Sports Injuries

Knee injuries can present in physically active individuals that lift weights. Can understanding the types of weightlifting knee injuries help in prevention?

Weightlifting Knee Injuries

Weight training is very safe for the knees as regular weight training can improve knee strength and prevent injury as long as the correct form is followed. For Individuals with knee injuries from other activities, incorrect weight-training exercises could worsen the injury. (Ulrika Aasa et al., 2017) As well as, sudden twisting movements, poor alignment, and pre-existing injuries can increase the risk of worsening or creating further injuries. (Hagen Hartmann et al, 2013) The body and the knees are designed to support vertical forces on the joints.

Common Injuries

Weightlifting knee injuries occur as the knee joints endure a wide range of stresses and strains. In weight training, the ligaments that attach to the complex bone system of the knee joint can be damaged by incorrect movements, overloading the weight, and increasing the weight too soon. These injuries can result in pain, swelling, and immobility that can range from minor to severe, from a sprain or a slight tear to a complete tear in serious cases.

Anterior Cruciate Ligament - ACL - Injury

This ligament attaches the thigh's femur bone to the lower leg's shin bone/tibia and controls excessive rotation or extension of the knee joint. (American Academy of Family Physicians. 2024)

• Anterior means front.
• ACL injuries are seen mostly in athletes but can happen to anybody.
• Severe damage to the ACL usually means surgical reconstruction and up to 12 months of rehabilitation.
• When weightlifting, try to avoid twisting knee movements, intentionally or accidentally, under excessive load.

Posterior Cruciate Ligament - PCL - Injury

• The PCL connects the femur and tibia at different points to the ACL.
• It controls any backward motion of the tibia at the joint.
• Injuries occur most with high-impact forces as a result of accidents and sometimes in activities where forceful trauma to the knee occurs.

Medial Collateral Ligament - MCL - Injury

• This ligament maintains the knee from bending too far to the inside/medially.
• Injuries mostly occur from impact to the outside of the knee or from accidental bodyweight force on the leg that bends at an unusual angle.

Lateral Collateral Ligament - LCL - Injury

• This ligament connects the smaller bone of the lower leg/fibula to the femur.
• It is opposite to the MCL.
• It maintains excessive outward movement.
• LCL injuries occur when a force pushes the knee out.

Cartilage Injury

• Cartilage prevents bones from rubbing together and cushions impact forces.
• Knee menisci are cartilage that cushions the knee joints inside and outside.
• Other types of cartilage protect the thigh and shin bones.
• When cartilage gets torn or damaged, surgery may be required.

Tendonitis

• Aggravated and overused knee tendons can lead to weightlifting knee injuries.
• A related injury known as iliotibial band syndrome/ITB causes pain to the outside of the knee, usually in runners, but it can occur from overuse.
• Rest, stretching, physical therapy, and anti-inflammatory medication are a common treatment plan.
• Individuals should consult a physical therapist for pain lasting longer than two weeks. (Simeon Mellinger, Grace Anne Neurohr 2019)

Osteoarthritis

• As the body ages, normal wear and tear can cause the development of osteoarthritis of the knee joints. (Jeffrey B. Driban et al., 2017)
• The condition causes the cartilage to deteriorate and bones to rub together, resulting in pain and stiffness.

Prevention

• Individuals can minimize their risk of weightlifting knee injuries and pain by following their doctor's and personal trainers' recommendations.
• Individuals with an existing knee injury should follow their doctor's or physical therapist's recommendations.
• A knee sleeve can keep the muscles and joints secure, providing protection and support.
• Stretching the leg and knee muscles can maintain joint flexibility.
• Avoid sudden lateral movements.
• Possible recommendations can include:

Avoiding Certain Exercises

• Isolation exercises like leg curls, standing, or on a bench, as well as using the leg extension machine, can stress the knee.

Deep Squat Training

Research shows that the deep squat can protect against lower leg injury if the knee is healthy. However, this is when done with proper technique, under expert supervision, and with a gradual progressive load. (Hagen Hartmann et al, 2013)

Individuals should talk to their doctor before beginning a new exercise routine. A personal trainer can provide training in learning the proper technique and weightlifting form.

How I Tore my ACL Part 2

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make 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 various 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 studies 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 contact 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

Aasa, U., Svartholm, I., Andersson, F., & Berglund, L. (2017). Injuries among weightlifters and powerlifters: a systematic review. British journal of sports medicine, 51(4), 211–219. https://doi.org/10.1136/bjsports-2016-096037

Hartmann, H., Wirth, K., & Klusemann, M. (2013). Analysis of the load on the knee joint and vertebral column with changes in squatting depth and weight load. Sports medicine (Auckland, N.Z.), 43(10), 993–1008. https://doi.org/10.1007/s40279-013-0073-6

American Academy of Family Physicians. ACL injury. (2024). ACL injury (Diseases and Conditions, Issue. https://familydoctor.org/condition/acl-injuries/

Mellinger, S., & Neurohr, G. A. (2019). Evidence based treatment options for common knee injuries in runners. Annals of translational medicine, 7(Suppl 7), S249. https://doi.org/10.21037/atm.2019.04.08

Driban, J. B., Hootman, J. M., Sitler, M. R., Harris, K. P., & Cattano, N. M. (2017). Is Participation in Certain Sports Associated With Knee Osteoarthritis? A Systematic Review. Journal of athletic training, 52(6), 497–506. https://doi.org/10.4085/1062-6050-50.2.08

Gymnastics is a demanding and challenging sport. Gymnasts train to be powerful and graceful. Today's moves have become increasingly technical acrobatic moves with a much higher degree of risk and difficulty. All the stretching, bending, twisting, jumping, flipping, etc., increases the risk of neuromusculoskeletal injuries. Gymnastics injuries are inevitable. Bruises, cuts, and scrapes are common, as are overuse strains and sprains, but severe and traumatic injuries can occur. 

Injury Medical Chiropractic and Functional Medicine Team can treat and rehabilitate injuries and help to strengthen and prevent injuries. The therapy team will thoroughly evaluate the individual to determine the injury/s severity, identify any weaknesses or limitations, and develop a personalized plan for optimal recovery, stability, and strength.

Gymnastic Injuries

One of the main reasons injuries are more prevalent is because today's athletes start earlier, spend more time practicing, perform more complex skill sets, and have higher levels of competition. Gymnasts learn to perfect a skill and then train to make their bodies look elegant while executing the routine. These moves require precision, timing, and hours of practice. 

Injury Types 

Sports injuries are classified as:

• Chronic Overuse injuries: These cumulative aches and pains occur over time.
• They can be treated with chiropractic and physical therapy and prevented with targeted training and recovery.
• Acute Traumatic injuries: These are typically accidents that happen suddenly without warning.
• These require immediate first aid.

Most Common Injuries

Gymnasts are taught how to fall and land to lessen the impact on the spine, head, neck, knees, ankles, and wrists. 

Back

• Common back injuries include muscle strains and spondylolysis.

Bruises and Contusions

• Tumbling, twisting, and flipping can result in various bruises and contusions.

Muscle Soreness

• This is the sort of muscle soreness experienced 12 to 48 hours after a workout or competition.
• Proper rest is necessary for the body to recover fully.

Overtraining Syndrome

• Overtraining syndrome happens when individuals train beyond the body's ability to recover.

Sprains and Strains

• Sprains and strains.
• The R.I.C.E. method is recommended. 

Ankle Sprains

• Ankle sprains are the most common.
• When there is a stretching and tearing of ligaments surrounding the ankle joint.

Wrist Sprains

• A sprained wrist happens when stretching or tearing the ligaments of the wrist.
• Falling or landing hard on the hands during handsprings is a common cause.

Stress Fractures

• Leg stress fractures result from overuse and repeated impact from tumbling and landings.

The most common include:

• Shoulder instability.
• Ankle sprains.
• Achilles tendon strains or tears.
• Gymnasts wrist.
• Colles' fracture.
• Hand and Finger injuries.
• Cartilage damage.
• Knee discomfort and pain symptoms.
• A.C.L. tears - anterior cruciate ligament.
• Burners and stingers.
• Low back discomfort and pain symptoms.
• Herniated discs.
• Spinal fractures.

Causes

• Insufficient flexibility.
• Decreased strength in the arms, legs, and core.
• Balance issues.
• Strength and/or flexibility imbalances - one side is stronger.

Chiropractic Care

Our therapists will start with an evaluation and a biomechanical assessment to identify all the factors contributing to the injury. This will consist of a thorough medical history to understand overall health status, training schedule, and the physical demands on the body. The chiropractor will develop a comprehensive program that includes manual and tool-assisted pain relief techniques, mobilization work, MET, core strengthening, targeted exercises, and injury prevention strategies.

Facet Syndrome Chiropractic Treatment

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make 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 various 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, don't hesitate to get in touch with 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

Armstrong, Ross, and Nicola Relph. "Screening Tools as a Predictor of Injury in Gymnastics: Systematic Literature Review." Sports medicine - open vol. 7,1 73. 11 Oct. 2021, doi:10.1186/s40798-021-00361-3

Farì, Giacomo, et al. "Musculoskeletal Pain in Gymnasts: A Retrospective Analysis on a Cohort of Professional Athletes." International journal of environmental research and public health vol. 18,10 5460. 20 May. 2021, doi:10.3390/ijerph18105460

Kreher, Jeffrey B, and Jennifer B Schwartz. "Overtraining syndrome: a practical guide." Sports Health vol. 4,2 (2012): 128-38. doi:10.1177/1941738111434406

Meeusen, R, and J Borms. "Gymnastic injuries." Sports medicine (Auckland, N.Z.) vol. 13,5 (1992): 337-56. doi:10.2165/00007256-199213050-00004

Sweeney, Emily A et al. "Returning to Sport After Gymnastics Injuries." Current sports medicine reports vol. 17,11 (2018): 376-390. doi:10.1249/JSR.0000000000000533

Westermann, Robert W et al. "Evaluation of Men's and Women's Gymnastics Injuries: A 10-Year Observational Study." Sports Health vol. 7,2 (2015): 161-5. doi:10.1177/1941738114559705

Skateboarding is a popular activity among children, teenagers, and young adults. It is recreational, competitive, fun, and exciting but, like any sport, carries a risk of injury. There are around 70,000 skateboarding injuries requiring a visit to the emergency room every year. The most common injuries involve the shins, ankles, forearms, wrists, elbows, face, and skull, with many left untreated that worsen as they heal improperly, leading to further damages and complications. Chiropractic can treat the injuries, rehabilitate the muscles and joints, and strengthen the body to get the skater back on their board. 

Skateboarding Injuries

Skateboarding injuries can range from scrapes, cuts, and bruises to sprains, strains, broken bones, and concussions.

