7 Strategies for Shoulder Conditioning Brian Justin, MHK, CEP, CSCS

Transcription

1 7 Strategies for Shoulder Conditioning Brian Justin, MHK, CEP, CSCS Objectives Very brief orientation to the shoulder Assessment procedures for the shoulder joint and interdependent areas Exercise ideas for conditioning the shoulder and interdependent areas for injury prevention This will be an incomplete look at shoulder assessment and training as we only have 1.5 hours. But I hope you can take away a few ideas to incorporate into your practice. Shoulder Joint Complex Ball and Saucer Joint! Acromioclavicular Sternoclavicular Glenohumeral Scapulothoracic Shoulder Complex SC joint: Mechanical Strut which holds scapula at a constant distance from the trunk. AC joint: Attaches clavicle to scapula. ST joint: Not a true anatomic joint. Movement here is the result of SC and AC joint movements. Provides a base of operation to the GH joint. GH joint: Most distal link of the Shoulder complex. Shoulder Movement = GH + ST movement Orientation of the Bones With the arm in anatomical position: Clavicle is 20 degrees posterior to frontal plane. Scapula is orientated 35 degrees ant. to the frontal plane. (Scapular Plane) Glenoid fossa is tilted upward 5 degrees relative to the medial border. Humeral head is rotated posterior about 30 degrees within the horizontal plane (matches scapular plane). 1

2 7 Strategies for Shoulder Conditioning 1. Systemic Hypermobility and Visceral Health Check 2. Breathing Patterns 3. Thoracic Spine Assessment and Training 4. Scapula Assessment and Training 5. Head Position Assessment and Training 6. GH Range of Movement 7. LPHC 1. Visceral Health Check Issues in visceral organs can manifest as MSK pain. Systemic issues show up as constant pain. Some questions to ask: Are you having any pain anywhere else in the body? Are you having symptoms of any other kind that I should know about? (i.e. digestive issues?) Pulmonary (T2-6) Gall Bladder (T7-10) Liver (T5-9) Pancreas (T7-9) Ipsilateral shoulder Upper trapezius R. Upper trapezius R. Shoulder R. T- spine R. Shoulder L. Shoulder 1. Visceral Health Check When to check for this: Signs or symptoms begin to fall out of expected patterns. Inability to reproduce familiar pain with motions or postures (clinical setting). Continuous and unrelenting pain that is greater at rest. Known visceral pathology. Past history of cancer. Night pain. Any of these: a referral to a doctor should be your next move. Visceral pain is not well localized (so it produces referred pain) due to the fact that: 1. Innervation of the viscera is multi-segmental. 2. There are few nerve receptors in these structures. Referred pain occurs because visceral fibers synapse at the level of the spinal cord close to fibers supplying specific somatic structures. Visceral pain corresponds to dermatomes from which the organ receives its innervations, which may be the same innervations for somatic structures. An example: the heart is innervated by C3-T4. Pain from a cardiac source can affect any body area (soma) innervated by these levels Huh? Beighton 9 point Systemic Hypermobility Scale 2. Breathing Patterns If breathing is not normalized, no other movement pattern can be. -Karel LewitMD, DRSc. Chest vs. Diaphragm Pinky finger 2

