Home Posts tagged "Labrum"

Hip Pain in Athletes: The Origin of Femoroacetabular Impingement?

Over the weekend, I attended my third Postural Restoration Institute seminar, Impingement and Instability.  I’ve written previously about how this school of thought has profoundly impacted the way that we handle many of our athletes – and this past weekend was certainly no exception.  This weekend was also my first chance to meet and learn directly from Ron Hruska, the man initially responsible for bringing many of these great ideas to light. While I am admittedly still processing all the awesome information from the weekend, I wanted to write today about one big “Ah-Ha” moment for me over the weekend.  At some point on Day 2, Ron said something to the effect of (paraphrased):

“A superior acetabulum isn’t much different than an acromion on a scapula.”

My jaw practically hit the floor.  I joked with the seminar organizer that I needed to go into the restroom to yell at myself for a few minutes for not thinking of this sooner.  Let me explain… Over the past few years, there has been a huge rise in hip injuries in athletes (I'd even written about it HERE in response to a New York Times article about number of hip injuries in baseball).  Sports hernias, labral tears, and femoroacetabular impingement (FAI) are commonplace findings on the health histories that I see every day on first-time evaluations. In terms of FAI, you can have bony overgrowth of the femoral head (cam), acetabulum (pincer), or both (mixed), as the graphic from Lavigne et al. below demonstrates:

  Many folks say that we’re getting better diagnostically and that’s why the prevalence has increased in recent years.  Let’s be real, though, folks: if we’d had hip pain and dysfunction on this level for decades, don’t you think anecdotal evidence would have at least tipped us off?  I find it hard that generations of athletes would have just rubbed some dirt on a painful hip, cowboyed up, and put up with it. Consider those over the age of 60, though.  Sher et al. reported that a whopping 54% of asymptomatic shoulders in this population have rotator cuff tears; that doesn’t even include those who actually have pain!  Why does this happen?  They impinge over and over again on the undersurfaced of the acromion process secondary to poor thoracic positioning, scapular stabilization, breathing patterns, and rotator cuff function.  The end result is reactive changes on the acromion process that lay down more and more bone as the years go on.  And, an anteriorly tilted scapula kicks that impingement up a notch.  The “early” cuff irritation likely comes in those with Type 3 (beak-shaped) acromions, whereas the Type 1 (flat) and Type 2 (hook) acromions need time to lay down more and more bone for their anterior tilt to bring them to threshold.

Conversely, consider femoroacetabular impingement of the hip.  You can get bony overgrowth of the acetabulum, femoral head, or both.  It’s widely debated whether those with FAI are born with it, or whether it becomes part of normal development in some kids.  Well, I guess it would depend on whether you consider playing one sport to excess year-round “normal.” You know what?  I’d estimate that over 90% of the femoroacetabular impingement cases I’ve seen have come in hockey, soccer, and baseball players.  What do these sports have in common?  They all live in anterior pelvic tilt – with hockey being the absolute worst.  Is it any surprise that the incidence of FAI and associated hip issues has increased dramatically since the AAU generation rolled in and kids played the same sport all 12 months of the year? Conversely, I’ve never seen a case of FAI in a field hockey player.  Additionally, when I just asked my wife (who rowed competitively in college) if she ever saw any hip issues in her teammates in years of rowing, she joked that there weren’t any until they added distance running to their training. Field hockey players and rowers live in flexion (probably one reason why they have far more disc issues).  And, taking it a step further, I’ve never seen an athlete with FAI whose symptoms didn’t improve by getting into a bit more posterior pelvic tilt.

Finally, a 2009 study by Allen et al. demonstrated that in 78% of cases of cam impingement symptoms in one hip, the cam-type femoroacetabular impingement was bilateral (they also found pincer-type FAI on the opposite side in 42% of cases).  If this was just some “chance” occurrence, I find it hard to believe that it would occur bilaterally in such a high percentage of cases.  Excessive anterior pelvic tilt (sagittal plane) would be, in my eyes, what seems to bring it about the most quickly, and problems in the frontal and transverse planes are likely to blame for why one side presents with symptoms before the other. People have tried to blame the increased incidence of hip injuries on resistance training.  My personal opinion is that you can’t blame resistance training for the incidence, but rather the rate at which these issues reach threshold.  Quality resistance training could certainly provide the variety necessary to prevent these reactive changes from occurring at a young age, or by creating a more ideal pelvic alignment to avoid a FAI hip from reaching threshold. Conversely, a “clean-squat-bench” program is a recipe for living in anterior tilt – and squatting someone with a FAI is like overhead pressing someone with a full-thickness cuff tear; things get ugly quickly.

