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Shoulder Injury Free Athletes: The Shoulder Chiropractor


For athletes who rely on their shoulders, here are the five major guidelines for maintaining them injury-free. Shoulder chiropractor, Dr. Alexander Jimenez assesses the data.

There is not any joint in the human body as complicated, intriguing, or bothersome as the shoulder. It can leave clinicians scratching their heads, wondering why a problem they've solved several times before is this time so stubborn. And shoulder problems can surely be stubborn! That's why, in every case, prevention is indeed much better than cure. Rarely is a pain which has surfaced a very simple matter of applying some ice -- it is more likely to be the tip of an iceberg!

An athlete's shoulder is either a joint that he/she hasn't given a second thought to, or it's ever-present in their minds -- it is either no problem, or an issue they cannot dismiss. It has been stated that the design elements which compose the shoulder are either close to perfection, or close to disaster! Now, of course, this greatly depends on the sport you're in: cross-country runners are unlikely to possess the shoulder difficulties that javelin throwers or swimmers may encounter. But it is uncommon for athletes using their shoulders as part of the main routine to not take at least a little pain, while others possess a background of a substantial shoulder problem.

This report takes a good look at the big picture of shoulder injury management, and tries to empower and instruct athletes with a few DIY home injury prevention and performance enhancement techniques. It presents, some complex concepts, and is therefore in no way an exhaustive explanation or listing of exercises.

Preliminary Precautions

If you have a shoulder injury and would like to try and treat yourself, please bear in mind:

● It would be wise to rule out structural damage first, via X-rays, CT-scan, US scan or MRI, particularly if your shoulder joint experiences sharp catching pains, locking sensations, clunks, pins and needles or numbness, looseness or laxity, or if the history of the injury was in any way traumatic, involving body contact or a fall.

● The length of time it took to develop your problem will give you some indicator of how long you will need to persist with correcting the faults before the results will be felt. Don’t forget, as I’ve said, that the pain is often only the tip of the iceberg, directing you to the real issue.

● However intelligent and self-aware you are, you will probably need the help of professionals – for treatment, guidance, feedback and motivation.

● Some treatment ‘pain’ is allowed, but only really what is associated with muscle fatigue as opposed to soft-tissue strain (therapeutic massage is an exception: no pain, no gain!).

● If you are already training and competing at high levels and have no difficulties with your shoulder, then be extremely careful how many new exercises you take on during the competitive season. It’s better to wait until the off-season to make sure you don’t overload your shoulder or throw it off balance by adding new demands.

Treatment, Prevention & Performance Enhancement

The information that follows describes the prevention and treatment for overuse injuries of the shoulder, not the management of traumatic or acute accidents such as glenohumeral dislocation, clavicular fractures, or tears of the labrum ('cartilage').

However, the broader principles of rehabilitating a shoulder that has been surgically repaired, or been stuck in a sling for four weeks, are not any different, although there could be limitations and time constraints imposed by orthopedic surgeons.

The most important principle of shoulder management is: start working on it now. Don't wait until your shoulder starts to hurt!

However, moreover, the preventative steps outlined below are sure to improve performanc they will really improve the way your shoulder operates, and consequently it will be more powerful, more coordinated, and reach farther and last longer befpre fatigue sets in. All the experts say it: injury prevention equals performance enhancement.

Some Simple Anatomy Of The Shoulder Complex

The shoulder joint really comprises four joints -- see If You're able to feel them on your own:

● Sternoclavicular (SC) joint (between the sternum and the collar bone) – this is actually the only bony connection that the shoulder has with the main skeleton;

● Acromioclavicular (AC) joint (between the collar bone and the point of the shoulder called the acromion, which is part of the scapula or shoulder blade);

● Glenohumeral (GH) joint between the glenoid part of the scapula – the socket – and the head of the humerus (HOH) – the ball; and the

● Scapulothoracic (ST) joint (the ‘false joint’ between the scapula and the rib cage that it rides over).

The GH joint is the most susceptible to injury as it is entirely dependent on non-bony connections for integrity. Whereas the hip joint (also a ‘ball and socket joint’) has a deep socket formed by the bone of the pelvis, the GH joint relies on the balance, strength and control of muscles, ligaments/capsule and labrum (cartilage) to function properly. The labrum acts like the edges of a skateboarding rink in preventing the HOH from spinning/sliding too far from the centre as it acts to deepen the socket. In an attempt to describe the delicate balance of the HOH sitting on the scapula, the GH joint has been likened to a seal balancing a ball on its nose.

