Recap: Testing, Treating, and Training the Shoulder
Written on November 18, 2009 at 10:41 am, by Eric Cressey
As many of you know, Mike Reinold and I put on a seminar that was “everything shoulder” this past Sunday at Cressey Performance. The event sold out within 36 hours back when we first announced it in early October, and we had strength and conditioning and rehabilitation specialists come from the likes of Canada, Texas, and the Midwest on only a month’s notice. Our goal was to keep the seminar more intimate to allow for more speaker-attendee interaction, Q&A, and easy viewing – as we also recorded the event on DVD.
While production won’t be complete until December at the earliest, I thought I’d give my loyal readers a little taste of some of what was discussed on Sunday. Our primary goals were to introduce some current concepts in evaluation of both symptomatic and asymptomatic populations as well as ways to treat/train them during and after injury. Above all else, we wanted to show how rehabilitation specialists and strength and conditioning specialists could work hand-in-hand to improve outcomes – but that this successful interaction hinged on whether all parties involved were willing to commit to learning about how the shoulder functions.
You can call this my “Random Thoughts” for the week:
1.The side-lying external rotation (SLER) has the highest EMG of any rotator cuff exercise, and the adducted position is the safest position for most “testy” shoulders. So, if you have to pick one cuff exercise to get you a safety and a great return on investment, roll with the SLER:
2. Simply providing a small amount of “propping” to put the humerus in a slightly more abducted position actually increases EMG of the posterior rotator cuff muscles by 23%.
3. Shoulder evaluations rarely work completely independently of one another. For example, poor thoracic spine mobility directly impacts function of the scapula and, in turn, range of motion at the glenohumeral joint. So, rather than hanging your hat on 1-2 assessments, you need a barrage of assessments that cover glenohumeral range-of-motion, scapular stability/positioning, thoracic spine mobility, breathing patterns, and forward head posture. Then, once you’ve got all your information, you can look at each test as one piece in an individualized puzzle.
4. There are a ton of superior labrum anterior-posterior (SLAP) tests out there. It’s because none of them are particularly great – but the better ones out there simulate the injury mechanism (e.g. pronated load and resisted supnation external rotation tests for overhead throwing athletes).
5. The true function of the cuff is – very simply – to center the humeral head within the glenoid fossa. So, rather than train it purely concentrically and eccentrically, we need to also work its isometric/stabilization function with rhythmic stabilization exercises. Here’s a really entry level one we use quite a bit with our pitchers:
6. MRIs and x-rays can only tell you so much about a shoulder. For instance, 79% of professional baseball pitchers have “abnormal labrum” features. Likewise, a huge chunk of asymptomatic people in the general population are walking around with partial and even FULL thickness tears of the rotator cuff. It actually makes you wonder if abnormal is actually normal! The take-home message is that having adequate mobility, stability, and tissue quality in the torso and upper extremities matters more than anything else. You have to ASSESS, not assume!
7. We talk a lot about glenohumeral internal rotation deficit (GIRD) – and it certainly is important – but you have to appreciate that it’s just one part of the total motion equation. Some internal rotation deficit is completely normal, and working to fix it may actually hurt some athletes. Look to total motion first, and then work backward to see whether IR, ER, or both need to be changed. It is better to be too tight than too loose!
8. If you have an athlete with good shoulders, thoracic spine, scapular stability, and tissue quality who has rehabbed and long-tossed pain-free, but has shoulder/elbow pain when he gets back on the mound, CHECK THE HIPS! Staying closed and flying open will be your two most common culprits, and this cannot be seen in a doctor’s office or on an MRI.
9. Anytime you see an individual with a pronounced shrugging pattern as they try to reach overhead, it’s wise to have them checked for a rotator cuff tear. The reason is that with a cuff tear, the deltoid’s vertical action overpowers the cuff’s compressive action. In a healthy shoulder, the supraspinatus “cancels out” this deltoid pull. Never, ever, ever, ever train through a shrugging pattern with overhead reaching!
10. External impingement and internal impingement are completely different “syndromes” that must be managed completely differently. Simply saying “impingement” is no longer acceptable with how far sports medicine has come! Both are generally multi-factorial issues that mandate a more specific diagnosis and comprehensive treatment/training plan. If you understand why/how they occur, you can understand how to train around them (and the same can be said about just about any shoulder condition).
UPDATE: The Optimal Shoulder Performance DVD set is now available! Check it out at www.ShoulderPerformance.com.
Thank you for all the extra time you put in with us this past weekend. I can speak for many of us out here in that we appreciate all your hard work! Just don’t be afraid to hit someone in the mouth if they do crazy crap in your gym!
I look a LOT at dynamic scapular positioning throughout the entire ROM into flexion/abduction and IR/ER. The traps tend to adduct(retract) the scap while the serratus tends to abduct (protract) the scapula. If full excursion isn’t occurring then the GH jt tries to make it up, usually with a deleterious effect!! Also the SLER tends to activate the posterior delt a LOT as well (which may or may not be a good thing). Just my 2 cents!!