• Shin injuries often happen during flip/twist tricks where the board or axle hits the shin causing bruising and swelling.
• Shoulder, wrist, and hand injuries are common when skaters lose their balance and fall with outstretched arms.
• Ankle injuries include rolls/sprains, as well as dislocations and fractures.
• Dislocations usually happen to the shoulders, wrists, and fingers.
• Facial injuries include teeth knocked out, broken nose, or jaw are typically caused by fast forward hard falls.
• Severe injuries include concussions and head injuries.

Injury causes

Skateboarding injuries typically occur from:

• Skating on irregular surfaces locks up wheels and affects balance, causing falls.
• Losing balance or losing control of the board and falling hard/slamming into the pavement.
• Inexperience, slow reaction times, and less coordination lead to falls and slams.
• Skating into another skater, a person walking or cycling, a car, or a road hazard.
• Trying an advanced trick/maneuver too soon and beyond their skill level.
• The inexperience of knowing how to fall to prevent injuries.

Chiropractic Therapy

A chiropractor can work with other doctors and specialists to:

• Assess and treat the skateboarding injury/s.
• Reset the spine, hips, arms, hands, and feet.
• Rehabilitate and strengthen the body.
• Recommend safety and prevention education.
• Help prevent further injuries and long-term effects.

Chiropractic Skateboarding Injury Treatment 

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 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

Forsman, L, and A Eriksson. “Skateboarding injuries of today.” British journal of sports medicine vol. 35,5 (2001): 325-8. doi:10.1136/bjsm.35.5.325

Hunter, Jamie. “The epidemiology of injury in skateboarding.” Medicine and sport science vol. 58 (2012): 142-57. doi:10.1159/000338722

Partiali, Benjamin, et al. “Injuries to the Head and Face From Skateboarding: A 10-Year Analysis From National Electronic Injury Surveillance System Hospitals.” Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons vol. 78,9 (2020): 1590-1594. doi:10.1016/j.joms.2020.04.039

Shuman, Kristin M, and Michael C Meyers. “Skateboarding injuries: An updated review.” The Physician and sportsmedicine vol. 43,3 (2015): 317-23. doi:10.1080/00913847.2015.1050953

Triathlon training involves running, biking, and swimming. This much fitness training takes a toll on the body. Pulled hamstrings, twisted ankles, and sore heels are common, but triathlon training can also cause or worsen back pain. Because the back muscles are connected to many other muscles, certain types of movement after a tough training session can present with back pain. There was an Ironman triathlete study that found that 90% of the athletes suffered some form of soft-tissue injury during training, with 70% reporting low back pain and/or sciatica. A 2020 study in BMC Musculoskeletal Disorders found that 14% of recreational half-marathon runners presented with low-back pain.

Triathlon Training Hard on the Back

High-impact activities/exercises, constant repetitive motion, places a heavy pounding on the body that impacts the joints and spine. Using improper techniques will aggravate any issues. The stresses applied from repetitive motions, and poor form can lead to the joints breaking down. If new to intense training the muscles might not be strong enough yet, which could also cause back pain and injury. The back stabilizer muscles tend to get neglected in the training, but these muscles support the structures in the midline, spine, and joints. Strengthening the:

• Base muscles
• Glutes
• Back muscles
• Core
• Ensures stability of the spine and joints from all the wear and tear.

Training and Overtraining Errors

Even veteran athletes can make mistakes during their training that can lead to sore backs. The biggest mistake individuals make during triathlon training is that they only swim, bike, and run. Training for the specific sport/s is important; but weight lifting, core strengthening, and flexibility training are just as important. Proper rest can become neglected as the individual wants to get in as much training as possible that often gets overlooked, leading to overuse injuries. However, rest is a vital part of training to allow the body to fully recover and operate at full and optimal potential.

Preventing and Avoiding Back Pain When Training

How to sidestep back pain altogether during training includes:

Sleep

A healthy lifestyle includes proper sleep cycles and is even more important during training. The mental aspects a triathlon competition can create require proper rest. Fatigue can also lead to poor technique/form, placing excess stress on the joints and the spine, leading to injury.

Flexibility

Muscles need to maintain flexibility to preserve function and recovery ability. After a training session stretching and working on flexibility will help with overall performance. Stretching should be done after activity when the muscles are warm, and the fibers can be stretched/elongated for optimal recovery.

Proper nutrition

The body needs high-performance fuel to support high-calorie deficits that are associated with intense training and competition.

Strengthening the body

Having a solid body foundation is the objective. Everything is balanced with strong muscles supporting healthy bones. Specific exercises that target the multifidus muscles. These are the body's back brace. Strengthening these muscles will help prevent spinal injury/s. Back-strengthening exercises include:

• Cat-cow stretch
• Glute bridges
• Bird dog
• Planks
• Mobility stretches

Rest days no matter what

Plan rest days no matter what. Pushing through will not make the body stronger or able to perform better, and could cause performance to decrease leading to injury. This does not mean sleeping all day, but engaging in active recovery where the body gets the rest it needs while still maintaining fitness. Active recovery includes:

• Moving
• Stretching
• Foam rolling
• Sports chiropractic massage
• Body rejuvenation
• Body and mind exercises
• Allows for a thorough recovery and enhances training.

Technique Improvement

Proper form and technique can really make the difference between staying injury-free and injury/s. Using the right form promotes healthy function. It could help to have gait, swim stroke, and bike techniques evaluated by a professional to ensure that proper form is being utilized.

Body awareness

Stop if the body signals one to stop. This is why the body feels pain. It is the internal mechanism that tells the individual something is wrong. It is not recommended to follow the phrases train through the pain, and no pain, no gain. Individuals are recommended to:

• Always pay attention if pain presents and does not go away after exercising or warming up.
• Pain that limits function.
• Pain that interferes with daily activities.
• These could significantly exacerbate a spinal injury and should be checked by a doctor.

Body Composition

Rest and Recovery

During rest and recovery, the body goes back to normal or homeostasis. This is the body’s resting rate or normal phase. The body is always trying to go back to homeostasis. This is done by:

• Maintaining core temperature regulated
• Blood pressure stable
• Muscles refreshed

When exercising/training, the homeostasis phase is disturbed, meaning the body needs a period of rest to return to normal. The process of homeostasis uses a lot of energy, which results in an abundant amount of calories burned. After exercise, there is an increase in excess post-exercise oxygen consumption or EPOC. The body uses up more oxygen during recovery than it does before or during exercise. This increase results in burned calories and strong muscles. The most important part of recovery is the rebuilding of muscle. When working out, especially resistance training, tiny tears are made in the muscle fibers. For the tiny tears to turn into growing muscles, they need to repair themselves. This happens during rest. Apart from the physiological benefits, rest helps prevent injury caused by overuse and assists in healing when injuries do occur. Time off helps with mental health as well to refocus, reassess, and apply what has been learned. What rest and recovery can do for the body includes:

• Burn massive calories
• Build muscle
• Refuels the muscles
• Prevents injury
• Improves mental health and motivation

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

American journal of physical medicine & rehabilitation/Association of Academic Physiatrists. (October 2014) “Efficacy of Aerobic Exercise for Treatment of Chronic Low Back Pain: A Meta-Analysis” https://www.researchgate.net/publication/266682158_Efficacy_of_Aerobic_Exercise_for_Treatment_of_Chronic_Low_Back_Pain_A_Meta-Analysis

Scientific Reports. (April 2017) “Running exercise strengthens the intervertebral disc” https://www.researchgate.net/publication/316262547_Running_exercise_strengthens_the_intervertebral_disc

Stretch Before and After Journal of Chiropractic Medicine. (Winter 2003) “Changes in low back pain in a long-distance runner after stretching the iliotibial band” https://www.sciencedirect.com/science/article/pii/S0899346707600718

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.

Menu 1: Floor, Static

Menu rationale

To develop a basic level of lumbar and pelvic stability, working front, rear and side muscles of the trunk. This menu can also be used as a maintenance dose of training for intermediate to advanced level athletes.

The Plank

Overview: A common exercise that requires good abdominal strength and co-contraction of the abdominal wall musculature to hold the lumbar spine and pelvis in correct alignment.

Level: Basic/intermediate

Muscles targeted: Rectus abdominis Abdominal wall (transversus abdominis/internal obliques)

Technique: Hold a straight body position, supported on elbows and toes. Brace the abs, and set the low back in the neutral position, once you are up. Sometimes this requires a pelvic tilt to find the right position. The aim is to hold this position, keeping the upper spine extended, for an increasing length of time up to a maximum of 60 secs. Perform 2 to 3 sets. Keep shoulders back and chest out while maintaining the neutral lumbar position. This makes the exercise considerably more challenging.

Progression: Lift one leg just off the floor; hold the position without tilting at the pelvis.

The Side Plank

Overview: Recommended as a safe and effective exercise for the obliques and quadratus lumborum (a key lumbar stabilizing muscle). Recent research also shows this to be an excellent exercise for the lower abdominal muscles.

Level: Basic/intermediate

Muscles targeted: Obliques (internal and external) Quadratus lumborum Transversus abdominis

Technique: Lie on one side, ensuring the top hip is ‘stacked’ above the bottom hip. Push up until there is a straight body line through, feet, hips and head. Hold the position, increasing the length of hold up to a maximum of 60 secs. Perform 2 to 3 sets. Keep the elbow under the shoulder to avoid upper body strain. Lower under control and repeat on opposite side.

Progression: Raise the top leg in the air and hold it in that position throughout.

The Gluteal Bridge

Overview: Research suggests this is more a low-back than gluteal exercise. However, it is a good way to learn how to recruit the gluteals (buttock muscles) in the ‘inner range’ position.

Level : Basic

Muscles targeted: Gluteus maximus Erector spinae/multifidus

Technique: Lie on the floor with your knees bent. Squeeze your gluteals and then push your hips up until there is a straight line through knee and hip to upper body. Shoulders remain on the floor. Beware of raising too high or of flaring the ribs, which pushes the back into hyperextension. Hold the position. Start with 5 sets of 10 sec holds, progressing to 2 to 3 sets of 60 sec holds.

Progression: Extend one leg carefully ahead of you, and hold the position without dropping or tilting the pelvis.

‘Birddog’ Or ‘Superman’

Overview: Recommended as a safe and effective exercise for the lumbar and thoracic portions of the erector spinae (long back) muscle. This exercise also requires co-contraction of the abdominal wall muscles to stabilize the pelvis.

Level: Basic/intermediate Muscles targeted: Thoracic and lumbar portions of erector spinae

Technique: Start with hands below shoulders and knees below hips. Set your low back into neutral and brace your abs slightly. Slowly slide back one leg and slide forward the opposite arm. Ensure that the back does not slip into extension, and that the shoulders and pelvis do not tilt sideways. Hold, increasing the duration up to a maximum of 20 secs. Slowly bring your leg and arm back and swap sides.

Perform sets of 5 to 10, alternating sides after each hold.

Progression: none.

Menu 2: Floor, Dynamic

Menu rationale

To develop a good level of strength endurance in the major trunk muscles. Overall the level of these exercises is intermediate to advanced.