The Rotator-Cuff Muscles

Without learned muscle control, any overhead action, let alone just lifting the arm, could be hopeless -- that the GH joint could dislocate or the HOH would jam under the arch of the acromion. The muscle group we all rely on for this control is your rotator-cuff (RC) muscles -- the infraspinatus, supraspinatus, teres minor, and subscapularis muscles (a body book will reveal where they lie). All of them arise in the scapula and are coordinated together to keep the HOH spinning/rotating as near the centre of the glenoid as possible with movement. The long head of biceps tendon running over the front of the GH joint also has a stability role to perform together with the RC, especially with the throwing action.

The muscles primarily designed to place the scapula for overhead motion are the trapezius (notably lower trapezius), and serratus anterior -- called therefore the 'scapular stabilizers' -- with counter forces being produced by levator scapulae, rhomboids and pec little muscles.

The larger and more powerful muscles that create motions of the arm are the deltoids, latissimus dorsi, and pectoralis major. So whereas the RC muscles organize the proper positioning of their HOH by acting near the centre of the joint (the 'inner core'), then the larger muscles with long lever arms move the arm with speed and force (the 'outer core').

The Five Guidelines: Balance Through Control

Let's sew what might be considered the five most essential ingredients for an athlete whose main weapon is the shoulder:

1. Sports-specific technique.

2. Flexibility.

3. Core stability.

4. Rotator-cuff control.

5. General strength.

The primary objective of these five regions of intervention is, in a word, balance. And the way to achieve it? Control. The higher your levels of functionality, the larger the control required to maintain equilibrium -- just as a Formula 1 car needs much higher levels of balance and control than does a standard road car. A deficit in any one area will ultimately trigger muscle imbalances to grow, which lead to soft-tissue breakdown and after even joint degenerative change. Picture a bike wheel in which one spoke in the wheel has been bent out of shape: a slow warping happens using use which creates an imbalance which further damages other spokes before the whole system comes to a grinding halt.

The more elite the athlete, the more committed he/she needs to be to getting expert help in satisfying and keeping these fundamentals. You'll also save yourself much time and distress should you seek experienced assistance as a preventative measure, rather than only requesting treatment once the issue has surfaced. Having a regular tune up/service can be done in the form of screening, where a sports-experienced physiotherapist can conduct you through a set of tests to find out if some of the areas below are not being adequately dealt with.

1. Sports-Specific Technique

Inadequate performance and shoulder pain very commonly originate in bad habits of technique. Often they're only clearly noticed when muscle fatigue sets in. But a fantastic coach will be able to pick up if this is occurring and recognize it is time for rest and recovery.

As a general rule, technique work ought to be performed after a thorough warm-up (or even as part of a warm-up), even whereas the muscles along with the brain-connections are still fresh and strong. On the flip side, when fatigue sets in can sometimes be a great time to do specific drills that don't load the shoulder, nevertheless will fortify good movement patterns. The only proviso is that one has to be extra diligent to observe when compensation strategies are setting in, and call a halt immediately.

Without wanting to state the obvious, practice is the key! Once you have mastered a new aspect of technique it must be repeated about 10,000 times before it will become an engraved on your mind, in other words, the point where the motion pattern becomes subconscious and feels 'natural'.

There are many methods to discover if your technique is faulty, however one of the greatest is video recording in order to slow down the action and break it into smaller components. The better the technology, the greater the outcome, but for actual worth it comes down to the experience of the person evaluating the picture. Using a mirror is seldom effective because the position of the mind focusing on the mirror may greatly affect the shoulder posture. The two main sources of opinions in this respect are your mentor and a bio-mechanist, and often a sports physiotherapist who has had a great deal of expertise in your sport.

What Faults To Look For

The assortment of overhead motions necessary for every sport gives rise to quite subtle and unique technique flaws. The following are some examples of things to look out for:

Tennis serve/smash: inadequate trunk twisting to open up torso in cocking position, ball toss too close to human anatomy or too far behind body, cutting follow-through short by whipping racquet.

