Shoulder Stretches: 5 Stretches to Improve Reaching Behind Your Back

If you are dealing with shoulder pain you probably have a few movements that are painful or even impossible.  One of those movements is likely reaching behind your back.  During your typical day you routinely reach behind your back for personal hygiene, retrieving our wallets, putting a belt on, or for females, fastening your bra. People with many different shoulder problems experience a great deal of pain and stiffness when attempting these types of activities.  Thankfully, there are shoulder stretches that can help you.

Oftentimes, reaching behind the back is the last movement to return to normal when dealing with a shoulder problem.  There are exercises you can perform at home to speed up your recovery.  This article highlights 5 shoulder stretches you can perform to improve reaching behind your back.

Breaking Down Behind the Back Movements

Reaching behind your back involves complex movements of your spine, shoulder blade, shoulder joint, and elbow joint.  All of these areas must be mobile in order to fully reach behind your back for functional tasks.  Your thoracic spine has to extend and rotate.  Your shoulder blade needs to tilt backwards.  And, your elbow must bend.  Most importantly, your shoulder must rotate internally.  Shoulder internal rotation stiffness is the most common problem associated with limitations reaching behind your back.  However, stiffness in any of the previously mentioned areas must be addressed in order for you to function without pain.

Proof Shoulder Stretches Work

In order to reach your back pocket or perform personal hygiene your shoulder must internally rotate at least 45 degrees.  People recovering from shoulder surgery or those with a frozen shoulder typically have about 50% or less of this range of motion.  People with rotator cuff tendinitis or impingement usually have about 2/3 of the required range of motion.  A recent study published in the journal Sports Health showed people with shoulder impingement and limited internal rotation range of motion respond very well to home shoulder stretches.  Those that performed shoulder stretches daily saw more than a 50% improvement in their range of motion and pain after 4 weeks.

Pec Minor Shoulder Stretch

Your pectoralis minor muscle attaches onto your ribs and shoulder blade.  Short pec muscles will pull your shoulder forward.  In order for your hand to get behind your back, your shoulder blade must tilt back.  If it can’t you will be limited and place more stress on other structures around your shoulder.  To stretch your pec minor, lie on a foam roll long ways or with a rolled up towel between your shoulder blades.  With your elbow bent allow your arms to fall down towards the floor.  Fully exhale and relax in this position for 30 seconds.  Perform 3 to 5 stretches each day.

Thoracic Reach Backs

Your upper back has to extend and rotate when you reach behind your back.  Many people have stiffness in their upper back.  This places additional stress on your neck and shoulder.  To perform the reach back stretch, begin sitting back on your heels, with one hand behind your head and your other forearm resting on the ground in front of you.  This position minimizes movement in your low back and maximizes movement to your upper back.  From here, rotate your elbow up to the sky while exhaling.  Your other forearm remains in contact with the ground.  Return to the starting position and repeat for 10 to 20 repetitions before switching to the other side.  You can modify or progress this exercise by placing your hand behind your back instead of behind your head.

Cross Body Stretch

This shoulder stretch addresses muscles in the back of your shoulder which are prone to tightness.  This stretch is performed lying on your involved side with your hips and knees bent.  Your involved shoulder and elbow are positioned in 90 degrees of flexion.  Your hand of the uninvolved arm grasps your elbow and gently pulls it across your body.  Once a mild stretch is felt on the outside or back of your shoulder, hold for 30 seconds.  Perform this stretch 2-3 times each session.  Research from several studies suggests this stretch is the most effective for improving shoulder internal rotation range of motion.  We agree.

Sleeper Stretch

The sleeper stretch is also very effective for improving internal rotation range of motion.  For this stretch, assume the same starting position as the cross body stretch.  However, with the sleeper stretch, gently move your wrist and forearm down towards the table.  Once a mild stretch is felt on the outside or back of your shoulder, hold it for approximately 30 seconds.  The stretch is typically performed 2-3 times each session.

Hand Behind the Back Stretch

The final stretch in this series is the most uncomfortable and in many cases, the most effective.  It is important that you perform this stretch gently without significant pain.  Restoring hand behind the back movements takes time.  Consider it a marathon, not a sprint. Don’t try to regain all your mobility back at one time.  Slow and steady is best with this stretch.

