I THREE FUNCTIONAL ZONES FOR REHAB

We will for the sake of clarity divide rehab drills into three zones that relate to the progressive increase in shoulder elevation:

1. Zone 1 (0-30°): Lower Trap emphasis

2. Zone 2 (30-120°): Serratus Anterior emphasis

3. Zone 3 (120-full elevation): Upper Trapezius emphasis

Note 1: despite giving emphasis to different scapula-thoracic muscles at different ranges of elevation, by no means am I saying that serratus is not active even immediately beginning elevation, or at the end of elevation. All three are likely active as a force couple all through.

Note 2: It is critical to achieve Subscapularis activation during all movements and angles as it. There seem to be two directions possible here (neither scientifi cally validated as yet):

• Clients can be taught to “suck” the ball back into the socket during the movements as an active skill. Many experienced practitioners have adopted to varying degrees of success these techniques and progressions – see the excellent work of Magarey (5,7) and Jam (9). This has not been my experience – I fi nd that clients seem generally less compliant with this system, and in my opinion it is too prone to subjectivity and inter-tester unreliability.

• An alternative as been suggested for this purpose: The use of Rehab Trainer “Iso-Integration Techniques” may be a very useful tool here to create stability and proprioception in many mid-range positions and movements. As discussed previously in the fi rst article (The Gym Junkie’s Shoulder), the gentle external rotation tension created with tubing and requiring an internal rotation force (which presumably activates Subscapularis) seems clinically and anecdotally to reduce impingement and instability feelings immediately upon applying the tubing at the right tension and at the right angles. Numerous clinical examples of successful rehab for impingement and/or gleno-humeral instability problems can be provided upon request, especially with recalcitrant and or biomechanically unaware clients who have poor capacity for skill relearning.

SHOULDER REHABREHAB WITH THE THREE RENOVATORS

Example shown of abduction withIso-Integration of Subscapularis

I ZONE 1 RETRAINING SCAPULAR ‘HOME’ POSITION

Client is taught to reposition scapula towards a more neutral position of scapular posterior tilt/ upward rotation/

external rotation/retraction. This takes time and patience, self feedback via palpation / use of mirrors / biofeedback

and tape. I fi nd the cues of simply retracting the scapula “back and together” or “hold shoulders down” NOT

effective, but rather the client needs to move the inferior angle of the scapula down and laterally towards their

lat dorsi (feeling like they are fl aring their scapula slightly towards their armpit). Upper traps and rhomboids need

to be soft. See before and after photos below. Numerous tubing and dumbbell exercises can be gradually added

to this static position to challenge the motor learning and gradually teach the lower trap to become active in a

shortened range.

This new position must be reinforced habitually over a 6 month period, as the new “normal”, or “home” for their

shoulder. Guys will feel strangely wider in the shoulders and girls will feel a little exposed with their chest more

open. Get used to the new you!

POOR POSITION

BETTER POSITION

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I ZONE 2 RETRAINING THROUGH THE IMPINGEMENT ARC

Biomechanically there must be suffi cient internal rotation range of movement to allow the humeral head to

depress and not be forced anteriorly (exactly how much is required is matter for debate: at 90° abduction testing it

would be safe to say that 45-70° internal rotation is mandatory). In addition however, normal shoulder abduction

from 80-120° requires subtle external rotation of the humerus to prevent the greater tuberosity impinging under

the acromion. This is a delicate balance as you can appreciate! Some shoulders seem to exhibit an inability to

externally rotate and feel less pain immediately that is taught, and others seem mainly to require loosening of the

tight external rotators and the impingement pain lessens.

DRILL: Lat pull down / tubing from above a door tensioned down

Use a very small load setting on the machine. Stand side on for abduction, or on a slight diagonal for “scaption”

(30°forward of abduction plane). Push gently down with hand on bar or holding tubing on tension. This set up

allows a minimized loading environment while client learns to upwardly rotate and posteriorly tilt their scapula

through the impingement arc. Pain must be eliminated during the drill. Client is taught to externally rotate the

humerus (not supinate their forearm – challenging!) through the range of 80-120°.