Javelin/water polo/baseball throw: side-arm activity, elbow behind the shoulder through follow-through, inadequate trunk rotation at late cocking stage to open up the torso and at conclusion of follow-through to dissipate forces following release of the object. The nearer the surface of the upper arm may follow the point of the front part of the chest, the less strain there will be about the shoulder joint, and also the longer rotation which may be harnessed from the shoulder, the less the strain on the elbow joint.

Freestyle swimming: insufficient body roll, just ever breathing to one side, catching the water too close to the midline, not keeping the shoulder blade scraped on the back during pull stage, not keeping the elbow high enough during recovery stage (a indication of insufficient flexibility).

2. Flexibility

The objective of flexibility varies for the different muscles around the shoulder. For the major power muscles, it is necessary that flexibility allows freedom of motion for your pelvis, trunk, scapula, and humerus. For your rotator cuff, the critical issue is that the balance of forces centering the mind of humerus, and to a lesser degree, liberty of motion. It's more critical that the internal and external rotators are equally elastic, rather than how flexible they may be.

A warning: to have an excessive amount of flexibility at the expense of control and strength could be dangerous due to the excessive shear forces causing wear and tear in the joint. This is very true of the glenohumeral joint at which the primary source of equilibrium are the rotator-cuff muscles functioning in conjunction with additional soft-tissue structures like the torso, ligaments and cartilage. Too much flexibility at the cost of muscle control puts strains on the soft tissues and causes injuries like rotator-cuff tendinitis and degeneration, labral tears, subluxations and possibly even a dislocation.

Do not start a flexibility program until you've seen a sports physician or physiotherapist if:

● your shoulder has ever had an episode of instability, such as rapidly popping out and in again, or if it has ever dislocated;

● you have other joints in your body that are very loose, or double-jointed, eg your elbows bending too far back; or

● your shoulder clunks or pops excessively.

Stretching

Stretching to increase flexibility should not be done prior to competition or training, but rather done during 'down' times in the week. This is because of the suppression of the 'stretch reflex' that occurs during sustained passive stretching of muscle tissue (ie repeated holds of 20-30 minutes). If you were to perform rapid forceful movements like throwing straight after such passive stretching, there could be an increased chance of muscle and tendon tears. For flexibility every muscle has to be stretched a few times in 20-30 seconds each, and repeated three to four times per week.

The most important areas for regular flexibility sessions are:

● Infraspinatus/teres minor (posterior rotator cuff and capsule).

● Pectoralis major/minor.

● Latissimus dorsi.

● Biceps/triceps.

● Thoracic spine (between shoulder blades).

● Upper trapezius/scalenes/levator scapulae.

● Gentle nerve extending (oscillations).

The perfect way to understand how to stretch the above areas is to be taught by a sports physiotherapist, sports conditionist or private coach.

It is important not to stretch the ligaments of the shoulder, which in due time may lead to laxity of the joint and potential instability. The most common case I see? Athletes stretching their pec muscles and ending up with their arm supporting them against the wall, but with their shoulder rolled forward, feeling the stretch onto the front of the point of the shoulder.

What is being stretched here are the anterior ligaments ('capsule'), not the muscle, which can be better stretched by pulling the scapula back and twisting from the trunk away from the shoulder (hands still on the wall). One then feels the stretch far more down to the chest area where it ought to be.

Warm-Up Practice & Theory

The shoulder ought to be warmed up thoroughly with gradually increasing movements -- large circles, across-body movements, back twists, shoulder-blade rolls and forward and backward squeezes. The objective of this is to increase blood circulation and temperature, thus increasing the elasticity and 'contribute' from the soft tissues. A streak of short-duration stretches (ie five to ten seconds) of all the major muscle groups should follow and then eventually a session of more sports-specific drills. These are utilized to heat up the brain's connection to the muscle, ie to fortify correct motor patterns, and also to place the right neural reflexes from the muscle.

Massage

One of the most essential features of massage is to decrease the build-up of 'trigger points' -- regions in the muscle which literally grab up due to excessive loading. This might make a muscle imbalance or be the result of one -- either way it must be 'published' via massage. Each of the muscles described above which are necessary to stretch are vulnerable to activate points and may become tight and/or feeble because of them. It is not unusual for a trigger point to develop in the muscle as the initial structure to start breaking down, gradually dragging different muscles, nerves, and the glenohumeral joint down into a cycle of inflammation and pain.

