Brian Schiff’s Blog

It is that time of year where baseball pre-season throwing is ramping up. I am starting to see throwers coming in to my clinic with shoulder and elbow issues. In many cases, injury can be avoided with proper stretching and strengthening as well as effective loading programs.

Pectoralis major/minor and latissimus muscle tightness along with poor scapular control often leads to postural dysfunction and shoulder problems. Improving shoulder mobility and scapular control can reduce injury risk and shoulder strain.

The video below from one of my Functional Fit columns will demonstrate an excellent exercise that can be programmed for every thrower to aid in optimizing shoulder mobility and promoting shoulder health.

I often use this exercise following soft tissue release techniques and in conjunction with thoracic spine extension mobilization on the roller. It is an excellent warm-up and activation exercise.

Click here to read the entire Functionally Fit column.

Whether you are lay person, trainer or therapist reading this blog, I try to keep you up to date on science, training and my interpretation/application of exercise based upon the research and practical application in my practice.

Today, I want to touch on an article just published in the Journal of American Sports Medicine.  It was based on a  study conducted by Tim Tyler et al in New York.  They set out to determine what effect decreasing GIRD (aka glenohumeral internal rotation deficit) and posterior shoulder tightness had on reducing symptoms associated with internal shoulder impingement.

For those unfamiliar with GIRD, it basically looks at total shoulder motion side to side but focuses on deficits in internal rotation.  Throwers often lack internal rotation on their dominant arms and exhibit excessive external range of motion for cocking and ball velocity.  We tend to call this acquired laxity.  Pitchers tend to have higher GIRD as well.  Keep in mind total shoulder motion is critical as well.  So, you cannot assume one will have problems just becasue there is decreased internal rotation.

You may see similar GIRD and psterior shoulder tightness patterns in other overhead athletes (swimmers, tennis players, volleyball players, etc.)  This particular study looked at the effect on 11 men and 11 women who received manual mobilization by a PT combined with ER ROM, posterior shoulder stretches and scapular strengthening.

They studied all 22 subjects (range of symptoms from 1 to 24 months) and then compared data on the patients with and without symptom resolution.  In effect the study revealed that posterior shoulder tightness was significantly improved in 12 of the subjects that had complete resolution of symptoms (more so than in the 10 who did not).  In addition, changes in GIRD did not seek to impact the results.

What is the take away from this study?  In a nutshell, if you have symptoms related to internal impingement, you should be doing posterior shoulder stretches.  So, what are the best ones to do?  There was a recent article in the NSCA Strength and Conditioning Journal (December 2009) that laid out some effective stretches (two of which I will show you in the video).  Also, you should note that this pattern of tightness is common in weight lifters.

I have included a short video clip with 3 effective stretches that easily can be done at home.  The stretches are as follows:

1. Standing cross chest shoulder pull (across the chest) – this is a basic stretch I start most clients with who are experiencing pain.  The drawback is that the scapula is not stabilized (or fixed) so you do not isolate the posterior shoulder effectively.  However, it tends to be more comfortable for many early on and you will still get some benefit.  When you are ready, it can be done against a wall to fix the scapula.
2. Side lying cross chest shoulder pull – this would be equivalent to doing stretch number 1 against a wall.  The floor acts to stabilize the scapula and then you pull the arm up and hold.
3. The sleeper stretch – go easy with this one as pushing too hard may actually increase inflammation in my experience.  You may also vary the angle of the upper arm to hit different portions of the joint capsule.  For example, you may elect to stretch at 90, 70 and 45 degrees.

I advocate holding each stretch for 20-30 seconds and repeating 2-3 times daily.  If you are in therapy, the stretching should be done following the joint mobilization by your therapist.   Click the video below to see the stretches.

If you have ever experienced shoulder pain (whether sudden or chronic) you have probably heard people or docs throw out the terms tendinitis, bursitis, or partial and full thickness tears.  In this post, I will attempt to summarize these and delineate as best I can between the symptoms you may experience.

Bursitis – inflammation of the subdeltoid bursa (fluid filled sac) beneath the deltoid.  Bursae are in place to cushion the soft tissue and prevent rubbing or friction.  They lie between tendon and bone or between the tendon and skin.  In the shoulder, signs of bursitis include:

• Pain and tenderness along the upper arm with radiating pain down the to the elbow in many cases
• Pain lying on the affected shoulder (esp. at night)
• Pain with repetitive motion (especially overhead and behind the back)
• Warmth and swelling along the middle deltoid

Tendinitis – the tendon itself becomes inflamed and swollen (usually the supraspinatus) and may become trapped or start rubbing beneath the acromion (top of the shoulder blade) and then becomes an impingement problem (known as impingement syndrome).  Pain may also be felt along the biceps tendon as it may undergo undue stress and strain in relation to a cuff issue.  It is also important to note that bursistis often accompanies tendinitis.  Typical symptoms include:

• Point tenderness at or near the top of the shoulder or over the biceps tendon as it meets the shoulder
• Pain and joint soreness along the front of the shoulder
• Pain that worsens with elevating the arm above 90 degrees or moving it away from or behind the body
• Pain with lying on the affected shoulder
• Pain tucking in your shirt, fastening a bra or styling your hair

Tear – defined by a disruption in the quality or integrity of the muscle and or tendon.  Tears are typically quantified by the location (articular or bursal side) size (in centimeters) and degree (partial or full thickness).  Not all tears are created equal – that is a fact.

I have seen small tears (less than 1-2 cm) create equisite pain and dysfunction, while large tears (greater than 3 cm) may produce less pain and limitations in daily activities for folks.  Hallmark symptoms of a tear include:

• Pain at night that interrupts sleep
• Persistent dull ache or even throbbing pain that is not affected by rest or positional changes
• Significant weakness or even muscle atrophy (look at the shoulder blade from behind or int he mirror)
• Loss of elevation and arm rotation overhead and behind the back
• A positive shrug sign (see below as excessive upper trap work that compensates to elevate the arm in light of a torn rotator cuff muscle)

Positive Shrug Sign

Some research suggests up to 90% of tears will worsen over time.  Tears do not spontaneously heal.  With that said, many respond well to conservative rehab with an emphasis on restoration of motion, appropriate strengthening and avoidance of abusive activity.

The prescription for healing bursitis and tendinitis is much the same.  However, catching the “itis” early on and using ice, rest and anti-inflammatory medication as prescribed can often cure it in weeks and prevent further damage.  Pain shouldreally guide all activity and exercise progression.  The other forgotten friend is ice – whether acute or chronic I advise daily icing for pain relief.

Want more answers to rotator cuff issues?  Visit my site at www.rotatorcufftraining.com.