 degrees as the ratio of scapular movement to glenohumeral movement is 1:1 instead of the normal 1:2 ratio throughout since the scapula is already in an excessively abducted posture at rest.

To read more on the application and exact execution of this exercise, click here to read my column for PFP Magazine.

I have been attending the 26th Annual Cincinnati Sports Medicine Advances on the Shoulder and Knee conference in Hilton Head, SC.  This is my first time here and the course has not disappointed.  I have always known that Dr. Frank Noyes is a very skilled surgeon and has a great group in Cincinnati as I am originally an Ohio guy too.

So, I thought I would just share a few little nuggets that I have taken away from the first three days of the course so far.  I am not going into great depth, but suffice it to say these pearls shed some light on some controversial and difficult problems we see in sports medicine.

Shoulder Tidbits

  1. Fixing SLAP tears may not always fix shoulder pain as in many cases it may be in part due to posterior capsule tightness and anterior instability leading to internal impingement.  Additionally, many of the docs here choose not to repair type 2 tears in those over 40 tears and provide a biceps tenotomy or tenodesis to instead to deliver more predictable pain relief as opposed to a labral repair.
  2. Intraoperative pain pumps in the shoulder are causing glenohumeral joint chondrolysis in the shoulder in many cases. According to the panel of docs, this has been seen in teenagers and patients in their twenties as well.  They have often undergone other procedures from outside docs and then developed increasing pain afterward.  Many have had to even undergo a total shoulder replacement after a few years post-op.  The MDs here have suggested even post-operative Marcaine injections for pain relief in the shoulder should probably not be used.  It was very sad to see an 18 y/o shoulder x-ray they put up that looked as if the patient was 80 years old.
  3. Double row rotator cuff tendon repairs seem to outperform single row repairs with respect to tendon healing (90% for DR and 76% for SR techniques in a comprehensive review of the literature)
  4. Stretching cross body horizontal adduction may be more important for throwers and overhead athletes than the sleeper stretch – best to have a therapist stabilize the scapula and then move the shoulder across the body keeping the shoulder in neutral rotation (it will tend to externally rotate)
  5. Arthroscopic stabilization is better than open surgery for posterior shoulder instability as the posterior cuff and deltoid are not violated, ROM recovery is more predictable, patient satisfaction is higher and there is a more predictable return to sport

Knee Tidbits

  1. Increased femoral anteversion and torsion is a developmental factor that does in fact control the knee to a great extent. The tibial tubercle-sulcus angle, thigh-foot angle and foot alignment is also key according to Dr. Lonnie Paulos.  In cases of miserable patella mal-alignment, many will need de-rotation and re-alignment procedures to improve their symptoms.
  2. The consensus among the orthopods here was that using a bone-tendon-bone patella tendon autograft to reconstruct torn ACLs in the younger more active athletes (soccer players and football players) is preferable to a hamstring graft or allograft.  Allografts did not seem to be the graft of choice by any of the docs for the younger patients.  Some would use a hamstring autograft provided there was no MCL pathology.  The PTG autograft was the gold standard for years (always my favorite graft choice for high level/demand athletes) so I was pleased to see the trend for this population moving away from the ST/gracilis HS grafts.
  3. Kevin Wilk, DPT (primary PT for Dr. James Andrews), was advocating restoring full and symmetrical ROM after ACL surgery.  I tend to agree with this principle myself.  However, Dr. Noyes was not in agreement and rather cautiously noted he would be okay with about 3 degrees of hyperextension on the repaired side no matter how much hyperextension was available on the other side.  Kevin also noted that restoring full flexion was paramount to restoring running mechanics and speed in higher level athletes.
  4. The golden time to repair a MCL tear is in the first 7-10 days.  Dr. Paulos also suggested it is absolutely necessary to fix the deep layer as well as the superficial layer.  His talk emphasized how big of a mistake it is to not repair the deep layer.  He also warns that the strength of the repair is less important than restoring proper length, tension and collagen.
  5. For PCL augmented repairs, a 2 bundle repair is repaired.  Most of the docs like to use a quad tendon autograft from the contralateral thigh, but will take it from the same leg if patients insist.  The consensus seemed to be that a repair should be done if there is 10 millimeters or more of drop off.

These are just some of the highlights I wanted to pass along.  There was lots of other good stuff (much of it a nice review of anatomy, biomechanics and protocol guidelines for rehab) but I wanted to pass along some of these key items while they were fresh in my head.  I will likely be sharing more in the future, particularly with respect to patello-femoral pain and SLAP tears as these are just so controversial in terms of surgical and rehab management.