Active Straight Leg Raise

Overview: Requires a strong static contraction of the abdominals to stabilize the lumbar spine against the load of the legs. It also requires good active range of motion of the hamstrings.

Level: intermediate/advanced

Muscles targeted: Rectus abdominis Abdominal wall hip flexors

Technique: Lie on your back with knees bent. Set your lumbar spine in neutral and brace the abs. Lift one leg up straight in the air, ensure your back does not move. Lift the other leg up, again keeping your back in place. (If the back cannot be stabilized during this movement, the exercise is too advanced, and more static transversus stability control work will be needed first.)

Keeping one leg in the air, slowly lower the other down to the floor. Only go as far as you can, until you feel the lumbar spine start to move. Placing your fingers under your back will help you to gauge when this happens. Keep bracing the abs and then lift the leg slowly back up. Repeat with the other leg.

Perform sets of 5 to 10 reps, alternating legs.

Progression: Lower and raise both legs together

Oblique Crunch

Overview: A good exercise for both the obliques and the abdominals.

Level: Intermediate

Muscles targeted: Rectus abdominis Obliques

Technique: Lie on your back with right ankle resting on left knee. Right arm is placed on the floor out to the side. Keeping the right shoulder down, curl the left shoulder up to the right knee. Crunch at the top and return slowly, under control. Perform sets of 15 to 30 reps on each side in turn. Avoid ‘head nodding’ during the movement: keep head off the floor and look forward throughout.

Progression: Hold a dumb-bell in the hand by your head. Keep arm still so you are forced to raise the dumbell using your abs and not your arm.

Side Lying Hip Abduction

Overview: This is an exercise to isolate the use of gluteus medius (upper buttock). Strength in this muscle group has been shown to be useful in preventing lower limb injuries in female athletes.

Level: Basic Muscles targeted: Gluteus medius

Technique: Lie on your side and set pelvis so your top hip is stacked above lower hip. Roll shoulders forward a little and brace the abs to control pelvic position. Lift the top leg slowly up and down, without hitching at the hip. Perform sets of 20 to 30 reps, each side in turn.

Progression: Weight the top leg with an ankle weight or tie a resistance band between your ankles and pull the band apart as you lift the leg.

Lying Windscreen Wipers

Overview: An advanced active mobility exercise working the obliques and trunk rotation.

Level: Advanced

Muscles targeted: Rectus abdominis Obliques

Technique: Lie on your back with arms out to the sides. Lift legs straight up in the air until the hip is at 90 degrees. Set the lumbar spine in neutral and aim to keep it set throughout. Keeping legs straight and maintaining hip angle, move the legs to one side, controlling any movement in the trunk. Go as far as you can in control, keeping your upper back and shoulders on the floor. Bring the legs to a halt, pull them back up to the start position and then over to the other side, under control. The slow side-to- side movement is like a ‘windscreen wiper’ arc.

Menu 3: Swiss Ball, Static

The four exercises in this routine challenge your ability to hold good posture and pelvic alignment against both bodyweight and the instability of the Swiss ball. The positions of the holds are similar to the static floor exercises in Menu 1, except that they are performed on the ball. Research shows that the performance of core exercises upon the labile surface of the Swiss ball can increase the levels of trunk muscle activation; so this menu is a progression from floor-based work. Overall Menu 3 is intermediate in difficulty.

Swiss Ball Sit & Leg Lift

Overview: Challenges your ability to co-contract the abdominal wall and maintain a neutral lumbar spine position on an unstable seat.

Level: Basic

Muscles targeted: Abdominal wall (transversus abdominis, internal obliques)

Technique: Sit on a Swiss ball with hips on the top of the ball and feet hip-width apart. Ensure the size of ball is correct: your knees should be level with or slightly lower than your hips and at 90 degrees in sitting.

Relax and find a neutral lumbar spine position. Set this position by lightly bracing your abdominal muscles. Think about good upper back and shoulder posture as you sit (stomach in, chest lifted, shoulders low and relaxed). It is important to hold an upright sitting position – not leaning forward or back.

Once you are set, carefully lift one foot a few centimeters off the floor. Maintain your balance, lumbar and pelvic alignments as you hold the position on one leg.

Hold for a count of 5 to 10, maintaining form. Perform 5 reps each side.

Progression: Keeping the lifted foot only just off the floor, straighten the leg in front of you, stretching the hamstring. Resist any tilting of your pelvis as the leg straightens by keeping a good hold of the abdominals and maintaining posture against the stretch.

Supine Swiss Ball Bridge

Overview: A posterior-chain exercise (hamstrings, gluteals and back), where the aim is to hold perfectly straight hip and back alignment against the load of your bodyweight and the instability of the ball. A big co-contraction of the trunk muscles is required to perform this exercise well.

Level: Intermediate

Muscles targeted: Gluteals Hamstrings Erector spinae Abdominals Obliques

Technique: Lie on your back with heels on the top of the Swiss ball, hip-width apart to aid stability. Suck in the abs and squeeze up from your gluteals, lifting your hips until there is a straight line from heels to upper back. Shoulders and head stay firmly on the floor. Take care not to lift the hips too high or flare the ribs so that your back hyperextends.

Hold for 30 seconds and lower under control. Perform 2 to 3 sets.

Progression:

i. Place the feet close together on the ball to increase the balance challenge as you lift your hips.

ii. Roll your legs slowly from side to side with control, keeping hips up for an advanced level of challenge.

Swiss Ball Gluteal Bridge

Overview: A second posterior-chain exercise. But with the knees bent and the weight bearing down through the feet, the work is felt mainly in the gluteal muscles

Level: Intermediate

Muscles targeted: Gluteals Erector spinae Abdominals Obliques

Technique: Lie on your back with your shoulders and head on the top of a Swiss ball; feet on the ground, hip-width apart for stability.

Squeezing up from the gluteals, lift hips until there is a straight line running through the knees, hips and shoulders. Do not lift the hips too high or flare the ribs so that your back hyperextends.

Hold for 30 seconds and lower under control. Perform 2 to 3 sets.

Progression:

i. Place the feet close together to increase the balance challenge.

ii. Single-leg bridge, alternating legs with 5 second holds, is an advanced challenge.

Swiss Ball Plank

Overview: A challenging strength exercise for abdominals, focusing on maintaining good alignment of the spine.

Level: Intermediate to advanced

Muscles targeted: Abdominals

Technique: Kneel in front of the Swiss ball and place elbows on the top of the ball in the center. Slowly roll the ball away from your body until there is a straight line through knees, hips and head and your weight is being supported through your elbows down on to the ball.

Once in this position it may be necessary to tilt the pelvis so that it is held in neutral with correct lumbar spine alignment. Also be careful not to round off the shoulders: aim for a ‘long spine’. The better your spinal alignment, the harder the work for the abdominals. If the main pressure is felt in the low back, either your alignment is incorrect or you have insufficient abdominal strength-endurance to hold the correct line.

Hold at the far point for 30 to 60 secs with good form. Perform 2 to 3 sets.

Progression: Move the ball around, forward, left and right with your upper body whilst keeping your hips in place and your head still in its alignment.

Menu 4: Swiss Ball, Dynamic

These exercises challenge trunk strength. The use of the Swiss ball both increases the difficulty because of the instability, and allows you to work through useful ranges of movement. This menu targets the front, back and side of the trunk musculature at intermediate to advanced level.

Swiss Ball Back Extension

Overview: The use of the ball for this exercise allows the movement to isolate back extension without hip extension; and to co-ordinate upper back extension with lumbar extension.

Level: Intermediate Muscles targeted: Erector spinae (lumbar and thoracic portions)

Technique: Kneel over a Swiss ball with thighs and stomach in contact with the ball and head and shoulders dipping over the front of the ball. With your back straight and parallel to the floor, position the lumbar spine in neutral and then set your hips so they do not move.

Allow the chest to drop and fall over the ball, flexing the upper back. Place your hands at the sides of the head, elbows bent. From this position, lift your chest up, extending your upper back until it is higher than at the starting position. Maintain abdominal contraction throughout to fix the hips and limit hyperextension of the lumbar spine.

Perform 10 reps under control, increasing to 20 reps; 2 to 3 sets.

Progression: Add a light dumb-bell held behind the head for extra resistance.

Swiss Ball Overhead Pulls

Overview: The use of the ball for this exercise allows full extension of the body. The abdominals have to work hard to support the spine as the arms extend and pull back. Very good for shoulder stability.

Level: Intermediate to advanced

Muscles targeted: Abdominals, Latissimus dorsi, Pectorals, Scapular stability muscles

Technique: Start in the press-up position with your shins on the ball and hands shoulder width apart under shoulders. Place knees apart slightly for stability. Set lumbar spine in neutral and ensure that the shoulders are stable with shoulder blades down and chest out.

Roll backwards until your hands are above your head, maintaining straight body position and neutral low back. Use your abs, ensuring your hips do not drop. Brace your abs and pull yourself forwards to return to the start position.

Perform 5 reps with good form, increasing to 10 reps; 2 to 3 sets.

Progression: Lengthen your bridge position by starting with feet alone on the ball. The abs have to support more bodyweight.

Swiss Ball Squat Thrust

Overview: The old-school exercise transposed to the ball. This allows for a focus on the flexion of the hips and low back, maximizing the use of abs. Holding the position through several reps is a great strength-endurance challenge for the abdominals. Unlike the traditional version where speed is of the essence, the Swiss ball version is more demanding if performed slowly with control.

Level: Intermediate

Muscles targeted: Abdominals

Technique: Start in the press-up position with shins on the ball, hands shoulder-width apart under the shoulders. Place knees slightly apart for stability. Set lumbar spine in neutral and ensure shoulders are stable with shoulder blades down and chest out.

Pull knees to your chest and crunch the abs to get an extra flex of the hips and back. Slowly extend knees back, using your abs to prevent the hips dropping down.

Perform 10 reps slowly, increasing to 20 reps; 2 to 3 sets.

Progression: Perform the squat thrust and the overhead pull as a combination exercise.

Swiss Ball Side Crunch

Overview: An excellent exercise for the obliques. The Swiss ball simply replaces the need for a frame or partner support for your legs. Electromyography research has shown this exercise delivers high recruitment levels of the obliques.

Level: Intermediate

Muscles targeted: Obliques

Technique: Position your- self sideways on the ball, balanced on lower hip with top hip stacked vertically. Brace feet against a wall, one slightly in front of the other for stability. Ensure a straight line through legs, hips and shoulders. Place your hands, elbows bent, by your head.

Lift upper body up away from the ball, crunching sideways towards your feet and focusing upon your oblique muscles. Slowly return, under control.

Perform 10 reps, increasing to 20 reps; 2 to 3 sets.

Progression: Hold a weight across your chest to increase the load.

Menu 5: Pulley, Kneeling

Bodyweight-only exercises by definition have strict limits on your ability to increase the load against which the muscles are working. So the main tool for progression is to increase the number of sets and reps being performed, which is good for muscular endurance, but not for pure strength.