It is possible to use Iso-Integration of subscapularis during this drill if pain is still present: introduce a gentle

external rotation tension at the same time (elbow must be a bit more bent) or loop some tubing around the back of

the glenoid and tension towards the front to create a small antero-superior shear that the client needs to resist.

Symptoms must reduce and hopefully the client can progress from the need for Iso-integration fairly quickly (few

days perhaps).

The best cues we have experimented with during this drill are:

• “Turn your elbow upwards during the movement”

• “Reach gently with your armpit as you lift”, and

• “Keep your neck soft”

POOR POSITION BETTER POSITIONduring abduction using above cues (note lower trap activation)

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I ZONE 3 RETRAINING FOR THE OVERHEAD ATHLETEAs elevation progresses past 120°, the ratio of scapula: humerus movement equalizises (1:1 ratio is established from

research), there is normally tightness of lat dorsi – teres major / pec major / thoracic spine / rhomboid to contend

with. A big stretch session before retraining in this zone is recommended for the above structures (our preferred

tool for self-myofascial release of all these areas is the Lockeroom Posture Pro tool available from The Rehab Shop

(www.rehabtrainer.com.au) in Australia or Body Logic in the UK).

DRILL I: Lat pull down lower trap isolation

Lower trap drill for dummies! Impossible to activate any of the other muscles mentioned earlier – therefore this drill

is excellent as a warm-up of warm-down.

This drill can be done as a static hold (10x10 sec) or as a movement (3x10 reps).

Hold bar in a pronated grip, keep arms straight and gentle depress the scapulae down and to the center of the thoracic

spine. Simple – but the arms must be straight!

DRILL II: Lat pull down serratus anterior isolation

Use a heavier weight on the machine stack, or gently hang from a horizontal bar, so that the arm is tractioned

vertically. Client must have a supinated grip (essential). Grip strength is also tested in this drill, which is considered by

many corrective exercise specialists such as Gray Cook to be a critical factor in upper limb injury.

Client allows the stretch to take place for up to 30 seconds. Then the client rotates (leading with their armpit)

towards the opposite direction of the injured shoulder, and holds for 10 seconds. Repeat 10X. This will isolate serratus

anterior – clients invariably report a signifi cant muscle fatigue feeling under their armpit. If this is done while hanging

from a horizontal bar, the movement required is to twist the trunk while hanging.

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DRILL III: Upper body home rehab drill

In a good sitting or standing posture, client places fi nger tips of both or only injured side at the back of the head

and gently applies pressure to back of head. Relax the neck, and hold as a static activation drill for subscapularis,

serratus anterior, lower traps, and neck stability musculature. Many birds with one stone!

Then add a “fl apping” movement emphasizing slow and full protraction and retraction while fi ngertips remain

pressing into back of the head (for subscapularis Iso-integration).

Do 3x10.(see R shoulder drill below)

DRILL IV: For the throwing athlete

Here elbow is gently pushing into the dura disc at angle of scaption, to activate serratus anterior, with tubing

used to generate static tension, then slow movements, progressing into faster movements of internal / external

rotation. Client can alter from “wind-up “to “follow-through” throwing positions by rotating the trunk. Then at late

stage combine gleno-humeral rotation with trunk rotation (all with tubing on tension for subscapularis activation).

Progress all drills with care to not exacerbate pain, and with emphasis on cueing and good technique.

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I OVERALL PRINCIPLES FOR HANDS-ON THERAPY TO GUIDE YOU TOWARDS INCREDIBLE RESULTS:

• Reduce the dominance patterns: It cannot be overstated that a critical and early part of empowering

the Three Renovators to work during functional movements (in order to reduce pain and improve range of

movement) requires the demolition crew (a multitude of releasing and loosening procedures from trigger point

and myofascial releases, to mobilizing, to stretching, etc). This will temporarily reduce the dominance of pec

minor, rhomboids, levator scapulae, infraspinatus / teres minor and posterior deltoid. In addition, the tightness

of pec major, lat dorsi and thoracic spine will be reduced and further enhance mobility.

