Optimal Shoulder Performance - Cressey Reinold

Optimal Shoulder Performance From Rehabilittaion to High Performance ShoulderPerformance.com

Eric Cressey, MA, CSCS is the president of Cressey Performance in Hudson, MA. Cressey is a highly soughtafter coach for healthy and injured athletes alike from youth sports to the Olympic and professional ranks, with baseball development as his greatest focus. Behind Eric’s expertise, Cressey Performance has rapidly established itself as a go-to high-performance facility among Boston athletes – and those that come from abroad to experience CP’s cutting-edge methods. Eric has lectured in four countries and more than one dozen U.S. states; written over 200 articles and four books; contributed on scientific journal articles and book chapters; and co-created four DVD sets. He publishes a free weekly newsletter and daily blog at http://www.EricCressey.com. A record-setting competitive powerlifter, Cressey has deadlifted 650 pounds at a body weight of 174 and is recognized as an athlete who can jump, sprint, and lift alongside his best athletes to push them to higher levels.

Michael M. Reinold, PT, DPT, SCS, ATC, CSCS is considered a leader in orthopedic and sports rehabilitation as a clinician, educator, and researcher, with specific emphasis on the shoulder and the treatment of overhead athletes. Mike is currently the Head Athletic Trainer of the Boston Red Sox and Coordinator of Rehabilitation Research & Education for the Sports Medicine Division of Massachusetts General Hospital. Mike has lectured extensively throughout the nation, published over 50 scientific journal articles and book chapters, and is the author of the textbook, The Athlete’s Shoulder, 2nd Edition. Mike’s contributions to sports medicine have earned recognition by groups such as the APTA, ESPN, Sports Illustrated, The Sporting News, Men’s Health, The Boston Globe, and The Boston Herald. For more information, visit Mike’s free educational website at http://www.MikeReinold.com.

This DVD and the following guidelines have been provided as general information for exercise and rehabilitation and are intended for educational purposes. Any individual beginning exercises

contained in this video, or beginning any other exercise program, should first consult with a qualified health professional. Discontinue any exercise that causes discomfort and/or dysfunction and consult with a qualified medical professional. Please consult with a physician prior to implementing any rehabilitation or exercise protocol. This DVD does not contain medical advice. The instructions and advice presented are in no way a substitute for professional testing, instruction, or training. The creator, producer, and distributor of this DVD and program disclaim any liabilities or loss, personal or otherwise, in connection with the exercises and advice herein.

Inefficiency vs. Pathology Eric Cressey www EricCressey com www.EricCressey.com www.CresseyPerformance.com

Miniaci A. et al. Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. Am J Sports Med. 2002 Jan-Feb;30(1):66-73. • 79% of professional pitchers (28/40) had “abnormal labrum” features g resonance imaging g g • …“magnetic of the shoulder in asymptomatic high performance throwing athletes reveals abnormalities that may encompass a spectrum of ‘nonclinical’ findings”

What would you think if a coach/trainer had… • 82% of his athletes with disc bulges or herniations at one level, and 38% at more than one level? • 27% of his athletes with vertebral fractures? • 34% of his athletes with rotator cuff tears? • 79% of his overhead throwing athletes with labral tears? • 26% of his jumpers with patellar tendinopathy?

Jost B et al. MRI findings in throwing shoulders: abnormalities in professional handball players. Clin Orthop Relat Res. 2005 May;(434):130-7. • Researchers looked at throwing and non-throwing shoulders of 30 handball players and non-athletes w/MRI • More abnormalities seen in throwing shoulders • “Although 93% of the throwing shoulders had abnormal magnetic resonance imaging findings, only 37% were symptomatic.” • “Symptoms correlated poorly with abnormalities seen on magnetic resonance imaging scans and findings from clinical tests. This suggests that the evaluation of an athlete's throwing shoulder should be done very thoroughly and should not be based mainly on abnormalities seen on magnetic resonance imaging scans.” • Not just about throwers, though! Has been demonstrated with swimmers, volleyball players, AND non-athlete controls…

*There are people out there – myself included – that think that you may very well need a SLAP lesion to throw hard in the first place!

