Optimal Shoulder Performance

From Rehabilittaion to High Performance

ShoulderPerformance.com

Eric Cressey, MA, CSCS is the president of Cressey

Performance in Hudson, MA. Cressey is a highly sought-
after coach for healthy and injured athletes alike from youth
sports to the Olympic and professional ranks, with baseball
development as his greatest focus. Behind Eric’s
expertise, Cressey Performance has rapidly established
itself as a go-to high-performance facility among Boston
athletes – and those that come from abroad to experience CP’s cutting-edge methods.

Eric has lectured in four countries and more than one dozen U.S. states; written over
200 articles and four books; contributed on scientific journal articles and book chapters;
and co-created four DVD sets. He publishes a free weekly newsletter and daily blog at
http://www.EricCressey.com. A record-setting competitive powerlifter, Cressey has
deadlifted 650 pounds at a body weight of 174 and is recognized as an athlete who can
jump, sprint, and lift alongside his best athletes to push them to higher levels.

Michael M. Reinold, PT, DPT, SCS, ATC, CSCS is considered a

leader in orthopedic and sports rehabilitation as a clinician,
educator, and researcher, with specific emphasis on the shoulder
and the treatment of overhead athletes. Mike is currently the Head
Athletic Trainer of the Boston Red Sox and Coordinator of
Rehabilitation Research & Education for the Sports Medicine
Division of Massachusetts General Hospital.

Mike has lectured extensively throughout the nation, published

over 50 scientific journal articles and book chapters, and is the
author of the textbook, The Athlete’s Shoulder, 2nd Edition. Mike’s contributions to
sports medicine have earned recognition by groups such as the APTA, ESPN, Sports
Illustrated, The Sporting News, Men’s Health, The Boston Globe, and The Boston
Herald. For more information, visit Mike’s free educational website at
http://www.MikeReinold.com.
This DVD and the following guidelines have been provided as general information for exercise and
rehabilitation and are intended for educational purposes. Any individual beginning exercises
contained in this video, or beginning any other exercise program, should first consult with a qualified
health professional. Discontinue any exercise that causes discomfort and/or dysfunction and consult
with a qualified medical professional. Please consult with a physician prior to implementing any
rehabilitation or exercise protocol. This DVD does not contain medical advice. The instructions
and advice presented are in no way a substitute for professional testing, instruction, or training. The
creator, producer, and distributor of this DVD and program disclaim any liabilities or loss, personal or
otherwise, in connection with the exercises and advice herein.
 What would you think if a
Inefficiency vs. Pathology coach/trainer had…
• 82% of his athletes with disc bulges or herniations
Eric Cressey at one level, and 38% at more than one level?
www EricCressey com
www.EricCressey.com • 27% of his athletes with vertebral fractures?
www.CresseyPerformance.com • 34% of his athletes with rotator cuff tears?
• 79% of his overhead throwing athletes with labral
tears?
• 26% of his jumpers with patellar tendinopathy?

Jost B et al. MRI findings in throwing shoulders: abnormalities

Miniaci A. et al. Magnetic resonance imaging of the shoulder in professional handball players. Clin Orthop Relat Res. 2005
in asymptomatic professional baseball pitchers. Am J May;(434):130-7.
Sports Med. 2002 Jan-Feb;30(1):66-73.
• Researchers looked at throwing and non-throwing shoulders of 30
• 79% of professional pitchers handball players and non-athletes w/MRI
(28/40) had “abnormal labrum” • More abnormalities seen in throwing shoulders
features • “Although 93% of the throwing shoulders had abnormal magnetic
g
• …“magnetic resonance imaging
g g resonance imaging findings, only 37% were symptomatic.”
of the shoulder in asymptomatic • “Symptoms correlated poorly with abnormalities seen on magnetic
resonance imaging scans and findings from clinical tests. This suggests
high performance throwing
that the evaluation of an athlete's throwing shoulder should be done
athletes reveals abnormalities that very thoroughly and should not be based mainly on abnormalities seen
may encompass a spectrum of on magnetic resonance imaging scans.”
‘nonclinical’ findings” • Not just about throwers, though! Has been demonstrated with
swimmers, volleyball players, AND non-athlete controls…
*There are people out there – myself included – that think that
you may very well need a SLAP lesion to throw hard in the first
place!

Jensen MC, et al. Magnetic resonance imaging of the lumbar

Rotator Cuff Fun… spine in people without back pain. N Engl J Med.1994 Jul
14;331(2):69-73.

• Sher et al. (1995): MRIs of 96 • MRIs of 98 asymptomatic backs

asymptomatic subjects, RTC tears
in 34% of cases, and 54% of those • “52 percent of the subjects had a bulge at at least one level, 27
older than 60. percent had a protrusion, and 1 percent had an extrusion [82%
• Miniaci et al. (1995): MRIs of 30 of subjects]. Thirty-eight percent had an abnormality of more
shoulders under age 50 with “no than one intervertebral disk. The prevalence of bulges, but not
of protrusions, increased with age. The most common
completely ‘normal’ rotator cuffs.”
nonintervertebral disk abnormalities were Schmorl's nodes
23% had evidence of partial- (herniation of the disk into the vertebral-body end plate), found
thickness tears. in 19 percent of the subjects; annular defects (disruption of the
• Connor et al. (2003): eight of outer fibrous ring of the disk), in 14 percent; and facet
20 (40%) dominant shoulders in asymptomatic tennis/baseball arthropathy (degenerative disease of the posterior articular
players had evidence of partial or full-thickness cuff tears. Five of 20 processes of the vertebrae), in 8 percent. The findings were
had MRI evidence of Bennett’s lesions. similar in men and women.”

