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The Shoulder Complex Part 3: Rehabilitation Approach

Rehabilitating Yourself for Shoulder Impingement…

The primary concern for both the therapist and athlete/client when it comes to approaching shoulder impingement is the initial pain and discomfort that the athlete/client experiences. This often prevents them achieving the movements they require in their training etc. If they can’t achieve a good range of movement without pain they won’t be able to strengthen their shoulder in a full range.

This article will offer a general approach to treating shoulder impingement. It is based upon my successful experience in working with many athletes who have this complaint. It is in no way an exclusive list of exercises and the only way to approach this condition.

Manual “Hands-On” Treatment…

Many manual, and hands-on techniques can be applied to help reduce any muscular tension and mobilise the joint into a more optimal position with the aim of relieving any symptoms of pain. You can visit a therapist and receive massage, muscle energy techniques, and mobilisation techniques which will help significantly in relieving pain and discomfort through reducing tension in tight and overactive areas as well as freeing the joint capsule and creating more space in the “sub-acromial” space.

Some people are reluctant to visit a therapist due to cost etc. so visits to the clinic may not be an option. Therefore I offered these self-treatment options to these individuals, and it is that self-treatment option that is the focus of this article.

Much like any exercise program all the aspects of rehabilitation (mobilisations, stretches, strength, and functional exercises) should take a progressive path not to further irritate the structures within the shoulder. Without going through a full rehabilitation program breakdown I will discuss some of the successful exercises I have used in the past. The people I see often have had this complaint for a prolonged period of time or it is a recurring complaint. Therefore they are often able to achieve a reasonable range of movement but it may be uncomfortable. For those who have significant ROM losses you will want to adjust the level of the following to suit their condition or seek further advice or more remedial exercises.

Self-Mobilisations, Stretching, and Joint Play…

As discussed in the previous article the humeral head and whole shoulder complex can translate forwards and rise, which encroaches into the sub-acromial space. Therefore to help relieve this encroachment, compression and ultimately the pain and discomfort we can help physically mobilise this joint into a more optimal position.

The aim is to try to free the humeral head in its socket so it increases that space under the acromion. Manually this would be done by the therapist passively applying a force to the humerus causing it to move into a more optimal position. However, there are also ways of doing this by yourself which I have found to be very relieving for my clients. As we identified in part 2 of this article this alteration in shoulder position, and impingement can stem from tissues becoming over-active and shortened.

Weight Plate Chest Release
Lie on your back on a bench and place a kettlebell or weight on your affected side pectoral muscle. Take a deep breath then press the weight into the muscle as much as discomfort will allow, then raise the arm diagonally above the head whilst maintain the pressure on the weight. You will feel the muscle stretching from the point of pressure. As you lower the arm again release the pressure on the muscle. You can alter the position of the weight to find areas of the pec that are tight. Do this until you notice some improvement in pec range of movement or a feeling of improved flexibility through the muscle.
Pec rlease 1
Pec Release 2

Upper Trapezius Stretch
Stand on a towel and grasp it at your side with your “bad” hand. Your arm should be hanging at a resting length, then lean away from the towel with your upper torso and tilt your head to the same side (so your ear drops towards the shoulder). You should feel the towel pulling your arm down as you lean away, this causes the upper trap to be stretched. Hold this position for 20-30 seconds and repeat 2-3 times.
shldr_neck_supra_infra_levator_scap_traps_spek_cer_capi_scal

Banded Distractions
Once less pain is experienced this is a good addition. Attach a heavy duty band/rope/towel to a stable object/frame at just above shoulder height. Grasp the band etc. with your “bad” hand, turn your palm upwards, then walk your body backwards and shift your weight backwards so the band pulls the arm “out of its socket”.