3 Breathing Assessment 1. Hands on shoulder 2. Hands on low back 3. Hands on ribs A balloon doesn t fill up in one direction! Crocodile breathing 2-3 minutes Great cool down activity to help promote recovery. Breath Training Muscles of Breathing Primary: Diaphragm External Intercostals Secondary: Sternocleidomastoid Scalenes Pectoralis major/minor Serratus anterior Levator scapula Serratus posterior superior Upper iliocostalis Scapulo-humeral Rhythm Setting phase: - abduction up to 30 degrees - flexion up to 60 degrees - variable and individualized - scapula seeks stability Early phase: (to 90 deg.) - Scapula laterally rotates stabilizing against the thoracic wall with little superior or inferior migration. -60 deg. GH and 30 deg. ST Late Phase: ( deg.) - At approx. 100 deg. of elevation the coracoclavicular ligament (CCL)tightens and pulls the posterior clavicle upward. Scapulo-humeral Rhythm (SHR) The scapula laterally rotates and posteriorly tilts (inferior angle moves toward thoracic cage). Ludewig and Cook have found that subjects with impingement have decreased posterior tilt, ext. rotation, and upward rotation. This could results from a shortened pecminor (from thoracic kyphosis), restricted scapular mobility, and inadequate shoulder complex muscle activity. Posterior tilt is critical for humeral head and rotator cuff tendon clearance during elevation. Keep in mind at various phases of the SHR and amount of arm loading the ratio can be different but overall it is 2:1 GH to ST 3. Thoracic Spine Normal curve is degrees. Scapula positioning depends on thoracic posture and mobility. Excessive thoracic kyphosis significantly reduces scapular upward rotation and posterior tilt and increases scapular internal rotation and elevation Scapulohumeral rhythm is dependent on: - scapular upward rotation. - Posterior clavicle rotation (40 deg.) - T-spine extension - scapular posterior tilt Chek, P. (2012) 3

4 3. Thoracic Spine If a client has limited T- spine rotation than they will have to get the motion from somewhere else the scapula! The scapula is the foundation of the GH joint and facilitates proper rotator cuff function. If it loses its stability then your GH joint function suffers to! 3. Assessing Thoracic Spine Measuring the curve with the inclinometer. FMS Shoulder mobility test Lumbar Locked T-spine Rotation Test (Greg Rose DC) deg. is normal Cressey and Reinold, Training the T-Spine Squat to Stand Drill (Cook, 2004) Thoracic mobilizations over a foam roller or doubled up tennis balls Lumbar-locked Thoracic rotations 3. Training the T-Spine Side-lying Internal- External Extension rotation Quadruped Extension Rotation 4. Scapula Assessment and Training Assess for the presence of downward rotation of the scapula. Measure the medial border of the scapula to the spine avg. 6cm Active shoulder abduction look for 60 deg. of upward rotation and for clunks, hikes, and wings!! Pec Minor Length Assessment 4. Scapula Assessment and Training Manual Pec minor stretch SB Pec minor Stretch Reach, roll, and lift Levator scapula stretch Rhomboid stretch Push ups with a plus (be careful with this one do we want to work the serratus anterior as a protractor or as an external rotator of the Scapula?) 4

5 4. Scapula Training Standing W s with tube or cable Y s what angle? T s thumbs up Wall Stabilizations (LT and SA activation) Reinold, Head Position For every inch the head moves forward it gains 10lbs in weight (Kapandji). FHP is coupled with rounded shoulders which leads to thoracic mobility issues and breathing dysfunction. Easy to assess is the ear in line with the shoulder? Tightens levator scapula. 5. Head Position Training Chin tucks (daily exercise done hourly) Incorporate with exercises - pressurize the neck (Weingroff, 2010) Quadruped Chin tucks Bent over row 6. GlenohumeralROM When working with overhead athletes or workers evaluate total motion (ER+IR). Often the dominant throwing arm has a deficit of internal rotation and a surplus of external rotation. Loss of int. rotation is normal. GIRD - internal rotation deficit of > degrees from the non-dominant arm. Exercise goal for GIRD: To increase total motion not internal rotation (Reinold, 2010) 6. GH Training Role of rotator cuff: ER/IR of arm. Function of rotator cuff: Center the humeral head within the glenoid fossa. Placing a towel between the arm and body increases the EMG of the rotator cuff by 23% when doing L-flyes. Activation of adductors causes inferior directed movement increasing SA space. Additionally, this positioning also allows for increased blood flow to RC muscles. 6. GH Training - Buchberger Supraspinatus exercise Start Finish 5