The pulley system allows us to treat trunk training like limb training, working at higher resistance levels as your strength improves. Overall, these exercises are advanced.

Chop Rotation

Overview: Excellent for dynamic trunk rotation strength co- ordinated with the upper body. This exercise and its pair are functional to many sporting and daily life movements. When performed in the kneeling position, the exercise requires dissociation between the pelvis and shoulder rotation, which is a great stability challenge.

Level: Advanced

Muscles targeted: Abdominals Obliques (Plus upper body)

Technique: Kneel, facing forwards, by the side of the pulley column. Handle attachment is set at (standing) head height. Fix the hips square to the front and set your lumbar spine in neutral. Twisting through the waist, turn shoulders towards the pulley column and grasp the handle with both hands. Pull down on the handle, rotating your shoulders away from the column and crunching down. Finish with hands by your hips and shoulders facing away. Hips remain square to the front throughout the movement.

Perform 8 to 10 reps; 2 to 3 sets each side.

Progression: Increase the weight, keeping to sets of 8 to 10 reps.

Lift Rotation

Overview: The natural opposite to the chop movement exercise. Perform these two as a pair to ensure balanced development of trunk rotation strength. The lift movement requires co-contraction of the low back muscles with the obliques to produce the rotation.

Level: Advanced

Muscles targeted: Erector spinae Obliques (Plus upper body)

Technique: Kneel, facing forwards, by the side of the pulley column. Handle attachment is set just below (kneeling) hip height. Fix hips square to the front and set your lumbar spine in neutral. Twisting through the waist, turn shoulders towards the pulley column and grasp the handle with both hands. Pull up on the handle, rotating the shoulders away. Finish with hands above your head and shoulders facing away from the column. Hips remain square to the front throughout.

Perform 8 to 10 reps; 2 to 3 sets each side.

Progression: Increase the weight, keeping to sets of 8 to 10 reps.

Pulley Crunch

Overview: This is a pure trunk flexion movement targeting the development of abdominal strength. The use of the weights allows for high resistances. Care must be taken to fix the hips throughout the exercise, otherwise the hip flexors will contribute, significantly reducing the training effect on the abdominals.

Level: Advanced

Muscles targeted: Abdominals

Technique: Kneel with back to the pulley column, holding a rope attachment with each hand around your neck. Start with hips fully extended (ie, kneeling fully upright) and pelvis set in neutral. Shoulders, hips and knees should all be in line and upright.

Focusing on the abs, crunch down, pulling the weight and flexing your trunk forward. The arms simply hold on – avoid using them to assist in pulling the weight. Ensure the pelvis remains set and stable throughout: all the movement comes from the spine flexion, so there should be no hip flexion, forward lean or forwards pelvic tilt.

Perform 5 to 10 reps; 2 to 3 sets.

Progression: Increase the weight, keeping to sets of 5 to 10 reps.

Weak buttocks destroy the runner. Discover just how, by firming up your buttocks, you can improve your performance. Science based core chiropractor, Dr. Alexander Jimenez evaluates the case.

How many routine runners would suspect that the upper buttock muscle (gluteus medius) is the offender in very many running overuse injuries? This fact is less surprising once you understand that through running you're always either completely in the air or dynamically balanced on one leg -- and in both conditions the gluteus medius is a key muscle.

Situated on the upper edge of the hip (see below), gluteus medius is responsible for lifting the leg away from the body (abduction), enabling it to bend inwards and outwards, and crucially, keeping the pelvis stable in some certain situations, including the stance phase of running.

During right stance phase, for example, the muscle contracts to slow the downward movement of the left side of the pelvis so that the pelvis does not tilt heavily towards the ground. If the gluteus medius isn't working well enough to accomplish this control, the athlete is said to have a 'Trendelenburg gait'. Frequently, but not necessarily, the exact same weakness could be noticeable in walking, making a waddling motion or, in extreme cases, a limp.

Adaptations

Runners that have a weak or easily fatigued gluteus medius are very likely to make various adaptations to their technique, which can hide the true reason for a running injury. Table 1 lists the adaptations or cheating movements that happen through the stance phase of running.

Adaptations 3 and 2 obviously cannot occur simultaneously, however a runner's technique may demonstrate a combination of adaptations, such as a mild Trendelenburg, inwards knee drift and a same-sided trunk shift.

In my experience, runners using inferior lively pelvic stability, for which gluteus medius is vital, will decrease their stride length and embrace a much more shuffling pattern to decrease the ground reaction force at contact and consequently the muscle control necessary to keep pelvic posture.

Weakness at gluteus medius will have consequences all the way down the kinetic chain. With Adaptation 2, for example, the buttock weakness will create inward drifting and rotating throughout the leg while running, which will leave the runner at higher risk of any condition concerning excessive or prolonged pronation of the foot, such as shin splints (medial tibial stress syndrome) or Achilles tendinitis.

An extremely informative analysis by Fredericson et al (2000)1 upholds the thought that gluteus medius weakness is a contributing element in ITB friction syndrome; affirms that injured and uninjured sides can be compared to ascertain weakness; also endorses retraining for strength gains as an effective treatment.

Fredericson measured hip abductor power in a group of injured male and female subjects, and found an average deficit of 2 percent in gluteus medius power on the injured side compared to the uninjured. Following a six-week retraining program, typical hip abductor torque improved by 34.9 percent for females and 51.4 per cent for males; 22 of the 24 injured athletes could return to running pain free. Above all, at a six-month follow-up no injury recurrences were reported.

Reference
1. Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA, ‘Hip abductor weakness in distance runners with iliotibial band syndrome’. Clin J Sport Med. 2000 Jul;10(3):169-75.

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The research findings might surprise you! Core chiropractic specialist, Dr. Alexander Jimenez investigates.

In the past ten years large inflatable plastic balls variously called Swiss balls, match balls or stability balls are becoming required gym gear. Ranks of them line the back walls of course studios, a few constantly lurk in the abs and stretch area and, increasingly, they are stored at the free weights area. They'll also be present in almost any self-respecting sports physiotherapy clinic.

Within a very similar period of time, 'core stability' has invaded the world of recreational sport and fitness, altering traditional approaches to training and keep fit at all levels of aspiration. And in the realm of core stability, Swiss balls have become crucial, almost synonymous with the very concept. If you are serious about core conditioning, you work out with a Swiss ball.

But are these cheap, cheerful, outsized space hoppers warrant their popularity concerning effectiveness? Sports science research goes a way towards helping us solve the issue of if Swiss balls are beneficial or just fashionable.

The fitness trainer Paul J Goodman argues that Swiss ball- based exercises are the key to effective improvements in back strength. Since activities done on the ball involve higher stimulation of the body's 'neuromuscular system', users build better balance, co-ordination and proprioception (sense of bodily awareness in distance), Goodman states. All these assertions are not backed up with any research references -- instead, they come from Goodman's experience of working with clients using Swiss balls.

Evidence to support the efficacy of Korean ball exercises comes in a piece of research in the Canadian lab. Kathryn Clark and her research team at Dalhousie University's School of Health and Human Performance compared the electro- myographic (EMG) activity of the upper stomach (rectus abdominis) muscle through various abdominal exercises2. By measuring the level of electrical activity, EMG provides an indication of the amount of muscle activity going on. Elevated levels of EMG are connected with high forces and a larger number of muscle fibers being recruited.

Clark's team studied several abdominal exercises: the curl upward (flooring), Swiss ball pops upward, reverse osmosis, ab roller curl up, Swiss ball roll-out to bridge, and supine leg-lower. The typical level of EMG activity for three repetitions of each exercise has been calculated as a proportion of each area's maximum level of EMG activity.

The most EMG for the upper abdominal muscle was determined by the topic performing a 'maximal voluntary contraction' (strongest muscle power potential) during the ab crunch movement against an immovable resistance created by a trainer pushing down the subject's shoulders.

The researchers discovered that the Swiss ball pops resulted in the highest EMG score out of all the ab exercises, at roughly 90 percent of maximum EMG -- significantly higher; for instance, compared to ab curl on the ground, which listed an EMG amount of approximately 70 percent.

Support for Clark's findings comes from another Canadian writer, Stuart McGill 3. His team also looked at the EMG activity of this Swiss ball ab curl versus the ab curl around the ground. McGill reports that the EMG activity of the upper abdomen and oblique muscles is higher whenever the ab curl has been done on the Swiss ball. Thumbs up for the Swiss ball up to Now.

Another piece of research looked at the Swiss ball from a different angle. David Behm and staff, from the Memorial University of Newfoundland, in comparison how much muscle force was used to do exercises under stable (on a bench) versus unstable (on a Swiss ball) conditions. They examined muscle power and EMG of the very front of thigh (quadriceps) muscle during leg extension and calf muscle during plantar-flexion (toe- extending), in stable and unstable modes, also noting that the electrical action of these opposing (antagonist) muscles (hamstrings and dorsiflexors).

This generated some unexpected outcomes. As may be anticipated, the leg extension and plantar-flexion forces were higher where the subject was steady, seated on the seat rather than on the Swiss ball. However, while the front-of-thigh and calf electrical activity was lower throughout the shaky movement, the EMG of the opposing muscles (hamstring and dorsiflexors) improved. This suggests that the amount of activity of the principal muscles (prime movers) is inhibited through shaky exercise, with increased muscular activity happening in the opposing muscles. So Swiss balls are not going to be the ideal way of developing prime-mover muscle strength.

The Newfoundland researchers didn't measure the impact of the various training surfaces on core muscle EMG (including the abdominals), however, the chances are that it might have improved appreciably over the Swiss ball, since the disturbance has the effect of dispersing the forces within a larger amount of joints and placing more stress on busy stabilizing muscles, thereby limiting the pressure directed via the prime-mover muscles.

Basically, the Swiss ball alters the activity from pure leg extension to leg extension while controlling the body. It transforms the movement into a stability/proprioception exercise rather than a limb-strengthening workout.

So while this research doesn't encourage the use of Swiss ball for strength exercises of the leg muscles, it will indirectly support Swiss ball exercises for use in core stability programs.

Together, these research findings will give encouragement to devotees of Swiss ball training as well as the growing number of trainers and therapists that prescribe ball-based exercises most of the time for all muscle groups, in the belief that this may enhance core stability and 'make the workout more operational'.

I regularly see athletes and fitness center users doing many exercises on chunks, such as core power, a selection of dumb-bell upper body exercises such as bench press, and squatting movements. Before we leap in and endorse this kind of approach, a couple observations and questions are in order.

Q: Can The Swiss Ball Automatically Increase Core Muscle Activation?

To do so, look not in the concept, but at what happens in training. Just because a research article indicates an increased core training impact can be obtained does not mean that the ordinary gym user or rehab patient will be able to reap those benefits. This is because it's the quality of the individual's technique, not the gear you use, which overwhelmingly determines how effective the exercise is.