From this position your can drop your chest towards the floor and rotate the body to loosen the joint capsule. Find areas that feel restricted and work into these. You can also then rotate the shoulder in and out keeping the arm straight. This has a stretching and loosening effect on the capsule as well as distracting the joint and freeing it up.
Band Distraction

Banded Chest/ Shoulder Opener
This helps open the chest musculature and front of the shoulders. Attach a band/towel etc. to a stable object or frame just above shoulder height. Grasp the band etc. with your “bad” hand then turn your whole body away from the band so your chest is opened right up. Again hunt around looking for uncomfortable tight areas then work into these by holding the position or oscillating in and out of this area. To incorporate the neck muscles into this you can turn you head away too. Play around with the height to achieve various stretches throughout the chest and front of the shoulders.
Opener

Lying Shoulder Drop
Lie on your back and raise your arms straight out in front of you vertically. From this position we are wanting the humerus to drop to the back of the socket. This will help free the space and improve our pain free range, especially flexion (raising the arms out to the front). To allow this drop of the shoulder, keep the arms straight and try relax the upper body, you should feel the space between the back of the shoulder and the floor reduce. Ideally you are wanting to feel your shoulder hit the floor on relaxation.

To aid this you can grab a weight or simply a bag of objects to help force the humerus back. Once you have mastered the relaxation and you feel the shoulder drop back, you can then start to rotate the humerus outwards by turning your thumb away from your body. Ensure as you do this the shoulder remains relaxed back into the floor and doesn’t rise. If it does rise up, stop and relax again.
KB 1

KB 2

Strengthening/Activation Exercises…

Banded Scaption
Grasp a band/towel with each hand at each end. Hold this straight out in front of you with straight arms, then pull the arms apart and turn your thumbs out creating tension in the band/towel. Find a band/towel suitable that allows you to pull your arms out at a 45° angle. From here raise your arms above your head keeping the tension and angle maintained then lower all the way back down again maintaining the tension, angle and thumbs out.

Turning the thumbs out externally rotates the humerus which is the better position for achieving optimal joint space. By pulling the arms out as well as this external rotation engages the rear rotator cuff muscles which are usually weak in impingement. By incorporating this engagement with overhead movement it retrains the muscles to work together in this overhead motion. As we mentioned previously it is usually the fact that the rotator cuff muscles are firing enough to stabilise the humerus in these movements. So by doing this move we are forcing the rotator cuff to activate whilst moving the arms overhead.
Scaption 1

Scaption 2

Banded Protraction/Retraction
Start with protraction and attach a band behind you (or can use cable machines) at shoulder height. Grasp the band/handle out in front of you with a straight arm. Then you are aiming to push the band forward by thrusting your whole shoulder forwards and feeling your scapula slide around your ribs as you do this. Ensure you keep your arm straight and initiate the movement form the shoulder not bending the elbow (as this becomes a chest press which is what we don’t want). Do 2-3 sets of 20-30 reps on each arm.

Retraction is in the same set up only you now face the band/cables and grasp the handle. Then, again keeping the arms straight, pull the band/cables back. You are looking to move the whole shoulder and feel the scapulae squeeze together. Do 2-3 sets of 20-30 reps.
Protraction
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Banded Shoulder Rotations
For external rotation, and to work the infraspinatus and teres minor, attach a band at head height and face the band. Then grasp it with your hand, place your upper arm out to the side so it is parallel with the floor (at 90°) with the forearm vertical. Then pull the band backwards as far as is comfortable then relax back to the start position, ensure you keep the upper arm parallel with the floor throughout.