Honestly, this probably isn’t revolutionary for folks out there – particularly in the medical field – who have watched the prevalence of femoroacetabular impingement rise exponentially in recent years, but Ron made a great point to reaffirm a thought I’d been having for years and strengthened the argument.  And, more important than the simple “Ah-Ha” that comes with this perspective is the realization that an entire generation of young athletes have been so mismanaged that we’ve actually created a new classification of developmental problems and pathologies: femoroacetabular impingement, labral tears, and sports hernias. Thanks, Ron, for getting me thinking! For more information on appropriately managing kids during these critical development time periods, check out the International Youth Conditioning Association’s High School Strength and Conditioning Certification, which I helped to write.

Sign-up Today for our FREE Newsletter and receive a four-part video series on how to deadlift!
Name
Email
Read more

Stuff You Should Read: 8/2/10

Here are a few blasts from the past that I think you'll like to kick off the week: Peak Power or Vertical Jump - Which one should you test in athlete training programs, and why? Back Squatting with a Posterior Labral Tear - This is a good follow-up to last week's post on shoulder mobility with squatting because sometimes, even good mobility won't matter. 5 Relative Strength Myths - I wrote this article back in 2005, and as I look back on it, in many ways, it helped to set the stage for my Maximum Strength book.

Cressey_9781600940576.indd

Read more

Cressey Performance Athletes Excel, Reporters Write About It, Villagers Rejoice

I don't know if there is something in the water that the reporters around the country (and particularly the Massachusetts sports scene) have been drinking, but Cressey Performance's Elite Baseball Development Program has gotten a lot of love in the news this weekend. Last week, CP athlete Tim Collins was part of a blockbuster trade, as he went from the Toronto Blue Jays to the Atlanta Braves.  Tim didn't disappoint in his debut, striking out five batters in two innings pitched without allowing a walk, hit, or run.  In a recent posting about Collins in the Atlanta-Journal Constitution, beat writer David O'Brien wrote the following: "I asked [Braves Manager] Bobby Cox if he knew anything about him, and Cox started talking about seeing video of him. Said he's extremely athletic, a muscular little guy who's real aggressive. Apparently the video showed him pitching and also working out, because he made quite an impression on Cox and others with the workout portion." Apparently, Bobby Cox is quite a fan of the EricCressey.com and Cressey Performance YouTube pages.  Hello, Bobby!

The AJC followed it up with a feature on Tim where my business partner, Pete Dupuis, was interviewed: Pitcher in Escobar Trade is 5-7 Fireballer.

Saturday night, CP athlete Kevin Youkilis had the game-tying and game winning RBIs for the Red Sox in a come-from-behind win at home against the Rangers. These features were followed shortly by another one - this time on a talented pitching prospect from Worcester, MA, Louisville pitcher Keith Landers.  The Worcester Telegram just did this feature on Keith and the training he started up about eight weeks ago at Cressey Performance as he works his way back from a shoulder surgery.

Landers Rehabbing Repaired Shoulder

landers

(yes, Keith is really almost as tall as I am, even though he's kneeling)

And, last, but certainly not least, the Daily New Tribue published this feature on CP athlete Travis Dean, who was drafted in the 14th round by the New York Yankees this year: Newton's Travis Dean Weighs Options as Yankees' Pitching Draftee.

Finally, here's a blog post from ESPN.com's Brendan Hall that features a boatload of CP studs who have had great summer showings: Tyler Beede, Adam Ravenelle, Carl Anderson, Barrett O'Neill, John Gorman, Jordan Cote, Ben Smith, Matt Luppi, AJ Zarozny, and David St. Lawrence.

Click here for more information on Cressey Performance's Elite Baseball Development Program.

Read more

Healthy Shoulders with Terrible MRIs?

In the same grain as Monday's post on lower back pain, today, I thought I'd highlight some of the common findings in diagnostic imaging of the shoulder, as these findings are just as alarming.

