Shoulder Rehab: Take #2

Shoulder injuries are common, and I encountered many patients with them while working as a physical therapy aid. Frozen shoulders, impingements, labrum tears, dislocations, separations, and rotator cuff tears are few that come to mind.

Individuals embark on fitness quests to lose weight, get strong, try a new activity, without giving a thought to shoulder health, when just a few regularly done exercises and a bit of shoulder awareness can go a long way toward keeping one out of a doctor’s office, or surgical suite.

Last week I went over some shoulder anatomy. I discussed the joints, “major mover” muscles, and smaller stability muscles. Check it out if you missed it. The last few components to cover are the ligaments and labrum.

  • Ligaments (connect bones to bones) play an important role in stabilizing the shoulder joint and help create a structure called the shoulder capsule. There are many ligaments in the shoulder joint but two to note are the Acromioclavicular (AC) ligament and Coracoacromial ligament. The AC ligament holds the clavicle (collar bone) to the acromion of the scapula (shoulder blade) and the Coracoacromial ligament holds the acromion from the back of the scapula to the coracoid process on the front of the scapula.

Shoulder-Anatomy-Diagram-image-OwxH

  • The Labrum. The tough trade off that comes into play with joint anatomy is that between mobility and stability. Joints tend to have one or the other. The shoulder is one of the most mobile joints in the body, but it lacks stability. Check out the glenoid fossa of the scapula, the “socket” that holds the arm to the body:
    Unknown
    It’s not deep. It doesn’t encapsulate the humerus (arm bone) either. This is where the labrum helps (a little bit). The labrum is a soft layer of connective tissue that lines the inside and rim of the glenoid fossa to give it depth and better secure the arm to the body.
    glenoid cavity and labrum

Common Shoulder Injuries

As stated in the beginning, there are quite a few injuries that can occur in the shoulder. I’ll never forget learning mechanisms of injury (methods of getting hurt) in one college class called Biomechanics of Musculoskeletal Injuries. “Falling on an outstretched arm” is one of the easiest ways to acquire shoulder injuries. So, just don’t fall like this and your shoulders should be okay ;-).

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  • Frozen Shoulder, also called adhesive capsulitis, is a condition where the shoulder capsule becomes inflamed and stiff with restricted range of motion (ROM) and pain. This condition is also the source of many of my terrible physical therapy dad jokes (Oh, your shoulder is frozen? It doesn’t feel that cold). Sometimes frozen shoulder occurs from lack of use of the shoulder, usually due to pain or other injury (for example if the arm is immobilized in a sling for a long period of time). Other times, frozen shoulder may happen spontaneously without an obvious trigger. One way to prevent this condition is to move your shoulder through the entirety of its ROM on a daily basis and address pains that prevent this movement in a timely manner.
  • Shoulder Separation. One of the more common ligament injuries (also called sprains) in the shoulder occurs in the AC ligament and is known as a shoulder separation. The AC ligament connects the clavicle and the acromion of the scapula. You can feel the location easily; it’s the big bony point at the top of your shoulder.
    95362-1There are 6 grades of severity in this injury. Grade 1 is the least severe, an overstretched, partially torn AC ligament, and Grade 6 is the most severe, including a complete rupture of the AC ligament, separation of those two bones, and injury to other nearby ligaments and structures. Shoulder separation injuries occur from direct impact to the shoulder (from a fall, car accident, sports accident).
  • Muscle injuries (called strains) can occur in the bigger muscles (deltoid, latissimus dorsi, pectoralis major) or the smaller muscles (rotator cuff muscles, long head of the biceps, long head of the triceps). One reason injuries of the shoulder are easy to acquire is that there are a lot of muscle tendons (tendons are on the ends of muscles and connect muscles to bones) and ligaments running through the joint and not a lot of space between the bones. When one of these gets irritated and even slightly swollen (inflamed), the pressure from that increase in volume between the bones causes pain and irritation in a lot of nearby tissues.
    shutterstock_89144563
  • Dislocations or partial dislocations, called luxations or subluxations, also occur in the shoulder joint, primarily because of that tradeoff between mobility and stability. The size of the muscles and structures holding the arm in the shoulder are fairly small and unstable (compared to those in other joints, for example those holding the leg in the hip).  95% of shoulder dislocations occur anteriorly, or to the front of the body from direct blows to the shoulder or falling on an outstretched arm.
    Luxation_epaule
    The other directions of dislocation are posteriorly (to the back of the body), often from electric shock or seizure, and inferiorly (downward) which is the rarest kind. The process of fixing a dislocation or returning the arm to its socket is called a reduction, and [PSA] if you ever find yourself with a dislocated shoulder, please fight the urge to reduce it yourself, and let a medical professional do it.
  • Labrum Tears. The labrum lines the “cup” where the arm bone is held to the shoulder blade to give a little more stability and security to the joint. It can be damaged during repetitive shoulder motions (throwing, weightlifting) or from traumatic incidents (falling on an outstretched arm, direct blow to the shoulder, sudden pulling of the arm, quickly reaching overhead to stop a fall or slide).
    labraltear.png

Prevent Shoulder Injuries

While we can’t do much to prevent injury from freak occurrences like falls and accidents, there are a few weekly or bi weekly exercises and a few avoidances as well that can help prevent shoulder injuries.

  1. Strengthen the rotator cuff muscles (teres minor and infraspinatus) with external rotations. This will increase the size of those muscles, the space in the shoulder joint, and the stability of the shoulder. Start really light with these movements, but don’t be afraid to increase strength. Don’t go to failure, though. This can leave the shoulder unsupported and more prone to injury.