The best way to begin is to get a hard tennis ball to perform your massage with, then try these two ideas:

Pectoralis minor/ major 'release': This is a important muscle to keep loose since if becomes too tight, it binds the scapula forward, leading to the head of the humerus being thrown off centre, especially in overhead positions. Hold on the tennis ball into the soft muscle overlying the chest directly at the front part of the shoulder. Lean towards a door frame and allow the tennis ball to press against it, with the same side arm halfway up the wall, palm facing towards the wall. Look for the tender trigger points, and when you find you, stay with the pressure on to it until it softens and the pain eases.

Rotator cuff 'release': Often accompanying the above condition is tightness and overactivity of the infraspinatus and teres minor, the net impact of that can also be to push the head of the humerus forward from the centre of rotation. Hold a tennis ball into the rear of the shoulder on the scapula, and press the back and side of the scapula onto the wall. The arm that is being worked on should be cradled in the opposite hand. Let it dig deep!

3. Core Stability

Core stability has come to be a whole science in itself in the last decade since all manner of sports professionals have realized just how crucial it is for the inner core of the human body, particularly those joints nearer to the backbone, to be encouraged from the postural muscles designed to achieve that. For your shoulder, the essential areas are the lumbar and cervical spine, and the scapulothoracic joint. If these areas aren't secure, then significant extra loading and strain will be passed on into the shoulder joint.

The stability of the lumbar spine is achieved by the combined effects of transversus abdominis and multifidus acting on the thoracolumbar fascia. Pulling in the lower navel area when tensing the lower-back muscles slightly activates the 'corset'. The cervical spine is stabilized by the upper cervical flexors in conjunction with the lower cervical extensors, to attain a 'tall' neck posture with the eyebrow slight drawn into the neck. Keep in mind that this can be easier for some than others, based on how your system has been trained -- for example, ballet dancers will come across the stable position of the neck comes naturally, rugby players may not. Activating the muscles is the first stage of the learning process; training the position till you are prepared to integrate it into simple movements that are relevant to your sport.

The scapulothoracic joint is the most important 'joint' for the shoulder, because the glenohumeral joint is formed by the glenoid (the socket) of the scapula and the humerus (the ball). The muscles most directly accountable for its stability would be the trapezius muscle (especially its own middle and lower fibres) behaving together with the serratus anterior muscle -- together they act to hold the scapula at a neutral position whether the arm is from the side or over the head. The neutral position is where the glenoid socket is most ideally orientated for the rotator cuff to control the HOH .

Imitate The Action Of The Seal

Bear in mind the earlier picture of a seal with a ball on its nose? The seal is the scapula trying to balance the ball of the humeral head using the rotator-cuff muscles. How amazing it is to think that these high levels of balance are being utilized when we perform overhead activity!

Deficiencies of core stability are always found with chronic shoulder injuries, or after surgery or injury, because pain will inhibit the postural muscles so they cannot do their job correctly.

The way to activate the lower trapezius/serratus anterior muscles would be to sit at a relaxed tall position, arms relaxed across your thighs. Gently pull the inner boundaries of your scapula together and down with the minimum of work, and hold it there for 10 minutes. Do not pull too far back or you may over- activate other muscles which are not meant to be the primary core stability muscles -- it is always a delicate and relaxed activity using a 10-second hold. When you have practiced this for a couple of days as frequently as you can, experiment with 'setting' your scapula into the neutral position with your arms out to the side, along with your arms on your hips, up behind your mind, etc..

Once you have mastered the 'setting', add small movements of your arm when holding the established position, and slowly over a few weeks you can increase the sophistication, speed and loading of your arm. Finally you're doing the setting in precisely the exact same time as you are carrying out the rotator-cuff strength and control exercises explained below.

4. Rotator-Cuff Strength & Control

The rotator-cuff muscles are all determined by the great positioning of the scapula for successful management. If the scapula is angled too far forward or downward, for example, while the tennis player reaches overhead to smash, the RC muscles are biomechanically disadvantaged and may neglect to maintain the HOH centered. The role of the RC muscles therefore is to keep the position of this HOH whereas the prime mover muscles create power.

