This week's post is really a post of posts in that I have organized and summarized all of my shoulder and overhead performance articles into one. The goal here is to collate what we have so far in order to fix and improve shoulder mechanics as this is, in my opinion, the scourge of the modern athlete. Even in general orthopedic populations, total shoulder replacements are increasing faster than ever. We need to stop playing catch up: pain and a torn rotator cuff are lagging indicators!
But the real purpose of this post is to draw attention to this fact: not one single post on this site, so far regarding the shoulder, has directly addressed only the shoulder joint itself. This calls attention to the fact that, while I certainly think the shoulder joint itself does need to be addressed, correcting it without addressing all the other mechanics we've discussed so far will only serve to frustrate you and your athletes. Think of the shoulder joint as a transmitter, rather than a generator, of energy within the kinetic chain. The joint's inherent stability and mobility demands set it up as a scapegoat for poor mechanics elsewhere in the system. Looking only at the dysfunctional shoulder as the source of the problem (i.e. myopically addressing rotator cuff function in an athlete with shoulder pain) is a fundamental error that will only serve to rob you of performance and time. You wouldn't take Tylenol for a headache everyday for 5 years and not start to wonder what the heck is the cause, right? Yet people do this everyday for musculoskeletal pain! Recurrent shoulder problems? We need to start looking elsewhere first and often the shoulder dysfunction will resolve itself.
This is by no means an exhaustive list - 1st rib and head position/control are big too, but here's what we've come up with so far (click the titles for the whole post and videos):
Wide Grip Bench Press is Hurting Your Power (and Shoulders): Using a narrower bench press grip, we can create torque through the shoulder system. This helps to achieve global extension via the lats and glutes and allows us to take advantage of the pectoralis' considerable cross-sectional area for improved power. Furthermore, a wide grip (which I see WAY too often) puts the upper extremity at an anatomical disadvantage increasing the demands on the shoulder's passive tissues (labrum, capsule, biceps tendon). Here's the video
Improving Shoulder Position for Push-ups and Presses: Improper positioning of the scapula on the ribcage (and in turn the humerus on the scapula) can alter shoulder mechanics during push-ups and presses. By potentially restoring the position of this system, we can better elicit function of the shoulder and its active stabilizers. This is a mobility exercise I find great success with, try it out. Here's the video
Elbow and Shoulder Pain During Pressing/Pushing: Importance of Load Ordering on Pressing Mechanics: Properly loading the shoulder girdle rather than the elbows during pressing and push-ups is essential to improve power and decrease shoulder and elbow pain. As discussed with squats, the tissue loaded first in the movement is the one loaded maximally. By prioritizing motor control, we can use the shoulder's active stability to generate powerful and consistent movement. Here's the rest of the post
Improving the Overhead Squat - Cueing and Maintaining an Upright Torso: This post goes into how to maintain an upright torso using neuromuscular cueing of the upper kinetic chain. Cueing a proper torso position allows improved positioning of the shoulder complex, which can help improve stability throughout the entire movement. Here's video 1. Here's video 2.
Overhead Shoulder Dysfunction - Fix Your Spine Position First: Sacrificing spinal position for overhead stability via lumbar overextension is a common movement fault and one that must be corrected. Otherwise, no matter how hard you work on your rotator cuff, etc. the underling movement pattern is faulty and will return. Research is beginning to demonstrate that proximal control drives distal mobility, this is a good start. Here's the video
Overhead Athletes and Pressers - Shoulder Mechanics and the Lats: Restrictive lats can seriously negate quality overhead position and potentially cause shoulder instability due to it's anterior-inferior pull on the humerus. Furthermore, they extend the lumbar spine resulting in both poor overhead stability and lumbar overextension, neither of which are good. Here the video
Thoracic Spine Extension and Rotation - A Motor Control Fix for Shoulder Pain: Improving active control of thoracic spine extension-rotation is crucial for shoulder function as it allows for optimal scapulothoracic positioning resulting in better shoulder control. Improving this takes more than just a foam roll or lacrosse balls, we have to facilitate the appropriate motor pattern for optimal results, this post tells us how. Here's video 1 - assessing. Here's video 2 - more assessing. Here's video 3 - correcting.
Again, this is not an exhaustive list and we shouldn't neglect the shoulder completely. But if we want performance improvements that stick we have to look at the shoulder as a system of systems. Again, don't let the drag of orthodoxy get in the way of proper mechanics.
Thoughts on what we have so far? Post 'em.
