Sports Injuries

Wrestling is a sport that requires speed, strength, and endurance that involves intense physical contact, pushing and pulling the muscles, tendons, ligaments, and joints to their limits. Wrestlers' are constantly contorting their bodies. Pushing the body to its limits increases the risk of developing wrestling injuries that include:

• Sprains
• Bruising
• Dislocations
• Fractures
• Concussions
• Skin infections

Wrestling Injuries

The most common injuries usually occur from forceful contact or twisting forces. And if a wrestler has been injured, there is an increase for re-injury. Wrestling tournaments typically take place over days, often with back-to-back matches, which significantly fatigues the body and increases injury risk. The most common wrestling injuries include:

• Muscle strains of the lower extremities and/or the back.
• Chronic problems can result from hours in the forward stance posture and repetitive motions.
• Trigger points.
• Neck injuries.
• Ligament knee injuries - Meniscus and MCL tears.
• Pre-patellar bursitis/Osgood Schlatter's syndrome from consistently hitting the mat.
• Ankle injuries.
• Hand and finger dislocations and fractures.
• Dislocations and sprains of the elbow or shoulder from take-downs.
• Cauliflower ear - is a condition that can cause ear deformity and develops from friction or blunt trauma to the ears.
• Skin infections occur from constant contact, sweating, bleeding, and rolling on the mats. Infections include herpes gladitorium, impetigo, folliculitis, abscesses, and tinea/ringworm.
• Concussions are usually caused by hard falls/slams or violent collisions with the other wrestler.

Injuries can cause wrestlers to alter/change their technique, exacerbating the existing damage and potentially creating new injuries.

Chiropractic Rehabilitation and Strengthening

There can be a variety of pain generators/causes when it comes to wrestling injuries. Joints and muscles can get overstretched, muscles can spasm, and nerves can become compressed and/or irritated. For example, a neck muscle spasm could be caused by nerve irritation from a shifted vertebrae. To determine the specific cause or causes of the injury/pain, a detailed chiropractic examination will be performed that includes:

• Range of motion testing
• Ligament tests
• Muscle palpation
• Gait testing 

Injuries often relate to the proper weight, neuromuscular control, core strength, proper technique, hygiene, and hydration management. Successful treatment depends on identifying the root cause of the wrestling injury. Chiropractic restores proper alignment through massage, specific manual adjustments, decompression, and traction therapies. 

Adjustments can include the back, neck, shoulder, hips, elbows, knees, and feet. Once correct body alignment is achieved, rehabilitative exercises and stretches are implemented to correct and strengthen muscle function. We work with a network of regional medical doctors specializing in referral situations and strive to return the athlete to their sport as soon as possible.

Wrestling Match

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified health care professional or licensed physician and is not medical advice. We encourage you to make your own healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and directly or indirectly support our clinical scope of practice.* Our office has reasonably attempted to provide supportive citations and identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Boden, Barry P, and Christopher G Jarvis. "Spinal injuries in sports." Neurologic clinics vol. 26,1 (2008): 63-78; viii. doi:10.1016/j.ncl.2007.12.005

Halloran, Laurel. "Wrestling injuries." Orthopedic nursing vol. 27,3 (2008): 189-92; quiz 193-4. doi:10.1097/01.NOR.0000320548.20611.16

Hewett, Timothy E et al. "Wrestling injuries." Medicine and sport science vol. 48 (2005): 152-178. doi:10.1159/000084288

Mentes, Janet C, and Phyllis M Gaspar. "Hydration Management." Journal of gerontological nursing vol. 46,2 (2020): 19-30. doi:10.3928/00989134-20200108-03

Wilson, Eugene K et al. "Cutaneous infections in wrestlers." Sports health vol. 5,5 (2013): 423-37. doi:10.1177/1941738113481179

Tennis is an intense sport that requires strength, agility, flexibility, stamina, endurance, and conditioning. And it’s a great way to stay in shape. However, with all of this intensity is the risk of injuries. Although they are lower compared to other sports injuries, injuries are more cumulative/repetitive based and wear and tear over time type. Tennis injuries can be painful and impair daily life. They can be treated and prevented with chiropractic medicine and strength training. Chiropractic can help the body heal quicker, and address underlying issues that led to the injury. This will help to worsen and prevent re-injury. The most common tennis injuries include...

Wrist Tendonitis

This is an injury that can happen to beginner players that don't have a great deal of arm/wrist strength, use a racquet that is too heavy, and begin developing an improper form to compensate. But it can also be caused by repetitive/overusing the wrist instead of the whole arm.  Symptoms are chronic stiffness and pain in the area surrounding the wrist joint. Chiropractic sports massage, physical rehabilitation, and learning proper form will help alleviate the pain and prevent worsening or developing new injuries.

Tennis Elbow

Tennis elbow is a condition that is caused by inflammation of the outside muscles in the forearm and tendons. This is usually an overuse injury from all the swinging and hitting, but using the improper technique could also be a cause. Chiropractic adjustments are highly recommended instead of steroid injections and other anti-inflammatories. The adjustments and massage relieve the discomfort and pain by naturally relaxing, stretching, and strengthening the muscles and tendons.

Shoulder Rotator Cuff Tendonitis

The rotator cuff belongs to a group of tendons and muscles that surround the shoulder joint. This allows the shoulder to perform 360-degree arm circles and is what stabilizes the shoulders. Tendonitis happens when the tendons inside the rotator cuff become inflamed. The inflammation causes pain with movement, especially overhead motions decreasing the range of motion in the shoulder. This injury is often caused by serving and hitting overheads with an improper technique. Chiropractic adjusting, heat and ice therapy, and electro-muscular stimulation loosen and stretch the muscles/tendons back to their proper form.

Knee Sprains and Strains

The knee goes through a lot in sports. And tennis is no exception, much like basketball and volleyball with all the jumping, pounding, shifting, twisting, losing balance, or extending beyond the normal range of motion causes injuries that result in:

• Pain
• Swelling
• Bruising
• Loss of the ability to move ​

Chiropractic will help relieve that pain and relax the damaged muscles. It also speeds the healing process by addressing the underlying issues.

Ankle Sprain

An ankle sprain also known as a twisted ankle happens when the ligaments attached to the joint become over-stretched or partially tear. These sprains happen from the:

• Quick start and stop movements
• Changing direction rapidly
• Quick sprints all around the court
• Causing the ankle to roll and/or twist.

A chiropractor will realign the ankle and provide physical therapy massage to allow the ligaments to heal properly and faster. Chiropractic treatment will allow the player to return to play quicker and prevent reinjury that if not treated correctly can become chronic. Having the proper personalized treatment plan will ensure the body heals correctly, prevent misalignments, loss of functionality, and/or range of motion.

PUSH Fitness

Aerobic Training

Aerobic exercise is a cornerstone for weight loss. Having the heart rate elevated for a continuous amount of time is the key. This is how calories are burned. Research has found that individuals involved in aerobic training lose more weight overall, including more fat mass than resistance training alone. When combined, aerobic and resistance training individuals gain more fat-free mass, including lean muscle. Aerobics causes the cardiorespiratory system to adapt. Maintaining heart function and health and keeps the body's energy metabolism system running at optimal levels. Aerobic exercise for fitness and weight loss is a key element of maintaining the body's health.

Disclaimer

The information herein is not intended to replace a one-on-one relationship with a qualified health care professional, licensed physician, and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the musculoskeletal system’s injuries or disorders. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request. We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, CTG*
email: coach@elpasofunctionalmedicine.com
phone: 915-850-0900
Licensed in Texas & New Mexico

References

Dines, Joshua S et al. “Tennis injuries: epidemiology, pathophysiology, and treatment.” The Journal of the American Academy of Orthopaedic Surgeons vol. 23,3 (2015): 181-9. doi:10.5435/JAAOS-D-13-00148

Minghelli, Beatriz, and Jéssica Cadete. “Epidemiology of musculoskeletal injuries in tennis players: risk factors.” The Journal of sports medicine and physical fitness vol. 59,12 (2019): 2045-2052. doi:10.23736/S0022-4707.19.09842-6

Stuelcken, Max et al. “Wrist Injuries in Tennis Players: A Narrative Review.” Sports medicine (Auckland, N.Z.) vol. 47,5 (2017): 857-868. doi:10.1007/s40279-016-0630-x

Willis, Leslie H et al. “Effects of aerobic and/or resistance training on body mass and fat mass in overweight or obese adults.” Journal of applied physiology (Bethesda, Md.: 1985) vol. 113,12 (2012): 1831-7. doi:10.1152/japplphysiol.01370.2011

Two surgeons discuss the diagnosis and treatment of acromioclavicular injuries in athletes. El Paso, TX. Chiropractor, Dr. Alexander Jimenez follows the discussion.

Acromioclavicular (AC) joint injuries most often occur in athletic young adults involved in collision sports, throwing sports, along with overhead activities like upper-extremity strength training. They account for 3% of all shoulder injuries and 40% of shoulder sports injuries. Athletes in their second and third decade of life are more often affected(1), and men are injured more commonly than women (5:1 to 10:1)(1,2).

Acromioclavicular dislocation was known as early as 400 BC by Hippocrates(3). He cautioned against mistaking it for glenohumeral (shoulder joint) dislocation and advocated treating with a compressive bandage in an attempt to hold the distal (outer) end of the clavicle in a diminished position. Almost 600 decades later Galen (129 AD) recognized his own acromioclavicular dislocation, which he sustained while wrestling(3). He left the tight bandage holding the clavicle down as it was too uneasy. In today's era this injury is better known, but its treatment remains a source of fantastic controversy.

Anatomy

The acromioclavicular joint combines the collarbone to the shoulder blade and therefore links the arm to the axial skeleton. The articular surfaces are originally hyaline cartilage, which affects to fibrocartilage toward the end of adolescence. The average joint size is 9mm by 19mm(4). The acromioclavicular joint contains an intra-articular, fibrocartilaginous disc which may be complete or partial (meniscoid). This helps absorb forces in compression. There is marked variability in the plane of the joint.

Stabilizers

There is little inherent bony stability in the AC joint. Stability is provided by the dynamic stabilizers -- namely, the anterior deltoid muscle arising from the clavicle and the trapezius muscle arising from the acromion.

Additionally, there are ligamentous stabilizers. The AC ligaments are divided into four -- superior, inferior, anterior and posterior. The superior is most powerful and blends with muscles. The acromioclavicular ligaments contribute around two- thirds of the constraining force to superior and posterior displacement; however, with greater displacement the coracoclavicular ligaments contribute the major share of the resistance. The coracoclavicular ligament consists of the conoid and trapezoid. The conoid ligament is fan-shaped and resists forwards motion of the scapula, while the more powerful trapezoid ligament is level and resists backward movement. The coracoclavicular ligament helps bunch scapular and glenohumeral (shoulder joint) motion and the interspace averages 1.3 cm.

Mechanism Of Injury

The athlete who sustains an acromioclavicular injury commonly reports either one of two mechanisms of harm: direct or indirect.

Direct force: This is when the athlete falls onto the point of the shoulder, with the arm usually at the side and adducted. The force drives the acromion downwards and medially. Nielsen(5) found that 70 percent of acromioclavicular joint injuries are caused by an direct injury.

Indirect force: This is when the athlete falls onto an outstretched arm. The pressure is transmitted via the humeral head into the acromion, therefore the acromioclavicular ligament is disrupted and the coracoclavicular ligament is stretched.

On Examination

The athlete presents soon after the severe injury with his arm splinted to his side. The patient may state that the arm feels better using superiorly directed support on the arm. Most motions are limited secondary to pain near the top of the shoulder; the degree varies with the grade of sprain. The hallmark finding is localized swelling and tenderness over the acromioclavicular joint.

In dislocations, the outer part of the collarbone will appear superiorly displaced using a noticeable step deformity (in fact, it is the shoulder which sags beneath the clavicle). Occasionally, the deformity may only be apparent later, if first muscle spasm reduces acromioclavicular separation. Forced cross-body adduction (yanking the affected arm across the opposite shoulder) provokes discomfort. The clavicle can frequently be moved relative to the acromion.

Acromioclavicular Visualisation

The typical joint width measures 1-3mm. It's regarded as abnormal if it is more than 7mm in men, and 6mm in women. Routine anteroposterior views of the shoulder reveal the glenohumeral jointnonetheless, that the acromioclavicular joint is over penetrated and so dark to interpret. Reduced exposure enhances visualization.

The individual stands with both arms hanging unsupported, both acromioclavicular joints on one film. Weighted viewpoints (stress X-rays) are obtained with 10-15 lb weights not held but suspended from the individual's wrists. They help differentiate type II-III injuries, but are of little clinical significance and therefore are no longer recommended in our practice.

Classification Of AC Separation

The importance of identifying the injury kind can't be over emphasized because the treatment and prognosis hinge on an accurate diagnosis. The injuries are graded on the basis of that ligaments are injured and how badly they're torn.

Allman (6) classified acromioclavicular sprains as grades I, II and III, representing respectively, no involvement, partial tearing, and total disruption of the coracoclavicular ligaments. More recently, Rockwood (1) has further classified the more severe injuries as standard III-VI.

The injuries are classified into six categories:

Treatment

The treatment of acromioclavicular joint injuries varies based on the seriousness or grade of the injury.

Initial treatment: These can be quite painful injuries. Ice packs, anti-inflammatories plus a sling are utilized to immobilize the shoulder and then take the weight of the arm. As pain starts to subside, it is important to start moving the fingers, wrist and elbow to prevent shoulder stiffness. Next, it's important to begin shoulder motion in order to stop shoulder stiffness.

Un-displaced injuries only require rest, ice, and then a slow return to activity over two to six weeks. Major dislocations require surgical stabilization in athletes if their dominant arm is involved, and if they participate in upper-limb sports

What's more, the patients treated non-operatively returned to full activity (work or athletics) earlier than surgically treated groups(10, 11). The exceptions to this recommendation include people who perform repetitive, heavy lifting, people who operate with their arms above 90 degrees, and thin patients who have prominent lateral ends of the clavicles. These patients may benefit from surgical repair(12).

Any discussion about the management of acute injuries to the AC joint must deal with which of the many methods of surgical therapy described is the best for their situation, but whether surgery should be considered at all. Surgery is generally avoided in athletes participating in contact sports since they will often re-injure the shoulder later on.

Surgery

Surgical repair can be divided into anatomical or non- anatomical, or historically into four types:

For the individual with a chronic AC joint dislocation or subluxation that remains painful after three to six months of closed treatment and rehabilitation, surgery is indicated to improve functioning and comfort.

Postoperatively, the arm is supported in a sling for up to six weeks. Following the first two weeks, the patient is permitted to use the arm for daily activities at waist level. After six weeks, the sling or orthosis is discontinued, overhead actions are allowed, formal passive stretching is instituted, and light stretching using elastic straps is initiated. Stretching and strengthening are begun slowly and gradually. The athlete shouldn't return to their sport without restriction until full strength and range of motion has been recovered. This usually occurs four to six months following operation.

Conclusion

AC joint injuries are an important source of pain at the shoulder area and have to be assessed carefully. The management of these injuries is nonoperative in the majority of cases. Type I and II injuries are treated symptomatically. The present trend in uncomplicated type III injuries are a non operative strategy. In the event the athlete develops following problems, a delayed reconstruction might be undertaken. In athletes involved in heavy lifting or prolonged overhead activities, surgery may be considered acutely. Type IV-VI injuries are generally treated operatively.

No matter what kind of treatment is chosen, the ultimate purpose is to restore painless function to the wounded AC joint so as to reunite the athlete safely and as quickly as possible back to their sport. It is possible in the vast majority of acromioclavicular joint injuries.

References

Reza Jenabzadeh and Fares Haddad

1. Rockwood CA Jr, Williams GR, Young CD. Injuries of the Acromioclavicular Joint. In CA Rockwood Jr, et al (eds), Fractures in Adults. Philadelphia: Lippincott-Raven, 1996; 1341-1431.

2. Dias JJ, Greg PJ. Acromioclavicular Joint Injuries in Sport: Recommendations for Treatment. Sports Medicine 1991; 11: 125-32.
3. Adams FL. The Genuine Works of Hippocrates (Vols 1,2). New York, William Wood 1886.
4. Bosworth BM. Complete Acromioclavicular Dislocation. N Eng J Med 2 41: 221-225,1949.
5. Nielsen WB. Injury to the Acromioclavicular Joint. J Bone Joint Surg 1963; 45B:434-9.
6. Allman FL Jr. Fractures and Ligamentous Injuries of the Clavicle and its Articulation. J Bone Joint Surg Am 1967;
49:774- 784.
7. Powers JA, Bach PJ: Acromioclavicular Separations: Closed or Open Treatment? Clin Orthop 1974; 104 (Oct): 213-223
8. Cox JS: Current Methods of Treatment of Acromioclavicular Joint Dislocations. Orthopaedics 1992; 15(9): 1041-1044
9. Clarke HD, Mc Cann PD: Acromioclavicular Joint Injuries. Orthop Clin North Am 2000; 31(2): 177-187
10. Press J, Zuckerman JD, Gallagher M, et al: Treatment of Grade III Acromioclavicular Separations: Operative versus
Nonoperative Management. Bull Hosp Jt Dis 1997;56(2):77-83
11. Galpin RD, Hawkins RJ, Grainger RW: A Comparative Analysis of Operative versus Nonoperative Treatment of Grade III Acromioclavicular Separations. Clin Orthop 1985; 193 (Mar): 150-155
12. Larsen E, Bjerg-Nielsen A, Christensen P: Conservative or Surgical Treatment of AC Dislocation: A Prospective, Controlled, Randomized Study. J Bone Joint Surg Am 1986;68(4):552-555
13. Bosworth BM. Complete Acromioclavicular Dislocation. N Engl. J. Med. 241: 221-225,1949.

An orthopedic surgeon explains why shoulders go wrong and what can be done to repair them. Shoulder chiropractor, Dr. Alexander Jimenez gets into the discussion.

The shoulder joint is frequently injured in the throwing athlete since it has a greater range of movement than any other joint in the body, and because its stability is dependent upon complete muscles and ligaments rather than supporting bone structures.

Phases Of Throwing

The five phases of throwing are wind-up, cocking, acceleration, deceleration and follow-through. The forces generated during those phases are significant and the subsequent pressures generated around the shoulder joint make it more likely to severe and chronic inflammatory conditions and injuries. A poor throwing technique will exacerbate the possibility of chronic inflammatory shoulder conditions.

A fantastic throwing technique requires the athlete to use his body weight as well as the big muscle groups of the legs, back and trunk to generate kinetic energy across the shoulder in the path of the thrown object. After the object is thrown, then the retained energy in the throwing arm has to be dissipated back to the large muscles which then absorb it. Poor mechanics throughout the wind-up and cocking stages require the shoulder muscles to generate extra energy to propel the object being thrown. This also contributes to exhaustion of the shoulder muscles, and can ultimately result in injuries.

When the object is thrown, a poor follow-through will lead to excess energy being retained in the delicate tissues of the shoulder, rather than returning to be consumed by the large muscles described previously, causing local tissue damage. Dynamic electromyographic analysis has substantiated a lot of the theory(2,3,4).

Simple Anatomy & Biomechanics

The shoulder (glenohumeral) joint is a ball (the humeral head) and socket (the glenoid fossa of the scapula) joint that's supported by the glenohumeral ligaments and labrum. The glenohumeral ligaments (inferior, middle and superior) are different capsular thickenings that restrict excessive rotation and translation of the humeral head. From the overhead throwing athlete, the more inferior glenohumeral ligament is the key anterior stabilizer when the arm is abducted beyond 90 degrees and externally rotated. The labrum is a thickening surrounding the glenoid which functions to deepen the glenoid cavity (the socket).

The shoulder is stabilized by both static and dynamic restraints. Static restraints include the articular anatomy, the labrum, the glenohumeral ligaments as well as also the negative pressure inside the joint. Dynamic restraints incorporate joint compression and also the steering effect of the rotator-cuff muscles (the very important small muscles around the shoulder).

The rotator-cuff muscles include the supraspinatus, infraspinatus, teres minor and subscapularis. The subscapularis is an internal rotator of the glenohumeral joint, whereas the infraspinatus and teres minor muscles are outside rotators. The rotator cuff as a whole functions to center the humeral head in the glenoid for stability and to allow maximal leverage during shoulder movements.

Shoulder Injuries In The Throwing Athlete

One of those dynamic or static restraint mechanisms could possibly be ruined by the throwing actions of this athlete, and there's a considerable overlap of injuries. Furthermore, an untreated or unrecognized injury may progress to additional injuries within the shoulder.

Common acute overuse injuries include rotator-cuff tendinitis and biceps tendinitis. Common chronic accidents include impingement syndrome, rotator-cuff tears, glenoid- labrum tears and shoulder instability.

The athlete will usually complain of anterior shoulder pain that is worst when trying to increase the speed or power of their throw.

Primary Instability & Secondary Impingement

Most athletes with anterior shoulder pain have favorable impingement signs and before a couple of years ago it was considered that they all had primary impingement. They subsequently underwent anterior acromioplasty (removal of the anterior part of the acromion process -- the acromion is a bony plate which juts up from the shoulder blade to supply a sort of protective roof over the shoulder joint) using rotator-cuff repair as necessary and the results of surgery proved to be inconsistent(5). It's currently known that symptomatic throwing athletes frequently have a primary instability of the shoulder with secondary impingement(6,7). Anterior acromioplasty with excision of the coracoacromial ligament in these people may actually raise shoulder instability and magnify symptoms.

Anterior instability can develop after a high-energy injury but in the throwing athlete it starts as an overuse injury. Chronic overuse can stretch the static stabilizers of the shoulder, resulting in instability. The scapular and rotator-cuff muscles act out of synchrony with each other placing an increased strain on the rotator cuff to maintain the head of the humerus at the center of the glenoid. As the rotator-cuff muscles weaken, the head subluxes anteriorly (moves forward) when the arm is abducted and externally rotated. This lateral subluxation causes a secondary impingement (compressing against) of the rotator cuff on the acromion and the coracoacromial ligaments, causing pain.

