An Open Letter to Crossfit: The 2 Mistakes (Part II)

Be sure to check out Part I for my thoughts on Crossfit and Mistake #1.

Mistake #2 = Not Training Unilaterally

Our bodies are inherently asymmetrical.  Don’t believe me?  Here are a couple examples of this natural asymmetry: we have a liver on the right, a heart on the left, 3 lung lobes on the left, 2 on the right, the stomach is tilted, one kidney is higher, the right diaphragm has a better zone of apposition, each brain hemisphere is lateralized for different tasks, and our left-otolitic dominance makes our motor system prefer the right side of our bodies.  On top of this, there are many other possible asymmetries and different morphologies due to genetics/ontogenetics.Not only are our bodies asymmetrical, but we live in a very asymmetrical world.  Everyday activities are asymmetrical; you push the car pedals with your right foot, grab your wallet out of the same pocket, open doors with your right hand, use the computer mouse on the same side.  Sporting activities are asymmetrical; you shoot with your right hand, kick with your right leg, swing a golf club to the same direction everytime.  And then there is just plain handedness.These asymmetries are normal and usually not a problem.  However, sometimes these asymmetries become too significant.  The imbalances become too much for the body to handle.This asymmetrical problem is taken to the next level when you add a symmetrical load to the system.  Symmetrically loading an asymmetrical system is the formula for injuries.  And this is one of the biggest mistakes Crossfitters make.While this applies to the entire body, it is critical in shoulders.  There are two reasons why:

1) You have a much more prominent handedness than footedness

2) Your legs benefit from some unilateral weight bearing activities everyday (walking, stairs)

Therefore, your upper extremity asymmetry is accelerated much faster compared to the lower extremity.  In other words, a right handed person can pretty much go all day without using their left arm at all.Fast forward to this person going from not using their non-dominant arm for most of their life (or past few years) and then throw a barbell at them.  It’s not going to go well.  The symmetrical external load (barbell) won’t be met with a symmetrical internal force (muscles).  Bringing a symmetrical exercise to an asymmetry is a recipe for disaster.Look at your car for an analogy.  If you car alignment is off, it’s going to cause some big problems.  Not only is most of the load going to be dumped onto one side, but it will also prevent a smooth straight path.  With the alignment off, the car will naturally want to veer from straight.  But it is being driven in a straight path, so the car has to pull (compensate) to maintain the desired direction.The same thing happens at your shoulders with barbell exercises.  One shoulder will get too much of the load, the other has to compensate to keep it straight, and it becomes an internal tug-of-war to keep the all important straight bar path.  Therefore, if you have a shoulder asymmetry, then the whole time you are cleaning, pressing, or snatching your shoulders will be compensating against each other.As mentioned in Part I, over time compensations lead to decreased performance and injuries.So what do you do about this?  Start brushing your teeth with your non-dominant arm?  Do barbell cleans with one arm?  Walk on your hands?

A Suggestion

The best thing you can do is incorporate some single arm (unilateral) strengthening into your weekly workouts.  This will not only prevent injuries, but it can also be used as an assessment.  If you can strict press 70# with your right arm, but only 50# with your left, then what do you think is happening when you strict press with a barbell?There are many different ways to work on unilateral strengthening, but in my opinion kettlebells are the best equipment to accomplish this.  They allow for the same metabolic burn, similar technique work, multi-joint strengthening, and most importantly - unilateral strengthening.  Pavel said it best "Your body has to adapt to the barbell while the kettlebell works with your body."Here’s a list of some unilateral shoulder exercises that can be done with just a kettlebell and some space:

Armbars, Bear Crawls, Quadruped T's, TGU, Single Arm Push Ups, Half/Tall-Kneeling/Standing KB Strict Press, Farmers Walks (overhead, rack, suitcase), Single Arm KB: Swing, Squat, Clean, Clean & Squat, Clean & Strict Press, Clean & Push Press, Snatch, Unilateral Suitcase Deadlift, Plank KB Pull Through

There are plenty of great coaches that can probably come up with some amazing unilateral upper extremity WODs.  There’s not just one right way to do it.  As long as you are training unilaterally and exposing weakness you will be decreasing your risk of injury and improving performance.For clinicians there is this Clinical Pearl

• If someone comes in with dominant side shoulder pain from bilateral/symmetrical training, the fix may be to strengthen the non-dominant side

Bottom Line

Like anything that becomes popular or trendy, there quickly becomes a group of people that jump on the bandwagon and a group of people that protest against it.  But this isn’t EDM, this isn’t Instagram, this isn’t the new iPhone.  This is simply another opportunity to help people stay active and exercise.  It’s not for everyone, but it’s not for no one.Medical professionals need to focus on ways to reduce injury and improve the activity rather than just pointing out what we don’t like.  Crossfit coaches need to focus on what’s best for the athletes health rather than what will give them the best workout.  And the Crossfit athletes need to be educated on the risk of lifting with poor technique and/or with a significant asymmetry.

References

Strength is a Good Thing1) Preethi Srikanthan, Arun S. Karlamangla. “Muscle Mass Index as a Predictor of Longevity in Older-Adults.” The American Journal of Medicine (2014) 2) Lauersen JB, Bertelsen DM, Andersen LB.  The effectiveness of exercise interventions to prevent sports injuries: a systematic reviewand meta-analysis of randomised controlled trials.  Br J Sports Med. (2014) Jun;48(11):871-7.3) Harridge, Stephen D.r., Ann Kryger, and Anders Stensgaard. "Knee Extensor Strength, Activation, and Size in Very Elderly People following Strength Training." Muscle & Nerve 22.7 (1999): 831-39.4) Suetta, C., S. P. Magnusson, N. Beyer, and M. Kjaer. "Effect of Strength Training on Muscle Function in Elderly Hospitalized Patients."Scandinavian Journal of Medicine & Science in Sports 17.5 (2007)5) Askling, C., J. Karlsson, and A. Thorstensson. "Hamstring Injury Occurrence in Elite Soccer Players after Preseason Strength Training with Eccentric Overload." Scandinavian Journal of Medicine and Science in Sports 13.4 (2003): 244-506) Nadler, Scott F., Gerard A. Malanga, Melissa Deprince, Todd P. Stitik, and Joseph H. Feinberg. "The Relationship Between Lower Extremity Injury, Low Back Pain, and Hip Muscle Strength in Male and Female Collegiate Athletes." Clinical Journal of Sport Medicine 10.2 (2000): 89-97.7) Peate, Wf, Gerry Bates, Karen Lunda, Smitha Francis, and Kristen Bellamy. "Core Strength: A New Model for Injury Prediction and Prevention."Journal of Occupational Medicine and Toxicology 2.1 (2007)8) Orchard, J., J. Marsden, S. Lord, and D. Garlick. "Preseason Hamstring Muscle Weakness Associated with Hamstring Muscle Injury in Australian Footballers." The American Journal of Sports Medicine25.1 (1997): 81-859) Jankowski, C.m. "The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial."Yearbook of Sports Medicine 2012 (2012): 65-66.10) Willson JD, Dougherty CP, Ireland ML, et al. “Core stability and its relationship to lower extremity function and injury.  J Am Acad Orthop Surg. (2005) Sep;13(5):316-25.11) Hewett TE, Lindenfeld TN, Riccobene JV, et al. “The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study.” Am J Sports Med. (1999) Nov-Dec;27(6):699-706.Movement Based Exercise vs. Isolated Exercise12) Gentil, Paulo, Saulo Rodrigo Sampaio Soares, Maria Claúdia Pereira, et al. "Effect of Adding Single-joint Exercises to a Multi-joint Exercise Resistance-training Program on Strength and Hypertrophy in Untrained Subjects." Applied Physiology, Nutrition, and Metabolism 38.3 (2013): 341-4413) Gottschall, Jinger S., Jackie Mills, and Bryce Hastings. "Integration Core Exercises Elicit Greater Muscle Activation Than Isolation Exercises."Journal of Strength and Conditioning Research 27.3 (2013): 590-96Exercising in Fatigued State14) Cortes, Nelson, Eric Greska, Roger Kollock, Jatin Ambegaonkar, and James A. Onate. "Changes in Lower Extremity Biomechanics Due to a Short-Term Fatigue Protocol." Journal of Athletic Training 48.3 (2013): 306-13.15) Santamaria, Luke J., and Kate E. Webster. "The Effect of Fatigue on Lower-Limb Biomechanics During Single-Limb Landings: A Systematic Review." Journal of Orthopaedic & Sports Physical Therapy 40.8 (2010): 464-73.16) Barnett S Frank, Christine M Gilsdorf, Benjamin M Goerger, et al.  “Neuromuscular fatigue alters postural control and sagittal plane hip biomechanics in active females with anterior cruciate ligament reconstruction.” Sports Health (2014) Jul;6(4):301-817) Quammen D, Cortes N, Van Lunen BL, et al. “Two different fatigue protocols and lower extremity motion patterns during a stop-jump task.” J Athl Train. (2012) Jan-Feb;47(1):32-41.18) Pau M, Ibba G, Attene G. “Fatigue-induced balance impairment in young soccer players.” J Athl Train. (2014) Jul-Aug;49(4):454-61.Imbalances Are Bad19) Knapik, J. J., C. L. Bauman, B. H. Jones, J. Mca. Harris, and L. Vaughan. "Preseason Strength and Flexibility Imbalances Associated with Athletic Injuries in Female Collegiate Athletes." The American Journal of Sports Medicine 19.1 (1991): 76-8120) Baumhauer, J. F., D. M. Alosa, P. A. F. H. Renstrom, S. Trevino, and B. Beynnon. "A Prospective Study of Ankle Injury Risk Factors." The American Journal of Sports Medicine 23.5 (1995): 564-70.21) Common Sense & Conventional Wisdom (>6 million years BC)Motor Learning22) Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.23) Schmidt, Richard A., and Craig A. Wrisberg. Motor Learning and Performance: A Problem-based Learning Approach. Champaign,IL: Human Kinetics, 2004.24) Williams, L. R., McEwan, E. A., Watkins, C. D., Gillespie, L., & Boyd, H. (1979). Motor learning and performance and physical fatigue and the specificity principle. Canadian Journal of Applied Sport Sciences, 4, 302-308.

