Shoulder Mobility Drills: How to Improve External Rotation (if you even need it)

Written on May 31, 2011 at 8:12 am, by Eric Cressey

Last summer, a college pitcher came up to Cressey Performance from the South to train for a month before his summer league got underway. He was seven months post-op on a shoulder surgery (Type 2 SLAP) and had been working his way back. Unfortunately, his arm was still bothering him a bit when he got up to see us.

After the first few days at CP, though, he told me that his arm felt as good as it’s felt in as long as he could remember. He’d been doing a comprehensive strength and conditioning program, but the “impact” stuff for him had been soft tissue work, some Postural Restoration Institute drills, an emphasis on thoracic mobility, and manual stretching into internal rotation, horizontal adduction, and shoulder flexion. From all the rehab, his cuff was strong and scapular stabilizers were functioning reasonably well – which led me to believe that his issues were largely due to tissue shortness and/or stiffness.

This realization made me immediately wonder what he’d been doing in the previous months for mobility work for his arm – so I asked. He then demonstrated the manual stretching series that every pitcher on his team went through every day on the table with their athletic trainer. Each stretch was done for 2x20s – and two of those stretches took him into extreme external rotation and horizontal abduction. I was pretty shocked.

Me: “You’re probably not the only guy on your team rehabbing right now, huh?”

Him: “No; there are actually too many to count.”

Me: “Elbows, too, I’m sure.”

Him: “Yep.”

Want to irritate a labrum, biceps tendon, or the undersurface of the rotator cuff? Stretch a thrower into extreme external rotation and simulate the peel-back mechanism. This also increases anterior capsular laxity and likely exacerbates the internal impingement mechanism over the long-term. To reiterate, this is a bad stretch!

Want to make an acromioclavicular joint unhappy? Stretch a thrower into horizontal abduction like this (again, this is a BAD stretch that is pictured):

Want to irritate an ulnar nerve or contribute to the rupture of an ulnar collateral ligament? Make sure to apply direct pressure to the forearm during these dangerous stretches to create some valgus stress. This is a sure-fire way to make a bad stretch even worse:

These stretches are very rarely indicated in a healthy population – especially pitchers who already have a tendency toward increased external rotation. The shoulder is a delicate joint that can’t just be manhandled – and when you’re dealing with shoulders that are usually also pretty loose (both from congenital and acquired factors), you’re waiting for a problem when you include such stretches. In fact, I devoted an entire article to this: The Right Way to Stretch the Pecs.

Everyone thinks that shoulder external rotation and horizontal abduction alone account for the lay-back in the extreme cocking position.

In reality, though, this position is derived from a bunch of factors:

1. Shoulder External Rotation Range-of-Motion – and this is the kind of freaky external rotation you’ll commonly see thanks to retroversion and anterior laxity:

2. Scapular Retraction/Posterior Tilt

3. Thoracic Spine Extension/Rotation

4. Valgus Carrying Angle

So, how do you improve lay-back without risking damage to the shoulder and elbow?

1. Soft tissue work on Pec minor/major and subscapularis – Ideally, this would be performed by a qualified manual therapist – especially since you’re not going to be able to get to subscapularis yourself. However, you can use this technique to attack the pecs:

2. Exercises to improve scapular retraction/depression/posterior tilt – This could include any of a number of horizontal pulling exercises or specific lower trap/serratus anterior exercises like the forearm wall slide with band.

3. Incorporate specific thoracic spine mobility drills – In most pitchers, you want to be careful about including thoracic spine mobility drills that also encourage a lot of glenohumeral external rotation. However, when we assess a pitcher and find that he’s really lacking in this regard, there are two drills that we use with them. The first is the side-lying extension-rotation, which is a good entry level progression because the floor actually limits external rotation range-of-motion, and it’s easy to coach. I tell athletes that they should think of thoracic spine extension/rotation driving scapular retraction/depression, which in turn drives humeral external rotation (and flexion/horizontal abduction). Usually, simply putting your hands on the shoulder girdle and guiding them through the motion is the best teaching tool.

A progression on the side-lying extension-rotation is the side-lying windmill, which requires a bit more attention to detail to ensure that the range-of-motion comes from the right place. The goal is to think of moving exclusively from the thoracic spine with an appropriate scapular retraction/posterior tilt. In other words, the arm just comes along for the ride. The eyes (and head) should follow the hand wherever it goes.

