Shouldering the burden, Addressing Shoulder mobility.

"Time spent in assessment will save time in treatment." Vladimir Janda

 We are now in part five of the joint mobility series and have arrived at the shoulders. They are complex joints which are responsible for movement of the upper extremities, they consist of approximately twenty muscles, and five articulations. Wow no wonder the shoulder is the other joint called the four knots by Dr. Mark Cheng. We use our shoulders on a daily basis in a wide variety of movements. Often times the importance of the joint will go unnoticed until there is an issue. Unfortunately recent stats show that issues with the shoulders are becoming all the more prevalent; Between 1998 and 2004, over 5 million physician visits were attributed to rotator cuff problems1, an increase of nearly forty percent in the given period. A recent study by the he American Academy of Orthopedic Surgeons, 5-40 percent of people without shoulder pain may have a torn rotator cuff.2 These tears will progress in 40% of these patients, and there will be an enlargement of the tear within a five-year period.3 Twenty-percent of these patients will experience no pain, while 80% percent will.3 Keeping the shoulders strong, maintaining good function and range of motion is imperative for everyone even if you are currently pain free. As you may know the main issue for sustained recovery is compliance. So after reading the blog and doing some research devise a corrective exercise plan for your training program that is user friendly and can be continually altered as you assess and correct.  My dream with this series is to have people moving pain free and properly. It is to be hoped that if you had some issues cropping up this has helped you or helped someone you know.  

 You may be asking Hmmm What do the shoulders have under the hood? The shoulder is a ball in socket joint much like the hip, except instead of the femur we have the humerus. The shoulder girdle is made up of three bones the clavicle (collar bone), scapula (shoulder blade) and the humerus. The scapula is complex it is the attachment site for a number of muscles responsible for movement and stabilization of the shoulder. It overlies the second to the seventh ribs and is encased by 17 muscles that provide stabilization against the thoracic wall. It is noted to be tiled forward at a 30 degree angle. The scapula has a shallow fossa on its lateral side into which the head of the humerus fist to form the glenohumeral joint.  The clavicle has an S shape and is the main connection of the upper arm and the rest of the skeleton. It is an attachment point for the pectoralis major, trapezius, sternoclaedomastoid, sternohyoid and the subclavius.  The clavicle meets the scapula at the top of the shoulder where it connects to the acromion process, forming the AC joint. The humerus is the bone in the upper arm that is the ball of the ball and socket joint at the shoulder. The head fits into the glenoid fossa of the scapula. The joints in the shoulder girdle; the glenohumeral joint, the acromioclavicular joint, sternoclavicular joint and the scapulothoracic joint. The glenohumeral joint is the ball and socket joint where the humerus meets the glenoid fossa  moving with the glenoid fossa of the scapula The head of the humerus is large in comparison to the fossa, resulting in approximately one-third  to one half of the head being in contact with the fossa at any one time. It is further supported by the glenoid labrum a ring of fibrous cartilage, this extends the fossa making it wider and deeper. The acromiclavicular joint is formed by the lateral end of the clavicle articulating with the medial aspect of the anterior acromium. The AC joint is important in transmitting forces through the upper extremity and shoulder to the skeleton. The supporting ligaments minimize the joints mobility. They are the acromioclavicular ligament restricts the movement of the clavicle on the acromion and the coracoclavicular ligament prevents vertical movement. The sternoclavicular joint occurs at the sternal end of the clavicle, the cartilage of the first rib, and the upper and lateral parts of the upper sternum. It is the only joint that truly links the upper extremity to the skeleton by way of the clavicles. This joint functions in all movements of the upper limbs and is importing in throwing and thrusting movements. The scapulothoracic joint relies entirely on the surrounding musculature for its control, the serratus anterior which holds the medial angle of the scapula against the chest wall. As well as the trapezius which rotates and elevates the scapula with elevation of the upper arm. Ligaments connect the bones of the shoulder, and tendons join the bones to surrounding muscles the biceps tendon attaches to the shoulder and helps to stabilize the joint. 