To work internal rotation, and the subscapularis, simply turn around with your back to the band. Then rotate the arm forwards pulling the band forwards. Again ensure you keep the upper arm parallel with the floor. Do 2-3 sets of 15-20 reps of both external and internal rotations.
ER
IR 2

Banded Squat to Row
For this you will need a light band, attach this at chest height in front of you. Grasp the band and walk back so there is moderate tension on the band when rowing your arms in. Ensure you can achieve a full range row, so elbows can be drawn all the way back. Once you find your starting position place the arms out straight in front, drop into a squat (engage core as you would any normal squat), rise out of the squat and as you reach the top row the band in. The band will want to pull your body forward but the idea is that you stabilise your body position whilst you row so you do not track forwards as you row the band in. Perform 2-3 sets of 15-20.
Squat to Row 1

Squat to Row 2

Once you can perform the squat to row with good stability and control. Set the band up as above but place a stepper in front of you. This time perform a step up bringing your trailing leg up so your thigh is parallel with the floor and you are balanced on one leg. As you get to the top of the step up, stabilise your body and then row the band in. Again as you row maintain the stability and minimise “wobble” or forward translation. To progress this further perform the row with one hand (the opposite hand to the standing leg). Perform 2-3 sets of 12-15 on each leg/arm.

The lower body and row exercises integrate the whole body, and activates the posterior system of the body which will help rectify any forward translation of posture. It also uses our target muscles in a whole body movement which is essential when wanting to achieve postural stability in everyday activities as we are never isolating one muscle group when performing our daily activities.

Further Strengthening Advice
In regards to any general strength work you are doing it should be pain free. If it is causing that nagging, nipping pain stop doing those exercises until your symptoms are relieved. Include the above into your current program, and even when your pain and symptoms have subsided use them as a warm up.

To really strengthen the shoulders as a unit work on all movements of the shoulder as you when strengthening any other muscles. Start progressing the weights lifted as pain allows. Put simply, short of providing a full rehabilitation program, work front and side raises, external/internal protraction/retraction, and overhead presses. When training these movements with weights however, don’t slip into the past habit of tightening the upper traps and chest to help you lift a heavy weight. Conscious think about the tension in these areas, and if you notice a rise in the traps or over-activation of the chest stop, relax and start again or drop the weight.

The above exercises are not a full rehabilitation approach, nor are they the “gold standard” for treating impingement, they are simply some exercises I have found to be successful with both myself and clients. Ensure you seek medical advice if symptoms continue without improvement.

Are Males Becoming Over-Healthy?

Are We Becoming Over-Health Conscious?
In the news over the last few weeks there has been mention of a change in pattern of alcohol and drinking habits between the younger and older generation. This got me thinking and with me being in this “young” bracket I asked myself what has been changing in this younger population to bring about this change? I am writing this short article to share with you my proposed suggestion for a contributor to this change in alcohol behaviour, and what may have taken its place.

Change in Statistics…

(http://www.ias.org.uk/uploads/pdf/Factsheets/Young%20people%20and%20alcohol%20FS%20May%202013.pdf)

The average weekly consumption of alcohol in 16-24 year olds dropped from 16.9 to 11.1 between 2005 and 2010. Interestingly, one surveyed showed that the number of men aged 16-24 claiming to have drank during the week, also showed a drop of 12 people (from 64 to 52) dropped between 2005 and 2011. The drop for women was much less. Also, the number of men claiming to drink 5 out of 7 days in the week dropped by half between 2005 and 2011 . Men, aged 16-24, claiming to drink over the daily limit also showed a pattern of decline, dropping from 46 to 32 for those drinking more than 4 units on at least one day. A drop in those drinking over 8 units also dropped from 32-22.

These are very brief statistics but it does show a trend that these figures for the young male population are dropping. So what has changed in these young men?

My Viewpoint…

I have a huge interest in and passion for male body image so I always take note of the behaviours of males in the gym (where I work). I have noticed a huge desire for the big, lean, and muscular physique within this population. The commitment to the gym, lifting weights, and meticulous attention to dietary habits is unbelievable. Even in school age boys, this desire is on the rise. This population is under huge pressure from media and peers to “look good”, this portrayal of looking good is plastered all over the TV, magazines, movies, and within sport. This portrayal is in the form of a big, “ripped”, muscular man who gives off the impression of increased female attention, success, and beauty. Is this focus on “looking good” contributing to these drops in the alcohol behaviour figures?

