P ERFORMANCE CONDITIONING. Inside the Bermuda Triangle of Chronic Shoulder and Elbow Pain- Part IV

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1 P ERFORMANCE VOLLEYBALL CONDITIONING A NEWSLETTER DEDICATED TO IMPROVING VOLLEYBALL PLAYERS Inside the Bermuda Triangle of Chronic Shoulder and Elbow Pain- Part IV Does the Risk Out Weight the Reward of these Common Exercises? How to Maximize Reward without Risk Lisa Bartels, Member SMPC, Doctorate of Physical Therapy, Cross Roads Physical Therapy, Lincoln, NE Presented by USA Volleyball Sports Medicine and Performance Commission USA Volleyball Sports Medicine and Performance Commission mission is to serve volleyball coaches and athletes through the assimilation, generation and dissemination of information in the areas of sports medicine and performance and to coordinate future research in these areas. Lisa was introduced to the science of Postural Restoration as a patient under the care of Ron Hruska. She had suffered from long-standing injuries sustained during her collegiate volleyball career and found success with the treatment techniques she learned at the Hruska Clinic and later received from the Postural Restoration Institute. Lisa returned to practice physical therapy at the Hruska Clinic Restorative Physical Therapy Services in Lincoln, Nebraska after completing her Doctorate of Physical Therapy from the University of Nebraska Medical Center in Omaha. Lisa is a member of the American Physical Therapy Association. Lisa Bartels In our last article we presented the third part of the Bermuda, Scapula Protraction and Upward Rotation- Why It's Important and How to Do. Net Link: To read the this article click HERE. In this issue we look at common exercises that create potentially more risk than the reward that might provide the overhead athlete and solutions to the issue. - Ken Kontor, Pulisher Shoulder and elbow injuries are becoming more and more common in our overhead athletes. Frequently coaches get a lot of the blame for overuse injuries, but counting pitches and reducing the number of volleyball swings will only go so far to help manage the problem. In my opinion, popular weight room exercises are a major causative factor. This discussion is part 4 of a series that has described shoulder joint anatomy, good and bad rotator cuff biomechanics, and corrective exercise for subscapularis, posterior deltoid, and serratus anterior. The purpose of this article is to summarize the series and discuss safe versus risky exercises. 6 Common and Very Risky Exercises Latissimus pulldowns (lats) Bench press Push ups Dips Weighted biceps curls Pull ups (These exercises need to be used sparingly if not completely avoided in overhead athletes) I can t think of a faster way to create shoulder impingement in an overhead athlete than to combine the following training scenario go to the weight room and turn on the lats and pecs with bench press, lat pull downs and pull ups, then immediately go to practice and take 200 swings, throws.

2 Transverse Ligament Coracoid Biceps Brachii (long head) Biceps Brachii (short head) Photo 1 Why? There are three primary shoulder girdle muscles that are frequently overused relative to weaker shoulder muscles in athletes experiencing shoulder and/or elbow pathology; the anterior chest wall (pectoralis major + pectoralis minor), biceps brachii, and the latissiumus dorsi. The six listed exercises heavily recruit these muscles. Adaptive shortening of the pectoral muscles (pec major and pec minor) can pull the scapula into a forwardly rotated position which will produce a forward or rounded shoulder appearance. Pec major can also cause translation of the humeral head forward. If the translation is significant enough, the length tension relationship of subscapularis is changed. Subscapularis is the anterior aspect of the rotator cuff and it is supposed to function as the primary shoulder internal rotator Brachioradialis Styloid The long head of the biceps enters the joint below the shoulder capsule via an extension of the synovial membrane and wraps around the anterior-superior aspect of the humeral head and inserts into the labrum (the fibrocartilage ring surrounding the glenoid...see Figure 1). What this means is that the long head of the biceps can contribute to the stability of the joint but if the posterior capsule is significantly restricted, the subscapularis is dysfunctional and not able to control humeral anterior translation, the biceps will attempt to function as the rotator cuff- a tremendous demand it was not designed for. If you have a biceps muscle that is trying to function as the anterior aspect of the rotator cuff, performing weighted biceps curls is going to exacerbate the problem. Anterior chest wall tightness in conjunction with a forward position of the scapula orients the humerus (arm bone) inward and increases the mechanical advantage of latissimus to assist with shoulder internal rotation. The latissimus is now recruited as a powerful internal rotator that has a more distal attachment on the neck of the humerus than the subscapularis. This leverage allows the humeral head to be pulled or translated forward as the latissimus internally rotates the shoulder; this further promotes adaptive shortening of the posterior shoulder capsule and anterior subluxation. (Photo 1 note the difference between shoulders). Ulna Figure 1 Brachialis Medial Epicondyle Fibrous Laceratus Photo 2a Photo 2b