Do you train loads of overhead throwing athletes (especially pitchers) like I do?  Miniaci et al. found that 79% of asymptomatic professional pitchers (28/40) had "abnormal labrum" features and noted that "magnetic resonance imaging of the shoulder in asymptomatic high performance throwing athletes reveals abnormalities that may encompass a spectrum of 'nonclinical' findings."  Yes, you can have a torn labrum and not be in pain (it depends on the kind of labral tear you have; for more information, check out Mike Reinold's great series on SLAP lesions, starting with Part 1).

slap_lesion

This isn't just limited to baseball players, either; you'll see it in handball, swimming, track and field throwers, and tennis as well.  And, it isn't just limited to the labrum.  Connor et al. found that eight of 20 (40%) dominant shoulders in asymptomatic tennis/baseball players had evidence of partial or full-thickness cuff tears on MRI. Five of the 20 also had evidence of Bennett's lesions.

The general population may be even worse, particularly as folks age. Sher et al. took MRIs of 96 asymptomatic subjects, finding rotator cuff tears in 34% of cases, and 54% of those older than 60 - so if you're dealing with older adult fitness, you have to assume they're present in more than half your clients!

rtc-tear

Also, in another Miniaci et al. study, MRIs of 30 asymptomatic shoulders under age 50 demonstrated "no completely 'normal' rotator cuffs."  People's MRIs are such train wrecks that we don't even know what "normal" is anymore!

As is the case with back pain, these issues generally only become symptomatic when you don't move well - meaning you have insufficient strength, limited flexibility, or poor tissue quality.  For more information on how to screen for and prevent these issues from reaching threshold, check out Optimal Shoulder Performance from Mike Reinold and me.

Sign-up Today for our FREE Newsletter and receive a four-part video series on how to deadlift!

Name
Email
Read more

MRIs vs. Movement

As many of you know, earlier this week, I spent three days at a huge sports medicine conference organized by Mass General Hospital in conjunction with the Harvard University Medical School.  It was a great event geared toward sports orthopedists, radiologists, physical therapists, and athletic trainers; I was very humbled to have been invited to present alongside some of the brightest minds in the sports medicine world.  The discussions on surgical technique, physical examinations, etiology of injuries, biomechanics, rehabilitation, and return-to-play guidelines were absolutely fantastic.  The stuff that caught my attention the most, though, actually came in the discussion of imaging - MRIs, MRAs, and x-rays - by some of the best radiologists in the world. Several of these brilliant radiologists made specific points of commenting on how not every abnormality you see on diagnostic imaging constitutes a symptom-causing issues.  A perfect example would be a SLAP 1 (superior labrum fraying) in a baseball pitcher, which is completely normal for 79% of major league pitchers.  Just because the labrum is fraying doesn't mean that the pitcher is going to be in pain; it's a passive stabilizer, and the active restraints (rotator cuff, scapular stabilizers) can get stronger to pick up the slack.  Likewise, just because a player is having shoulder pain and he has a SLAP 1 lesion on imaging doesn't mean that the frayed labrum is the cause.  It could be coming from the biceps tendon or rotator cuff, for instance, and the labral issue is just "there." So what does that mean for strength and conditioning professionals?  Well, as I wrote in Inefficiency vs. Pathology, there isn't a whole lot we can do to effect favorable changes in what diagnostic imaging looks like, but we can go out of our way to ensure that clients and athletes move efficiently and have adequate muscular strength, stability, and tissue quality.

btea_set

This is actually my exact topic on the Perform Better tour (next stop is Long Beach at the end of July).  If you can't make it to Long Beach, I'd highly encourage you to check out these previous writings of mine: Inefficiency vs. Pathology (noted above) To Squat or Not to Squat An Interview with Dr. Jason Hodges The Proactive Patient
Read more

Hip Injuries In Baseball

Q&A: Hip Injuries in Baseball Q: On Sunday, The New York Times published this article that discusses the dramatic increase in hip injuries in Major League Baseball in recent years.  I know you work with a ton of baseball players and was curious about your thoughts on the article.  Do you agree with their theories? A: As always, my answer is "kind of" or "maybe."  I think they make some great points in the article, but as is the case with mainstream media articles, they're written by reporters with word count limits, so a lot of the most important points get omitted.  For example, with respect to the hips, it isn't as simple as "weak or strong."  You can have guys with ridiculously strong adductors that are completely overused, balled up, and short - but terribly weak hip extensors and abductors.  So, part of the problem is that journalists don't even qualify as casual observers to exercise physiology, so the public only gets part of the story.