“The body does not have the capacity to learn movement patterns when highly stressed/fatigued. This factor is not related to the specificity of training principle associated with overload adaptation in energy systems. The specificity principle of physiological adaptation does not apply to motor learning. To learn skilled movement patterns that are to be executed under fatigued conditions, that learning has to occur in non-fatigued states” — Williams 1979

 --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Everything is Moving Proximally

In the past 10-20 years there has been a trend towards stabilizing the proximal joint.  Everything seems to be going more and more proximally.  And this is a good thing!  It is providing us with better outcomes and quicker pain free rehabilitation.If you look at the knee joint you can see the progress.  We've gone from isolated patella mobs and VMO strengthening to hip strengthening.  And now we are going even further up the chain and looking at lumbo-pelvic complex.The same thing is happening with the shoulder.  We've gone from isolated thera band ER/IR to scapula stabiliztion.  And now we are going even further and looking at the thoracic spine and ribs.And if we go just 1 step further at both joints we end up where it all began in the first place...the core.

The Greats Love Proximal Stability

This is no where close to being a new concept.  Many of our professions greatest clinicians have been emphasizing the influence of proximal stability on the distal extremities for years.Shirly Sahrman always discussed relative flexibility/adjacent stiffness, PRI's focus is achieving a Zone of Apposition (ZOA), PNF (Kabat & Knott) has always advocated Proximal Stability before Distal Mobility, Gray Cook prioritizes Symmetrical Core Stability, Stuart McGill discusses Super Stiffness, DNS (Kolar) starts with a Centrated Spine for a Punctum Fixum, Kelly Starrett talks about Midline Stabilization, and Janda's Upper/Lower Crossed could be argued to be the result of poor core stability.Anyone that uses these approaches knows of the benefits of core stability for extremity function.It's becoming more and more common in clinics, training rooms, and gyms.  But it goes beyond empirical cases; the research on the influence of the core on the extremities seems to be increasing as well.I would bet that in several years, core training and integration for extremity dysfunction will be as common as hip strengthening for dynamic valgus.

The Core

We could sit here for days and argue over semantics on the definition of the core.  We can then spend another couple hours arguing about how it can be separated: inner core, outer core, local muscles, global muscles, anterior, posterior, lateral, etc.This is great and can provide for some interesting discussion, but these semantics don't change how the core works.I try to keep it simple and define the core is the center of the body.  It's your axial skeleton and all the muscles that connect to it.Regardless of your definition, the focus should be on how the core works, how to assess it, and how to train it for each individual patient.

The Developmental Perspective

Looking at movement through the neuro-developmental lens gives us an unbiased perspective of how we ALL started to move.  Every generation has developed motor functions through the same neuro-developmental kinesiology.  It's a pre-written genetic code with more than 6 million years of evolution.  We are all born with full mobility; and then we struggle our way from rolling, to sitting, to crawling, to walking.We develop our first movement patterns with minimal influence of external factors.  It's the purest form of movement that we have in this world.It's before shoes deprive our sensory input and lock up our ankles.  It's before we're forced into chairs and give away all sorts of proximal mobility.  It's before someone tries to coach or teach us how to move.  It's before we can be influenced by a certain model of movement (yoga, pilates, martial arts, powerlifting, sports, etc.).The developmental perspective shows us how humans move before the detrimental influence of their culture.Needless to say, it's a good standard to measure against.

How the Core Works

Developmentally, all movement starts at our core.  We start to control our head, we start to gain sagittal spinal stability, and then we start moving our extremities.  This combination of spinal stability in concert with extremity movement then drives the rest of the movement development.   Once we have this extremity motion integrated, we start rotating and rolling, then we sit up, then we go from creeping to crawling to cruising to walking.This is all basically a core motor control and strengthening progression.  The core stability demands increase with the each progression of the developmental milestones (least=supine/prone, most=standing/walking).  It's the first SAID principle our bodies have to deal with.If the core doesn't fire efficiently, the baby won't be able to perform the task and the baby will fall down.  Without an integrated core, the baby won't be able to use their extremities for manipulation and movement.In this manner, developmental kinesiology prevents humans from progressing to the next milestone without mastering the previous one.  It's natures perfect self-limiting exercise.Babies don't perform planks, do 3 sets of 10 crunches, or isolate their transverse abdominis.  Thats not how the core works.  The core works to create efficient proximal stability for the production, control, and transfer of force.  The core works to create a stable base for goal oriented movement.  It's a complex, integrated system of feed-forward and feed-back strategy.  And it is developed through the use of the extremities.It's important to note that this "efficiency" is not a measure of strength.  It's an assessment of the neuromuscular patterns.Core efficiency involves the complex coordination, timing, and motor control of ALL the muscles involved in the specific task.  From the big toe on the ground to the opposite shoulder, all muscles must be fire in concert with the core.  It's not just "pre-activating" your inner core.So what happens if your core isn't stable?  If you're not able to transfer force and stabilize your center of gravity?  If you're not able to centrate your center?

What Happens When the Core Doesn't Stabilize

What happens is that the next joint down has to do extra work to stabilize.  The next joint down can't transfer (unload) force to the proximal core.  The next joint down ends up taking on a lot more force.  The next joint down overworks to make up for the lack of efficient proximal stability.  The next joint down gets locks down in attempt to "stabilize" and becomes "tight".  The next joint down becomes inefficient.This is an example of how not having proximal stability leads to decreased distal mobility.So that hip might be restricted and feel tight because it can't transfer (unload) forces proximally because of a lack of core stability.  And those ankles might always be locked up because they might be constantly active as a postural balance strategy because of a lack of core stability (unstable center of mass=instability=terminal segment compensation).That's not to say it can't swing the other way.  With a lack of proximal stability, the distal segment will not be as efficient at producing force/torque.So that overhead shoulder might feel weak because it can't receive valuable proximal force production from the core.  And those achilles might be overworked because they're trying to make up for the lack of proximal stability from the hips and core.

Assessment & Intervention

Assessment

I assess the core using a developmental postural stability progression.  This progression is essentially going from lying on the ground to standing.  From a stable base to a narrow base.  From minimal degrees of freedom to maximal degrees of freedom (joints available).

Postural Assessment

Each posture is progressed from wide base of support to a narrow base of support.