Let us take the Swiss ball ab curl, which the investigators have proved includes a superior training impact to the model done lying on the floor. Typically I have observed, the exerciser working out on the Swiss ball does not have sufficiently good technique to be gaining any substantial benefit.

What normally happens is that the exerciser simply pivots their low back around the curvature of the ball, levers their shoulders up and probably uses their hip flexors to help pull their back up. This lever activity significantly lowers the load on the abdominals and side stomach (oblique) muscles.

These gym-goers have never been taught the way to fix their pelvises using the buttock muscles (gluteals), so that the pelvis holds fast as the shoulders curl up the ball off. Unless you have this degree of technique (which means, by the way, that you currently have some core power), then you'll be better off doing the exercise on the floor.

Swiss ball 'roll ups' -- because I predict the bad-technique variant -- are easy and anyone can perform many repetitions without any benefit. Swiss ball curl ups -- adjusting the clitoris with strict technique -- are tough, and sets of 10 reps will be hard for most people.

Using the Swiss ball, then, is no guarantee of increased training achievement. Balls alter exercises -- generally making them more advanced -- and you'll need superior power and strategy to carry out the modified exercises efficiently. Instructors should always put technique and correct muscle recruitment ahead of any 'favorite' piece of equipment. If the exerciser can't utilize the targeted muscle groups efficiently or control the unstable surface satisfactorily, then the exercise will not have the desired effect and the instructor should find an alternative.

Q: Are Swiss Ball Exercises Suitable For People With Low Back Issues?

If Swiss ball curl ups (with good technique) are very capable of challenging the abdominals, McGill's research alerts us to elevated levels of trunk muscle 'co-contraction', which is connected with increased spinal loading. This is important for anyone undertaking injury rehab for their back: you'll need to take great care to not over stress your recovery back once you use a Swiss ball.

McGill also challenges another modern instability fashion, for example Swiss chunks or air cushions as convenient sitting surfaces at the office (a Swiss ball and frame is designed to replace your office chair). The rationale is to help the individual strengthen their trunk muscles during daily activity and maintain their spine mobile throughout the day. McGil's study shows that spinal loads are greater on unstable surfaces in contrast to sitting on a chair. He wouldn't recommend this for his patients.

Q: Why Perform Leg & Arm Exercises On The Swiss Ball?

It is very common these days to see people in the gym performing conventional strength exercises on Swiss balls, often using dumb-bells or similar free weights, in the belief that this will make the actions somehow more 'functional' or assist them further enhance their core stability.

Yet as we've observed previously, the Newfoundland research discovered that the particular strength-training influence using Swiss balls is reduced, as exercise pressures are dissipated through the entire body.

The amount of weight lifted in a shoulder press exercise on a Swiss ball is significantly less than when sitting on a bench.

There's little additional benefit, in fact. The dumb-bell bench press, for example, already requires co-ordination of elbow and shoulder and stability in the trunk, even when performed on the stable bench. When the exercise is moved to a lying position on the ball, the truth is that the leg muscles are quite active and provide a lot of the stabilizing function to restrain the moving ball below the spine as the dumb-bells are pressed down and up. This is only because the legs would be the natural anchors when lying on your back on a ball.

In general, then, I would argue that it's more efficient to lift heavier weights and gain the entire strength advantage with conventional (and steady) leg and arm exercises, and then compliment these with specific exercises for the back muscles which are guaranteed to target the core. More research is required to establish the complete range of benefits and limitations of using Swiss balls, but in the absence of scientific support, you'd do well to not assume that everything done on a ball adds value to your training regiment. Some of it might perform (if you are already advanced enough in your fitness and strategy to cope with it); other exercises will do you little or no good and in case you have a low back injury you may be impeding the healing process.

References
1. Goodman P, Performance Training Journal of the US National Strength and Conditioning Association, vol2 no6 p9-25
2. Clark et al, Journal of Strength and Conditioning Research 2003 17(3), 475-483
3. McGill S, ‘Low Back Disorders’, Human Kinetics 2002
4. Behm D et al, Journal of Strength and Conditioning Research 2002 16(3), 416-422

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We're not supposed to sit around all day. So when we do, here's what happens. Core chiropractor, Dr. Alexander Jimenez investigates this way of life for so many.

Sitting for extended periods during the day may adversely affect your performance in your chosen sport and can be quite frequently a predisposing factor in injury. The majority of us are not professional athletes and invest huge amounts of daily sitting hunched over a computer, at a car or slumped on the couch.

In most individuals, prolonged sitting will cause all or a few of the following:

The better the position one can maintain during the day, the less likely it is that the aforementioned areas will become debatable. Conversely, the older the athlete and the more time spent sitting down over time, the further ingrained these issues will be.

Let's consider Jack, a 30-year old delivery guy who is attempting to break a three-hour marathon time. His training is being increasingly affected by the low back and rear thigh distress he feels whenever he tries to run more than 15km. Jack sits the majority of the day in rather bad posture, slouched over with his knees out to the side. All of which has generated some muscle imbalances, weaknesses and restrictions on his range of hip motion through recent years.

Jack's daily training regimen and flexibility program have to be corrected to combat the hours that he spends sitting at the truck. Now meet Denise, a 40-year-old lawyer and triathlete who spends hours on end, day and night, in front of a computer, and then more hours sitting on a bike -- mostly in the hunched 'aero' position. Denise has an increased curvature of the mid-spine plus also a 'poked chin'. She also has several muscular imbalances and weaknesses, and flexibility limits in her shoulders and mid-spine. These can endanger Denise's efficiency in her swimming stroke, and worse still make her a traditional candidate for a shoulder impingement/tendinitis injury -- the last thing she would want leading up into a qualifying race.

Exactly like Jack, Denise should undertake daily flexibility exercises and regular standing to combat the consequences of spending so much time in a seated position. She'll also need a workout program to train postural and shoulder equilibrium muscle groups.

Intense sitting has also been associated with acute muscle breeds in lively sports, particularly hamstring strains. The lower spine stiffness related to sitting contributes to transformed neural input into the back thigh, the theory goes. This may manifest as increased muscle tone of their hamstrings, which will increase the danger of strain.

Sit Up & Pay Attention

The solution begins with education. You must first learn how to set your body into good posture during the day; the way to hold your spine in a correct position. Lots of people try to sit up tall by just leaning back in the base of the backbone without altering their mid-spine or shoulder posture. What you should do is finding a neutral lower spine position and correcting your mid- to upper-back position, so that you may effectively pull your shoulder blades down your back working with the reduce shoulder muscles, combatting the propensity to hunch forward.

But it's extremely hard to hold good posture if your workstation is badly set up; for example with the computer keyboard too high or sat at an old seat with a sloping back-rest. A workplace evaluation should help by changing the height and positioning of office equipment or introducing corrective devices to help with great sitting.

Jack may require a lumbar roll to get his low back from flexion and a block beside the vehicle's door to stop his knee and cool out of falling outwards to the side all of the time. Denise might need to elevate the height of her monitor to eye level, lower the keyboard height so that her hands are at elbow level, and utilize a postural brace for her shoulder girdle and upper back while she is relearning to sit correctly. Seating wedges are very useful where chairs are too low (which forces you to sit with your knees higher than your hips and sets your lower back to flexion). The wedge is also very handy to fix bucket seats in cars.

Sourced From:

Sean Fyfe

Science chiropractor, Dr. Alexander Jimenez investigates the methods described in treating a tight calf muscle.

Assess The Calf Complex

In the calf complex, the medial sural nerve descends between the two gastrocnemius heads and also at mid-calf level combines with a branch of the peroneal nerve to form the sural nerve(1,2). As we get older, the body's connective tissue gets less pliable. Nerves are naturally surrounded by connective tissues -- sometimes they even run through connective tissues, so with aging the nerves can get trapped, trapped or tethered to surrounding muscle or fascia(3).

This can manifest as a feeling of tightness deep in the calf muscle that never changes, no matter how much the customer stretches the muscles.

Action! Evaluate The Calf

The perfect method to appraise the calf is to palpate the muscle in a relaxed position (see Fig 1. below). Begin with your patient's unaffected calf; palpate (feel) deeply between the gastroc heads supporting the knee and work down the calf into the Achilles tendon. This will give you a sensation of the deep neuro myofascial tissue enclosing the tibial nerve, and what 'normal' feels like in this patient. Beware: it's generally quite uncomfortable to do so because of the sensitive neural structures.

Then feel the affected calf in the exact same way. If there is a difference in the deep center section (eg tightness, pain, lumpiness) and if, when you press, then it replicates their usual 'pain' or 'tightness', it might indicate a nerve tethering problem that needs hands-on intervention.

Assess the nerves of the lower limb by using the slump test (see Fig 2, below) or the straight leg raise test to cross-check your client's neural system and compare sides.

Treat The Neural Calf Complex

Once you've found something asymmetrical, you can treat the problem.

Warning: this therapy could be painful, but in my experience you need to treat very firmly to get results. Warn your patient.

Action! -- Friction The Deep Structures

In the exact same position (see Fig 3, below), ensure finger tips are together and palpating right on the tight, painful area. With firm pressure, friction across the line of the nerve with your finger tips going into the left with both hands and then to the right (firm treatment is essential).

Repeat this along the length of the tibial nerve down the area where the patient has identified a difference in the feel compared to the other side. After you have loosened the neuro-myo-fascial constructions, get your client to walk or jog to see how it feels.

Action! Educate Your Client To Self-Treat

Sitting with knees bent, they should use their thumbs to palpate; ensure they can replicate the sensation you produced with your treatment. This way, your active patient can make chronically tight and painful calves a thing of the past.

Sourced From:

Individuals can become overly passionate about exercising. However, constantly training the body without taking enough time to rest and recover can impact athletes and fitness enthusiasts physically and mentally and lead to overtraining syndrome. Excessive training can cause decreases in athletic physical performance that can be long-lasting, sometimes taking several weeks or months to recover. Individuals who don't learn to manage overtraining can have injuries and more frequent illnesses and infections. And the psychological effects can also lead to negative mood changes. Learn the signs and how to cut back to prevent injury and/or burnout.

Overtraining Syndrome

Athletes and fitness lovers often exercise longer and harder than average to reach peak performance. Even individuals just getting started with exercise can push their limits as they try to figure out what works for them. This means taking into consideration the following:

• The mental side of training.
• How to get and stay motivated.
• How to set up a safe and effective program with balanced cardio and strength training.
• How to avoid skipping workouts when things get in the way.
• Exercising too much is a mistake many beginners make, putting themselves at risk for injury.

Overtraining syndrome is when the body goes through and feels:

• Extreme fatigue.
• Physical performance problems.
• Mood changes.
• Sleep disturbances.
• Other issues due to working out or training too much and/or too hard without giving the body enough time to rest.

Overtraining is common among athletes who train beyond their body's ability to recover, usually when preparing for a competition or event. Conditioning for athletes and enthusiasts requires a balance between work and recovery.