• Activate the inhibited stabilizers: You may even employ myofascial techniques to activate subscapularis,

upper and lower traps and serratus anterior.

• Work with a good Allied Health Therapist who knows how to release muscle tightness and tension, hammer

the main areas repeatedly over a month or two, and your shoulders will recover faster – guaranteed.

• See the work of Travell and Simons, Chaitow, and many others for excellent techniques in the areas of

Trigger Point Release, Myofascial and Active Release Techniques.

• Taping and temporary training modifi cation and teaching self-massage will greatly prevent pain returning

in between sessions and until the three renovators are up to speed.

• Get rid of pain as a highest priority to prevent on-going inhibition: In many cases this therapy and loosening

work will remarkably reduce pain and improve functional movement, thus allowing you to begin proactive

retraining / rehab drills at a further progressed point.

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degrees of shoulder elevation in healthy subjects North Am J Sports Phys Ther. 2007 Feb; 2(1):34-43.

2. Kristof De Mey et al Trapezius Muscle Timing During Selected Shoulder Rehabilitation Exercises 10.2519/jospt.2009

3. Hides et al Multifi dus muscle recovery is not automatic following resolution of acute fi rst episode low back pain. Spine. 21: 2763-2769. 1996.

4. Hodges et al. Delayed postural contraction of the transverses abdominis in low back pain associated with movement of the lower limbs. Journal of Spinal Disorders. 11: 46-56. 1998.

5. Magarey ME, Jones MA. Dynamic evaluation and early management of altered motor control around the shoulder complex. Man Ther. 2003;8:195-206.

6. Blasier R, Guldberg R, Rothman E. Anterior shoulder stability: contribution of the rotator cuff forces and the capsular ligaments in a cadaver model. J Shoulder Elbow Surg. 1992;1:140-150

7. (13) David G, Jones M, Magarey M. Rotator cuff muscle performances during gleno-humeral joint rotations: An Isokinetic, Electromyographic and Ultrasonographic Study. Manipilative Physiotherapists Association of Australia Conference Proceedings.

8. Reinold, et al Electromyographic Analysis of the Supraspinatus and Deltoid Muscles During 3 Common Rehabilitation Exercises, J Athl Train. 2007 Oct–Dec; 42(4): 464–469.

9. (14). Bahram Jam, MPhty, BScPT, FCAMT New Paradigms in Rotator Cuff Retraining

10 Ann M. Cools, et al Scapular Muscle Recruitment Patterns: Trapezius Muscle Latency with and without Impingement Symptoms, Am J Sports Med July 2003 vol. 31 no. 4 542-549

11. (17). Hawkins et al, Serratus anterior muscle activity during selected rehabilitation exercises. American Journal of Sports Medicine. 27: 784 – 791.1999.

12 (18). Hawkins et al Subscapularis muscle activity during selected rehabilitation exercises. American Journal of Sports Medicine. 31: 126 – 134.2003.

13 (19) Kibler B The role of the scapula in athletic shoulder function. American Journal of Sports Medicine 26 (2); 325–339, 1998

14 (20). Kibler B Sport-specifi c conditioning. The American Journal of Sports Medicine 22(3): 121–432 1994

15 (24). Glousman et al. Dynamic electromyographic analysis of the throwing shoulder with glenohumeral instability. J Bone Joint Surg Am. 1988;70:220-226.

16 (25) Preventative Rehabilitation for Rugby Injuries to the shoulder complex – a literary review. By Janine Gray

17 (42) McLaughlin HL, Recurrent dislocation of the shoulder,part II: a comparative study. J Trauma. 1967;7:191.

18 (43) Herrington and Horsley Electromyographic analysis of selected shoulder muscles during a rugby football tackle Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2009, 1:10doi:10.1186/1758-2555-1-10

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