Stand holding a towel or stretch-out strap.  Drape the strap over your opposite shoulder and gently pull your hand up your back.  Your body will want to lean forward.  Try to remain standing tall.   Also, avoid holding your breath.  Concentrate on each slow breath.  Hold the stretch at least 10 seconds to start.  Work up to performing each stretch for 30 seconds for 3 to 5 repetitions each day.

Want Help Getting Started Stretching Behind the Back?

These are the 5 shoulder stretches we think are best for improving range of motion reaching behind your back.  Most people can perform the first 3 shoulder stretches without considerable pain or difficulty.  The sleeper stretch and stretch behind the back will likely cause some pain.  Start easy, be consistent each day and go slow.  If you need more help give us a call.  We are here for you.  Many people do better when they perform their home shoulder stretches supplemented with manual therapy performed by your physical therapist.

Shoulder Labrum Tears: 5 Exercises Before Jumping into Surgery

Pain with or without clicking deep in your shoulder may indicate an injury to your labrum. The glenoid labrum is a layer of cartilage within the socket of your shoulder joint.  It plays an important role in stabilizing your shoulder during pushing movements, overhead reaching and sports that involve throwing.  Repetitive overhead throwing in baseball players often leads to breakdown of the labrum.  Repetitive pressing or pushing movements in the gym can also irritate your labrum.  Trauma such as falling on an outstretched arm or bracing yourself during a motor vehicle accident can injure your labrum.

Surgery is often recommended to repair a torn labrum.  However, exercise can also be a very effective treatment option.  Non-operative management includes non-steroidal anti-inflammatory drugs and steroid injections to decrease pain and inflammation.  Physical therapy and exercise also plays an important role in recovering full function of your shoulder. This article outlines a game plan for rehabilitating your injured shoulder after a labrum injury.

Glenoid labrum tear

Surgery or No Surgery for Glenoid Labrum Tears?

Both surgery and a non-surgical approach can lead to satisfactory results in 66% to 85% of people with labrum tears.  A small study published in The American Journal of Sports Medicine suggests nearly half of those with labrum tears do well with surgery.  The same may be true for those who pursue non-surgical treatment.  Regardless of treatment, it appears that 80 to 85% report satisfactory results 2 to 3 years later.  However, the level of satisfaction and return to sport in overhead athletes is closer to 66%.  This is understandable given the demands baseball pitchers and tennis players place on their shoulders.

Patients with labrum injuries should undergo 3 to 6 months of non-surgical treatment before considering surgery.  If this approach fails your doctor may recommend surgery.  Rehabilitation focuses on improving shoulder range of motion and strengthening the rotator cuff and shoulder blade muscles.  Below are videos of 2 important stretches and 3 commonly prescribed strengthening exercises you can perform in your home.

Cross Body Stretch

This stretch addresses tightness in the back of your shoulder which is often stiff in overhead athletes.  The infraspinatus, teres major, and teres minor muscles can become shortened from repetitive throwing or weight training.  This stretch is performed lying on your side with your hips and knees bent.  Your involved shoulder and elbow are positioned in 90 degrees of flexion.  Your hand of the uninvolved arm grasps your elbow and gently pulls it across the body.  You want to feel a mild stretch on the outside or back of your shoulder.  Hold this position for 30 seconds.  Perform this stretch 2 to 3 times each session.

Sleeper Stretch

The cross-body stretch is superior to the sleeper stretch for improving shoulder range of motion in young baseball players.  However, the sleeper stretch is the more popular of the two stretches.  Start in the same position as the cross-body stretch.  However, with the sleeper stretch, your wrist and forearm are gently moved down towards the table.  You want to feel a mild stretch on the outside or back of your shoulder.  Hold this position for 30 seconds.  Perform 2 to 3 stretches each session.   For most people, both the sleeper and cross-body stretch do not need to be performed.  My personal experience, and the best available evidence, suggests the cross-body stretch is the most beneficial for improving range of motion.  Choose which one works best for you.

Shoulder Flexion in Side-lying

It is important to strengthen your shoulder muscles while limiting stress on your injured labrum.  The biceps tendon attaches to your labrum.  Strong contractions of your biceps muscle can pull on the upper part of your labrum.  Therefore it is best to perform strengthening exercises which minimize biceps activity.  Perform shoulder flexion raises in a side-lying position to minimize biceps activity and reduce strain on your labrum.  Start on your side holding a light dumbbell.  Your elbow remains straight as you raise your arm slightly overhead.  Your arm remains parallel to the floor as you perform the movement.  Perform 3 sets of 10 to 20 repetitions several times per week.