Signs and Symptoms

There are several signs to look for, with the more common symptoms being:

• Mild muscle or joint soreness, general aches, and pains.
• Decreased training capacity, intensity, or performance.
• Lack of energy, constantly tired, and/or drained.
• Brain fog.
• Insomnia.
• Decreased appetite or weight loss.
• Loss of enthusiasm for the sport or exercise.
• Irregular heart rate or heart rhythm.
• Increased injuries.
• Increased headaches.
• Feeling depressed, anxious, or irritable.
• Sexual dysfunction or decreased sex drive.
• Lower immunity with an increase in colds and sore throats.

Prevent Overtraining

• Predicting whether there is a risk of overtraining can be tricky because every person responds differently to various training routines.
• Individuals have to vary their training throughout and schedule adequate time for rest.
• Individuals who believe they may be training too hard should try the following strategies to prevent overtraining syndrome.

Take Note of Mental and Mood Changes

Methods exist to test for overtraining objectively.

• One is taking note of psychological signs and symptoms associated with changes in an individual's mental state can be an indicator.
• Decreased positive feelings for exercise, physical activities, and sports.
• Increased negative emotions, like depression, anger, fatigue, and irritability, can appear after a few days of intense training.
• If these feelings and emotions begin to present, it is time to rest or dial the intensity down.

Training Log

• A training log that notes how the body feels daily.
• It can help individuals notice downward trends and decreased enthusiasm.
• This can help individuals learn to listen to their body's signals and rest when necessary.

Monitor Heart Rate

• Another option is to track changes in heart rate over time.
• Monitor heart rate at rest and specific exercise intensities while training, and record it.
• If the heart rate increases at rest or a given intensity, this could be a risk indicator, especially if symptoms develop.
• Track resting heart rate each morning.
• Individuals can manually take a pulse for 60 seconds immediately after waking up.
• Individuals can also use a heart rate monitor or fitness band.
• Any marked increase from the norm may indicate that the body has not fully recovered.

Treatment

Rest and Recovery

• Reduce or stop the exercise and allow the mind and body a few rest days.
• Research on overtraining shows that complete rest is the primary treatment.

Take Extra Rest Days

• Starting anything new will usually make the body sore.
• Be prepared for the aches and take extra rest days when needed.
• The body won't have the same energy levels from day to day or even from week to week.

Consult A Trainer

• Not sure where to start or how to approach working out safely.
• This is the time to meet with a professional who can look at physical and medical history, fitness level, and goals.
• They can develop a customized program to meet specific needs.

Nutrition and Hydration

• Maintain optimal body hydration with plenty of H2O/water and rehydrating drinks, vegetables, and fruits.
• Staying properly hydrated is key to both recovery and prevention.
• Getting enough protein and carbohydrates supports muscle recovery.
• Carbs are important for endurance, and protein is important for muscular strength and power.

Sports Chiropractic Massage

• Research shows that sports massage benefits muscle recovery and can improve delayed onset muscle soreness/DOMS.
• Massage keeps muscles loose and flexible and increases blood circulation for expedited recovery.

Relaxation Techniques

• Stress-reduction techniques such as deep breathing and progressive muscle relaxation exercises can improve rest and recovery.

Total recovery from overtraining syndrome can take a few weeks or longer, depending on the individual's health status and how long the excessive training has gone on. A physician can refer individuals to a physical therapist or sports chiropractor, who can develop a personalized recovery plan to get the body back to top form.

Military Training and Chiropractic

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make 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 various 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, don't hesitate to get in touch with 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

Bell, G W. "Aquatic sports massage therapy." Clinics in sports medicine vol. 18,2 (1999): 427-35, ix. doi:10.1016/s0278-5919(05)70156-3

Carrard, Justin, et al. "Diagnosing Overtraining Syndrome: A Scoping Review." Sports Health vol. 14,5 (2022): 665-673. doi:10.1177/19417381211044739

Davis, Holly Louisa, et al. "Effect of sports massage on performance and recovery: a systematic review and meta-analysis." BMJ open sport & exercise medicine vol. 6,1 e000614. 7 May. 2020, doi:10.1136/bmjsem-2019-000614

Grandou, Clementine, et al. "Symptoms of Overtraining in Resistance Exercise: International Cross-Sectional Survey." International Journal of sports physiology and Performance vol. 16,1 (2021): 80-89. doi:10.1123/ijspp.2019-0825

Meeusen, Romain, et al. "Brain neurotransmitters in fatigue and overtraining." Applied physiology, nutrition, and metabolism = Physiologie applique, nutrition et metabolisme vol. 32,5 (2007): 857-64. doi:10.1139/H07-080

Peluso, Marco Aurélio Monteiro, and Laura Helena Silveira Guerra de Andrade. "Physical activity and mental health: the association between exercise and mood." Clinics (Sao Paulo, Brazil) vol. 60,1 (2005): 61-70. doi:10.1590/s1807-59322005000100012

Weerapong, Pornratshanee, et al. "The mechanisms of massage and effects on performance, muscle recovery, and injury prevention." Sports medicine (Auckland, N.Z.) vol. 35,3 (2005): 235-56. doi:10.2165/00007256-200535030-00004

Any form of physical sports activity puts the body at risk for injury. Chiropractic care can prevent injury for all athletes, weekend warriors, and fitness enthusiasts. Regular massaging, stretching, adjusting, and decompressing enhances strength and stability, maintaining the body's readiness for physical activity. A chiropractor assists in sports injury prevention through analysis of the body's musculoskeletal system addressing any abnormalities from the natural frame and adjusts the body back into proper alignment. Injury Medical Chiropractic and Functional Medicine Clinic provides various sports injury prevention therapies and treatment plans personalized to the athlete's needs and requirements.

Sports Injury Prevention

Individuals involved in sports activities push themselves through rigorous training and play sessions to new levels. Pushing the body will cause musculoskeletal wear and tear despite meticulous care and training. Chiropractic addresses potential injuries by proactively correcting the problematic areas within the musculoskeletal system to improve body functionality. It ensures that all system structures, spine, joints, muscles, tendons, and nerves are working correctly and at their healthiest, most natural state.

Performance

When muscles are restricted from moving how they are designed to, other areas over-compensate and over-stretch to make the movement possible, increasing the risk of injury as they overwork. This is how the vicious cycle starts. Regular professional chiropractic:

• Regularly assesses the alignment of the body.
• Keeps the muscles, tendons, and ligaments loose.
• Spots any imbalances and weaknesses.
• Treats and strengthens the imbalances and deficiencies.
• Advises on maintaining alignment.

Treatment Schedule

Consecutive treatments are recommended to allow the musculoskeletal system to adapt to regular treatments. This allows the therapists to get used to how the body looks, feels, and is aligned. The chiropractic team gets used to the body’s strengths and weaknesses and learns the areas that need attention during each treatment. Initial treatment could be every week or two, allowing the chiropractor to spot any discrepancies in movement patterns and giving the body a chance to acclimate to the therapy. Then regular treatment every four to five weeks depending on the sport, training, games, recovery schedule, etc., helps maintain a relaxed, balanced, and symmetrically aligned body.

Pre-Workouts

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make 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 various 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, don't hesitate to get in touch with 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

Hemenway, David, et al. “Injury prevention and control research and training in accredited schools of public health: a CDC/ASPH assessment.” Public health reports (Washington, D.C.: 1974) vol. 121,3 (2006): 349-51. doi:10.1177/003335490612100321

Nguyen, Jie C et al. “Sports and the Growing Musculoskeletal System: Sports Imaging Series.” Radiology vol. 284,1 (2017): 25-42. doi:10.1148/radiol.2017161175

Van Mechelen, W et al. “Incidence, severity, etiology and prevention of sports injuries. A review of concepts.” Sports medicine (Auckland, N.Z.) vol. 14,2 (1992): 82-99. doi:10.2165/00007256-199214020-00002

Weerapong, Pornratshanee et al. “The mechanisms of massage and effects on performance, muscle recovery, and injury prevention.” Sports medicine (Auckland, N.Z.) vol. 35,3 (2005): 235-56. doi:10.2165/00007256-200535030-00004

Wojtys, Edward M. “Sports Injury Prevention.” Sports health vol. 9,2 (2017): 106-107. doi:10.1177/1941738117692555

Woods, Krista et al. “Warm-up and stretching in the prevention of muscular injury.” Sports medicine (Auckland, N.Z.) vol. 37,12 (2007): 1089-99. doi:10.2165/00007256-200737120-00006

Whenever stepping out onto a playing field or gym, there is a risk of suffering sports back injuries. Back pulls, strain and sprain injuries are the most common. Low back pain is one of the most prevalent complaints at all levels of competition. 90% of these acute back injuries will heal on their own, usually in about three months. However, sometimes these injuries can be more severe and require professional medical care. Treatment options for different groups of athletes include nonsurgical motorized spinal decompression.

Sports Back Injuries

Injury mechanisms vary from sport to sport, but there are recommendations regarding spinal decompression treatment for these injuries and return to play. Chiropractic healthcare specialists understand the sport-specific injury patterns and treatment guidelines for athletes following a back injury. Spinal decompression treatments are beneficial and result in higher rates of return to play depending on the specific sport of the injured athlete. A chiropractor will create a personalized spinal decompression treatment plan for the sport-specific context to meet the athlete's short and long-term needs.

• An estimated 10–15% of athletes will experience low back pain.
• All types of sports place increased stress on the lumbar spine through physically demanding and repetitive movements/motions.
• The repetitive shifting, bending, twisting, jumping, flexion, extension, and spinal axial loading motions contribute to low back pain even though the athletes are in top shape with increased strength and flexibility.
• Injury patterns demonstrate the increased stresses that athletes place on the lumbar spine.

Common Spine Sports Injuries

Cervical Neck Injuries

• Stingers are a type of neck injury.
• A stinger is also known as a burner is an injury that happens when the head or neck gets hit to one side, causing the shoulder to be pulled in the opposite direction.
• These injuries manifest as numbness or tingling in the shoulder from stretching or compressing the cervical nerve roots.

Lumbar Lower Back Sprains and Strains

• When trying to lift too much weight or using an improper lifting technique when working out with weights.
• Fast running, quick stopping, and shifting can cause the low back and hip muscles to get overly pulled/stretched.
• Staying low to the ground and springing/jumping up can cause abnormal stretching or tearing of the muscle fibers.

Fractures and Injuries to the Supporting Spinal Structures

• In sports that involve repetitive extension movements, spinal stress fractures are relatively common.
• Also known as pars fractures or spondylolysis, these happen when there is a crack in the rear portion of the spinal column.
• Excessive and repeated strain to the spinal column area leads to low back pain and injury.

Nonsurgical Spinal Decompression

Nonsurgical spinal decompression is motorized traction that is used to relieve compression pressure, restore spinal disc height, and relieve back pain.