• Supine/prone is assessed with either rolling patterns or foam roll marching (depending on client and space).
• Quadruped is assessed with Alternate UE & LE ("bird-dog").
• Tall & Half Kneeling is assessed with half kneeling to ensure that there are no asymmetries.
• Single leg stance is assessed with eyes open and eyes closed.

I usually assess people for 10-20 seconds in each posture.  I look for the movement quality, common pattern dysfunction, and compensatory strategies.  The goal is for the patient to stabilize the closed chain extremities through their core.  I don't get too caught up in the positioning of the open chain extremities.

Intervention

My intervention follows the developmental postural stability progression in a static to dynamic fashion (low threshold to high threshold).After I have their core movement assessed, I use these positions at their "Edge of their Ability" to develop reflexive static stability and core efficiency.  I usually tell my patients to "find the point where they struggle, but don't fail".http://www.youtube.com/watch?v=b06-S2F3qm0Once they can demonstrate the most difficult level of static stability (narrow base), I add either upper extremity or lower extremity dynamic movements in these postures.  From here, the possibilities are limited by your creativity.Some Examples:

• Upper Extremity: Wall Slides in Tall Kneeling, Plank with Reach, Quadruped T's, UE PNF Patterns in Developmental Postures

• Lower Extremity: Side-Plank with Hip Abd/Flex, Bridges with Marching, Plank with Hip Extension

• Both: Chops & Lifts, Single Leg Asymmetrical Deadlift, Resisted Quadruped Alt UE/LE, Turkish Get-Up, Quadruped Rocking, Crawling/BearCrawling

Bottom Line

• "Any purposeful movement first requires spinal stabilization" -Pavel Kolar

I try to add some core integration for all of my patients.  It's easy to do, there are tons of benefits, and the patients usually like it.  Plus, it taps into the hard-wired CNS developmental patterns.You can incorporate this tomorrow.  Just keep doing what you've been doing with your patient, but throw them at the edge of stability in one of the developmental postures.  They'll get more sensory input, and therefore a better motor output.  Their core gets integrated, and you have a new trick up your sleeve.  Everyone wins.Even if you don't buy into this whole proximal stability thing, you should at least consider it when that ankle dorsiflexion hasn't improved in 6 weeks.

Dig Deeper

Gray Cook:

Motor Control, Stability, and Prime Movers

Sequence of Core Firing

Edge of Ability  

Kelly Starrett - Midline Stabilization, Example of Midline Stabilization FaultSeth Oberst - Motor Control Priority Steve Smith - DNSLieberman, Daniel. The Story of the Human Body: Evolution, Health, and Disease. New York: Pantheon, 2013. PrintWalter, Chip. Last Ape Standing: The Seven-million Year Story of How and Why We Survived. New York: Walker &, 2013. Print.Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.Liebenson, Craig. Rehabilitation of the Spine: A Practitioner's Manual. Philadelphia: Lippincott Williams & Wilkins, 2007. Print.Studies:Moreside JM, et al.  Hip joint range of motion improvements using three different interventions.  J Strength Cond Res. 2012 May;26(5):1265-73.Leetun DT, et al.  Core stability measures as risk factors for lower extremity injury in athletes.  Med Sci Sports Exerc. 2004 Jun;36(6):926-34.Kibler WB, Press J, Sciascia A.  The role of core stability in athletic function.  Sports Med. 2006;36(3):189-98.Wilson JD, et al.  Core stability and its relationship to lower extremity function and injury.  J Am Acad Orthop Surg.  2005; Sept13(5):316-325Shinkle J, et al.  Effect of core strength on the measure of power in the extremities.  J Strength Cond Res. 2012 Feb;26(2):373-80Granacher U, et al.  The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: a systematic review.  Sports Med. 2013 Jul;43(7):627-41.Gottschall JS, Mills J, Hastings B.  Integration core exercises elicit greater muscle activation than isolation exercises.  J Strength Cond Res. 2013 Mar;27(3):590-6. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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The New Overhead Concept (Part II)

In Part I you learned the concepts behind upward rotation and the overhead shoulder.  This article builds off of these concepts and will show you how to properly assess and treat for the overhead shoulder.I cannot emphasize enough how important a thorough assessment is before prescribing overhead shoulder exercises.  Without an assessment to determine any impairments or movement dysfunctions you will not be able to properly prescribe the correct exercises.  Before someone starts overhead movements you should make sure they're clear in all of the overhead shoulder characteristics (Part I).  Failure to do so could result in injury.However, a full biomechanical assessment is beyond the scope of this article.  Only general shoulder type and posture will be addressed in the assessment.

Assessment

Once you have cleared their shoulder biomechanics you can start to look back at the movement and shoulder type.There are several ways to assess the scapula position and shoulder type.  The Kibler Scapula Classification is one of the more common assessments.However, as we learned in part I, the scapula is only part of the kinetic chain.You need to also look globally.  And lucky for us, one of the best ways to assess global shoulder types is by simply looking at posture.

Posture

Don't just look at the glenohumeral joint, or even just the scapula.  You need to start at the center and work your way out.  Each level will determine what part of overhead training the patient will need to focus on.

Lumbar Spine: Look for the degree of their lordosis/anterior pelvic tilt.  If someone is hyperextended and hinges at the T-L junction you will need to address their anterior core before going overhead.

Thoracic Spine: You will usually either see a kyphotic thoracic spine or a flat thoracic spine.  Both cases will have difficulty stabilizing their scapula.  This needs to be addressed so that the scapula can move efficiently.  The scapula can be viewed like the patella; "it's not the train that needs fixin', its the tracks".

Clavicle: Due to its attachments, it will be a giveaway for the scapula.  You want to see a 6-20° upslope.

Scapula: This is the biggest giveaway.  The scapula is the "liaison" between the arm and the trunk.  But remember it moves in many planes, not just forward in back.

• Anteriorly or Posteriorly Tilted (Sagittal)• Upward or Downwardly Rotated (Frontal)• Elevated or Depressed (Frontal)• Internally Rotated (Winged) or Externally Rotated (Transverse)

Even a quick global view will give you a good indication.  For example, look at the picture to the left.Mr. Burns is a mess.  All his time obsessing about money and abusing his employees has left his shoulders depressed and his thoracic spine kyphotic.On the other hand, Juggernaut's uncontrollable rage has left his shoulders so high he appears to have no neck.These two would respond completely differently to an overhead program and require completely different exercises and cues.

Shoulder Flexion / Abduction

Once you have a good postural/static assessment you can then assess how they move dynamically when going overhead.  This movement pattern assessment will be a very valuable insight to their compensatory strategies.Have the patient flex and/or abduct their arms all the way overhead.  Look for fluid motion.  It shouldn't be a struggle for someone to get their arm overhead.You want to look for similar things that you do during the postural assessment, but you can focus on 3 things.

1. Centrated Spine (lack of rib flare)
2. Full Scapular Upward Rotation (55-60°).
3. Level Hands in Full Flexion

Intervention

After your assessment you will have a better idea of what your patient needs.  Their needs and movement patterns displayed in the assessment will dictate where to start.My progression usually starts with the anterior core integration, then goes to unloaded overhead, then to loaded overhead.  I know this is vague, but its more about making sure you aren't missing a step in the process.  Going to a loaded press without assuring correct unloaded movement patterns or anterior core stability is a dangerous way to treat.

Compensations / Substitutions

Before you start pressing away, it's important to know what common compensations occur with overhead shoulder movement.  Here is a list of the most common strategies I see (this is not conclusive, some people find amazing ways to compensate).