 Onto the rotator cuff!!!  The rotator cuff is made up of four muscles supraspinatus, infraspinatus, teres minor, and subscapularis. All of these muscles originate on different portions of the scapula and insert on the humeral head where they converge at the glenohumeral joint capsule to form a tendinous cuff around the joint. They assume the role of stabilizing the humeral head within the glenoid cavity, each of the muscles also contribute to humeral motion.  The supraspinatus originate on the upper border of the scapula and inserts on the humeral head. It assists the deltoid in abduction of the humerus the muscle is capable of abducting the humerus without the deltoids assistance. It is responsible for preventing subluxation in overhead motions such as throwing, tennis serves, military presses, lateral raises. Also it is one of the most injured rotator cuff muscle.  The infraspinatus has points of attachment on the posterior scapula and humeral head. The muscle contributes to several humeral motions, including external rotation horizontal abduction and extension. The teres minor originates just below the infraspinatus on the posterior scapular surface and inserts on the humeral head. The muscle contributes to several humeral motions, including external rotation, horizontal abduction, and extension. Along with the infraspinatus, it maintains posterior stability at the glenohumeral joint. The subscapularis is the only one of the rotator cuff muscles originating on the anterior surface of the scapula, and is thus hidden behind the rib cage and several larger muscles. With its insertion on the humeral head, it acts on the humerus through internal rotation, abduction, extension and stabilization. The subcapularis receives quite a bit of work with high volume of internal rotator work in most training programs. So direct subscapularis work is not necessary unless there is a strength deficit.

This article is slightly different as we will be addressing a dysfunction and some pre-hab or preinjury work you can do to avoid injuries. Our dysfunction of the day is shoulder impingement syndrome it is sometimes called swimmers or throwers shoulder. It is caused by the muscles of the rotator cuff becoming impinged as they pass through the subacromial space. The muscles will become inflamed and irritated with repetitive pinching. This can lead to thickening of the tendon which may cause further issues as there is very little free space, so as he muscles become larger, they are impinged further by structures of the shoulder joint and muscles. Impingement Syndrome can be caused by a number of different diagnoses such as bone spurs, rotator cuff injury, labral injury, shoulder instability, biceps tendinopathy, and scapula movement dysfunctions. The treatment plan for impingement syndrome is rest, ice therapy, seek out a sports injury specialist and a gradual return to your sport.   Why would we “work” or “train” the rotator cuff?  To have a strong joint and to have continually increasing strength we need a stable flexible joint. If you have the flexibility or the stabilizers of a baby do you think you will be able to move heavy loads or even handle high volumes of work with a light load?  The other reason is the most programs people do when they start out are chest/front deltoid dominant with biceps and triceps, a lot less back, rear delts and rows. Hey I was guilty of this as well does not make you a bad person. Lets learn from our mistakes and move on.  Oh just to address strength again once you address any gunk in the rotator cuff and strengthen the shoulder your numbers should jump considerably.  Please reference the pictures below as well as the descriptions.

• Isometric shoulder external rotation: Stand in a doorway with your elbow bent 90 degrees and the back of the wrist on your injured side pressed against the door frame. Try to press your hand outward into the door frame. Hold for 5 seconds. Do 2 sets of 15.
• Isometric shoulder internal rotation: Stand in a doorway with your elbow bent 90 degrees and the front of the wrist on your injured side pressed against the door frame. Try to press your palm into the door frame. Hold for 5 seconds. Do 2 sets of 15.
• Wand exercise, Flexion: Stand upright and hold a stick in both hands, palms down. Stretch your arms by lifting them over your head, keeping your arms straight. Hold for 5 seconds and return to the starting position. Repeat 10 times.
• Wand exercise, Extension: Stand upright and hold a stick in both hands behind your back. Move the stick away from your back. Hold this position for 5 seconds. Relax and return to the starting position. Repeat 10 times.
• Wand exercise, External rotation: Lie on your back and hold a stick in both hands, palms up. Your upper arms should be resting on the floor with your elbows at your sides and bent 90 degrees. Use your uninjured arm to push your injured arm out away from your body. Keep the elbow of your injured arm at your side while it is being pushed. Hold the stretch for 5 seconds. Repeat 10 times.
• Wand exercise, Shoulder abduction and adduction: Stand and hold a stick with both hands, palms facing away from your body. Rest the stick against the front of your thighs. Use your uninjured arm to push your injured arm out to the side and up as high as possible. Keep your arms straight. Hold for 5 seconds. Repeat 10 times.

