Tuesday, November 24, 2009

Dealing with Shoulder Injuries

This is an article I wrote that appeared on Strengthcoach.com and I have had many questions so I thought I would reprint it:

There is a common belief in the strength and conditioning community that overhead pressing exercise should not be used for the typical “shoulder athlete.” These athletes being from the sports of baseball, volleyball, tennis, and swimming. This belief is that the overhead pressing exercise will lead to injury, primarily a shoulder impingement.
When looking at typical overhead shoulder problems, there is usually a lack of certain mechanical requirements that enable a healthy movement. These are proper scapular control, good thoracic spine mobility, lumbar stability, and good hip mobility. I will also mention good C-spine stability is another preventor of many shoulder problems. Gray Cook calls this the joint by joint approach to movement and it makes things quite simple. Shoulder impingement problems are rarely caused by the shoulder, but rather a collection of poor function of the surrounding joints.
In working with swimming athletes, we find that a swimmer does not perform much in the way of co contraction due to the effect of gravity or being in a closed chain environment. With the exception of a few microseconds at the start and in open turns of the breast stroke and butterfly the swimmer is purely using concentric contractions. This alone, can result in a variety of injuries to the shoulder with repeated stresses to the extensors and internal rotators without the stabilizers kicking in. Take a look at the reasons why we switched away from machines using an open chain movement. No co contraction, no joint stability, which led to injury in the sporting activity. This is why swimmers are known to have shoulder injuries of the when, not if, variety.
The standard dry land training program typically consisted of simple rotator cuff exercises of internal/external rotation, flexion, and extension exercises with tubing.
It was economical and strengthened the shoulder to prevent injuries. This was usually combined with some push ups and some “ab” work consisting of crunches and straight leg throws. The isolation of the shoulders and the hip flexor dominant training has led and continues to cause the overuse shoulder injuries that swimmers endure.
Look at most swimmers and you will see a very anterior dominant musculature:
• large pecs
• wide lats
• six pack abs
• tremendous quads

From a postural viewpoint, the scapulae tend to be winged out, shoulders internally rotated, thoracic spine kyphotic, zero gluteal development, and little calf development.
When looking at the causes of shoulder injuries and returning to the joint by joint approach, we have found that the flexor dominant training of the hip leads to very tight hip flexors and poor glut utilization. The tight hip flexors, when kicking will lead to a hyperextension of the lumbar spine causing stress. The kyphotic thoracic spine will not allow good gliding of the scapula, which will lead to poor GH action and therefore, overuse injuries will occur.
To avoid such injuries, a total body approach to the shoulder must be taken. We build the shoulders from the ground up. We strengthen the shoulders by building a good foundation from the hips. Remember that when building a house, you need a strong foundation, then a good framework, a roof, and finally, you make it look nice. The hips need to gain good mobility and posterior strength in order for the (again repeating myself) lumbar spine to be stable, thoracic spine mobile, etc. Proper instruction and technique for our swimmers need to happen in this order to establish a relationship between the hips, core, and shoulder:
• correct squat
• correct lunge
• proper plank
• plank with rotation
• correct push up
• overhead squat
• single arm overhead walk
• single arm overhead lunge

Once the athlete has established this relationship with the core and the hips, we can begin pressing exercises. All of our pressing exercises are done with a dumbbell or kettlebell. I like the kettlebell because of the added stability requirements by not holding its center of gravity and you cannot “balance” the weight overhead. The pressing exercises utilizing the entire kinetic chain will work in the following progressions:

1. Good hip work
2. Static overhead hold and walk
3. Static overhead split squat
4. Static overhead hold and lunge
5. Lunge and press (to many variations)

The shoulder is a complex joint and is prone to injury in isolation. Many of the exercises that are used here for swimming athlete can transfer over to other athletes as to not be too “sport specific” in nature. Since we have put this program together for our athletes, we have had no issues with the shoulder in a very “shoulder injured” sport.
The key to good shoulder stability with the athlete is to look at the whole system instead of isolation in the shoulder itself. Good strength and good mobility are the foundations of the healthy athlete. As strength professionals, it is our duty to keep the athlete playing and competing in their sport, not to make a great lifter out of them.
©2009 Unlimited Athlete, Inc.

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