There is perhaps no joint in the human body as complex, fascinating, or baffling as the shoulder. It can leave clinicians scratching their heads, wondering why a problem they have solved many times before is this time so stubborn. And shoulder problems can certainly be stubborn! That’s why, in every case, prevention is so much better than cure. Rarely is a pain that has surfaced a simple matter of applying some ice – it is more likely to be the tip of an iceberg! An athlete’s shoulder is either a joint that he/she has never given a second thought to, or it is ever-present in their minds – it is either no problem, or a problem they cannot ignore. It has been said that the design elements that make up the shoulder are either near perfection, or near disaster! Now, of course, this greatly depends on the sport you are in: cross-country runners are unlikely to have the shoulder difficulties that javelin throwers or swimmers may encounter. However, it is rare for athletes who use their shoulders as part of their main routine not to carry at least a niggling pain, while many have a history of a significant shoulder problem. This article takes a good look at the big picture of shoulder injury management, and tries to empower and educate athletes with some DIY home injury prevention and performance enhancement techniques. It aims to present, as simply as possible, some complex concepts, and is therefore in no way an exhaustive explanation or listing of exercises, just a sufficient one.
If you have a shoulder injury and would like to try to treat yourself, please remember:
l It would be wise to rule out structural damage first, via X-rays, CT-Scan, US Scan or MRI, particularly if your shoulder joint experiences sharp catching pains, locking sensations, clunks, pins and needles or numbness, looseness or laxity, or the history of the injury was in any way traumatic, involving body contact or a fall. l The length of time it took to develop your problem will give you some indicator of how long you will need to persist with correcting the faults before the results will be felt. Don’t forget, as I’ve said, that the pain is often only the tip of the iceberg, directing you to the real issue.
The advice that follows relates to the prevention and treatment of overuse injuries of the shoulder, not the management of acute or traumatic injuries such as glenohumeral dislocation, clavicular fractures, or tears of the labrum (‘cartilage’). However, the broader principles of rehabilitating a shoulder that has been surgically repaired, or been stuck in a sling for four weeks, are no different, although there may be restrictions and time constraints imposed by orthopaedic surgeons. The most important principle of shoulder management is: start working on it NOW. Don’t wait until your shoulder starts to hurt! But, in addition, the preventative measures outlined below are guaranteed to improve your performance – they will genuinely improve the way your shoulder works, and thus it will be stronger, more coordinated, reach further and last longer before fatigue sets in. All the experts say it: injury prevention equals performance enhancement.
The shoulder joint actually comprises four joints – see if you can feel them on yourself:
The GH joint is the most susceptible to injury as it is entirely dependent on non-bony connections for integrity. Whereas the hip joint (also a ‘ball and socket joint’) has a deep socket formed by the bone of the pelvis, the GH joint relies on the balance, strength
and control of muscles, ligaments/capsule and labrum (cartilage) to function properly. The labrum acts like the edges of a skateboarding rink in preventing the HOH from spinning/sliding too far from the centre as it acts to deepen the socket. In an attempt to describe the delicate balance of the HOH sitting on the scapula, the GH joint has been likened to a seal balancing a ball on its nose.
Without learned muscle control, any overhead activity, let alone just lifting the arm, would be impossible – the GH joint would dislocate or the HOH would jam under the arch of the acromion. The muscle group we rely on for this control is the rotator cuff (RC) muscles – the infraspinatus, supraspinatus, teres minor, and subscapularis muscles (an anatomy book will show where they lie). They all originate from the scapula and are coordinated together to keep the HOH spinning/rotating as close to the centre of the glenoid as possible with movement. The long head of biceps tendon running over the front of the GH joint also has a stability role to play in conjunction with the RC, especially with the throwing action. The muscles primarily designed to position the scapula for overhead movement are the trapezius (especially lower trapezius ), and serratus anterior – called therefore the ‘scapular stabilisers’ – with counterforces being produced by levator scapulae, rhomboids and pec minor muscles. The larger and more powerful muscles that generate movements of the arm are the deltoids, latissimus dorsi, and pectoralis major. So while the RC muscles co-ordinate the proper positioning of the HOH by acting close to the centre of the joint (the ‘inner core’), the larger muscles with long lever arms move the arm with speed and force (the ‘outer core’).
Let us now unpack what could be considered the five most essential ingredients for an athlete whose main weapon is the shoulder:
The primary goal of these five areas of intervention is, in a word, balance. And the way to achieve it? Control. The higher your levels of performance, the greater the control required to maintain balance – just as a Formula 1 car needs much higher levels of balance and control than does a standard road car. A deficit in any one area will ultimately cause muscle imbalances to develop, which lead to soft-tissue breakdown and later even joint degenerative change. Picture a bike wheel where one spoke in the wheel is bent out of shape: a gradual warping takes place with use which creates an imbalance that further damages other spokes until the whole system comes to a grinding halt.