Clinical Examination

Active and passive array of motion, shoulder strength and regions of tenderness ought to be elicited. Most athletes with shoulder pain have favorable impingement signs. Pain during forward flexion while the examiner stabilizes the scapula is the principal impingement sign. Pain during active abduction of this internally rotated arm is your secondary impingement sign.

Examination of shoulder stability is significant and also the signals may be subtle. The apprehension test may be utilized to detect anterior instability and entails abduction of the shoulder to approximately 90 degrees followed by external rotation. As the outside rotation is increased, the athlete with anterior instability will feel as though the shoulder will 'pop out' or sublux forward. He/she will attempt to guard against further external rotation and eventually become very apprehensive.

The movement evaluation is done in a similar manner with the patient lying supine (on his/her back) and applying lateral pressure into the posterior aspect of the humeral head when abducting and externally rotating the arm. When there's anterior instability, this may be painful, but by employing a posteriorly directed force into the humeral head, the pain will ease because the humeral head is put in the anatomic position.

The existence of posterior capsular stimulation may be modulated by the presence of decreased internal rotation of the shoulder.

Imaging

Recent studies suggest that MRI is superior to ultrasound and CT scanning in assessing shoulder pain caused by rotator-cuff tears, subacromial impingement and osteoarthritis of the glenohumeral and acromioclavicular joints(8,9,10). Ultrasound evaluation in the hands of a good musculoskeletal radiologist is much cheaper, however, and allows dynamic evaluation. With a good history and evaluation, however, such imaging might not be required from the great majority of instances.

Plain radiographs should be taken to exclude bony pathology such as fractures, calcific tendinitis, metastatic disease and osteoarthritis. Axillary views may demonstrate signs of instability, namely spurring or erosion of the anterior glenoid or even a Hill-Sachs lesion (osteochondral depression on the anterior humeral head brought on by impaction of the dislocated humeral head on the glenoid rim).

Other Diagnostic Tools

Selective local anesthetic shots can help pinpoint the painful area in the shoulder.

Diagnostic arthroscopy allows excellent visualization of the glenohumeral joint and the subacromial space with little soft- tissue destruction and brief rehab period. Whilst the individual is anesthetised, the existence, level and management of this shoulder instability might be evaluated(11). Of course, it is likely to proceed to fix or fix many of the pathological conditions in the shoulder arthroscopically.

Non-Operative Treatment

The mainstay of initial treatment for primary instability and secondary impingement is non-operative(12). A huge analysis of non-operative management for subacromial impingement syndrome demonstrated that non steroidal anti inflammatory drugs with specific rehabilitation programs gave sufficient results in 67% from 616 patients and that just 28% needed a subacromial decompression(13). There ought to be a period of 'comparative remainder' where overhead activity is avoided(14).

An individualized chiropractic program should then be initiated. Stretching of tight muscle groups whilst avoiding stretching the anterior muscles and capsule in a patient with anterior instability should be followed by strengthening exercises for the scapular rotators and rotator-cuff muscles. This should last for six to 12 months under supervision. If now it's still not possible due to pain, a surgical procedure to address the problem with the anterior capsule and labrum should be sought. Athletes with recorded rotator-cuff tears, labral lesions or loose bodies should have these lesions repaired or debrided.

Operative Treatment

The athlete with chronic shoulder instability whose ligaments are excruciating, resulting in capsular laxity, must have a surgical alteration to the ligament tension in order to restore ligament equilibrium if non-operative measures have failed. Such processes are termed capsulorrhaphies or capsular changes (that they efficiently demand a tightening of the capsule to stop unwanted movement). The adjustment is made medially, inferiorly or laterally in the capsule(15,16). Other processes are described but are contentious as they work by limiting the selection of motion so that the end-range laxity isn't challenged. That is obviously not ideal for the athlete. Recent work has been printed on laser-assisted capsulorrhaphy(17) andthermal-assisted capsular shrinkage (18) --that the jury is still out on those techniques.

Primary or secondary impingement could be surgically treated by open or arthroscopic acromioplasty. Care has to be taken to avoid elimination of the lateral acromion, to stop deltoid detachment and to eliminate just enough bone. The aim is that by removing the source of mechanical abrasion of the supraspinatus tendon of the rotator cuff, progression of impingement to partial and full thickness tears will probably be ceased. But, inadequate vasculature, tendon nutrition, established fibrosis and makeup changes in the tendon imply that the practice of degenerative disease and cuff tearing continues despite relief of painful symptoms(19).

The anticipated outcome after acromioplasty for impingement syndrome, whether performed within an open or arthroscopic procedure, is comparable(20). Roughly 80% of individuals will experience sufficient pain relief(21,22). There are, however, a lack of some standardized tests, so an accurate comparison between studies is not actually possible.

Post-operative rehabilitation originally requires the recovery of a pain-free passive array of motion and then the growth of active strength. The results of surgery frequently seem poor for the first three months but tend to improve over the first year.

The principal benefits of arthroscopic surgery include the shorter hospital stay, less anesthetic morbidity and reaching rehabilitation landmarks quicker(23). Sadly, some studies suggest poorer results where patients have been involved in compensation claims(24).

Referred neck pain pathology should always be excluded. Repetitive pressure may also injure the acromioclavicular and sternoclavicular joints. Finally, bear in mind the less common causes of shoulder pain in the throwing athlete. These include quadrilateral space syndrome, suprascapular nerve entrapment, axillary artery occlusion, axillary vein thrombosis, lateral capsule laxity and glenoid spurs. These investigations lie in the domain of the professional shoulder surgeon.

References
1. Review of Sports Medicine and Arthroscopy, Philadelphia, pp123, 1995
2. Annals of Cases on Information Technology, Vol 70(20, pp220-226, 1998
3. Journal of Shoulder & Elbow Surgery, Vol 7(6), pp610-615, 1998
4. American Journal of Sports Medicine, Vol 12(3), pp218-220, 1984
5. Clinical Orthop & Related Research, Vol 198, pp134-140,1985
6. Knee Surgery, Sports Traumatology, Arthroscopy, Vol 1(2), pp97-99, 1993
7. Journal of Orthopaedic & Sports Physical Therapy, Vol 18(2), pp427-43, 1993
8. Manual Therapy Vol 4(1), pp11-18, 1999
9. Radiographics, Vol 17(3), pp657-673, 1997
10. European Journal of Radiology, Vol 35(2), pp126-135, 2000
11. American Journal of Sports Medicine, Vol 18(5),pp480-483,1990
12. Medicine & Science in Sports & Exercise, Vol 30(4), pp18-25, 1985
13. Journal of Bone and Joint Surgery, Vol 79(5), pp732-737, 1997

14. Clinics in Sports Medicine, Vol 8(4), pp657-689, 1989
15. Acta Orthop Scand, Vol 68(5), pp447-450, 1997
16. American Journal of Sports Medicine, Vol 22(5), pp578-584, 1994
17. Arthroscopy, Vol 17(1), pp25-30, 2001
18. Instructional Course Lectures, Vol 50, pp17-21, 2001
19. Journal of Bone and Joint Surgery, Vol 80(5), pp813-816, 1998
20. Arthroscopy, Vol 11(3), pp301-306, 1995
21. American Journal of Sports Medicine, Vol 18(3), pp235-244, 1990
22. Arthroscopy, Vol 14(4), pp382-388, 1998
23. Arthroscopy, Vol 10(3), pp248-254, 1994
24. Journal of Bone and Joint Surgery, Vol 70(5), pp795-797, 1988

Dr. Alexander Jimenez, shoulder injury specialist and sports injuries explains how overhead athletes may prevent chronic shoulder pain.

Does your shoulder ache after overhead activity? Is it getting worse and now restricting that action? Has a span of rest apparently resolved the issue just for the pain to recur when you return to the game? Chronic shoulder pain is unfortunately an all-too-common consequence of repetitive 'overhead activity', such as serving and smashing in tennis, freestyle or butterfly swimming, bowling in cricket, javelin, or baseball throwing and above-shoulder weight-training exercises. Chronic pain in the 'overhead' athlete is normally the consequence of damage to the rotator-cuff muscles of the shoulder (a group of four, small, deeply located, strap-like muscles). This article will look at how such repetitive damage is caused and how the athlete could have the ability to prevent it happening in the first place.

Structure Of The Shoulder

The shoulder joint complex is in fact made up by four joints: the glenohumeral joint (the ‘ball-and socket’ joint between the upper arm or humerus and the shoulder blade or scapula, which most non-experts consider to be the shoulder joint), the acromioclavicular joint (the joint between the lateral end of the collar bone or clavicle and the scapula), the sternoclavicular joint (the joint between the medial end of the clavicle and the breast bone or sternum) and the scapulothoracic joint (the ‘virtual’ joint between the undersurface of the scapula and the chest wall). Problems at any of these four joints may result in ineffective function of the shoulder-joint complex and consequently pain.

There is more movement possible in the shoulder joint than at any other joint in the human body. Over 1,600 places in 3- dimensional space can be assumed from the shoulder. The price to be paid for this extreme selection of movement is an inherent lack of stability.

To attain peak performance during overhead activity, there has to be optimum balance between mobility and stability. It is well-known that swimmers who over-stretch their shoulders in an effort to boost the range of their stroke, without improving their functional stability, are at heightened risk of injury to the rotator cuff.Tennis players and throwing athletes, actions which are essentially asymmetrical, often develop greater shoulder external rotation in their dominant shoulder and this is often associated with functional instability. Shoulder-injury prevention strategies need to concentrate on improving shoulder stability.

Impingement & The Rotator Cuff

The bony anatomy of the glenohumeral joint includes a large chunk (the head of the humerus) and also small socket (the glenoid of the scapula) together with all the muscles of the rotator cuff and scapular rotating (stabilizing) muscles acting as the most important dynamic stabilizers of this joint. The muscles of the rotator cuff envelop the glenohumeral joint itself, and include the supraspinatus, infraspinatus, teres minor and subscapularis muscles. Supraspinatus abducts the arm (moves it laterally away from the face of the body), infraspinatus and teres minor externally rotate the shoulder, and subscapularis is chiefly an inner portion of the shoulder. Sitting above the cuff is that the coracoacromial arch, composed of the coracoid and acromion bony processes of the scapula and a ligament connecting the two processes. Since the arm is abducted away from the human body or flexed (brought forward), 'impingement' or squeezing of the rotator cuff involving the head of the humerus below along with the coracoacromial arch above can happen. The healthy, conditioned rotator cuff functions effectively as an integrated component to stabilize and depress the head of the humerus, opposing the activity of the big deltoid muscle and thus preventing impingement.

Any overhead activity that includes the arm being taken regularly enough from below the shoulder level to over shoulder level has the capacity to damage the rotator cuff. With recurrent impingement, a badly ventilated cuff may get damaged, along with a cycle of cuff damage, diminished function, additional impingement and worsening cuff harm is initiated.

This form of primary impingement is most commonly found in weight coaches who overemphasize the development of the 'prime moving muscles' (pectoralis major, latissimus dorsi and deltoid) in the expense of their rotator cuff. It looks increasingly prevalent in athletes as they reach their thirties. Primary impingement is preventable and, even if the cuff is suitably conditioned, exercises like behind-the-neck press, incline bench press and also prolonged front laterals, won't lead to pain.

Secondary impingement refers to impingement secondary to underlying glenohumeral instability, when the rotator cuff is fatigued by its own attempts to maintain the humerus centered on the glenoid and thus allows the head of the humerus to ride up, reducing the subacromial space. This is possibly the most common mechanism of cuff injury found in younger athletes, especially those with increased joint laxity, and is observed frequently in swimmers and throwers. The principal difficulty here is instability and, unless that is treated, pain will probably be ongoing and progressive.

Scapular Stability

A strong and healthy rotator cuff is essential to the overhead athlete. In recent decades, the function of the scapula-stabilizing muscles in positioning the glenohumeral joint for optimum rotator-cuff work has been increasingly highlighted. Coordinated action of the set of muscles is needed to supply a stable base for pain-free overhead activity. The excessively simplistic 'ball and socket' model of the shoulder joint has been superseded by a model similar to the acting seal that could balance a ball on its nose. The seal equates into the scapula, and constant little adjustments by the seal (scapula) are required to avoid the ball dropping off its nose (glenoid). Overhead athletes must be able to effectively control the position of their scapula for optimum cuff function.

Injury Prevention Plans

Most cuff injuries can be prevented relatively simply. The crucial point is not to overwork the rotator cuff by increasing shoulder work too quickly. Keeping increases in workload to less than 10 percent per week will significantly reduce the risk of injury.

The key balance between stability and variety of shoulder movement has already been emphasized. Athletes with access to sports medicine support will benefit from an official evaluation of dynamic shoulder function. This should encompass an extensive overview of static and dynamic anatomy, range of movement at all four joints of the shoulder joint complex, muscle strength and balance (particularly of the rotator cuff and scapular stabilizers) and an assessment of inherent glenohumeral stability in all three planes. Significant abnormalities detected should be addressed and fixed. Such screening is becoming more and more regular for the more elite overhead athlete and validated evaluation and treatment protocols have been defined.

Strategy should be evaluated by the trainer and appropriate technical changes incorporated into the rehab program.

The Function Of The Kinetic Chain

More importantly, the use of force generation by other body parts has been assessed. For instance, the power generated by the shoulder at the tennis serve was preceded by power generated by the legs, trunk and back. The muscular mass of this shoulder is comparatively modest, and if insufficient power is generated by the previous connections in the kinetic chain the shoulder has to perform 'catch-up' and generate power rather than acting as a power regulator. Improving the server's leg activity, spinal strength and trunk rotation during the function will reduce the prevalence of rotator-cuff injury. Such biomechanical evaluation is difficult however, in skilled hands, is a crucial and effective component in injury prevention.

How Can An Athlete Prevent Injury?

Though shoulder rehab protocols after injury need to deal with subtle muscle imbalances and joint restrictions, and so require oversight, isolated rotator-cuff strengthening exercises can be very effective as part of a pre-participation conditioning program and can be performed using the next three simple exercises. The key is to strengthen the inner ozone (subscapularis), external rotators (infraspinatus and teres minor) and abductor (supraspinatus) muscles of the shoulder. This is most easily and safely performed using the varying resistance of a cliniband -- a length of flat rubber available from large chemists in varying resistances. You'll need about two meters; begin with the lowest resistance and workout!

To strengthen the right scapularis muscle, begin by holding your right arm from the side of your body with your elbow bent/ flexed at 90 degrees (the forearm will be at right angles to the upper arm and the line of the forearm points forward). Attach or loop one end of this cliniband above a door handle to the right of your own body and hold the other on your right hand. Internally rotate your humerus against the resistance of this cliniband (seen from above, the forearm moves in anti-clockwise direction towards the left) while maintaining your elbow bent at 90 degrees and at the side of your body. Let your forearm return to its starting place by the pull of the cliniband in a controlled manner.

The external rotators are strengthened from the opposite actions. From the same starting place but using the cliniband looped over a door handle to a left, externally rotate your right humerus from the immunity of the cliniband (viewed from above, the forearm moves in a clockwise direction to the right) while the elbow is again retained to the side of your system in 90 degrees. The forearm is again allowed to come back to the beginning position in a controlled fashion. Single sets include a minute of either internal or external rotation exercises and can be replicated three to five times a day. The cliniband needs to follow you around during the day! To strengthen the internal and external rotators of the left shoulder demands similar but mirror-image maneuvers.

Supraspinatus conditioning requires abduction work and initially should be carried out under shoulder level. The beginning position is quite different from the previous two exercises. To strengthen your proper supraspinatus, put one end of this cliniband beneath your left foot and then extend (keep straight) your right elbow. Hold the other end of the band on your hand and then internally rotate your right arm so that your right thumb points towards the floor and the back of your right hand faces forwards. Then, keeping your elbow extended, move your right arm away from your body (keeping the elbow straight) against resistance to just below shoulder level, and then let it go back to the beginning place in a controlled manner. An easy refinement is to unite pure abduction with just a little flexion so that you bring the arm forwards as you move it away from your side.

Pinch Your Scapulae Together

Pain shouldn't be felt through any of the three exercises. Three- to-five minute sets over the course of a day will generate a conditioning effect. By shortening the length of the band you will have the ability to progressively increase resistance. There are a massive number of variants on the exercises clarified that attain similar conditioning gains, and I make no claims for the superiority of their chosen three. But they have functioned well in my medical practice and infrequently cause unanticipated issues. Similar exercises could be performed using the pulley systems found in most gyms and with further adaptations can be done with free weights. Maintaining scapular retraction (the scapulae are 'pinched together' towards the middle of your spine and 'pushed down') while carrying out these exercises enables you to develop your scapular stabilizing muscles at the same time.

Strengthening the scapular stabilizers without specialist supervision is more difficult, but there is benefit from integrating wall leans (standing push-ups against a wall), knee push-ups and regular push-ups in any conditioning program. Seated rowing will strengthen the latissimus dorsi and should be undertaken while trying to keep scapular retraction.

The narrative of Anna's dodgy shoulders holds two lessons: the value of superior stability and the value of a rigorous strategy by sports therapists. Core chiropractor, Dr. Alexander Jimenez takes a closer look.

Anna, a tall, slender 15 year old, came for her appointment to see me with her mom. Together they explained that she had a national swim meet in two weeks, but that her shoulders were really giving her problems and had been doing so for about three months. Throughout this time Anna had improved her training before the state championships, where she had done surprisingly well in different freestyle and medley events, considering how little training she'd done before.

Anna seemed quite gangly, with stooping posture, a gait that looked very sloppy (knees bending backwards & unstable pelvis) with rather large feet... it was like she was designed for the pool!

She complained that her shoulders clicked, and sometimes felt like they 'popped out of joint' when she was doing a difficult sprint session. They tended to hurt largely as an ache, often after she'd cooled off, but occasionally during her warm-up. They could feel very tight when she would wake up.

A GP they'd visited prescribed anti-inflammatory medication, told her she'd rotator cuff tendinitis inflammation), and delivered her for stretching and ultrasound therapy. Anna's trainer was keen to talk with me about what was going on with his star swimmer and whether she'd be ready for the nationals in two weeks' time.

Deciding What's Wrong

The moment a clinician was presented with the injury, their mind begins to play with different diagnostic scenarios. This process, known as 'clinical reasoning', constitutes the subjective (from interview) and objective (from hands on testing or other investigative processes) information from the customer, and gradually develops an evidence-based rationale for the most likely diagnosis. The identification forms the building block for most future management; therefore: no accurate diagnosis, no good result.

In this instance, based on what we understood from Anna's story, we needed to assess the validity of the following potential diagnoses, in order of best likelihood (there are other possible shoulder pathologies, but I thought these were the very likely):

Multi-Directional Instability (MDI) Of The Gleno-Humeral Joint

This was the most powerful likelihood. How Anna has been having trouble in both shoulders indicated a probable genetic/familial component and MDI tends to occur on either side in shoulders where there is a genetic tendency towards hyper-mobility. Excessive translation (shearing movement) and also inferior centering of the head of humerus (the 'ball' in the shoulder socket) in all directions leads to gradual destruction of the cartilaginous rim (the labrum) and rotator cuff tendon. Pain and clicking effect, together with the head of humerus in impact repeatedly popping slightly in and out of the joint throughout the swimming stroke.

Uni-Directional Instability Of Gleno-Humeral Joint

Excessively protracted posture (round shoulders destroy the uterus!) Can cause the middle of rotation of the head of humerus slowly to drift forwards. The subscapularis muscle loses its ability to control it, straining on the joint capsule and loosening, which soon leads to instability. Finally the head of humerus will start to pop out, or even the rotator cuff tendon would impinge (catch) below the acromion (top outer edge of the shoulder blade), resulting in pain and clicking. Uni-directional instability are more likely to occur in one overloaded shoulder, especially on the non-dominant arm at a bilateral sport, not in two.

Superior Labrum Anterior Posterior (SLAP) Lesion

Looseness in the front part of the shoulder joint may also induce the long head of biceps tendon and the lower part of the joint capsule, which ends up destabilizing the link of the cartilage on the rim into the bony glenoid. However, this kind of shoulder injury more commonly afflicts throwing athletes and, again, generally presents on only one side.

Rotator Cuff Impingement Or Tendinitis

According to Anna's account of her symptoms, this is likely to be a secondary issue caused by instability: uni- or multi- directional. In fact gleno-humeral instability is a much under-diagnosed source of rotator cuff impingement or tendinitis. Anna, at age 15, is quite unlikely to have tearing or significant degenerative change of her rotator cuff, even though it might be inflamed.

Clinical Testing

Tests performed by an experienced physiotherapist will greatly help to decide or confirm their hypothesis. We utilized the following tests to help us work out which of the above diagnoses finest clarified Anna's issue.

Anterior laxity testing: (moving the extended arm through various positions) This test will determine how far the head of humerus passively moves forwards in its socket; the results are graded l to lll, depending on the distance it moves relative to the width of the head of humerus. The therapist would also do forwards and backwards moves of the head of humerus in sitting, to help work out the direction and extent of laxity.

Apprehension testing: the test is positive if a backwards (posterior) glide of the head of humerus in a ‘stop’ sign takes away discomfort.

We also did tests for:

• rotator cuff flexibility
• impingement
• stability

Short-Term (Pre-Competition) Aims Of Management

Having completed the above tests we reasoned that Anna's main problem was indeed a multi-directional uncertainty of the shoulder joint, suspended in being genetically hypermobile. This had led to secondary annoyance and impingement of the rotator cuff tendon.

After we were fairly certain of our diagnosis, we devised a management program, originally focused on the big upcoming competition; thereafter looking to supply a long-term resolution of Anna's injuries. Trying to be realistic about what we could achieve in just two weeks, we limited our pre-competition approach to three areas:

1. Establish Accurate Diagnosis As Early As Possible

This was essential. It may require another opinion from a sports doctor, and possibly scans: ultrasound for rotator cuff tendon ethics, CT arthrogram/ / MRI for labral (cartilage) tears, X-ray to view shallowness of the glenoid socket.

2. Minimize Short-Term Pain & Additional Joint Breakdown

We used trigger-point massage and work on the rotator cuff to get rid of pain from active movements, impingement positions and finally, Anna's swimming stroke. We undertook deep-tissue massage of this key back, torso, torso, shoulder and arm muscles. We mobilized the mid- and upper back.