External Rotation Diagonal

Stand holding a resistance band in one hand.  Anchor the band at knee to waist level.  Start with your hand positioned in front of your opposite front hip pocket.  Your elbow remains bent at a right angle throughout the exercise.  Perform the movement by flexing and rotating your arm across your body.  You will end up in a position similar to the arm cocking part of throwing.  Hold this position 1 to 2 seconds.  Reverse the movement back to the starting position.  This is a great exercise for the rotator cuff and lower trapezius muscle.  Perform 3 sets of 12 to 20 repetitions several times per week.

Prone Row to External Rotation

Position yourself on your stomach with your arm hanging over the side of your bed or a treatment table (if available).  Hold a light weight.  Usually 1 or 2 pounds is enough to begin with.  Perform a high row with your elbow in line with your shoulder.  Pause 1 to 2 seconds then rotate your hand upwards towards the ceiling.  Hold this position 1 to 2 seconds.  Reverse the movement back to the starting position.  This is another great exercise for the rotator cuff and lower trapezius muscle.  Perform 3 sets of 8 to 12 repetitions several times per week.

Tips for Getting Started

Symptoms of a labrum injury can range from a minor annoyance to debilitating.  In many people it severely limits overhead activity and the ability to carry out routine daily activities.  The right exercises can help.  For the best results, exercise 3 to 5 times per week.  Infrequent or random exercise will do you little good.  Give these 5 exercises a shot for at least 3 months and see how things go for you.  If you want more help give us a call.  Our physical therapists can help you find additional exercises right for you and supplement these with manual therapy treatments.   You don’t have to keep suffering and you have options other than surgery.

5 Yoga Poses to Decrease Your Shoulder Pain

Are you one of the nearly two-thirds of adults in the United States with shoulder pain?  You may have difficulty reaching overhead, placing your hand behind your back, or lying on your side at night.  The causes of your shoulder pain can range from a mild sprain or strain to a complete tear of the rotator cuff.   Thankfully, there is a great chance your shoulder pain will resolve with a short period of rest and the right type of exercise.  There are many forms of exercise which can be helpful for you.  Yoga is a popular choice for many people.  Yoga is a great way to strengthen some of the smaller muscles around your shoulder.  Strong shoulders are more resistant to injury and pain.

More about Yoga for Shoulder Pain

Yoga combines breathing techniques, meditation, and various body postures.  Yoga reduces stress, depression, and anxiety.  It also improves your concentration, coordination, flexibility, balance, and blood pressure.  Yoga has been proven to be particularly effective helping women recover their shoulder function following breast cancer surgery.  Many yoga postures require high activity of the shoulder stabilizing muscles.  The most critical of these muscles are the middle trapezius, lower trapezius and serratus anterior.  The following 5 exercises engage and challenge these key muscles.  All 5 can easily be performed in your home.  They are described in order of difficulty starting with the least difficult first.

Yoga for shoulder pain

With each exercise it is important to concentrate on your breath.  This will clear your mind and relax your body.   Three-part breathing is an excellent technique to start with. During the three-part breath, you first completely fill your lungs with air, as though you are breathing into your belly, rib cage, and finally upper chest. Then you exhale completely, reversing the flow.  At first you may only be able to hold each pose for 1 breath.  That is okay.  As you become stronger try holding each pose for at least 3 to 5 slow breaths.

Locust Arms Back

The locust pose is an excellent way to strengthen your middle and lower trapezius.  These muscles are important for your overhead function and posture.  Start by lying face down with your legs straight and your thighs touching together.  Point your toes with the tops resting on the floor.  Place your arms to your side with your shoulders and elbows straight.  Slightly lift your hands from the floor with your palms down.  Pull your shoulder blades back and slightly lift your chest.  Focus your gaze slightly forward and down.  Hold this posture for at least 3 to 5 slow breaths.  Concentrate on each breath.

Locust Arms Forward

To increase the level of difficulty, perform the locust pose with the arms above your head.  Lie face down with your legs straight and your thighs touching together.  Point your toes with the tops resting on the floor.  Place your arms overhead to form a “V”.  Maintain your elbows straight.  Slightly lift your hands from the floor with the thumbs point up.  Pull your shoulder blades back and slightly lift your chest.  Focus your gaze slightly forward and down.  Hold this posture for at least 3 to 5 slow breaths.  Concentrate on each breath.