6 6. GH Training - Buchberger 6. GH Training - Buchberger This exercise is a great way to concentrically activate the infraspinatus and teres minor with a short lever and then stress them eccentrically with a long lever simulating the follow-through phase of throwing or punching. 1. Start 2. Mid The only thing I would change is to put a towel here. 3. Arm extension 4. Thumbs down eccentriccontrolled 5. Follow through 6. GH Training: Cuff training Adequate strength (2-3:1 of posterior : anterior) Muscular balance Stable base of support Endurance Dynamic stability Prone internal rotation Side-lying cross body assisted stretch to restore loss IR 6. GH Training: Cuff training Self cross body stretch Sleeper stretch if working alone. Side-lying ext/int. extension rotation from thoracic section Intramuscular coordination to intermuscular coordination: L-Flyes Standing W s PNF diagonals Prone roller exercises (closed chain) Rhythmic stabilization 6. GH Training Standing W s Closed Chain Stability in 4 point stance (Chek, 2012) Semi closed chain (compression + movement) Benefits of Closed Chain Exercises Muscular co-contraction Increased proprioception compressive action and joint approximation stimulates periarticular afferent receptors and in concert with spindles and mechanoreceptors improves joint position awareness and feedback The shoulder functions in open chain as well in many situations so we need to do semi and open chain movements as well. Semi- open chain activity: compression + movement 6

7 Rhythmic Stabilization (bodyblade (linear pattern) or twister ball (circular pattern) 6. GH Training For throwing or similar pattern athletes check hip rotation and hip abduction strength Wind-up phase Isometric hip abduction of trail leg to prevent contralateral hip drop. Cocking Phase begins Gluteus medius muscles of trail leg are used to propel the lead leg forward. This leg drive is associated with arm velocity. Decreased strength = more strain on shoulder. Acceleration Phase Lead foot should contact the ground with the toes facing the target. Hips must rotate to do this. Trail leg internally rotates and the lead leg externally rotates. If internal rotation is lacking to square the body the player must throw across his/her body = decreased velocity (pitchers tend to have less trail leg int. rotation!) Follow through Lead leg hip internal rotation is needed to offset deceleration forces 7. LPHC 7. LPHC Assessment (Kibleret al., 2006) 7. LPHC Assessment (Kibler et al.,2006) Single leg stance Single leg squat Rotation on two legs Rotation on one leg 3 Plane Core Strength Test Not the only tests you can do. Just a sampling! Assessment Needs: - eccentric action - load absorbing function - closed chain Single leg Stance: - Trendelenburg? Single leg squat: - builds on single leg stance - Trendelenburg? - corkscrewing (exaggerated flexed or rotated posture weak hip Sagittal Wall Test (3 inches from wall) - Goal: move body backward slowly and barely touch wall - Eccentric control? Quality of motion? - Two legs to single leg Transverse plane wall test (3 inches from wall) - Goal same as sagittal except touch one shoulder barely against the wall. - Eccentric control? Quality of motion - Two legs to single leg 7. LPHC Assessment 7. LPHC Training That s Kibler! Frontal plane wall test (3 inches from wall) - Goal Move body sideways slowlyand barely touch one shoulder against the wall. - Eccentric control? Quality of motion? - Two legs to single leg Standing Rotation: - Note asymmetry in each side. - Note asymmetry in each leg. - Two legs then evaluate single leg. - Train accordingly. Train core rotation to bridge lower and upper body force transference. Poor core strength will cause the shoulder to work harder. Need proximal stability for distal mobility! Train anti-rotation first Then move to dynamic rotation exercises. Over utilization of the crunch exercise can decrease shoulder ROM as it promotes poor posture. 7

8 Programming Suggestions 1. Muscle balance and flexibility. 2. Static and dynamic stability. 3. Strength 4. Power (Chek, 2012) Screen Assess Reassess Isolate to innervate then integrate in order to coordinate 8