• Rib Flare
• Lumber Hyperextension
• Cervical Protusion
• Inadequate Upward Rotation
• Elbow Flexion
• Scapular Protraction/Anterior Tilt
• Trunk Lateral Shift

Cues

It is important to have the right cues to prevent compensations.  Each individual will require a different cue depending on their movement patterns and potential compensations/substitutions.Eric Cressey uses 4 Different Cues depending on the athlete:

1) For Lumbar Hyperextension / Lordosis / Rib Flare = cues to engage antere core and keep ribs down

2)For Kyphotic "Desk Jockeys" = cues to keep chest up (posteriorly rotate rib cage, not lumbar extension)

3) For Depressed Sloping Shoulder Blades = cues to shrug as arms go overhead (not before) to get full upward rotation

4) For Upper Trap Dominant = cue posterior tilt of the scapula

The Exercises

Basic Anterior Core Integration

I always find it advantageous to start with some basic anterior core integration.  Many people have difficulty with this concept.  If you skip this step and start training scapular upward rotation on a weak/inhibited core you will only be setting them up for failure in the future.  Without the core, the shoulder has to do twice as much work.The reachback / pullover exercise is a great place to start.  If the patient has difficulty getting their ribs down, you may need to regress the exercise a simple breathing drill (full exhale helps achieve "down" position and engages core).http://www.youtube.com/watch?v=blJcjYIRiokOn the other side of the difficulty continuum, the standing anti-extension exercise is a great way to integrate the core with shoulder flexion.  I find this exercise very challenging when done correctly.http://www.youtube.com/watch?v=nxkawQ_sanc

Unloaded Overhead Training

After you integrate the core it's time to start training overhead.  But before you load it up you want to make sure your movement patterns are clean.  Start "greasing the groove" without resistance or load first.  These are also great warm-ups for advanced patients.

• Unloaded PNF D2 Patterns (supine, half/tall-kneeling, quadruped, standing)

• Reach, Roll, & Lift

• Prone Y's & ILY's

• Wall Slides

• Back-to-Wall Shoulder Flexion

• Bilateral Shoulder Flexion in Deep Squat

3 Loaded Overhead Training Progressions

• 1. Static Load in Full Flexion

Often times when people have difficulty squatting or deadlifting we start from the bottom and/or shorten the range (i.e. box squats, FMS corrective squat, rack pulls).  We can apply the same logic to the same with the press.  We can start from the top and shorten the range.The top down press (Rack Press) is essentially working from the full overhead position and progressing your way down.  This allows the patient to reap the benefits of the overhead position without going through the provocative motions to get there.  Remember from Part I, this loaded full overhead position is where you reap all of the benefits (core, scapula, t-spine, RTC, etc.).http://www.youtube.com/watch?v=EZAIDV7vMOIThe emphasis for the rack press should be the static loaded hold in full flexion.  I usually have my patients hold this position for at least 3 breaths per repetition.  The more time in this position, the better.Other exercises include:

Bottoms-Up Kettlebell Overhead Hold / Farmers Walk

Reactive Neuromuscular Training (RNT) with Lower Extremity (the possibilities are endless)

• 2. Progressive Angles

Another great way to progress loaded overhead training is with progressive angles.  I learned this one from Eric Cressey.  Starting with angled presses/pulls decreases the provocative positions while allowing for overhead adaptation.

Landmine Press (Angled Press)

Angled Pull-Down

Resisted PNF D2 Flexion

1/4 Turkish Get-Up (to elbow)

• 3. Full Range Overhead Training

Once your patient is able to handle all the exercises above it is safe to progress to full overhead training.  From this point it is more about the SAID principle and maintaining clean movement.

Yoga Push-Up (at 2:10 in this video)

Full Turkish Get-Ups

Resisted Y's (TRX Y's)

Kettlebell Overhead Press

Push-Press

Barbell Overhead Press (OHP)

Pull-Ups (eccentric → concentric)

Bottom Line

Sometimes just mentioning overhead shoulder work makes people cringe and grab their shoulders.  It is often avoided in rehab and is performed/progressed incorrectly in performance training.Everyone should be able to get their arm overhead.  This position is incredible for the human body.  With this article series you should be able to better assess and prescribe exercises for overhead shoulder work.

Dig Deeper

Eric Cressey - Upward Rotation in Athletes - Why You Struggle to Train Overhead & What to Do About itLudewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther 2000;80:276-91Johnson G, Bogduk N, Nowitke A.  Anatomy and actions of the trapezius muscles.  Clinical Biomechanics.  1994;9:44-50.Struyf F, Nijs J, Meeus M, Roussel NA, Mottram S.  Does Scapular Positioning Predict Shoulder Pain in Recreational Overhead Athletes?  Int J Sports Med. 2013 Jul 3; --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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The New Overhead Shoulder Concept (Part I)

Traditional Down & Back

At this point we all know the importance of a stable and strong scapula for shoulder function.  Almost every PT, athletic trainer, and personal trainer trains the shoulder with a "down and back" cue.  This cue allows for a better stable position of the scapula and enables the rotator cuff to work more effectively.  Kolar has summed this concept up in a single sentence:

• "The muscle may not be weak in itself, but it may not function well because its attachment point is insufficiently fixed."

New Upward Rotation Emphasis

However, in my experience there have been many patients that don't seem to get back to their full function after a shoulder injury despite the scapula strengthening and the down and back shoulder packing.  In my search for answers I came across Eric Cressey's blog several times.  Where most clinicians are terrified of allowing a shoulder to elevate due to the Upper Trap/Lower Trap ratio that we were taught to fear, Cressey advocates the opposite.  He trains many of his clients in an overhead position with an emphasis on upward rotation using the trapezius.

• "We may have ruined a whole generation of athletes with the cue back and down" - Eric Cressey

Does the statement above bother you?  Bring up some defensive arguments?  It did for me when I first heard it.  I've been cueing people with "back and down" for years.  However, once I got past my ego and opened up to this concept my shoulder patients started to get MUCH better.

Overhead/Upward Rotation/Upper Trap Concept

While this upper trap/overhead concept may not be brand new or fully original to Eric Cressey (I know Sahrmann is an advocate of this); he is the first I've heard to discuss it with such clarity and clinical relevance.  Most of the time when you hear about a new concept it's really just somebody trying to sell something or someone just offering an interesting perspective with no clinical solutions.  However, Cressey not only helps to define this paradigm shift, but he also offers detailed strategies to address it (for free!).Much of this post series, especially the assessment & intervention (part II), is based upon Cressey's work.It's important to note that this isn't just a protocol you blindly apply to everyone.  It's a detailed concept that requires an individualized assessment to determine if they need more upward rotation (and where they need to get it from).

Why is Overhead Position Important?

We're Losing It

Our current species of the hominin is starting to de-volve.  To understand this, we have to look at where we came from.  First when we used to live in the trees our shoulders were oriented upward and forward.  Then when the climate changed and we were forced to our bipedal states in the savanna, our shoulders re-oriented less upward and more forward to manipulate objects.  Next, to increase our hunting prowess our shoulders re-oriented more laterally facing to allow us to throw objects at our prey.  Now, with all the use of technology and poor postures our shoulders are starting to regress back to facing more forwrard.

Displays Optimal Shoulder Function

The FMS/SFMA had it right with the overhead squat assessment.  For more reasons than I realized.Being able to get both arms overhead without compensatory patterns is a sign of great shoulder function.  If you have any pain, restrictions, weaknesses, or dysfunctional movement patterns you will not be able to do this.  The same cannot be said for non-overhead shoulder positions.

People Like to Use it

Even if you don't buy into the last two, you can't argue with this one.  Most of our patients love to participate in recreational activities and exercise.  For these patients to return to such activities they need to display good overhead shoulder mechanics.  You can't just have them doing sidelying ER and expect them to go out and hit a tennis serve without problems.Even if they're not athletes they'll need it for everyday tasks of putting dishes away, washing your hair, hailing a cab, slapping someone taller, etc.

What is Required for the Overhead Shoulder Position?

Before you can assess and correct the overhead shoulder, you first must truly understand what goes into an overhead shoulder.  Each of these things have their own complexity and should not be underestimated.

What You Get When You Train Overhead?

A cascade of events occur when you lift your arm to the full overhead position with a proper movement pattern.  From a simple perspective it strengthens the upward rotators and lengthens the downward rotators.  Full scapula upward rotation is paramount (increased GH congruency in overhead position).  However, it's much more complex than just upward/downward rotation.First it's important to understand that most people only have about 170 degrees of pure shoulder flexion.  Often time they'll cheat with lumbar/T-L junction hyperextension to get to the full 180.  But if you can teach your patients not to cheat and to actively get to a stable compensatory free full overhead shoulder position, a lot of good things will occur.So what happens when you try to go for the full 180?  A cascade of events occurs leading to a stable shoulder position with activated thoracic extensors, scapula stabilizers, rotator cuff, and anterior core.Load this position with a weight and a ton of great things happen.  The simple physics of it:Long Lever + High COG over Small BOS = Inherent Instability = Reactive Stability.Plus, adding a compressive load gets the reflexive stabilization of the RTC and scapula in this great position.