We instantly stopped Anna from ongoing any dangerous or aggravating practices, such as bad sleeping positions (along with her shoulders at extreme positions and being leant on poorly); carrying too heavy a backpack; and any dangers from different sports she might be playing.

We assessed Anna's stretching regime, believing it was likely that most of her moves would be damaging because of her bad control. As a better alternative we taught her to do self- trigger point therapy and massage.

We taped the shoulder blades for support out of the pool and to assist Anna in re-educating her posture. In the pool we experimented with a different kind of tape for joint support and to help her get feedback on joint position.

We discussed with Anna's coach a short-term decrease in her training load and intensity for pain control, and established a focus on quality not quantity during the run-up to the competition (for instance, minimizing her butterfly training due to the greater loads this stroke places on the joint structures at the front of the shoulder).

We used non-steroidal anti-inflammatories and ice after training as required.

3. Educate Anna, her parents and her coach

The key things to communicate were:

Her long-term goal had to be management and prevention. She would need to learn to stay on top of it by doing positive things for her shoulders, particularly when they were feeling good.

Long-Term (Post-Competition) Aims Of Direction

We are confident that a full resolution of Anna's shoulder problem is possible, with a return to symptom-free swimming, and a complete training and competitive load. She'll likely need, a preventative regime to ensure she remains injury-free. Much like many athletes that have experienced sports accidents, Anna will have to get accustomed to taking responsibility for preventing a recurrence before the day she decides to hang up her goggles.

We had three primary long-term tactical objectives.

1. Maximize the muscular control of her shoulder joint

This entails growing, together with Anna, her parents and her trainer, a graduated plan to combat weaknesses and lively instability.

The retraining work should begin with local stability muscles, working around three key areas:

• Trunk (transversus abdominis)
• Scapula(lower trapezius and serratus anterior)
• Head of humerus (subscapularis)

The business of getting an athlete to learn how to activate correctly these tonic (holding) stability muscles is a fairly exact clinical science which may require the use of equipment and manual feedback by a proficient physiotherapist.

This stability and strengthening work will take three to six months, divided into three phases:

Activation - of proper muscles, as described previously. For example, if Anna didn't learn to activate the muscles controlling her shoulder blades, then she would perpetually tend towards downward turning, which makes it impossible for her subscapularis muscle to control the mind of humerus correctly. So the mid-lower traps (upward rotators of the shoulder blade) must be trained within the rhomboids for stability (see exercise 1 below).

Recruitment  - of same stability muscles within rehab and dry-land swimming exercises. As local equilibrium improves, the exercises should slowly stress global strength and stability muscles. The quality of control remains a top priority as the exercises are progressed (see exercises 2a to 2c).

Training - stability and strength gains on property could be incorporated into gradually increasing intensity and space in the pool. So long as Anna's shoulders have been asymptomatic after a couple of months of rehab training, her swimming training and competition schedule must not need to get affected. Pool drills will further develop her awareness and endurance. Throughout warm-up, Anna should do low-load stability drills rather than extending, to trigger the brain-body connection.

Regardless of whether the shoulders are symptomatic, Anna's off-season period will have to include a few weeks of stability and strength work from the lead-up to the start of swim training.

2. Resolve technique issues

Video analysis would be introduced through all 3 phases of rehabilitation training, in close liaison with the coach. It's critical that an athlete's knowledge and consciousness of good stability runs alongside their correction of poor technique, so they could understand and apply the muscle retraining to create necessary but often subtle modifications to movement mechanics. As an example, learning to hold the back and shoulders still while 'catching' the water through straight enhances scapular stability.

3. Long-term flexibility management

Anna's priorities are her thoracic spine, back, chest and neck musculature, to enhance the stability of her trunk, shoulder blade and head of humerus. She would be likely to require maintenance physio and massage, particularly in periods of intense training and competition, in order to stay symptom-free.

If Anna can conquer the hurdles in this phase of her career, she could open up for herself the chance to achieve what the shoulders of Ian Thorpe have: genetic hyper flexibility coupled with excellent control and strength, resulting in top level success.

Sourced From:

Ulrik Larsen

This case study focuses on the Australian over-105kg weight-lifter Damon Kelly, who injured his left shoulder, which he had jarred while performing a mis-timed snatch. Injury scientist, Dr. Alexander Jimenez takes a look at the case.

In the snatch movement, the bar must be lifted above the head to full arm extension at one continuous rapid movement. The weight-lifter should then be held steady until the judges have accepted the lift.

While practicing, Damon had captured the pub just too far behind his head, causing a slight "shift within his gleno-humeral joint along with a sharp pain. He immediately dropped the bar and had been resting almost completely from the grab component of his training.

Damon currently presented with "stiffness" and pain, largely on reaching across his body (horizontal flexion) along together with his hands behind his back (complete operational internal rotation). All stationary muscle tests were negative, and also his shoulder elevation was ordinary, much to my relief.

He reported being able to perform shoulder press with no pain in any way, even in a moderately heavy load for him. He was, however, getting some pain with the grab position under load, and was quite apprehensive about this (it felt "weak in that position).

I have generally found that the Queensland weight-lifters I've looked after over the years are utilized to training with pain and have very low anxiety over injury. They are specialists at load- modification and development, appreciate strongly the value of correct technique, and the majority of them understand training periodization fairly intuitively.

My provisional identification was a rotator cuff "strain , using a minimum likelihood of this weight-lifter really having ripped any tendon fibers. Posterior impingement of the rotator cuff at the glenoid was a distinct possibility -- hypothetically the pain at the posterior rotator cuff may have been solely due to compressive forces and consequent tendon impingement, maybe not overstrain/ overload at end of scope.

There was also a distinct possibility that he had experienced a small anterior subluxation occasion in the snatch position, but given how quickly it was resolving, and that he noted no parasthesia or clunking/ snapping feelings at the joint, I believed that this was unlikely. Feelings of "instability in the snatch position might have had less to do with any disruption to the normal capsuloligamentous restraints into the joint than using inhibition of the rotator cuff (especially the medial rotator, subscapularis), for example that it couldn't hold the "ball as tightly in the socket as usual.

The Way The Injury Occurred

Let's picture what the position and load of the "snatch needs of the rotator cuff:

With the bar quickly being forced to grab position by a strong concentric contraction of the external rotators, and abruptly coming to sit above the mind in 1 rotational movement, the strength and timing of subscapularis suddenly having to generate a huge eccentric internal spinning force has to be impeccable. If the time is repeatedly poor, or if the external rotators have slowly become too tight (a common result of some number of training variables), then subscapularis might not perform its job quite nicely enough and the ball will slightly shear anteriorly from the socket. Within a untrained shoulder, an entire spectrum of damage is possible, the worst being anterior shoulder dislocation.

Treatment

Employing deep-tissue massage and trigger- point releases, stretching and dry needling, we focused on repeatedly attaining two effects during the following four weeks, so as to restore normal rotator cuff function in the snatch position:

This treatment -- subduing overactive external rotators and triggering a dormant subscapularis -- for me clinically forms a common routine in sport injury.

Aiding Activation

On the very first day I saw Damon, I began experimentation by having him hold the bar in the grab position with elastic tube tensioned to pull the bar back over his head behind him (see Figure 1). He found that this instantly gave him a feeling of "security together with his joint under load. The pull of the tubing enhances the stimulation of subscapularis, so it can be used to centralize the job of this gleno-humeral joint by neutralizing the rotational forces of the cuff. In effect it provides a boost to the less powerful or inhibited subscapularis.

Damon continued to utilize the tubing for 3 weeks since he slowly increased his holding time in snatch standing and introduced the snatch movement with progressively increasing heaps. Then he used the tubing only during warm-up, and finally weaned himself off it entirely using a week to spare before his next contest.

Trainers and gym-goers can certainly use the tubing concept themselves at bench press and shoulder press. First implement a standard shoulder press with the bar, then attach a moderate strength of tensioned tubing to pull the bar from beneath, and see how "smooth and "simple the press movement now feels. It's nearly as though the socket has abruptly been lubricated, as the load requirement for your external rotators is reduced, and the subscapularis has been requested to step up and function. It certainly worked for Damon Kelly, with nearly 200kg over his head.

Swimming is a intricate sport that places huge demands on the body for propelling through the water. The shoulders often suffer as a consequence of this, but, injury chiropractor, Dr. Alexander Jimenez asks, what are the implications of musculoskeletal shoulder asymmetry?

Overview

Swimming is a hugely popular game for both recreational and competitive functions. The nature of exercising against the water immunity provides a special setting compared to the field or court in all other sports. Likewise, most other sports utilize a dominant side, whereas in swimming that the repetitive, continuous motions require either side of your system to be coordinated and equally strong. This can place an accumulation of stress physically. The overhead actions of a swimming stroke may notably strain the shoulder joints and around 73% of swimmers will experience shoulder pain at any stage within their career(1).

Taking this advice on board, surprisingly, swimmers do not usually develop symmetrically with equal muscle power on each side. And in which there is muscle imbalance, they commonly compensate by using different muscles more than ordinary to guarantee the total force generated is the same(2). Swimming also does not provide that point of contact or source to hold on to enjoy most other sports have. Swimmers rely on their inbuilt strength throughout the body along with the entire kinetic chain to generate maximum force propulsion. Expertise and strategy are important facets to contribute to this, however if there's a natural muscle imbalance then this can further affect technique, however much technique instruction you provide.

Asymmetry is defined when there's a muscle imbalance between the left and right sides greater than 10%(two). This means that the muscles on one side are more powerful or more efficient compared to those on the opposite side. A recent study that screened nationwide- level hens found that 85% were asymmetrical(two). Asymmetry usually develops because of the shoulder or whole arm being used wrongly or too often. Excessive repetition with no adequate rest causes the muscles to exhaustion. This decreases muscle activity and induce generation, and eventually causes biomechanical abnormalities as the swimmer attempts to overcome these failing mechanisms(3). A third of those swimmers in the study that were discovered with asymmetry were also identified as having compensatory plans(2). Asymmetry can lead to:

Every one of these can alter technique and thus performance execution. This might be the difference between finishing first and finishing second in competition.

Screening For Shoulder Asymmetry

Screening is the process of assessing a variety of characteristics that are significant with the game. This allows the identification of possible flaws and muscle imbalances. Strengthening applications to rectify such findings may provide optimum strength, functionality and prevention of injury.

Table 1 details the key screening tests for identifying asymmetry in shoulder power for swimming. This scale details if the athlete can move against gravity (tier 3), then resist your force (grade 4), and supply full strength to resist (grade 5).

Shoulder flexion is not listed here as a screening test as it's been found that it doesn't have any effect on shoulder asymmetry(2). This implies that many swimmers all have an equal stroke length. It seems to be the abduction, adduction and rotational components which become imbalanced and make the asymmetry of the shoulders.

Arm dominance and breathing side can also be often considered significant factors in procedure perfection; however studies have not found these to have any consequences on performance(two). For more technically precise ways to assess these functions with dynamometer, see the original research articles(1,2).

Even though these are significant testing purposes, it's just as important to look elsewhere when trying to identify potential weaknesses. The surrounding muscles like the latissimus dorsi should be considered.

Latissimus Dorsi Stiffness

The latissimus dorsi is your largest muscle of the trunk and is responsible for all pushing and pulling type activities. The repetitive character of swimming and thus overuse of the latissimus dorsi usually means that this muscle may be prone to stiffness.

Each of these issues alters the way the shoulder blade operates mechanically. This modified mechanics can then develop injuries as other structures become caught or pinched within the shoulder joint distances. These injuries will influence technique as the shoulder will slowly lose power and strength.

Have the athlete in crook lying with their back flat against the bed. Ask them to lift their arms over their head. If there is latissimus dorsi stiffness they'll struggle to fully stretch the arms overhead, and/or their spine will lift up away from the mattress.

For a more accurate and technical evaluation method refer to this analysis by Illinois University(1).

Power Exercises For Fat Loss

The added resistance that the water provides requires strengthening exercises to be carried out in similar motions to replicate the coils. This may improve the specificity and ensure the correct muscles have been targeted. Key exercises for scapular strengthening that carry over ideally for swimming are shown below.

1. Breaststroke

2. Swimming

3. Low row

4. Front crawl simulation

Summary

References:
1. Phys Ther in Sport. 2013; 14:50-53.
2. Phys Ther in Sport. 2013; http://dx.doi.org/ 10.1016/j.ptsp.2013.02.002
3. Rehab Res and Practice. 2012; ID:853037; 1-9.
4. McKesson Healthcare Solutions. 2004. www.mckesson.co.uk
5. Phys Ther in Sport. 2004; 3:109-124.
6. Musculoskeletal assessment. 2000. 2nd Ed; 150-156.
7. Clinical Sports Med. 2006. 3rd Ed; .246-247.
8. http://www.shoulderdoc.co.uk/article.asp?article=1381
9. http://www.youtube.com/watch?v=AcPZEtWP1x4 (2013).
10. APPI Pilates Matwork Handouts manual.2012. www.ausphysio.com

Frozen shoulder isn't a common disorder in women and sportsmen, however when it does happen & it can be debilitating. Chiropractor, Dr. Alexander Jimenez looks at the most recent thinking on the best treatment options for restoring shoulder functionality.

Frozen shoulder, even more properly known as adhesive capsulitis (AC), has been a frequent source of shoulder pain and loss of movement in the over 40s. In 'primary' cases of AC, there is absolutely no reason for the onset stiffness or pain, whereas AC can happen following illness, trauma, surgery or an injury. AC is believed to affect around 3 percent of the population, with women at higher risk than men. In people below age 40, AC that is primary is likely to be secondary in character -- for instance, also is infrequent, however. However, it could lead to significant disruption particularly given the timescale it requires to resolve, when it does occur.

Causes Of AC

As its terminology implies, adhesive capsulitis describes a state where the joint capsule becomes inflamed and 'sticky' (see Figure 1), making the whole joint rigid and difficult/painful to move. AC's etiology is known. We do understand, however, that because the capsule becomes inflamed, scar tissue forms, which leaves space for the humerus to move through its normal selection of motion and causes pain.

Histological samples of capsular tissue from patients with frozen shoulder have identified a pathological picture comparable to Dupuytren's disease, with an increase in neighborhood collagen production, myofibroblasts, and fibroplasia, suggesting a fibro-proliferative mechanism to the condition(1). On the macro-scale, patients using AC present with synovitis with thickening and contracture of the anterior capsule, particularly the ligament and also the glenohumeral ligament, and inside the rotator interval. This process contributes to a diminished glenohumeral joint volume, and limits movements of the shoulder, especially affecting external rotation in neutral and mid-elevation(two).

Some studies have suggested that poor posture (especially rounded shoulders) can cause shortening of at least one of the ligaments of the shoulder, which might also lead to the condition. Athletes whose training results in and/or that are overdeveloped abbreviated pectoral and anterior musculature may therefore be at increased risk. Also, prolonged immobility (such as after a rotator cuff injury or shoulder fracture) is regarded as a risk factor for AC -- a fantastic reason for athletes to rehab a shoulder injury as quickly as possible.

There appears to be a link between AC risk and some conditions. For example, studies indicate that a greater than normal amount of blood sugar (eg in diabetes) is a risk factor for AC(3). Insulin-dependent diabetics are at the maximum risk, and the problem is particularly severe in such cases. Likewise, high blood lipid levels are also associated with an increased risk of AC(4), while AC is also frequently observed in thyroid disorders, Parkinson's disease, and a variety of cardiac and pulmonary disease. Despite each of these risk factors, however cases of AC remain idiopathic in nature, something which can be very frustrating for clinicians and sufferers .

Typical Characteristics

Concerning characteristics, AC typically displays a progression through three distinct phases: freezing, frozen and thawing (schematically represented in Figure 2). In the initial phase (freezing), patients typically present with noticeable pain that comes on over a span of a couple weeks with action. There isn't a loss of range of movement. During this phase, many individuals respond by utilizing the shoulder which subsequently contributes to stiffness, developing a kind of vicious cycle.

The frozen (adhesive) phase typically lasts for 3-9 months, together with significant stiffness and pain in the extremes of motion. Patients presenting within this stage maintain the arm in adduction and internal rotation. From time to time, atrophy of the shoulder muscles are available and on palpation, there can be diffuse tenderness along the shoulder joint. There is a worldwide restriction of debilitating, movements of the shoulder and, in particular, there's almost complete reduction of external rotation.

The thawing (resolution) stage typically lasts for 9-18 months, and is characterised by steadily diminishing levels of pain and stiffness. The advancements are just slow and it might thawing to happen. Indeed, several studies have clarified AC for a self- limiting condition which typically resolves in 12-36 months(5-7). But some studies have suggested that a substantial percentage of patients may remain symptomatic for up to ten years after the initial phase(8). Regardless, even an early resolution of AC still present a challenge for any sportsman or woman. If their sport does not rely heavily on shoulder joint usage and variety of motion, there are few sports in which shoulder motion is absent, meaning that sport exercise may cause or increase pain and distress.

Diagnosis

AC can be difficult to differentiate from ordinary shoulder ailments and to diagnose in its early stages. Because of this, X-rays of the shoulder can be very useful to exclude constipation of the other or joint pathologies. Besides the clinical features described above (specifically the nearly total loss of external rotation in passive movement), the typical routine of AC beginning is also useful in making a diagnosis. In situations where uncertainty remains, MRI scans demonstrating a thickening in the joint capsule and the ligaments that are affected, in addition to indications of synovitis provide further evidence for AC(9,10).

The widely held opinion among clinicians is that a diagnosis of AC can typically be verified in the practice and doesn't normally require extensive investigation(11). However, recent research published this season suggests caution, especially in early- stage AC(12). Scientists studied the validity of widely used clinical identifiers of early- phase primary/idiopathic adhesive capsulitis. These identifiers were range of motion pain and loss during eight moves. The results demonstrated (rather surprisingly) that none of the clinical identifiers for early-stage AC formerly suggested by expert consensus were verified as well as the researchers concluded: "Clinicians should bear in mind that commonly used clinical identifiers may not be related for this point."

Treatment Options

AC's treatment stays controversial, based on the extent of the pain and stiffness, and the stage of the disorder. Conservative treatment options include the use of non-steroidal anti- inflammatory medication (NSAIDs) and physiotherapy. NSAIDs can help provide some symptomatic relief but there's little evidence they affect the disease development. Physiotherapy by contrast may be more successful. Lots of studies examining the use of physiotherapy in the early and mid-stage of AC have shown an improvement in pain scores, operation and range of motion(13-19). Despite these more recent study is much equivocal, as we will see.

When treatment options are ineffective, surgery or injections remain options. The most common approaches are manipulation under anaesthesia capsular release and capsular distension medications. In a poll of UK caregivers, just 3 percent recommended surgical procedures for the initial painful freezing stage but for its second and third phases, this increased to almost 50 percent of the surveyed(20).

There remains controversy about efficacy. As an example, 1 study on 110 instances of AC found that patients receiving physiotherapy alone had better clinical results than patients undergoing MUA(14). By contrast, however, a study of 77 patients with AC demonstrated that 'supervised neglect' supplied better results at two years in comparison with a intensive physiotherapy regime, suggesting that physiotherapy might not alter disease progression, especially if the regime is too aggressive(21).

Latest Thinking

The character of AC perhaps explains why there's no clear consensus on the optimum treatment protocol for AC. It so happens that 2014 watched the publication of a Cochrane Database systematic review to the efficacy of manual therapy and exercise -- specifically, how it than the glucocorticoid shots(22).

The research groups accumulated statistics from 32 randomized controlled trials (RCTs) and quasi-randomized trials (a total of 1836 patients), which compared with any manual therapy or exercise intervention versus placebo, no intervention, another sort of manual therapy or exercise or any other intervention. Interventions included mobilization, manipulation and exercise, delivered independently or in conjunction. The outcomes of interest were active shoulder abduction, overall pain, shoulder function, global evaluation of treatment success pain relief of 30% or greater, quality of life and also the amount of participants.

The main findings were as follows:

• The outcome differences involving interventions Which Were clinically important were discovered up to seven weeks, after
• A combination of exercise and therapy for six months resulted in improvement at seven months but a similar number of adverse events compared with glucocorticoid injection;
• The mean improvement in pain with shot was 58 points on a 100-point scale, and 32 points with exercise and manual therapy;
• The improvement in function with glucocorticoid injection was 39 points onto a scale, and 14 points with exercise and manual therapy;
• Forty-six per cent of participants reported treatment success with manual therapy and exercise in comparison to 77 percent (40/52) of participants receiving glucocorticoid injection;
• Including a combination of manual therapy, exercise and electrotherapy for four months to injection did not confer benefits over glucocorticoid injection at every time point.
• 1 trial of 119 participants discovered a combination of manual therapy, exercise, electrotherapyandoralnon-steroidalanti- inflammatory drug (NSAID) for 2 weeks didn't confer clinically significant benefits over oral NSAID independently in terms of function and patient-reported treatment achievement at fourteen days.

The authors concluded: "The best available data show that a mix of manual therapy and exercise might not be as effective as glucocorticoid injection in the short term." These findings fit with a previous meta- review carried out in 2012(23). In this analysis, the authors pooled data from 31 clinical efficacy research, which assessed the benefits of steroid injection, sodium hyaluronate, supervised neglect, physical treatment (mainly physiotherapy), acupuncture, and manipulation under anaesthesia, distension and capsular release. The authors concluded that there was limited evidence on the effectiveness of treatments for primary shoulder but in regard to cost-effectiveness, some evidence suggested that steroid shots may be more cost-effective compared to steroid physiotherapy or plus physiotherapy alone.

Stretching Success

One study that wasn't included in the above mentioned review (since it is too recent) is much more promising. This analysis looked at the efficacy of sustained stretching of the inferior capsule in the managing of a frozen shoulder -- specifically the potency of a shoulder counter grip apparatus on range of motion, pain, and function in patients with a frozen shoulder(24). A total of 100 participants were randomly assigned to a control group or an experimental group, with each group. While the experimental group obtained traction and physiotherapy the control group received. The treatment time was 20 minutes a day for five days per week for two weeks.

