Total Knee Replacement (TKR), also known as a Total Knee Arthroplasty (TKA), is a surgical procedure commonly used to relieve knee pain due to arthritis or in some cases trauma-related injury. TKR is a viable option when the individual’s function is extremely limited due to pain and when conservative care, an exercise program, and weight loss was not substantially effective in relieving symptoms. Greater than 600,000 TKR are performed each year with approximately 90% of individuals experiencing significant symptom reduction.
Knee Replacement Surgery
There are multiple surgical approaches with Total Knee Replacement with most common types being Traditional and Minimally Invasive Surgery (MIS). In both approaches, the damaged cartilage and bone surfaces are removed and replaced with prosthetic implants. The Traditional approach will typically result in an 8-12 inch scar, whereas the MIS results in a 3-4 inch incision. Research suggests outcomes for both procedures are similar over the long term, with fewer complications experienced with the Traditional approach.
The Role of Physical Therapy
Following TKR most individuals are fully weighted bearing on the involved lower extremity, but will likely have to use an assistive device for a short period (walker, crutches, cane). Best evidence supports that patients receive outpatient orthopedic physical therapy where the focus is on restoring normal knee motion, strength training, normalizing walking patterns and restoration of prior functional/recreational activities. Your physical therapist will work with you targeting your greatest impairments and develop a plan of care to help you achieve your goals. The entire surgery and rehabilitation process is typically 12 weeks in length with continued functional gains made after 12 weeks by the performance of a home exercise program.
A recent study suggests that approximately 98% of individuals who undergo TKR will be able to return work, including heavy work activities. Depending on the type of work patients with sedentary jobs can return to their work tasks as early as 1 month after surgery, whereas more strenuous jobs may take up to 3 months. Patients can expect to realistically return to walking without an assistive device, swimming, golfing, driving, light hiking, biking, dancing, and other low-impact sports. However, outcomes are specific to each patient and is based on prior levels of function.
Physical therapy following knee replacement surgery requires a team approach between the patient, surgeon, and physical therapist. If you are considering undergoing a knee replacement, or have recently undergone this procedure, please call one of our physical therapists to learn more about your recovery and return to function.
A reverse shoulder arthroplasty (RSA) or replacement is characterized by changing, or “reversing”, the position of the ball and socket so that the ball is on the socket side of the joint and the socket is on the ball side. In the normal shoulder, the rotator cuff muscles help the large deltoid muscle to raise the arm. When the rotator cuff is torn and non-functional, the humeral head (arm bone) “escapes” upwards within the joint, and the deltoid is then unable to lift the arm by itself. By reversing the position of the ball and socket the loss of the normal rotator cuff is compensated for and the deltoid muscle can once again raise the arm.
Who Benefits from Shoulder Replacement Surgery?
RSA has been performed for over 25 years in Europe but has only been FDA approved in the United States since 2003. In 2011 approximately 1/3 of shoulder replacement procedures were RSA . Approximately 80% of patients who undergo RSA do so because of arthritis and rotator cuff-deficiency1. Another common and increasing indication is complex fractures of the upper part of the arm bone (humerus), accounting for about 10% of reverse shoulder arthroplasty’s1,2. Other indications include rheumatoid arthritis and revision arthroplasty.
The Role of Physical Therapy
Physical therapy following reverse shoulder arthoplasty is based on three important considerations: protecting the healing joint, maximizing deltoid muscle function, and establishing appropriate functional and range of motion expectations. Rehabilitation during the first 4 weeks following surgery focuses on joint protection strategies (including sling use), pain control and gradual restoration of range of motion. Joint protection is important to minimize the risk of complications following surgery. Shoulder dislocation is one such complication which requires care during the early phases of recovery. Movements such as reaching behind the back should be avoided or minimized due to the vulnerability of the shoulder to dislocate in this position following RSA.
By the sixth postoperative week gentle deltoid and shoulder blade muscle strengthening exercises are initiated3. These exercises are important in order to regain functional use of the arm for activities of daily living (dressing, bathing, etc) and light athletic activities (tennis, swimming, etc)4. Normal full active range of motion following RSA is not expected in most cases. However we have witnessed some very impressive results where individuals have recovered to the same extent, or better, than their uninvolved shoulder.
From our experience and the latest research, recovery of functional ROM is dependent on the patient’s pre-surgery status, the extent of rotator cuff damage, and the patient’s adherence with their home exercise program4-6. If you are considering undergoing a reverse shoulder replacement, or have recently undergone this procedure, please call one of our physical therapists to learn more about your recovery and return to function.
Schairer WW, Nwachukwu BU, Lyman SL, Craig E V., Gulotta L V. National utilization of reverse total shoulder arthroplasty in the United States. J Shoulder Elb Surg. 2014;24(1):1–7.
Anakwenze O a., Zoller S, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for acute proximal humerus fractures: A systematic review. J Shoulder Elb Surg. 2014;23(4):e73–e80.
Boudreau S, Boudreau E, Higgins LD, Wilcox RB. Rehabilitation Following Reverse Total Shoulder Arthroplasty. J Orthop Sport Phys Ther. 2007;37(12):734–743.
Simovitch RW, Gerard BK, Brees J a., Fullick R, Kearse JC. Outcomes of reverse total shoulder arthroplasty in a senior athletic population. J Shoulder Elb Surg. 2015;24(9):1481–1485.