Rotator Cuff Fun… • Sher et al. (1995): MRIs of 96 asymptomatic subjects, RTC tears in 34% of cases, and 54% of those older than 60. • Miniaci et al. (1995): MRIs of 30 shoulders under age 50 with “no completely ‘normal’ rotator cuffs.” 23% had evidence of partialthickness tears. • Connor et al. (2003): eight of 20 (40%) dominant shoulders in asymptomatic tennis/baseball players had evidence of partial or full-thickness cuff tears. Five of 20 had MRI evidence of Bennett’s lesions.

Jensen MC, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med.1994 Jul 14;331(2):69-73. • MRIs of 98 asymptomatic backs • “52 percent of the subjects had a bulge at at least one level, 27 percent had a protrusion, and 1 percent had an extrusion [82% of subjects]. Thirty-eight percent had an abnormality of more than one intervertebral disk. The prevalence of bulges, but not of protrusions, increased with age. The most common nonintervertebral disk abnormalities were Schmorl's nodes (herniation of the disk into the vertebral-body end plate), found in 19 percent of the subjects; annular defects (disruption of the outer fibrous ring of the disk), in 14 percent; and facet arthropathy (degenerative disease of the posterior articular processes of the vertebrae), in 8 percent. The findings were similar in men and women.”

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Soler T, Calderon C. The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med. 2000 JanFeb;28(1):57-62. • 8% of elite Spanish athletes affected • 27% of track & field throwers, 17% of rowers, 14% of gymnasts, and 13% of weightlifters • L5 most common (84%), followed by L4 (12%). • Bilateral 78% of the time • Only 50-60% of those diagnosed actually reported low back pain • Presence of spondylolysis is estimated at 15-63%, with the highest prevalence among weightlifters. • Presence is estimated at 3-7% in the general population

You Kneed to Know… Cook JL et al. Patellar tendinopathy in junior basketball players: a controlled clinical and ultrasonographic study of 268 patellar tendons in players aged 14-18 years. Scand J Med Sci Sports. 2000 Aug;10(4):216-20. • 34 elite jjunior basketball players p y (268 ( total patellar p tendons)) • Only 19 tendons (7%) presented clinically with symptoms of tendinopathy. • However, under ultrasonographic examination, 26% of all tendons could be diagnosed with tendinopathy based on degenerative changes. • For every one diagnosed, more than three are overlooked… • This is magnified as one ages!

We’ve misinterpreted the meaning of the word “pathology.” • “any deviation from a healthy, normal, or efficient condition” (dictionary.com) • In I other th words, d “inefficiency” “i ffi i ” and d “pathology” may in fact be the same thing.

Chou R et al. Imaging strategies for low-back pain: systematic review and meta-analysis. The Lancet, 2009;373 (9662), 463-472. • Review of imaging for low back pain without significant red flags suggesting serious conditions (cancer, fracture, etc) • “Lumbar imaging for low back pain without indications of serious underlying y g conditions does not improve p clinical outcomes.” • “Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low back pain and without features suggesting a serious underlying condition.” • Some research suggests that MRI leads to poorer outcomes in back pain patients

Just to Scare You a Bit More… “Somewhere between 2 and 8 percent of the time in American hospitals, a patient havingg a genuine g heart attack gets sent home – because the doctor doing the examination thinks for some reason that the patient is healthy.” -Malcom Gladwell, in Blink

Wordplay? • My primary goal for today is to show you that if you correct the inefficiency, you’ll markedly reduce the likelihood that these “ h l i ” reach “pathologies” h threshold. h h ld • Effective screening, and an understanding of population-specific “norms” is the key. • The site of the pain isn’t always the source of the problem…

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Perhaps the Best Example… • The Tendinopathy Debate • Tendinosis – osis = degenerative – Tissue loading exceeds tissue tolerance

• Tendinitis – itis = inflammatory – Inflammation should be easily controlled with cortisone injections and/or NSAIDs

The Truth is… • Anyone who has ever dealt with a “tendinitis” diagnosis knows that it isn’t so easy to fix… • So,, traditional treatment modalities are often based on the wrong diagnosis. • Many people get healthy simply because they implement rest for the tissues – not because they address underlying inefficiencies.