(Sorry, but that digression was totally worth it.) First, I agree that one of the reasons we are seeing more of these issues is because doctors have become better at diagnosing the problems.  The "corollary" to this would be that the issues are perceived as more severe because so few physical therapists, athletic trainers, and strength and conditioning coaches are comfortable treating and preventing the problems.  That's not to say that hip issues aren't serious in nature; it simply implies that there is a divide between diagnostic capabilities and treatment/prevention strategies. Second, I agree wholeheartedly that early specialization at the youth levels can lead to injuries down the road.  We're dealing with some significant rotational velocities at the hips.  In previous analyses of professional hitters, the hips rotated at a velocity of 714°/second.  This same velocity isn't the same with little leaguers, but with skeletally immature children, it doesn't take as much stress to impose the same kind of damage.  So, I don't see it as at all remarkable that some pro ballplayers have hip problems after they may have played baseball year-round from age 9 all the way to the time they got drafted.  They also have bad shoulders, elbows, knees, and lower backs that have taked years to reach threshold.  It just so happens that folks are getting better at diagnosing these problems, so we now have an "epidemic," in some folks' eyes. What I can tell you, though, is that it's borderline idiocy to think that strength training is responsible for these problems.  Injuries don't occur simply because you enhance strength. In fact, muscular strength reduces the time to threshold for tendinopathies, and takes stress off passive restraints such as ligaments, menisci, labrums, and discs. Making this assumption is like saying that strength training drills to bolster scapular stability may be the reason we see more shoulder and elbow injuries nowadays.  Um, no.  Shoulders and elbows crap out because of faulty mechanics, poor flexibility (e.g., shoulder internal rotation ROM), bad tissue quality, and muscular weakness.  Granted, the shoulder (non-weight-bearing) and hips (weight-bearing) have different demands, but nobody ever tried to pin the exorbitant amount of arm problems in pitchers on "the advent of strength training." That said, injuries occur when you ignore things that need to be addressed: pure and simple. To that end, I can tell you that a large percentage of the baseball players I see - including position players, pitchers, and catchers - have some signficant hip ROM and tissue quality problems.  In terms of range of motion, the most common culprints are hip internal rotation deficit (HIRD) and a lack of hip extension and knee flexion (rectus femoris shortness).  Pitchers are often asymmetrical in hip flexion, too, with the front leg having much more ROM. In terms of tissue quality, the hip external rotations, hip flexors, and adductors are usually very restricted. This is has proven true of guys who lift and guys who don't lift.  The latter group just so happens to be skinny and weak, too! Done appropriately, strength training isn't causing the problem - particularly when we are talking about huge contracts that restrict how aggressive programming can be.  Trust me; guys with $20 million/year contracts aren't squatting 500 pounds very often...or ever. The risk-reward is way out of whack, and no pro strength coach is going to put his job on the line with programming like that. However, strength training may be indirectly contributing to the problem by shifting an athlete's focus away from flexibility training and foam rolling/massage.  Pro athletes are like everyone else in this world in that they have a limited time to devote to training, but to take it a step further, they have a lot of competing demands for their attention: hitting, throwing, lifting, sprinting, stretching, and soft tissue work.  So, they have to pick the modalities that give them the biggest return on time investment and prioritize accordingly in terms of how much time they devote to these initiatives.  Some guys make bad choices in this regard, and hip flexibility and tissue quality get ignored.

mm1

Baseball is a sport that doesn't permit ignorance, unfortunately, and this is one of many reasons why it has one of the highest injury rates in all of professional sports.  We are talking about an extremely long competitive season with near daily games - a schedule that makes it challenging to maintain/build strength, flexibility, and tissue quality.  Throwing a baseball is also the fastest motion in all of sports.  Rotational sports have the pelvis and torso rotating in opposite directions at the same time.  And, as I noted in Oblique Strains and Rotational Power, most professional ballplayers have a stride length of about 380% of hip width during hitting.  It is really just a matter of which joint will break down first: hip, knee, or lower back.  Taking immobile hips with poor tissue quality out into a long season with these demands is like doing calf raises in the power rack when someone is around with a video camera: you are just asking for a world of hurt.

So, what to do?  Well, first, get cracking on tissue quality with regular foam rolling and massage (the more an athlete can afford, the better).  Here is the sequence all Cressey Performance athletes go through before training.

In many of our guys, we also add in extra adductor rolling on the stretching table.