Leung B, Horodyski M, Struk AM, Wright TW. Functional outcome of hemiarthroplasty compared with reverse total shoulder arthroplasty in the treatment of rotator cuff tear arthropathy. J Shoulder Elbow Surg. 2011:1–5
The rotator cuff is a group of four muscles spanning from the shoulder blade to the upper arm or humerus bone. These four muscles are the supraspinatus, infraspinatus, teres minor, and subscapularis. The primary role of these muscles is to center the ball (end of the humerus) in the socket (shoulder blade). A poorly functioning rotator cuff can result in pain, weakness, altered movement, and disability.
The tendons of the rotator cuff muscles can become injured or torn by trauma such as a fall. However, many tears do not involve any trauma. The incidence of rotator cuff tears increases with age. The prevalence of tears has been reported between 20% and 30% in those 60 to 80 years old. However, many individuals with tears of all sizes do not have any symptoms.
The torn tendons of the rotator cuff may not fully heal themselves. Even after being repaired by surgery, many tendons re-tear. Although as high as 20% to 30% of rotator cuff repairs may re-tear, functional outcomes are typically very good following surgery. However, surgery may not be a viable option for some individuals. Many with rotator cuff tears seek non-operative solutions. Exercise has been shown to be an effective non-surgical treatment option for many with small and large tears.
Research Supporting Exercise to Manage Rotator Cuff Tears
A recent study out of Denmark, showed 5 months of exercise improved function by nearly 50% in patients with irreparable rotator cuff tears. Strength, range of motion, pain, and quality of life also showed significant improvements in these patients who were judged not to be surgical candidates. Another study from researchers at Vanderbilt University showed 75% of patients with full-thickness tears respond well to exercise. After two years, only 25% of patients in this study chose to pursue surgery. These studies support the role of exercise as an alternative to surgery for those with symptomatic tears.
So we know exercise can be effective but what are some of the best exercises to strengthen the shoulder in those with a rotator cuff tear? Recall, the primary role of the rotator cuff is to center the ball in the socket to allow the arm to function. A secondary role is to produce rotational movements of the upper arm. These rotational movements are necessary and occur along with other functional movements such as reaching overhead or behind the back. Therefore, exercises which preferentially activate the rotator cuff and those which involve coordination with other muscles should be performed.
Sidelying external rotation is one important exercise which preferentially activates the rotator cuff. In particular, this exercise targets the posterior rotator cuff. These muscles are the infraspinatus and teres minor. This exercise should be performed with very light weights or perhaps only the weight of the arm at first. Another lower level exercise which can be incorporated is the standing row or any of its variations. The row activates all rotator cuff muscles at a low level along with strengthening the muscles of the shoulder blade. Rows can be performed with a cable, resistance bands, or light dumbbells.
After proficiency with these baseline exercises has been achieved, more advanced exercises may be incorporated. However, not everyone will need to progress to these more challenging exercises. Arm raises lying in prone preferentially activate the supraspinatus and infraspinatus muscles along with the muscles of the shoulder blade. The supraspinatus is the most commonly torn tendon. Also, diagonal movements train coordination of all rotator cuff muscles along with the muscles of the upper arm and shoulder blade.
Rotator cuff tears can be effectively managed through exercise in many individuals. There is no one-size fits all exercise program suitable for everyone with tears. An individualized exercise program should be developed by an exercise professional. The exercise program should be based on a detailed interview and physical examination. Exercises should then target the specific areas of weakness and goals of the individual.
Christensen BH, Andersen KS, Rasmussen S, Andreasen EL. Enhanced function and quality of life following 5 months of exercise therapy for patients with irreparable rotator cuff tears – an intervention study. BMC Musculoskeletal Disord. 2016;17(252):1-8. doi:10.1186/s12891-016-1116-6.
Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: A multicenter prospective cohort study for the MOON Shoulder Group. J Shoulder Elbow Surg. 2013;22:1371-1379. doi:10.1016/j.jse.2013.01.026.
Little League elbow is an overuse injury affecting the inside part of the overhead athlete’s elbow. The injury occurs in youth athletes 8 to 13 years old with open growth plates. In these youth baseball players, the growth plate is much weaker than the ligaments and muscles surrounding it. Once the growth plates fuse, athletes are more likely to injure soft tissues such as the ulnar collateral ligament (UCL). Little League elbow is most common in baseball pitchers but can also occur in any position player, softball players, or tennis players.
During the late cocking and acceleration phases of throwing, the shoulder and elbow are subjected to very high forces. The repetitive stress of throwing can lead to pain, swelling, and tenderness in this area. The youth baseball player may also show signs of decreased throwing velocity and accuracy. If untreated, there is a small chance for early growth plate closure or fracture, which could require surgery. Little League elbow will often heal completely with 2 to 4 months of rest and an individualized physical therapy program. Below are 5 things parents and coaches should know to prevent Little League elbow in youth baseball players.
#1: Elbow injuries are more common in those who play year-round
The repetitive stress of throwing a baseball subjects the growing elbow to excessive forces. The growing bones of youth athletes need time away from throwing. Youth baseball players should take 3 to 4 months off from throwing each year. This period should be devoted to playing other sports in order to develop overall athleticism. This is also the ideal time to perform resistance exercise to build strength in the lower body, core, and arm. Players who throw year-round or in multiple leagues are often plagued by arm fatigue. Throwing with fatigue is the number one risk factor for shoulder and elbow injury in youth baseball players.
