Brian Schiff’s Blog

Lately, I have been working with an elite swimmer hoping to make it to the 2012 Olympics in London.  It has been blast training her since she is so fit, driven and willing to embrace training with a smile each session.  I mean seriously, how many 16 year olds do you know that swim 5 hours per day, go to school, and train with someone like me 3x/week?

While I utilize many common exercises in her program, I definitely pepper in several ones aimed at maximizing core and shoulder strength/stability.  One of the exercises I use from time to time with her is a shoulder glide exercise.  I thought I would share this little gem today.

This is NOT an exercise I recommend for people with shoulder impingement, recurrent instability, poor shoulder mobility or those lacking a high level of fitness to begin with.  In other words, this is no sissy exercise and it can be dangerous if used improperly.

To start with, I had my swimmer do it with both hands.  Once she demonstrated the right form with ease, we progressed to this version in the video below:

So, if you are looking for a great way to challenge and improve shoulder and core strength, this is one to add to your arsenal.  Be wary of gliding out too fast as this is a sign your upper body and/or core is not strong enough to decelerate the motion effectively.  The pull back motion is a great way to strengthen the lats and swimming muscles as well, all the while exposing and resolving any single sided deficiencies.

Since publishing my rotator cuff manual over 4 years ago, I have received emails from all over the world with shoulder related lifting questions.  Invariably, I discover that many shoulder injuries are simply caused by repetitive micro-trauma in the weight room.

What does this mean?  In effect, it is like taking sand paper and rubbing it over your rotator cuff day in and day out for weeks, months and years until you either create tendinitis or wear a small hole in it.  Exercises that often get people in trouble are bench press, dips, flies, lateral dumbbell raises, and military press to name a few.  I show modifications for all these in my book.

In my shoulder rehab programs, I have always advocated front lat pull downs.  Why?  Simply because I can strengthen the posterior chain muscles, improve posture and activate scapular stabilizer muscles while encouraging retraction and downward rotation of the shoulder blade.  These are necessary things to balance the shoulder.

Some experts and customers question this technique from time to time because they disagree with taking the arm above shoulder height during periods of inflammation.  I say this  varies from person to person.  I have worked with over 10,000 people and can tell you there is never one certainty among symptoms and response to exercise.  With that said, I do not want people to exercise through pain.

To that end, I offer a modified version of the pat pull down to accomplish a similar movement.  The straight arm lat pull will effectively target the same things when done properly.  I have included  a video below showing the technique with a traditional straight bar on a pulley as well as with resistance tubing.

The key points to remember are these:

1. Begin at or below shoulder height
2. Keep the knees slightly bent at all times
3. Maintain a tight core (contract abdominals throughout)
4. Keep the elbows straight at all times
5. Focus on pulling the shoulder blades closer together on the pulling motion
6. Return to the start position under control to avoid momentum taking over
7. Breathe out on the way down and in on the way up

I have found this to be an excellent alternative for those unable to continue with traditional lat pull downs during the course of a shoulder injury or rehab.  It is 100% safe.  The only precaution would be not going forcefully past the hips with the tubing pulls for those with anterior shoulder instability or a known labral tear.  This is not an issue with the cable pull as the bar stops prior to this point.

Over the past few weeks I have had numerous questions and comments on the blog about SLAP tears.  So, I thought I would add another post with more in depth information on classification of tears, typical treatment and outcomes.  This is a relatively common injury that many know so little about.  To see a diagram, click here.

Different types of SLAP tears

1. Type I – Fraying of the edge fo the superior labrum
2. Type II – detachment of the biceps anchor from the glenoid labrum (most common)
3. Type III – Bucket handle tear of the superior labrum with otherwise normal biceps anchor
4. Type IV – Bucket handle tear of the superior labrum extending into biceps tendon causing detachment of the biceps anchor

Other surgeons have expanded on these classifications as well, but i will not go into that depth here.  You should know that some sub classify type II tears into anterior, posterior and combined anterior and posterior lesions.  In effect a SLAP tear can cause a microinstability thereby leading to articular sided rotator cuff tears.  In plain terms, a posterior labral tear could create a posterior partial thickness rotator cuff tear and an anterior labral tear could create an anterior cuff tear.

The shoulder exam itself often reveals pain with passive external rotation at 90 degrees of abduction (picture the cocking phase of throwing here).  Weakness and instability may also be present depending on the type of tear and if there is already a cuff injury present as well.  There are a number of diagnostic clinical tests done including the O’Brien test, Speed’s test, crank test and biceps load test to name a few.  Many have been successful at confirming labral pathology.  In the end, the MRI is the gold standard in confirming an injury.