The more elite the athlete, the more committed he/she needs to be to getting professional help in fulfilling and maintaining these principles. You will also save yourself much time and anguish if you seek experienced help as a preventative measure, rather than only asking for treatment once the problem has surfaced. Having a regular tune up/ service can be done in the form of screening, where a sports-experienced physiotherapist will run you through a series of tests to find out if any of the areas below are not being adequately dealt with.
Poor performance and shoulder pain very commonly originate in bad habits of technique. Often they are only clearly seen when muscle fatigue sets in. However, a good coach will be able to pick up when this is happening and realise it’s time for rest and recovery.
As a general rule, technique work should be done after a thorough warm-up (or even as part of a warm-up), while the muscles and the brain-connections are still fresh and strong. On the other hand, when fatigue sets in can occasionally be a good time to do specific drills that do not load the shoulder, yet will reinforce good movement patterns. The only proviso is that one must be extra diligent to see when compensation strategies are setting in, and call a halt immediately. Without wanting to state the obvious, practice is the key! Once you have mastered a new aspect of technique it must be repeated around 10,000 times before it becomes engraved on your brain, in other words, the point at which the movement pattern becomes subconscious and feels ‘natural’. There are many ways to find out if your technique is faulty, but one of the best is video recording in order to slow down the action and break it into smaller components. The better the technology, the better the result, but for real value it comes down to the experience of the person evaluating the picture. Using a mirror is rarely effective since the position of the head focusing on the mirror can greatly affect the shoulder position. The two most important sources of feedback in this regard are your coach and a biomechanist, and often a sports physiotherapist who has had a lot of experience in your sport.
The variety of overhead movements required for each sport gives rise to very subtle and unique technique faults. The following are some examples of what to look out for:
Tennis serve/smash: insufficient trunk twisting to open up chest in cocking position, ball toss too close to body or too far behind body, cutting the follow-through short by whipping the racquet.
Javelin/water polo/baseball throw: side-arm action, elbow behind the shoulder during follow-through, insufficient trunk rotation at late cocking phase to open up the chest and at end of follow-through to dissipate forces after release of the object. The closer the line of the upper arm can follow the line of the front of the chest, the less strain there will be on the shoulder joint, and the more rotation that can be harnessed from the shoulder, the less the strain on the elbow joint.
Freestyle swimming: insufficient body roll, only ever breathing to one side, catching the water too close to the midline, not keeping the shoulder blade stabilised on the trunk during pull phase, not keeping the elbow high enough during recovery phase (a sign of insufficient flexibility).
The purpose of flexibility varies for the different muscles around the shoulder. For the major power muscles, it is important that flexibility allows freedom of movement for the pelvis, trunk, scapula, and humerus. For the rotator cuff, the critical issue is the balance of forces centring the head of humerus, and to a lesser degree, freedom of movement. It is more critical that the internal and external rotators are equally flexible, rather than how flexible they are. A warning: to have too much flexibility at the expense of strength and control can be dangerous because of the excessive shear forces causing wear and tear in the joint. This is particularly true of the glenohumeral joint where the primary source of stability is the rotator cuff muscles working in conjunction with other soft- tissue structures such as the capsule, ligaments and cartilage. Too much flexibility at the expense of muscle control puts strains on the soft tissues and causes injuries such as rotator cuff tendinitis and degeneration, labral tears, subluxations and possibly even a dislocation. Do not begin a flexibility programme until you have seen a sports doctor or physiotherapist:
Stretching to increase flexibility should never be done prior to training or competition, but instead done during ‘down’ times in the week. This is because of the suppression of the ‘stretch reflex’ that takes place during sustained passive stretching of muscle tissue (i.e., repeated holds of 20-30 seconds). If one were to do rapid forceful movements such as throwing straight after such passive stretching, there would be an increased chance of muscle and tendon tears. For flexibility every muscle needs to be stretched three to four times at 20-30 seconds each, and repeated three to four times per week.
The most important areas for regular flexibility sessions are:
The best way to learn how to stretch the above areas is to be taught by a sports physiotherapist, sports conditionist or personal trainer. It is important not to stretch the ligaments of the shoulder, which in due time can cause laxity of the joint and potential instability. The most common example I see? Athletes stretching their pec muscles and ending up with their arm behind them against the wall, but with their shoulder rolled forward, feeling the stretch on the front of the point of the shoulder. What are being stretched here are the anterior ligaments (‘capsule’), not the muscle, which is better stretched by pulling the scapula back and twisting from the trunk away from the shoulder (hand still on the wall). One then feels the stretch a lot more down on the chest area where it should be.