3 The Solution Implement a strength program that emphasizes the triceps, posterior deltoid, subscapularis, serratus anterior, and lower trapezius muscles, and a flexibility program that continually manages the length of the anterior chest wall, the latissimus, and the posterior shoulder capsule. Safe exercises that are sport specific. 1. Subscapularis isometrics (ball drops- burmuta triangle article # 2) with shoulder internal/external rotation (Photos 2a and 2b). As the athlete regains strength in the subscapularis and flexibility in the gleno-humeral capsule they should achieve degrees of pure internal rotation, meaning the resting position of the ball and socket is congruent and the athlete has good flexibility of the gleno-humeral capsule. Now the athlete can be progressed to more sport specific shoulder activities. 2. Supine hook lying weighted triceps curls (Photos 3a and 3b). Chick HERE to see on YouTube. Figure 2 Acromion Photo 3a Photo 3b Triceps Brachii (lateral head) Triceps Brachii (long head) Olecranon Anconeus Triceps has significant attachment to the posterior aspect of the humerus as well as the inferior aspect of the glenoid (see Figure 2). Triceps is a primary elbow extensor and shoulder extensor. An athlete needs this muscle to be strong enough to help oppose anterior translation of the humerus, by opposing the anterior chest wall and the biceps. 3. Serratus anterior facilitation-rockerboard progression The rocker board should be a precursor to a push-up as well as many open chain shoulder exercises such as dumbbell shoulder press, punch matrix, etc. If your athlete can not demonstrate end range protraction ability in quadruped on a rocker board-they do not have appropriate strength for a push up. During any pushing activity or arm elevating exercise an athlete should feel push power from the serratus. (Photos 4a and 4b). Look at the size of this muscle, it is comparable to the size of pec major (see Figure 3).

4 Photo 4a Photo 4b Superior View Serratus Anterior Serratus Anterior IMA Sternoclavicular Joint Clavicle B A Figure 3 4. Functional shoulder flexion/abduction (wall wash, D2 flexion, dumbbell press, etc.) Specifically a healthy shoulder should demonstrate 180 degrees of shoulder abduction as the result of 120 degrees of GH motion and 60 degrees of scapulothoracic upward rotation. 60 degrees of scapular motion is a lot. Many athletes do not have enough ST motion because they do not know how to correctly move and manipulate their scapulae with serratus anterior. (Photos 5a and 5b).Chick HERE to see on YouTube. Photo 5a Photo 5b In review and conclusion, the primary function of latissimus dorsi and the sternocostal head of pectoralis major is shoulder adduction and extension, in other words pull the arm down on the body or pull the body up to the arms. Throwing athletes must be able to do the exact opposite. They must fully abduct. Full shoulder flexion/abduction should be degrees. I frequently screen volleyball players that stop at degrees of flexion because the lats and pecs are that overdeveloped and tight. (Photo 6a the tight, Photo 6b the normal) This is a massive loss of functional

5 range of motion needed for their specific sport. There is no way this athlete can correctly recruit posterior deltoid and the rotator cuff, specifically subscapularis, with a throwing motion. They literally can t get their arm up! Pushing a bar off a chest, pulling a bar down, pulling the body up to a bar, etc. None of these popular weight room activities resemble anything an overhead athlete must do! Why are overhead athletes performing exercises that reproduce the demands of climbing a rope or playing football?!? Photo 6a More Information Please! Contact Lisa at lisa_bartels@hotmail.com Photo 6b References Figures 1, 2 and 3: Kinesiology of the Musculoskeletal System - Foundations for Physical Rehabilitation, Donald A. Neumann