Shoulder Pain Prevention

If you experience shoulder pain, here may be why it’s happening. Then come see us at San Diego Sports Physical Therapy for rehabilitation and improvement!
By Brian Sutton MS, MA, PES, CES, NASM-CPT

Is shoulder pain stopping you from, playing your favorite sport or achieving your personal fitness goals? Chances are, if you are experiencing shoulder discomfort or pain, you’ll have to alter your lifestyle to accommodate this dysfunction. Shoulder pain can occur in a multitude of ways and is prevalent in 21% of the general population (1,2) with 40% of that population having injuries persisting for at least one year (3). The treatment measures of shoulder pain can accumulate to an estimated annual cost of $39 billion (4).

Shoulder injuries have many different mechanisms or pathologies ranging from acute trauma to chronic overuse injuries. Acute trauma typically comes from a direct force, such as falling directly on the shoulder, or from an indirect force, such as landing on an outstretched hand. Either of these mechanisms may result in fractures of the humerus, clavicle, scapulae and glenoid fossa, or dislocations and tears of the capsular ligaments or labrum. However, the most commonly seen injuries in athletes or the active population stem from overuse syndromes.

Overuse Injuries

Overuse injuries (aka cumulative trauma disorders) are any type of muscular or joint injury caused by repetitive stress that surpasses the body’s natural repair processes (i.e., tendonitis, stress fractures). Overuse injuries of the shoulder are common among athletes who consistently perform overhead movement patterns (i.e., baseball pitchers, swimmers, tennis players) and individuals who repeatedly work with their arms raised (i.e., painters, construction workers) (5-9). Among the overuse injuries, shoulder impingement is the most prevalent diagnosis accounting for 40-65% of reported shoulder pain (10).

Common symptoms of shoulder overuse injuries include (11):

Minor pain during activity and at rest
Pain observed at the top or front of the shoulder during overhead activity (i.e., overhead presses) or during chest activities (i.e., incline bench press)
Tenderness on the lateral aspect (outside) of the shoulder
Loss of strength and range of motion (ROM)
Pain during throwing motions
Poor Posture
In addition to overuse injuries, individuals who exhibit poor static posture of the upper body are at risk for shoulder dysfunction. A common postural distortion of the upper body identified by Janda is the Upper Crossed Syndrome (UCS) and is characterized by protracted shoulders and a forward head (12). UCS generally involves tightness (overactivity) within the anterior chest region (pectoralis major/minor), latissumus dorsi, and cervical extensors (sternocleidomastoid, levator scapulae, scalenes), coupled with lengthening and weakening (underactivity) of the mid-and-upper back muscles (mid/lower trapezius, serratus anterior, rotator cuff) and deep cervical flexors. Individuals who sit for extended periods working on a computer may be at risk for developing upper body dysfunction and poor posture if certain precautions are not made such as taking frequent breaks and working at an ergonomically sound work station (13).

Exercise Selection
Similar to overuse and poor static posture, improper exercise selection can also contribute to shoulder dysfunction. For example, if a baseball pitcher tries to increase velocity of his pitches by only strengthening the superficial muscles of the shoulder (prime movers) that produce internal rotation (pectoralis major, latissimus dorsi) more than the stabilizers/external rotators of the shoulder (infraspinatus, supraspinatus, teres minor), these stabilizers become reciprocally inhibited (underactive) and fail to stabilize the glenohumeral joint during the throwing motion. Without adequate stability the athlete may develop a subacromial impingement, leading to subacromial bursitis, rotator cuff tendonitis, and possible tears of the external rotators (14).

Another example of poor exercise selection involves the over reliance on uniplanar, isolated resistance training exercises. Athletes and fitness enthusiasts oftentimes place too much emphasis on uniplanar exercises strictly focusing of concentric force production (e.g., presses and pulls) while neglecting total-body movements that integrate the entire kinetic chain (lower body, core, upper body) in multiple planes of motion (sagittal, frontal, transverse). Everyday activity occurs in all three planes of motion (front-to-back, side-to-side, and rotational) and only training in one plane (predominately the sagittal plane) will not effectively improve the individual’s ability to move in a coordinated fashion in the frontal and transverse planes. This form of program design may lead to muscle imbalance and faulty movement patterns increasing the individual’s risk of injury and/or joint dysfunction.

Using these two examples, fitness professionals should design exercise programs from an integrated (all-inclusive) perspective. An integrated exercise program encompasses both uniplanar and multiplanar movements; single, compound and total-body exercises; and adequately targets on all muscle groups (prime movers and stabilizers).