Second, you've got to hammer on flexibility.  We spend a ton of time with both static stretching and dynamic flexibility.  Here are a few of the static stretching favorites (the first to gain hip internal rotation, and the second to gain hip extension and knee flexion ROM):

lyingknee-to-kneestretch

kneelingheeltobuttstretch

Third, as Dr. Eric Cobb has written, you use resistance training to "cement neural patterns."    This includes all sorts of lower-body lifting variations - from single-leg movements, to glute-ham raise, to deadlifting and squatting variations - and multi-directional core stability drills.  And, often overlooked is the valuable role of medicine ball training in teaching good hip (and scap) loading patterns:

For more information, check out my previous newsletter, Medicine Ball Madness, which describes our off-season medicine ball programs in considerable detail.

All taken together, my take is that the increase in hip injuries at the MLB level has everything to do with early baseball specialization and improved diagnostic capabilities.  However, when you examine hip dysfunction under a broader scope, you'll see that this joint breaks down for many of the same reasons that lower backs and knees reach threshold: inattention to tissue quality and targeted flexibility training.  Strength training works synergistically with these other components of an effective program just like it would at any other joint.

*A special thanks goes out to Tony "Explosive Calves" Gentilcore for being a good sport in the videos in this newsletter.

Sign-up Today for our FREE Baseball Newsletter and Receive a Copy of the Exact Stretches used by Cressey Performance Pitchers after they Throw!
Name
Email
Read more

A Good Rule of Thumb for Working with Injured Pitchers

If you have a pitcher athlete with good shoulder ROM (normal GIRD and symmetrical total motion), sufficient thoracic spine mobility, good scapular stability, and adequate 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; this cannot be seen in a doctor's office!  Changing lead leg positioning is a quick way to indirectly (and negatively) impact the position of the arm.  Guys who stay closed have to throw across their body, and guys who fly open often have problems with the arm trailing too far behind (out of the scapular plane). For more information, check out the Optimal Shoulder Performance DVD Set. Sign-up Today for our FREE Baseball Newsletter and Receive a Copy of the Exact Stretches used by Cressey Performance Pitchers after they Throw!
Name
Email
Read more

Back Squatting with a Posterior Labral Tear?

Q:  I'm a baseball pitcher who was diagnosed with a posterior labral tear.  Since I was young and the doctor didn't feel that the tear was too extensive, he recommended physical therapy and not surgery.  I'm still training the rest of my body hard, but am finding that I can't back squat because it causes pain in the shoulder.  Any idea why and what I can do to work around this? A: It isn't surprising at all, given the typical SLAP injury mechanism in overhead throwing athletes.  If there is posterior cuff tightness (and possibly capsule tightness, depending on who you ask), the humeral head will translate upward in that abducted/externally rotated position.  In other words, the extreme cocking position and back squat bar position readily provoke labral problems once they are in place. The apprehension test is often used to check for issues like this, as they are commonly associated with anterior instability.  Not surprisingly, it's a test that involves maximal external rotation to provoke pain:

apprehension-test

The relocation aspect of the test involves the clinician pushing the humeral head posteriorly to relieve pain.  If that relocation relieves pain, the test is positive, and you're dealing with someone who has anterior instability.  So, you can see why back squatting can irritate a shoulder with a posterior labrum problem: it may be the associated anterior instability, the labrum itself, or a combination of those two factors (and others!). On a related note, most pitchers report that when they feel their SLAP lesion occur on a specific pitch, it takes place right as they transition from maximal external rotation to forward acceleration.  This is where the peel-back mechanism (via the biceps tendon on the labrum) is most prominent.  That's one more knock against back squatting overhead athletes. If you're interested in reading further, Mike Reinold has some excellent information on SLAP lesions in overhead throwing athletes in two great blog posts: Top 5 Things You Need to Know about a Superior Labral Tear Clinical Examination of Superior Labral Tears The solutions are pretty simple: work with front squats, single-leg work (dumbbells or front squat grip), and deadlift variations. If you have access to specialty bars like the giant cambered bar and/or safety squat bar, feel free to incorporate work with them.

And, alongside that, work in a solid rehabilitation program that focuses not only on the glenohumeral joint, but also scapular stability and thoracic spine mobility. Sign-up Today for our FREE Baseball Newsletter and Receive a Copy of the Exact Stretches used by Cressey Performance Pitchers after they Throw!