#2: Little League elbow is common in both pitchers and catchers
A 2004 study in the American Journal of Bone and Joint Surgery found 70% of youth catchers demonstrate signs of Little League elbow on x-rays. In comparison, 63% of pitchers demonstrated these findings. Approximately half of these pitchers and catchers complained of elbow pain. The other half were not experiencing pain. However, catchers complained of elbow soreness more often than pitchers. During a game, catchers and pitchers may perform an almost equal number of throws. Also, catchers often throw from a squat or semi-squat position. Without the ability to generate force from the lower body, this position may place additional stress on the catchers elbow. It may be advantageous for catchers to throw from a standing position whenever possible. In any case, parents and coaches should closely monitor catchers and pitchers during the course of a season. Any signs of altered throwing or complaints of pain by the athlete should prompt a medical evaluation.
#3: Taller players are more likely to develop Little League elbow
Overall height and a recent increase in growth have been shown to be risk factors for developing Little League elbow. During the growth spurt it is believed that the rate of bone length growth exceeds the rate of bone strength development. Therefore, the growing bone and growth plate may be more susceptible to those who are experiencing rapid changes in height. Taller players are also more likely to throw at greater velocities which subject the elbow to greater stress. Therefore, the stress associated with these developmental factors, along with throwing excessively at increased velocities, may predispose the taller baseball player to elbow injury. Parents and coaches should keep a close eye on these taller players and be on the lookout for any early warning signs of arm pain or fatigue.
#4: Little League elbow is more common in players working with private coaches
A recent study investigating Little League players in the United States found two factors associated with positive elbow MRI findings. These two factors were year-round play and working with a private coach. Additionally, a history of arm pain was also associated with year-round play and working with a private coach. This is not to say that youth baseball players should not work with private coaches. Private coaches can be instrumental in improving throwing mechanics thus potentially improving performance and reducing injury risk. However, working with pitching coaches can contribute to throwing excessively or even year-round. Baseball players should be encouraged to work with coaches to improve their skills and love for the game. However, it is extremely important that these players get ample rest from throwing so they do not jeopardize their long-term playing career.
#5: Strengthening and stretching exercise can reduce the risk for developing elbow injuries
Muscle imbalances and poor movement patterns during and following growth spurts predispose youth athletes to overuse injuries such as Little League elbow. Modifiable risk factors for injury relate to improving shoulder flexibility and total arm strength. A recent study in the American Journal of Sports Medicine showed youth baseball players can significantly reduce their risk for elbow injury by engaging in a regular stretching and strengthening program. These exercises should target the trunk and arm musculature to address factors shown to be associated with injury risk. Strengthening the shoulder blade and rotator cuff muscles us often emphasized in overhead athletes. Athletes should be instructed in individualized programs based on their own unique needs. There is no one size fits all program for baseball players. Below are a few exercises which are useful for some overhead athletes.
Little League elbow is becoming increasingly more common as youth baseball players are throwing more often and at greater velocities. It is more important than ever for parents and coaches to closely monitor all youth baseball players for excessive amounts of throwing and the early signs of arm fatigue. Also, pitchers, catchers, taller players, and those with private coaches may be at an increased risk for injury thus requiring close observation. Youth baseball players who adhere to regular stretching and strengthening exercise can reduce their risk for injury. Therefore, preventing Little League elbow requires a team approach involving the player, parents, coaches, trainers, and the medical staff.
Hang DW, Chao CM, Hang Y. A clinical and roentgenographic study of Little League elbow. Am J Sports Med. 2004;32(1):79-84. doi:10.1177/0095399703258674.
Pennock AT, Pytiak A, Stearns P, et al. Preseason assessment of radiographic abnormalities in elbows of Little League baseball players. J Bone Jt Surg. 2016;98:761-767.
Sakata J, Nakamura E, Suzuki T, et al. Efficacy of a prevention program for medial elbow injuries in youth baseball players. Am J Sports Med. 2017; Published:1-10. doi:10.1177/0363546517738003.
Yukutake T, Kuwata M, Yamada M. A preseason checklist for predicting elbow injury in Little League baseball players. Orthop J Sports Med. 2015;3(1):1-7.
Little League shoulder is an overuse condition that affects the upper arm growth plate in the throwing arm of skeletally immature youth baseball players. The image above (A) shows widening of the upper arm growth plate in a young athlete diagnosed with Little League shoulder. The condition is characterized by generalized shoulder or upper arm pain during throwing. In more severe cases, Little League shoulder may cause pain with activities of daily living or at rest.
Little League shoulder is treated with a period of rest, physical therapy, and programs to improve strength and throwing mechanics. Premature closure and fractures of the growth plate have been reported in association with Little League shoulder but these are extremely rare complications. Most will eventually ‘‘outgrow’’ the condition spontaneously with normal growth plate closure. However, some continue to experience pain during the preadolescent or adolescent years which may considerably limit participation.
Little League shoulder most commonly occurs in youth overhead athletes between the ages of 11 and 16 years. Thirteen years is the most common age at which players move out of Little League and to a larger diamond. This requires a longer distance for pitches to cross home plate. Therefore this is the period where coaches and parents should most closely monitor youth athletes for early signs of pain. Below are five key considerations for returning injured youth baseball players back to play safely.