I overhear a lot of conversations in the gym and they all breed the same topics such as eating habits, progress updates, and restricting certain behaviours etc. There is always a young man talking about how he is reducing or restricting his carbohydrate intake in order to reduce his body fat and get “ripped” or someone talking about his “gains” and how he is tailoring everything to achieve these “gains”. This made me think maybe these lads are reducing behaviours such as alcohol intake as it is deemed an intake “empty” calories and bad for their “gains”.

Then it hit me in the face (or ears), over hearing a group of lads talking about a night out. One responded with “I will come out, but will drive, I am not drinking. I am making gains, can’t have booze reducing my test (testosterone) levels”. I have also been more aware of my friends adopting the same outlook, turning down nights out or meeting up for drinks because they are “in training”. Bearing in mind a lot of them don’t play sport or train for any reason other than aesthetics. So here it is, one possible reason for young lads reducing their drinking habits, they are focused on “looking good” and making “gains”.

This is Great Right?

At face value, this is brilliant, the younger population no longer living up to this binging stigma, and improving their health by reducing these toxins in their bodies. Yes, but if you then delve into what else these young lads engage in are they just swapping one potentially unhealthy behaviour for others?
The media portrayal of males in today society has a lot to answer for. Young impressionable men are buying into this ideal physique and going to great lengths to achieve it. Yes they may be adopting healthy behaviours in that they tidy up their diet, engage in regular exercise, and reduce their unhealthy behaviours such as alcohol intake. But what happens when they a) don’t quite get to that ideal, b) realise they want more than that ideal, or c) the ideal changes and becomes even bigger, leaner and more muscular?

They then modify their diet to extreme levels, exercise more (maybe to extreme levels), and introduce other “aids” and potentially harmful behaviours. So realistically, they have simply swapped one unhealthy behaviour (alcohol) for another (or more than one) such as steroid use, disordered eating, or excessive exercise. Now exercise and a clean diet is healthy, but is this latter progression of exercise and dietary behaviour a sign of us being “over-healthy”? By being “over-healthy” are we actually making what we do unhealthy both physically and mentally?

Don’t get me wrong the drop in alcohol related incidents and health related problems in this population is a great thing and deserves this exposure. However, despite me being biased in that my passion is in the area, I do believe we need to see this and ask why? Then look into men’s health with a focus on their exercise psychology. If we can tap into this and provide education regarding male body image, their drive for muscularity, and safe exercise and nutritional behaviour we may be able to help also reduce the prevalence of other unhealthy extreme behaviours.

Now this is a very short article designed to introduce the topic and express my view and passion. I have completed an MSc research project in this area of male body image concerns, in particular Muscle Dysmorphia. If anyone is further interested please do not hesitate to contact me. I am also in the process of applying for a PhD in this area, with the hope of contributing to tackling the issue of Men’s Health and their image issues.

The Shoulder Complex Part 2: Common Dysfunctions

The Shoulder Complex Part 2: Common Dysfunctions in Impingement

The focus for this article is impingement syndrome in particular and what common dysfunctions and factors contribute to the development of impingement within the shoulder complex. The reason for this focus is because over recent months I have assessed and treated several clients who all present with symptoms of impingement and appears to be a common complaint within the sporting and recreational fitness world.
As mentioned briefly in part 1 impingement syndrome is not a diagnosis in itself it is more a result of some alteration in function, strength or stability of the shoulder complex or in many cases a combination of these factors. This may be through an acute injury or usually a more chronic occurrence.

What is Impingement Syndrome?
This complaint involves the area under the acromion process of the scapula, known as the sub-acromial space, see image below. This space is where the tendon of the supraspinatus muscle passes and also where a fluid filled sac, known as the sub-acromial bursa, sits and acts as a sort of shock absorber or lubricator. In brief impingement syndrome is when this space is reduced and encroached upon and the tissues within that space are compressed. Impingement has been categorised into primary and secondary impingement.