• Spinal decompression works to gently stretch the spine changing the force and position of the spine.
• The gel-like cushions between the vertebrae are pulled to open up the spacing taking pressure off nerves and other structures.
• This allows bulging or herniated discs to return to their normal position and promotes optimal circulation of blood, water, oxygen, and nutrient-rich fluids into the discs to heal, as well as, injured or diseased spinal nerve roots.

DRX 9000 Decompression

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 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

Ball, Jacob R et al. “Lumbar Spine Injuries in Sports: Review of the Literature and Current Treatment Recommendations.” Sports medicine - open vol. 5,1 26. 24 Jun. 2019, doi:10.1186/s40798-019-0199-7

Jonasson, Pall et al. “Prevalence of joint-related pain in the extremities and spine in five groups of top athletes.” Knee surgery, sports traumatology, arthroscopy: official journal of the ESSKA vol. 19,9 (2011): 1540-6. doi:10.1007/s00167-011-1539-4

Lawrence, James P et al. “Back pain in athletes.” The Journal of the American Academy of Orthopaedic Surgeons vol. 14,13 (2006): 726-35. doi:10.5435/00124635-200612000-00004

Petering, Ryan C, and Charles Webb. “Treatment options for low back pain in athletes.” Sports health vol. 3,6 (2011): 550-5. doi:10.1177/1941738111416446

Sanchez, Anthony R 2nd et al. “Field-side and prehospital management of the spine-injured athlete.” Current sports medicine reports vol. 4,1 (2005): 50-5. doi:10.1097/01.csmr.0000306072.44520.22

Strength training: The Centers for Disease Control have estimated that around 16% of six to nineteen-year-olds in the US are overweight or obese. This comes from inactivity, no movement, exercise, and poor diet. On the other end, young athletes search for ways to gain an edge, often falling victim to steroids, and all of the negative effects they have.

This is where strength training comes in. This could be an answer to getting kids off the couch, moving, and offers a healthy alternative to the young athletes looking for that competitive edge. Fitness experts, doctors, health coaches, and parents say absolutely.

Strength Training

Kids' strength training is very different than strength training for adults. This exercise program focuses on:

• Controlled movements
• Proper technique
• Correct form
• Uses more repetitions
• Uses lighter weights.

This type of workout program can be done with:

• Free weights
• Weight machines
• Resistance bands
• A child's own body weight

The focus for children in strength training is not to bulk up, as this is not weightlifting, powerlifting, or bodybuilding. Fitness experts agree that these types of training regiments are not healthy or safe for children. The goal is to:

• Build strength
• Improve muscle coordination
• Enhance long-term health
• Rehabilitate injuries
• Prevent injuries

Added benefits of strength training can help young athletes improve performance through increased endurance.

Training Guidelines

It is fundamental to find a program that is safe and successful for children. Parents want a program that is designed specifically for kids, is supervised by a fitness professional with child experience, and most of all that it is fun. For strength training there is not a minimum age, however, the kids should be able to understand and follow directions.

Before starting a child on any new fitness program check with their doctor or healthcare provider.

A training program should include:

• A session should start with a 5-10 minute warm-up exercise/s like stretching and light aerobics.
• Every session should end with a cool-down combined with stretching and relaxation.
• Kids should not immediately be using weights until proper form and technique are learned.
• Kids should start with their own body weight, bands, or a bar with no weight.
• Using 6-8 different exercises that address all the muscle groups, begin with 8-15 repetitions.
• Each exercise should be done with a complete follow-through of the full range of motion.
• If the repetitions are too much with a specific weight, reduce the weight.
• Repetitions and sets should gradually increase over time to maintain the intensity of the training.
• Add more weight only when the child displays the proper form and can easily do at least 10 reps.
• Workouts should be 20 to 30 minutes long, 2 to 3 times per week to get the most benefit.
• Make sure to rest a day between each workout day.

Safety

Strength training was not always considered appropriate exercise for kids. Doctors and fitness professionals believed that it was unsafe for a child's growing body because of the added pressure on growth plates or the cartilage that has not fully turned into solid bone. Experts now know that with proper technique and supervision, kids can safely participate in a strength training program.

As with any type of exercise/fitness regiment, safety measures need to be in place along with heightened supervision. Most injuries happen when kids are not supervised, not using proper techniques, or from trying to lift too much weight. Here are some safety precautions to remember:

• Learning new exercises should be done under the supervision of a trainer/instructor making sure proper technique and form are used
• Smooth controlled motions should be the goal
• Controlled breathing and not holding their breath needs to be taught
• Proper technique will help avoid injuries
• The kids' progress should be monitored
• Have the children keep a record of the exercises they have done, how many reps, and the amount of weight/resistance.
• If enrolled in a strength training class, a good ratio is one instructor per 10 students. With this ratio, the kids can receive proper instruction and supervision.
• Kids should train in a hazard-free, well-lit, and properly ventilated facility.
• Make sure the kids drink plenty of water during and after the workout
• Fitness trainers/instructors will see to it that there are frequent rest and rehydration breaks

Keep in mind

In a strength training program for children, there should be no competitive drive. The focus should be on participation, learning the movements, and positive reinforcement. Set realistic goals and expectations for the child, so that they understand that it will take time to learn these new skills.

Remember that kids do not increase muscle size until after puberty. Make sure the kids enjoy the strength training sessions and that they are having fun. Keep in mind that kids can become easily bored. Therefore use a variety of exercises and routines keeping them excited and wanting to learn and do more.

Healthy Habits

Getting kids interested in fitness early on can help establish a life-long habit of wanting to be and stay healthy. This includes a balanced diet, plenty of rest, and regular exercise. When done correctly strength training can be a fun and highly beneficial activity.

PUSH Fitness

Dr. Alex Jimenez’s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate 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 also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to 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. The provider(s) Licensed in Texas& New Mexico

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.

Core chiropractor, Dr. Alexander Jimenez continues from part I through the core stability routines.

Menu 6: Pulley, Standing

This menu challenges pelvic stability during unilateral standing upper body movements. The kinds of arm movements undertaken in many sports create strong rotational forces that have to be controlled by the trunk and pelvic muscles. The aim of these exercises, therefore, is to develop co-ordination and control of the pelvis.

Research has shown that unilateral exercises increase the recruitment of the core musculature. The core and pelvic muscles will all be using static contractions to hold the required postures, while the upper body muscles will be producing the limb movements. The resistance load on the arm is secondary to the stability challenge of the core. Overall this menu is intermediate.

Rear Sling

Overview: The challenge of this exercise and its pair (see opposite) is to establish perfect pelvic alignment, while standing on one leg, against a rotational force from the upper body.

Level: Intermediate

Muscles targeted: Abdominal wall Adductors, Gluteus medius, (Deltoid and rotator cuff)

Technique: Stand on one leg to the side of the pulley column. Handle is attached at below-hip height. Grasp the handle with the hand on the opposite side (opposite to standing leg). Set perfect posture and pelvic alignment.

Brace the core and then pull the weight up and around the body, keeping the elbow straight, so that the arm rotates up and out. Finish with hand above your head and out to the side slightly. The aim is to maintain perfect balance and pelvic alignment as you raise and lower the arm diagonally. Reposition to repeat exercise for opposite leg/arm.

Perform 10 reps each side increasing to 20 reps; 2 to 3 sets.

Progression: Increase the weight.

Front Sling

Overview: This is the natural opposite of the rear sling exercise. It involves a forward arm rotation, which must be controlled.

Level: Intermediate

Muscles targeted: Abdominal wall Adductors, Gluteus medius, (Pectorals and rotator cuff)

Technique: Stand on one leg to the side of pulley column. Handle is attached at above shoulder height. Grasp the handle with the arm nearest the column (opposite side to standing leg). Set perfect posture and pelvic alignment.

Brace your core; pull the weight down and around the body, keeping the elbow straight so that the arm rotates down and round. Finish with hand next to your hip across your body. The aim is to maintain perfect balance and pelvic alignment as you lower and raise the arm. Reposition to repeat with opposite leg/arm.

Perform 10 reps each side, increasing to 20 reps; 2 to 3 sets.

Progression: Increase the weight.

One Leg, One Arm Rowing

Overview: The challenge of this exercise is to maintain stability while standing on one leg and controlling against a pulling force from the upper body. The pelvis must stay fixed when the upper back and shoulder are pulling backwards.

Level: Intermediate

Muscles targeted: Abdominal wall, Adductors, Gluteus medius, (Rear deltoid, rhomboids, latissimus dorsi)

Technique: Stand on one leg, facing the pulley column. Handle is attached at waist height. Grasp the handle with the opposite arm (same side as lifted leg). Your hand will be out directly in front of you in the start position. Set perfect posture and pelvic alignment, standing tall with shoulders back.

Brace your core; pull on the cable, leading with the elbow in a rowing movement Finish with hand by your side and elbow behind you. The aim is to maintain perfect balance and pelvic alignment as you perform the rowing movement. Reposition to repeat with opposite leg/arm.

Perform 10 reps each side; 2 to 3 sets.

Progression: Increase the weight.

Menu 7: Medicine Ball, Floor

The four exercises in this menu all involve throwing and catching the medicine ball while performing a trunk flexion or rotation movement. The action of throwing the ball during the muscle-shortening phase of each of the exercises increases the force production of the trunk muscles. The action of catching the ball at the start or during the muscle-lengthening phase of each exercise not only increases the force production but also the overall stability challenge.

The impact that the catch has on the upper limb has to be controlled by the trunk. You should be aiming to maintain good spine alignment and correct movement while making the catch. Only use a weight of medicine ball that will allow you to perform the exercises with good technique. If the ball is too heavy, you will sacrifice core stability, irrespective of your arm strength.

Overall these exercises are advanced. However they are also safe and effective for young athletes using light medicine balls to develop dynamic trunk movement and control.

Sit Up & Throw

Overview: An advanced version of a sit-up exercise, in which the throwing action makes the crunch phase faster and the catching action adds load to the return phase.

Level: Advanced

Muscles targeted: Abdominals (Plus upper body)

Technique: You will need a partner to receive and pass the ball. Alternatively perform the exercise in front of a wall and use a medicine ball that will bounce back.

Start in the sit-up position (knees bent) with hands up ready to receive the ball. Catch the ball and begin to lower back down. Do not collapse back down, control it with the abs and keep hands above the head as you lower down.

Once shoulders are touching the floor (keeping head up and eyes forward), reverse the movement. Throw the ball forward and crunch up at the same time. Follow the throwing action and complete the sit-up as fast as possible. Make sure you crunch as you throw so that the abs contribute to the force of the throw and help you sit up faster. Men should start with a 5kg ball; women with a 3kg ball.

Perform 10 to 20 reps; 2 to 3 sets

Progression: Progress to heavier ball once 3 sets of 20 reps is comfortable

45-degree Sit, Catch and Pass

Overview: A very tough stability exercise that requires massive trunk musculature co-contraction to hold a good spine alignment against the impact of making the catch.