When countertraction was given along with physiotherapy, the scores for shoulder flexion improved from 94.1° at baseline to 161.9° after intervention (see Figure 3). Abduction selection of movement rose from 90.4° into 154.8° after intervention, while pain decreased from a score of 8.00 to 3.48. Overall, 60 percent of the participants were enhanced to the fourth stage of satisfactory joint function (based on the Oxford Shoulder Score) at the experimental group compared to only 18% in the management group. Whether these improvements were sustained over a longer period of time was not investigated, but the first results are encouraging.

While bars show before/after scores for abduction bars show before and after for shoulder flexion goniometer scores

Ultrasound/PRF Benefits?

Recent studies have demonstrated that pulsed radiofrequency (PRF) lesioning of the suprascapular nerve (SSN) using a fluor- oscopy- or computed tomography-guided technique can relieve shoulder pain.

Until recently, there were no studies into PRF lesioning using practices. However, a newly published 2014 study has compared the effect of physical treatment alone with physical treatment and PRF lesioning of their SSN using guided ultra- noise(25). From the study, 60 patients have been randomized to the following two classes:

• An intervention group comprising patients who received a treatment of weeks of therapy;
• A control group comprising patients who received 12 weeks of therapy alone.

The researchers assessed shoulder pain (visual analogue score -- VAS), disability indicator, and passive array of motion at 1, 4, 8, and 12 weeks after therapy and compared the 2 groups.

The results demonstrated that the intervention group had a notably shorter time to onset of significant pain relief (6.1 vs. 28.1 times) and a much greater decrease of VAS score at week 1 (40% .4.7 percent) than the control group. A comparison of both groups indicated progress in the intervention group at all times in shoulder pain and VAS, passive array of motion and in handicap index scores -- an effect that lasted for at least 12 weeks.

Surgical Options

Finally, in cases what exactly does the current study say about effective choices? A 2014 study has compared the outcomes of three different forms of operation in patients experiencing persistent primary AC(26). These were:

• A combination of arthroscopic capsular release and subacromial decompression (21 topics);
• Subacromial decompression combined with mobilisation under anaesthesia (18 topics);
• Selective capsular release. (15 subjects).

Before and after operation, all the subjects were assessed for glenohumeral selection of movement (abduction, flexion and external rotation) and the subjects were monitored for an average of 37 weeks after surgery.

Each of three surgical treatments enhanced the selection of motion in every direction, with equal improvements in abduction and flexion. All treatments also improved external spinning, but selective arthroscopic capsular release trended towards a greater gain than the other two treatments (though this result was not big enough to be considered statistically significant). The authors reasoned that the surgical techniques improved ranges of motion in the glenohumeral joint but that overall, arthroscopic capsular release (independently or with subacromial decompression) demonstrated the best results postoperatively and should hence be advocated as the first choice treatment in persistent AC.

Summary & Conclusions

AAC is fairly infrequent and uncommon in younger sportsmen and women . Trainers who suffer with type I diabetes are at increased risk, as are athletes near the time of the menopause it may affect anyone at any time.

AC presents challenges for the clinician. Not only does this take a considerable time to resolve even in the best case situation, there remains much uncertainty about treatment approaches that are effective. But even if there is little evidence that it significantly simplifies the length of the problem, any intervention that can help reduce pain is desired, possibly making all the difference between an athlete not being able to tackle any training whatsoever and having the capability to execute some restricted training.

The evidence healing speeds is feeble although conservative approaches such as therapy remain the primary port of call. But some recent evidence suggests that the accession of countertraction or ultrasound-guided PRF lesioning into physiotherapy maybe more effective than physiotherapy.

These more specialized techniques may be harder to justify and are of course time consuming and expensive to do given the evidence from systematic reviews suggesting that shots alone may be an effective treatment. In persistent and severe cases of AC, surgery may be the best option. In this situation, while the data is limited evidence suggests that arthroscopic capsular release is likely to be more effective than manipulation.

References
1. J Bone Joint Surg Br. 1995;77(5 ):677
2. J Bone Joint Surg Am . 1989 ;1(10 ):1511
3. South Med J. 2008 Jun;101(6):591-5
4. Rheumatol Int. 2014 Jan;34(1):67-74
5. Br Med J 2005;331(7530): 1453-6
6. Curr Rev Musculoskelet Med 2008; 1(3): 180-9
7. Br J Gen Pract 2007; 57: 662-7
8. Scand J Rheum 1975; 4(4): 193-6
9. J Bone Joint Surg Br 1995; 77(5): 677
10. J Bone Joint Surg Am 1989 ;71(10): 1511
11. Open Orthopaedics J, 2013, 7, (Suppl 3: M10) 352-355
12. Phys Ther. 2014 Jul;94(7):968-76
13. J Bone Joint Surg Am 2000; 82(10): 1398.
14. Arch Orthop Traum Surg 1995; 114(2) : 87-91.
15. Ann Rheum Dis 1984; 43(3): 353-60.
16. Arthritis Rheum 2003; 48(3): 829-38.
17. Physiotherapy 2002; 88(8): 450-7.
18. Br Med J 1998; 317(7168): 1292-6.
19. Cochrane Database Syst Rev 2003;(2): CD004258
20. Shoulder Elbow 2010; 2(4): 294-300
21. J Shoulder Elbow Surg 2004; 13(5): 499-502
22. Cochrane Database Syst Rev. 2014 Aug 26;8:CD011275
23. Health Technol Assess. 2012;16(11):1-264
24. Clin Orthop Relat Res. 2014 Jul;472(7):2262-8.
25. Anesth Analg. 2014 Sep;119(3):686-92
26. Acta Orthop Belg. 2014 Jun;80(2):172-7.

Chiropractor Alexander Jimenez investigates the relevant anatomical and biomechanical considerations related to the subscapularis, plus injury within the subscapularis, how to assess subscapularis function & finally rehabilitation ideas for injured as well as dysfunctional subscapularis muscles.

Introduction

Injuries to the muscle are infrequent causes of shoulder pain in the athlete. Immediate injuries to the muscle- tendon unit can affect the athlete like swimmers and tennis players. Malfunction in the subscapularis in the kind of fatigue and inhibition can lead to biomechanical abnormalities in the glenohumeral joint such as poor lateral stabilization of the shoulder joint in the shoulder that is athletic.

Anatomy

The subscapularis originates the anterior scapular (subscapular fossa) and inserts onto the lesser tuberosity of the humerus. It's the largest of the rotator cuff muscles and its cross-sectional area is larger than the other three rotator cuff joint (infraspinatus, teres minor, surpraspinatus). Its main roles on the glenohumeral joint are:

1. Depressor of the humeral head;

2. Anterior stabilizer of the humeral head (glides the humeral head posteriorly relative to the glenoid fossa);

3. Internal rotator of the shoulder (together with the highly effective pectoralis major and latissimus dorsi).

The tendon fibres mix with the anterior capsule of the shoulder and therefore fortify the posterior shoulder capsule. The muscle is regarded as less significant as a shoulder internal rotator (as the pectoralis major and latissimus dorsi are powerful internal rotators) also is significantly more important as a dynamic anterior stabilizer of the glenohumeral joint through its activity in preventing anterior shear/glide of the humeral head.

The subscapularis has an intimate relationship with the long head of the biceps via the shoulder "Twist". This is a complex that functions to stabilize the long head of the biceps tendon in the bicipital groove. The pulley complex consists of the superior glenohumeral ligament, the coracohumeral ligament, along with the ventral attachment of the subscapularis.

Tendon, and is located inside the rotator Interval between the anterior edge of the subscapularis tendon of the superior edge and the tendon. Injuries to the subscapularis tendon may compromise the integrity of their bicep's 'sling' (Nakata et al 2011). To keep the knee tendon in place and stabilized, tension from the superior glenohumeral ligament and the help of the very superior insertion stage of the subscapularis from supporting the fascia is demanded (Aria et al 2010). Disruption of this 'biceps sling' is a frequent pathology in athletes that require forceful and frequent shoulder rotation such as the position in baseball pitching.

Injuries To Subscapularis

Like All of the rotator cuff muscles subscapularis is susceptible to pressure forces which may damage the muscle-tendon and also muscle unit's integrity. Although tears to the subscapularis are not as prevalent as tears from the other rotator cuff (particularly supraspinatus), injuries to the subscapularis might prove to be problematic due to its anatomical proximity to the long head of the biceps tendon.

Ruptures of the subscapularis have been reported in the literature (Gerber and Krushell 1991). The mechanism is a pressured hyper-extension rotation force such as falling onto an outstretched arm, on the shoulder or infrequently it might be a result of a shoulder dislocation. These kinds of injuries will lead to severe shoulder pain using a painful weakness in internal rotation, greater range of motion into external rotation (which is then constrained by pain at end of range) along with also a weak/pathological 'lift-off' test (see below).

Injuries to the subscapularis tendon can also occur in athletes or occupations that take a great deal of forceful shoulder internal rotation (baseball pitching, tennis, swimming). Overuse of those complicated can create a strain response and fibrosis tissue deposition in the gut, may lead to. Trigger points in the muscle can create that weaken and tighten the muscle.

In these instances, pain is felt as a deep anterior shoulder pain, exacerbated by overhead inner spinning movements (swimming and serving), weakness in the 'lift-off' evaluation (see above) and also reduced array of passive external rotation whilst the arm is placed by the side is noted (Thurner et al 2013).

Finally, a neighborhood muscle imbalance shoulder between the subscapularis and the infraspinatus can cause positional faults from the mind of the humerus, whereas the humeral head is not centralized in the glenoid fossa and excessive anterior shear of the humeral head happens that leads to impingement and uncertainty sensations in the shoulder.

Role Of Subscap In Shoulder Stability

Hess et al (2005) found that in a simulated throwing action using shoulder rotation, participants with shoulder pathology had a delayed onset on recruiting of subscapularis compared infraspinatus and supraspinatus. Nevertheless, in regular pain free shoulders that the subscapularis was activated earlier and until the shoulder began to externally rotate, evidence that the subscapularis functions in a mechanism to 'pre-empt' movement and also to contract to provide anterior shoulder stability.

It is suggested therefore that shoulder pain patients lose part of their energetic mechanisms that are stabilizing in the shoulder and as a result the humeral head shear and can glide anteriorly and superiorly from the glenohumeral joint, thus leading to anterior shoulder impingements.

Imbalances in force production involving the subscapularis and the externally infraspinatus could create a local issue from the glenohumeral joint. It's typical for the athletic shoulder to really have a misaligned and tight infraspinatus in connection to the subscapularis. This neighborhood imbalance sets a mechanical issue in the shoulder the infraspinatus pushes forward the humeral head in relation to the glenoid and the inhibited subscapularis can't counteract this lateral shear effect. Consequently the head shears and impinges the anterior pain and shoulder structures may result.

Conclusion

Research shows that the muscle has an significant role in supplying anterior glenohumeral joint stability. It centres the humeral head into the movements of this arm/shoulder. Dysfunction in this muscle may lead to of the humeral head which might be a precursor to shoulder instabilities and the more shoulder impingements.

It's important for the clinician to detect dysfunction inside this muscle through a battery of tests and also direct exercises will be required to rehabilitate function for this muscle.

References
1. Aria et al (2010) Functional anatomy of the superior glenohumeral and coracohumeral ligaments and the subscapularis tendon in view of stabilization of the long head of the biceps tendon. Journal of Shoulder and Elbow Surgery. 19(1):58-64
2. Barth et al (2006) The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 20(10). 1076 -1084.
3. Burkhart SS, Tehrany AM. (2002) Arthroscopic subscapularis tendon repair: Technique and preliminary results.
Arthroscopy ; 17:454-463
4. Gerber C and Krushell RJ (1991) Isolated rupture of the tendon of the subscapularis muscle. The Journal of Bone and Joint Surgery. 73-B(3); pp 389-394.
5. Hess et al (2005). Timing of Rotator Cuff Activation During Shoulder External Rotation in Throwers With and Without Symptoms of Pain. JOSPT. 35(12); pp 812-820.
6. Nakata et al (2011). Biceps pulley: normal anatomy and associated lesions at MR arthrography. Radiographics. 31(3):791-810
7. Scheibel et al (2005) The Belly-Off Sign: A New Clinical Diagnostic Sign for Subscapularis Lesions. Arthroscopy: The
Journal of Arthroscopic and Related Surgery, 21(10): pp 1229-1235
8. Thurner et al (2013) Subscapularis Syndrome: a case report. International Journal of Sports Physical Therapy. 8(6); pp 871-882.

Serratus anterior is an important muscle for the overhead athlete. Dysfunction in this muscle can lead to shoulder injuries such as impingement, rotator cuff breakdown and performance decrements during overhead tasks. Chiropractor, Dr. Alexander Jimenez looks at its anatomy and biomechanics, and highlights some clinically relevant exercises designed to retrain serratus anterior function.

Choosing to receive treatment from a chiropractor won’t stop your slice or improve your putting, but it just might end up improving your overall game and lowering your score. It’s no secret that golf can be hard on your lower back. The quick, repetitive twisting motion required to swing a club puts your back at risk every time you play, and if you already have a back injury you’re putting other muscle groups at risk. Keep reading to learn how to improve your golf game in El Paso with chiropractic care.

How Chiropractic Boosts Your Game

Since a chiropractor is specifically trained to treat the entire neuromusculoskeletal system they are able to help golfers reduce the amount of stress and strain placed on their bodies. The lower back does undergo a lot of stress with the torque of a standard golf swing, but there are other body parts that can affect your golf game, too. Pain or range of motion issues in your shoulders, elbows, knees or wrists will definitely affect your swing and lead to inflated scores.

Chiropractic treatment can put your body back into alignment, remove nerve compression, and improve blood flow to vital muscles. When you are free from pain and your mobility isn’t hindered in any way, you can swing freely and focus on your game.

It All Begins With You

Although you can improve your golf game in El Paso with chiropractic, taking steps to help yourself will improve it even further. Arrive early at the course and do some warm up stretching and light swings before your game. Whether you hit some balls at the practice range or not, stretching and loosening up is key. You’ll also want to perform some light stretches after your round to keep your muscles loose and lengthened.

It’s easy to get dehydrated out on the golf course, but not drinking enough can set the stage for a strained muscle or similar injury. Make sure you drink plenty of water before, during, and after playing golf, especially if it is hot outside. If you walk the course when you play, avoid carrying your bag and pull it instead. Carrying a heavy golf bag over 18 holes can cause disc problems and irritate nerves.

If you have the option, avoid wearing metal spikes when you play. They have the potential to get stuck in the ground during your swing, causing a serious knee or back injury. And if you find that your swing is causing pain in any area of your body, consider taking lessons to learn a more efficient way to swing your clubs. If you follow these tips you’ll enjoy a pain-free round every time out.

Bowling is a fun physical activity that is enjoyable for all ages. Today, there are college bowlers, recreational bowlers, amateur, semiprofessional, professional leagues, and tournaments worldwide. Although it might not be the first sport that comes to mind when thinking of injuries and chronic pain conditions, it can place significant stress on the muscles and tendons of the upper and lower body. It is important to know and understand how to avoid injuries. 

How Bowling Injuries Happen

There are two main causes of injuries and chronic pain related to bowling. The first is poor mechanics, and the second is repetitive over-use. Both cause/develop painful symptoms that can turn into injuries that become chronic conditions. Many injuries are caused by:

• Slip and fall accidents
• Players dropping the ball on their feet
• The majority of injuries come from overuse/repetition and improper body mechanics.
• Overuse injuries result from repetitive and/or strenuous actions/movements that place profound stress on the body’s musculoskeletal system.

For example, a semi-pro and professional bowler will play fifty or more games a week. This means throwing a sixteen-pound ball for ten frames per game. When consistently repeated over and over, this can cause serious wear and tear to the body. With amateur and recreational bowlers, they don't play as much, so they don't experience overuse injury as much, but what they do experience is improper/poor form techniques that shift the body in non-ergonomic ways, wrong equipment like oversized/too-small shoes that can cause awkward postures and body motions, a ball that is too heavy causing an individual to overthrow and strain their arms, backs, hips, and legs. Or a ball with small finger holes that get stuck or too large, causing finger, hand, arm, shoulder pulls strains, and sprains.

Common Bowling Injuries

The most common injuries and conditions associated with bowling include: 

• Hand pain
• Finger sprain
• Trigger/bowling finger
• Wrist Tendonitis
• Carpal Tunnel Syndrome
• Medial epicondylitis
• Annular ligament sprain
• Shoulder Tendonitis
• Rotator Cuff Tear
• Shoulder Instability
• Low Back Pain
• Hip Bursitis
• Piriformis Syndrome
• Sciatica
• Herniated Disc
• Low back strain and sprain
• Spondylolysis
• Knee ACL injury
• Knee LCL injury
• Knee MCL injury
• Knee PCL injury
• Knee Meniscus Tear
• Patellofemoral Syndrome
• Illiotibial Band Syndrome
• Arthritis

Many of the injuries can lead to tendonitis or arthritis later in life.

Trigger/Bowler's Finger

Symptoms include:

• Hand pain after bowling, specifically in the fingers
• A clicking or popping when moving the fingers
• A finger gets locked in a bent position

Rest, and no bowling is recommended. How long a rest depends on how long the symptoms have been presenting. Physical therapy, along with chiropractic exercises, can help improve finger strength. Splinting the finger could be required to improve the condition. If all fails or does not generate adequate relief, hand surgery could be optioned with a trigger finger release. The surgery allows the finger to move more freely.

Bowler’s Thumb

This usually happens to bowlers that want to generate a lot of spin on the ball. If the thumb’s hole is too tight, it can pinch the ulnar nerve inside the thumb. If the thumb injury is not serious, rest and getting the correct ball size can correct the issue. This is where purchasing a personal bowling ball can help.

Finger Sprain

This is an injury to one or more of the ligaments in the fingers. It most often takes place in the collateral ligaments along the sides of the fingers inside the ball. The ligament/s gets stretched or torn when the finger is forced beyond its normal range of motion. Common symptoms of a finger sprain include swelling, tenderness, stiffness, and pain in the affected finger. This usually occurs from:

• The weight of holding the ball with the fingers alone
• A poor release
• Using a ball that doesn’t properly fit the fingers
• A finger sprain falls into grades on the severity of how much the ligament is stretched or torn:

Grade 1

Stretching or microscopic tearing.

Grade 2

Less than 90% of the ligament is torn.

Grade 3

More than 90% of the ligament is torn. Grade three sprains can be accompanied by joint instability and immobility.

Herniated Disc

A herniated disc is when the discs get injured/damaged from overuse, wear, and tear, or a traumatic injury to the spine. The disc can dry out, become less flexible, bulge out, or rupture. Bowlers are constantly:

• Bending during the final approach and throw
• Carrying a heavy ball
• Shifting, twisting, and releasing, increasing the pressure within the discs

In bowling, the majority of herniated discs happen in the low back. The most common symptom is backaches and back pain. Lumbar herniated discs left untreated can cause sciatica.

Avoid and Prevent Injury

The best way to prevent injury is to stay aware of body position, mechanics, equipment, and what the body says.

Stretching

Stretching is one of the best things to avoid injury before practicing, competing, or just playing. Stretching will increase flexibility, especially in the wrist, hand, arm, and low back.

Improving technique

Continually using poor techniques over and over is a perfect set-up for injury. Working with a coach will ensure the proper form. This is important when it comes to generating spin on the ball, as well as, making sure the grip does not place too much strain on the hands.

Using the right ball

The ball being used might not be the right fit for your hand or strength. The holes could be too far apart, causing strain on the fingers. Get as much information as possible and try out different styles and weights to get a comfortable feel for the right ball.

Bowling less

Hard-core bowlers could be overdoing it. Cutting back, and creating a balance will allow the body to recover thoroughly and not cause flare-ups.

Getting in shape

Studies show that individuals who bowl and do not exercise significantly increase the risk of a back injury than those who exercise their back and core. Bowling is not as strenuous as other sports, but it still requires the body to be able to handle the stress.

Body Health

Test Body Composition

Testing body composition regularly is the best way to ensure the body stays healthy. Tracking body composition tracks Lean Mass and Fat Mass gain or loss. The information provided allows the individual to make the necessary changes to ensure they stay fit and healthy.

Diet adjustment

Diet needs to be adjusted to match the individual's current activity level, or risk running a caloric surplus. A great way to optimize diet is to use Basal Metabolic Rate which will make sure the body is getting enough nutrients to fuel muscle growth, and lose belly fat.

Physical activity that fits the new lifestyle

Increase physical activity levels that work with current lifestyle. This does not mean performing at high levels every day. Be active on a schedule that works for you. Two days of strength training a week offer great physical and mental benefits. The key is to maintain the balance between food consumption and exercise/physical activity that fits your current lifestyle.

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified health care professional, licensed physician, and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Almedghio, Sami M et al. “Wii knee revisited: meniscal injury from 10-pin bowling.” BMJ case reports vol. 2009 (2009): bcr11.2008.1189. doi:10.1136/bcr.11.2008.1189

Kerr, Zachary Y et al. “Epidemiology of bowling-related injuries presenting to US emergency departments, 1990-2008.” Clinical pediatrics vol. 50,8 (2011): 738-46. doi:10.1177/0009922811404697

Kisner, W H. “Thumb neuroma: a hazard of ten pin bowling.” British journal of plastic surgery vol. 29,3 (1976): 225-6. doi:10.1016/s0007-1226(76)90060-6

Miller, S, and G M Rayan. “Bowling related injuries of the hand and upper extremity; a review.” The Journal of the Oklahoma State Medical Association vol. 91,5 (1998): 289-91.

Shoulder chiropractor, Dr. Alexander Jimenez examines the latest research into shoulder problems and gives practical advice on achieving balanced upper-body development.

Chronic shoulder injury is a common issue, and not only for athletes. Among the people at large, day-to-day activities such as DIY or gardening can produce chronic pain, as may resistance work at the gym, when weightlifters pile on the weight without paying attention to the demand for balanced strengthening. Adults beyond age 50 are more vulnerable to general to rotator-cuff tears, the incidence increasing with age(1).