The last few weeks we have discussed how to improve the overhead position essential for nearly any skilled athlete who needs to generate an active, stable shoulder. Whether it's throwing, pressing, overhead squatting, hand-stands, pull-ups, you NEED a stable and powerful position to safely and highly perform the skill.
Once you've fixed midline stability and assessed for lat tightness, we need to look at the coupled motion of thoracic extension-rotation. In order to accommodate the scapula tipping backwards as the arm comes up overhead, the thoracic spine and ribs need to extend and rotate out of the way to allow the scapula room to upwardly rotate and provide a stable base for the humerus. Basically, improved thoracic extension+rotation → improved scapular position and rotation → improved balance of shoulder in socket (think golf ball on a tee) → better shoulder position and stability overhead. Research supports this model of Regional Interdependence.
So, how do we functionally assess the system's ability to couple thoracic extension and rotation to improve shoulder girdle position? Check out the video:
Then try it with the shoulder flexed to make it more position specific:
* For both of these, it's very important to maintain full lumbar flexion to prevent cheating with the lumbar spine. Also cueing the athlete to follow the hand/elbow with the head keeps the thoracic spine engaged.
As mentioned in the video, while improving the joint/soft-tissue mobility is absolutely essential, it's only one piece of the ultimate goal to improve overhead shoulder position. If the goal is to improve performance then we need to improve the ability to control the system in these new ranges. Believe it or not, gravity is sometimes too much resistance especially in those with poor motor control so we need to facilitate those movements (an SFMA/Gray Cook principle and one that I agree with) in order to allow the motor program to develop without so much load that it only serves to reinforce the problem.
Here's a fix:
What I like about this exercise is that it not only cues the thoracic extension and rotation needed for overhead range and performance, but it also cues the crucial trapezius/serratus force couple needed for appropriate shoulder stability.
How do you know if it works? Try as many reps as it takes to improve the ease at which you can perform the exercise (20-30 reps is a good start). Remove the band, re-try the extension-rotation test without facilitation. Increased range? You're welcome. If not, hit your classic thoracic extension mobility exercises harder (foam roll, lacrosse ball) then re-try the band facilitation. Re-test your overhead position and watch it improve. Remember if you don't see change, there is no change.
This is a great addition to your warm-up to prime this coupled movement and prep the system for loading.
1) Shoulder pain and poor performance overhead? Assess control of thoracic extension and rotation by removing the lumbar spine from the equation.
2) Facilitate this motion - it should cue an improvement in mobility and, more importantly, control.
3) Try the shoulder flexion cue once you've got the first piece down. Goal is to make this as positionally-appropriate as possible.
P.S. Here's a bonus video from Eric Cressey on a lat mobility exercise (not as much a thoracic mobilization in my opinion) to address that lat restriction we talked about last week:
This week's post is a follow-up to last week's primer on midline stability in overhead positions. In it we discussed how to prioritize fixing the overhead pressing position by correcting lumbar overextension first. Oftentimes poor anterior core control is lacking, putting the shoulder (and spine) in a mechanically disadvantageous position. As you correct the lumbar overextension and stop hurting your spine, you may find an inability to get the arm completely overhead. Enter the lats (aka latissimus dorsi muscle - literally meaning broad because I mean they're huge): check out the video and discussion below.
Anatomically, the lats originate from the thoracolumbar fascia and spinous processes on the thoracic and lumbar spine and insert onto the lesser tubercle of the humerus. Thus the lats have the ability to extend the lumbar spine, particularly when unopposed by the anterior core musculature. Given its role on the humerus in pulling tasks (deadlift, pull-ups, rows, etc.) and acceleration during throwing (Jake Peavy of the Boston Red Sox actually tore his lat off it's insertion on the humerus a few years ago - not good) this muscle can become quite restrictive and negate quality overhead shoulder position and stability.
As described in the video we know that if unopposed by the anterior core, the lats will pull the spine into extension to allow us to get the arm overhead for pressing, throwing, and pull-ups. So by comparing shoulder flexion range with the spine extended vs. flexed we can appreciate the impact lat length has on the shoulder. By the way that supine position with hips and knees flexed looks an awful lot like a snatch or bottom of an overhead squat, hence the usefulness! Now, the thoracic spine also plays a role in generating a full, stable overhead position but if your lats are tight and you're an overhead athlete, CrossFit athlete, or doing work overhead you need to recognize this man.