1

Soler T, Calderon C. The prevalence of spondylolysis in the
Spanish elite athlete. Am J Sports Med. 2000 Jan-
Feb;28(1):57-62.
• 8% of elite Spanish athletes affected
• 27% of track & field throwers, 17% of rowers, 14% of
gymnasts, and 13% of weightlifters
• L5 most common (84%), followed by L4 (12%).
• Bilateral 78% of the time
• Only 50-60% of those diagnosed actually reported low back
pain
• Presence of spondylolysis is estimated at 15-63%, with the
highest prevalence among weightlifters.
• Presence is estimated at 3-7% in the general population
Chou R et al. Imaging strategies for low-back pain:
systematic review and meta-analysis. The Lancet,
2009;373 (9662), 463-472.
• Review of imaging for low back pain without significant
red flags suggesting serious conditions (cancer, fracture,
etc)
• “Lumbar imaging for low back pain without indications of
serious underlying
y g conditions does not improve
p clinical
outcomes.”
• “Therefore, clinicians should refrain from routine,
immediate lumbar imaging in patients with acute or
subacute low back pain and without features suggesting a
serious underlying condition.”
• Some research suggests that MRI leads to poorer outcomes
in back pain patients

You Kneed to Know… Just to Scare You a Bit More…

Cook JL et al. Patellar tendinopathy in junior basketball players:
a controlled clinical and ultrasonographic study of 268 patellar “Somewhere between 2
tendons in players aged 14-18 years. Scand J Med Sci Sports. 2000 and 8 percent of the time in
Aug;10(4):216-20.
American hospitals, a patient
• 34 elite jjunior basketball players
p y (268( total patellar
p tendons)) havingg a genuine
g heart
• Only 19 tendons (7%) presented clinically with symptoms of attack gets sent home –
tendinopathy.
• However, under ultrasonographic examination, 26% of all tendons
because the doctor doing
could be diagnosed with tendinopathy based on degenerative changes. the examination thinks for some reason that the
• For every one diagnosed, more than three are overlooked…
patient is healthy.”
• This is magnified as one ages!
-Malcom Gladwell, in Blink

We’ve misinterpreted the meaning Wordplay?

of the word “pathology.”
• “any deviation from a healthy, normal, or • My primary goal for today is to show you
that if you correct the inefficiency, you’ll
efficient condition” (dictionary.com) markedly reduce the likelihood that these
• In
I other
th words,d “inefficiency”
“i ffi i ” and
d “ h l i ” reach
“pathologies” h threshold.
h h ld
“pathology” may in fact be the same thing. • Effective screening, and an understanding
of population-specific “norms” is the key.
• The site of the pain isn’t always the source
of the problem…

2
 Maffulli N, Khan KM, Puddu G. Overuse tendon conditions:
Perhaps the Best Example… time to change a confusing terminology. Arthroscopy. 1998
Nov-Dec;14(8):840-3.
• The Tendinopathy Debate • “In overuse clinical conditions in and around tendons, frank
• Tendinosis inflammation is infrequent, and is associated mostly with tendon
ruptures. Tendinosis implies tendon degeneration without
– osis = degenerative clinical or histological signs of intratendinous inflammation, and
– Tissue loading exceeds tissue is not necessarily symptomatic.
symptomatic Patients undergoing an
tolerance operation for Achilles tendinopathy show similar areas of
degeneration. When the term tendinitis is used in a clinical
• Tendinitis context, it does not refer to a specific histopathological entity.
– itis = inflammatory However, tendinitis is commonly used for conditions that are
– Inflammation should be easily truly tendinoses, and this leads athletes and coaches to
controlled with cortisone underestimate the proven chronicity of the condition.”
• “The combination of pain, swelling, and impaired performance
injections and/or NSAIDs
should be labeled tendinopathy.”

The Truth is… Waiting to Reach Threshold?

• Anyone who has ever dealt with a “tendinitis”
diagnosis knows that it isn’t so easy to fix…
• So,, traditional treatment modalities are often
based on the wrong diagnosis.
• Many people get healthy simply because they
implement rest for the tissues – not because
they address underlying inefficiencies.
• Remember Cook et al.: while
26% of tendons could be
diagnosed with tendinopathy
under ultrasonographic exam,
only 7% presented clinically
with symptoms
• The other 19% are just
waiting to reach threshold.
• Tendinopathy is a constant
“give and take” in every
muscle in the body, and
degeneration is population
and activity-specific.