Shoulder Injury Prevention Strategies
If a client presents pain or dysfunction the fitness professional should never attempt to diagnose the problem but rather refer his or her client to a qualified medical professional. However, utilizing various movement screens, fitness professionals should assess their clients to identify potential muscles imbalances (muscle weakness and muscle tightness) and faulty movement patterns and subsequently implement a corrective exercise strategy to proactively address these concerns. For a list of comprehensive movement screens and corrective strategies for the shoulder complex see NASM’s Corrective Exercise Specialist.

Following a comprehensive fitness assessment (including a battery of movement screens), fitness professionals should implement a corrective exercise program that is individualized for their client:

Step 1: Inhibitory techniques (self-myofascial release) should be used to decrease tension and effects of latent trigger points of the overactive muscles surrounding the shoulder complex.
Step 2: Static stretching should be performed for a minimum of 30 seconds on identified overactive muscles to help facilitate optimal joint ROM and muscle extensibility.
Step 3: Isolated strengthening exercises should be used to facilitate the underactive muscles of the scapulae. Auditory and tactile feedback while performing these exercises can also help develop neuromuscular activation with proper kinetic chain positioning and control.
Step 4: Lastly, exercises are progressed by incorporating activities that integrate the entire kinetic chain (multijoint, compound movements). During these exercises clients should be instructed to maintain scapular retraction, depression, and posterior tilting while limiting winging by keeping the scapula on the costal surface. Refer to Figure 1 for an example shoulder corrective exercise program.
shoulder prevention

References:

1. Bongers PM. The cost of shoulder pain at work. BMJ. 2001;322(7278):64-65.
2. Urwin M, Symmons D, Allison T, Busby H, Roxby M, Simmons A, Williams G. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis.1998;57(11):649-655.
3. Van der Heijden G. Shoulder Disorders: A state of the art review. Baillieres Best Pract Res Clin Rheumatol.1999;13(2):287-309.
4. Johnson M, Crosley K, O’Neil M, Al Zakwani I. Estimates of direct health care expenditures among individuals with shoulder dysfunction in the United States. J Orthop Sports Phys Ther. 2005;35(1):A4-PL8.
5. Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. The recognition and treatment of superior labral (slap) lesions in the overhead athlete. Int J Sports Phys Ther. 2013 Oct;8(5):579-600.
6. Reinold MM, Curtis AS. Microinstability of the shoulder in the overhead athlete. Int J Sports Phys Ther. 2013 Oct;8(5):601-16.
7. Reinold MM, Gill TJ, Wilk KE, Andrews JR. Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes, part 2: injury prevention and treatment. Sports Health. 2010 Mar;2(2):101-15.
8. Reinold MM, Gill TJ. Current concepts in the evaluation and treatment of the shoulder in overhead-throwing athletes, part 1: physical characteristics and clinical examination. Sports Health. 2010 Jan;2(1):39-50.
9. Stenlund B, Lindbeck L, Karlsson D. Significance of house painters’ work techniques on shoulder muscle strain during overhead work. Ergonomics. 2002 May 15;45(6):455-68.
10. van der Windt DA, Koes BW, Boeke AJ, Deville W, De Jong BA, Bouter LM. Shoulder disorders in general practice: prognostic indicators of outcome. Br J Gen Pract.1996;46(410):519-523.
11. American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=a00032. Accessed November 12, 2013.
12. Janda V. Muscles and Motor Control in Cervicogenic Disorders. In: Grant R, ed. Physical Therapy of the Cervical and Thoracic Spine. St. Louis, MO: Churchill Livingstone; 2002:182–99.
13. Cho CY, Hwang YS, Cherng RJ. Musculoskeletal symptoms and associated risk factors among office workers with high workload computer use. J Manipulative Physiol Ther. 2012 Sep;35(7):534-40.
14. Cowderoy GA, Lisle DA, O’Connell PT. Overuse and impingement syndromes of the shoulder in the athlete. Magn Reson Imaging Clin N Am. 2009 Nov;17(4):577-93.

– See more at: http://blog.nasm.org/cex/shoulder-pain-prevention/#sthash.mPXeZhdS.dpuf

Core Training for Injury Prevention

Since core training is of extreme importance, Christopher McGrath shares some great exercises and benefits of core training for injury prevention.

For more on the anatomy and purpose of training, functional considerations including stabilization and reactive movement, and techniques to incorporate integrated core training, join ACE fitness expert Chris McGrath for our live one-hour webinar on Wednesday, Oct. 10 at 11 a.m. PST.

With perhaps the exception of aesthetic purposes, the most popular reason for training the core is “protection” or injury prevention—primarily for the back. We often hear the phrase, “The best way to protect your back is to strengthen your core.” While this may not be untrue, it is not quite as simple as this statement suggests. If core training is important for injury prevention, especially for the back, we must be able to explain how core training helps and, conversely, why a “weak core” might lead to injuries. And exactly what do we mean by “weak core?”