Again, these are only exercises we use with certain players who we’ve deemed deficient in external rotation. If you’re a thrower, don’t simply add these to your routine without a valid assessment from someone who is qualified to make that estimation. You could actually make the argument that this would apply to some folks in the general population who have congenital laxity as well (especially females).

4. Throw!!!!! – Pitchers gain a considerable amount of glenohumeral external rotation over the course of a competitive season simply from throwing. Sometimes, the best solution is to simply be patient. I really like long toss above all else for these folks.

In closing, there are three important things I should note:

1. You don’t want to do anything to increase valgus laxity.

2. You’re much more likely to get hurt from being “too loose” than you are from being “too tight.” When it comes to stretching the throwing shoulder, “gentle” is the name of the game – and all mobility programs should be as individualized as possible.

3. Maintaining internal rotation is a lot more important than whatever is going on with external rotation. In fact, this piece could have just as easily been named “The Two Stretches Pitchers Shouldn’t Do, Plus a Few That Only Some of Them Need.”

To learn more about testing, training, and treating throwing shoulders, check out Optimal Shoulder Performance: From Rehab to High Performance.

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Shoulder Hurts? Start Here.

Written on May 16, 2011 at 7:45 am, by Eric Cressey

As you can probably imagine, given that I deal with a ton of baseball players – and the fact that I’ve written about shoulder pain a ton over the past decade – a lot of people initially come to Cressey Performance because their shoulder hurts.  It might be rotator cuff pain, AC joint irritation, or any of a host of other issues, but you’d be surprised at how many similarities there are among the ways that you address most of these issues.

The problem is that pain can throw a wrench in your plans and limit you in your ability to get to exactly where someone needs to improve movement-wise.  For instance, you might have someone who has a significant glenohumeral (ball-and-socket) internal rotation deficit, but it’s hard to manually stretch them into internal rotation without further irritating a cranky AC joint.  Or, someone with a partial thickness rotator cuff tear may be dramatically limited in shoulder flexion, but even shoulder flexion with assisted scapular posterior tilt and upward rotation exacerbates their symptoms.  Very simply, you can’t just pound round pegs into square holes when it comes to dealing with a delicate joint like the shoulder – and that applies to both asymptomatic and symptomatic shoulders.

To that end, there are three initiatives that I think are the absolute most important places to start in just about every case.

First, I’m a huge advocate of soft tissue work with a skilled manual therapist.  In our office, we have a massage therapist and chiropractor who performs both Active Release and Graston.  And, we make sure that any physical therapist to whom we refer clients uses manual therapy as an integral part of their treatment approach.  Whether you’re a regular exerciser or not, tissues can get dense, nasty, and fibrotic, and integrating some hands-on work on the pec minor, posterior rotator cuff, lats, scalenes, sternocleidomastoid, and several other areas can dramatically reduce an individual’s symptoms and improve range-of-motion instantly – and that allows us to do more with a corrective exercise program.

Understandably, not everyone has access to a qualified manual therapist all the time, so you can always utilize self-myofascial release in the interim.  Here, in a video from Show and Go: High Performance Training to Look, Feel, and Move Better, CP massage therapist Chris Howard goes over a quick and easy way to loosen up the pecs:

The second area where you really can’t go wrong is incorporating thoracic spine mobilizations.  The thoracic spine has direct interactions with the lumbar spine, rib cage, cervical spine, and scapulae; as a result, it has some very far-reaching effects. Unfortunately, most people are really stiff in this region – and that means they wind up with poor core and scapular stability, altered rib positioning (which impacts respiration), and cervical spine dysfunction.  Fortunately, mobilizing this area can have some quick and profound benefits; I’ve seen shoulder internal rotation improve by as much as 20 degrees in a matter of 30 seconds simply by incorporating a basic thoracic spine mobility drill.