Kinesio-Taping
The Law of Repetitive Motion
• Perfect example of the
difference between I = NF/AR
tendinitis and • I = Insult/Injury to the tissues
tendinosis
• N = Number of repetitions
• It works
k tto redistribute
di t ib t • F = Force or tension of each repetition as a percent
stress appropriately of maximum muscle strength
• Training should do • A = Amplitude of each repetition
the same!!
• R = Relaxation time between repetitions (lack of
pressure or tension on the tissue)

3
 The Law of Repetitive Motion Building Blocks to Dysfunction:
I = NF/AR
Soft Tissue Restrictions
• Poor posture: higher forces with
Lifting tasks (no change in amplitude Pec Minor
or relaxation => high insult) Inferior Capsule
• Sitting at a computer: high number Subscapularis
p
Teres Minor
of reps (constant activation) with low
Infraspinatus
amplitude and lower relaxation time.
• The weaker you are, the higher the percentage of maximal
strength you’ll use to accomplish a task.
• Resistance training can be extremely effective in correcting
problems quickly. Otherwise, we’d have to sit with For more information, check out Dr. William Brady
“more-than-perfect” posture for an equal amount of time to at www.integrativediagnosis.com.
iron things out.

The Bigger Picture: Quantify what you can, and

12 Shoulder Health Factors video/photo whatever you can’t!
Overuse
Rotator Cuff Weakness
Scapular Stability
Poor Glenohumeral ROM
Soft Tissue Restrictions
Poor Thoracic Spine Mobility
Type 3 Acromion
Poor Exercise Technique
Poor Cervical Spine Function
Opposite Hip/Ankle Restrictions
Poor Structural Balance in Programming
Faulty Breathing Patterns

We need to look at all of them to be comprehensive.

Things We Quantify:
• Glenohumeral internal rotation, external
rotation, and total motion
• Thoracic spine mobility Case Studies!
• Hip internal rotation, external rotation, and
flexion
• Knee flexion
• Combined Tests (fist-to-fist)

4
 Glenohumeral Internal Rotation Deficit (GIRD)
16-year old Pitcher

• Medial Elbow Pain

• Previous treatments included forearm
exercises,, ultrasound,, rotator cuff
strength/endurance, and scapular stability
• Cleared for a full return to play
• No assessment of glenohumeral range of
motion or front hip ROM.

The “Perfect” GIRD? GIRD “Threshold?”

Right Shoulder: 19°IR, • Burkhart et al. reported that all of a 124-thrower
103°ER, sample size with Type II SLAP lesions presented
122° Total Motion with an internal rotation deficit of greater than
25°.
Left Shoulder: 53°IR • Myers et al.
al pinned that “don’t
don t cross this line
line”
90°ER number at a 19.7° deficit.
143° Total Motion • The research on non-symptomatic throwing
shoulders was in the 12-17° range.
Asymptomatic, and cleared for a full return • Every little bit matters – and this applies to
to play with a 21° total motion deficit and elbows, too!
34° GIRD.

Treatment?
Same Deficits, Slightly Different Problem
• 16-year old got
• 23 year-old Professional Pitcher
ultrasound
• Medial Elbow Stress Fracture
• 28° GIRD, 16° Total Motion
• 23-year old got a
Deficit bone stimulator
• 35° Hip IR on Front Leg (goal = • Neither of them
>40°) fixed their shoulder
• 124° Knee Flexion on Front Leg or hip ROM deficit!
(goal = >135°)

5
 • This is like banging your head against the
wall.
• Does the wall or your head break first?
• Incorrect Approach: patch the wall or
take some ibuprofen for your head
• The Correct Approach: Stop banging
your head against the wall.
Wow…
• Fractured Right Hip
Three Years Earlier
• 23° of Hip Internal
Rotation (goal = >40°)
40 )
• You can “cheat” on
your hip motion with
long toss, but you can’t
cheat when on the mound, when stress is higher.
Lessons…
• Similar injuries, different causes!
• Different injuries, similar causes!
• Each hit threshold for different reasons. This may
be age-specific.
• Your assessment and corrective approach must be
thorough – and specific to the sport.
• Look at multiple joints – both strength and
flexibility – as well as tissue quality
• Follow-up exercise selection and overall
programming must be appropriate – and the
exercises must be performed correctly.
17-year-old Left-Handed Pitcher
• Chronic Left Shoulder Pain
• Positive SLAP tests
• Tried rotator cuff and scapular stability
exercises
• Could long-toss pain free, but had
significant pain with throwing off the
mound
• What gives?
Another 17-year-old Pitcher
• Both posterior shoulder pain and medial elbow
pain
• Addressed cuff weakness, hip ROM issues, soft
tissue quality – and pretty much did everything
right!
i h!
• But, athlete jumped the gun on his throwing
program – and didn’t integrate the new hip
mobility into his movements.
• You can lead a horse to water, but you can’t make
him drink…
I know, I know…
• Most of you aren’t rehabilitation specialists – and
I wouldn’t consider that my realm, either!
• In reality, though, this is because less black and
white – and a lot more gray nowadays.
• Why?
W y?
– Insurance companies are more and more stingy.
– As I showed earlier, pretty much everyone is
messed up – and even those who aren’t usually
don’t move well.
• And let’s be honest…
6
 Active vs. Passive Restraints
• Active: muscles, tendons, and (to a lesser
degree) bone
Later on, we’ll go through how to
• Passive: meniscus, labrum, discs assess the function of all these
• Poor active restraint function (strength, active restraints…
tissue quality, or ROM) leads to increased
stress on the passive restraints, or issues
with the active restraints themselves.