In a previous post you said “prop the arm to about 30 degrees of abduction, which is actually less stressful on the shoulder than having the arm completely up against the side.”
So this actually makes 30-degrees of abduction the first progression before moving on to having the arm almost flush against the side during the SLER?
You say a shrugging pattern when reaching overhead is bad as it may signal rotator tears. But being that you are supposed to shrug at the end of a barbell overhead press, and there is a weight pressing back down, could that compensate for the lack of compressive force from an injured supraspinatus? Or would the injured shoulder still shrug too much?
I also don’t follow the explanation that deltoid > supraspinatus. Isn’t shrugging a function of the upper traps?
Eric,
I really liked the article and it sounds as though the seminar was a success. No surprise. My question deals with performing the SLER with pure adduction of the glenohumeral joint. I have heard many medical professionals state that for some reason executing this drill or its standing equivalent can induce unecessary stress to the area, unless there is some degree of abduction at the shoulder (towel or half foam roll @ the elbow)? Just wanted to hear your thoughts on the matter, thanks.
Travis, just thought I would comment on your post. I am a PT student and have actually had this discussion with a certified manual PT that I know. By slightly abducting the humerus, you actually improve the working line of pull of the Infraspinatus muscle as it crosses over the glenohumeral joint…which I am assuming is the reason for the increase in EMG activity found in the study that is listed above. With the humerus placed at the side with no Abduction, you do not have as efficient line of pull of the ER musculature and thus are strengthening the muscle in a less than optimal position…which I would bet that Eric would agree is not what we want, especially when working with an injured athlete or someone with rotor cuff weakness. Hope this helps a little bit. Great question.
November 18th, 2009 at 11:21 am
Can’t wait till the video comes out.
November 18th, 2009 at 11:51 am
real stoked cressey
November 18th, 2009 at 12:08 pm
Hurry with that DVD! I need it for my training team. Thanks for all your good work.
November 18th, 2009 at 2:33 pm
I wouldn’t have expected anything less than a foam roller used as a pillow for those SLERs.
November 18th, 2009 at 2:51 pm
Thank you for all the extra time you put in with us this past weekend. I can speak for many of us out here in that we appreciate all your hard work! Just don’t be afraid to hit someone in the mouth if they do crazy crap in your gym!
November 18th, 2009 at 2:57 pm
I look a LOT at dynamic scapular positioning throughout the entire ROM into flexion/abduction and IR/ER. The traps tend to adduct(retract) the scap while the serratus tends to abduct (protract) the scapula. If full excursion isn’t occurring then the GH jt tries to make it up, usually with a deleterious effect!! Also the SLER tends to activate the posterior delt a LOT as well (which may or may not be a good thing). Just my 2 cents!!
November 18th, 2009 at 5:27 pm
Eric,
In a previous post you said “prop the arm to about 30 degrees of abduction, which is actually less stressful on the shoulder than having the arm completely up against the side.”
So this actually makes 30-degrees of abduction the first progression before moving on to having the arm almost flush against the side during the SLER?
November 18th, 2009 at 6:36 pm
You say a shrugging pattern when reaching overhead is bad as it may signal rotator tears. But being that you are supposed to shrug at the end of a barbell overhead press, and there is a weight pressing back down, could that compensate for the lack of compressive force from an injured supraspinatus? Or would the injured shoulder still shrug too much?
I also don’t follow the explanation that deltoid > supraspinatus. Isn’t shrugging a function of the upper traps?
November 20th, 2009 at 7:06 am
Great info! I’d like to hear more about where you place these exercises in your workouts.
November 21st, 2009 at 1:23 pm
Would something like an Over head squat or Snatch
count as a shrugging pattern with overhead reaching?
November 30th, 2009 at 12:11 am
Eric,
I really liked the article and it sounds as though the seminar was a success. No surprise. My question deals with performing the SLER with pure adduction of the glenohumeral joint. I have heard many medical professionals state that for some reason executing this drill or its standing equivalent can induce unecessary stress to the area, unless there is some degree of abduction at the shoulder (towel or half foam roll @ the elbow)? Just wanted to hear your thoughts on the matter, thanks.
Travis
December 11th, 2009 at 10:39 pm
Travis, just thought I would comment on your post. I am a PT student and have actually had this discussion with a certified manual PT that I know. By slightly abducting the humerus, you actually improve the working line of pull of the Infraspinatus muscle as it crosses over the glenohumeral joint…which I am assuming is the reason for the increase in EMG activity found in the study that is listed above. With the humerus placed at the side with no Abduction, you do not have as efficient line of pull of the ER musculature and thus are strengthening the muscle in a less than optimal position…which I would bet that Eric would agree is not what we want, especially when working with an injured athlete or someone with rotor cuff weakness. Hope this helps a little bit. Great question.