To help break down the answers (of which there may be dozens of combinations), we must first have a fundamental understanding of the functionality of the core—and a clear concept of what “the core” actually is. At the risk of repeating many other core-related educational materials, here is a brief overview of the core:

The abdominal muscles are not the core. The abdominal muscles are some of the muscles that make up the core.
The core consists of a stabilization unit and a mobilization unit.
The stabilization unit consists of mostly muscles you can’t see because they are deeper in the body.
In function, all of the abdominal muscles are designed as stabilizers, not as primary movers. (Yes, this includes the rectus abdominus and the external obliques.)
The spinal erector muscles are part of the stabilization unit.
The mobilization muscles are typically bigger muscles that move the body, but also influence pelvic and lumbar positioning and stability.
Planks and crunches do not constitute a balanced or comprehensive core-training workout.
What is a Weak Core?

“Weakness” is associated with a lack of strength, but is a lack of strength always associated with weak muscles? Absolutely not! Naturally, weak muscles can be a factor, but there are many individuals with no shortage of strong muscles (including “ripped” abdominal muscles) who still fall prey to back injuries—and not always during high-risk activities or exercises. So why might this happen? What else can “weak” mean?

In its simplest explanation, the stabilization unit of the core is responsible for two things—posture and timing—which are not mutually exclusive. When the stabilizers are irresponsible (i.e. not doing their job), poor postureresults. When our timing is irresponsible, poor posture results during activity. This presents as a form of “weakness.” Individual muscles may be “strong,” but can be simultaneously weak during functional activities. At the very least, poor timing affects efficiency and performance, but it also carries the risk of injury. In other words, the core must work in the right place, at the right time, to provide the stability needed to perform and protect.

Posture, which the core is largely responsible for, can be observed in two basic ways: statically (standing, sitting and/or balanced on a single leg) and dynamically (through movement). While static posture can be thought of as “neutral spine,” or “standing tall,” dynamic posture is not that simple. Dynamic posture requires control through stabilization, deceleration and/or reactivity. In some instances (typically under maximal loads), this might require a rigid and forceful “standing tall.” But in other instances, maintaining a rigid and neutral posture will inhibit performance (as in swinging a baseball bat or tying one’s shoe).

Observing dynamic posture is not exercise-specific—it is movement-specific, which means the core needs to act differently depending on the activity performed, a fact that is rooted in one of the fundamental principles of exercise science—specificity. Therefore, while there may be some carryover, we should not assume floor-based exercises would have an automatic transfer to activities performed on our feet. Floor-based exercises can be good and may actually be the best place to start, but without integration with other activities, functional core strength may not be fully realized.

Dynamic Core Posture

Given the countless movements performed in everyday life, it is helpful to define some basic patterns for observing dynamic core posture:

Under low loads (body weight)
Under moderate loads with endurance (either lighter weights or body weight with some momentum as in walking or jogging)
Under high loads (heavier weights and explosive activities)
Anti-rotation (resisting rotation when applied with a low to moderate force)
Bilateral stance movements (e.g., squatting)
Unilateral stance movements (e.g., stepping)
Split stance movements (e.g., lunging)
In line with specificity, just because the core works well on a bilateral movement doesn’t guarantee it will work well in a split-stance movement. Additionally, it should not be assumed that low-load or low-intensity core control will predict high-intensity core function and visa-versa. High-load observations were included in the previous list, but should only be observed if the client is currently participating (or intends to participate) in high-load activities, sports or training. Also, don’t be surprised if the high-intensity participant struggles with low-intensity core challenges.

Improving Timing

Low-intensity core stabilization should be viewed as the introductory phase for core training and timing, and may be accomplished through floor exercises from supine, prone and side-lying positions. Adding low-intensity perturbations to excite reactive responses in different planes can help prepare the core for low-grade dynamic stabilization, which is what the core encounters during everyday activities outside of exercise, sport and manual labor. This can also serve as an appropriate preparation for more progressive training. Finally, find ways to reactively stimulate the core through integrated exercises (while standing) and workouts. This will allow the core to adapt to higher demands in different situations and therefore offer better protection and better results.

It is worth repeating that timing and reactivity is enhanced through progressive training and is key to functionality. The ACE Integrated Fitness Training® (ACE IFT®) Model offers strategies for developing the core for function. While not all exercises in early stages seem terribly exciting, they serve as prerequisites to more advanced core-training practices—much like learning basic chords and scales on an instrument eventually allows the musician to play songs efficiently and effortlessly.