The shoulder should be warmed up thoroughly with gradually increasing movements – big circles, across body movements, trunk twists, shoulder blade rolls and forward and backward squeezes. The purpose of this is to increase blood flow and temperature, thereby increasing the elasticity and ‘give’ in the soft tissues. A series of short duration stretches (i.e., 5-10 seconds) of all the main muscle groups should follow and then finally a session of more sports specific drills. These are used to warm up the brain’s connection to the muscle, i.e. to reinforce correct motor patterns, and also to set the right neural reflexes in the muscle.
One of the most important functions of massage is to reduce the build-up of ‘trigger points’ (see SIB, issues 10 and 11) – areas in the muscle that literally seize up due to excessive loading. This may cause a muscle imbalance or be the result of one – either way it must be ‘released’ via massage. All the muscles described above that are necessary to stretch are susceptible to trigger points and can become tight and/or weak because of them. It is not uncommon for a trigger point to develop in the muscle as the first structure to begin breaking down, slowly dragging other muscles, nerves, and the gleno-humeral joint down into a cycle of pain and inflammation. The best way to begin is to get a hard tennis ball to do your massage with, then try these two ideas: Pectoralis minor/ major ‘release’: This is a critical muscle to keep loose because if becomes too tight, it binds the scapula forward, resulting in the head of the humerus being thrown off centre, especially in overhead positions. Hold the tennis ball to the soft muscle overlying the chest right at the front of the shoulder. Lean towards a door frame and allow the tennis ball to press against it, with the same side arm half way up the wall, palm facing towards the wall. Search for the tender trigger points, and when you find one, stay with the pressure on to it until it softens and the pain eases.
Rotator cuff ‘release’: Often accompanying the above condition is tightness and over activity of the infraspinatus and teres minor, the net effect of which is also to push the head of the humerus forward from its centre of rotation. Hold a tennis ball to the back of the shoulder on the scapula, and press the back and side of the scapula onto the wall. The arm that is being worked on should be cradled in the opposite hand. Allow it to dig deep!
Core stability has become a whole science in itself in the last decade as all manner of sports professionals have realised how critical it is for the inner core of the body, namely those joints closer to the spine, to be supported by the postural muscles designed to do so. For the shoulder, the critical areas are the lumbar and cervical spine, and the scapulothoracic joint. If these areas are not stable, then significant extra loading and strain will be passed on to the shoulder joint. The stability of the lumbar spine is achieved by the combined effects of transversus abdominis and multifidus acting on the thoracolumbar fascia. Pulling in the lower navel area while tensing the lower-back muscles slightly activates the ‘corset’. The cervical spine is stabilised by the upper cervical flexors in conjunction with the lower cervical extensors, to achieve a ‘tall’ neck position with the chin slightly drawn into the neck. Keep in mind that this is easier for some than others, depending on how your body has been trained – for instance, ballet dancers will find the stable position of the neck comes naturally, rugby players may not. Activating the muscles is the first stage of the learning process; practise the position until you are ready to incorporate it into simple movements that are relevant to your sport.
The scapulothoracic joint is the most relevant ‘joint’ for the shoulder, because the glenohumeral joint is formed by the glenoid (the socket) of the scapula and the humerus (the ball). The muscles most directly responsible for its stability are the trapezius muscle (especially its middle and lower fibres) acting with the serratus anterior muscle – together they act to hold the scapula in a neutral position whether the arm is by the side or above the head. The neutral position is where the glenoid socket is most ideally orientated for the rotator cuff to control the HOH.
Remember the earlier picture of a seal with a ball on its nose – the seal is the scapula trying to balance the ball of the humeral head using the rotator cuff muscles. How amazing it is to think that such high levels of balance are being utilised when we do overhead activity! Deficiencies of core stability are always found with chronic shoulder injuries, or after surgery or trauma, because pain tends to inhibit the postural muscles so they cannot do their job properly. The way to activate the lower trapezius/serratus anterior muscles is to sit in a relaxed tall posture, arms relaxed across your thighs. Gently pull the inner borders of your scapula together and down with the minimum of effort, and hold it there for 10 seconds. Don’t pull too far back or you will over-activate other muscles that are not designed to be the main core stability muscles – it is always a subtle and relaxed action with a 10 second hold. When you have practised this for a few days as often as you can, experiment with ‘setting’ your scapula into the neutral position with your arms out to the side, with your arms on your hips, up behind your head, etc.
Once you have mastered the ‘setting’, add small movements of your arm while holding the set position, and gradually over a few weeks you can increase the complexity, speed and loading of your arm. Finally you are doing the setting at the same time as you are carrying out the rotator cuff strength and control exercises described below.
The rotator cuff muscles are dependent on the good positioning of the scapula for effective control. If the scapula is angled too far forward or downward, for instance, while the tennis player reaches overhead to smash, the RC muscles are biomechanically disadvantaged and may fail to keep the HOH centred. The role of the RC muscles therefore is to maintain the position of the HOH while the prime mover muscles generate power. As you improve your scapular control, the RC muscles are able to act more efficiently and independently of the scapular control muscles. That is to say that you should be able to hold the scapula quite still in the neutral position while you independently move your arm. This skill is called ‘Glenohumeral Dissociation’.
Thus with each of the following exercises, it is assumed that the scapula is being held as close as possible to neutral:
Internal/external rotation with arm by the side. Standing. Rolled towel held between elbow and ribs. Attach one end of an elastic or theraband to a door knob and hold the other end in your hand with elbow bent 90°. Set scapula. Slowly pull across body at the same time – 3x10 pulling to right, 3x10 pulling to left.
Internal/external rotation with arm at 90° away from body. Lying on back. Attach one end of an elastic or theraband to a chair leg and hold the other end in your hand with elbow bent 90° resting on ground. Set scapula. Pull hand forward until limit of flexibility and slowly release. 3x10. Opposite movement – pulling hand up above head – 3x10.
End of range gentle flicks. Standing. Elastic tied to doorknob. Face away from doorknob, holding arm up above head with elastic in hand on tension. Allow arm to slightly drop backwards from elastic tension, pull forward slightly on tension. Repeat slowly, gradually increasing speed and tension over the following two or three weeks. Monitor any shoulder soreness the next day to determine whether you’ve gone too hard!
Stand facing wall with ball (Swiss or other) held up on wall at head height. Step back so you’re leaning onto ball. Set scapula. Make small circles on the wall with outstretched hand on ball. 5x10 anti/clockwise each. Rest and repeat.
Squeeze tennis ball in hand. Go through throwing motion slowly while squeezing ball. Set scapula at outset of throw, slowly releasing and doing an exaggerated follow-through with whole body motion. Repeat 10-20 times Excellent for co-contraction of RC muscles to increase their activity and control of the HOH.
Once the foundational issues of technique, flexibility, core stability, and rotator cuff control are being implemented, we must look at the bigger picture of the ‘outer core’. What is the rest of your body like – does it help or hinder the performance of your shoulder? In every sport that relies heavily on the shoulder, it is vital to see it as only one link in a ‘kinetic chain’ – all the other links must also be sufficiently developed to aid in the development of rotary torque or the shoulder will be overloaded. There is a ‘winding up’ and an ‘unwinding’ that takes place at a rapid speed starting from the legs, progressing through the hips, pelvis, lumbar spine, thoracic spine, shoulder, elbow, and wrist. And each must be taught to absorb its fair share. Golf is the classic sport to use as a clear example of this transfer of rotary power – a series of wind-ups finally being unwound as the stable base of the hips whips back in the opposite direction.
To this end there is a whole section that could be written on the value of plyometrics, the exercise science concerned with harnessing the eccentric strength of muscles to gain greater power. The rotary power of the body is greatly strengthened by developing the eccentric contraction strength between the kinetic links described earlier – and this is where medicine balls, harnesses, and other strength and conditioning equipment come in.
Avoid this imbalance
It is clear to most athletes that a gym routine needs to include strengthening work for the deltoids (three heads), latissimus dorsi, pec major, upper trapezius, and the rectus abdominis because they are the prime movers of the shoulder. Often what is critically overlooked, however, is the imbalance that can develop between the front of the shoulder and the back.. In those athletes who are carrying an overuse injury in the shoulder, nine times out of ten they have overdeveloped pecs and lats relative to their trapezius, rhomboids, posterior deltoids, and posterior rotator cuff. In these situations, flexibility must often be improved, scapular setting must be taught, and the focus of gym exercises changed towards the back. Seated and upright row, dumbbell flies for the back, bench pull, and lat pull downs with the bar behind the head are all exercises that must take greater priority. During all gym work it must be stressed that scapular setting and the activation of core stability muscles for good posture are vital for injury prevention.
So there we have it – the big picture of injury prevention and performance enhancement for athletes who depend on their shoulder for playing their sport. Decide today which one of these issues you might need some more work on, try some of the home exercises, and perhaps seek professional help to maximise the results of your efforts.