Is the Upper Trapezius Really a Problem?

The poor upper trap.  It gets blamed for everything.  People often say that it's too tight and too active.  Historically many people have tried to decrease the upper trapezius tone by spending a ton of manual therapy and stretches to "loosen" them up.  Then they try force the little lower trapezius and serratus anterior to do all of the upward rotation work.The problem is that the upper trapezius should be considered with the opposite point of view.  We should look at it as an important shoulder muscle that needs to be strengthened.This concept should be agitating for anyone that went to physical therapy school, as we learned about UT/LT ratio's and how much of a problem the UT can be.To accept and utilize this paradigm shift you have to understand the true function of the upper trapezius.

2 Aspects of the Upper Trap Function

1) The UT is an important part of scapular upward rotation.  Many people know this, but tend to spend all their time on the LT & SA.  If you only focus on the LT and SA then you are missing out on  33% of the upward rotators.  How can you get someone back to full function by only strengthening 66% of their muscles?2) Almost all the fibers of the UT attach to the posterior boarder of the distal third of the clavicle (Johnson et al, 1994).  This would mean the fiber orientation would actually cause medial rotation of the clavicle, compress the sternoclaviculalr joint, posteriorly tilt of the scapula, elevate the lateral clavicle, and increase upward rotation.

So have we been completely wrong all along?

Yes and no.Yes, there can be an excessive elevation during the initial stages of shoulder flexion.  So there is a movement dysfunction.But no, the UT isn't capable of elevation with the arm at the side.  The UT works synergistically with the LT and SA after the shoulder has started to flex/abduct.  The excessive elevation is from the levator scapula (the main scapula elevator with the arm at the side).To make matters worse, when the upper trap is weak the levator scapulae will jump in and try to make up for this weakness.  Unfortunately the LS doesn't upward rotate, so it just pulls on the cervical spine, jacks up the scapula, and throws off all force couples.

Bottom Line

The down and back traditional treatment of shoulders may not be the best approach for all patients.  Not to mention there is a great deal of benefit from training in full scapular upward rotation (i.e. increased subacromial space, UT/SA/LT strengthening, downward rotator lengthening, t-spine extension, anterior core stability, etc.).After reading this article you will have the necessary understanding to better assess and treat the overhead shoulder (part II).

Dig Deeper

Eric CresseyWarren Hammer - Dynamic ChiropracticAdam Meakins - Upper Trapezius James Speck - UT Doesn't Fire IndependentlyLudewig PM, Cook TM. Alterations in shoulder kinematics anda ssociated muscle activity in people with symptoms of shoulder impingement. Phys Ther 2000;80:276-91Johnson G, Bogduk N, Nowitke A.  Anatomy and actions of the trapezius muscles.  Clinical Biomechanics.  1994;9:44-50. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Quadruped

The quadruped position is a very important developmental posture.  From this posture we learn to crawl and transition to half-kneeling (which then transitions into standing).  Through this posture we develop core, shoulder, and hip stability, learn reciprocal UE/LE motion, and begin to control our spine through our weight-bearing extremities.  The quadruped position has many details that are often lost or forgotten when training.  Mastering these subtleties and progressing within the edge of your ability will lead to a great effect on your stability.

What it Does

• Taps into Hard-Wired CNS Developmental Stage
• Increases Hip, Shoulder, and Core Stability
• Self-Limiting Posture
• Challenges Rotary Stability
• Develops Reciprocal Motion & Coordination
• Removes Ankle/Knee Compensations
• Allows for Unloaded Spinal Stability

3 Keys to Performance

1. Maintain Neutral Spine
2. Hips and Shoulders should be at 90 degrees
3. Do not allow any pelvis or shoulder girdle rotation

Common Faults to Avoid

• Hyperlordosis with leg extension
• Compensatory pelvic rotation (usually opening)
• Scapula winging and or elevation on weight-bearing arm
• Non-neutral cervical position (looking forward or cervical protrusion)
• Compensatory weight shift over weight bearing extremity
• High-threshold strategy

Clinical Use

Examination

Using this posture for assessment can determine whether a patient has a weight-bearing stability issue, an open chain compensation, a spinal stability dysfunction, or a combination of these dysfunctions.  Furthermore, it can help determine the specific position of instability (i.e. hip flexion vs hip extension, shoulder end-range flexion vs mid-range flexion).  Determining the specifics of their motor pattern dysfunction can help you further individualize your plan of care.For more advanced and active patients you can take them through a 6 level progression (see video below) to determine their level of stability and determine whether it is a static or dynamic dysfunction.  Make sure to pay attention to any asymmetries, compensations, or faults.http://www.youtube.com/watch?v=kK0-jpxMbos

Intervention (Train the Brain)

A proper assessment leads to a more effective intervention.  By taking the patient through the 6 level quadruped progression you can determine the limits of their ability.  Once you determine this you can train them within their edge of ability to improve their stability.  It's important to avoid compensations or making the exercise too difficult.  This should be a low-threshold training exercise.  Think about training the pattern instead of the muscles.After mastering the 6 levels of quadruped stability you can further add other extremity movements, resistance, or perturbations to make the exercise more difficult.  Many clinicians and trainers even use creeping, crawling, and even the bear crawl for exercise progressions.

Summary

The developmental perspective shows us that movement was developed in patterns, not by isolated muscle strengthening.  Using developmental postures can help to re-wire dysfunctional movement patterns.  Before progressing to more complicated postures (half-kneeling, single leg stance), make sure your patient is efficient in this quadruped position. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Breathing - Part I - Anatomy & Mechanics

The average person takes about 21,000 breaths a day.  This makes it one of the 3 biggest aspects of our patients life that we can have a profound effect on (other 2: posture & walking).This post will discuss the holistic effects of breathing, anatomy, and the important cascade of events for proper breathing and inner core stabilization.

Why Work On Breathing?

Because everyone is doing it.  Power lifters have been controlling their intra-abdominal pressure to lift massive weights for years.  Yoga and eastern medicine have been using breathing for over 2,000 years (PT isn't even a century old) .  Gray Cook and the SFMA require a full breath at the end-range of every movement test to achieve a FN.  The neuro-orthopedic approach leans on breathing and even mentions that a deep breath glides the median nerve 1 inch.  There is an increasing amount of approaches that are including breathing (PRI, SFMA, DNS).  Many of the leading experts in the field are incorporating breathing.  And there is more and more research coming out discussing the benefits of breathing.  So if you're not doing it, or at least aware of it, then you are probably that guy.

Holistic Breathing

Breathing has a huge influence on the entire body.  Breathing influences sympatho-vagal balance.  Dyfunctional breathing can induce hypocapnia (effect of hyperventilation).  Hypocapnia causes increased neural activity and synaptic transmission.  You know those patients that feel that every muscle is tight and you can never decrease their muscle tone for more than 24 hours?  Maybe it's because of their breathing.  Breathing can actually produce an amplification of the parasympathetic nervous system.  This can have a tremendous effect on muscle tone (a nervous system issue).Breathing also has a significant role in the circulatory system, pH regulation, and metabolism.  It has been tied to many psychological disorders and can have a major effect on self-regulation of stress and emotion.  Breathing even has an important role in some religions and spiritual practices.Breathing has a therapeutic, homeostatic, regulatory, psychophysiological, and spiritual function.  If your patients are alive, then breathing should be considered as an aspect of their care.

Breathing Anatomy

A global understanding of breathing anatomy can be expanded from knowledge of the deep front line.  This line from Anatomy Trains goes into the fascial attachments of the diaphragm in great detail.  Or simply stated, "the 12th rib is where walking meets breathing"-Tom Myers.

Diaphragm

The diaphragm has a dual function: respiration and stability.  It should be able to perform this dual function at all times.  A common injury is caused by a failure of this mechanism.  The overweight, sedentary, desk-jockey wakes up to shovel snow out of his driveway.  After 5 minutes he's exhausted and his diaphragm has to devote all of its power for respiration.  Now his diaphragm has lost it's stability function.  Now he can't control and use his intra-abdominal pressure (IAP).  And now he just hurt his back.Want another reason why we should know about the diaphragm's stability role?  It's the most proximal muscle...to everything.  There's nothing more proximal than the diaphragm.  It helps to organize and stabilize the upper and lower quarter.  Sue Falsone agrees that the diaphragm is the most proximal.  Regarding this concept she has said that she always starts rehab "from the belly button out."