Level: Advanced

Muscles targeted: Erector spinae, Abdominals, Obliques

Technique: Sit up with knees bent and lean back at 45 degrees. Aim to hold a ‘lengthened’ spine, with lumbar spine in neutral, shoulders back and neck long and relaxed. It takes a fair amount of control and strength endurance simply to hold this posture perfectly. Aim to get this right before progressing on to the catch and pass.

Raise hands in front of your face and receive a pass from a partner, around this height. As you catch the ball you must hold the long spine position. Do not flex the low back, or become round-shouldered. Gently throw the ball back. Men should start with a 3kg ball; women with a 2kg ball.

Complete a few passes, holding the position for 30 seconds. Perform 2 to 3 sets.

Progression: Raising the hands to above head height makes the stability challenge of the catch significantly harder. Catches made to either side of the head are also more challenging.

Sit & Twist Pass

Overview: A trunk rotation exercise involving catching and passing the medicine ball, which provides a challenge to the obliques to produce powerful rotation, but also pelvic stability, so that the sitting position is stable throughout the movement.

Level: Advanced

Muscles targeted: Abdominals, Obliques

Technique: Sit up with knees bent and lean back at 45 degrees. Aim to hold a ‘lengthened’ spine, with lumbar spine in neutral, shoulders back and neck long and relaxed. Your feet, knees and hips should remain reasonably still throughout this exercise, the rotation coming from your waist and not your hips.

Hold hands to one side ready to receive the ball. Catch the ball to one side and absorb the catch by turning your shoulders further to that side. Reverse the rotation, turning back to the middle and release the ball. Continue rotating to the other side; receive the ball the other side and continue. Ensure you can hold good posture throughout the movement, with a long spine and wide shoulders. Men should start with a 4 to 5kg ball; women with a 2 to 3kg ball.

Perform 10 to 20 reps.

Progression: Increase the weight of the ball once you can perform a set of 20 reps comfortably with perfect technique.

Kneeling Twist Pass

Overview: To perform the rotation movement in this position demands a greater range of motion, helping to develop strength through the full range of trunk rotation. It may also help to develop trunk rotation range of movement.

Level: Intermediate to advanced

Muscles targeted: Obliques

Technique: Kneel upright with good posture (lumbar spine in neutral, chest out, shoulders low). Start with the ball in hands and twist shoulders and head round as far as you can. Then, under control, twist around to the other side as far as possible, and hand the ball to partner. Turn back to the start position, receive the ball again and continue.

The aim of the movement is to rotate through the biggest shoulder turn you have. You can allow the hips to rotate a little with the shoulders, but not too much. You should feel a stretch in the side at the end of each twist.

As you gain greater flexibility and stability you will be able to fix your pelvis square to the front and rotate through an increasingly full range of motion. Men should start with a 5 to 6kg ball; women with a 3 to 4kg ball.

Perform 10 reps then take the ball to the opposite side and repeat.

Menu 8: Medicine Ball, Standing

The aim of this menu is to perform trunk movements while standing on one leg. This is functional training for balance in sports and daily living activities. These exercises are advanced because of the requirements for lower limb balance and body movement awareness, which makes controlled performance of these trunk movements quite difficult. These moves also use the hip rotator and abductor muscles for control and stability.

One-leg Twist Pass

Overview: A trunk rotation exercise performed on one leg. This requires good pelvic stability at the hip of the standing leg, for the trunk rotation to be dissociated from the pelvis.

Level: Advanced

Muscles targeted: Gluteus medius, Piriformis, Abdominal wall, Obliques

Technique: Stand on one leg with hips facing square to the front. Hold medicine ball slightly out in front. Slowly twist from side to side. The rotation comes from the waist only, head turning with the shoulders. Keep pelvis fixed square and knee in line with second toe throughout. Men should start with a 5 to 6 kg ball; women with a 3 to 4 kg ball.

Perform 10 slow reps; 2 to 3 sets. Repeat on other leg.

Progression: Swap the ball for a pulley machine and add resistance, once you have mastered the controlled balance on one leg.

One-leg Deadlifts with Rotation

Overview: An advanced exercise for the posterior chain of muscles, which includes rotation to challenge control of pelvis.

Level: Advanced

Muscles targeted: Erector spinae, Gluteals (max and med) Hamstrings, Piriformis

Technique: Stand on one leg. Flex the free leg a little at the knee to lift it off the floor, but do not flex or extend the hip of the free leg throughout the movement, in order to keep pelvis in control. Hold the ball in front of you.

Bend down, flexing at the knee and the hip. Lower down until the ball touches the floor by your foot, all the time keeping your arms straight and without reaching excessively with your upper back (ie, maintain a reasonably flat back). Stand back up, pushing down through the foot to use your gluteals correctly to extend the hips.

Alternate between touching the ball down on the inside and then the outside of the standing foot. This means you are internally or externally rotating the hip on alternate repetitions, challenging control of hip rotation. Keep the knee in line with second toe as much as possible throughout. Men should use a 5kg ball; women use a 3kg ball.

Start with 5 slow controlled reps, 2 to 3 sets. Build up to 10 reps. Repeat on the opposite leg.

Progression: Increase the weight of the ball or use a dumb-bell as you get stronger.

One-leg Catch & Pass

Overview: The main aim of this exercise is to control the impact of the catch without losing balance or rotating excessively at the hips. It’s all about how effectively you can anticipate the impact and produce the required stiffness throughout the body to retain good posture and control. This is a very useful ‘reaction’-type stability exercise.

Level: Advanced

Muscles targeted: Everything

Technique: Stand on one leg with good posture (lumbar spine neutral, chest out, shoulders wide) and with hips square to the front. Hold hands up ready to catch. Receive catches anywhere within arm’s reach. Make sure the passes are varied in their placement. Aim to restrict movement to arms and/or turning your shoulders, keeping the pelvis and lower limb stable. Use a 2 to 3kg ball that is not too big, so it is easy to catch.

Start with 30 sec bouts of catch and pass on each leg; 2 to 3 sets.

Progression: Receive more forceful passes so the impact of the catch is greater.

Menu 9: Resistance-Based

Menu rationale

The aim of these three exercises is to progress the loading in order to build high-level trunk muscle strength. These exercises can be performed in the 5- to 10-repetition range with a suitably high weight for this number of reps. As you get stronger, you should prioritize an increase in weight rather than an increase in the number of reps. Overall, these exercises are very advanced.

Crunch with Weight

Overview: The standard isolated abdominal exercise with increased load.

Level: Advanced

Muscles targeted: Abdominals

Technique: Perform the crunch in the usual way: knees bent, low back flat, head up and looking forward. Curl the shoulders up and down using just the abdominals. The weight (medicine ball, dumb-bell or barbell weight plate) should be held above or behind the head. Arms are fixed, all they do is hold the weight in place. Do not use arms to move the weight relative to head as the crunch is performed. Keeping the elbows out helps to achieve this.

Perform 5 to10 reps; 2 to 3 sets.

Progression: Increase weight, maintaining the range of 5 to 10 reps per set.

Reverse Hypers

Overview: An excellent hip and back extension exercise to which it is very simple to add load.

Level: Advanced

Muscles targeted: Erector spinae, Gluteals

Technique: Lie on your front on a horizontal bench, with hips just off the end of the bench. Grasp bench legs firmly for support. Your legs should be straight with a dumb-bell between the ankles for resistance. Squeezing the gluteals, extend hips and lift legs and the dumb-bell off the floor. Stop when your back is slightly hyper-extended and hips are fully extended. Lower slowly until feet are just off the floor and continue.

Perform 8 to 10 reps; 2 to 3 sets.

Progression: Increase weight, maintaining the range of 8 to 10 reps per set.

Reverse Crunch with Weight

Overview: This is a great exercise, as it requires good coordination and strength. Research shows that the obliques as well as the abdominals work very hard during this exercise, making it excellent value.

Level: Advanced

Muscles targeted: Abdominals, Obliques

Technique: Lie on back with hands behind head and elbows out to the sides. Knees should be bent and heels close to bum. Hold weight between your legs. Initiate the movement by curling the pelvis upwards (flattening the back into the floor) and then continue to use the abs to pull the low back and pelvis off the floor. This is the bit that requires good co- ordination, as the temptation is to kick with the legs and pull the hips up with the hip flexors. Learn to focus on the abs before you add weight, as if you do this strictly it is very tough, especially for women (whose pelvises are relatively heavier).

Perform 5 to 10 reps; 2 to 3 sets.

Progression: Increase weight, maintaining the range of 5 to 10 reps per set.

Menu 10: Hanging Bar

Menu rationale

The aim of these three exercises is to work the abdominals as hard as possible with very advanced, gymnastic-style movements. Reasonable upper body strength is required for these exercises.

Hanging Leg Lifts

Overview: This exercise requires you to lift the full weight of your legs and (if possible) your pelvis, while hanging from a bar. Anyone who can perform these movements well through a good range of motion has achieved good strength.

Level: Advanced

Muscles targeted: Abdominals, Obliques, Hip flexors

Technique: Hang from a bar with arms straight. Lift knees, bringing them up as high as possible. At the top of the movement the knees should be near the chest and pelvis should be curled upwards (low back flexed). This extra curl of the pelvis ensures that the abdominals are working maximally. Do not kick legs up or swing the body excessively. Simply draw up knees, crunching as you lift. It is important to feel that the abdominals are doing the lion’s share of the work rather than the hip flexors or front of thigh muscles.

Perform 5 to 10 reps;, 2 to 3 sets.

Progression: Perform the same exercise with straight legs, lifting them up to 90 degrees in front of you, curling the pelvis at the top of the movement.

Windscreen Wipers

Overview: The ultimate ab-buster. Anyone who can do 10 reps of this exercise with good technique has a very strong core!

Level: Super advanced

Muscles targeted: Abdominals, Obliques, Hip flexors

Technique: Hang from bar with arms straight. Lift legs up in the air until feet are at approx head height. Maintaining the height of the lift, take the legs from side to side in an arc. The movement will look like a windscreen wiper, moving from side to side. Aim for at least 45 degrees of movement to each side.

Perform 5 to10 reps; 2 to 3 sets.

Progression: The straighter the legs, the harder the exercise. Increasing the range of movement to each side also makes it tougher.

Candlesticks

Overview: Another beauty! Lots of strength required to control this movement; only for the very strong.

Level: Super advanced

Muscles targeted: Abdominals, Obliques, Hip flexors

Technique: Lie flat and raise yourself up to a shoulder stand position, holding on to a bench/table leg/partner's leg with your hands above your head. Establish a fully extended hip and leg position and then begin to lower your body down slowly to the floor. The body should move in an arc as a single unit (no sagging in the back, or bending at the hips or knees). Lower under control from vertical to just above horizontal.

Gripping firmly for stability, lift your body back up into shoulder stand, again keeping everything straight and aligned in a single unit.

Slow and controlled movement on the way down will help, and a maximal contraction of everything will get you back up.

Perform 3 to 5 reps; 2 to 3 sets.

Progression: There it is.

Sourced From:

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.