One large group, known as 'overhead athletes', are at increased risk of chronic shoulder injuries. The overhead group covers a broad array of sports such as swimming, tennis, cricket, javelin and baseball, all of which include variations on the standard throwing activity where the arm moves over the head (see below).

The throwing movement recruits a large number of muscles and unites a massive assortment of arm motion with high forces or levels at the shoulder joint. All overhead athletes often perform many repetitions of the movement, typically with the dominant arm only, as part of their sports training.

For the shoulder and arm to maneuver efficiently requires coordinated movement of the scapula and humerus, called scapulo-humeral rhythm. By way of instance, arm abduction is accompanied by some upward rotation of the scapula, allowing the deltoid muscle to maintain a good length-tension relationship throughout the whole 180 degrees of abduction.

Scapular and humeral coordination also involves the stabilizing muscles of the scapula working in concert with the rotator-cuff stabilizing muscles of the glenohumeral joint. If the scapula retains its position correctly, the rotator cuff is going to do its job more effectively. Or, to put it another way, active stability is necessary to prevent excessive stress on the shoulder joint.

Get The Balance Right

The importance of rotator-cuff muscle strength in throwing was examined by a researcher from the West Point Army Hospital at the US(2). Scoville et al looked at the strength of ordinary subjects without any shoulder injury symptoms, comparing strength ratios of the end range of lateral and medial rotation. Subjects were assessed on an isokinetic dynamometer (which measures joint strength). Full range of motion (ROM) was defined as 90 degrees of lateral rotation (forearm vertical) to 20 degrees of medial rotation (forearm 20 degrees below the horizontal). The average force produced in the last 30 degrees of each direction was assessed as end ROM.

The group average strength ratios outcomes are as follows:

The concentric lateral rotation to eccentric medial rotation ratio of 1:2.4 indicates the lateral rotators have readily enough strength to decelerate the arm as it moves back into the cock position. The eccentric lateral turning to concentric medial rotation ratio of 1.05:1 suggests that the lateral (external) rotators are capable of decelerating the forward motion, but only just.

The results of Scoville's study suggest that ordinary adults without a shoulder problems possess adequately balanced strength for effective biomechanics of throwing. But it also shows how significant it really is for overhead athletes to keep that equilibrium of muscle strength, otherwise the lateral rotators might not have the ability to manage the more powerful lateral spinning force, compromising the shoulder joint.

Problems often arise when athletes concentrate on their training solely on the prime mover muscles, such as pectorals and deltoids, resulting in a relative weakness of the rotator-cuff and scapular stabilizer muscles. It is common practice now for overhead athletes to pay additional focus on lateral rotator strengthening. The same information will apply to all those that do resistance training: be certain to include exercises for the rotator-cuff and scapular stabilizers in order to create balanced strength in the upper body.

While the Scoville study analyzed rotation strength alone, we have already noted above that throwing combines spinning with flat extension and flexion movements. The rear deltoid muscles should also therefore act eccentrically to decelerate the arm throughout the end range when the pectorals and anterior deltoid are working concentrically. So strengthening applications must also look closely at back shoulder strength, including pulling and rowing movements to equilibrium pressing movements.

Here, again, gym-goers have a tendency to be most unaware of the need for balanced development, typically focusing on the 'mirror muscles' (pectorals, deltoids and biceps) and neglecting the back. The ideal program is going to be one that boosts strength in all muscle groups and also develops a balanced physique, front and back.

What Goes Wrong

Recent research from Kibler and McMullen (3) utilizes the idea of 'scapular dyskinesis': a change in the normal position or motion of the scapula during combined scapulo-humeral moves. They suggest that a wide variety of symptoms reveal exactly the same biomechanical fault, the inhibition or disorganization of activation patterns in scapular stabilizing muscles, resulting in altered scapular function.

This idea is supported by research from a team from Belgium(4). Cools et al investigated the time of trapezius muscle activity during a sudden downward decreasing motion of the arm, comparing the operation of both 39 overhead athletes with shoulder impingement against the of 30 overhead athletes with no impingement. The trapezius operates on the scapula in 3 sections: the lower portion depresses, the centre portion retracts, and the upper portion raises it.

Cools measured the time that the muscles took to change on in all three parts of the trapezius and at the middle deltoid, and discovered significant differences between both groups. Those with impingement showed a delay in muscle activation of the middle and lower trapezius the muscles which are important for preserving good shoulder positioning.

Another study from Cools and his group(5) researched if 19 overhead athletes with impingement symptoms had differences in their scapular muscle power (measured by isokinetic dynamometer) and electromyographic activity on the affected and uninjured sides. They found that the injured side revealed significantly lower peak force during protraction, a significantly lower ratio of protraction to retraction force and significantly lower electromyographic activity in the lower trapezius through retraction.

Collectively these findings support the idea of scapular dyskinesis involving abnormal recruitment timing and strength of the trapezius muscle, specifically the middle and lower portions. These results indicate the importance for harm prevention of good scapular stability in the depression and retraction movements.

Research in Germany highlighted changes in flexibility at the shoulders of overhead athletes(6). Using ultrasound-based measurement, Schmidt-Wiethoff et al found that the dominant arm at a group of pro tennis players had a considerably greater range of external rotation compared to the non-dominant arm, even while their internal rotation showed a substantial deficit relative to the non-dominant arm. Furthermore, the total rotational assortment of motion of the dominant arm was significantly less than that of the non-dominant arm or of a management group. Among the control group (not included in any overhead sports), there were no important differences in flexibility between their own shoulders.

How To Protect Your Shoulders

It would appear in the study that incorrect muscle function (developed through sport-specific demands or injury) is most evident at the lower and middle trapezius and lateral rotator-cuff muscles. From a practical viewpoint this means overhead athletes and people involved with weight training need to spend time on specific strengthening exercises to encourage injury prevention and ensure balanced strength and good posture.

Step 1: Equalize Front & Rear Strength

The beginning point is a balanced program for front and back shoulder muscle growth. Opposing muscle groups have to be trained equally. While exercises for the anterior shoulder and pectorals create power, to train just those muscles will unbalance the shoulder. The better approach is to plan exercise pairs that work opposing muscles (see Table 1). Coaches and therapists must check that equivalent quantities of sets from each column are written into strength programs.

Step 2: Develop Good Pulling Form

It's crucial to do row or pull exercises with proper technique so as to ensure that the middle trapezius, rhomboids and lower trapezius muscles are properly recruited.

As an example, the lat pulldown is a popular exercise for the upper-back and rear-shoulder muscles, involving adduction of the arm. The workout begins with the arms above the head. Throughout the pulldown motion the exerciser must focus on utilizing the lower trapezius muscles to depress the scapula while the massive latissimus dorsi muscles pull on the elbows downwards. And throughout the return motion, it's important to make the lower trapezius muscle 'keep hold' of the scapula as the arms rise with the weight.

This recruiting creates the proper scapulo-humeral rhythm. Without correct use of these lower traps, the lat pulldown is performed in a hunched shoulder position, which promotes poor mechanics.

Exactly the same coaching principle applies to rowing exercises. These involve horizontal expansion of their arm, utilizing the powerful latissimus dorsi muscles, and require concurrent scapular retraction in the middle trapezius and rhomboids. Exercisers should concentrate on retracting the scapula at the same time as the elbow is pulled straight back and maintaining the scapula retracted as the arm goes forward with the weight on the return motion. If the scapula is not stabilized the athlete will perform the practice in round-shouldered (kyphotic) posture, which again leads to bad shoulder joint mechanics.

Measure 3: Isolate The Rotator Cuff

The small but essential muscles of the rotator cuff should be targeted alongside the lower traps to prevent developing weakness or dysfunction. In the following four exercises, look closely at the coaching points.

A club golfer was cured of a nagging consistent shoulder pain. Shoulder injury chiropractor, Dr. Alexander Jimenez evaluates the case study.

Here’s a pertinent quote from the late lamented author of Letter From America, Alistair Cooke: ‘To get an elementary grasp of the game of golf, you must learn, by endless practice, a continuous and subtle series of highly unnatural movements, involving about 64 muscles, that result in a seemingly “natural” swing, taking all of two seconds from beginning to end.’

An avid club golfer with a handicap of 4 and a right-handed stroke asked for assistance with his nagging L shoulder pain that had recently become markedly worse and finally was threatening to stop him playing. He explained he knew he must have asked for help sooner, but he believed it would just go away (one of the most commonly heard statements by treating practitioners!) and it had now been hanging around for about six months in total, despite routine training.

He explained that initially it only used to damage when he caught his chipper from the grass and disrupted his follow-through, but now if he used an iron he'd feel a sharp pain unless he happened to stroke the ball flawlessly. It would also ache when he slept on the side, and after playing a full round it ached for some days. He had tried a million stretches and even appeared quite flexible with specific movements around the shoulder. In addition, for some years he had battled with R low- back pain and anterior hip pain which, when really bad, would render him limping a couple of days after an 18-hole round.

Assessment

Evaluation showed all the signs of rotator-cuff tendinitis (inflammation and microscopic breakdown of tendon), together with accompanying weakness of the muscle itself, leading, over time, to excessive anterior translation of the head of his humerus (extra shearing of the ball in his socket joint) on follow-through. This would likely cause an impingement of his already thickened tendon beneath the rectal acromial arch of the shoulder, giving him the sharp stabs of pain he complained of more lately.

His standing posture gave us the most clear clues as to why this had evolved, without ever needing to video his stroke biomechanics: rounded shoulders and a very noticeable low- rear arch (lumbar lordosis) are classic signs of poor postural control resulting in wrong movement patterns within his stroke. Gradually over time something needed to give often it's the non-dominant arm.

Had he had been middle-aged, we may have X-rayed his shoulder to search for any calcification of his tendon (he'd just turned 30), and only if progress wasn't going well would we believe doing an ultrasound scan to find out the size of scarring and limb breakdown.

Treatment

Rehabilitation could have a month or two if all went according to plan the key unknown factor is how well he'd take on the challenge of holding his shoulders and pelvis differently; this re-education procedure is frequently the most difficult. The general treatment procedure will first entail improving flexibility so that appropriate posture positions can be held most of us get stiffness in a number of our joints because of gravity wrecking our great posture.

Recent improvements in sports physiotherapy have enhanced the speed of the process significantly. Aside from a systematic stretching regime from the patient, we 'release' muscle tightness by deep-tissue massage and trigger-point treatment, heat, a home program of self-pressure massage with a tennis ball, and mobilizing of the tight parts of the capsule of the shoulder with seat-belts. Tightness in the posterior rotator-cuff muscles of this specific patient took a lot of effort to workout, and lat dorsi and pec major/minor were also big players.

Additionally, he had considerable stiffness in his thoracic spine, particularly with L rotation, which was worked loose, as were certain gluteal and hip-flexor muscles.

The Next Two Phases

Secondly, postural muscles needed to be 'turned on', ie recruited correctly, and a schedule of gradual strengthening of their ability to restrain the joints to which they're responsible began. In this instance the crucial ones were the lower and mid trapezius and transversus abdominus muscles we also taped up them sometimes to help him remember to continue using them, until it became more habitual.

Around this time, pain has gotten less and less of a problem along with his postural control was growing nicely. He was able to come back to his coach and start utilizing the positional changes in his stroke, slowly increasing the stroke distance and frequency and all the while maintaining his flexibility with the tennis ball. This third phase, which entails integrating the right posture into the stroke, has to do with the coach, and requires substantial discipline on the part of the athlete to ensure he remains inside the realms of what his brand new system can tolerate without being overloaded. Because he can still overdo it!

All went well, with all the golfer reaching one of his best-ever scores in the Queensland Open Tournament three months later. However, two weeks after that he dived badly in a game of rugby and twisted the exact same L shoulder and ripped the exact same rotator-cuff tendon he'd worked so hard to fix. Back to the chiropractor.

Sports fitness & injury chiropractor, Dr. Alexander Jimenez suggests additional exercises that will assist you avoid shoulder pain.

The functional anatomy of the shoulder an the way the weakness at the rotator cuff and an inability of the scapula to stabilize the shoulder are the significant contributors to shoulder impingement injuries. Three important exercises for strengthening the rotator cuff and approaches to boost scapula stabilization. This article provides more exercise suggestions and provides further practical tips to help athletes prevent shoulder pain.

1. Balance Your Upper-Body Workouts

A good way to prevent shoulder injuries is to ensure that your upper-body strength sessions are more balanced. This means that every push or press exercise must be balanced using a pull or row exercise. Too many athletes and weight trainers focus on creating the 'mirror muscles', the upper trapezius, anterior deltoid and pectorals. As a result, the 'non mirror- muscles', lower trapezius, rhomboids, latissimus dorsi and rear deltoid, are underdeveloped. This also contributes to a muscle imbalance in the shoulder, which results in poor scapular stabilization because the non-mirror muscles are those that function to stabilize the scapula. Moreover, over developed mirror muscles may lead to some round-shouldered position, which wrongly places the scapula up and forward. Redressing this imbalance is quite vital for the prevention and rehabilitation of shoulder impingement injuries.

The following is a good illustration of a balanced upper-body workout which I would recommend.

Note the 1:1 ratio between push/press and pull/row exercises.

For those who are more prone to shoulder pain or are recovering from a shoulder injury, then I would advise changing the ratio to 2:1 in favor of the non-mirror muscles. Remember, it is the push/press exercises which cause the problems, so you need to change your accent before the imbalances have been redressed. Additional pull/row exercises include: bent-over row, single-arm dumbbell rows, single-arm cable pulls, bent-over rear fly, pull-ups (wide or narrow), stiff-arm pull-downs with cable/flexaband.

2. Limit Your Range Of Movement, & Take It Easy

Rehabilitation from a shoulder impingement injury should focus on rotator-cuff strengthening. But it is important to remember that when it comes to re-introducing your own weight-training exercises, you must progress slowly. Frequently this implies avoiding specific ranges of movement where the shoulder joint sub-acromial space is compressed the most. The impingement zone to avoid is between 70 and 120 degrees of shoulder abduction (when you move the arm laterally away from the side of the body).

To start training the non-mirror muscles, start with the seated row, since the shoulder joint is not abducted in this workout. Once the pain is totally gone, then introduce the overhead exercises for example pull-ups and lat pull-downs. You ought to be even more careful when it comes to the mirror-muscle exercises. I'd avoid lateral raises, upright rows and shoulder presses completely for a while. But, incline bench press with arm abducted to 45 degrees are a great place to begin again. Slowly build up to the normal bench-press range as strength improves.

It is also crucial that you don't increase your weights too soon. Bear in mind that the tendons and ligaments need to accommodate to exercise as well as the muscles, and they may take longer to do so. I'd suggest staying in the 12-20 rep scope for a while before pushing up the weights, particularly with the mirror- muscle exercises. While I realize that it is important for many athletes to be powerful at exercises such as the seat and shoulder press, I would advise that you develop gradually to maximum advantage. Reducing your reps by two every 2 weeks is a fantastic guideline. During heavy workouts, ensure that you warm up the shoulder joint and rotator cuff thoroughly prior to lifting.

3. Correct Scapula Positioning When Performing Exercises

The appropriate position for the scapula (shoulder blade) is back and rotated down. Essentially, this means maintaining a great 'military posture', together with shoulders back and chest out. A round- shouldered or hunched posture is to be avoided at all times.To achieve the right position, you need to use your rhomboids, mid and lower trapezius muscles to retract the shoulder and pull the scapula down.

When you do any upper-body weight-training exercise, always get into the habit of starting with good upper-body posture and pinching the shoulder blades together. You need to feel that the scapula is a good platform which keeps the shoulder properly positioned as you do the exercise. As mentioned by Dr Kemp, a fantastic way to learn the correct position is through the seated row exercise by keeping your scapula down and back while you move your arms. Throughout the exercise, you should believe that the rhomboids and trapezius muscles have been statically contracting to maintain the scapula set up, and the latissimus is working to carry out the movement. After you have the feel for maintained scapula stability during the seated row, try to achieve it during all upper-body exercises. What you may find is that exercises such as the press-up or front raise, in which the shoulder may become impinged, won't be painful if you stabilize your scapula correctly. In effect, by using the scapular muscles you can achieve better shoulder mechanisms and avoid injury.

Correct scapular stability is hard to learn and demands a lot of concentration and practice during your training sessions. First you need to understand what the correct position is, and frequently this needs a trainer/physio to guide you. Then, during training sessions, instruction and observation from a trainer can help you reach and maintain the right shoulder position.

4. Sports-Specific Exercises Plyometrics For The Shoulder

Just as rehabilitation training for leg injuries needs a functional progression from simply strength exercises to sports- specific exercises, so does rehab for your shoulder. This means that for the athlete, eg a thrower or tennis player, conventional resistance exercises at the gym might not be enough to allow a full return to competition. Often what is needed to bridge the gap would be plyometric exercises for the shoulder that mimic sports- specific movements. Plyometrics for the shoulder usually involve medicine balls of different weights.

Plyometric exercises have two advantages. First, they're performed fast, and second, they demand stretch-shortening- cycle movement patterns. This means that they are much more sports-specific than traditional resistance exercises. Specifically, plyometric exercises for the rear-shoulder and external rotator muscles are extremely useful since they provide eccentric training for these muscles. This enhances their ability to control the shoulder through the potent concentric actions of the pectorals and anterior deltoid involved in throwing or serving. Thus it's important to ensure that your plyometric workouts are balanced between the prime movers (pectorals, latissimus, anterior deltoid) as well as also the rear-shoulder and upper-back muscles. I would recommend incorporating shoulder plyometrics through general conditioning exercises to prevent injuries and in the later phases of shoulder rehab to guarantee a functional progression back to competition.

Here are two suggestions. The key to both these exercises is that the medicine ball is caught, the impact quickly absorbed (fast eccentric phase) and then thrown back explosively (powerful concentric phase).

For athletes who rely on their shoulders, here are the five major guidelines for maintaining them injury-free. Shoulder chiropractor, Dr. Alexander Jimenez assesses the data.

There is not any joint in the human body as complicated, intriguing, or bothersome as the shoulder. It can leave clinicians scratching their heads, wondering why a problem they've solved several times before is this time so stubborn. And shoulder problems can surely be stubborn! That's why, in every case, prevention is indeed much better than cure. Rarely is a pain which has surfaced a very 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 hasn't given a second thought to, or it's ever-present in their minds -- it is either no problem, or an issue they cannot dismiss. It has been stated that the design elements which compose the shoulder are either close to perfection, or close to disaster! Now, of course, this greatly depends on the sport you're in: cross-country runners are unlikely to possess the shoulder difficulties that javelin throwers or swimmers may encounter. But it is uncommon for athletes using their shoulders as part of the main routine to not take at least a little pain, while others possess a background of a substantial shoulder problem.

This report takes a good look at the big picture of shoulder injury management, and tries to empower and instruct athletes with a few DIY home injury prevention and performance enhancement techniques. It presents, some complex concepts, and is therefore in no way an exhaustive explanation or listing of exercises.

Preliminary Precautions

If you have a shoulder injury and would like to try and treat yourself, please bear in mind:

Treatment, Prevention & Performance Enhancement

The information that follows describes the prevention and treatment for overuse injuries of the shoulder, not the management of traumatic or acute accidents 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 not any different, although there could be limitations and time constraints imposed by orthopedic surgeons.

The most important principle of shoulder management is: start working on it now. Don't wait until your shoulder starts to hurt!

However, moreover, the preventative steps outlined below are sure to improve performanc they will really improve the way your shoulder operates, and consequently it will be more powerful, more coordinated, and reach farther and last longer befpre fatigue sets in. All the experts say it: injury prevention equals performance enhancement.

Some Simple Anatomy Of The Shoulder Complex

The shoulder joint really comprises four joints -- see If You're able to feel them on your own:

The Rotator-Cuff Muscles

Without learned muscle control, any overhead action, let alone just lifting the arm, could be hopeless -- that the GH joint could dislocate or the HOH would jam under the arch of the acromion. The muscle group we all rely on for this control is your rotator-cuff (RC) muscles -- the infraspinatus, supraspinatus, teres minor, and subscapularis muscles (a body book will reveal where they lie). All of them arise in the scapula and are coordinated together to keep the HOH spinning/rotating as near 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 perform together with the RC, especially with the throwing action.

The muscles primarily designed to place the scapula for overhead motion are the trapezius (notably lower trapezius), and serratus anterior -- called therefore the 'scapular stabilizers' -- with counter forces being produced by levator scapulae, rhomboids and pec little muscles.

The larger and more powerful muscles that create motions of the arm are the deltoids, latissimus dorsi, and pectoralis major. So whereas the RC muscles organize the proper positioning of their HOH by acting near the centre of the joint (the 'inner core'), then the larger muscles with long lever arms move the arm with speed and force (the 'outer core').

The Five Guidelines: Balance Through Control

Let's sew what might be considered the five most essential ingredients for an athlete whose main weapon is the shoulder:

1. Sports-specific technique.

2. Flexibility.

3. Core stability.

4. Rotator-cuff control.

5. General strength.

The primary objective of these five regions of intervention is, in a word, balance. And the way to achieve it? Control. The higher your levels of functionality, the larger the control required to maintain equilibrium -- 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 trigger muscle imbalances to grow, which lead to soft-tissue breakdown and after even joint degenerative change. Picture a bike wheel in which one spoke in the wheel has been bent out of shape: a slow warping happens using use which creates an imbalance which further damages other spokes before the whole system comes to a grinding halt.

The more elite the athlete, the more committed he/she needs to be to getting expert help in satisfying and keeping these fundamentals. You'll also save yourself much time and distress should you seek experienced assistance as a preventative measure, rather than only requesting treatment once the issue has surfaced. Having a regular tune up/service can be done in the form of screening, where a sports-experienced physiotherapist can conduct you through a set of tests to find out if some of the areas below are not being adequately dealt with.

1. Sports-Specific Technique

Inadequate performance and shoulder pain very commonly originate in bad habits of technique. Often they're only clearly noticed when muscle fatigue sets in. But a fantastic coach will be able to pick up if this is occurring and recognize it is time for rest and recovery.