Chris McGrath, M.S., is the founder of Movement First, a New York City-based, health and fitness education, consulting and training organization. With more than 20 years of fitness and coaching experience, McGrath specializes in a variety of training modalities including sports performance, injury prevention, post-rehabilitation and lifestyle/wellness coaching. McGrath is a Senior Fitness Consultant to the American Council on Exercise and has established himself as an international fitness expert.

The Real Benefits of Strengthening Your Core…Beliefs

You core is an important part of you body. It ties everything together! So here are some tips from Dr. Michael Mantell at ACE Fitness about how to do so! Then come see us at San Diego Sports Physical Therapy for more tips on how to strengthen your core.

Your core muscles form the sturdy link in a chain that connects your upper body and your lower body. Regardless of what you do while you’re lifting, twisting or bending – from putting on your gym shoes and socks to taking out the trash – your core is at work.

Low back pain? Check your core.

Problems playing your favorite sport? Check your core.

Trouble doing household chores? Check your core.

Issues with your posture? Check your core.

A little shaky on your balance and stability? Check your core.

Not thinking clearly or acting wisely? Check your core.

Wait a moment? What does your core have to do with thinking clearly or acting wisely? Plenty – if it’s your core BELIEFS that you’re talking about.

Typically clients know the drill for core exercises, but I’m going to show you additional exercises you may incorporate to add an additional real benefit to your coaching sessions. Have your clients ask themselves (and perhaps ask yourself) this simple question: “What idea have I feverishly and insistently held onto that causes many of the problems in my life?”

Here’s a list adapted from the work of Albert Ellis, Ph.D., founder of Rational Emotive Behavior therapy. Known as the forerunner of cognitive behavior therapy, Ellis has compiled a list of the most common irrational thinking that leads to the most universal forms of human upset:

The idea that it is a dire necessity for adults to be loved by significant others for nearly everything they do instead of their concentrating on their own self-respect, and on loving rather than on being loved.
The idea that certain acts are awful or wicked, and that people who perform such acts should be severely damned instead of the idea that certain acts are self-defeating or anti-social and that people’s poor behaviors do not make them bad individuals.
The idea that it’s horrible when things are not the way we like them to be instead of the idea that it’s unfortunate and if it’s not possible to change the situation, we should temporarily accept their existence.
The idea that human misery is invariably externally caused and is forced on us by outside people and events instead of the idea that our upset is caused by the view we take of unfortunate conditions.
The idea that if something is or may be dangerous or fearsome we should be terribly upset instead of the idea that we should face it and accept the inevitable.
The idea that it is easier to avoid than to face life’s difficulties and self-responsibilities instead of the idea that the so-called “easy way” is usually much harder in the long run.
The idea that we absolutely need something other, stronger or greater than yourself to rely on instead of the idea that it’s better to take the risks of thinking and acting independently.
The idea that we should be thoroughly competent, intelligent and achieving in all possible respects instead of the idea that we should accept ourselves as imperfect creatures with general human limitations and specific fallibilities.
The idea that because something once strongly affected our life it should indefinitely affect it instead of the idea that we can learn from our past experiences.
The idea that we must have certain and perfect control over things instead of the idea that the world is full of probability and chance, and despite this we can still enjoy life.
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Help strengthen your own and your client”s core beliefs by answering the following questions in writing:

“What idea have you feverishly and insistently held onto that is the cause of many problems in your life?”

Ask yourself what’s inaccurate about this unhelpful thought. Do you have any evidence the useless thought is true? If not, why keep holding onto what’s unnecessary? What can you replace this adverse thought with one that’s more helpful?

Do this exercise mindfully everyday, one set, as many reps as needed.

Feel better? Thinking more clearly? Acting more wisely? Congratulations!

Michael R. Mantell, Ph.D., the Senior Fitness Consultant for Behavioral Sciences for ACE, earned his doctorate at the University of Pennsylvania after completing his M.S. degree in clinical psychology at Hahnemann Medical College where he wrote his thesis on the psychological aspects of obesity. He has served as Chief Psychologist for San Diego’s Children’s Hospital and Health Center and the San Diego Police Department and has been on the clinical faculty of UCSD’s Department of Psychiatry. He is a Behavior Science coach for fitness trainers, health coaches, world-class athletes and fitness enthusiasts for mental and behavioral performance enhancement. He has taught for the Equinox Fitness Training Institute, is an Ambassador for PHIT America, serves on the expert panel for greatist.com, is a weekly contributor to Fox 5 News, writes monthly for IHRSA, and is a member of the Sports Medicine Team at the Sporting Club of San Diego specializing in fitness behavioral science. Dr. Mantell