#1 Little League Shoulder is Occurring with Increasing Frequency
The increasing frequency of Little League shoulder is due to overuse and throwing with arm fatigue. This trend is likely due to greater numbers of youth pitchers participating in competitive leagues and doing so at increasingly younger ages. Increased velocity of pitches thrown, as compared with previous decades, is also a likely contributor. Year-round participation, participation on multiple teams in a season, the influence of private pitching coaches, and ‘‘showcase’’ events all contribute to increasing stress to the skeletally immature athlete. It is imperative that coaches and parents monitor players in accordance with Little League pitch count recommendations. It is also strongly recommended that players take at least 3 to 4 months per year off from throwing.
#2 Little League Shoulder Treatment Always Includes Rest from Throwing
During the late portion of the arm-cocking phase of throwing, there are considerable rotational forces acting on the shoulder. These forces can deform the cartilage of the growth plate and play a role in the development of Little League shoulder. The only way to remove these stresses and allow for healing is to stop throwing. The longer players throw with arm pain, the longer resolution of symptoms will take. Therefore, the initial treatment plan for Little League shoulder always consists of cessation of throwing. This period typically lasts 2 to 4 months. Pain usually resolves within the first 1 to 2 months of rest. However, premature return to throwing often leads to recurrence of symptoms. It has been estimated that approximately 25% of injured players will experience a recurrence of pain within 6 months of resuming throwing.
#3 Early Physical Therapy Should be Prescribed
Physical therapy treatment is initiated early to normalize shoulder range of motion and to begin a progressive strengthening program. Differences in side-to-side shoulder rotation ROM is believed to contribute to shoulder pain in the youth baseball player. These asymmetries have also been associated with a recurrence of Little League Shoulder. Therefore, it is important that youth athletes with Little League Shoulder are evaluated and treated by a physical therapist in order to address these risk factors. The cross body stretch targets posterior shoulder tightness which contributes to loss of motion in overhead athletes.
Strengthening the rotator cuff and shoulder blade muscles is important to build arm strength while resting from throwing. Weakness of the rotator cuff muscles has been shown to be a risk factor for shoulder and elbow injury in adolescent pitchers. Youth baseball players should demonstrate full pain-free strength of the rotator cuff muscles before throwing is resumed. Sidelying external rotation and prone horizontal abduction exercises target the posterior rotator cuff muscles which are often weak in young throwers. It is also important for athletes to strengthen the lower body and core musculature. Weakness in these areas will result in increased stress transferred to the throwing arm.
#4 Throwing Programs Should be Undertaken after Arm Strength is Developed
Structured interval throwing programs allow for a safe transition back to play. These programs are designed to replicate game conditions in a progressive and safe manner. Because individual differences exist, these programs must be tailored to the injured athlete’s physical and emotional needs. Omitting or rushing throwing programs often leads to recurrence of symptoms and delayed return to play. Also, long toss throwing should be used judiciously due to increased rotational forces imposed on the healing growth plate. Communication between the medical team and coaching staff is important to ensure the success of interval throwing programs.
#5 Flaws in Pitching Mechanics Should be Corrected Before Returning to Play
Before returning to unrestricted play, injured athletes should have their throwing mechanics assessed by a coach. In particular, the rate of trunk and pelvis rotation during the acceleration phase of throwing has been linked to shoulder injuries in youth baseball players. Hip-to-shoulder separation refers to the position of the hips relative to shoulder just prior to the front foot contacting the ground. Under ideal pitching mechanics, the hips are facing home plate and the shoulder continues to face towards third base in a right-handed pitcher. This allows for the optimal transfer of force from the core to the throwing arm. As fatigue increases, the hips and shoulder begin to rotate in unison resulting in an open hip-to-shoulder separation. This loss of force transfer and power generation results in increased stress placed upon the shoulder and elbow. This flaw should be correctedto reduce shoulder stress in the youth overhead athlete.
Little League shoulder usually resolves with 3-4 months of rest but symptom recurrence may occur. It is important to not rush youth athletes back to throwing before range of motion and strength are normalized. Correcting any pitching mechanic flaws and a progressive throwing program is also required before unrestricted return to play. Even after returning to play, close monitoring of athletes for at least 1 year is recommended to ensure prevention of recurrence. Finally, current guidelines regarding pitch counts, rest, and activity modification should continue to be emphasized for long-term health.
Harada M, Takahara M, Maruyama M, et al. Outcome of conservative treatment for Little League shoulder in young baseball players: Factors related to incomplete return to baseball and recurrence of pain. J Shoulder Elbow Surg. 2018;27:1-9.
Heyworth BE, Kramer DE, Martin DJ, Micheli LJ, Kocher MS, Bae DS. Trends in the presentation, management, and outcomes of little league shoulder. Am J Sports Med. 2016;44(6):8-11.
Sabick MB, Kim Y, Torry MR, Keirns MA, Hawkins RJ, Frcs C. Biomechanics of the shoulder in youth baseball pitchers implications for the development of proximal humeral epiphysiolysis and humeral retroversion. Am J Sports Med. 2005;33(11):1716-1722.
Are you experiencing lingering elbow pain? Have you experienced elbow pain in the past and are unsure why? Weakness of the shoulder muscles and stiffness in your upper back or neck might be underlying problems contributing to these elbow injuries. Shoulder weakness and upper back stiffness are common in athletes (baseball players, tennis players, and swimmers) and most of the general population. Our sedentary lifestyles and less than optimal exercise programs are likely strong contributors to elbow pain.