• Resisted shoulder external rotation: Stand sideways next to a door with your injured arm farther from the door. Tie a knot in the end of the tubing and shut the knot in the door at waist level. Hold the other end of the tubing with the hand of your injured arm. Rest the hand of your injured arm across your stomach. Keeping your elbow in at your side, rotate your arm outward and away from your waist. Make sure you keep your elbow bent 90 degrees and your forearm parallel to the floor. Repeat 10 times. Build up to 2 sets of 15.
• Resisted shoulder internal rotation: Stand sideways next to a door with your injured arm closest to the door. Tie a knot in the end of the tubing and shut the knot in the door at waist level. Hold the other end of the tubing with the hand of your injured arm. Bend the elbow of your injured arm 90 degrees. Keeping your elbow in at your side, rotate your forearm across your body and then back to the starting position. Make sure you keep your forearm parallel to the floor. Do 2 sets of 15.
• Scaption: Stand with your arms at your sides and with your elbows straight. Slowly raise your arms to eye level. As you raise your arms, spread them apart so that they are only slightly in front of your body (at about a 30-degree angle to the front of your body). Point your thumbs toward the ceiling. Hold for 2 seconds and lower your arms slowly. Do 2 sets of 15. Progress to holding a soup can or light weight when you are doing the exercise and increase the weight as the exercise gets easier.
• Side-lying external rotation: Lie on your uninjured side with your injured arm at your side and your elbow bent 90 degrees. Keeping your elbow against your side, raise your forearm toward the ceiling and hold for 2 seconds. Slowly lower your arm. Do 2 sets of 15. You can start doing this exercise holding a soup can or light weight and gradually increase the weight as long as there is no pain.
• Horizontal abduction: Lie on your stomach on a table or the edge of a bed with the arm on your injured side hanging down over the edge. Raise your arm out to the side, with your thumb pointed toward the ceiling, until your arm is parallel to the floor. Hold for 2 seconds and then lower it slowly. Start this exercise with no weight. As you get stronger, add a light weight or hold a soup can. Do 2 sets of 15.
• Push-up with a plus: Begin on the floor on your hands and knees. Keep your arms a shoulder width apart and lift your feet off the floor. Arch your back as high as possible and round your shoulders (this is the "plus" part or the exercise). Bend your elbows and lower your body to the floor. Return to the starting position and arch your back again. Do 2 sets of 15.

Next week is the final week of the mobility series we will be speaking to a sports injury specialist with six degrees in nutrition to address post injury supplementation and to highlight some of the newest techniques available.  Entering into a corrective exercise program should be done with supervision, please contact if your interested in a program of this nature or want a movement assessment.  

References

1. American Academy of Orthopaedic Surgeons, Research Statistics on Rotator Cuff Repairs, National Ambulatory Medical Care Survey, 1998-2004. Data obtained from: U.S. Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for Health Statistics Retrieved on May 9, 2007, from http://www.aaos.org/Research/stats/patientstats.asp 
2. American Academy of Orthopaedic Surgeons, Rotator Cuff Tear-Surgery versus Rehabilitation, Retrieved on May 9, 2007, from http://orthoinfo.aaos.org/indepth/printer_page.cfm?topcategory=Shoulder&Thread_ID=2 
3. Tempelhof S, Rupp S, Seil R. (1999) Age Related prevalence of rotator cuff tears in asymptomatic shoulders. Journal of Shoulder and Elbow Surgery Jul-Aug;8(4):296-299