Name
Email
Read more

A Great Weekend in Houston

As I mentioned last week, this past weekend was Ron Wolforth's Ultimate Pitching Coaches Bootcamp just outside of Houston, TX.  To say that it was an awesome experience would be an understatement.  I considered myself really lucky to be presenting alongside the likes of Brent Strom (St. Louis Cardinals), Phil Donley (Philadelphia Phillies consultant who has rehabbed loads of million-dollar arms), Perry Husband (Downright Filthy Pitching), and Ron himself.  These guys are not only getting important information out there for coaches, but also getting their hands dirty in the trenches to take athletes and coaches to the next level with new information.

Just as great as the presenters were the 100+ attendees.  In addition to many enthusiastic high school and private sector coaches and a few physical therapists, you had pitching coaches and/or baseball strength coaches from big-time colleges like Vanderbilt, South Carolina, Auburn, Kennesaw St., Savannah College of Art and Design, Michigan, Virginia Tech, Columbia, and Trinity.  These guys immediately earned a ton of respect in my book for thinking outside the box, and it makes me want to encourage a lot of my stud athletes their way post-high school because I know that they're going to get coaches who are always looking for ways to help them succeed. The title of my presentation was "Building the Complete and Superior Pitching Athlete."  In my introduction to the coaches, I tried to make it very clear that my goal wasn't to try to teach them everything there was to know about S&C for baseball players, but rather to give them the knowledge (and resources, in the form of my handouts) to become informed consumers in dealing with the folks who carry out their players' programs.  I wanted them to know that you CAN give a pitcher a tremendous training effect without injuries to the throwing arm or interfering with velocity by losing pitching-specific mobility. I think that the secret to appreciating what it takes is understanding that baseball strength and conditioning is not just about lifting and running.  Sure, these are components of the overall process, but if you only address these two components, you DO run the risk of impairing a pitcher's development.  Sure, you've got to pay attention to these issues, but you also have to strategically address flexibility and mobility (yes, they are different), optimize soft tissue quality, and appreciate that you can use medicine ball work to maintain pitching-specific mobility during down-periods from throwing without all the stresses that come with throwing itself.

I also tried to get folks to think about what they already are doing with respect to distance running, "core" training, upper and lower body lifting, assessments, warm-ups (check out the Monster Mobility Pack for ideas), and post-throwing flexibility work.  I discussed the difference between inefficiency and pathology and how your can have a terrible-looking MRI and/or x-ray and still be pain free.

You can still get all the information from the event by purchasing the DVDs of the entire weekend.  I'd highly recommend them, as they include some great pitching analysis and recommendations from Brent Strom, awesome information on glenohumeral internal rotation deficit (GIRD) by Phil Donley, intriguing thoughts on "effective velocity" from Perry Husband, and excellent ideas on "blending" by Ron Wolforth.  Just head over to Pitching Central's UPCBC page and pick up a copy now.

upcbc-08-pic

Sign-up Today for our FREE Baseball Newsletter and Receive a Copy of the Exact Stretches used by Cressey Performance Pitchers after they Throw!
Name
Email
Read more

The Truth About Shoulder Impingement: Part 2

In Part I, I went into some detail on why I really didn’t like the catch-all term “shoulder impingement.” This week, I’m going to talk about the different kinds of shoulder impingement: external and internal.

External impingement, also known as outlet impingement, is the one we hear about the most. Here, we’re dealing with compression of the rotator cuff – usually the supraspinatus, and over time, the infraspinatus (and biceps tendon) – by the undersurface of the acromion. This impingement can lead to bursal-sided rotator cuff tears - and happens a lot more with ordinary weekend warriors and very common in lifters (not to mention much more prevalent in older populations.

External impingement can be further subdivided into primary and secondary classifications. In primary impingement, the cause is related to the acromion – either due to bone spurring or congenital shape. As you can see in the photo below, hook (II) and beak (III) are worst than flat (I), as there are marked difference in “clearance” under the acromion.

Secondary impingement, on the other hand, is usually related to poor scapular stability (related to both tightness and weakness, as described in last week’s newsletter), which alters the position of the scapula. In both cases, pain is at the front and/or side of the shoulder and is irritated with overhead activity, scapular protraction, and several other activities (depending on the severity of the tissue problems). You’ll also generally see a lack of external rotation range-of-motion, as these are folks who do too much bench pressing and computer work (both of which shorten the internal rotators).