Upward Dog

The upward dog pose involves weight bearing through the arms and shoulders.  This involves all the stabilizing muscles of the shoulder and upper back.  Lie face down with your hands in line with your chest.  Point your fingers forward and support your weight on your hands.  Straighten your arms.  Press the tops of your feet into the mat so that your thighs elevate off the floor.  Pull your shoulder blades back.  Focus your gaze forward.  Hold this posture for at least 3 to 5 slow breaths.  Concentrate on each breath.

Side Angle

The side angle pose integrates an overhead reach with a lower body side lunge.  Stand with your left heel aligned with the arch of your right foot.  Your left knee will bend and track over your foot.  Do not allow your knee to move past your toes.  At the same time your left elbow bends and your forearm rests on your left front thigh. The right knee remains fully straight.  Raise your right arm fully overhead, next to your ear.  Focus your gaze forward.  Hold this posture for at least 3 to 5 slow breaths.  Concentrate on each breath.  With each breath try to stretch your hand further and further towards the sky.  If you experience pain or are unable to fully raise your arm overhead you can try raising the arm out to your side.

Side Plank

The side plank places greater demand on the shoulder muscles because of its one-arm weight-bearing position.  From a push-up position, transfer all your weight onto your right hand.   Align your left shoulder on top of your right.  Reach towards the ceiling with your left arm.  Stack your feet on top of each other.   Maintain a neutral spine.  A straight line should extend from your head through your spine and down to your toes.  Focus your gaze forward.  Hold this posture for at least 3 to 5 slow breaths.   Concentrate on each breath.  With each breath try to stretch your hand further and further towards the sky.

Get Started with Yoga

The popularity of yoga is increasing. Unfortunately the number of people experiencing shoulder pain is going to continue to rise.  Keeping your shoulders strong and mobile is your best defense against future problems.  These 5 yoga poses are great to incorporate into your workouts.  I recommend performing them two days per week.   You can cycle through each pose several times.  They will probably take you no more than 30 minutes each day.  If you experience any difficulty give us a call.  We would love to help you out.

 

 

How to Manage Your Shoulder Arthritis with Exercise

Shoulder arthritis is present in approximately 15% of people over the age of 65.  It is more common in women.  As with other forms of arthritis, most often it begins with a slow progressive loss of cartilage within the joint.  This leads to changes of the bone and joint lining.  Joint inflammation, stiffness, muscle weakness, pain, and deformities within the joint are common.  Despite popular belief, arthritis is not always a perpetual cycle of pain culminating in a joint replacement surgery.  Many people we work with who have shoulder arthritis achieve excellent results by committing to the right exercise program.

Osteoarthritis

Non-Surgical Treatment of Shoulder Arthritis

Lifestyle changes, activity modification, and adoption of strategies to protect the shoulder joint are important parts of treatment.  Activities that involve weight bearing or impact on the joint should be minimized or avoided.  Examples include push-ups and heavy overhead work.  In cases of acute pain, medications or injections can be helpful.  However they should be used sparingly due to their long-term adverse effects on the joint and other body systems.

Exercise is beneficial because it improves health of the existing cartilage, decreases joint stiffness, improves muscle strength, decreases pain, and improves function.  Gentle passive exercises are performed first.  These are usually performed lying down with the assistance of a cane or wand.  Manual therapy techniques performed by a physical therapist can enhance the benefits of exercise.  As pain and range of motion improve, stretching exercises are progressed and strengthening exercises are added.  The following 5 videos show examples of exercises we have used with excellent results for many people with shoulder arthritis.

Wand-Assisted Shoulder Flexion

Begin on your back holding a cane or wand in each hand.  Space your hands slightly wider than shoulder-width.  The cane or wand is grasped between your thumb and index finger with a thumb-up position.  The thumb-up position will maximize movement at your shoulder joint.  With both elbows straight, lift your arms overhead until a mild to moderate stretch is felt.  Hold this position for 5 to 10 seconds.  Then slowly lower back to the start position.  Perform 10 to 20 repetitions each day.

Wand-Assisted Shoulder External Rotation

Begin lying on your back with a small pillow or towel roll under the upper arm.  Hold a cane, golf club, or similar object in both hands.  Use the non-involved arm to passively rotate your involved arm out to the side.  Your elbow of the involved arm should be maintained at a 90-degree angle throughout the exercise.  When a mild stretch is felt, pause and hold the position for 5 to 10 seconds.  Perform 10 to 20 repetitions each day.  Avoid exercising through pain.