That said, not all thoracic spine mobility drills are created equal.  Many of these drills require the glenohumeral joint to go into external rotation, abduction, and horizontal abduction in order to drive scapular posterior tilt/retraction and, in turn, thoracic spine extension and rotation. If you’ve got a cranky shoulder, this more extreme shoulder position usually isn’t going to go over well.  So, drills like the side-lying extension-rotation are likely out:

For most folks, a quadruped extension-rotation drill will be an appropriate regression:

And, if the hand position (behind the head) is still problematic for the shoulder, you can always simply put it on the opposite shoulder (in the above example, the right hand would be placed on the left shoulder) and keep the rest of the movement the same.

Last, but certainly not least, you can almost always work on forward head posture from the get-go with someone whose shoulder hurts.  We start with standing chin tucks, and then progress to quadruped chin tucks.

Additionally, working on cervical rotation is extremely valuable, although teaching that is a bit beyond the scope of this post.

Keep in mind that these three broad initiatives are really just the tip of the iceberg when it comes to a comprehensive corrective exercise plan that would also include a focus on scapular stabilization and rotator cuff exercises, plus additional mobility drills.  They are, however, safe entry-level strategies you can use with just about anyone to get the ball rolling without making a shoulder hurt worse in a strength and conditioning program.

For more information on what a comprehensive shoulder rehabilitation program and the concurrent strength and conditioning program should include, check out Optimal Shoulder Performance, a DVD set I co-created with Mike Reinold, the Head Athletic Trainer and Rehabilitation Coordinator of the Boston Red Sox.

The Optimal Shoulder Performance DVD is a phenomenal presentation of the variables surrounding shoulder health, function, and performance. It combines the most current research, real world application as well as the the instruction on how to implement its vast amount of material immediately. After just one viewing, I decided to employ some of the tactics and methods into our assessment and exercise protocols, and as a result, I feel that myself, my staff and my clients have benefited greatly.

Michael Ranfone BS, CSCS, LMT, ART
Owner, Ranfone Training Systems

Weight Training Programs: Assess, Don’t Assume

Written on May 10, 2011 at 8:06 am, by Eric Cressey

Late last week, my buddy Nick Tumminello made the follow comment that some folks, unfortunately, took out of context:

“Everyone is talking about assessments (and that’s cool). But, no one seems to talking about simply not allowing poor form in training. If you can’t keep good form in a certain exercise (movement pattern), simply don’t do that exercise until you’ve improved the movement or decided that you’re simply not built for it to begin with. Not sure why things need be any more complicated than that!”

For the record, I agree 100% with Nick and understood what he meant, but it would have been easy to assume that he was referring to “trainers train, and therapists assess.”  In other words, many folks assume that as long as you aren’t symptomatic in some way, then you’re safe to start exercising because you can simply “feel” things out as you go and, if something hurts, you don’t do it.

While you obviously shouldn’t do something if it hurts, just because something doesn’t hurt doesn’t mean that it’s not harmful long-term – and to me, that’s the difference between “working someone out” and provided them with an optimal training experience.  As physical therapist Mike Reinold has said, “Assess; don’t assume.”

To illustrate my point, here are a few examples.

Let’s say you have someone with a chronically cranky acromioclavicular joint or osteolysis of the distal clavicle that might only be apparent upon reviewing a health history, palpating the area, or taking someone into full horizontal adduction at the shoulder.  While direct over-pressure on the area (as in a front squat) would surely elicit symptoms, my experience is that most folks won’t notice a significant amount of pain until the next day if the strength exercise selection is inappropriate (e.g., dips, full range-of-motion bench pressing).  You might have avoided what “hurt” during the session (presumably because the individual was warmed up), but you find out after the fact that you just set an individual back weeks in their recovery and fitness program.

How about right scapular winging?  It’s not easily observed if a client has a shirt on, and if you simply throw that individual into a bootcamp with hundreds of push-ups each week, you’re bound to run into trouble.  Here’s the thing, though: even if you observed that winging and wanted to address it in your training, you really have to consider that it can come from one or more of several factors: weak scapular stabilizers, a stiff posterior cuff, insufficient right thoracic rotation, faulty breathing patterns, or poor tissue quality of pec minor, rhomboids, levator scapulae (or any of a number of other muscles/tendons).  Just doing some rows and YTWL circuits will not work.

Also at the shoulder, a baseball pitcher with crazy congenital and acquired shoulder external rotation may have a ton of anterior instability in the “cocking” position of throwing (90 degrees of abduction and external rotation), but be completely asymptomatic.  Back squatting this athlete would exacerbate the problem over the long haul even if he didn’t notice any symptoms acutely.