Non-operative treatment is often unsuccessful in most cases.  Patients with Type I tears may do better than most (JOSPT February 2009).  Therapeutically, we often see GIRD.   GIRD stands for glenohumeral internal rotation deficit, meaning the affected shoulder has significant posterior capsule tightness and decreased internal rotation (common among overhead athletes and throwers).  Restoring this motion may prevent injury that often occurs between the supraspinatus tendon and the posterior superior labrum.  Research is unclear if GIRD increases risk for a labral tear.

In addition to this stretching the posterior capsule, it is critical to strengthen the scapular muscles and rotator cuff to restore optimal mechanics and motion between the humerus and scapula.  Due to poor posture, flexibility issues and muscular imbalances, the average person may have an altered scapulo-humeral rhythm.  If non-operative treatment fails, one typically opts for surgery.

Arthroscopic surgery is the standard procedure today with debridement of the labrum and reattachment via sutures.   In many cases, surgeons debride rotator cuff tears with less than 50% torn, while opting for primary repair if greater than a 50% tear.  According to a leading surgeon, David Altchek, he will excise a longitudinal biceps tear that is less than 1/3 of the diameter of the tendon, while optiong to repair one that is greater in size back to the major portion of the tendon.

Common rehab timetable 

• Max protection for 0-3 weeks in sling with limited external rotation and overhead activity
• No biceps strengthening for 2 months
• Focus on motion restoration in weeks 3-8
• More aggressive strengthening begins at week 8
• Return to throwing begins at month 4 in most cases

These are some rough guidelines and progressions vary based on each case and the type of tear and associated damage as well as desired activity level.  About 90% of patients experience good to excellent results with Type II repairs in the short to mid term follow-up, but there is not extensive long term data out there.  It should also be noted that throwers and overhead athletes tend to exhibit lower satisfaction with repsect to return to pre-injury levels after surgery.  Recent studies also seem to indicate throwers with an overuse related injury do not do as well as those with a specific traumatic injury resulting in a type II tear.

I hope this post is helpful for those suffering from labral tears or who suspect they may have one.  It is an intricate injury but quite disabling to function with long term implications for the health and function of the shoulder.

Ever have a persistent ache in the shoulder with certain exercises in the gym?  I am talking about a nagging pain along the top or end of the shoulder with bench press, flies, dips, military press or even pull-ups?

Well, one of my staff members has just this type of pain.  He first asked me to look at his shoulder about 6 weeks ago.  I felt there was nothing substantially wrong with the rotator cuff or labrum and recommended he work on rotator cuff and scapular strengthening while backing off the heavy strength training (he is a natural body builder preparing for a show).

He told me about 2 weeks ago that it was still not better.  He complained of more site specific pain along the AC joint.  There was no obvious subluxation present but he was tender right along the end of the clavicle.  I suggested he see a shoulder specialist I know.

The AC joint below (joined by ligaments not visible on x-ray)

His MRI results revealed a micro fracture of the distal clavicle.  Doc says he can continue to train but needs to back off the weight on bench press and avoid pull-ups.  I also suggested he skip dips and he has been now for some time.  So, what caused it?  Good question as he only recalled pain when doing flies during a workout a few months back. 

Could this have caused it?  Maybe.  Pulling the arm across or toward the mid line of the body brings the clavicle into close approximation with the acromion of the shoulder.  There may have been a loading moment (especially with heavy dumbbells) where he strained the joint.  Or, perhaps it was the result of repetitive micro-trauma as the result of lots of heavy chest work.

Regardless, the take away points here are:

• Repetitive upper body lifts (especially those requiring lots of clavicle spinning, elevation and rotation like pressing, dips, pull-ups, and upright rows) may cause stress to the AC joint. 
• Flies do cause approximation and in people with any AC joint arthritis mild compression of the AC joint as the arm comes toward mid line
• Chest movements are likely to affect pain as the pecs attach directly to the clavicle
• Obscure chronic shoulder pain may be related to AC joint irritation that does not show up on an X-ray
• Shoulder pain with lifting may be related to AC joint pain rather than rotator cuff dysfunction in some cases

As a general rule, I caution all my clients over the age of 35 to go easy on the dips for sure as I find this one exercise more than any other tends to flare up an arthritic AC joint fast.  That is the double edged sword of strength training – repetition is necessary to get results but the repetitive nature is capable of taking good exercises and wreaking havoc on the body long term.  Form matters as does avoiding harmful range of motion with lifting.

In the end, let your shoulder guide your decision making in the gym.  In my staff member’s case, he will be fine and recover 100%, although he will likely have to modify his lifting and endure some pain as he pushes on toward his competition.