Waiter’s Bow

Begin standing with the hand of the involved arm resting on a table top or counter.  Relax the shoulder and neck muscles.  Slowly step backwards while keeping the hand on the table or counter.   When a mild stretch is felt, pause and hold the position for 5 to 10 seconds.  Perform 10 repetitions each day.  Avoid holding your breath, bouncing, or exercising through pain.

Wall Chest Stretch

This purpose of this exercise is to restore normal posture and position of your shoulder.  Most people with arthritis develop rounded shoulders and this further increases joint stress within the shoulder.  To begin, stand next to the corner of a wall or door jam.  Place the hand, forearm, and elbow on the wall.  Take a small step forward and slightly turn your body away from the wall.  You should feel a mild to moderate stretch in the front of your shoulder or chest.  Hold the stretch for 15 to 30 seconds and perform 3 to 5 repetitions daily.  If you experience pain, slightly lower the arm or decrease the intensity of the stretch.

2-Arm Band Row

The row is a great exercise to begin strengthening the muscles around the shoulder.  This exercise emphasizes the muscles that hold the shoulder blades back.  To perform this exercise, anchor a resistance band to a piece of furniture or door knob.  Grasp the ends of the band in each hand and step back so there is tension on the band with the arms stretched in front of you.  Pull the hands and elbows back.  The most important part of the movement involves squeezing or pinching the shoulder blades together.  Perform 10 to 20 repetitions for multiple sets 3 times per week.

Get Started

Exercise can not reverse or cure arthritis.  Nothing can, not even surgery.  But the pain and suffering from shoulder arthritis can be managed with the right exercise program.  Shoulder surgery can be extremely successful for some but it is not an option for everyone.  If you are looking for a different approach, your physical therapist can help you.  Begin with the strategies discussed in this article.  And if you need more help and are interested in teaming up with a physical therapist, give us a call.

Band Rotator Cuff Exercises for Baseball: Part 2

Nearly 50% of all baseball pitchers experience shoulder or elbow pain that limits participation at some point in their careers.  The repetitive stress of overhead throwing leads to overuse injuries of the shoulder and elbow.  However, many of these overuse injuries are preventable.  Exercises targeting the rotator cuff are one such approach.  In a previous article (Part 1) we wrote about free weight exercises for the rotator cuff.  Resistance band or tubing exercises are also commonly used to assist in reducing injury risk.  This article discusses the role of band exercises for the rotator cuff as part of a warm-up or conditioning program.

Band or tubing exercises are an important part of pre-throwing warm-up routines for some baseball players.  There are several solid products designed specifically for baseball players.  I recommend any of these: J-Bands, ArmCare2Go, and Kbands.  Band or tubing programs typically include several exercises to activate muscles important in the throwing motion.  They are conveniently performed in the bullpen, dugout, and locker room or on the sidelines.  These same exercises are also important components of rehabilitation and long-term arm care conditioning programs.  The goal of these programs is to maintain high levels of strength and endurance in the shoulder muscles.  Particular attention is given to the rotator cuff and scapular stabilizers because they play a key role in reducing injury risk.

Overview of Band Rotator Cuff Exercises for Baseball Players

During the throwing motion, large forces are generated from the lower body.  Energy is then transferred through the core to the arm.  The arm’s primary function is to dissipate these forces in order to minimize stress to the shoulder and elbow.  Band exercises are a great way to prepare the upper body muscles prior to throwing.  Under these circumstances, 5-7 exercises are performed as part of a warm-up.  One set of 30 repetitions performed in a controlled fashion is recommended.

As part of a conditioning program, these same exercises can be performed for multiple sets 3 to 4 times per week.  It is important to keep in mind; arm care exercises are integrated into a total body conditioning program including the lower body and core.  The following 5 rotator cuff exercises can be integrated into a long-term conditioning program or as part of an individualized warm-up.

Band Diagonal Flexion Pattern

Stand or kneel with a band anchored to a solid base at the side.  The hand begins positioned in front of the opposite hip with the palm facing the body.  The movement of this exercise resembles drawing a sword.  The hand moves across the body and upwards.  The finish position includes rotating the arm so the thumb is pointing behind the body.  As you lower the arm back to the starting position the palm rotates back to face the body.   This exercise activates all rotator cuff muscles at moderate to high levels.  It also performed in a fashion similar to the throwing motion.  This makes it ideal to incorporate into any pre-throwing warm-up.