Primary Impingement
Primary impingement is a direct encroachment on the sub-acromial space, and this is usually a result of a structural deformity of the acromion itself, it may be genetically more hooked or can grow bone spurs which directly compress the structures underneath. These spurs can be a result of conditions such as osteoarthritis. Detection of primary impingement requires scans of the affected area and often requires surgical intervention to reduce the bone spurs and free up the space under the acromion. This type of impingement is usually observed in the older athlete or client, although not exclusive to this population.

Secondary Impingement
This is the type of impingement that you are more likely to see in your athletes. It stems from postural and movement related causes. In many cases, much like the ones I have seen, there is a whole combination of factors related to the cause of impingement. These factors include an instability in the shoulder due to ligament laxity, or muscular weakness. An alteration in movement patterns can also result in impingement, which again can be down to muscular weakness or imbalance. This can be treated by targeting the weakness/imbalance and rectifying any compensatory movements.

Common Symptoms of Impingement
• A “painful arc” – pain within the middle portion of the movement when moving the arm out to the side or up in front.
• Nipping sensation that can send pain from top of the shoulder to the elbow.
• Dull ache in the shoulder, and point tenderness around the front and/or side of the acromion process.
• Pain exacerbated by overhead movements, weakness in overhead lifting movements.
• Pain on side lying on affected side.

Below I discuss the common factors I have encountered in the cases of impingement that I have experienced. This is not an exclusive list, only the common factors associated with impingement that I have seen.

Muscle Weaknesses

Rotator Cuff
One of these factors is a weakness in the rotator cuff, i.e. the supraspinatus, infraspinatus, teres minor and subscapularis. These muscles, as described in part 1, have the primary role of rotating the humerus externally and internally respectively. However, they also play a big role in the stabilisation of the humeral head, they pull it down and depress it into the socket. Therefore if these muscles are weak this ability is diminished and therefore during arm movements the humeral head rides up and compresses the supraspinatus tendon against the arch between the acromion and coracoid process (coracoacromial arch). The symptoms of this compression tend to be replicated with overhead movements. During these arm movements of the shoulder complex there is a force couple between the deltoid and the rotator cuff. As the arm moves the deltoids pulls vertically upwards on the humerus, and the rotator cuff muscles pull horizontally towards the midline of the body. If the rotator cuff is weak and this horizontal pull doesn’t keep the humeral head pulled in then the upward rise occurs and the compression and pain occurs.

Serratus Anterior
As described in part 1, this muscle aids protraction and rotation of the scapula. It also plays an important role in holding the scapula in against the ribcage. If this muscle is weak or not functioning correctly then the scapula position will be altered and thus its movements will be hindered. The scapula and GH joint work together to allow full range of motion. If the scapula is not able to rotate effectively and is not pulled in to the ribs it is likely to tilt away from them, this is likely to cause the whole shoulder unit to move forward or rise to compensate for the lack of scapula rotation. This may then contribute to the reduction in the sub-acromial space and result in the compression and impingement of the structures within it.

Rhomboids
A weakness in the rhomboids have a similar effect as above. This muscle is responsible for pulling the scapula back (retraction) and holding the scapula onto the rib cage. If these are weak the scapula will translate forwards and tilt away from the ribs as above, and again the shoulder unit will translate forwards. This will result in compression of the sub-acromial structures for the same reason as discussed above.

Mid and Lower Trapezius
A weakness of this portion of the trapezius is quite common. This muscle holds the shoulder blades back and down, this stabilises the scapula and controls rotation. If this portion is weak then this control of rotation and stabilisation is lacking and therefore any over-activity of the upper trapezius, discussed next, will lift and elevate the scapula excessively affecting its rotation and thus overall shoulder motion. This dysfunctional movement may cause translation of the humeral head as previously mentioned and thus contributing to any impingement.