7
 Testing, Treating, & Training the Shoulder This Presentation

• Discuss some general concepts behind shoulder

Clinical Examination of the Shoulder examination
• Where we are with evidence-based exams
• How to use evidence & experience!
• Some differential diagnosis tests
• When to refer out
• When to treat & correct
• Clips from DVD on shoulder exam
from AdvancedCEU.com
Michael M. Reinold, PT, DPT, SCS, ATC, CSCS
Boston Red Sox / MGH Sports Medicine
MikeReinold.com

Evidence Experience

• Unfortunately the evidence is still a • What your past experience has shown you
work in progress • Important component
• But getting closer every day • Put the pieces of the puzzle together
• Algorithm approach – each portion of exam leads the next
• The problem – portion
– Can’t completely base your exam on
evidence alone
– Not enough studies
– Conflicting information in the literature
– Different patient populations

Expertise – Combining Experience and Evidence The True Use of the Exam

• How does a recent graduate • To determine where to start with the patient and when to
conduct a shoulder send out to more qualified discipline
examination? – Secondary purpose to refer out as needed!
• How does the expert conduct a • What to perform and what to avoid
shoulder examination? • Make list of objective goals and plan to improve

• Be careful! Don’t get stuck in

your ways!

8
 Impingement Vs. Cuff Tear Assess Active Motion

• Progressive cuff pathology AC joint or subacromial

• Irritation Æ inflammation Æ fraying Æ tearing Impingement
• Identifying where in the process the person is currently

Rotator cuff tear vs.

inflammation

Impingement Tests Internal Impingement

The Thrower’s Shoulder Wilk,Reinold,Crenshaw,et al: ‘‘99

99--09
Motion and Laxity
• Examined ROM in 1400+
• Common findings professional baseball players
– Excessive ER • ER @ 90 deg abduction:
– Limited IR – Dominant: 129 + 10 deg
– Non-Dom: 121 + 9 deg.
deg
• Anterior laxity • IR @ 90 abduction:
• Posterior tightness – Dominant: 61 + 9 deg
– Non-Dom. 68 + 8 deg
• Total Motion: 190 + 14

Total Motion Equal Bilateral !!!

9
 Total Motion Concept Range of Motion After Throwing
Wilk et al AJSM 2002 Loss of Total Motion

• Pitching with loss of total

motion results in greater
chance of injury
– Ruotolo: JSES ’06
06
– Myers: AJSM ‘06

ER + IR = Total Motion

Range of Motion After Throwing

Loss of Total Motion

• Loss of IR normal
adaptation
• Injury occurs when loss
of TM
• Cumulative microtrauma
due to eccentric and
tensile forces

Causes of Loss of IR Motion

Humeral Retroversion
• Several studies have shown
retroversion of the humerus
– Crocket AJSM 2002
– Reagan AJSM 2002

10
 Causes of Loss of IR Motion
Not Posterior Capsule Contracture
• Borsa, Wilk, Reinold: AJSM 2005
• Examined GH translation in 43
professional baseball pitchers
– Anterior: 2.81 mm
– Posterior: 5.38 mm
• Significantly greater posterior translation
• No differences between D and ND
– No correlation between IR ROM and
posterior translation

Causes of Loss of IR Motion

Posterior Muscular Contracture
• Reinold: AJSM ‘08
• ROM Before & After Throwing
• Measure PROM before and
after pitching in 117
professional baseball players
• Significant decrease in:
– IR: -8.5°
– TM: -9.5°
– elbow extension: -2.4°
• Changes still present at 24
hours

Tomiya:: AJSM ‘04

Tomiya Tomiya:: AJSM ‘04
Tomiya

11
 Range of Motion After Season
Reinold & Gill: 2006
2006--2009

• I am not sure that the posterior capsule is the

• ROM changes over course of season
cause of the changes in IR in overhead
• Subjects stretched daily
athletes
Beginning End Change
– I have not seen this to be common in the healthy
Flexion 175 176 -
or the injured athlete
ER 133 138 +5 • IR is supposed to be less in the throwing arm,
IR 46 47 - amount depends on retroversion
TM 179 185 +6
– Throwing causes acute loss of IR, can become
E Flex 135 136 -
cumulative
E Ext -4 -6 -2
• Assess, DON’T ASSUME!

What is a Shrug??? What a Cuff Tear Looks Like

Assess cuff vs. capsule

DO NOT work through

a shoulder shrug arc of motion !!!

12
 What About Instability? Traumatic Dislocation

• Different types of instability

• Acute first time dislocation vs. congenital laxity MDI
• Actual capsulolabral tear vs just looseness

• Laxity
L it vs. IInstability
t bilit

Torn Posterior Capsule Voluntary Subluxation

Congenital Laxity CONGENITAL LAXITY!