Band Internal Rotation @90 Degrees

Stand or kneel with your back to the band anchored to a solid base. With the shoulder elevated and the elbow bent, begin with the shoulder in external rotation similar to the arm cocking phase of throwing.  Move the shoulder into full internal rotation and then return to the starting position while maintaining the shoulder and elbow positions.   A common mistake is to gradually allow the arm to drop during the exercise.   This exercise results in high activation of the subscapularis muscle.  This rotator cuff muscle functions to stabilize the shoulder joint and accelerate the arm towards home plate.

Band External Rotation @ 90 Degrees

Stand or kneel facing a band anchored to a solid base. With the shoulder abducted and the elbow bent, begin with the shoulder in internal rotation.  Move the shoulder into full external rotation similar to the arm cocking phase of throwing.  Slowly return to the starting position while maintaining the shoulder and elbow positions.   A common mistake is to gradually allow the arm to drop during the exercise.  This exercise activates all rotator cuff muscles at moderate to very high levels.  It is performed in a position similar to the arm cocking and early acceleration phase of throwing where high stress is imparted on the shoulder and elbow.

Band Throwing Acceleration

Stand in a lunge stance holding the band or tubing with the throwing arm in a position of abduction and external rotation.  This is similar to the arm cocking phase of throwing.  Begin the exercise by moving the arm across the body similar to the acceleration phase of throwing.  Shift your body weight from the rear to the front leg as you perform the throwing motion.  Return to the starting position in controlled fashion shifting your bodyweight back to the rear leg.  This exercise results in very high activation of the subscapularis and teres minor of the rotator cuff.  The subscapularis functions to accelerate the arm towards home plate.  The teres minor acts to stabilize the shoulder and control the upper arm during the acceleration and follow-through phases of throwing.

Band Throwing Deceleration

Stand in a lunge stance holding the band or tubing with the throwing arm in a low position.  This is similar to the follow-through or ending phase of the throwing motion.  Begin the exercise by moving the arm back and up towards a position of abduction and external rotation (arm cocking position).  Shift your body weight from the front to the rear leg as you perform this motion.  Return to the starting position in controlled fashion shifting your bodyweight back to the front leg.   This exercise results in very high activation of the teres minor.  The teres minor acts to stabilize the shoulder and control the upper arm during the acceleration and follow-through phases of throwing.  This exercise emphasizes an eccentric muscle action similar to how the rotator cuff functions during throwing.

Closing Thoughts on Band Rotator Cuff Exercises for Baseball Players

Arm overuse throwing injuries for the baseball player can derail a career.  However, many of these injuries are preventable. These 5 exercises are only a small sample of band rotator cuff exercises for baseball players which can be helpful. They can be performed during any part of a pre-throwing warm-up or year-round training program. Your physical therapist can perform an individual assessment and design an exercise program based on your deficiencies and goals. The objective is to increase the baseball player’s likelihood of a long injury-free and successful career. Contact us today if you questions about which exercises are right for you.

 

6 of the Best Middle Trapezius Exercises

Your trapezius is a large broad muscle spanning your upper back.  It has attachments to the spine, shoulder blade, and collar bone.  Your trapezius is divided into 3 parts: the upper, middle, and lower portions.  As a whole, your trapezius plays an important role in overhead function.  Your middle trapezius is also responsible for retracting or pulling back the shoulder blade.  Poor function of your middle trapezius has been associated with shoulder, neck, and elbow pain.  Thankfully, there are a variety of middle trapezius exercises that will decrease your pain and improve function.

The Role of Middle Trapezius Exercises in Overhead Sports

Your middle trapezius plays an important role in in positioning and controlling movement of the arm during overhead sports.  This is especially true in sports such as baseball and swimming.  During baseball pitching, the middle trapezius is activated at very high levels to control the position of the shoulder blade as the pitcher’s arm accelerates towards home plate.  Youth pitchers with a history of shoulder pain have less strength in their middle trapezius compared to pitchers without pain.

In swimmers, weakness of the middle trapezius is associated with shoulder pain and disability.  Also, athletes with shoulder impingement exhibit poor timing of their middle trapezius muscle.  As a whole, weakness and poor timing of the middle trapezius can place excessive stress on other areas of the arm.  This predisposes the athlete to poor performance or injury.  The 6 exercises in this article are simple examples of how to train your middle trapezius.