Kinesio-Taping • Perfect example of the difference between tendinitis and tendinosis • It works k tto redistribute di t ib t stress appropriately • Training should do the same!!

Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy. 1998 Nov-Dec;14(8):840-3. • “In overuse clinical conditions in and around tendons, frank inflammation is infrequent, and is associated mostly with tendon ruptures. Tendinosis implies tendon degeneration without clinical or histological signs of intratendinous inflammation, and is not necessarily symptomatic. symptomatic Patients undergoing an operation for Achilles tendinopathy show similar areas of degeneration. When the term tendinitis is used in a clinical context, it does not refer to a specific histopathological entity. However, tendinitis is commonly used for conditions that are truly tendinoses, and this leads athletes and coaches to underestimate the proven chronicity of the condition.” • “The combination of pain, swelling, and impaired performance should be labeled tendinopathy.”

Waiting to Reach Threshold? • Remember Cook et al.: while 26% of tendons could be diagnosed with tendinopathy under ultrasonographic exam, only 7% presented clinically with symptoms • The other 19% are just waiting to reach threshold. • Tendinopathy is a constant “give and take” in every muscle in the body, and degeneration is population and activity-specific.

The Law of Repetitive Motion I = NF/AR • I = Insult/Injury to the tissues • N = Number of repetitions • F = Force or tension of each repetition as a percent of maximum muscle strength • A = Amplitude of each repetition • R = Relaxation time between repetitions (lack of pressure or tension on the tissue)

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The Law of Repetitive Motion I = NF/AR • Poor posture: higher forces with Lifting tasks (no change in amplitude or relaxation => high insult) • Sitting at a computer: high number of reps (constant activation) with low amplitude and lower relaxation time. • The weaker you are, the higher the percentage of maximal strength you’ll use to accomplish a task. • Resistance training can be extremely effective in correcting problems quickly. Otherwise, we’d have to sit with “more-than-perfect” posture for an equal amount of time to iron things out.

The Bigger Picture: 12 Shoulder Health Factors

Building Blocks to Dysfunction: Soft Tissue Restrictions Pec Minor Inferior Capsule Subscapularis p Teres Minor Infraspinatus

For more information, check out Dr. William Brady at www.integrativediagnosis.com.

Quantify what you can, and video/photo whatever you can’t!

Overuse Rotator Cuff Weakness Scapular Stability Poor Glenohumeral ROM Soft Tissue Restrictions Poor Thoracic Spine Mobility Type 3 Acromion Poor Exercise Technique Poor Cervical Spine Function Opposite Hip/Ankle Restrictions Poor Structural Balance in Programming Faulty Breathing Patterns

We need to look at all of them to be comprehensive.

Things We Quantify: • Glenohumeral internal rotation, external rotation, and total motion • Thoracic spine mobility • Hip internal rotation, external rotation, and flexion • Knee flexion • Combined Tests (fist-to-fist)

Case Studies!

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16-year old Pitcher

Glenohumeral Internal Rotation Deficit (GIRD)

• Medial Elbow Pain • Previous treatments included forearm exercises,, ultrasound,, rotator cuff strength/endurance, and scapular stability • Cleared for a full return to play • No assessment of glenohumeral range of motion or front hip ROM.

The “Perfect” GIRD? Right Shoulder: 19°IR, 103°ER, 122° Total Motion Left Shoulder: 53°IR 90°ER 143° Total Motion Asymptomatic, and cleared for a full return to play with a 21° total motion deficit and 34° GIRD.

Same Deficits, Slightly Different Problem • 23 year-old Professional Pitcher • Medial Elbow Stress Fracture • 28° GIRD, 16° Total Motion Deficit • 35° Hip IR on Front Leg (goal = >40°) • 124° Knee Flexion on Front Leg (goal = >135°)

GIRD “Threshold?” • Burkhart et al. reported that all of a 124-thrower sample size with Type II SLAP lesions presented with an internal rotation deficit of greater than 25°. • Myers et al. al pinned that “don’t don t cross this line line” number at a 19.7° deficit. • The research on non-symptomatic throwing shoulders was in the 12-17° range. • Every little bit matters – and this applies to elbows, too!