Zone of Apposition

The Postural Restoration Institue defines the ZOA as the "cylindrical aspect of the diaphragm that apposes the inner aspect of the lower mediastinal (chest) wall."  This is one of the most important aspects of breathing.  The ZOA is responsible for:

• Efficient length-tension relationships of the diaphragm
• Maintains vertical alignment of diaphragm muscle fibers
• Allows postero-lateral (bucket-handle) movement of the lower rib cage

Overall the ZOA is paramount for proper diaphragm function.  Some have found it to be as much as 30% of the inner surface of the ribcage.  A decreased ZOA will result in inefficient diaphragm contraction, lung hyperinflation, increased accessory muscle use, lack of postero-lateral movement of the rib cage, and an increased anterior rib flare.

Abdominals & Pelvic Floor

The abdominals and pelvic floor play a huge role in inspiration (eccentrically) and expiration (concentrically).  During inspiration they contract eccentrically to increase the intra-abdominal pressure (i.e. stability)  and ensure that the ZOA is maintained long enough to produce postero-lateral expansion of the lower ribcage.  During expiration they concentrically contract to help push the diaphragm cephallically, thus restoring optimal ZOA.

Thoracic Cavity

The thoracic cavity is where the actual breath occurs.  It's where the air molecules and gas exchange occurs.  The thoracic cavity must have the appropriate amount of mobility to accommodate this pressure change and flow of molecules.  During inspiration the ribs must be able to ER and the spine must be able to extend.  During expiration the ribs must be able to IR and the spine must be able to flex.Breathing plays a major role in the hydration of the thoracic discs.  If you look at the anatomy of the ribs attachment to the thoracic spine it almost looks like a lever.  This lever actually pry's open the thoracic spine and elongates it, thus bringing hydration and nutrition to the discs.

Breathing Mechanics (Core from the Inside Out)

There is a cascade of events that leads to controlled intra-abdominal pressure through the activation of the diaphragm and core musculature.  By using the breath with the core you are achieving natural muscle activation and increased intra-abdominal pressure.  This pressurized stability is much more efficient than muscle activation alone (abdominal hallowing/isolated TVA activation).The best way to have a proper breathing pattern is to get it right from the inhale.  A proper inhale will put you in the correct position for a proper exhale.  Clinically there are many things that can go wrong with inspiration, whereas the only thing that often goes wrong with expiration is decreased expired air (hyperventilation/decreased ZOA).The inhale is the initiation of core stability.

Inspiratory Cascade of Events

1) Diaphragm Concentrically Contracts

2) Beginning of Increased IAP

3) Abdominals and PF Eccentrically Contract

4) Controlled Increase in IAP & Inner Core Stability

Bottom Line

Understanding breathing anatomy and mechanics will allow you to easily assess and intervene respiration.  The effects of proper breathing are: adequate respiration, proper biochemical balance, decreased/prevention of psychological distress, and most important for physical therapist - natural activation of the inner core stability.  Part II will deal with ideal & dysfunctional breathing patterns, assessment, and some simple interventions.

Dig Deeper

Dean SomersetHans Lingren - Core Stability Inside OutRosalba CourtneyErson ReligiosoSportsRehabExpert - Ron Hruska InterviewMike Robertson - Video CoachingPatrick WardPostural Restoration InstitueConnor CollinsCraig LibensonBill HartmanTara RobertsonSeth Oberst - 1 & 2

References

Tom Myers & Leslie Kaminoff.  The Breath in the Pelvis - Seminar (NYC 2012).Courtney R,Reece J (2009). Comparison of the Manual Assessment of Respiratory Motion (MARM) and the Hi Lo breathing assessment determining a simulated breathing pattern.  International Journal of Osteopathic Medicine.Courtney R (2009). The functions of breathing and its dysfunctions and their relationship to breathing therapy.  International Journal of Osteopathic MedicineCourtney R (2011).  Dysfunctional Breathing - It's paramaters, measurement and relevance.  Thesis RMIT University. (a must read - click here)Kaminoff L. (2006). "What yoga therapists should know about the anatomy of breathing." International Journal of Yoga Therapy.McLaughlin L. (2009). "Breathing evaluation and retraining in manual therapy." Journal of Bodywork and Movement Therapies.McGill S , Sharratt M ,Sequin J P. (1995). "Loads on spinal tissues during simultaneous lifting and ventilatory challenge." Ergononomics.Janssens L , Brumagne S, Polspoel K, Toosters T, McConnell A. (2010). "The effect of inspiratory muscles fatigue on postural control in people with and without recurrent low back pain." Spine.Hodges P , Heijnen I, Gandevia S C. (2001). "Postural activity of the diaphragm is reduced in humans when respiratory demand increases." Journal of Physiology.Hodges P , Butler J ,Mackenzie D K, Gandevia S C. (1997). "Contraction of the human diaphragm during rapid postural adjustments." Journal of Physiology 505(Pt. 2Wang S., McGill S (2008).  Links Between the Mechanics of Ventilation and Spine Stability.  Journal of Applied Biomechanics.McGill S, Sharratt M & Seguin J (1995). Loads on the spinal tissues during simultaneous lifting and ventilatory challenge. Ergonomics.Robey J, Boyle K (2009). Bilateral Functional Thoracic Outlet Syndrome in a College Football Player. N Am J Sports Phys Ther.Boyle K, Olinick J, & Lewis C (2010).  The value of blowing up a balloon.  N Am J Sports Phys Ther.Kolar P, Sulc J, Kyncl M, et al. (2010) Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Appl Physiol.Kolar P, Sulc J, Kyncl M, et al. (2012).  Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain. JOSPT.Hagins M, Lamberg EM (2011). Individuals with low back pain breathe differently than healthy in- dividuals during a lifting task. JOSPT.Clifton-Stmith T, Rowley J (2011). Breathing pattern disorders and physiotherapy: inspiration for our profession.  Physical Therapy Review.Hruska R (2005).  ZOA Position & Mechanical Function.  Postural Restoration Institue.Cook, Gray. Movement: Functional Movement Systems : Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Subacromial Space

Regardless of the patho-anatomical etiology, most shoulder injuries involve a disruption in the delicate subacromial space (SAS).  Once this space is altered the structures (joint capsule, articular cartilage, rotator cuff, biceps tendon, bursa) have increased risk for damage and misuse.  This also leads to subsequent changes in muscle length-tension relationships, arthrokinematics, and motor patterns.The subacromial space is only 10mm.  This is a very small amount of space to deal with; there is little room for error.  To put this in perspective keep in mind that a dime is a little over 1mm thick.   So even a very small change in the SAS could lead to potential clinical improvements.  This increase in space will allow for decreased compression on structures and increased blood flow to allow for healing.Managing this space is very important in expediting the recovery process, especially in the acute phase.  While assessing for movement dysfunction and physical impairments is important to develop an individualized plan of care, increasing the subacromial space will afford your patient decreased pain and increased function.

6 Ways to Increase Subacromial Space

• 1) Glenohumeral Adduction Force
• 2) Scapula Retraction, Upward Rotation, & Posterior Tilt
• 3) Increase Serratus Anterior Activation/Strength
• 4) Thoracic Extension
• 5) Good Posture & the Kinetic Chain
• 6) Rotator Cuff Co-Activation

Mechanism of Increasing Subacromial Space

1) Glenohumeral Adduction Force

Most impingement tests involve a provocative glenohumeral abduction moment to decrease the SAS.  So it would only make logical sense that glenohumeral adduction would increase SAS.  Research has agreed with this logic and shown an shown that adducting muscle forces lead to a significant increase of the subacromial space (138% at 90 degrees relative to abduction forces).  This adduction force can be used for everything from muscle energy techniques to simply holding a towel between your arm and torso.  The latter can have a great effect during the acute stage and ensure reciprocal inhibition of the deltoid to decrease its superior compressive force on the SAS.

