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shoulder injury

Shoulder Injury : How to restore high-level shoulder strength

Chris Mallac offers detailed guidance for professionals working with top-end athletes.

Beware: what follows is highly practical! While a comprehensive understanding of the dynamics of the glenohumeral complex is critical for proper implementation of rehabilitation programmes for high-level athletes with shoulder injuries, the emphasis in this article is squarely on post-clinical rehab. Many therapists feel inadequate when it comes to communicating with strength and conditioning coaches regarding top-end shoulder rehabilitation, so this piece is designed for those who would appreciate some guidance on the principles behind gym-based rehab to restore to their athletes a functional and strong shoulder complex.

These principles are most appropriate for athletes in the following situations:

  • late-stage rehab after shoulder stabilisation surgery (more than 12 weeks post operative)
  • conservatively managed shoulder instability
  • acromioclavicular joint pathology and surgery
  • non acute shoulder impingement syndromes and tensile tendon problems.

Movement not muscles

When we describe exercise selection for the upper quadrant, it is more appropriate to think about movement direction rather than muscle groups. So instead of breaking down the weights plan according to, say, deltoid, pectorals, latissimus dorsi and rotator cuff, we gain a better appreciation of balanced programming if we think about movement directions. The strength coach Ian King (1) describes shoulder strength training based on the four dynamic movements along the push and pull axis. I have taken this idea and developed it to include three more movement types.

Seven movement directions

The seven types of movement we need to train for are:

  • horizontal pushing
  • horizontal pulling
  • vertical pushing
  • vertical pulling
  • internal rotation
  • external rotation
  • diagonals

Horizontal pushing

In essence this involves horizontal flexion of the shoulder. Examples of exercises focusing on this movement direction are: bench press (and all its derivatives), flyes and push-ups. The main muscle contributors are: pectorals, anterior deltoid, triceps and scapular protractors such as serratus anterior.

Horizontal pulling

This involves horizontal extension of the shoulder. Choice exercises are: seated row, single-arm rows, barbell bent-over rows, reverse flyes and Dorian rows (see below). The prime movers in this direction are latissimus dorsi, posterior deltoid, the elbow flexors and scapular retractors such as middle trapezius and rhomboids.

Vertical pushing

This involves the combined anatomical movements of glenohumeral abduction and flexion, along with scapular elevation/external rotation. It encompasses all shoulder press movements, lateral raises, front raises, upright rows (actually a pull but included here in terms of muscles used) and shrugs. These work the anterior and middle deltoids, clavicular head of pectoralis major and upper trapezius.

Vertical pulling

The combined movements of glenohumeral adduction and extension, along with scapular retraction/downward rotation/depression. Chin-ups, lat pulldowns and all the variations involve these movements. The muscle focus is on latissimus dorsi, the teres group, posterior deltoid, lower trapezius.

Internal rotation

Self-explanatory as a movement. Heavily focused on pectoralis major, latissimus dorsi and subscapularis.

External rotation

Recruitment of the infraspinatus, supraspinatus and posterior deltoid.

Diagonals

Based on the fundamental principles of proprioceptive neuromuscular facilitation (PNF) patterns of movement. PNF patterns are founded on the premise that the body only knows about patterned and functional movements. That is, when a muscle such as pectoralis major contracts, it wants to perform all three of its actions: horizontal flexion, adduction and internal rotation. Therefore, strength exercises for the shoulder should incorporate all the relevant components, alongside their opposing movements. The best way to do this is with diagonal movements. The movement directions outlined in Table 1 below are known as the diagonal 1 (D1) and diagonal 2 (D2) pattern (2).

Table 1: Diagonal movement patterns

D1 starts from abduction/external rotation/flexion and moves towards adduction/internal rotation/extension.

D2 starts from abduction/ internal rotation/ extension and moves towards adduction/ external rotation/flexion.

Functional diagonals

The therapist must not forget that the body moves in a kinetic chain. Shoulder movements are heavily linked to hip movements via the ‘myofascial slings’ acting over the skeletal structure. For an in-depth explanation of these slings see SIB 36.

In a nutshell, a great way to perform diagonals using the cable machine in the gym is to do them in standing. That way the hip and lower limb muscles are involved via their link through the myofascial slings. As a brief example, the posterior oblique sling (latissimus dorsi, thoracolumbar fascia and contralateral gluteus maximus) is best worked using the diagonal movements described above in standing while isometrically tensing the opposite gluteus maximus.