13
 Acquired Laxity Instability

• Apprehension sign

Congenital Laxity Sulcus

• Sulcus sign
• > 10 mm positive

Sulcus Beighton Laxity Score

14
 SLAP Lesions
• SLAP’s are trendy right now
• Likely a little over diagnosed
• Well over 20 published “tests”
to detect a SLAP lesion
• Several variations of SLAPs
• Different tests for different
types of SLAPs

Compression Injuries Traction Injuries

Peel Back Lesions

Reinold & Gill: Sports Health ‘09

Wilk, Reinold, Andrews: JOSPT ‘05
Myers, Andrews: AJSM ‘06

15
 Shoulder Examination
Key Points
• We are still evolving into
evidence based examination
• Challenging progression
• Understand how the shoulder
functions
• Determine
– Specific structures involved
– When to refer out
– Where to begin
– What to avoid
• Look at causative factors
• The complete picture

16
 Training the Injured Shoulder
During and Post-Rehabiliation
Eric Cressey
www.EricCressey.com
Ei C
www.CresseyPerformance.com
Important Prerequisites…
• Primary goal should always be to fix what’s
wrong, not just keep things “fun.”
• When applicable, you can always train the
uninjured limb with great benefits.
• Know when to refer out. Two minds and skill sets
are better than one!
• Make the athlete feel like an athlete, not a patient.
• Look to soft tissue quality early-on…

External Impingement
External Impingement
• The Sedentary/Stationary
Shoulder Problem • Primary vs. Secondary
• Pain with: • Scapulohumeral Rhythm
– Overhead motion • Populations
p most commonlyy affected: lifters,, desk
– Approximation jockeys, elderly
– Periods of inactivity
(night, morning) • Tendinosis? Tendinitis? Bursitis?
– Internal Rotation • Supraspinatus? Infraspinatus? Biceps Tendon?
– Scapular Protraction Labrum?
• Bursal-sided cuff issues

External Impingement
External Impingement
• Eliminate overhead activities
• Soft tissue work: pec minor/major, upper
• Modify/Eliminate Horizontal Pressing traps, levator scap, scalenes, rhomboids,
• More horizontal ppulling,
g, asymptomatic
y p cuff RTC,, lats
exercises, scapular stabilization exercises • Thoracic Extension and Rotation
(improve upward rotation function)
• Avoid “at-risk” position: front squat in
• Gentle stretching for the internal rotators place of back squat
and pec minor
• Optimize thoracic spine mobility

17
 External Impingement Why?
Once symptomatic with ADLs: • Limited ROM before full ROM
(Feet-Elevated) Push-up Isometric Holds > (Feet- • Adducted before abducted
Elevated) Body Weight Push-up > Stability Ball
Push-up > Weighted Push-up > Neutral Grip DB • Unstable before stable
Floor Press > Neutral Grip Decline DB Press > • Cl d h i before
Closed-chain b f open-chain
h i
Pronated Grip Decline DB Press > Barbell Board
Press (gradual lowering) > Barbell Floor Press > • Dumbbells before barbells
Neutral Grip DB Bench Press > Low Incline DB • Isometrics before “regular” speeds
Press > Close-Grip Bench Press > Bench Press >
• Traction before approximation (e.g., pull-ups
Barbell Incline Press > ???Overhead Pressing???
would come before overhead pressing)

Internal Impingement Why is baseball an at-risk sport?

• AKA posterior-superior • Very Long Competitive Season
glenoid impingement – >200 games as a pro?
• Supra- and infraspinatus – >100 College/HS?
against P-S glenoid and • Unilateral Dominance/Handedness Patterns
labrum (articular-sided cuff
issues) – Asymmetry is a big predictor of injury
• High-speed, overhead – Switch hitters – but no “switch throwers!”
activities: swimmers, tennis • The best pitchers – with a few exceptions – are the
players, baseball players tallest ones. The longer the spine, the tougher it is to
• Encompasses a broad stabilize.
spectrum of more specific • Short off-season + Long in-season w/daily games =
diagnoses and pain tough to build/maintain strength, power, flexibility, and
presentation patterns optimal soft tissue quality

Kibler WB, Press J, Sciascia A. The role of core

The Demands of Throwing stability in athletic function. Sports Med.
2006;36(3):189-98.
• Shoulder stability is sacrificed for mobility
• Highly reliant on soft tissue function for stability
• 49% of athletes with posterior-superior
• Some numbers to consider during acceleration:
– 7,200+°/second internal rotation ((20 full revolutions pper
labral tears also had a hip rotation ROM
second) d fi i or abduction
deficit bd i weakness k
– 2,300°/second elbow extension
– 650°/second horizontal abduction
• Requires a collaborative effort of DOZENS of
muscles, not just the rotator cuff!