2) Scapula Retraction, Upward Rotation, & Posterior Tilt

Clinically I find the scapula to have the greatest impact on patients with impingement.  A small alteration in the scapular orientation can greatly affect the amount of SAS.  There is an overwhelming amount of evidence displaying altered scapula kinematics in patients with SAIS.  More specifically, many studies have shown that scapula retraction, upward rotation, and posterior tilt increase the SAS.  One study found that scapula retraction increases SAS by 200%.  Most of these studies examine the kinematic differences between patients with impingement and pain free individuals.  Here is what these studies have found in patients with SAIS:

• Decreased Upward Rotation (significantly at the end of the 1st of 3 phases - with concurent decreased UT firing)
• Increased Anterior Tipping at the end of the 3rd phase
• Increased Scapular Medial rotation under loaded conditions

There is an abundance of corrective exercises for the shoulder (just search on youtube).  To emphasis an increase in SAS you should try to select exercises that strengthen/activate the muscles that produce scapula retraction, upward rotation, and posterior tilt.

3) Increase Serratus Anterior Activation/Strength

The serratus anterior gets its own section because of the unique role it has in controlling the inferior angle of the scapula against the thorax.  This feature helps lift the anterior acromion off of the most common site of impingement.   If you consider the scapula motionts that increase SAS  you will notice that the serratus anterior has a role in each of these motions.  Ludwig and Cook found that subjects with SAIS demonstrated decreased activity in this muscle across all loads and planes.

4) Thoracic Extension

Thoracic extension is an important part of the kinetic chain.  It significantly alters scapular kinematics and is associated with decreased muscle force.  Looking at the position of the thoracic spine will often display a correlated scapula position.  For example, in the kyphotic thoracic spine the scapula would be anteriorly and superiorly tilted.We often consider treating patellafemoral patients by correcting the alignment and movement of the structures underneath the patella (dynamic valgus - femur & tibia).  You can use the same logic to treat shoulder patients.  Tom Myers has described the scapula as a sesamoid bone.  Using this theory you could affect the scapula orientation and shoulder muscle forces by simply correcting the thoracic spine dysfunction.

5) Good Posture & the Kinetic Chain

While local interventions may have the most immediate impact, it is worth considering the global view of increasing SAS.  Proper scapula position and thoracic extension are aspects of good posture, but in severe cases it is important to look at the bigger picture and modify posture from all angles.  Research has shown that normal motor patterns of voluntary upper extremity movement include preparatory lower extremity and trunk muscle activation.  Poor posture may alter optimal muscle length-tension relationships and effect the shoulder.  It could be helpful to integrate a kinetic chain approach to accelerate rehabilitation and restore normal motor patterns.

6) RTC Activation

This is classic physical therapy and the conventional local method for increasing SAS.  The rotator cuff externally rotates the greater tubercle away from the acromion and creates a concave compressive force.  Studies have shown that there is reduced co-activation of the rotator cuff in patients with SAIS during the initiation of elevation below 30°, but not at higher angles.  This validates the importance of reactive neuro-muscular training for the rotator cuff.

Bottom Line

This post was focused on the mechanisms and kinesiology that affects subacromial space.  A full assessment is imparitive for effective treatment.  By understanding the mechanisms that maximize the subacromial space you will have a better idea of what to look for and how to correct it.

6 Ways to Increase Space

1. Glenohumeral Adduction Force
2. Scapula Retraction, Upward Rotation, & Posterior Tilt
3. Increase Serratus Anterior Activation/Strength
4. Thoracic Extension
5. Good Posture & the Kinetic Chain
6. Rotator Cuff Co-Activation

References

Hinterwimmer, Stefan, Ruediger Von Eisenhart-Rothe, Markus Siebert, Reinhard Putz, Felix Eckstein, Thomas Vogl, and Heiko Graichen. "Influence of Adducting and Abducting Muscle Forces on the Subacromial Space Width." Medicine & Science in Sports & Exercise 35.12 (2003): 2055-059Solem-Bertoft E, Thuomas K-A¨ , Westerberg C-E. The influence of scapula retraction and protraction on the width of the subacromial space: an MRI study. Clin Orthop 1993;296:99-103Ludewig PM, Cook TM. Alterations in shoulder kinematics andassociated muscle activity in people with symptoms of shoulder impingement. Phys Ther 2000;80:276-91 (Best Article)McClure PW, Michener LA, Karduna AR. Shoulder function and 3-dimensional scapular kinematics in people with and without shoulder impingement syndrome. Phys Ther 2006 August;86(8):1075-90.Kebaetse, M. "Thoracic Position Effect on Shoulder Range of Motion, Strength, and Three-dimensional Scapular Kinematics." Archives of Physical Medicine and Rehabilitation 80.8 (1999): 945-50.Finley, M., and R. Lee. "Effect of Sitting Posture on 3-dimensional Scapular Kinematics Measured by Skin-mounted Electromagnetic Tracking Sensors☆." Archives of Physical Medicine and Rehabilitation 84.4 (2003): 563-68Myers JB, Hwang JH, Pasquale MR, Blackburn JT, Lephart SM. Rotator cu coactivation ratios in participants with subacromial impingement syndrome. J Sci Med Sport. 2009;12:603-608McMullen J, Uhl TL.  A Kinetic Chain Approach for Shoulder Rehabilitation.  J Athl Train. 2000 Jul-Sep; 35(3): 329–337.Cordo PJ, Nashner LM. Properties of postural adjustments associated with rapid arm movements. J Neurophysiol. 1982;47:287–308 --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Shoulder Stability - Dynamic Stabilizers (3 of 3)

Dynamic Stabilizers of the glenohumeral joint include the contractile tissues and the associated sensorimotor system involved with proprioception, kinesesia, and the sensation of resistance.  For optimal shoulder stabilization the dynamic stabilizers must be working in an efficient synergistic fashion.

Rotator Cuff

The rotaor cuff muscles have a smaller cross-section area and size, a closer to center of rotation on which they act, their lever arm is shorter, and they generate smaller forces.  Which means they are made to provide stability to a dynamic fulcrum during GH movement.  It is also important to realize that the rotator cuff tendons blend with the joint capsule.  They not only help to dynamically stabilize and move the humerus, but they reinforce the joint capsule (dynamic ligament tension).In addition to the concatity-compression effect to stabilize the humeral head in the center of the glenoid fossa, the rotator cuff helps to externally rotate and depress the humeral head to avoid contact (impingement) of the greater tubercle with the acromion.  While external rotation comes mainly from the teres minor/infraspinatus, the downward depressive moment comes from the force couple of the subscapularis and teres minor/infraspinatus.  This downward force component helps to prevent the dominance of the deltoid's upward force (depressive forces at maximum between 60 and 80 degrees of elevation).   This is synergistic relationship often referred to as the RTC/Deltoid force couple.Assessing for adequate dynamic stability in every direction requires knowledge of the contractile structures around the joint and how they function with each humeral vector force.  There are 3 ways I tend to look at this dynamic stability.

1. Resistance to translation from opposite side pull of muscles
2. Support of same side structures through muscle stiffness/capsular tensioning
3. Synergistic force coupling for efficient controlled axis of rotation/motion

We'll use anterior translation of the humerus during external rotation at 90° as an example since it is the most common clinically.  On the posterior side of the GH joint, the external rotators would fire to "pull" the humeral head back.  It has been proven in research that the external rotators help to prevent anterior translation of humerus (Kuhn et al 2005).  On the anterior side of the joint, the internal rotator would provide anterior capsule tightening and act as a sling to prevent excess anterior translation.  The force couples of the scapular musculature, teres minor/infraspinatus and subscapularis, and supraspinatus would help to stabilize the humeral head in the glenoid fossa.

• Supraspinatus - compression, abducts, and generates a small ER torque , peaks at 30°-60°, generates most force in scapular plane
• Infraspinatus & Teres Minor - compression, generates inferoposterior force, provides great ER torque, generates most force at 0° abduction
• Subscapularis - compression, provides anterior stability, generates IR torque, generates most force at 0° abduction, primary IR at 90° abduction

Long Head of Biceps Brachii

The LHB as a stabilizer of the shoulder joint has been a topic of controversy for a long time now.  Some believe that the forces of the LHB are negligible and do not function to stabilize the glenohumeral joint.  Others believe it is anywhere from a secondary to tertiary stabilizer of the shoulder.  Although, there are many different views as to how the muscle functions as a stabilizer.  It has been theorized that the LHB is a humeral head depressor, reduces anterior translation in late cocking phase of throwing and can increase the torsional rigidity of the joint resisting ER, and some have pointed out that at low levels of elevation it stabilizes the joint anteriorly when the arm is in IR and posteriorly when the arm is in ER.Research still seems to be inconclusive as to the function of the LHB in stabilizing the shoulder joint.  However, the fact that the biceps tendon often plays a role in symptoms (anterior shoulder pain) and pathologies (SLAP lesions) leads me to believe that the LBH plays a role in stabilizing the shoulder joint.

