The
topic of injury, and in particular, shoulder injury is something that has come
to my attention a lot lately. Within my role as an Exercise Physiologist, I am
often referred clients through Medical Practices, who’s GP’s seek out Allied
Health Practitioners to implement strategies with their patients who present
with a multitude of injuries and issues. The idea is that chronic conditions
can be managed through specific intervention, by the right people. In a lot of
cases, we are referred patients who present with ongoing musculoskeletal issues,
and like I stated above; the shoulder continues to be an area of concern for a
lot of people. Within the blog post I am going to talk you through how I
approach shoulder injuries and the best practice I have found to restore health
and function of the shoulder joint. This is a step by step process which always
begins with a thorough Initial Consultation.
Initial Consultation:
Within an Initial Consultation, I feel it is extremely important to gather a history
as well as recount a series of recent events. This story can often begin to
outline the root cause of the issue in the first place. Let’s not forget,
injuries usually only stem from 3 main causes; the first being trauma. In order
to sustain this current injury, has there been a recent or pre-existing trauma to
the area? Has this issue been medically addressed through appropriate
conversation with a Dr? Has there been any imaging and has a Physiotherapist
been involved? These are all “must know” questions and pre-requisites to any
involvement in which I am going to have. Let’s just assume that there is no
traumatic injury, which is often the case with clients who are referred to me.
From here, we begin to look at the idea of this injury stemming from “over-use”
and potentially poor posture, poor set up with resistance training within the
gym and muscular asymmetry. This is generally where I do my best work and can
begin to examine the client from all avenues, and intervene accordingly.
Lastly, an injury or pain may be stemming from degeneration. There could be a
history of over-use or trauma that has been left for too long, and now
resulting in degeneration of the structures within the joint. This provides a
whole new set of questions regarding range of motion, strength and support,
specific pain points and over-use within other areas by way of compensation.
This is a more complex scenario, however is somewhat addressed the same as an
over-use injury if possible.
Movement Assessment:
To put it bluntly, if you are not being screened thoroughly for your current
movement capacities, find another clinician. Movement is the forefront of all
rehabilitation plans, as well as all Initial Consultations where injury is
concerned. Having an understanding of what you are looking for within a
movement screen is a skill that develops over time, but more often than not;
similarities begin to occur. Below are a list of the minimum movement patterns
I screen for, and I will explain each in detail within the following section.
1)Supine shoulder flexion.
2)Side lying thoracic rotation.
3)Shoulder abduction.
4)Shoulder horizontal adduction.
5)Shoulder external rotation with 90 degrees abduction.
The above movement patterns begin to tell a story of how the shoulder moves
currently. These assessments focus heavily on what the Lat will allow the
shoulder and thoracic spine to do and also incorporate moments of stability.
The supine shoulder flexion would have to be the ‘go-to’ assessment as it gives
you shoulder flexion, thoracic compensation and lumbar involvement all in one.
Quite often the lat will not allow flexion at the shoulder, simply because it
is too tight. This brings the humeral head forwards within the glenoid fossa
(shoulder capsule) and begins to create an anterior impingement. This is
worsened through any flexion at the shoulder or horizontal adduction of the
arm, as there is simply not enough space in the joint to stop tendons and
ligaments being pressed into places that they shouldn’t be. Addressing thoracic
rotation side lying takes the above idea and puts it into practice,
highlighting the impact that tight lats can have on rotation. The inability to
rotate will continue to stiffen the T spine and either make the anterior delt
do all of the work within rotational tasks, or the lumbar spine. None of those
2 outcomes are conducive to pain free movement long term, hence why it is
number 2 on the list. By addressing shoulder abduction and adduction, we begin
to see whether or not the individual has adequate stability through the
involvement of the rotator cuff, along with adequate range; or if the traps are
becoming overly dominant. Too much trapezius involvement can lead to neck pain
and headaches long term, so it’s good to have an idea of how the shoulder is
moving in all directions. Lastly we have the external rotation at 90 degrees,
which is followed by internal rotation in order to see if we have an even
amount of length and stability both ways. Again, we can see if the traps are
overly involved, if anything else is tight and restrictive and if there is any
pain throughout this movement.
Appropriate Intervention:
Through a thorough movement screening and history taking, we can begin to act.
Quite often, movement assessment and postural assessment will tell the whole
story. If this is the case, there needs to be an appropriate action plan which
aims to provide length, strength and education to the client. People do not
know these things to this degree, and that is where a detailed and well
explained plan needs to be implemented. If you receive a series of banded
external and internal rotation exercises and your therapists feels that this is
adequate, find a new therapist immediately. A shoulder rehab plan will be a
minimum of 30 minutes of appropriate intervention performed 3 to 4 days per
week, updated every 4 weeks. I approach rehab as if it is a performance plan dialled
back slightly. All plans are within a continuum of rehab to performance and I
do not consider an injury to be any different. I haven’t met too many people
who screen perfectly anyway, so all plans need to be specific towards long term
movement proficiency as well as adequate strength improvements. All rehab plans
should incorporate a series of trigger point releases, followed by mobility
work using poles, walls and bands, and then lastly involve some strengthening work.
The degree of difficulty, the equipment involved and the sets/reps/holds will
all be dependent on where the client is at currently. Some of my absolute ‘go-to’
rehab drills for shoulders are as follows.
Foam roll lats.
Foam roll upper back.
Trigger traps.
½ kneeling pole lat stretch.
Thoracic extension over a foam roller.
Book opening.
Supine wall L sit crunch.
Wall sit overhead reach.
Prone W/Y/T.
Band pull apart.
3 point stance dumbbell row.
Now if you look at that list and think it is very long, you need to realise
that every name on that list has a purpose, and will begin to restore shoulder
health. The shoulder is the most freely moving joint within the body and having
a mix of length and strength doesn’t happen overnight. Release work takes time
to create change. Mobility work takes time to create change and strength work
most certainly takes time to create change. If you are paying a physiotherapist
to give you a few band exercises and 1 cable row, maybe consider a new
approach. The above list is a bare minimum in my opinion and is always changing
and evolving, depending on the client. Nothing is set in stone, but this is a
good place to start.