Tennis Elbow Pain and Shoulder Weakness
Tennis elbow, also known as lateral epicondylitis, is a common tendon disorder which occurs in both tennis players and the general population. These individualls describe pain on the outside of the elbow aggravated by gripping or lifting activities. Local treatment to the elbow is often unsuccessful or leads to only temporary improvements. Common treatments which often produce minimal lasting benefits include medications, injections, braces, ultrasound, laser, or electrical stimulation. Often, muscle weakness at the elbow and neighboring regions of the body are contributing to the onset and persistence of elbow pain. Research suggests there is an association between posture and shoulder muscle weakness in those with tennis elbow.
Recent research shows a link between tennis elbow and muscle strength of the serratus anterior, lower trapezius, and middle trapezius. Poor scapular muscle and rotator cuff strength is linked to tennis elbow in both non-athletes and athletes (i.e., tennis players). These muscles are important for orienting and positioning the shoulder blade during functional activities involving the arm. Poor strength or endurance of these muscles can result in overload to the elbow and wrist muscles. Strengthening the scapular stabilizers is an important part of rehabilitation for patients with tennis elbow. Targeting the middle and lower trapezius muscles using dumbbells lying in the prone position is an excellent starting point.
Baseball Players with Poor Posture & Shoulder Weakness are at an Increased Risk for Elbow Injury
Youth baseball players, ages 6 to 12, with a flexed or rounded upper back are 2.5 times more likely to sustain an elbow injury. Exercises which restore mobility in the thoracic spine and strengthen the muscles of the shoulder blade are important to address these problems. Loss of mobility in the thoracic spine from a rounded back position will limit a baseball player’s ability to achieve the late cocking phase of throwing. Often, these athletes will compensate at the shoulder and elbow in order to achieve the cocked position. Over time, the increased forces at the elbow will over stress the soft tissue and bony structures leading to injury and pain.
Scapular muscle and rotator cuff weakness is associated with throwing-related elbow and shoulder pain in youth baseball players. Also, baseball players with ulnar collateral ligament injuries show decreased strength of the infraspinatus and subscapularis. Similarly, weakness of the supraspinatus muscle is linked to serious arm injury in high school baseball players. These rotator cuff muscles stabilize the shoulder joint during throwing. Weakness at the shoulder will increase stress further down the chain at the elbow. Baseball players should be performing regular arm care exercises which target the scapula and rotator cuff muscles. Examples of these exercises include shoulder external rotation and diagonal patterns with a band or dumbbell.
Strengthening the shoulder muscles is an integral component of rehabilitation from elbow injury. Perhaps, more importantly these exercises can reduce the risk of elbow injury before pain starts. Strengthening exercises for the elbow and wrist are also important considerations. However, the shoulder and upper back region is often neglected when it comes to improving elbow function. This is one reason why elbow inuries and pain often persist longer than expected. Human movement is more complex than isolated muscles or joints. Therefore, exercise programs should integrate the entire body in order to restore or optimize function. Give these 5 exercises a try and let us know how you make out.
Bhatt JB, Glaser R, Chavez A, Yung E. Middle and lower trapezius strengthening for the management of lateral epicondylalgia: A case report. J Orthop Sport Phys Ther. 2013;43(11):841-847. doi:10.2519/jospt.2013.4659.
Day JM, Bush H, Nitz AJ, Uhl TL. Scapular muscle performance in individuals with lateral epicondylalgia. J Orthop Sport Phys Ther. 2015;45(5):414-425. doi:10.2519/jospt.2015.5290.
Garrison JC, Johnston C, Conway JE. Baseball players with ulnar collateral tears demonstrate decreased rotator cuff strength compared to healthy controls. Int J Sport Phyiscal Ther. 2015;10(4):476-482.
Lucado AM, Kolber MJ, Cheng SM, Echternach JL. Upper extremity strength characteristics in female recreational tennis players with and without lateral epicondylalgia. J Orthop Sport Phys Ther. 2012;42(12):1025-1032. doi:10.2519/jospt.2012.4095.
Trakis JE, Mchugh MP, Caracciolo PA, Busclacco L, Mullaney M, Nicholas SJ. Muscle strength and range of motion in adolescent pitchers with throwing related pain. Am J Sports Med. 2008;36(11):2173-2178.
Tyler TF, Mullaney MJ, Mirabella MR, Nicholas SJ, Mchugh MP. Risk factors for shoulder and elbow injuries in high school baseball pitchers: The role of preseason strength and range of motion. Am J Sports Med. 2014;42(8):1993-1999. doi:10.1177/0363546514535070.
Anyone interested in strengthening the core and shoulder musculature should be performing some type of row variation as part of their workouts. The row is a pulling movement which involves flexing the elbow, extending the shoulder, and pulling the shoulder blade back, also known as retraction. The row challenges the muscles of the upper back (trapezius, rhomboids, and erector spinae) as well as muscles of the core and low back. Also, when performed in various standing positions, this exercise can train the entire kinetic chain from the lower body, through the trunk, to the upper body.
It is common for the row to be performed seated with the use of exercise machines. This is fine for those first learning the movement pattern. However, seated machine rows do little to challenge the core or lower body musculature. There are much better options for athletes, those with a history of injury, and those looking to take their workouts to the next level.