Here's why: overhead work with tight lats results in a trade-off. You either let your anterior core give in to the spinal extension moment created by the lats and remain overextended in the lumbar spine subjecting it to risk of a spondy, stress fracture, and stenosis. OR you maintain midline stability (which is good) but now can't get your shoulder fully overhead and externally rotated as the lats also exert a tremendous anterior and internally rotated force on the shoulder resulting in a weak and unstable shoulder (think: SLAP lesion, instability, ugly clunking during pull-ups). Either way the result is an inability to create torque and decreased performance with overhead presses, throwing, snatches which is what we really care about. How do we fix this? Organize your midline getting out of that overextended position. Once this is addressed shoulder flexion still may be lacking so look at the lats.
1) Address midline stability first.
2) If the athlete is then unable to reach full shoulder flexion, check out the athlete in supine looking at lat length as outlined above. If restricted, unrestrict it!
I'll address some lat and t-spine mobilizations in an upcoming post but in order to figure out why shoulders are getting blown out an insane right with overhead athletes and lifters we need to look at the causes, today's post is a strong step in that direction.
Remember: there's nothing funny about tight lats
Shoulder pain is the 3rd most common orthopedic complaint (behind the low back and knee) and it's no wonder considering how so many of the sports, exercises, and skills we perform are 'shoulder expensive'. Olympic lifts, volleyball, throwing sports, swimming all require a tremendous combination of mobility and stability at the shoulder joint itself as well as the scapulothoracic articulation (though it's not a true joint, people, just the interaction between scapula and thorax). Classic interventions/corrective exercises target the rotator cuff and potentially the periscapular muscles - though it is surprising (disappointing) how many physios will neglect even this. However, the purpose of this post is to draw attention to how screwed up your lumbar spine position is with overhead tasks and it's impact on shoulder mechanics. Check it:
Here's the deal: Before we can even attempt to fix your messed up shoulder we first have to look at the ability to globally control the midline. Last week's post is a good start in looking at motor control and stability though it doesn't account for the extreme demands on the torso seen in overhead positioning. Without accounting for the ribcage flying open due poor control of the spine, our best efforts to fix the shoulder are thwarted by the undue loads placed upon it due to lack of spine control. We can get the scapula under control, mobilize the thoracic spine, and optimize the rotator cuff, but once we go back to throwing, pressing, or spiking all is lost if midline control is compromised. Not to mention loading an overextended spine is dangerous for the facets (hello spondy) and nerve roots being crushed by the vertebrae above.
But most importantly, this robs force generation and power production. Minimal active tension prevents control at the end-ranges where we need it most. Want a stronger spike, faster pitch, better push-press? Proximal stability will buffer poor mechanics much better than a soft spinal position. Otherwise we're just blowing through our much smaller engines at the shoulder and elbow and asking them to do what they aren't built for.
Try it yourself: take your arm up overhead. If you can't get your arm to your ear (with your elbow straight!) without flying open and exposing your rib cage, then there's a problem. Why is it a problem? Well if your a thrower, opening up too soon alters the load to the shoulder and elbow - there's a ton in the pitching mechanics world about the detriments of opening too soon and over-extending. It also changes the positional relationship between the arm and torso and can cause excess anterior translation of the humeral head (not good for your labrum and biceps tendon) making it more difficult to actively stabilize the shoulder - particularly in Olympic lifters and overhead pressers.
Key Point: The question then becomes, is the athlete flying open because their thoracic spine is stiff? Maybe but if they're over-extended then they're.... over-extended. Fix this first then we can address the t-spine. Otherwise the learned pathomechanical motor pattern remains, such that even if we do loosen up the thoracic spine the athlete will not likely utilize this new range during the task. As evidenced in the hip by Dr. Stuart McGill, a must read. We need to organize before and while we mobilize! The athlete can loosen up the thoracic spine as much as they want (and I do think that thoracic spine mobility is hugely important) but without the training to overcome the hundreds or thousands of reps they performed overextended, the carry-over will be minimal.
You will be shocked at how organizing your spine (squeezing your butt and bracing the abs) generates much more stability and power with overhead tasks. Try an active brace while holding something overhead, you literally feel the difference. One point I should make - this often feels weird for athletes who are used to being so over-extended. They feel as if they are pitched forward (another indication their sense of midline control is lost). Hollow rocking is a great way to initiate anterior core function while making the connection to overhead position prior to reloading the athlete overhead. Nothing in sport happens statically, so we need to progress to dynamic isolation quickly where possible.
Bottomline: organize your lumbar spine and pelvis first (noticing a theme here from previous posts?) then we can address the thoracic spine, scapula, and rotator cuff when dealing with overhead positioning. More to come....
Here's a quick vid on hollow rocks: