Shoulder Care 101

Contrary to common belief, being able to throw a 90 mph fastball or strict pressing 225 pounds does not mean that the athletes are doing these competently. Although it is great that the athlete is able to perform the task, we must look and see if he or she will be able to continue to perform the task. Longevity is the name of the game, whether it’s sports or general fitness, it is important to check for movement competency.

Kids are playing sports at younger ages than ever before. Add in things like Fortnite, cell phone use and lack of a proper strengthening regimen and you have a recipe for problems in posture and overall shoulder integrity. Fortunately, there are many ways to evaluate whether the shoulder is being compromised or not.

The three simple variables that we are going to look at to see how competently an athlete is doing these tasks are:

1. Integrity of the joint- is the humerus in a good position in the socket?
2. Mobility of the joint- are there any asymmetries limiting its ability to move?
3. Strength of the musculature around the joint- does the athlete possess the strength to move and stabilize the joint?

These are just a few things to look at and by no means the tell all. However, these are broad ways to assess any underlying problem that an athlete may have or could have in the future. This could potentially save you a lot of money and heartache when an injury occurs and a specialist is needed.

WHAT ENCOMPASSES THE SHOULDER?

When talking about the shoulder, we are more or less talking about the proximal head of the humerus (upper arm) and where it attaches in the glenohumeral joint. As well as the scapula (shoulder blade) and where the scapula attaches to the clavicle (acromioclavicular joint) and lastly, where the clavicle attaches to the sternum (sternoclavicular). They work hand in hand, and if either one is weak, or tight, it will cause problems down the line.

Another thing that should be taken into consideration about the shoulder is the relationship of the ball and socket in the glenohumeral joint. It is often represented as a “golf ball on a tee” as to represent the relationship of the larger size of the ball and small size of the socket in the shoulder. While this is a little exaggerated, it shows the balancing act of the shoulder joint and how easily the shoulder could be swayed to one way or the other.

SCAPULAR MOVEMENT

Proper terminology would be scapulothoracic mobility, however, we will just call it the shoulder blade and upper back mobility for ease of use. The scapulothoracic joint involves articulation between the ribs and shoulder blade, with the shoulder blade sitting flush against the posterior rib cage in addition to still having the ability to move freely from the ribs.

The movement of the shoulder blade is almost completely dependent on outside musculature, which is why training the muscles controlling its many movements is crucial to the shoulders health. Some of the muscles attaching to the shoulder blade are the trapezius, levator scapula, serratus anterior, rhomboids, and the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis). All of which keep the scapula in a good position and move it through elevation, depression, anterior/posterior tilt, protraction (shoulder blades move apart), retraction (shoulder blades pinch together), and upward and downward rotation.

Without possessing the ability to move the shoulder blade(s) freely, it is almost a guarantee that your athlete will experience some sort of shoulder impingement or injury if not addressed. At the same time, doing too much of one strengthening exercise could cause it to be overreactive in any one movement/muscle, which could also result in injury. This is why it is important to always reevaluate your athlete for any new asymmetries.

WHAT TO LOOK FOR?

How often do you hear people say “I work out every day, but I am still experiencing shoulder pain” or “I stretch my shoulders every day and I never see progress?” This just shows that in order to fix a shoulder problem you have to understand where the problem is coming from. Usually, this is when you ask yourself, where is my problem?

First, in order to get an idea of if and where there is a problem, we can simply look at the shoulder joint while the athlete is in a relaxed position. You can often see deficits that an athlete has by how the shoulder is sitting in the joint. Is it sitting forward? Is it sitting high? Or is it maybe sitting too low? These are all questions to ask while evaluating the position of the upper arm in its joint.

ANTERIOR HUMERAL GLIDE (Forward Rotated Shoulder)

This is when the shoulder is sitting anterior to the body or humeral joint capsule, which would indicate that the athlete's posterior cap (shoulder blade) is under reactive and weak, and possibly in a forward tilt. While the prime movers for adduction such as the pectoralis major, pectoralis minor, serratus anterior, and even the lats could be tight causing excessive internal rotation. This results in improper movement of the shoulder blade and AC joint.

So by analyzing that the shoulder is sitting forward in the socket, we have now classified that its integrity is compromised. This directly affects the mobility and strength of the joint.

The results of forward rotated shoulder(s) could be but are not limited to, the inability to perform overhead movements, pressing movements, or just pulling movements such as an overhead squat, military press, bench press, rows, pull-ups, and even throwing.

This can mostly be attributed to the acromion (bone above the upper arm) being too close to the humerus, not giving it adequate space to move freely, which causes impingement or pinching of the muscles that surround the joint.

CAUSES OF ANTERIOR HUMERAL GLIDE

This is a very common problem with athletes who are consistently performing some sort of throwing or pressing motion in the same plane (normally the sagittal plane) of movement with the same grip. However, one of the biggest contributors of anterior humeral glide is posture.

In fact, more times than not an athlete or even the general population acquire their imbalances and weaknesses in their sport or job rather than the weight room. For example, posture while sitting in the car, desk, or walking will have a huge impact on shoulder health. As most people spend a significantly greater amount of time doing those things poorly on a day to day basis. Fortunately, making the conscious effort to sit with your shoulders back correctly and keep the chest upright is a step in the right direction in fixing the problem. However, there are many examples of thing that we can do better in each of these scenarios that often go unnoticed until a problem arises.