If absolute strength is the goal, heavy barbell or dumbbell bent over rows are the best options. However, these row variations require coaching and practice to perfect proper technique. Performing heavy rows with improper technique makes one susceptible to low back or shoulder injury. Again, there are better options, especially for those with a history of injury and looks to train in a more specific fashion. Try the following five row variations and see which ones work best for you.
Standing 1-Arm High Cable Row
Set up a cable system with the cable positioned slightly above the level of the head. Stand in a lunge position with the left foot in front of the right. The majority of body weight should be on the front leg with the knee bent approximately 45 degrees. Start with a palm down grip with the right arm extended out in front. To begin the movement, pull the cable, bending at the elbow, straight back towards the trunk while maintaining a neutral spine. Be sure to emphasize scapular retraction which refers to pulling the shoulder blade back and slightly down. Also, avoid shrugging the shoulders or arching the low back.
This exercise challenges the core by activating the trunk musculature to resist rotation as the arm and scapula produce the row movement. This makes the 1-arm high cable row a good option for those who are looking to train anti-rotational trunk muscle endurance. This high-cable position and lunge stance set-up have also been shown to result in favorable muscle activation patterns of the lower and upper trapezius. This is important for overhead athletes or those with a history of shoulder problems.
Cable Lawnmower Pull
This exercise begins with the trunk flexed and rotated to the opposite side of the exercising arm. The hand of the exercising arm starts at the level of the opposite knee. To begin the movement, the trunk is rotated toward the exercising arm while extending the hip and trunk to a vertical position. The exercise ends with the arm at waist level with the shoulder blade retracted as if placing the elbow in the back pocket. Pause for 1 or 2 seconds then slowly reverse the movement returning to the starting position.
The lawnmower pull is a multi-joint functional exercise performed in a diagonal pattern replicating many movements in sport. The exercise incorporates the transfer of force from the lower body through the trunk to the upper body. It has been shown to activate the trapezius and serratus anterior muscles at low to moderate levels. These muscles are important for maintaining shoulder health in overhead athletes (i.e., baseball players) and those with a history of shoulder pain. The exercise can be performed with a cable system, resistance band, or dumbbell.
1-Arm Band Rotational Row
Set up a resistance band anchored at approximately waist to belly button level. Position the front leg with the foot facing towards the anchored band. The rear leg will begin facing the same direction but must be free to pivot once the exercise commences. The right arm begins extended and the majority of body weight begins on the left leg. The movement occurs with the simultaneous coordination of an upper-body row, trunk rotation, and weight shift to the rear leg. Pause in the end position for 1 to 2 seconds before reversing the movement in a slow and controlled fashion.
This row variation is ideal for rotational athletes such as baseball players. It incorporates the coordinated activity of the lower body, trunk, and upper body. Controlling the eccentric, or negative, part of the exercise is important. This exercise also teaches weight transfer and weight acceptable from the rear to lead leg and vice versa. Be sure to perform the exercise from both sides to avoid reinforcing any side to side asymmetries which are common in athletes.
Suspension Trainer Row
Anchor a suspension trainer, such as a TRX, in an overhead position. Grasp both handles with the arms extended. Position the feet in front of the body spread slightly wider than shoulder-width apart. Your body should be maintained in a neutral position with your head, trunk, and legs forming a straight line. Perform the row movement and pause at the top position for 1 to 2 seconds before returning to the start position in a slow and controlled fashion. Maintain the trunk in a rigid position throughout the exercise. To increase the challenge of this exercise position your feet further away from your upper body to assume a more inverted position.
The inverted position assumed in the suspension trainer row elicits high activation of the abdominals, latissimus dorsi, upper back muscles, and hip extensor muscles (glutes and hamstrings). This exercise produces lower levels of lumbar spine muscle activity due to lower spine loads incurred from the suspended position. These factors make the suspension trainer or inverted row a good option for patients with a history of low back pain.
Dumbbell Renegade Row
Hold two dumbbells and assume a push-up position with the feet spread slightly wider than shoulder-width apart. Align the head, trunk, and lower body in a straight line and maintain this position throughout the exercise. Initiate a row with one arm while maintaining stability through the trunk and lower body. Control the descent of the load back to the floor. Be sure to alternate sides with each repetition. Light loads are recommended when first learning this exercise.
The push-up position utilized in the renegade row increases challenges to the abdominal musculature. Furthermore, 1-arm row variations have been shown to elicit great oblique abdominal muscle activity compared to rows performed with both arms simultaneously. This is a more advanced row variation so it may be best to start with cable or suspension rows before embarking on the renegade row.
There are many variations to the row exercise and I have described only five. For beginners, it is best to start with cable row variations and suspension trainer rows. The lawnmower pull and rotational row are more complex movements which require total body coordination. Thus, these exercises are more challenging to master. To really challenge the core and shoulder stability, the renegade row is a higher level option. The most important points are that you choose the most appropriate variation for your level of training and that your technique is as close to perfect as possible.
De Mey K, Danneels L, Cagnie B, Lotte VDB, Johan F, Cools AM. Kinetic chain influences on upper and lower trapezius muscle activation during eight variations of a scapular retraction exercise in overhead athletes. J Sci Med Sport. May 2012:6-11. doi:10.1016/j.jsams.2012.04.008.
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The lower trapezius muscle plays an important role in moving and positioning the shoulder blade (scapula) during overhead sports. The lower trapezius spans from the lower 6 thoracic spine vertebrae to the upper portion of the scapula. Along with the middle and upper portions, the lower fibers comprise the large trapezius muscle of the upper back. The lower trapezius, upper trapezius, and serratus anterior muscles work together to upwardly rotate the scapula. This function is important to optimally position the arm during overhead function such as the cocking phase of throwing a baseball. This muscle is often ignored when it comes to developing resistance training programs for athletes or fitness enthusiasts.
Role of the Lower Trapezius in Sport
Poor thoracic spine posture or loss of thoracic spine extension places the lower trapezius at a disadvantage to fulfill its role as a scapular stabilizer. Therefore, exercises which restore thoracic extension are often included in programs which train the lower trapezius. Delayed lower trapezius activation has been demonstrated in overhead athletes with shoulder pain. Weakness of this muscle has been implicated with upper extremity injuries in baseball, swimming, and tennis.
Exercises performed with the arms below shoulder level elicit very little lower trapezius activity. In order to optimally activate the lower fibers of the trapezius, movements which facilitate scapular upward rotation with depression should be performed. The lower fibers are aligned at an approximate 135-degree angle from the spine. This corresponds to the 10:00 and 2:00 positions on a clock. Exercises such as the wall slide, prone trapezius raise, and shoulder external rotation in 90 degrees of abduction position the scapula for optimal lower trapezius activation.
Prone 1-Arm Lower Trapezius Raise
This exercise is performed lying face down with one arm over the side of the table or bench. Be sure to keep the neck in a relaxed neutral position resting on your other forearm. With the thumb up, arm straight, elbow slightly bent, lift toward the ceiling at a 45-degree angle from your head (the 10:00 and 2:00 positions of a clock). This position is aligned with the muscle fibers of the lower trapezius. Be careful to avoid shrugging the entire shoulder as you raise the arm. Instead, think about tilting the shoulder blade backward as you raise the arm. Pause at the top of the movement before returning to the start position in a controlled manner.
Prone External Rotation in 90 Degrees of Abduction
Lie face down with one arm over the side of the table or bench supported on a small towel roll. Be sure to keep the neck in a relaxed neutral position resting on your other forearm. Rotate the hand up towards the sky in a slow and controlled manner. Be careful to avoid shrugging the entire shoulder as you perform the exercise. Pause at the top of the movement before returning to the start position.
Wall Slides at 135 Degrees with Lift Off
Stand to face a wall with one foot slightly ahead of the other. Place both forearms against the wall starting just below shoulder level. Initiate the movement by sliding the forearms toward the ceiling at a 45-degree angle from your head (the 10:00 and 2:00 positions of a clock). This aligns with the muscle fibers of the lower trapezius. Once the elbows are fully extended, slightly lift the hands and arms away from the wall. Be sure to avoid arching the low back as you lift away. Instead, think about tilting the shoulder blades backward as you lift away. Pause at the top of the movement before returning to the start position in a controlled manner.
The serratus anterior is a key muscle involved with the performance of many overhead movements such as throwing a baseball, serving in tennis, and pressing a barbell overhead. The serratus anterior muscle spans from the upper 8 ribs along the side of the trunk up to the inner border of the shoulder blade. This muscle assists with rotating the shoulder blade (scapula) upwards and tilting it backward in order to position the shoulder and arm for optimal overhead function. Along with thoracic spine extension mobility, these scapular movements are often ignored as important components of overhead function. The serratus anterior is also the primary muscle which protracts the scapula during upper extremity function. This involves the scapula moving forward along the rib cage such as when punching in boxing.
The Serratus Anterior and Overhead Function in Athletes
Individuals with shoulder problems demonstrate decreased upward rotation of the scapula, decreased posterior tilt of the scapula, and increased activity of the upper trapezius muscle. In particular, swimmers and baseball pitchers commonly present with a pattern of decreased serratus anterior activation and increased activation of the upper trapezius. This alteration in muscle patterns leads to compensatory movements, decreased overhead range of motion, and increased stress to other structures such as the rotator cuff and elbow joint.
Exercises which combine scapular upward rotation, posterior tilt and protraction are ideal to activate the serratus anterior. It is also advantageous to include closed chain exercises where the hand is fixed to a surface or weight bearing through the floor or a wall. Finally, exercises performed with the arm elevated above the shoulder or eye level elicit greater activation of the serratus compared to exercises performed at or below shoulder level. Wall slide and bear crawl variations fulfill these criteria which are optimal to train the serratus anterior in overhead function.
Wall Slide with Foam Roll
Begin with your forearms resting on a foam roller against the wall placed just below shoulder height. Protract the shoulder blades by pushing the upper back away from the wall to activate the serratus anterior. Next, “roll” the forearms up the wall in a controlled manner to approximately eye level or slightly higher, making sure you don’t lose protraction. Return back to the starting point in a controlled manner and repeat for the desired number of repetitions.
Serratus Anterior Wall Walks with Band
Begin by wrapping a resistance band around your wrists and pulling your wrists apart. Your forearms should remain parallel and take the form of the number “11” throughout the exercise. Protract the shoulder blades by pushing the upper back away from the wall to activate the serratus anterior. Then, “walk” the forearms up the wall in a controlled manner to approximately eye level or slightly higher, making sure you don’t lose protraction. Return back to starting point in a controlled manner and repeat for the desired number of repetitions.