Scapula

The scapula is of great importance when considering shoulder stability.  Achieving proper balance of force couples, resolving any muscle-length limitations, and ensuring dynamic stabilization of the scapula throughout the entire ROM is necessary for optimal functioning of the shoulder joint.  It is important to ensure a retracted and slightly depressed scapula during all shoulder exercises.A discussion of the influence of the scapula is beyond the scope of this article.  A future post will provide more detail.

Examination

Examination and assessment of the dynamic stability of the shoulder complex can be very difficult.  Most special tests do not provide adequate specificity or sensitivity, subjective complaints may be misleading, and there are many structures they may be involved.  I have found it helpful to assess the shoulder in various degrees of motion in all 3 cardinal planes.For example, I will preform the kennedy-hawkins in 3 different transverse plane degrees to attempt to differentiate the influence of pain from the acromial and/or coracoid.  I usually MMT IR/ER and abduction strength in 3 different frontal plane degrees in attempt to determine a more specific directional instability and to assess the RTC force coupling efficiency.  I also find it helpful to consider the sagittal plane and palpate the humerus and scapula to determine if and where any uncontrolled motion is coming from.

Bottom Line

Assessing and treating dynamic stability of the shoulder joint is a very complex task.  A thorough understanding of the kinesiology and structures involved is necessary to determine the specific dynamic stability impairments.  Since the shoulder joint has the most mobile joint in the body, it is important to consider all planes of motion to locate the uncontrolled motion.

Best of the Web

http://www.eorif.com/Shoulderarm/Shoulder%20anat/Shoulderanatomy.htmlhttp://www.mikereinold.com/2011/03/6-key-factors-in-the-rehabilitation-of-shoulder-instability-part-1.htmlhttp://www.mikereinold.com/2010/11/shoulder-impingement-3-keys-to.htmlhttp://www.shoulderdoc.co.uk/http://www.physiodigest.com/376/shoulder-examination/http://www.orthoontheweb.com/shoulder.asphttp://thebodymechanic.ca/2011/01/18/shoulder-impingement-rehabilitation-part-one/http://www.thesportsphysiotherapist.com/subacromial-impingement-syndrome-posterior-capsule-tightness-and-the-%E2%80%9Cdiablo-effect%E2%80%9D/http://robertsontrainingsystems.com/blog/5-more-shoulder-saving-tips/http://optimumsportsperformance.com/blog/?p=2076

References

Ticker JB, Beim GM, Warner JJ.  Recognition and treatment of refractory posterior capsular contracture of the shouder.  Arthroscopy.  2000;16:27-34Sethi PM, Tibone JE, Lee TQ.  Quantitative assessment of glenohumeral translation in baseball players: a comparison of pitchers versus nonpitching athletes.  Am J Sports Med.  2004;32:1711-5Terry GC, Thomas M, Chopp.  Functional Anatomy of the Shoulder.  Journal of Athletic Training.  2000;35(3):248-255Izumi T, Aoki M, Tanaka Y et al.  Stretching positions for the coracohumeral ligament: Positional strain during passive motion using fresh/frozen cadaver shoulders.  Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2011.Kuhn JE, Huston LJ, Soslowky LJ et al.  External rotation of the glenohumeral joint: ligament restraints and muscle effects in the neutral and abdcuted positions.  Journal of Shoulder and Elbow Surgery.  2005;14(1):S39-S48.Myers JB, Lephard SM.  The Role of Sensorimotor System in the Athletic Shoulder.  Journal of Athletic Training.  200;35(3):351-363Reinold MM, Escamilla R, Wilk KE.  Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature.  JOSPT.  2009;39(2)105-117Mike Reinold On-Line Shoulder Course - Recent Advances in Evidenced-Based Evaluation and Treatment of the Shoulder --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Shoulder Stability - Static Stabilizers (2 of 3)

Static stabilizers are the non-contractile tissue of the glenohumeral joint.  They are very important in shoulder stability at end-range ROM and/or when there is a dysfunction of the dynamic stabilizers.  These static stabilizers set the base of support for the shoulder joint.

Articular Surface

The articular surface is much like the meniscus of the knee joint.  It thicker at the periphery, provides foundation for concativy-compression effect of RTC.

Labrum

The labrum is a firbrous connective tissue which increases articular surface area for the humeral head by deepening the glenoid fossa.  Provides attachment of the glenohumeral ligaments, long head biceps tendon, capsule, and scapular neck.  Contributes to approximately 50% of depth of shoulder joint.  Stretches out anteriorly with external rotation, stretches out posteriorly with internal rotation.  A loss of labrum integrity has been shown to decrease the resistance to translation by 20%.

Joint Capsule

The capsule is twice the size of the humeral head.  Has most extensibility anteriorly and inferiorly.  "Winds up" in abduction and external rotation.  The joint capsule and glenohumeral ligaments are intimately adherent anatomically and mainly function as stabilizers at the extremes of motion.  This static end-range stabilization is very important when all other stabilizing mechanisms are overwhelmed.The joint capsule has an inherit negative intra-articular pressure that holds the joint together.  The osmotic action of the synovium removes free fluid, keeping a slightly negative pressure within the joint.  This slightly negative intra-articular pressure holds the joint together much like "2 wet microscopic slides placed together" (Terry GC et al 2000).

Ligaments

Glenohumeral

There are 3 main ligaments in the glenohumeral joint:

1. The Superior Ligament limits inferior translation and parallels the course of the coracohumeral ligament.
2. The Middle Ligament limits ER at 45° of abduction, anterior translation in 60-90° of abduction.
3. The Inferior Ligament is the thickest of the ligaments and has 3 different portions: anterior band, posterior band, and the axillary pouch.

It is important to consider that the anterior band of the inferior ligament is the primary stabilizer against anterior translation in the throwing position of abduction and external rotation.

Coracohumeral Ligament

Limits anterior and inferior translation.  Is taught at lower levels of elevation, extension, and extension with adduction (Izumi et al 2011).

“Circle Stability Concept”

For a full dislocation to occur, both sides of the capsule and ligaments must be damaged.  The capsule preventing the direction of location would be considered the primary restraint and the opposite side would be considered the secondary restraint.

Examination

Using the sulcus test and the drawer/load and shift tests at different angles of abduction, the clinician can differentiate between these 3 different ligaments to determine the specific structure involved.  Consider the magnitude of translation and primary and secondary restraints involved with these movements.

Sulcus Test

Position the patient in a relaxed seated position with the arms at the side resting on the thighs.  An inferior translation force is applied through the humerus.  Assessment of the amount of inferior translation will determine if there is a positive "sulcus sign".

• 0-20° Abduction = Primary Restraint is Superior Glenohumeral Ligament
•  45° Abduction = Primary Restraint is Anterior Band of the Inferior Glenohumeral Ligament
• 90° Abduction = Primary Restraint is Posterior Band of the Inferior Glenohumeral Ligament

Anterior Drawer / Load and Shift Test

Patient is positioned in the same position as the sulcus test.  Stabilize the scapula with one hand and genlty shift the humeral head obliquely forward in the plane of the scapula.  A "normal" shoulder reaches a firm end point with only slight anterior displacement and no clunking, popping, or pain.  This test can also be performed supine if the patient has difficulty relaxing.

• 0° Abduction = Primary Restraint is Superior and Middle Glenohumeral Ligament
• 45° Abduction = Primary Restraint is Middle Glenohumeral Ligament
• 90° Abduction = Primary Restraint is Inferior Glenohumeral Ligament

Bottom Line

Understanding the static stability of the shoulder allows the clinician to assess the baseline stability independent of dynamic support.  Finding the direction of impaired static stability will also help to reveal which dynamic stability structures need to be emphasized in the plan of care.

Shoulder Stability

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