As you enhance your scapular management, the RC muscles can act more effectively and independently of the scapular control muscles. That's to say that you should have the ability to hold the scapula quite still in the neutral position while you individually move your arm. This ability is known as 'glenohumeral dissociation'.

Thus with each of the exercises following, it's presumed that the scapula is being held as close as possible to neutral:

Internal/external rotation with arm by the side. Standing. Rolled towel held between elbow and ribs. Attach one end of an elastic or theraband to a door knob and hold the other end in your hand with elbow bent 90 degrees. Set scapula. Slowly pull across body at the same time – 3x10 pulling to right, 3x10 pulling to left.

Internal/external rotation with arm at 90 degrees away from body. Lying on back. Attach one end of an elastic or theraband to a chair leg and hold the other end in your hand with elbow bent 90 degrees resting on ground. Set scapula. Pull hand forward until limit of flexibility and slowly release – 3x10. Opposite movement – pulling hand up above head – 3x10.

End-of-range gentle flicks. Standing. Elastic tied to doorknob. Face away from doorknob, holding arm up above head with elastic in hand on tension. Allow arm to slightly drop backwards from elastic tension, pull forward slightly on tension. Repeat slowly, gradually increasing speed and tension over the following two or three weeks. Monitor any shoulder soreness the next day to determine whether you’ve gone too hard!

Stand facing wall with ball (Swiss or other) held up on wall at head height. Step back so you’re leaning onto ball. Set scapula. Make small circles on the wall with outstretched hand on ball – 5x10 counter/clockwise each. Rest and repeat.

Squeeze tennis ball in hand. Go through throwing motion slowly while squeezing ball. Set scapula at outset of throw, slowly releasing and doing an exaggerated follow-through with whole-body motion. Repeat 10-20 times. Excellent for co- contraction of RC muscles to increase their activity and control of the HOH.

5. General Muscle Strength

When the foundational issues of technique, flexibility, core stability, and rotator-cuff controller are being executed, we have to take a look at the larger picture of this 'outer core'. What is the rest of your body like -- does it help or hinder the functioning of your shoulder?

In every sport that relies heavily on the shoulder, it is vital to view it as merely one link in a 'kinetic chain' -- all the other connections must also be adequately developed to aid in the growth of rotary torque or the shoulder will be overloaded. There is a 'winding up' and an 'unwinding' which takes place at a quick speed starting from the legs, progressing through the hips, pelvis, lumbar spine, thoracic spine, shoulder, elbow, and wrist. And each must be educated to absorb its fair share. Golf is your classic game to use as a very clear case of this transfer of rotary power -- a succession of wind-ups finally being unwound since the stable base of this hips whips back into the opposite direction.

To this end there is a whole segment that may be written on the value of plyometrics, the exercise science involved in harnessing the eccentric strength of muscles to get increased power. The rotary energy of the human body is greatly strengthened by developing the eccentric contraction power involving the kinetic connections described earlier -- and this is where medicine balls, harnesses, and other strength and conditioning equipment come in.

Avoid This Imbalance

It is clear to most athletes that a gym routine needs to include strengthening function for the deltoids (three heads), latissimus dorsi, pec major, upper trapezius, and the rectus abdominis since they are the prime movers of the shoulder. Frequently what is critically overlooked, however, is the imbalance which could develop between the front part of the shoulder and the back.

In those athletes which are carrying an overuse injury at the shoulder, nine times out of ten they have overdeveloped pecs and lats comparative to their trapezius, rhomboids, posterior deltoids, and posterior rotator cuff. In these scenarios, flexibility must frequently be enhanced, scapular setting must be taught, and also the focus of gym exercises changed in the direction of the back. Seated and vertical row, barbell flies to the back, seat pull, and lat pull-downs with the bar behind the head are all exercises that must take higher priority.

Throughout all gym work it must be stressed that scapular setting along with the activation of core stability muscles to get good posture are vital for injury prevention.

Summary

So there we have it -- that the big picture of injury prevention and performance enhancement for athletes who rely on their own shoulders for playing their sport. Decide today which among these issues you may need some more work on, try some of the house exercises, and possibly seek out expert assistance to maximize the results of your efforts.

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