18
 Symptomatic Internal Impingement Eccentric Stress
• Glenohumeral Internal Dictates Dysfunction
Rotation Deficit (GIRD)
• Reinold et al. Changes in shoulder and elbow
• Why does it happen? passive range of motion after pitching in
• Role in SLAP lesions professional baseball players. Am J Sports Med.
• Almost everybody has 2008 Mar;36(3):523
Mar;36(3):523-77.
labral fraying and partial • “A significant decrease in shoulder internal
thickness cuff issues, but rotation (-9.5 degrees), total motion (-10.7
not necessarily w/symptoms degrees), and elbow extension (-3.2 degrees)
occurred immediately after baseball pitching in the
• Possible elbow dominant shoulder (P<.001). These changes
complications continued to exist 24 hours after pitching.”

Important Note: Some GIRD is Normal! External vs. Internal

• GIRD is a measurement, not a pathology
• If you throw, you're going to have retroversion even if you throw the soft tissue
Impingement
and capsular issues out the window.
• I typically use 12° as our cut-off of what is acceptable, and the number tends to
• External: • Internal:
get a little larger as guys get older and accumulate more mileage on their arms. – Physiological norm – Posterosuperior
• We are very IR focused with our stretching in-season and during the early off- Impingement
– Primary (acromion
season as our g guys
y come back from longg seasons (or
( we get
g kids with messed spurring) and – Specific to throwing
up shoulders and elbows for the first time) athletes
secondary (muscular
• Some guys never need it - particularly the multi-sport athletes. – Humeral head impinges on
weakness)
• Obviously, total motion plays into this as well. posterior labrum and
• Don’t just look at IR; look at posterior cuff strength, scap stability, t-spine
– RTC/biceps tendon glenoid
mobility, hip mobility, ankle mobility, soft tissue quality impingement under – Multiple pathologies can
• My general rules: <12° through age 18, <15° for 18-22, <18° for 22+ acromion result
• ¾ arm slot guys tend to be more pronounced that over the top guys – Bursal sided cuff – Articular-sided cuff issues
issues

The beauty of working with internal

Internal Impingement impingement cases…
• Optimize upward rotation function • Generally, almost anything you do in the weight-
room is fair game.
• Avoid stretching into external rotation, • Excluding:
horizontal abduction,
abduction and full extension! – Overhead
O h d lifti
lifting (not
( t chin-ups,
hi th
though)
h)
• Rest and NSAIDs won’t cut it! – Straight-bar benching
– One-Arm Medicine Ball Work
• Optimize GH ROM symmetry. – Upright rows
• Posterior cuff strength, t-spine mobility, – Front/Side raises (especially empty can)
scapular stability… – Olympic lifts
– Back squats

19

Why don’t you do overhead work?
It’ss part of their sport
It sport, so you need to
expose them to it…
Retro-what?
• Throwing shoulders have more humeral and glenoid
retroversion (may occur when pre-pubescent athletes throw
when the proximal humeral epiphysis isn’t closed yet)
• Retroversion gives rise to a greater arc of total rotation
range of motion (total motion concept = IR + ER)
range-of-motion
• NO EXERCISE WILL CHANGE BONE STRUCTURE!!!
• Warp bones to throw heat?
• Retroversion may actually spare the anterior-inferior
capsule from excessive stress during external rotation
Laudner KG, Stanek JM, Meister K. Differences in Scapular
Upward Rotation Between Baseball Pitchers and Position Players.
Am J Sports Med. 2007 Dec;35(12):2091-5.
“CONCLUSION: Baseball pitchers have less scapular upward
rotation than do position players, specifically at humeral
elevation angles of 60 degrees and 90 degrees.”
“CLINICAL RELEVANCE: This decrease in scapular upward
rotation may compromise the integrity of the glenohumeral joint
and place pitchers at an increased risk of developing shoulder
injuries compared with position players. As such, pitchers may
benefit from periscapular stretching and strengthening exercises
to assist with increasing scapular upward rotation.”
A few reasons…
• Labral fraying: less mechanical stability
• GIRD: non-neutral humeral positioning
• Approximation is not traction!
• Subscapularis microtrauma
• Cervical spine hyperextension tendency
• O-Lifts: UCL and wrist/forearm/hand stress
Congenital Factors? Huh?
• Bigliani et al. found that 67% of pitchers and 47%
of position players at the professional level have a
positive sulcus sign in their throwing shoulder
• Adaptation to imposed to demand? Yes, but…
• Those researchers also found that 89% of the
pitchers and 100% of the position players with that
positive sulcus sign also came up positive in their
non-throwing shoulder.
• Natural selection!
Things we like…
• Push-up variations
• Multi-purpose bar
• Neutral grip DB pressing variations
• E
Every row andd chin-up
hi you can imagine
i i
(excluding upright rows)
• Loads of thick handle/grip training
• Medicine Ball Work: Rotational and Overhead
• Specialty bars: Giant Cambered, Safety Squat
20
 Acromioclavicular Joint Pain Anecdotally…
• Traumatic vs. Insidious • Lifting-specific population
w/insidious onset
• Piano key sign?
• Most have significant
• Osteolysis scapular anterior tilt, and
marked GIRD is common
• Pain with: • Lower
L resting
i posture off
– Direct Palpation the scapula allows
– Horizontal adduction acromion to slip anteriorly
– Full extension and inferiorly relative to
– Approximation?
clavicle.
• Thoracic outlet? SC joint
• Active vs. Passive Restraints issues?