As a general rule, technique work ought to be performed after a thorough warm-up (or even as part of a warm-up), even whereas the muscles along with the brain-connections are still fresh and strong. On the flip side, when fatigue sets in can sometimes be a great time to do specific drills that don't load the shoulder, nevertheless will fortify good movement patterns. The only proviso is that one has to be extra diligent to observe 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 about 10,000 times before it will become an engraved on your mind, in other words, the point where the motion pattern becomes subconscious and feels 'natural'.

There are many methods to discover if your technique is faulty, however one of the greatest is video recording in order to slow down the action and break it into smaller components. The better the technology, the greater the outcome, but for actual worth it comes down to the experience of the person evaluating the picture. Using a mirror is seldom effective because the position of the mind focusing on the mirror may greatly affect the shoulder posture. The two main sources of opinions in this respect are your mentor and a bio-mechanist, and often a sports physiotherapist who has had a great deal of expertise in your sport.

What Faults To Look For

The assortment of overhead motions necessary for every sport gives rise to quite subtle and unique technique flaws. The following are some examples of things to look out for:

Tennis serve/smash: inadequate trunk twisting to open up torso in cocking position, ball toss too close to human anatomy or too far behind body, cutting follow-through short by whipping racquet.

Javelin/water polo/baseball throw: side-arm activity, elbow behind the shoulder through follow-through, inadequate trunk rotation at late cocking stage to open up the torso and at conclusion of follow-through to dissipate forces following release of the object. The nearer the surface of the upper arm may follow the point of the front part of the chest, the less strain there will be about the shoulder joint, and also the longer rotation which may be harnessed from the shoulder, the less the strain on the elbow joint.

Freestyle swimming: insufficient body roll, just ever breathing to one side, catching the water too close to the midline, not keeping the shoulder blade scraped on the back during pull stage, not keeping the elbow high enough during recovery stage (a indication of insufficient flexibility).

2. Flexibility

The objective of flexibility varies for the different muscles around the shoulder. For the major power muscles, it is necessary that flexibility allows freedom of motion for your pelvis, trunk, scapula, and humerus. For your rotator cuff, the critical issue is that the balance of forces centering the mind of humerus, and to a lesser degree, liberty of motion. It's more critical that the internal and external rotators are equally elastic, rather than how flexible they may be.

A warning: to have an excessive amount of flexibility at the expense of control and strength could be dangerous due to the excessive shear forces causing wear and tear in the joint. This is very true of the glenohumeral joint at which the primary source of equilibrium are the rotator-cuff muscles functioning in conjunction with additional soft-tissue structures like the torso, ligaments and cartilage. Too much flexibility at the cost of muscle control puts strains on the soft tissues and causes injuries like rotator-cuff tendinitis and degeneration, labral tears, subluxations and possibly even a dislocation.

Do not start a flexibility program until you've seen a sports physician or physiotherapist if:

Stretching

Stretching to increase flexibility should not be done prior to competition or training, but rather done during 'down' times in the week. This is because of the suppression of the 'stretch reflex' that occurs during sustained passive stretching of muscle tissue (ie repeated holds of 20-30 minutes). If you were to perform rapid forceful movements like throwing straight after such passive stretching, there could be an increased chance of muscle and tendon tears. For flexibility every muscle has to be stretched a few times in 20-30 seconds each, and repeated three to four times per week.

The most important areas for regular flexibility sessions are:

● Infraspinatus/teres minor (posterior rotator cuff and capsule).

● Pectoralis major/minor.

● Latissimus dorsi.

● Biceps/triceps.

● Thoracic spine (between shoulder blades).

● Upper trapezius/scalenes/levator scapulae.

● Gentle nerve extending (oscillations).

The perfect way to understand how to stretch the above areas is to be taught by a sports physiotherapist, sports conditionist or private coach.

It is important not to stretch the ligaments of the shoulder, which in due time may lead to laxity of the joint and potential instability. The most common case I see? Athletes stretching their pec muscles and ending up with their arm supporting them against the wall, but with their shoulder rolled forward, feeling the stretch onto the front of the point of the shoulder.

What is being stretched here are the anterior ligaments ('capsule'), not the muscle, which can be better stretched by pulling the scapula back and twisting from the trunk away from the shoulder (hands still on the wall). One then feels the stretch far more down to the chest area where it ought to be.

Warm-Up Practice & Theory

The shoulder ought to be warmed up thoroughly with gradually increasing movements -- large circles, across-body movements, back twists, shoulder-blade rolls and forward and backward squeezes. The objective of this is to increase blood circulation and temperature, thus increasing the elasticity and 'contribute' from the soft tissues. A streak of short-duration stretches (ie five to ten seconds) of all the major muscle groups should follow and then eventually a session of more sports-specific drills. These are utilized to heat up the brain's connection to the muscle, ie to fortify correct motor patterns, and also to place the right neural reflexes from the muscle.

Massage

One of the most essential features of massage is to decrease the build-up of 'trigger points' -- regions in the muscle which literally grab up due to excessive loading. This might make a muscle imbalance or be the result of one -- either way it must be 'published' via massage. Each of the muscles described above which are necessary to stretch are vulnerable to activate points and may become tight and/or feeble because of them. It is not unusual for a trigger point to develop in the muscle as the initial structure to start breaking down, gradually dragging different muscles, nerves, and the glenohumeral joint down into a cycle of inflammation and pain.

The best way to begin is to get a hard tennis ball to perform your massage with, then try these two ideas:

Pectoralis minor/ major 'release': This is a important muscle to keep loose since if becomes too tight, it binds the scapula forward, leading to the head of the humerus being thrown off centre, especially in overhead positions. Hold on the tennis ball into the soft muscle overlying the chest directly at the front part of the shoulder. Lean towards a door frame and allow the tennis ball to press against it, with the same side arm halfway up the wall, palm facing towards the wall. Look for the tender trigger points, and when you find you, 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 overactivity of the infraspinatus and teres minor, the net impact of that can also be to push the head of the humerus forward from the centre of rotation. Hold a tennis ball into the rear 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. Let it dig deep!

3. Core Stability

Core stability has come to be a whole science in itself in the last decade since all manner of sports professionals have realized just how crucial it is for the inner core of the human body, particularly those joints nearer to the backbone, to be encouraged from the postural muscles designed to achieve that. For your shoulder, the essential areas are the lumbar and cervical spine, and the scapulothoracic joint. If these areas aren't secure, then significant extra loading and strain will be passed on into 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 when tensing the lower-back muscles slightly activates the 'corset'. The cervical spine is stabilized by the upper cervical flexors in conjunction with the lower cervical extensors, to attain a 'tall' neck posture with the eyebrow slight drawn into the neck. Keep in mind that this can be easier for some than others, based on how your system has been trained -- for example, ballet dancers will come across the stable position of the neck comes naturally, rugby players may not. Activating the muscles is the first stage of the learning process; training the position till you are prepared to integrate it into simple movements that are relevant to your sport.

The scapulothoracic joint is the most important '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 accountable for its stability would be the trapezius muscle (especially its own middle and lower fibres) behaving together with the serratus anterior muscle -- together they act to hold the scapula at a neutral position whether the arm is from the side or over the head. The neutral position is where the glenoid socket is most ideally orientated for the rotator cuff to control the HOH .

Imitate The Action Of The Seal

Bear in mind 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 these high levels of balance are being utilized when we perform overhead activity!

Deficiencies of core stability are always found with chronic shoulder injuries, or after surgery or injury, because pain will inhibit the postural muscles so they cannot do their job correctly.

The way to activate the lower trapezius/serratus anterior muscles would be to sit at a relaxed tall position, arms relaxed across your thighs. Gently pull the inner boundaries of your scapula together and down with the minimum of work, and hold it there for 10 minutes. Do not pull too far back or you may over- activate other muscles which are not meant to be the primary core stability muscles -- it is always a delicate and relaxed activity using a 10-second hold. When you have practiced this for a couple of days as frequently as you can, experiment with 'setting' your scapula into the neutral position with your arms out to the side, along with your arms on your hips, up behind your mind, etc..

Once you have mastered the 'setting', add small movements of your arm when holding the established position, and slowly over a few weeks you can increase the sophistication, speed and loading of your arm. Finally you're doing the setting in precisely the exact same time as you are carrying out the rotator-cuff strength and control exercises explained below.

4. Rotator-Cuff Strength & Control

The rotator-cuff muscles are all determined by the great positioning of the scapula for successful management. If the scapula is angled too far forward or downward, for example, while the tennis player reaches overhead to smash, the RC muscles are biomechanically disadvantaged and may neglect to maintain the HOH centered. The role of the RC muscles therefore is to keep the position of this HOH whereas the prime mover muscles create power.

As you enhance your scapular management, the RC muscles can act more effectively and independently of the scapular control muscles. That's to say that you should have the ability to hold the scapula quite still in the neutral position while you individually move your arm. This ability is known as 'glenohumeral dissociation'.

Thus with each of the exercises following, it's presumed that the scapula is being held as close as possible to neutral:

5. General Muscle Strength

When the foundational issues of technique, flexibility, core stability, and rotator-cuff controller are being executed, we have to take a look at the larger picture of this 'outer core'. What is the rest of your body like -- does it help or hinder the functioning of your shoulder?

In every sport that relies heavily on the shoulder, it is vital to view it as merely one link in a 'kinetic chain' -- all the other connections must also be adequately developed to aid in the growth of rotary torque or the shoulder will be overloaded. There is a 'winding up' and an 'unwinding' which takes place at a quick speed starting from the legs, progressing through the hips, pelvis, lumbar spine, thoracic spine, shoulder, elbow, and wrist. And each must be educated to absorb its fair share. Golf is your classic game to use as a very clear case of this transfer of rotary power -- a succession of wind-ups finally being unwound since the stable base of this hips whips back into the opposite direction.

To this end there is a whole segment that may be written on the value of plyometrics, the exercise science involved in harnessing the eccentric strength of muscles to get increased power. The rotary energy of the human body is greatly strengthened by developing the eccentric contraction power involving the kinetic connections 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 function for the deltoids (three heads), latissimus dorsi, pec major, upper trapezius, and the rectus abdominis since they are the prime movers of the shoulder. Frequently what is critically overlooked, however, is the imbalance which could develop between the front part of the shoulder and the back.

In those athletes which are carrying an overuse injury at the shoulder, nine times out of ten they have overdeveloped pecs and lats comparative to their trapezius, rhomboids, posterior deltoids, and posterior rotator cuff. In these scenarios, flexibility must frequently be enhanced, scapular setting must be taught, and also the focus of gym exercises changed in the direction of the back. Seated and vertical row, barbell flies to the back, seat pull, and lat pull-downs with the bar behind the head are all exercises that must take higher priority.

Throughout all gym work it must be stressed that scapular setting along with the activation of core stability muscles to get good posture are vital for injury prevention.

Summary

So there we have it -- that the big picture of injury prevention and performance enhancement for athletes who rely on their own shoulders for playing their sport. Decide today which among these issues you may need some more work on, try some of the house exercises, and possibly seek out expert assistance to maximize the results of your efforts.

A 35-year-old man with what his sports physician described as "left periscapular pain of unknown origin." The sports doctor was hoping that a physiotherapy test and subsequent treatment would settle the symptoms. Chiropractic injury specialist Dr. Alexander Jimenez investigates...

This gentleman had a 15-year history of work from the sheeting department of a local hardware store. His job took him to lift and load on to trucks around 200 plasterboard sheets daily. The store man was also an energetic outrigger canoeist, currently in heavy training for an upcoming long-distance event.

In outrigger canoeing six paddlers sit at a 14m canoe built of Kevlar, graphite and S glass (a magnesiaalumina- silicate glass with high tensile strength). The kayak design comprises an elongated arm (the outrigger), which helps to balance the canoe in open water. The canoeists use 4--5ft paddles, and possess a specific paddling sequence where they change sides every 15--20 strokes.

He described a vague persistent pain in the left periscapular area proximal to the medial edge of the scapula (ie, only by the long border of the shoulder blade close to the spine). The pain was severe enough to be preventing him from sleeping through the night.

Upon questioning he stated he thought the pain had been mildly gift for the best part of ten years. Employer records confirmed that he had complained of a similar pain seven decades before but had chosen not to seek treatment, having thought that the symptoms in the time to be too gentle for any intervention. However, the symptoms had lately become far more acute -- to the point where he could no longer physically carry the plasterboard sheets at work.

A few days prior to visiting me, the store guy's symptoms had significantly slowed following a lengthy paddling session (20km). The final straw came in the close of the session when group members had to carry the 145kg canoe about 50m to load it on into the back of a trailer. He had been carrying the kayak with his left hand and the pain radiating from his mid spine area had become excruciating. He decided to take illness leave out of work and cease all of his coaching.

Upon examination, I could see that he had a very long and gloomy left scapula, with hypertonicity (overdevelopment) in the left posterior shoulder muscles and right-sided paraspinals. The costo-transverse joints of the third to seventh ribs on the left side were especially hypomobile.

All active motions of the shoulder and cervical spine were normal selection and all of the muscle tests round the shoulder and cervical spine seemed to offer normal results. The customer described no history of significant left knee or cervical spine injury or injury.

He demonstrated that the lift and carry technique he was using with all the plasterboard sheets. He also carried the sheets on his left side with his left arm fully externally rotated and elbow in extension so he could hold the base of the sheet. This activity seemed to force his scapula to a depressed and protracted position. He would then elevate the right arm above his head to hold the top of the sheet. In this manner he can "hang the sheet off his left arm, together with his right hand to balance it.

On palpating the offending area, I found he had two spots of exquisite tenderness. The first was just under the medial edge of the scapula; the second on the rib angle of the fourth or fifth rib. Due to the severity of his symptoms, the night pain and point tenderness about the rib angle, I called him to get further investigation (x ray and bone scan) to rule out any stress fractures of the rib.

The x-rays came back negative, so I guided my therapy at mobilization, muscle energy techniques to address the rib hypo-mobility, and soft-tissue therapy and acupuncture for the rhomboids, back shoulder and upper trapezius. Following two weeks my canoeist showed no improvement in symptoms and his night pain continued. I referred him for a CT scan to rule out degenerative changes in the thoracic spine, costo-transverse or costo-vertebral joints.

So two weeks farther on, without a clear diagnosis and no actual improvement in symptoms, I routed the store guy for an MRI scan to rule out any additional soft-tissue harm to rhomboids or middle trapezius, and to investigate the cervical spine to exclude virtually any radiculopathies in that area that might mimic soft-tissue injury in the periscapular area.

After consulting with the referring doctor, we all agreed that the store man could vanish for a while off on a much needed holiday. I sent him off with directions to self-manage the injury, using a tennis ball to the rhomboids, a thoracic roller to mobilize his thoracic spine and some scapular-setting/ stabilization exercises.

He returned three weeks later (seven months after his initial trip to the clinic) at exactly the exact same state as when he'd left. Client and physiotherapist both being exasperated with the lack of progress, we decided to take the plunge and see whether the sports physician could diagnostically block the pain, with a regional anesthetic infiltration.

The sports physician palpated the painful place thoroughly and determined that the most tender stage was the spot under the lateral border of the scapula, which he believed corresponded to tendon material of their rhomboid. Miraculously, the pain at the periscapular area fully disappeared with the local anesthetic -- despite there was no evidence of degenerative or inflammatory modification on the MRI. The physician followed this up with a corticosteroid injection in the same spot.

Fourteen days after the patient was ongoing to become symptom free so we began a progressive rehabilitation program to re-strengthen that the rhomboids and proceeded to handle the thoracic spine and rib joint hypomobility. Following six weeks (16 months from initial presentation), he returned to perform and paddling, and although perhaps not 100% symptom-free, was able to resume sheet- carrying at work and was back into paddling long distances without any ill effects.

An Unusual Tendinopathy?

Even the rhomboid muscles (minor and major) are described as strong retractors and downhill rotators of the scapula. There is very little from the literature on pathologies affecting the rhomboids, which makes it apparent that these deep bending shoulder muscles are not often injured in either sporting or occupational environments. This case shows that the rhomboid muscle and its bony scapular attachment can be just as vulnerable to pathological tensile and compressive loading as other more common culprits (like Achilles tendon), provided the right mixture of repetitive and traumatic stress.

For me this was an extreme blend of occupational and sporting stress that had led to an isolated instance of "rhomboid tendinopathy , although the exact origin of the pain still remains a mystery, as nothing ever showed up on the MRI. Perhaps the magnetic strength of the MRI (1.5 Tesslar) was not powerful enough to pick up high signal density at the rhomboid tendon, or perhaps that the MRI results returned as a false negative, a case occasionally seen in chronic patellar/ Achilles tendinopathies.

It seems that the recurrent protraction and melancholy of the scapula brought on by carrying and holding heavy plasterboard sheets over many years -- and exacerbated by the repeated action of the paddling -- had contributed to an inflammatory or degenerative process in the thoracic and attachments of the rhomboid muscle on to the scapula. Upon release the individual still exhibited a somewhat protracted and gloomy scapula. It is likely that this imbalance may never be completely solved with the scapular retraining exercises; the protracted period of time that his scapula was subjected to the unbalancing forces could have led to permanent length-tension changes from the rhomboids and upper trapezius.

Science based therapist, Dr. Alexander Jimenez looks at the several types of SLAP lesions, a few frequent clinical indicators, orthopedic evaluations and explores the very best rehab methods... 

Overhead athletes (like baseball pitchers, tennis, swimming, water polo and throwing athletes). All put enormous strain on their shoulders when participating in their chosen sport. An elite baseball pitcher's arm was listed at over 7000deg/second which puts it arguably as the fastest human body movement in game. This all happens at a joint that's been likened to a golf ball sitting on a tee -- ie it is structurally unstable. Considering all of this, is it any wonder that shoulder pain is a common occurrence in the overhead athlete? Throwers with shoulder pain will often complain of a "dead arm" which restricts them from throwing at pre-injury velocity/or control. SLAP (Superior Labrum Anterior-Posterior) lesions are common causes of this "dead arm" and will be the focus of this article.

What Is A SLAP Tear?

What Is The Mechanism Of Injury?

The exact mechanism still remains controversial with three major theories present. The deceleration theory initially proposed that in a throwing athlete a SLAP lesion happened during the deceleration phase of projecting as a result of eccentric contraction of the biceps tendon(7). They suggested that this overloaded the biceps anchor that detached it from its intra- articular attachment. A direct blow to the shoulder has also been believed to be a cause for a SLAP lesion -- for instance, an athlete landing in an outstretched arm might compress/pinch the labrum between the glenoid and the humerus(1). More lately, Burkhart described the acceleration or "peel back mechanism" which occurs when the arm is at the cocked position of abduction and external rotation. They explained that during arthroscopy in shoulder abduction and external turning the thoracic fascia presumes a more vertical and posterior angle which generates a twist at the bottom of their biceps and a torsional force on the anterior superior labrum(1).

Kuhn experimentally compared the deceleration and acceleration theories in cadavers models(1). They applied a brute force to the biceps tendon from the follow through place and were able to generate a superior labral avulsion in 20% of his specimens with a massive push. To simulate the peel back mechanism they placed the arm at an abducted and externally rotated position. In 90% of the shoulders analyzed, they could create a type 2 SLAP lesion with 20 percent less force than at the deceleration version. From this it can be proposed that the peel back mechanism is more likely to cause a SLAP lesion than the deceleration model and that the bicep tendon is not pulled but peeled from the bone.

What Is The Clinical Presentation?

Subjective

Objective

Standing Posture

Ordinarily, overhead athletes with SLAP tears will have poor scapula position at rest on their dominant side: Figure 2 shows inferior scapula position in a right-arm thrower. Burkhart explained this asymmetrical scapula position as with a SICK (Scapular malposition, Inferior border prominence, Coracoid pain and dysKinesis of scapula motion) scapula(3). It is also important to note thoracic posture, as increased kyphosis and lack of trunk rotation can also increase load on the shoulder when throwing.

Shoulder ROM

Active ROM of the shoulder must then be assessed to ascertain any motion restriction or pain. Glenohumeral rotation range ought to be assessed in all overhead athletes. A thrower's shoulder needs to have enough laxity to allow for excessive external rotation (demand of good throwing) with adequate dynamic stability to avoid subluxation. Glenohumeral rotation array is conventionally done in supine with the arm in 90-degree abduction. Commonly these athletes will get an increase in external rotation range (possibly due to repetitive stretching of their anterior capsule at the cocking phase and/ or humeral retroversion when they threw a lot if they were young) and a drop in internal rotation range. This absence of internal rotation range is frequently due to contracture of the posteroinferior capsule contracture and is popularly known as GIRD (Glenohumeral Internal Rotation Deficit). Sleeper stretches (see Figure 3) have been demonstrated to not only reduce GIRD but also to reduce shoulder injuries by around 40% in major league baseball players(1).

Treatment

A Case Study

Shoulder injuries in the throwing athlete would be initially managed with conservative therapy with therapy focused on improving GIRD and/ or scapula control. In most cases the whole kinetic chain should be assessed and proper exercises should be implemented based upon the requirements of their game.

Figure 2 reveals a cricketer who bowls and throws with his right arm. When I first saw him, he complained of pain and "fatigue" in his shoulder when he bowled and threw from the boundary. He also had pain through range on abduction, which resolved if his scapula position was fixed (posterior tilted). He had no reduction of glenohumeral range on his right side. In this case (because of the success of posteriorly tilting his scapula on his pain through the evaluation) treatment focused on lengthening techniques of the muscles that anteriorly tilt his scapula, ie pec minor, and strengthening for his lower and middle trapezius that help to posteriorly tilt his scapula. This player was given a range of exercises in prone to improve his scapula position (see Figures 10 - 11).

His pain improved over a four- week period and he is now able to throw in the boundary without any signs.

Conservative treatment isn't always effective especially if a type 2 SLAP lesion is current. In such cases operative therapy is required and the athlete can take 9-12 months to return to sport and they'll report that it requires up to two years to go back to their pre-injury level.

Conclusion

In summary, SLAP lesions are typical in the overhead athlete and a structured evaluation particularly looking at scapula control, glenohumeral rotation range in addition to orthopaedic tests can help to identify when a SLAP lesion is current and will also help direct therapy. Frequently in elite-level athletes, particularly when a type 2 lesion is present, surgery is needed(4).