WHY THIS COULD CAUSE PROBLEMS?

By placing the shoulder in the forward position, it keeps the shoulder blade in a compromised position all day, with no break, and the muscles become fatigued. So if you figure that the backside of the shoulder is fatigued just by poor posture, just think if you are to go and load that shoulder via throwing, lifting, or even hard contact like in football. The demand placed on the rotator cuff over time will ultimately result in injury.

For example, when constantly accelerating an object, in this case a ball, forward over hundreds of repetitions, the shoulder is indeed placed under demand while performing this task. However, the problem stems from what happens when the ball is released. The arm just slings down to the side of the athlete stopping abruptly from its forward motion bringing the scapula forward even more. Now you can see why over a series of 60 throws the shoulder would take a beating, after accelerating and getting stopped/jerked abruptly. It is that constant motion without strengthening that causes some asymmetries or weakness in the shoulder. Fortunately, through various strengthening and mobility exercises, this asymmetry can be counteracted if handled correctly.

LIMITING FACTORS TO SHOULDER MOBILITY

1. Thoracic Mobility: This is the ability of the body to rotate at the shoulders, otherwise called T-spine mobility. Stiffness in the T-spine is caused by the same muscles aiding in shoulder movement, so the mobility of the spine will limit an athlete's overhead position, throwing mechanics and other basic movements.
2. Fatigue: One thing to always consider is fatigue and how to compensate and work around it. Again, we see great fatigue and tightness in the anterior shoulder with our throwing athletes due to the overuse of the arm for a long period of time. However, the same thing goes for someone who has been sitting at the desk all day with poor posture. Your muscles tighten up and fatigue, resulting in the compromised integrity of the shoulder. This is why for the most part, with your throwing athlete, there isn’t a tremendous need for vertical and in most cases horizontal pressing due to those muscles being used so heavily. Coincidentally, attacking the posterior muscles of the scapula and shoulder won’t work either, it will only further induce fatigue. So the best time for athletes to manage fatigue is during the off-season when there is limited time performing the skills associated with the sport, and more time for strengthening.

EXERCISES TO AVOID

It is important to realize that these movements don’t cause problems for everyone. However, if you have any shoulder issues, doing these movements could only further compromise the joint.

Bench Dips:

Bench dips should be avoided because it puts the shoulder blade in an elevated position driving the humerus even further forward in the socket.

Upright Row:

The reason a problem arises here is that the movement puts the shoulder into internal rotation and elevation. This is a bad combination as it does not allow the scapula to free up enough space for the arm to move to its desired height. This ultimately results in impingement and pain of the muscles of the shoulder and bicep tendon.

CORRECTIVE EXERCISES FOR FORWARD ROTATED SHOULDER

With an anterior glide, the scapula is put in elevation and anterior tilt. So the first thing we want to do is work the muscles that will get the scapula sitting flush against the ribs again.

Scapular Protraction/Retraction Drill:

In this drill we are trying to just work proper articulation of the Scapulothoracic Joint. By going through these motions an athlete can better comprehend how to manipulate the position of the scapula. For example; if you tell the athlete to keep their shoulders down and back during a Deadlift. They will (after performing drills like this multiple times) be able to reciprocate the proper technique.

Serratus Plank Push-Up:

We are focused on getting the serratus anterior firing during this drill. The emphasis here is to not just push away but to foresfully drive your chest away from the floor. The serratus has a great deal to do with proper scapular positioning and also allows proper upward rotation of the scapula.

Draw the Arrow: Alternative to upright row

MOBILITY EXERCISES

T- Spine mobility work is crucial in opening up the muscles of the upper back to allow for adequate shoulder blade movement.

The seal hip bridge will open up the front side of the shoulder while externally rotating the hands allowing the shoulder to not be pulled so heavily forward.

Supine Aztecs:

This is a great way to work on internal and external rotation with contact through the floor being the goal. End goal is to be able to lay forearm and palms flat on the ground on each rotation.

STRENGTHENING EXERCISES

The first thing when choosing your exercises is again knowing that the shoulder is pulled forward. So a lot of the exercises should encompass in some way, shape or form, external rotation or scapular/shoulder stability

This is a very simple way to hit the external rotators of the shoulder, however, with their being shoulder flexion involved this can sometimes cause impingement if the acromion is sitting to low.

So if you are experiencing this you can perform this same movement on your side.

Banded ER with Step-Out:

This is a great overload for external rotation, with emphasis on the eccentric. This will work on deceleration of the Arm and strengthen the posterior cap. (Shoulder should come forward once hand reaches for hip as this is a natural component to decelerating the arm)

Lateral Banded ROM:

As soon as the arm is raised from the hip, the shoulders stabilizers are now working. Then by taking the shoulder through flexion the shoulder stabilizers will have to stabilize through the full range of motion. It may be difficult to go all the way through the motion, in this case stop there and build up to a full range.

If you do not have a band here is a simple Stability ROM alternative.

Same principle, which is to lift dumbbell or plate of the hip, and then go through a full range of motion. In this video the down arm (The one being laid on) is in external rotation (thumb to the floor) and is pushing down through the ground.