It might explain why…

• …soft tissue work on the levator scap, pec minor,
and infraspinatus/teres minor have worked.
• Subscap activation work has been key.
• Michael Hope, PT: manual depressions of the
clavicle have helped.
• As always, optimizing upward rotation is key.
• Supine Test of the Coracoid Process Muscles
Acromioclavicular Joint Pain
• Active vs. Passive Restraints
• Training Modifications
– Front Squat Harness, GCB, SSB, Back Squats
– Never do another dip!
– Push-up holds > Board Presses/Floor Presses>Full-
ROM benches
– Overhead pressing is sometimes okay
– Pulling exercises may need to be modified to avoid full
extension

Important Takeaways
• Work hand-in-hand with rehabilitation specialists
to formulate an appropriate return-to-action plan
• Remember that different shoulder conditions
mandate different training modifications
• Understanding the causes, symptoms, and
exacerbating exercises for each condition not only
makes it easier to recover from the problem, but to
prevent its recurrence.

21
 Treating the Athlete’s Shoulder The Athlete’s Shoulder
Testing, Treating, and Training the Shoulder
Introduction
• Common site of injury
» Repetitive forces / stresses
• Tremendous joint forces
» Anterior shear forces 1-
1-1.5 X BW
» Distraction forces 75
75--100% X BW
• High velocities (7,265 0/sec)
• Tremendous mobility
Michael M. Reinold, PT, DPT, SCS, ATC
ATC,, CSCS
» Repetition & fatigue
» Arm fatigue & injury patterns
» Number of pitches

The Athlete’s Shoulder The Athlete’s Shoulder

Introduction Introduction
• Injuries to the rotator cuff are • To treat the athlete you
common must understand:
• Range from minor to severe » The shoulder
• Specific pathologies » The unique
» Internal impingement characteristics of the
» Rotator cuff tensile overload overhead athlete
» Subacromial impingement
» The specific pathology
» Partial thickness Æ full
thickness tear

Function of the Rotator Cuff The function of

• Let’s take a step back… the rotator cuff is
to simply center
• What is the function of the rotator cuff? the humeral head
» ER/IR the arm?
within the glenoid
» Elevate arm in the scapula plane?
» Initiate arm elevation? fossa

22
 Principles of RTC Rehab
• Need adequate strength
• Need muscular balance
• Need stable base of support
• Need endurance
• Need dynamic stability
• Can’t work the cuff to failure!!!

Rotator Cuff Strength

• Based on scientific evidence
» Reinold, Escamilla, Wilk: JOSPT ’09
» Wilk, Reinold, Andrews: The
Athlete’s Shoulder ‘09
• EMG studies showing what
muscles are active in athletics
» Jobe:
Jobe: AJSM ‘83, ’84
» Digiovine:
Digiovine: JSES ‘92
• EMG studies showing the safest
and most effective exercise
» Reinold et al: JOSPT ‘06
» Reinold et al: J Athl Train ‘08

23
 EMG of Posterior Rotator Cuff
Reinold: JOSPT ‘04

EMG of Posterior Rotator Cuff EMG of Supraspinatus

Reinold: JOSPT ‘04 Reinold: J Athl Train ‘07
• Placing a towel between the
arm and the body increases
muscular activity
• Balance between the superior
shoulder muscles that ER the
arm and the inferior shoulder
muscles that adduct the arm
to hold the towel
• 23% increase in EMG

Rotator Cuff Balance

• Balance net forces
• Focus on posterior
dominant shoulder
» At least 2-
2-3:1 ratio of
posterior:anterior
• ER strength is key to
the shoulder

24
 Goal:
Improve
“muscular
b
balance”
l ”
“Posterior Infra, teres

dominant
shoulder” Lat, pec
pec,,
subscap, ant.
subscap,
delt

Stable Base of Support

• Scapula posture, strength, and balance
• Upper body cross
• Thoracic spine

Scapular Position
• Static resting position of
scapula is protracted and
anterior tilted
» Bastan
Bastan,, Reinold, Wilk: APTA ’06
» Macrina, Wilk: ‘08
08
» 71 Professional baseball pitchers
• These positions have strong
correlation with decreased
serratus and lower trapezius
strength
» Thigpen, Reinold, Gill: APTA ‘08
» 50 Professional baseball pitchers

25
 Endurance of Cuff
• Fatigue contributing factor of injury
» Lyman: MSSE ‘01
» Lyman: AJSM ‘02
02
• Endurance of cuff is extremely
important
• Need adequate base of strength before
emphasizing
• Remember, can not work cuff to failure!