Treatment? • 16-year old got ultrasound • 23-year old got a bone stimulator • Neither of them fixed their shoulder or hip ROM deficit!

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• This is like banging your head against the wall. • Does the wall or your head break first? • Incorrect Approach: patch the wall or take some ibuprofen for your head • The Correct Approach: Stop banging your head against the wall.

Wow… • Fractured Right Hip Three Years Earlier • 23° of Hip Internal Rotation (goal = >40°) 40 ) • You can “cheat” on your hip motion with long toss, but you can’t cheat when on the mound, when stress is higher.

17-year-old Left-Handed Pitcher • Chronic Left Shoulder Pain • Positive SLAP tests • Tried rotator cuff and scapular stability exercises • Could long-toss pain free, but had significant pain with throwing off the mound • What gives?

Another 17-year-old Pitcher • Both posterior shoulder pain and medial elbow pain • Addressed cuff weakness, hip ROM issues, soft tissue quality – and pretty much did everything right! i h! • But, athlete jumped the gun on his throwing program – and didn’t integrate the new hip mobility into his movements. • You can lead a horse to water, but you can’t make him drink…

Lessons…

I know, I know…

• Similar injuries, different causes! • Different injuries, similar causes! • Each hit threshold for different reasons. This may be age-specific. • Your assessment and corrective approach must be thorough – and specific to the sport. • Look at multiple joints – both strength and flexibility – as well as tissue quality • Follow-up exercise selection and overall programming must be appropriate – and the exercises must be performed correctly.

• Most of you aren’t rehabilitation specialists – and I wouldn’t consider that my realm, either! • In reality, though, this is because less black and white – and a lot more gray nowadays. • Why? W y? – Insurance companies are more and more stingy. – As I showed earlier, pretty much everyone is messed up – and even those who aren’t usually don’t move well. • And let’s be honest…

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Active vs. Passive Restraints • Active: muscles, tendons, and (to a lesser degree) bone • Passive: meniscus, labrum, discs • Poor active restraint function (strength, tissue quality, or ROM) leads to increased stress on the passive restraints, or issues with the active restraints themselves.

Later on, we’ll go through how to assess the function of all these active restraints…

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This Presentation

Testing, Treating, & Training the Shoulder

Clinical Examination of the Shoulder

• Discuss some general concepts behind shoulder examination • Where we are with evidence-based exams • How to use evidence & experience! • Some differential diagnosis tests • When to refer out • When to treat & correct • Clips from DVD on shoulder exam from AdvancedCEU.com

Michael M. Reinold, PT, DPT, SCS, ATC, CSCS Boston Red Sox / MGH Sports Medicine MikeReinold.com

Evidence • Unfortunately the evidence is still a work in progress • But getting closer every day • The problem –

Experience • • • •

What your past experience has shown you Important component Put the pieces of the puzzle together Algorithm approach – each portion of exam leads the next portion

– Can’t completely base your exam on evidence alone – Not enough studies – Conflicting information in the literature – Different patient populations

Expertise – Combining Experience and Evidence • How does a recent graduate conduct a shoulder examination? • How does the expert conduct a shoulder examination?

The True Use of the Exam • To determine where to start with the patient and when to send out to more qualified discipline – Secondary purpose to refer out as needed!

• What to perform and what to avoid • Make list of objective goals and plan to improve

• Be careful! Don’t get stuck in your ways!

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Impingement Vs. Cuff Tear

Assess Active Motion

• Progressive cuff pathology • Irritation Æ inflammation Æ fraying Æ tearing • Identifying where in the process the person is currently

AC joint or subacromial Impingement

Rotator cuff tear vs. inflammation

Impingement Tests

The Thrower’s Shoulder Motion and Laxity • Common findings – Excessive ER – Limited IR

• Anterior laxity • Posterior tightness

Internal Impingement

Wilk,Reinold,Crenshaw,et al: ‘‘99 99--09 • Examined ROM in 1400+ professional baseball players • ER @ 90 deg abduction: – Dominant: 129 + 10 deg – Non-Dom: 121 + 9 deg. deg

• IR @ 90 abduction: – Dominant: – Non-Dom.