    Notice how these are performed with the arm at a 30 degree angle from the body and not right alongside it.
  2. Learn how to bench press properly! Keep your shoulder blades retracted and depressed, have a little arch to your back, keep your elbows at a 45 degree angle to your body, and use your feet. Check out Eric Cressey’s Shoulder Savers Article for more information on correct form.
  3. Back Attack! Use the Seated Cable Row with strict form to train proper scapular retraction (squeezing shoulder blades together behind the body).
  4. Upright row with caution. Done with a barbell, the humerus is extremely internally rotated and is elevated into the “impingement zone” each rep.  A safer option is performing it with dumbbells (or not at all).
    upright row
  5. Maintain your mobility! Try out this awesome warmup.

For more reading on healthy shoulders check out:

Eric Cressey’s Shoulder Savers Part 1, Part 2, Part 3.

What do you do to keep your shoulders healthy?

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Active Rehab: Overhead Flexibility

My personal goal in these weekly rehab posts is to prepare my body to safely learn some Olympic lifts next month (February), to document my progress along the way, and to educate whomever decides to read along in the process. Olympic lifts include two movements called the “clean and jerk” and the “snatch” and their many variations.

As you can see, these movements involve a significant overhead component (as well as strength, flexibility, and cardiovascular ability), and it has recently come to my attention that, while I’m fairly flexible in my lower body, I currently lack the ability to completely extend my arms overhead without making other compensations such as arching my upper back or pushing my head/neck forward.

 

Shoulder: Joints

To narrow in on what may be tight around my shoulder, I’m going to look through the anatomy of the shoulder joint. The shoulder is composed of 3 bones (the humerus, scapula, and clavicle) and 2 joints:

  1. The glenohumeral joint between the glenoid fossa  (a landmark on the scapula or shoulder blade) and the humerus (upper arm bone).
    figure-3.-glenohumeral-golf
  2. The acromioclavicular joint (AC joint) made up of the acromion process (bony landmark of the scapula or shoulder blade) and clavicle (collar bone).
    shoulder_acromionclavicular_arthrosis_anat02

Shoulder: Muscles

There are 5-6 “major mover” muscles that attach to these bones and cause movement of the arm at the shoulder. The major movements the arm can perform are: flexion (raising arm in front of body), extension (moving arm behind body), abduction (raising arm out to side), and adduction (bringing arm to side of body).

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I’m classifying major movers as the muscles that move the arm in these two planes of motion:

  1. Deltoid– a muscle at the top of the arm involved in flexion, abduction, and extension of the arm. Its name is deltoid because it is shaped similar to the character delta Δ.
    shoulder-muscles
  2. Pectorals Major and Minor–the chest muscles, important in flexing the arms, for instance during pushups. (Sorry for the creepy picture face)
    pectoralis-major
  3. Latissimus Dorsi (also just known as the lats, because the full name is a mouthful and ain’t nobody got time for that). The lats are important for extension and adduction, or bringing the arms back to the body, as in pull ups or rows.
    latissimus-dorsi
  4. The Teres Major is a smaller muscle just above the lats that performs a very similar function to the lats, assisting with extension and adduction of the arms.
    teres-major
  5. Other muscles of honorable mention in this category are the long head of the biceps, which crosses the shoulder joint and performs some flexion of the arm, and the long head of the triceps which also crosses this joint and performs some extension of the arm.

Then, there are the minor movers of the shoulder, primarily the rotator cuff muscles. These muscles mostly provide stabilization to the shoulder joint, holding the head (top) of the humerus in the correct position against the glenoid (socket) during movements and performing internal rotation and external rotation of the arm.

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  1. Supraspinatus– tiny muscle that assists in lifting the arm overhead and is frequently injured from lifting overhead.
  2. Infraspinatus–external rotation
  3. Teres Minor–external rotation
  4. Subscapularis–internal rotation

There are other important structures of the shoulder including ligaments and the labrum, but I’ll discuss those at a later time when I expand on common injuries at the shoulder joint.

Weekly Rehab Fix

Last week I focused on tension in my neck through stretching the pecs, scalenes, and levator scapulae and soft tissue massage with a small ball in the pecs and traps. I didn’t do it every day, but I managed to do the routine 5 out of 7 days of the last week. It has helped with the post-workout headaches I was experiencing (none in the last week), but it hasn’t eliminated that “need to stretch” sensation in my neck or chest muscles. I’m going to keep these exercises in my rehab routine this week and do them at least every other day.

This week’s focus is on the lats and back-of-the-shoulder muscles like the posterior deltoid, infraspinatus, teres major, and teres minor. I’m adding in some small-ball-massage of my lats (just the thought is painful because mine are soo sensitive) and posterior deltoid area (the back side of the shoulder), a stretch for the lats, and 2 mobility exercises. Let’s see if this helps my overhead reach!

  1. Small ball massage of the lats, 1 minute each side
    With the arm raised overhead, palm facing inward toward the head, sandwich the ball between the wall and the edge of your latissimus dorsi (on the side of the body, underneath the armpit). Gently massage back and forth.
  2. Small ball massage posterior deltoid area, 1 minute each side
    With arms at sides or hugging your chest, sandwich ball between the back of the shoulder the wall. Massage around that shoulder area.
  3. Wall Lat Stretch, 30sec each side, 3 times
    walllatstretchwithstabilization
  4. Bench T-Spine Mobilization, 10 times focusing on form, nice and slow. You can use a broom stick, empty paper towel roll, or any stick that’s light.
  5. Wall Slide with Upward Rotation and Lift off , 10 times, slow and controlled.

This routine should take less than 12 minutes to complete. I’ll update my instagram with pics through the week as I do these 5 exercises daily. Let me know if you give ’em a shot!