Dynamic Stability
• By far the most important aspect of RTC
• Video 9, 10, 11
rehab in the athlete
• Center the humeral head
• Stabilize the joint during sport

26
 The KEY to
Static Shoulder Stabilization
treating the athlete
• Athletes inherently • Train the rotator cuff to be strong &
have poor static SMART
stability
y
» Require precise
interaction of the
dynamic
stabilizers

27
 • 3 position stab video

Do’s and Don’t’s Do’s and Don’t’s

Subacromial Impingement Internal Impingement
• DO: • DO:
» Focus on posture, posterior strength » Restore posterior flexibility
» Soft tissue » Maximize strength AND dynamic stability
» Shoulder – scapula interaction • DON’T:
• DON’T: » Force into ER
» Work the cuff to failure » Mobilize the posterior capsule
» Work through “pinches”

Do’s and Don’t’s Do’s and Don’t’s

Instability Congenital Laxity
• DO: • DO:
» Allow healing » Focus on strength of entire shoulder
» Strengthen in stable range » Dynamic stability
• DON’T: » Fatigue
Fatigue--resistant
» Force motion • DON’T:
» Progress to aggressive exercises too early » Stretch
» Put in disadvantageous positions
» Focus on big muscle groups

28
 Do’s and Don’t’s Key Points
SLAP Lesions • Understand:
» Shoulder – Athlete -
• DO: Pathology
» Focus on strength & dynamic stability • Principles of Treatment
» Strength, balance, base of
• DON
DON’T:
T: support
» Stretch into excessive ER » Posterior dominant
» Aggressive closed chain too early » Dynamic stability
» Biceps • Specific pathology
» Remember the Do’s and
Don’t’s

29
 Total Motion Fist-to-Fist Forward Head
Posture

Scapular Humeral T-Spine

ER IR
Supine Standing Chin Quadruped
Coracoid Tucks Chin Tucks
Process

Shoulder Supine Pec Abduction

T-Spine Ext. Breathing
Doorway Manual w/roller
Slides Stretching Flexion Minor Patterns
(supine) Wall
Quadruped
Corner Pec Pushups
Ext.
Side-Lying Sleeper Minor Rotation
Extension Stretch
Rotation Wall Prone Belly
Static 3-Point Ext.
Triceps Breathing
Side-Lying Posture Rotation
Side-Lying Cross Body
Reach, Roll,
Internal – Stretch Lumbar Bent Over
Lift
External Locked T-Spine
Extension Rotation Rotation
Prone Scapular
Rotation
Internal Wall Slides
Rotation Side-Lying
No Money Ext.
Drill Rotation
Dynamic
Blackburns Scapular
Squat-to-
Pushups
Stand
w/Ext. 30
Forearm
Rotation
Wall Slides
 Examination Lab 
Impingement 
Neer Sign    Hawkins Sign      Internal Impingement 

     

Laxity 
  Sulcus Sign          Beighton Score    

31
Instability 
Apprehension Sign 

 
 

SLAP Tests   
Pronated Load          Resisted Supination ER Test 

32
 Bench Pressing Variations Bench Pressing Variations (cont.)
• Narrower grip is generally less stressful (although
many post-AC joint injuries will handle wider • Use your handoff!
grips better) • Ease the bar over the pins; think of it as a
• Feet directly under or slightly behind knees, not “slide-over.”
up on bench!
• Retract and depress scaps, then position eyes 4-6 • Count:
C t “1 “1, 22, G
Gulp!”
l !”
inches down the bench from the bar. • Belly up, chest up: go get the bar.
• Slide back to the starting position with your eyes
under the bar. • Pull the bar down to your lower sternum
• Keep the upper arms at 45° angle to torso

Bench Pressing Variations (cont.)

Board Pressing
• Don’t let the scaps “roll” forward.
• Think of pushing yourself away from the • Very similar cues as bench pressing
bar. • Important to sink the bar into the board, not
• If your ffeett lleave the
th floor,
fl you are a tool.
t l just bounce off it.
it
• Never, ever, ever, ever, EVER let your • Set-up options
spotter say, “All you, man.” – Partner (preferred)
– Band-Assisted
– Under shirt

Floor Pressing Push-ups

• Similar cues as benching
• Less overall loading needed • Ensure appropriate hand position
• Less scapular stability possible because of • Glutes tight
firm floor;
oo ; therefore,
t e e o e, it’s
t s good to use a pad • Brace core
beneath the body.
• “Pull” torso to floor:
• I tend to favor board pressing initially for
impingement-type cases, and floor pressing – preactivates scapular stabilizers
for AC joint type issues. – ensures that chest gets to floor before face
(eliminates forward head posture)

33
 Push-ups (cont.)
• Don’t let hips sag.
• Keep arms at 45° angle to body.
• While it takes a bit more strength and core
stability, many individuals will do better
initially with feet-elevated push-ups.
Increasing the amount of shoulder elevation
increases serratus anterior recruitment (Lear
and Gross, 1998).
Push-up Iso Holds
• Great for teaching ideal posture,
sequencing, and activation patterns.
• Excellent for females in conjunction with
elevated push-ups off pins/benches.
• You can add in perturbations to challenge
both dynamic shoulder stability and core
stability.

Standing 1-arm Cable Rows

• My personal favorite
• Avoid forcing humeral extension/horizontal
abduction on a fixed scapula
• Pull the shoulder blade down and back
toward opposite hip
• If possible, use non-working hand to feel
scapular movement.

34
 Treatment Lab 
Rhythmic Stabilizations 
     

Closed Kinetic Chain 

 
 

35
Manual Resistance 

Reactive Neuromuscular Control 
 

36
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