References
1. Burkhart S, Morgan C, Kibler B (2003) The disabled throwing shoulder: Spectrum of pathology, Part 1: Pathoanatomy and Biomechanics. Arthroscopy: the Journal of arthroscopic and related surgery, Vol 19, No4, 404-420
2. Burkhart S, Morgan C, Kibler B (2003) The disabled throwing shoulder: Spectrum of pathology, Part 2: Evaluation and treatment of SLAP lesions in throwers. Arthroscopy: the Journal of arthroscopic and related surgery, Vol 19, No5, 531-539
3. Burkhart S, Morgan C, Kibler B (2003) The disabled throwing shoulder: Spectrum of pathology, Part 3: The SICK scapula, scapula dyskinesis, the kinetic chain and rehabilitation. Arthroscopy: the Journal of arthroscopic and related surgery, Vol 19, No6, 641-661
4. Brukner P and Khan K (2012) Clinical Sports Medicine 4th edition McGraw Hill
5. Krupp R et al (2009) Long head of bicep tendon pain: differential diagnosis and treatment. Journal of orthopaedic and sports physical therapy Vol 39, no 2 55-70
6. McFarland E, Tanaka M, Papp D (2008) Examination of the shoulder in the overhead and throwing athlete, Clinical Sports Medicine 27, 553-578
7. Myers T et al (2005) The resisted supination external rotation test; A new test for diagnosis for SLAP lesions, the American Journal of Sports Medicine, Vol 33, No9 1315-1320
8. Ryu J, Pedowitz R (2010) Rehabilitation of bicep tendon disorders in athletes. Clinical Sports medicine 29 229-246

Swimming is renowned as a fantastic all-round sport with a low risk of injury -- but this doesn't equate to 'no' danger. Scientific chiropractor, Dr. Alexander Jimenez looks at what the current study has to say.

Swimming is a really low-impact sport where the loading is spread across a wide range of muscles and joints: hardly surprising, therefore, that it is often recommended since the low-injury threat sport for a vast range of participants. However, the low-impact nature of swimming does not signify that swimmers -- especially aggressive swimmers -- are immune from injury risk.

A glance at some numbers shows why: in a typical two-hour swimming session, an elite-level competitive swimmer could normally be anticipated to swim between 5,000 and 6,000 meters. This soon mounts up, with many competitive swimmers clocking up an average yearly mileage between between 20 and 40 kilometers -- that the aerobic equivalent of conducting 80 to 160 miles!

Broken down to limb movements, the figures are even more startling. On a typical training day, an elite swimmer can be expected to perform between 1,500 and 4,000 stroke cycles, which equates to anything up to 1,000,000 stroke cycles per training year(1,2). And because female swimmers, normally, have shorter arm strokes, they can execute an additional 660,000 stroke cycles per year -- ie over a 1.5 million annually(3)!

The causes of shoulder pain (that we'll look at in more detail later) are multifactorial but include the athlete's gender, their swimming experience, training space, stroke choice and workout intensity, the total amount of hand paddle use (that increases loading), and their upper-body strength and flexibility, and of course their prior trauma history(4,5).

Prevalence Of Shoulder Pain

Since then, other studies have looked into the incidence of shoulder pain among swimmers. A 1998 survey by McMaster and his colleagues looked at the correlation between shoulder laxity (see Box 1) and pain that interfered with instruction in a sample of competitive swimmers(7). It found that 35 percent of senior federal and Olympic swimmers experienced shoulder pain which prevented them from training efficiently. Other studies have variously noted that shoulder pain is the most frequent esophageal injury in swimmers, with a reported prevalence of between 40 percent and 91%(8-13).

Meanwhile, a 2012 study looked in the risk factors associated with shoulder pain and disability throughout the life span of competitive swimmers(16). The swimmers answered questions about any other game they participated in and the quantity of swimming training they played on a weekly basis. Data was also gathered about the amount of months per year that they practiced and the number of years they had engaged in competitive swimming.

This information was subsequently correlated with the amount of shoulder pain that the swimmers experienced and how much Feedback this caused them. Pain was rated in rest, with regular activities (eating, dressing, bathing etc), and with strenuous pursuits. The DASH sports module instructs participants to rate four objects (physical ability with sport technique, participation, satis- faction, and frequency), using a five-point scale, with '1' indicating no difficulty along with '5' signaling unable to participate within the last week.

Furthermore, several of physical steps were taken, including:

When the data was examined, several findings emerged. Primarily, it was clear that the issue of shoulder pain was very common indeed. Twenty-one percentage of swimmers aged 8 to 11 decades, 18.6% of swimmers aged 12 to 14 years, 22.6% of high school swimmers, and 19.4 percent of masters swimmers had shoulder pain and disability. Of these, high school swimmers were the most symptomatic and incurred the greatest load in terms of hours swum a week and annually. Across all age groups, shoulder pain issues and disability increased with enhanced upper extremity usage -- either via swimming or water polo. Meanwhile, participation in another game -- particularly football in youngsters and walking or running in older swimmers -- diminished the amount of shoulder pain and impairment.

The predisposing variables towards pain were not the same across all age groups; symptomatic swimmers who were less than 12 decades old tended to have diminished shoulder versatility, feebleness of the middle trapezius and shoulder internal rotators and latissimus dorsi tightness. By comparison, symptomatic swimmers that were 12 years of age or older tended to have pectoralis minor stimulation and decreased core endurance.

Shoulder Pain Causes

As was mentioned earlier, the reason behind shoulder pain in swimmers is very often multifactorial and includes(17,18):

However, to fully appreciate the stresses experienced in the shoulder region area, it's helpful to break down the biomechanics throughout the stroke activity. The front crawl is the fastest and most efficient stroke through the water, which is why it is universally used in a diverse assortment of contest environments like pool swimming pool, open-water swimming and triathlon. It's also the stroke most utilized during exercise swimming sessions. Figure 2 shows the four stages of the front crawl stroke, the position of the shoulder in every stage, and then muscles are all loaded. What's apparent is that even with near flawless stroke procedure, there's ample opportunity for a shoulder injury to develop.

Impingement, Fatigue & Laxity

Impingement -- Shoulder impingement in competitive swimmers is usually brought on by altered kinematics because of muscle fatigue or laxity instead of pathological changes, which can be observed in other patient populations. Subacromial impingement can occur when the bursal surface of the rotator cuff impinges from the anteroinferior acromion.

At the point when the hand enters the water, the hydrodynamic force applied on the hand by the water creates a massive moment in the shoulder joint, causing elevation of the humeral head and following impingement.

The hyperextension of the upper extremity in the late pull-through phase (submerged portion) of the stroke compels the humeral head anteriorly and moves it internally, which may aggravate an impingement when muscle fatigue is currently present.

Muscle fatigue -- Because the shoulder is an inherently unstable joint, adequate muscle strength is vital in order to maintain stability, appropriate stroke appropriate movement, and painless function. Much of the propulsive force in swimming is generated by adduction and internal rotation of the upper extremity due to pectoralis major and the latissimus dorsi muscles. Unfortunately, the training-induced adduction and internal rotation strength in swimmers can cause a strength imbalance, which leads to decreased glenohumeral stability.

The reason for this is that the teres minor muscle provides an external rotation pressure and stabilizes the humeral head in combination with the pectoralis major. The repeated contraction of those smaller stabilizing muscles during swimming makes them prone to exhaustion, increasing instability since they are less able to counteract the forces produced by the larger pectoral and latissimus muscles.

Laxity -- In most competitive swimmers, shoulder laxity with enhanced lateral movement of the humeral head could be seen(18). Although, there might be a hereditary element on the job in these swimmers, just around 20 percent of the subgroup meets the criteria for generalized ligamentous laxity(19). It's more probable the laxity increases over time as a result of continual overuse during competitive swimming. A certain level of glenohumeral laxity may be advantageous by allowing a swimmer to achieve both a body posture that reduces drag and a greater stroke length, both of which may help boost speed through the water. However, the diminished passive stability given by the glenohumeral ligaments in much more lax shoulders means that a greater contribution in the thoracic muscles is required to control the glenohumeral translation. This might cause muscle overload and subsequent muscle fatigue, with all the issues described previously.

Some common tests used to identify frequent shoulder pathologies in competitive swimmers are displayed in Table 1 below.

Shoulder Pain Prevention

As well as optimizing stroke biomechanics (see Box 2), a comprehensive program of stretching, strengthening, and endurance training ought to be considered as an essential part of each competitive swimmer's instruction program. Since musculoskeletal injuries in swimmers undergoing heavy training loads normally result from cumulative, repetitive injury, so it is critical that coaches and physicians carefully track each swimmer's training volume, intensity, and duration. This can help to minimize overuse injuries and identify people at risk.

Endurance training of the heart muscles is a vital part in any injury prevention program. Therefore, abdominal strengthening should be emphasized from the dry-land training program, the aim of which is to develop increased control of the pelvis by preventing excessive anterior pelvic tilt and lumbar lordosis, which in turn will enhance body alignment in the water.

Meanwhile, scapular muscle strengthening can also be recommended to help improve glenohumeral stability. An endurance training and strengthening program for your shoulder and periscapular muscles, with emphasis placed on the serratus anterior, rhomboids, lower trapezius, and subscapularis, may assist in preventing injuries(17). Individual swimmers should be evaluated to determine endurance, strength, or flexibility shortages.

As soon as any swimmer experiences increased shoulder pain, their training program needs to be altered accordingly:

Stretch Or Not?

Finally, it is worth mentioning extending. Most swimmers stretch but there is evidence that stretching may be more detrimental than useful(20). For example, the majority of the stretches which swimmers do stretch the lateral capsule of the shoulder. If the capsule is overstretched, the risk of uncertainty and subsequent injury increases, maybe permanently(19). Any extending, therefore, ought to be specific to the patient and designed to correct particular muscle or capsular tightness.

Because swimmers generally have a relatively tight posterior capsule, which may encourage impingement pain, swimmers without pain should concentrate on extending the posterior capsule and anterior torso muscles. To selectively extend the posterior capsule without even stretching the scapular stabilizer muscles, it is necessary to stabilize the scapula. The easiest way to do so is to stretch the shoulder while lying supine, partially rolled onto the lateral border of the scapula.

In swimmers who've kyphotic posture due to tight anterior chest and shoulder musculature, stretching those muscles without stretching the anterior capsule helps reduce the forward shoulder posture and increase the subacromial area(5). Swimmers with shoulder pain ought to be instructed to stop all anterior capsule extending and rather focus on posterior capsule extending.

Swimmers with multidirectional instability or a background of subluxation should steer clear of all extending -- notably 'spouse extending' -- because it can easily force a shoulder beyond its normal limit and promote additional anatomic damage(19). For swimmers in whom extending is contraindicated, a gentle warm-up is sufficient to increase blood circulation to the muscles and get ready for the workout.

Summary

Correct stroke technique is crucial to help prevent harm and trainers should ensure that they carefully track training loads and identify stroke adjustments that may cause or change pain. Abdominal, core, scapular, and rotator cuff muscle strengthening exercises should be highlighted in a accident prevention program, and should the swimmer experience any shoulder pain, training intensity, distance, and frequency ought to be adjusted accordingly. Stretching is only recommended when a particular need has been identified.

References
1. Am J Sports Med 1997;25(2):254-260
2. Clin Sports Med 1999;18(2):349-359
3. Scand J Med Sci Sports 1996;6(3):132-144
4. Clin Sports Med 2000;19(2):331-349
5. Sports Med 1996;22(5):337-347
6. Orthop Clin North Am 1977;8(3):583-591
7. Am J Sports Med 1998;26(1):83-86
8. Clin J Sport Med. 2010;20(5):386-390
9. Am J Sports Med. 1997;25(2):254-260
10. Scand J Med Sci Sports. 2007;17(4):373-377
11. Clin Sports Med. 1986;5(1):115-137
12. Br J Sports Med. 2010;44(2):105-113.
13. Int J Sports Med. 1995;16(8):557-562.
14. Stedman’s Concise Medical Dictionary for the Health Professions, ed 3. Baltimore, Williams & Wilkins, 1997, pp 446-446, 480
15. Arch Orthop Trauma Surg 2002;122(8):472-487
16. J Athletic Training 2012:47(2):149–158
17. Rodeo SA. Swimming. In: Krishnan SG, Hawkins RJ, Warren RF, eds. The Shoulder and the Overhead Athlete. Philadelphia, PA: Lippincott, Williams & WIlkins; 2004:350
18. Clin J Sport Med. 1996;6(1):40-47
19. Orthop Clin North Am. 2000;31(2):247-61
20. Physician and Sports medicine 2005; vol 33, no. 9

90% of swimmers will experience shoulder pain at some time in their careers. Chiropractor, Dr. Alexander Jimenez examines injury rehabilitation recommendations and, in particular, the demand for an appropriate return to a swimming program in the pool.

Though swimming is a relatively low-risk sport for injury, shoulder pain is common in swimmers. A variety of studies show that over a lifetime, between 40 percent and 91 percent of swimmers will endure a swimming-related shoulder injury(1-4). However, if you think about that elite swimmers might be racking up in the pool every day over 10km, and that the arms would be the prime generators of forward push, we should be surprised. High volume training may result in muscle fatigue of the rotator cuff, upper back, and pectoral muscles, which in turn might lead to micro trauma as a result of reduction of dynamic stabilization of the humeral head(5,6).

Etiology Of Shoulder Injury In Swimmers

It will help to understand the biomechanics of the stroke cycle, to appreciate the vulnerability of a swimmer's shoulder to injury. Since freestyle is the most commonly used stroke (for example, the stroke of selection in related sports such as triathlon) we'll concentrate on this particular style. The stroke contains four distinct phases, which are shown in figures 1-4.

In freestyle swimming, each one of these phases has the potential to raise the risk of shoulder injury when executed. Some of the common errors are as follows:

Hand entry -- the swimmer's hand enters the water either medial or lateral to the ideal line (with the swimmer's head representing 12 o’clock, a right hand should enter the water at approximately 1 o’clock and a left hand at 11 o’clock). A deviation either way increases stress on the rotator cuff.

Early pull through -- a 'dropped elbow' (where the elbow is lower than the hand while the arm pulls under the body) will fail to fully engage the latissimus dorsi muscles, which can boost the chance of impingement. In addition, it inhibits a symmetrical body roll, which is needed to keep the scapula appropriately anchored on the thorax and to decrease stress on the rotator cuff muscles.

Straight arm recovery -- a fully extended elbow while the arm is out of the water in the recovery phase is another frequent error. In this phase, there is a bent elbow much preferred because it decreases the amount of stress on the rotator cuff.

In more general terms, it's important to appreciate that a balance of muscle forces are critical for maintaining stability, proper motion, and function that is painless and that the shoulder is an joint. Since the bulk of the propulsive force in swimming is generated by adduction and internal rotation of the upper arm involving contraction of pectoralis major and the latissimus dorsi, high training volumes tend to favor increased adduction and internal rotation strength, which may lead to imbalance and reduced glenohumeral stability(7,8). It's also worth noting that female swimmers, on average, have shorter arm strokes than those of their male colleagues and are, from a biomechanical perspective, at a greater risk of suffering an overuse injury, due to the requirement for more arm revolutions per lap(2).

Land-Based Prevention & Rehab Training

Studies indicate that an endurance training and strengthening program for the shoulder and periscapular muscles, with emphasis placed on the serratus anterior, rhomboids, lower trapezius, and subscapularis, may help prevent injuries and speed recovery when injury does occur(9,10). There's also evidence that abdominal and scapular muscle strengthening performed in dry-land training can yield benefits; in particular, the goal of core and abdominal strengthening is to develop greater control of the pelvis by avoiding excessive anterior pelvic tilt and lumbar lordosis(11,12). Table 1 shows some example of some commonly-used dry-land training exercises that fulfill these criteria.

When shoulder injury does occur, clinical evaluation and diagnosis is recommended (see SIB issues 128 and 136 for a fuller discussion), together with complete or relative rest and the judicious use of dry-land rehab exercises. During periods of relative rest, ice may be used and short courses (up to 1 week) of non-steroidal anti-inflammatory medication might be beneficial. Injection of corticosteroid into the bursa is a option and should be limited to swimmers with constant pain. In all circumstances, the resumption of training should be monitored and gradual although it's hard to determine the length of relative rest. A period of absolute rest is recommended, if the pain persists, and the swimmer should be reassessed before resuming training in the water. If pain persists upon the resumption of training, an evaluation by a physician is indicated(13).

Returning To Swim Training

Much has been written about land rehab training following shoulder injury and pain management. On the other hand, the return to pain-free swimming training in the water presents a challenge. All too often, symptoms improve or resolve to replicate after rest and dry-land training only when the swimmer is back in the pool. The specific hurdles that need to be overcome at this stage are ironing any stroke imperfections while building up swimming training volume without overload and gradually.

There are two criteria that have to be achieved before a return swimming program can be begun by a swimmerthe swimmer be in a position to attain active extension and external rotation of the glenohumeral joint and should be nearly pain free in the shoulder complex. Secondly, the strength of the rotator cuff and scapular stabilizing muscles should be scored at 5/5 when tested using traditional manual muscle testing(14,15).

Dry-land training performed is generally very effective at getting the swimmer. As the predisposing factors to injury may be present, it is important for physiotherapists to appreciate that simply handing the swimmer back to the coach without any additional support or advice risks further setbacks. There is a preferred approach collaboration with the coach to ensure the subsequent training is both measured and appropriate.

In a recently published paper on this topic, Spigelman et al suggest a two-phase approach(16):

Phase 1 - Focuses on stroke technique drills to protect against the swimmer from reverting. The distance increases only to allow assessment of the shoulder is coping with the resumption of training and to prevent overuse;

Phase 2 - Once the swimmer has successfully completed phase 1, the focus switches to interval work, which is designed to help build the swimmer's muscular and cardiovascular fitness levels. In this phase distance increases in bigger increments in order to help build endurance -- but only if the swimmer can demonstrate she or he can tolerate practices.

What's important to keep in mind is that a return to swimming program's objective is to return the swimmer focusing on the swimmer's speciality stroke or distance isn't important at this time. When the swimmer can swim reasonable training volumes with technique and without pain should event-specific training be considered.

Communication

It follows from the above that communication is necessary, both between the swimmer and coach, and between the coach and physiotherapist. The coach should communicate with the swimmer the significance of providing constant feedback about how their shoulder is responding to the increasing training load. It needs to be stressed that any signs of pain or discomfort need to be reported so the coach can pause the training if necessary and evaluate the circumstance. A useful instrument in this regard is the 'Swimming Soreness Rules', which can help the swimmer recognize pain, along with the coach/chiropractor adjust the swimming part of shoulder rehab in the swimmer's program(16). These rules are displayed in Box2.

Criteria For Progression

A thorough description of suitable drills and swimming workouts for the swimmer returning to the pool is beyond the scope of this article and will of course depend on the swimmer in question, his/her event, stage of development etc.. On the other hand, the general criteria for progression from phase 1 to phase 2, and from phase 2 to resuming training can be given. A good instance of this in practice is shown in Table 2. It must be emphasized that the swimmer and coach both need to understand that progression should only be very gradual. Any increases in pain, soreness or discomfort have to get recognized by the swimmer and coach as warning signs that are potential to decrease while re-evaluation occurs, or suspend training.

Summary

Overuse injuries to the shoulder are all too typical in competitive swimmers, especially where training volumes are high and stroke technique is less than perfect. Evaluation by the clinician, proper and rest strengthening exercises that are dry-land are an important first phase of any recovery program. The process of rehab shouldn't stop there.

The first couple of weeks in the pool as part of a return to swimming program are important for a full recovery, and this is a time when cooperation between the swimmer's coach and the clinician can be useful. During the return to swimming program, any increase in workload should only be very gradual with an emphasis on correcting any stroke errors as opposed to rushing the swimmer back. A key part of this process is constant feedback from the swimmer and monitoring of that chiropractor and the coach can make any adjustments to the program as needed.

References
1. Clin J Sport Med. 2010;20(5):386-390
2. Am J Sports Med. 1997;25(2):254-260
3. Scand J Med Sci Sports. 2007;17(4):373-377
4. Clin Sports Med. 1999;18(2):349-359
5. Orthop Clin North Am. 2000;31(2):247-61
6. Br J Sports Med. 2010;44(2):105-113
7. Am J Sports Med. 1993;21(1):67-70
8. Clin Sports Med.2001;20(3):423-438
9. Am J Sports Med. 1991;19(6):569-576
10. Rodeo SA. Swimming. In: Krishnan SG, Hawkins RJ, Warren RF, eds. The Shoulder and the Overhead Athlete. Philadelphia, PA: Lippincott, Williams & WIlkins; 2004:350
11. Phys Sportsmed. 2003;31(1):41-46.
12. Kibler WB, Herring SA, Press JM. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, MD: Aspen Publishers; 1998
13. Sports Health. 2012 May;4(3):246-51
14. J Chiropr. 2004;41(10):32-38.
15. Kendall FP, Kendall FP. Muscles : Testing and function with posture and pain. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2005
16. Int J Sports Phys Ther. 2014; vol 9 (5) 712

Chiropractor, Dr. Alexander Jimenez takes a look at a often injured shoulder muscle...

The supraspinatus muscle is one of the four rotator cuff muscles of the shoulder. It originates in the central area of the supraspinatus fossa of the scapula then courses laterally to cross the joint capsule of the shoulder and attaches onto it it then passes under the acromion and the coracoacromial ligament and fans out and inserts to the lateral and superior aspects of the greater tuberosity of the humerus. The fascia supraspinata covers the superficial region of the muscle. Superiorly it contacts the deltoid and trapezius muscles, whereas the deep fascia attaches to the joint capsule.

The supraspinatus has a function in the initiating active shoulder abduction and providing abduction torque (especially in the first 30 levels of shoulder abduction) along with the more powerful deltoid, and it also plays a role in depressing the humeral head and centralizing the humeral head in the glenoid through abduction/flexion moves. It's been proven in biomechanical studies which during busy shoulder abduction, the pressure vector made by the supraspinatus (which acts as a humeral head compressor and depressor) as well as the anterior/middle deltoids (humeral head elevators) creates a force couple whereby the humeral head stays centred in glenoid fossa. In the event of a weakened supraspinatus, greater deltoid activity ensues and this is going to bring about a superior shear of the humeral head with regard to the glenoid(2,3). This may then create the superior rim and a impingement between the humeral head, acromian procedure and arch.