Common mistakes

Internal v external rotation

In SIB 42, Bob Garrett made a very important observation in his letter to the editor, which should not be missed by those working in shoulder rehabilitation. The shoulder’s internal rotators are much bigger and nastier than the external rotators. If you think about it, the bulk of the pectoralis major, latissimus dorsi and subscapularis (all internals) far outweighs the size of the minuscule but highly important external rotators (infraspinatus, posterior deltoids, teres minor and supraspinatus).

Despite this clear imbalance, most gym programmes seem to focus primarily on the internal rotators. The most popular upper body exercises are the bench press (pecs – internal rotators) and lat pull- downs/chin ups (latissimus – internal rotators). Without proper balancing of the external rotators, a gym trained athlete will over time adopt that ‘carrying suitcases’ look: glenohumeral internal rotation with scapular protraction.

The pectorals and latissimus become tight and facilitated, with the posterior deltoids, posterior cuff and scapular retractors (middle trapezius and rhomboids) becoming weak and lengthened. This will lead to anterior translation of the humeral head and potentially damage to the anterior structures and subacromial structures when the arm is taken into an elevated position. This becomes a problem when overhead elevation is repeatedly performed.

The best high-level exercise for the external rotators is 2 to 1 shoulder external rotations. In side lying, use both hands to concentrically lift a dumbbell into full external rotation (the ‘2’ component) and then use only the one arm to eccentrically lower the dumbbell (the ‘1’ component). This allows the external rotators to be maximally loaded, as the concentric component is assisted through its weakest part with both hands (see figs 1 and 2).

Figure 1: 2 to 1 dumbell external rotations, concentric

Figure 1: 2 to 1 dumbell external rotations, concentric

Figure 2: 2 to 1 dumbell external rotations, eccentric

Figure 2: 2 to 1 dumbell external rotations, eccentric

Scapular protractors v scapular retractors

The main focus of movement involved here is horizontal push and horizontal pull. Traditionally the ‘pulling’ movements have been poorly performed and undervalued in strength programmes. It is commonly argued that this is because the individual cannot see the pull muscles, so they don’t put much time and care into training them. I believe the real reason is that no exercises truly load the scapular retractors and shoulder extensors the same way as one can load the scapular protractors and shoulder flexors. If you think about it, it’s much harder to pull the same poundages as one can push. If an individual can bench press 150kg, it is difficult to pull the same amount of weight. Or is it?

The Dorian row is the daddy of all hor- izontal pulling movements, because when an athlete is well trained, they can achieve similar weights to those they are bench pressing. This allows the ‘balance’ of push and pull to be addressed.

I named this exercise after the great English bodybuilder Dorian Yates. He perfected a method of performing bent- over rows by using a higher trunk angle and supinated grip on the bar. The angles involved (hip is 30 degrees from vertical and knee 30-40 degrees, depending on length of leg and leverage) allow the lifter to handle much heavier weight while really focusing on the scapular retractors and shoulder extensors. Ensure that the bar starts against the thigh just above the knee (see figs 3 and 4).

Figure 3: Dorian row, start position

Figure 3: Dorian row, start position

Figure 4: Dorian row, maximum retraction

Figure 4: Dorian row, maximum retraction

Guidelines for programming

1. Prioritise the weakest movements

In most cases, the weakest and most underdeveloped movements will be horizontal pulls and vertical pulls. External rotation will generally be weaker and underutilised compared to internal rotation.

2. Form before weight

In initial programming, tempo of the movement is critical as it allows the rota- tor cuff enough time to dynamically con- trol glenohumeral joint position, and the scapular stabilisers to control scapular movements. So speeds such as 2:2:2 (2 second eccentric, 2 second hold, 2 second concentric) are a good starting point before moving on to faster and more dynamic lifting speeds.

3. Aim for balance

If you consider an athlete to have excellent development of a movement direction such as horizontal push, but poor devel- opment of horizontal pull, then make sure they redress this imbalance. If necessary, you could forbid an athlete from per- forming push movements until their pull movements catch up in terms of weight used. I have often seen rugby players with impingement-type syndromes caused by too much bench pressing. By forbidding them from doing bench presses until their strength on a pulling exercise catches up, very often their shoulder pain clears up without active treatment, rehab or even medication, and never recurs.