Finally, in my recent article, Corrective Exercise: Why Stiffness Can Be a Good Thing, I spoke about how someone can have crazy short hip flexors and still manage a perfect squat pattern because his stiffness at adjacent joints is outstanding.  If I don’t assess him in the first place and just assume that he squats well, I’m just waiting for him to strain a rectus femoris during sprinting or any of a number of other activities.  Gross movement in a strength and conditioning program wouldn’t tell me anything about this individual, but targeted assessments would.

The point is that while Nick’s statement is absolutely true – demanding perfect form is corrective in itself – you’ve still got to assess to have a clear picture of where you’re starting.  Otherwise, many cases like this will slip through the cracks.

To that end, I’m happy to announce that my long-time friend and colleague, Mike Robertson, recently released his Bulletproof Knees and Back Seminar DVD Set.  This comprehensive product covers anatomy, assessments, program design, and coaching.  In fact, almost the entire second day is focused on coaching, and that’s an area in which most trainers really do need to improve.  All in all, this isn’t a collection of bits and pieces; it’s Mike’s entire philosophy on training someone who is suffering from knee or low back pain (and how to prevent it in the first place).  Effectively, Mike covers what both Nick and I are getting at in the paragraphs you just read.

Since Mike’s a great friend – and because he and his wife just had a new baby daughter that will surely shop a ton in her teenage years, go to college, and have an expensive wedding – I want to sweeten the deal and help him with sales, especially since this is tremendously valuable information that fitness professionals need to hear.

With that said, anyone who purchases the Bulletproof Knees and Back Seminar DVD Set by this Friday (5/13) at midnight will receive a free 37-minute upper extremity assessment video I recently filmed for my staff in-service and uploaded to the web.  In other words, Mike covers the back and lower extremity and I cover the upper extremity, meaning you’ve got a head-to-toe resource at your fingertips.  Just forward your receipt to me at ec@ericcressey.com and I’ll send it along this weekend.

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Stuff You Should Read: 5/2/11

Written on May 2, 2011 at 5:59 am, by Eric Cressey

Here are a few recommended reads to kick off the week:

The Truth About Gluten – Here’s an excellent piece from Dr. Mike Roussell on how gluten intolerance can sabotage your nutritional efforts.

Waterhorse: The Legend of Tim Collins’ Nickname – This was a funny write-up in the Kansas City Star on how Cressey Performance Athlete and KC Royals pitcher Tim Collins got his nickname while training at CP.

Why I Do Not Like YTWL Shoulder Exercises – Here’s a great post from Mike Reinold – and I agree with him 100%.

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Stuff You Should Read: 4/25/11

Written on April 25, 2011 at 5:19 am, by Eric Cressey

To kick off the week, here’s a quick rundown of things you might like to read (or watch):

The 5 Most Common Deadlift Mistakes – I published this blog at Men’s Health last week, and thought I’d give you a heads-up on it.  It’s a good tag-along to the FREE video I provide HERE on how to deadlift (you can also subscribe in the opt-in box at the bottom of this blog to get access).

Does Hip Range of Motion Correlate to Low Back Pain?  Maybe Not in Everyone – This is a good post from Mike Reinold that talks about how research on the topic can be tough, and that rotational sport athletes and sedentary folks need to be considered differently.

Anti-Rotation Sled Dragging – Here’s an innovative core exercise from Jim “Smitty” Smith utilizing the sled for your strength and conditioning program.

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Why Nobody Except Your Mom Reads Your Fitness Blog

Written on April 20, 2011 at 2:32 pm, by Eric Cressey

I got an email from Dean Somerset last weekend if I’d be willing to write up a post for his blog about how I built up a popular fitness blog myself.  I thought it over, and while I like Dean and enjoy reading his blog, I really didn’t think I was the right person to write such a piece.  There are folks who are much smarter when it comes to behind-the-scenes stuff that goes in to running a blog – from WordPress updates, to HTML formatting, to SEO optimization.   And, there are certainly folks out there who have monetized their blog far better than I ever will.