Prone Row

Begin lying on your stomach holding a dumbbell.  Starting with your arm in an extended position, perform a row.  Your elbow stays close but not all the way against the side of your body.  Hold the top position for 1-2 seconds before slowly lowering the weight.  It is important to pull the shoulder blade back as you raise your elbow.  Avoid overextending and shrugging your shoulder.

Prone Shoulder Extension

Begin lying on your stomach with the arm holding a dumbbell.  Starting with your arm in an extended position, raise your arm up with your elbow straight.  Your elbow stays close but not all the way against the side of your body.  Hold the top position for 1-2 seconds before slowly lowering the weight.  It is important to pull your shoulder blade back as you raise your arm.  Avoid overextending and shrugging your shoulder.

Prone Horizontal Abduction in External Rotation

This is my “go-to” exercise for strengthening the middle trap.  Lie face down with your arm over the side of a table or bench.  Be sure to keep your neck in a relaxed neutral position resting on your other forearm.  With your thumb up and arm straight lift toward the ceiling at a 90-degree angle (the 9:00 and 3:00 positions of a clock).  This position is aligned with the muscle fibers of the middle trapezius.  Be careful to avoid shrugging your entire shoulder as you raise the arm.  Instead, think about tilting the shoulder blade backward as you raise your arm.  Pause at the top of the movement before returning to the start position in a controlled manner.

Prone Lower Trap Raise

This exercise strengthens all ports of the trapezius.  Lie face down with one arm over the side of a table or bench.  Be sure to keep your neck in a relaxed neutral position resting on your other forearm.  With your thumb up and arm straight 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 your shoulder as you raise your arm.  Instead, think about tilting the shoulder blade backward as you raise your arm.  Pause at the top of the movement before returning to the start position in a controlled manner.

Side-Lying ER

Lie on your side holding a dumbbell with your elbow bent.  Place a towel roll in the armpit to increase activation of your rotator cuff during the exercise.  Rotate your arm upwards maintaining the elbow against the side of your body.  Hold the top position for 1-2 seconds before slowly lowering the weight.  It is important to pull your shoulder blade back as you raise your arm.  This increases activation of the middle and lower trapezius muscles.

Prone Row + ER

Lie face down with your arm over the side of a table or bench.  Be sure to keep your neck in a relaxed neutral position resting on your other forearm.  First, perform a high row with a pause at the top.  From this position externally rotate your arm upwards towards the ceiling.  Pause at the top and reverse the sequence back to the start position.  Be careful to avoid shrugging your shoulder as you raise your arm.  Instead, think about tilting the shoulder blade backward.  This exercise results in high activation of the rotator cuff, middle trapezius, and lower trapezius.

Closing Thoughts about Middle Trapezius Exercises

The middle trapezius is often neglected in rehabilitation and conditioning programs.  However, this muscle plays a very important role in overhead function and sports.  Middle trapezius exercises should be included as part of a well-rounded strengthening program.  These 6 middle trapezius exercises can be easily performed in the gym or at home.  It is not necessary to perform all 6.  Instead, select 2 or 3 which you are comfortable performing.  Start with light weights (2 to 3 lbs).  Multiple sets (2 to 3) of 10 to 20 repetitions, a few times per week is recommended.  Contact your physical therapist if you need help getting started.

Thoracic Outlet Syndrome: 5 Exercises to Help

Thoracic outlet syndrome (TOS) refers to compression of the major nerves and blood vessels in the area between the neck and shoulder.  More than 90% of cases involve compression and irritation of the nerves as they pass through the thoracic outlet.  It is less common for the blood vessels to be involved.

Common symptoms of thoracic outlet syndrome include pain in the neck, upper back, shoulder, arm, or hand.  It is also common to experience numbness, tingling, and weakness of the arm, hand, and fingers.  Symptoms are aggravated with overhead positions or activities such as throwing a baseball.  Also, repetitive tasks such as prolonged typing exacerbate symptoms of TOS.

Anatomy of the Thoracic Outlet

Thoracic outlet syndrome exercise

There are 3 components to the thoracic outlet extending from the neck to the front of the shoulder.  The 1st component is the interscalene triangle.  Nerves exit the neck and pass between the two scalene muscles.  Abnormalities of these muscles can contribute to compression or irritation of the nerves.  The 2nd component of the thoracic outlet is called the costoclavicular space.  This is the area between the collar bone and first rib.  Abnormalities of the first rib or an extra rib sometimes called a “cervical rib” can lead to irritation of the nerves or blood vessels.  The 3rd component of the thoracic outlet is the area between the pectoralis minor muscle and the rib cage.