4. Don’t fatigue the rotator cuff

Rotator cuff work is often included in an upper body lifting programme as a form of ‘prehab’ before moving on to the heavy compound movement component of a programme. This makes sense to pre-fire the rotator cuff muscles so they are involved in the dynamic control of shoul- der movement with other lifts. However, in the ‘prehab’ component, keep the vol- ume and intensity short. Too much cuff work may fatigue these and undermine their role during the heavier lifting com- ponent. Leave the fatigue work until the end of the programme.

5. Stretch

Spend 25-35% of the allocated training time on stretching. So in a one-hour train- ing/lifting session, 15-20 minutes should be spent stretching. This allows full range of available shoulder motion to be achieved with lifting, and will enable the habitually lengthened muscles (eg rhom- boids) to work against reduced resistance from the stronger muscles (such as pec major/minor) which tend to hold the shoulder in internal rotation and scapula in protraction. For most people, the four key areas that need to be lengthened are latissimus dorsi, pec major and minor, short external rotators such as infraspinatus and scapular elevators such as trapezius and levator scapulae.

Sample programme

Athlete is 16 weeks post-shoulder reconstruction. Has full range of motion but needs to start focusing on heavier lifting to prepare shoulder for contact training in four weeks.

Workout 1 (early in the week): horizontal pulling/vertical pushing
Exercise sets reps tempo (sec:sec:sec) other
1. Stretch (10 mins): lats, pecs, posterior cuff and upper traps
2. Side lying external rotation 1 10   1 up 1 down; eg 5kg plate
3. Side lying external rotation 2 8   2 up 1 down; eg 10-15kg dumbbell
4. Prone flutters (face down, arms by sides with elbows locked out, retract scapula and hold)   2   30 sec hold
5. Prone flyes 2 8 2:2:2  
6. Dorian rows

SUPERSET WITH...
1
1
1
8
6
4
2:2:2
2:2:2
2:2:2
 
7. Seated dumbell shoulder press
palms forward
palms facing body
Arnold press (palms start facing
body but twist to end forwards)
 
1
1
1
 
 
8
8
8
 
 
2:2:2
2:2:2
2:2:2
 
 
8. Single-arm row 3 6 2:1:2  
9. Alternate front/side raises 3 8 (4 each direction) 2:1:2  
10. Standing cable diagonals (high cable) 2 6 (each direction)    
11. Stretch (10 mins): lats, pecs, posterior cuff and upper traps
12. Side lying external rotation 1 10   1 up 1 down; eg 5kg plate
13. Side lying external rotation dumbbell 2 8   2 up 1 down; eg 10-15kg
14. Prone flutters (as before)   2   30 sec hold

 

Workout 2 (later in the week): horizontal pushing/vertical pulling
Exercise sets reps tempo (sec:sec:sec) other
1. Stretch (10 mins): lats, pecs, posterior cuff and upper traps
2. Side lying external rotation 1 10   1 up 1 down; eg 5kg plate
3. Side lying external rotation dumbbell 2 8   2 up 1 down; eg 10-15kg
4. Wall slides 2 10    
5. Dumbell bench press

SUPERSET WITH...
1
1
1
10
8
6
2:2:2
2:2:2
2:2:2
 
6. Lat pulldowns 1
1
1
10
8
6
2:2:2
2:2:2
2:2:2
 
7. Incline close grip bench press 3 6 2:1:2  
8. Chin-ups 3 6 2:1:2  
9. Standing cable diagonals (low cable) 2 6 (each direction)    
10. Stretch (10 mins): lats, pecs, posterior cuff and upper traps
11. Side lying external rotation 1 10   1 up 1 down; eg 5kg plate
12. Side lying external rotation dumbbell 2 8   2 up 1 down; eg 10-15kg
13. Wall slides 2 10    

Supersetting involves alternating between sets of the two specified exercises without rest, thereby performing six sets of two exercises before resting.

 

Chris Mallac is an Australian physiotherapist from the University of Queensland currently working as head of sports medicine at Bath Rugby Union.

Illustrations by Viv Mullett

References

  1. King I (2002) Get Buffed. King Sports Publishing. Reno NV
  2. Knott M, Voss DE (1968) Proprioceptive Neuromuscular Facilitation. Harper & Row, New York

shoulder injury