61 + 9 deg 68 + 8 deg

• Total Motion: 190 + 14 Total Motion Equal Bilateral !!!

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Total Motion Concept Wilk et al AJSM 2002

Range of Motion After Throwing Loss of Total Motion • Pitching with loss of total motion results in greater chance of injury – Ruotolo: JSES ’06 06 – Myers: AJSM ‘06

ER + IR = Total Motion

Range of Motion After Throwing Loss of Total Motion • Loss of IR normal adaptation • Injury occurs when loss of TM • Cumulative microtrauma due to eccentric and tensile forces

Causes of Loss of IR Motion Humeral Retroversion • Several studies have shown retroversion of the humerus – Crocket AJSM 2002 – Reagan AJSM 2002

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Causes of Loss of IR Motion Not Posterior Capsule Contracture • Borsa, Wilk, Reinold: AJSM 2005 • Examined GH translation in 43 professional baseball pitchers – Anterior: 2.81 mm – Posterior: 5.38 mm • Significantly greater posterior translation • No differences between D and ND

– No correlation between IR ROM and posterior translation

Causes of Loss of IR Motion Posterior Muscular Contracture • Reinold: AJSM ‘08 • ROM Before & After Throwing • Measure PROM before and after pitching in 117 professional baseball players • Significant decrease in: – IR: -8.5° – TM: -9.5° – elbow extension: -2.4°

• Changes still present at 24 hours

Tomiya:: AJSM ‘04 Tomiya

Tomiya:: AJSM ‘04 Tomiya

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Range of Motion After Season Reinold & Gill: 2006 2006--2009 • ROM changes over course of season • Subjects stretched daily

Flexion ER IR TM E Flex E Ext

Beginning 175 133 46 179 135 -4

End 176 138 47 185 136 -6

Change +5 +6 -2

What is a Shrug???

• I am not sure that the posterior capsule is the cause of the changes in IR in overhead athletes – I have not seen this to be common in the healthy or the injured athlete

• IR is supposed to be less in the throwing arm, amount depends on retroversion – Throwing causes acute loss of IR, can become cumulative

• Assess, DON’T ASSUME!

What a Cuff Tear Looks Like

Assess cuff vs. capsule

DO NOT work through a shoulder shrug arc of motion !!!

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What About Instability?

Traumatic Dislocation

• Different types of instability • Acute first time dislocation vs. congenital laxity MDI • Actual capsulolabral tear vs just looseness • Laxity L it vs. IInstability t bilit

Torn Posterior Capsule

Voluntary Subluxation

Congenital Laxity

CONGENITAL LAXITY!

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Acquired Laxity

Instability • Apprehension sign

Congenital Laxity

Sulcus

• Sulcus sign • > 10 mm positive

Sulcus

Beighton Laxity Score

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SLAP Lesions • SLAP’s are trendy right now • Likely a little over diagnosed • Well over 20 published “tests” to detect a SLAP lesion • Several variations of SLAPs • Different tests for different types of SLAPs

Compression Injuries

Traction Injuries

Peel Back Lesions

Reinold & Gill: Sports Health ‘09 Wilk, Reinold, Andrews: JOSPT ‘05 Myers, Andrews: AJSM ‘06

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Shoulder Examination Key Points • We are still evolving into evidence based examination • Challenging progression • Understand how the shoulder functions • Determine – – – –

Specific structures involved When to refer out Where to begin What to avoid

• Look at causative factors • The complete picture

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Training the Injured Shoulder During and Post-Rehabiliation Eric Cressey www.EricCressey.com Ei C www.CresseyPerformance.com