That said, I do feel that there was one incredibly valuable point I should make to the aspiring fitness bloggers out there:

If you don’t have good content, your blog won’t get consistent traffic.  It’s really that simple.

I started this blog in early 2006 with really no idea what I was doing on the technology side of things.  I loved my job and was passionate about teaching – and writing gave me an avenue through which to do it.  Sometimes, I wrote about what I knew well, and sometimes, I wrote about topics where I wanted to improve – and researching them and teaching them to others was the best way to get better in these areas.  Before I ever hired someone to make my site look pretty, I’d built up a solid following of people who knew me purely for my content, enthusiasm, and accessibility to readers.

A trend I see with “rookie” fitness bloggers nowadays is to design a spectacular site from the get-go and devote all their resources to SEO optimization, pop-up ads, Google Adwords, and the like.  Unfortunately, these efforts are sabotaged by these bloggers’ poor grammar/spelling and, more significantly, a complete lack of valuable information to offer to readers.

In any industry, you look for commonalities among those who succeed at what we do.  For ease of calculating “success,” let’s just use Alexa ranking.   You can learn more about it (and download a free toolbar) at www.Alexa.com, but for the sake of brevity, just understand that it is a measure of the popularity of a website.  Get more hits, receive more inbound links from popular sites, and have people spending more time on your site, and your Alexa rank will go down (a lower number is better).  Google is #1, Facebook is #2, Yahoo is #3, and so on.  It’s not a perfect measure by any means, but when you are dealing in the top one million sites or so, it’s generally accepted to be pretty good. I’m lucky to be at around 101,000 right now, and have been as high as 89,000 in the past.

If you’re in the top one million or so, you’re likely doing some very good traffic – and certainly enough to monetize your blog.  My buddy Tim Ferriss’ blog, for instance, currently has an Alexa ranking of 3,644, and he’s an absolute ninja on the entrepreneurial side of things, with two New York Times bestsellers and ownership stakes in the likes of Facebook, Twitter, Stumbleupon, and several other companies.  He’s a success, in part, because every single one of his posts (and books) provides outstanding content that readers not only enjoy – but pass along to their friends.

Translating this message to the fitness industry, look at a guy like Charlie Weingroff.  He might be one of the few guys out there who understands technology less than I do, and there is absolutely nothing flashy about his site.  To be candid, it’s pretty basic.  You know what, though?  Charlie is an extremely bright (and strong) dude with a ton to teach, a passion for teaching it, and a knack for relating complex information in a user-friendly manner.  I don’t think his blog has even been out for a year, yet he’s ranked around 639,000.  And, he’s used his blog to make his expertise known, build a loyal following, and launch a successful product (which is outstanding, by the way).

There are several other fitness bloggers who’ve become “top one million” success stories purely with content.  John Berardi dominates with Precision Nutrition (64,000), which has been built with science, integrity, and an ultra-personal touch to great content all along.  My business partner, Tony Gentilcore (706,000) kicks out great content and entertains people like crazy.  My good friend Mike Robertson (103,000) is an awesome teacher and genuinely great guy.  Nick Tumminello (537,000) innovates like crazy to build a following, and Chad Waterbury (475,000) only recently created his own web presence and has used content to quickly ascend the ranks.  Nate Green (202,000) is an excellent writer who has carved out a great niche for himself and built a great following at a young age because of his unique content.  Mike Reinold (400,000) has built a great following in a smaller internet segment (physical therapists) with consistent content featuring up-to-date research, attention to many different clinical perspectives, and a specific focus on upper extremity dysfunction.  These guys all offer something others don’t.

You know who hasn’t built a big following?

• The random fitness dudes who send Facebook friend requests to my wife because they have mutual friends – and these guys want to build their lists.  I’ve yet to meet a single one who is in the top 2 million.

• The “fitness business guru” who emailed me four times, called my office twice, and snail-mailed me once (each of which was ignored) to try to get me to promote his product, which he guaranteed would make personal trainers “rich.”  His website ranked at higher than 6.6 million – which essentially means that he has zero traffic other than himself (and he’s probably just checking in to see if he’s gotten his first hit yet).  Instead of focusing on content (and moving out of his parents’ basement), he’s putting the cart in front of the horse and trying to sell a product on a topic (success) that he doesn’t even understand.