Conversely, internal impingement, also known as posterosuperior impingement, really wasn’t proposed until the early 1990s. This form of impingement is more common in younger individuals who are involved in overhead sports, making it more of an “athletic impingement.” Adaptive shortening and scarring of the posterior rotator cuff in these athletes causes a loss of internal rotation and an upward translation of the humeral head during the late cocking phase of throwing (or swimming): external rotation and abduction.  These issues are magnified by poor scapular control, insufficient thoracic rotation, and weakness of the rotator cuff.

When the humeral head translates superiorly excessively in this position, it impinges on the posterior labrum and glenoid (socket), irritating the rotator cuff and biceps tendon along the way. So, pain usually starts in the back of the shoulder, as you are seeing irritation of the posterior fibers of the supraspinatus and anterior fibers of the infraspinatus tendons. Gradually, this pain may “shift” toward the front as the biceps tendon, and that implies labral involvement.  At least initially, the pain is purely mechanical in nature; it won't bother an athlete unless the "apprehension" position (full external rotation at 90 degrees of abduction) is created.

We often hear about SLAP lesions in the news. This refers to a superior labrum, anterior-posterior injury. In reality, when we are talking about labral injuries in overhead athletes as they relate to internal impingement, it’s mostly just posterior (although serious cases can eventually affect the anterior labrum, too). There are different kinds of SLAP lesions (1-4). Every baseball pitcher you’ll meet has a SLAP 1, which is just fraying. SLAP 2 lesions are far more serious and often require surgical intervention. SLAP 1 issues become SLAP 2 lesions when poor mobility and dynamic stability aren't established.

So, just to bring you up to speed, we’ve got two different kinds of impingement, one of which (external) has two subcategories that mandate different treatment strategies (primary = surgery, secondary = corrective exercise). We also have two separate areas where pain presents (external = front/side, internal = back). That’s just the tip of the iceberg, though, as we have two more considerations…

First, symptomatic internal impingement tends to be "mechanical pain." Unless you’re dealing with a more advanced case, athletes with symptomatic internal impingement only have pain when they get into the late cocking phase (and sometimes follow-through). It usually isn’t present when they’re just sitting around – and for this reason, they can usually be more aggressive in the weight room with upper body training. Keep in mind that I use the term “symptomatic” because I think that internal impingement is a physiological norm, just like I observed last week with external impingement.  You're essentially just going to go out of your way to avoid this "apprehension" position in the weight room by omitting exercises like back squats.  An apprehension test - illustrated in the most enthusiastic video in internet history - is a quick and easy assessment many doctors and rehabilitation specialists use to check for symptomatic internal impingement, as it reproduces the injury mechanism.

Second, and perhaps more importantly, you are dealing with two rotator cuff tears that are fundamentally different. It’s these differences that make me think doctors need to get rid of the term “impingement.” Here’s the scoop:

Let’s say that we have two guys with partial thickness tears of the supraspinatus – one from external impingement and one from internal impingement.

With external impingement, we’re usually dealing with a bursal-sided tear, as the rubbing comes from the top (acromion). These issues will generally heal more quickly because the bursa actually has a decent blood supply.

With internal impingement, on the other hand, we’ve got an articular-sided tear, meaning that the wear on the tendon comes from underneath (glenoid). The tear is more interstitial in nature. Blood supply isn’t quite as good in this area, so healing is slower (or non-existent).

Traditionally, articular has been an athletic injury, and bursal has been a general population issue. This is not always the case, though.

Factor in the activity demands of overhead throwers, and they have more challenging tears and greater functional demands. Fortunately, they also typically have age and tissue quality on their sides, so things tend to even out.

With all these factors in mind, if a doctor ever tells you that you have "shoulder impingement," ask:

1. Internal or external?

2. If external, is it primary or secondary? (It’ll probably be both)

3. If internal, is there labral involvement? Biceps tendon?

4. If internal, what is the internal rotation deficit? (They should measure it, as this will begin to dictate the rehabilitation plan)

5. Given my age, activity level, and the nature of the tear, do you feel that surgical or conservative treatment is best?

Click here to purchase the most comprehensive shoulder resource available today: Sturdy Shoulder Solutions.

Sign-up Today for our FREE Baseball Newsletter and Receive Instant Access to a 47-minute Presentation from Eric Cressey on Individualizing the Management of Overhead Athletes!

Name
Email
Read more
Page 1 2
LEARN HOW TO DEADLIFT
  • Avoid the most common deadlifting mistakes
  • 9 - minute instructional video
  • 3 part follow up series