Assume an all-4’s position with the hands in front, shoulder-width apart, feet behind the hips and up in the air. The knees should remain elevated from the floor so you are stabilized by 4 points of contact. Begin by pushing the back up towards the sky to protract the scapula and activate the serratus anterior. Crawl forward starting with your right hand and your left foot following with the left hand and the right foot. After each step, pause briefly to exhale. Take four steps or more depending on space, then turn around and bear crawl back.
Building a foundation of strength targeting the scapular muscles is crucial for overhead athletes. This foundation should include movements which facilitate activation of the serratus anterior through scapular upward rotation, posterior tilt, and protraction. These exercises can be included as part of a strength training session warm-up or part of a regular arm care program. Overhead athletes, such as baseball players and swimmers, should particularly include exercises targeting the serratus anterior as part of their year-round strength and conditioning program.
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The position and mobility of the thoracic spine directly affects the amount of overhead shoulder movement available. A more erect and mobile thoracic spine and rib cage will result in greater overhead range of motion. A slouched posture or stiffness in the thoracic spine and rib cage will result in a loss of range of motion reaching overhead. Excessive thoracic kyphosis, or a slouched posture, may alter the position of the shoulder blade and impair muscle activation patterns both of which contribute to limited overhead function and shoulder pain.
Approximately 15 degrees of thoracic spine extension mobility is required for full overhead motion when lifting both arms such as when performing a barbell overhead press. Full 1-arm elevation requires approximately 9 degrees of thoracic extension. Thoracic spine rotation is also crucial for rotational sports such as baseball where a large amount of power is transferred through the trunk. A baseball pitcher who lacks thoracic spine rotation will compensate by increasing movement and stress through the shoulder and elbow joints.
Strength is foundational for optimal shoulder health but thoracic spine mobility is often a neglected area when athletes attempt to maximize their overhead shoulder function. Therefore, exercises targeting thoracic spine extension and rotation mobility should be included in any rehabilitation or performance enhancement program seeking to optimize shoulder function. Instead of jumping to restore shoulder mobility with bands and balls, try these thoracic spine mobility exercises first.
Bench T-Spine Mobilization
This is my favorite exercise for restoring thoracic spine extension. It also provides a nice stretch to the lattisimus dorsi muscle which can also limit overhead mobility. The exercise begins by assuming a kneeling position facing a bench. Place your elbows on the bench in front of you holding a PVC pipe or dowel with the palms facing up. Sit back, pushing your buttocks towards your heels, keeping your spine relaxed, until you feel a stretch in your upper back. For an added stretch you can bend your elbows further past your head. Hold this position, and exhale fully. Reverse the motion to return to the start and repeat the desired number of repetitions.
Thoracic Extension + Rotation (Reach Backs)
Begin this exercise by sitting back on your heels, face down, with one hand behind your head and the opposite forearm resting on the ground in front of you. This position minimizes available movement in the low back and maximizes movement to the upper back. From this position rotate your elbow up to the sky while exhaling. The opposite forearm remains in contact with the ground. Return to the starting position and repeat for the desired number of repetitions before switching to the opposite side.
Foam Roll Thoracic Extension Mobilization
This exercise can be a challenge to perform correctly. Most end up extending through the lumbar spine and not the thoracic spine. Begin in a lying position over a foam roll. Place the hands behind the neck supporting, but not pulling on, the neck. Raise the buttocks off the ground and roll the upper back up and down the foam roll. Identify a sensitive, stiff, or tender area and then drop the buttocks down to the ground. From this position perform small extension movements by lifting the elbows up towards the ceiling. Be careful not to overextend at the lower back.
Thoracic Spine Windmill
This is my “go to” exercise to restore thoracic spine rotation. Begin on your side with both arms outstretched in front of you. Place a foam roll under your top leg with the knee and hip bent to 90 degrees. The bottom knee and hip remain extended throughout the exercise. Reach forward with your top hand and then complete a large circular windmill motion as you rotate your entire upper body. Keep reaching as if you were attempting to lengthen your entire arm. Follow your hand with your eyes to ensure proper thoracic spine and rib cage movement. The top knee and leg should remain in contact with the foam roll throughout the exercise. Perform the desired number of repetitions and then repeat on the opposite side.
Standing Thoracic Rotation Mobilization
The standing rotation exercise is ideal to incorporate into a pre-workout dynamic warm-up. From a standing semi-squat position place one arm between your thighs just above the knees. This position will block unwanted hip and pelvic movement. Next, rotate the body upwards towards the sky by following your open hand with your eyes. At the top of the movement, exhale before returning to the starting position. Perform the desired number of reps and then repeat on the opposite side.
After performing these mobility drills it is important to work on strength and endurance of the thoracic muscles. Also, manual therapy to the thoracic spine and rib cage has been shown to accelerate recovery and reduce shoulder pain immediately and for up to 1 year. Maintaining or improving thoracic spine mobility is imperative for any active individual who regularly functions overhead. Manual therapy, mobility drills, and strength/endurance exercise targeting the thoracic spine can lead to significant gains in overhead function for athletes and the general population. These 5 mobility drills can be easily integrated into any pre-workout warm-up routine or as part of a home exercise program.