External Impingement • The Sedentary/Stationary Shoulder Problem • Pain with: – Overhead motion – Approximation – Periods of inactivity (night, morning) – Internal Rotation – Scapular Protraction • Bursal-sided cuff issues

External Impingement • Eliminate overhead activities • Modify/Eliminate Horizontal Pressing • More horizontal p pulling, g, asymptomatic y p cuff exercises, scapular stabilization exercises (improve upward rotation function) • Gentle stretching for the internal rotators and pec minor • Optimize thoracic spine mobility

Important Prerequisites… • Primary goal should always be to fix what’s wrong, not just keep things “fun.” • When applicable, you can always train the uninjured limb with great benefits. • Know when to refer out. Two minds and skill sets are better than one! • Make the athlete feel like an athlete, not a patient. • Look to soft tissue quality early-on…

External Impingement • Primary vs. Secondary • Scapulohumeral Rhythm • Populations p most commonlyy affected: lifters,, desk jockeys, elderly • Tendinosis? Tendinitis? Bursitis? • Supraspinatus? Infraspinatus? Biceps Tendon? Labrum?

External Impingement • Soft tissue work: pec minor/major, upper traps, levator scap, scalenes, rhomboids, RTC,, lats • Thoracic Extension and Rotation • Avoid “at-risk” position: front squat in place of back squat

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External Impingement Once symptomatic with ADLs: (Feet-Elevated) Push-up Isometric Holds > (Feet-

Elevated) Body Weight Push-up > Stability Ball Push-up > Weighted Push-up > Neutral Grip DB Floor Press > Neutral Grip Decline DB Press > Pronated Grip Decline DB Press > Barbell Board Press (gradual lowering) > Barbell Floor Press > Neutral Grip DB Bench Press > Low Incline DB Press > Close-Grip Bench Press > Bench Press > Barbell Incline Press > ???Overhead Pressing???

Internal Impingement • AKA posterior-superior glenoid impingement • Supra- and infraspinatus against P-S glenoid and labrum (articular-sided cuff issues) • High-speed, overhead activities: swimmers, tennis players, baseball players • Encompasses a broad spectrum of more specific diagnoses and pain presentation patterns

The Demands of Throwing • Shoulder stability is sacrificed for mobility • Highly reliant on soft tissue function for stability • Some numbers to consider during acceleration: – 7,200+°/second internal rotation ((20 full revolutions pper second) – 2,300°/second elbow extension – 650°/second horizontal abduction

Why? • • • • • • •

Limited ROM before full ROM Adducted before abducted Unstable before stable Cl d h i before Closed-chain b f open-chain h i Dumbbells before barbells Isometrics before “regular” speeds Traction before approximation (e.g., pull-ups would come before overhead pressing)

Why is baseball an at-risk sport? • Very Long Competitive Season – >200 games as a pro? – >100 College/HS? • Unilateral Dominance/Handedness Patterns – Asymmetry is a big predictor of injury – Switch hitters – but no “switch throwers!” • The best pitchers – with a few exceptions – are the tallest ones. The longer the spine, the tougher it is to stabilize. • Short off-season + Long in-season w/daily games = tough to build/maintain strength, power, flexibility, and optimal soft tissue quality

Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Med. 2006;36(3):189-98.

• 49% of athletes with posterior-superior labral tears also had a hip rotation ROM d fi i or abduction deficit bd i weakness k

• Requires a collaborative effort of DOZENS of muscles, not just the rotator cuff!

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Symptomatic Internal Impingement • Glenohumeral Internal Rotation Deficit (GIRD) • Why does it happen? • Role in SLAP lesions • Almost everybody has labral fraying and partial thickness cuff issues, but not necessarily w/symptoms • Possible elbow complications

Eccentric Stress Dictates Dysfunction • Reinold et al. Changes in shoulder and elbow passive range of motion after pitching in professional baseball players. Am J Sports Med. 2008 Mar;36(3):523 Mar;36(3):523-77. • “A significant decrease in shoulder internal rotation (-9.5 degrees), total motion (-10.7 degrees), and elbow extension (-3.2 degrees) occurred immediately after baseball pitching in the dominant shoulder (P