Overactive Shortened Muscles

Upper Trapezius
It is common for the upper trapezius to become overactive and become shortened. As this portion of the muscle acts to, rotate, lift and elevate the scapula it will cause the scapula to rise into excessive elevation and affect the ability of the scapula to rotate. This again affects the motion and position of the scapula so when the arm is raised the sub-acromial space is further reduced due to this elevation. Also the GH joint position and movement may be altered to achieve its ROM with the limited/altered scapula movement, i.e. the humeral head may rise to help achieve overhead ranges. This occurrence of over-activation of the upper trapezius tends to occur in combination with a weakness of the other scapula rotator muscles such as the serratus anterior.

Levator Scapulae
Similarly to the above, the levator scapulae becomes overactive as it has to work harder in compensation for a weakness of other scapula stabilising muscles. When this muscle becomes shortened it excessively lifts the scapula, and has the same effect as above in the upper trapezius.

Pectorals
Many of my clients with impingement symptoms present with very over-active, tight pectorals (both major and minor). A tightness and shortened state of the pectoralis major pulls the head of the humerus forwards in its socket. If the pectoralis minor is also tight, which it usually is, this will pull the scapula forwards into protraction which again moves the whole shoulder unit forwards. This forward translation of the humerus and shoulder complex reduces that sub-acromial space and the head will compress the structures within this space.

Altered Kinematics (Movement) and Posture

Scapula Dyskinesis
This term scapula dyskinesis sometimes gets thrown at people almost in a diagnostic sense, much like impingement. However it is not a diagnosis in itself. Scapula dyskinesis basically means a dysfunction in the movement of the scapula. This could take many forms, anything that strays from normal scapula movement could be termed scapula dyskinesis.

Common characteristics that I have seen with my clients have been excessive protraction and tilt of the scapula, this results in the scapula “sticking out” or “winging” and reduces the movement of the scapula around the ribcage. This could arise through some of the above factors such as weak rhomboids, serratus anterior, and mid-lower trapezius.

I have also seen excessive elevation which reduces the ability of the scapula to rotate optimally, this could arise from a combination of weak scapula stabilisers and an overactivation of the upper trapezius, and levator scapulae.
The movement of the scapula in some cases is judders and lacks control which stems from a combination of imbalances and fatigues of the mentioned muscles. Scapula dyskinesis often comes down to alterations in muscular control, strength or endurance. These altered movements of the scapula then alter the movement of the whole shoulder complex as previously mentioned. There are compensations, both muscular and mechanical, that occur to achieve different ranges of motion. For example the position of the humeral head in the GH joint may alter with poor scapula mechanics in order to achieve full abduction or flexion.

Upper Cross Syndrome
This concerns a common position that someone with shoulder problems may adopt. It often consists of a forward head position, rounding of the neck and upper back and also the altered position of the scapula that have been included above. These positions including anterior tilt (winging), elevation and protraction.

The altered mechanics and posture in the shoulder complex such as scapula dyskinesis and upper crossed syndrome alters the axis of shoulder movement in the GH joint this can then cause the humeral head to encroach on the sub-acromial space and compress the structures within leading to impingement.

Take Home Message as a Therapist

As a therapist we should not use impingement as scape goat. We should dig deeper and assess the whole shoulder complex. Be that therapist that is annoyingly pedantic and looks at areas that people wouldn’t think to look at. Don’t leave any stone unturned when it comes to impingement. In the long run it will help your client with a truly successful rehabilitation. Look for those weaknesses, altered mechanics, lack of control, and over-active structures and design your rehabilitation to alter these factors. These are the real diagnoses not simply “you are experiencing impingement” and prescribe the generic shoulder rotation exercises.

Do ensure that serious pathologies are cleared as a priority, such as a long thoracic nerve pathology which affects the control and position of the scapula. Clear all neurological symptoms by testing athletes’ sensations and looking for any significant motor weakness, numbness, tingling, or complete loss of muscle tone.

Part 3 of this article will discuss potential approaches to treating shoulder impingement.