Finally, the supraspinatus may contribute to internal rotation torque manufacturing and external rotation; however, that is varied upon flexion/extension angles of the shoulder and the abduction. For the most part, it contributes little towards pure rotation torque at the glenohumeral joint.

Incidence Of Injury

Injury has a high prevalence From the population. It's very common in the older population which suggests that progressive degeneration is a element in developing a full thickness tear in the tendon. Research has postulated that in individuals under the age of 40 the prevalence is a small 4 percent; however, in those ages 60 and above the incidence rapidly increases to 54 percent(4).

Even in patients with no shoulder pain, The incidence of rotator cuff injury is comparatively high. Tempelhof et al (1999) found that even in asymptomatic people, ultrasound finding demonstrated that at the 50-59 age group 13\% had tears, at the 60-69 age category 20 percent, at the 70-79 age group 31\% and at the older 80+ age group 51 percent of asymptomatic shoulders had tears in the rotator cuff (5).

Yamamoto et al (2010)(6)) supports this Predisposition by indicating arm dominance as well as that and preceding shoulder trauma, era was in creating a rotator cuff tear, another risk factor. What they found was that the incidence of rotator cuff tears increased linearly with age (0 percent in the 20s group, 2.5\% at the 30s group all the way around 50 percent in the 80s group). Interestingly, 17\% of issues with rotator cuff tears complained of no symptoms. In essence, many older individuals may have a true partial/full thickness tear of the supraspinatus and be completely unaware that the injury exists(6).

Research shows that from the Lack of a supraspinatus (due to a complete thickness tear of the supraspinatus tendon), the humeral head will migrate superiorly and abut the acromian, highlighting the value of the supraspinatus in centering the humeral head in the glenoid and preventing a superior migration of the humeral head(7,8,9,10). Repeated exceptional migration of the humeral head will produce an impingement scenario and repeated episodes of impingement will result in breakdown and damage to the subacromial bursa, arthritic changes in and around the glenoid and humeral head and acromioclavicular joint fluctuations in the inferior part of the joint.

From the younger athletic population, true Partial/full thickness tears are rare unless it's associated with a serious shoulder injury such as a dislocation or when the arm is forcefully whilst a scenario which might occur in contact sports such as rugby and NFL, in an abducted position. Injury to the supraspinatus involves phase tendinopathy which might result in an supraspinatus tendon due to mechanical overload. Finally, trigger factors that are active can develop in the supraspinatus that can create searing pain throughout the deltoid and upper arm.

Mechanism Of Injury

Interestingly in the population that is elderly, Injuries to the supraspinatus may come from activities like lifting a heavy bag or holding a puppy on a lead and the puppy runs or stops, leading to a tug onto the arm. From the younger people, direct injury to the supraspinatus may appear due to a trauma episode such as fall onto an outstretched hand, dislocating a shoulder, sustaining a solid adduction force on a flexed/ abducted shoulder or falling off a bicycle and retaining hold of the handles. It might come from exercise like swimming pool, tennis and other sports that are overhead through overload movements such as Olympic-type lifting, repetitive and powerlifting trauma.

The supraspinatus is a tendon that is Exposed to forces within an extended time period, highlighting the prevalence of tears from the people. Neer (1983)(11) has been the first to describe the three phases of rotator cuff disease, particularly the changes found from the supraspinatus. But he didn't elucidate if the trigger was tendon degeneration or mechanical impingement or a combination of the two. Stage I occurs in patients < 25 years using oedema and haemorrhage of the tendon and bursa. Period II involved inflammation and fibrosis of the rotator cuff in patients aged between 25 and 40 years old. Phase III involves tearing of the rotator cuff, either partial or full- depth, and occurs in patients 40 years old(11).

It is possible that some small Supraspinatus tears can heal or become smaller; however, Yamanaka and Matsumoto (1994) revealed that roughly 53\% grow further and 28\% might advance to full thickness tears. It is thought that full thickness tears do not heal due to poor vascularisation within the tendon(12).

Presenting Symptoms & Signs

Subjective
The more serious thickness tears or the patient with a grade supraspinatus injury will complain of antero-lateral shoulder pain that is made worse by any action where the arm is raised up to 90 degrees of abduction or flexion. Sleeping on the shoulder might be painful. Holding weights and lifting like hanging towels on a clothes 14, things might turn out to be rather painful and functionally impossible to perform. As emphasized previously, many incidences of supraspinatus pathology can in reality be curable and painless.

Objective

Palpation

The individual will usually be tender to Palpate in and around beneath the acromian process the head.

Energetic Movements

Abduction moves and full flexion will Most probably be hard and painful to completely execute based on severity of the injury. Whereby the pain will be present from 80-160 levels of abduction, stage 1-type accidents will have an arc of pain throughout abduction. In more serious partial thickness and full thickness tears, complete abduction could be impossible to perform because of an inability of the muscle to commence abduction, or the quality of the movement might be quite poor whereby the individual elevates or 'hitches' the scapula to commence abduction.

The test for supraspinatus/rotator Cuff impingement is the Neer test first Clarified in 1972. In this evaluation the patient is Asked to bend the shoulder Whilst the holds stable the scapular examiner. Typically the pain is felt at Around 120 levels of shoulder flexion(13). Jia et al (2011) looked in the internal Construction of the shoulder an Arthroscope and found that in most cases The rotator cuff (supraspinatus contained) contacted the superior glenoid rim. These findings Patients believed The pain when assessed clinically. Therefore accidents to the supraspinatus May present as pain in the anterior/lateral Once the arm is flexed to 120, shoulder Levels(14).

Resisted Muscle Tests

Patients with grade supraspinatus pathology will test normal with the vast majority of resisted spinning movements and abduction moves. The more serious tendon lesions such as partial/full tears will usually pose as weakness in external rotation and abduction ( with or without pain). Muscle testing to the supraspinatus can be accomplished using an 'empty can' or 'complete can' test.

Researchers have been studying the 'best' position for analyzing and retraining the supraspinatus because Jobe and Moynes (1982) offered the 'empty can' motion as being a successful supraspinatus strengthening workout(15). In this movement, the arm is abducted from the scaption plane (30° lateral to frontal together with the arm internally rotated -- like pouring fluid from a can. The examiner may push downwards on the hands to include extra resistance. This position will ordinarily be felt as being weak and painful in the presence of a supraspinatus lesion.

However, a lot of studies since have shown that the 'empty can' position is not necessarily the ideal position for exercising and testing for supraspinatus with no extra curricular activation. The scientific basis for this debate has stemmed from the many EMG research studies in the past decade which have quantified supraspinatus activity. For example, Blackburn et al (1990) indicates the contrary movement for testing/strengthening supraspinatus -- that the 'full can' movement. That is equal to the 'empty may' the arm has been retained in external rotation as opposed to internal rotation. This elucidates the identical degree of supraspinatus activity, without the superior shear effect of the deltoid(16).

Testing places and exercises that produce higher degrees of activity in regard to supraspinatus activity may be counter-productive in patients with weakness of the rotator cuff, shoulder pain, and stabilization that is ineffective. As a result, the may place may give false positives because the source of pain may be direct impingement of the subacromial structures as a result of superior migration of the head as a result of deltoid contraction.

From an anatomical and biomechanical standpoint, the full can exercise also might be the most beneficial position to both test and exercise and provoke the smallest amount of pain due to the least quantity of humeral head outstanding migration and increased minute arm of the supraspinatus muscle in this place compared with the empty can place.

Rehabilitation Of Supraspinatus Injuries

Partial thickness tears and early stage supraspinatus accidents may do well when managed. Larger partial thickness tears and total thickness tears will need to be properly managed to acquire a favourable outcome. For the paper's purposes, the discussion will focus on the conservatively managed supraspinatus injury.

It appears that the best exercises to the supraspinatus would elicit the best quantity of activity that is supraspinatus while reducing particularly the deltoid, the muscle activity. Boettcher et al (2009)(17) studied this specific phenomenon when they analyzed that the EMG activity (15 subjects) of a number of shoulder muscles including supraspinatus, infraspinatus and deltoids whilst performing these motions: full can moves, empty may move, prone elevation, external rotation in 0 degrees abduction and prone external rotation positions. The exercises were performed together with the scapular in a retracted position. Each of of the exercises were stored isometrically for five minutes, using a one-second build-up phase, a grip along with a discharge phase.

They sought to appear at which ones recruited deltoids at the least but also which exercises greatest supraspinatus that was triggered. What they found was that each of five selected exercises triggered the supraspinatus to a degree, and specifically there was no difference between 'can' and 'empty can' moves. They discovered more prone activated muscles within this order of magnitude: posterior deltoid anterior. The rotation at 0 degrees and the prone external spinning activated infraspinatus the most, however, supraspinatus action still out performed all the deltoids; and more importantly, both of these exercises also recruited far less deltoid than the 'full can' and 'empty may' moves. They contended that the best exercise to get supraspinatus was that the exercises that incorporate external rotation rather than the 'can' and 'can' movements. The researchers assert that exercises need to be selected as it has a superior migratory influence in the head, that restrict deltoidscausing impingement of the supraspinatus against the coracoacromial and acromian space.

Reinold et al (2007)(18) conducted a similar study on comparing the 'empty can', ' 'full may' and 'inclined full can' moves and quantifying EMG activity from the middle deltoid, posterior deltoid and supraspinatus muscles. What they discovered was that even though all three exercises produced comparable amounts of activity that is supraspinatus, the can exercise generated significantly less action of the deltoid muscles and could possibly be considered to be the optimal place to recruit the supraspinatus muscle for testing and rehabilitation. The empty may exercise could be a good exercise and also the full that is more likely can exercise may be a great exercise. These findings have been supported by Lee et al (2014)(19) who revealed using PET/CT imaging the 'full can' position was more effective as an exercise for supraspinatus without predominant deltoid action. Ultimately, Escamilla et al (2009)(20) suggests that scapular protraction and scapular anterior tilt, both of which reduce subacromial space width and increase impingement hazard, are higher when performing scaption moves with inner rotation ('empty can') compared with scaption with external rotation ('total may').

Therefore it appears that the 'safest' exercises to recruit supraspinatus and also minimise the deltoid are the 'full can position' and also the 'external that is prone rotation' exercise. These two exercises may form the basis of applications that are re-strengthening that are supraspinatus. These exercises have been described below. Furthermore, supraspinatus function that is effective will only be evident with a scapula base that is functioning and strong. Immediate exercises to retrain the anterior and strengthen and lower trapezius will be required to allow scapular positioning.

The Exercises

1. Full Can Exercise

Stand holding small dumb-bells (2.5pound women , up to 5kg for guys) or rubber tubing. Begin with the hands by both sides along with the horn turned outwards. Lift the arm to abduction whilst retaining the angle of the arm around 30 degrees to the frontal plane. Initially if the shoulder is painful the scope may be limited to 30 levels; nonetheless, as pain and strength boost they may move the arm to further positions of abduction.Work on three sets of 15-20 repetitions.

2. Prone Spinning exercise

Lie begin with the arm dangling down along with the arm at 90 degrees abduction and face down. Gently retract and depress the scapula. Slowly raise the arm to external rotation whilst attempting to keep up the scapula position. Perform three sets of 15-20repetitions.

3. Scapular Wall Slides

As per the graphic below, begin with the forearms in contact. Slide the arms up the wall slowly externally rotating forearms on the way upward. This will produce scapula spinning and protraction to activate the anterior, a muscle at the control of scapula motion and thus rotator cuff function in overhead sports.

4. Lower Trapezius Setting

The most easy way to perform this and also to teach this as an exercise is to do this drill on a lat pulldown machine. Use only light resistance such as 3-4 plates on the pulldown machine. Seated with the hands gripping the lat pulldown bar, gradually draw on the scapula down and in (retract and depress). Hold for a quick 1-2 seconds and then repeat for two sets of 15 reps.

Conclusion

Research shows that the supraspinatus plays an important part in the shoulder as it centers the humeral head into the movements of the arm/ shoulder. Dysfunction in this muscle may lead to excess of the head which might be a precursor to shoulder instabilities and the more shoulder impingements. Injuries to the supraspinatus are typical as well as also the cause of rotator cuff disorder especially in the older athlete. This article has offered a framework for treatment and evaluation of dysfunction.

References
1. Journal of Ultrasound 2010; 13. 179-187.
2. Biomechanics of the shoulder. In: Rockwood CA, Matsen FA, eds. The Shoulder. Philadelphia, PA: WB Saunders; 1998:233–276.
3. Clin Orthop Relat Res 1978; 135. 165–170
4. J Bone and Joint Surgery (Am) 1985; 77-A. 10-15.
5. J Shoulder and Elbow Surgery 1999; 8(4). 296-299.
6. J Shoulder and Elbow Surgery 2010; 19(1). 116-120.
7. Clin. Imaging 1995; 19. 8–11.
8. Clin. Biomech 2006; 21. 942–949.
9. J. Shoulder Elbow Surg 2003;. 12. 179–184.
10. Clinical Biomechanics 2007; 22. 645–651
11. Clin Orthop 1983. 173; 70-77.
12. Clin Orthop 1994; 708. Pp 68-73.
13. J Bone Joint Surgery (Am) 1977: 54. 41-50
14. Clin Orthop Relat Res 2011; 469: 813–818
15. Am J Sports Med 1982;10:336–339.
16. Athl Train J Natl Athl Train Assoc 1990; 25:40–45.
17. Sci. Sports Exerc 2009. 41(11); 1979-1983.
18. J Athl Train 2007; 42(4): 464–469
19. J Orthop Surg Res 2014; 9(1): 85.
20. Sports Med 2009. 39(8). 663-685.

Child Athlete Injuries

As a team physician for the St Louis Cardinals during their 2011 World Series Championship season, I learned a lot about the importance of players taking care of themselves firsthand. I would see players preparing themselves both mentally and physically for the game ahead. Kids look up to these players and emulate them. Major League Baseball (MLB) recognizes this and wants their youth players to be healthy and play as safely as possible. This is why MLB took time, energy, and resources, to determine what would be best for today’s young pitchers. Below is a snapshot of what the MLB and the American Sports Medicine Institute (ASMI) found as risk factors for the young pitcher. It’s recommended that these guidelines be followed by coaches, parents, and players.

The MLB Pitch Smart guidelines provide practical, age-appropriate parameters to help parents, players, and coaches avoid overuse injuries and encourage longevity in the careers of young pitchers.

It was found that specific risk factors were seen as creating a higher incidence of injuries. According to the ASMI, youth pitchers that had elbow or shoulder surgery were 36 times more likely to regularly have pitched with arm fatigue. Coaches and parents are encouraged to watch for signs of pitching while fatigued during their game, in the overall season, and during the course of the entire year.

The ASMI also found that players that pitched more than 100 innings over the course of a year were 3.5 times more likely to be injured than those who did not exceed the 100 innings pitched mark. It’s important to note that every inning counts. Games and showcase events should count toward that total number of 100.

Rest is key. Overuse on a daily, weekly, and annual basis is the greatest risk to a young pitcher’s health. Numerous studies have shown that pitchers that throw a greater number of pitches per game, as well as those who don’t get enough rest between outings, are at a greater risk of injury. In fact, in little league baseball, pitch count programs have shown a reduction in shoulder injuries by as much as 50% (Little League, 2011). Setting limits for pitchers throughout the season is vitally important to their health and longevity in the game.

Pitching with injuries to other areas of the body will also affect a player’s biomechanics and change the way he delivers his pitch. An ankle, knee, hip, or spinal injury can cause changes in the biomechanics of how a player throws and will put more stress on his arm. Be cautious with these injuries, because at times the changes in the mechanics of the player can be very subtle; however, they can cause a significant amount of strain on a player’s pitching arm.

For best results for your youth baseball player’s longevity in the sport and keeping a healthy arm for seasons to come follow the MLB’s pitch count and required rest guide.


3 Common Shoulder Sports Injuries

The shoulder is the most mobile joint in the body, which also makes it prone to injury. If you’re an athlete, taxing your shoulder over time with repetitive, overhead movements or participating in contact sports may put your shoulder at risk for injury.


There are several nonsurgical and surgical options available to treat labrum tears in the shoulder.

See Labrum Tear Treatments

These are three common shoulder injuries caused by sports participation:

1. SLAP Tear

This is a tear to the ring of cartilage (labrum) that surrounds your shoulder's socket. A SLAP tear tends to develop over time from repetitive, overhead motions, such as throwing a baseball, playing tennis or volleyball, or swimming.

See SLAP Tear Shoulder Injury and Treatment

You may notice these telltale symptoms:

• Athletic performance decreases. You have less power in your shoulder, and your shoulder feels like it could “pop out.”
• Certain movements cause pain. You notice that pain occurs with certain movements, like throwing a baseball or lifting an object overhead.
• Range of motion decreases. You may not throw or lift an object overhead like you used to, as your range of motion decreases. You may also find reaching movements difficult.
• Shoulder pain you can’t pinpoint. You have deep, achy pain in your shoulder, but you can't pinpoint the exact location.

See SLAP Tear Symptoms

If you have a SLAP tear, you may also notice a clicking, grinding, locking, or popping sensation in your shoulder.

See SLAP Tear Causes and Risk Factors

2. Shoulder Instability

It’s common to experience shoulder instability if you’re an athlete. This injury can occur if you’re participating in contact sports, including football or hockey, or ones that require repetitive movements, like baseball.

Shoulder instability happens when your ligaments, muscles, and tendons no longer secure your shoulder joint. As a result, the round, top part of your upper arm bone (humeral head) dislocates (the bone pops out of the shoulder socket completely), or subluxates (the bone partially comes out of the socket).

Dislocation is characterized by severe, sudden onset of pain; subluxation (partial dislocation) may be accompanied by short bursts of pain. Other symptoms include arm weakness and lack of movement. Swelling and bruising on your arm are visible changes you may also notice.

See Treating Acute Sports and Exercise Injuries in the First 24 to 72 Hours


When treating a rotator cuff injury, doctors may order medical imaging right away or prescribe nonsurgical treatment and take a wait-and-see approach. 

See Rotator Cuff Injuries: Diagnosis

3. Rotator Cuff Injury

This is another injury commonly seen in athletes participating in repetitive, overhead sports, including swimming and tennis. Rotator cuff injuries are typically characterized by weakness in the shoulder, reduced range of motion, and stiffness.

See Rotator Cuff Injuries

Rotator cuff injuries are also painful. Here’s what you need to know:

• Pain at night is common; you may not be able to sleep comfortably on the side of your injured shoulder.
• Pain may be experienced with certain movements, especially overhead movements.
• Pain in your shoulder or arm may also occur.

Similar to a SLAP tear, people with rotator cuff injuries often experience achy shoulder pain.

See Rotator Cuff Injuries: Causes and Risk Factors

Being aware of these injuries and knowing their symptoms may encourage you to seek medical treatment sooner; early treatment intervention could result in a better outcome and earlier return to sports.

Learn More

The P.R.I.C.E. Protocol Principles

Labrum Tear Treatments


6 Tips to Prevent Shoulder Pain

There’s nothing more frustrating for an athlete than sitting injured on the sidelines watching others compete. Although there’s not one foolproof way to stop shoulder pain from occurring, there are several tips that may help prevent it from starting or getting worse.

See Shoulder Injuries

Shoulder pain and injury are more common in people who play sports with repetitive overhead shoulder motions, like tennis. 

See Rotator Cuff Injuries: Causes and Risk Factors


1. Rest

If you notice shoulder pain during certain activities, say while throwing a baseball or swimming, stop that activity for a period of time and find an alternative exercise, such as riding a stationary bike. Doing so can give your shoulder some time to rest and heal, while maintaining your cardiovascular fitness.

At the same time, don’t eliminate all shoulder movement. This is because you don’t want to develop a stiff shoulder from infrequent use. Consider doing some mild stretches to keep your arm moving.

2. Change Your Sleeping Position 

If you notice pain in your right shoulder, don’t sleep on your right side. Try sleeping on your left side or back instead. If sleeping on your back irritates your shoulder, try propping your arm up with a pillow.

3. Warm Up 

Exercising cold muscles is never a good idea. Before practicing your volleyball serve or baseball pitch, warm up your body with mild exercise. For example, start walking for a few minutes and gradually build up to a jog. Doing so raises your heart rate and body temperature and activates the synovial fluid (lubricant) in your joints.1 In other words, a mild warm up gets your body ready for the intense workout that follows.

4. Build Up Your Endurance

It’s a good idea to increase your endurance over time. If it’s been a few weeks or months since you’ve hit the tennis court, consider playing for a short period of time—maybe just 20 minutes to start—and build up to a longer period of playing time. Don’t fall into the trap of doing too much too soon, especially when your body is not used to it.

Simple Exercise Ball Routines

5. Increase Your Shoulder Strength

Strengthening your shoulder muscles can help provide support and stabilization to your shoulder joint. This, in turn, may prevent painful injuries like a shoulder dislocation, which is when the ball of your shoulder comes out of its socket.

Speak to your doctor before starting a strengthening program. They can suggest exercises to perform or may recommend working with a physical therapist.

6. Cross-Train

Some sports are particularly taxing on the shoulder due to repetitive, overhead movements. So you may want think about cross-training. If you’re a swimmer, for example, alternate some of your swimming workouts with a running or biking workout to reduce the stress on your shoulder, while still staying physically fit.

Exercises to Lessen Back Pain While Running

Alternatively, if you’re a painter or construction worker—two occupations commonly associated with repetitive, overhead movements—talk to your boss and ask if there are other non-repetitive tasks you can take on.

Above all, listen to your body and be proactive. You may need to make some adjustments to workout or daily routine to help prevent further damage down the road. It may also be worth getting your doctor’s input, even if you think you’ve got a minor injury. Catching injuries or discomfort early may help keep you in the game and prevent painful injuries down the road.

Learn more:

Flexibility Routine for Exercise Ball

Advanced Exercise Ball Program for Runners and Athletes