• The random dude who wants to exchange links with me or be added to my blogroll so that he can improve his rankings without doing a thing, much less providing some value to me (or society in general).

The only thing that’s worse than sucking at what you do is sucking at what you do and spending time and money to draw attention to it.

I started out thinking that this would be a short, to-the-point, blog, but as I now realize, that one little point was actually a very big one.  Pretty websites and behind-the-scenes tinkering are undoubtedly important components of taking an online presence to the next level, but the truth is that they don’t matter a bit unless the content that accompanies them is useful and entertaining.

If it’s not, then you’ll have a hard time even getting Mom’s attention.

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A Great Read on Shoulder Instability

Written on March 30, 2011 at 6:39 am, by Eric Cressey

My next blog (which is one of the best things I’ve ever written, in my opinion – so don’t miss it!) will go live tonight, but in the meantime, I wanted to encourage you to check out a great two-part article from my buddy Mike Reinold, the head athletic trainer and rehabilitation coordinator for the Boston Red Sox (not to mention the co-creator of the Optimal Shoulder Performance DVD set).  Mike delves into shoulder instability in great detail:

Key Factors in the Rehabilitation of Shoulder Instability: Part 1

Key Factors in the Rehabilitation of Shoulder Instability: Part 2

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Stuff You Should Read: 1/31/11

Written on January 31, 2011 at 6:07 am, by Eric Cressey

Testing, Treating, and Training the Shoulder – This recap of my seminar with Mike Reinold features ten important takeaways from the day.

You Are What You Absorb – I thought this was an excellent article from John Meadows – both in terms of the background information he provides and the corrective strategies he advocates.

Rollouts: Friend or Foe and Two Anterior Core Progressions – These two video blogs were quite popular when they ran back in 2009.

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Stuff You Should Read: 1/23/2011

Written on January 23, 2011 at 2:22 pm, by Eric Cressey

It’s been a while since I gave you a list of recommended reading, but that changes today!

Rotten Resolutions – I usually bring this article to light right at the beginning of January each year, but forgot in light of the busy last few weeks.  Check it out.  It might make you see your strength and conditioning program goals in a new light.

Ankle Dorsiflexion Immobility Impairs Lateral Step Down Test – This is a good post from Mike Reinold about how ankle restrictions can alter testing further up the kinetic chain and make you see “the big picture.”

The Proactive Patient – I still think that this is one of the better articles I’ve ever written at T-Nation.  What do you think?

High Performance Training without the Equipment: Installment 2

Written on January 4, 2011 at 11:03 am, by Eric Cressey

It goes without saying that some of the absolute posterior rotator cuff exercises are cable external rotation variations.

Unfortunately – as you may have inferred from the title of this post – not everyone has access to a cable column or functional trainer where exercises like this can be performed.  To that end, I thought I’d devote today’s post to a few exercises one can substitute to get a very similar training effect without cable access.

Option 1: Elbow-Supported DB External Rotation

This movement parallels that of the cable option, but all you need is a dumbbell and something to prop your upper arm.  The only downside is that the resistance just isn’t as “continuous” throughout the range of motion – but it’s still a good option.

Options 2 and 3: Horizontal Abduction Variations

While the recruitment patterns aren’t going to be exactly the same, it’s safe to say that you’re getting almost all the same benefits when you do horizontal abduction work as with true external rotation work (and likely a bit extra scapular stabilization benefits).  Two variations I like:

Prone Horizontal Abduction off Table

Side-Lying Horizontal Abduction (I like to load this one up more eccentrically and focus on really controlling the load on the way down)

Option 4: Side-Lying External Rotations – arm abducted 30 degrees

This movement might not be the most “specific” of all rotator cuff exercises because of the position in which it occurs, but it does give you the best posterior cuff EMG of just about any drill.  We use it a ton, especially in those who may have pain with positions requiring more shoulder elevation.

These drills are just the tip of the iceberg in terms of the modifications you can use – and, indeed, what should comprise a comprehensive shoulder health program.  However, they should be enough to help you work around the lack of a cable in your resistance training arsenal.

For more information, check out our Optimal Shoulder Performance DVD set.

Related Posts

High Performance Training without the Equipment: Installment 1
Clearing up the Rotator Cuff Controversy