Treatment for Thoracic Outlet Syndrome

Treatment for TOS begins with rest from any aggravating activity such as overhead sports (baseball pitching) or repetitive tasks such as keyboarding.  Referral to a physical therapist is the next step.  Physical therapy for thoracic outlet syndrome targets the 3 primary compression sites.  Manual therapy techniques and stretching exercises target the scalene muscles, first rib, and pectoral muscles.   Nerve gliding exercises are prescribed to improve the health of the irritated nerves.  Postural correction exercises are also an important component.  A slouched or flexed posture closes down the space of the thoracic outlet and increases irritation of the nerves and blood vessels.  Finally, pain-free strengthening exercises for the shoulder and upper back muscles are prescribed based on the patient’s individual needs and goals.

Scalene Muscle Stretch

Stretching the scalene muscles alleviates irritation of the nerves and blood vessels within the interscalene triangle.   Begin sitting with a strap or belt draped over the affected shoulder.  Pull down on the strap towards your opposite hip.  Side-bend the neck away from the affected side and slightly turn towards the affected side. Finally, perform a gentle chin tuck to increase the stretch in the side of the neck.  Hold this position for 30 seconds.  If you experience symptoms during the stretch, start with shorter hold times and work up to 30 seconds.

First Rib Self-Mobilization

Improving the mobility and position of the first rib alleviates irritation of the nerves and blood vessels just below it.   Begin sitting with a strap or belt draped over the affected shoulder.  Pull down on the strap towards your opposite hip.  Side-bend the neck toward the affected side.  Look down to the armpit.  This position relaxes the scalene muscles so the forces are directed to the rib.   While holding pressure with the strap, perform 10 slow and deep breaths to mobilize the rib.

Pec Minor Stretch

Improving pectoralis minor length and mobility will alleviate irritation of the nerves under this muscle.  Begin lying over a foam roll under the hips and spine.   With the elbow bent allow the arms to fall down towards the floor.  Fully exhale and relax in this position for 30 seconds.  It is important for your spine to maintain contact with the foam roll.  If you experience symptoms during the stretch, start with shorter hold times and work up to 30 seconds.

Trapezius Muscle Strengthening

To strengthen the lower trapezius muscle lie 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.

The middle trapezius is trained in a similar fashion.  To target the middle trapezius perform the movement with the arm straight out to the side.  This corresponds to the 9:00 and 3:00 positions of a clock.  Strengthening both the middle and lower trapezius will orient the shoulder blade so that irritation of the nerves in the thoracic outlet is diminished.

Closing Thoughts About Thoracic Outlet Syndrome

Thoracic outlet syndrome can be debilitating and negatively impact your quality of life.  Not everyone with TOS has to suffer.  These 5 exercises are only a small sample of the types of exercises that can help.  Meet with your physical therapist and get started on the road to recovery.  Your physical therapist will continually assess your injury and progress your exercise program based on your goals.  The objective is to decrease pain and give you your quality of life back as quickly as possible.  Contact us today if you are experiencing symptoms suggestive of TOS or if you have questions about which treatments are right for you.

 

Rotator Cuff Exercises for Baseball Players: Part 1

The health of the rotator cuff muscles is crucial for the baseball player. The rotator cuff is composed of 4 small muscles connecting the shoulder blade to the upper arm bone. The 4 muscles are the supraspinatus, infraspinatus, teres minor, and subscapularis. The primary function of the rotator cuff is to maintain the ball of the shoulder centered within the socket of the shoulder blade. Weakness, fatigue, or injury to the rotator cuff results in abnormal movement of the ball within the socket. For the baseball player, this may lead to pain, loss of throwing velocity, poor performance, and injury. Thankfully, exercise targeting the rotator cuff can reduce injury risk for the baseball player and improve performance.

The Rotator Cuff During Throwing

Rotator Cuff Anatomy

There are 6 sequential phases to baseball pitching. The rotator cuff is most active during the arm cocking through arm deceleration phases. These are the phases where the greatest stress is placed on the thrower’s shoulder and elbow. Subsequently, most overuse injuries occur due to repetitive stress during these phases. A strong and healthy rotator cuff is essential to withstand these stresses.

A classic study performed by the late Dr. Frank Jobe and his colleagues revealed the activity levels of the rotator cuff during the different phases of pitching. The supraspinatus muscle is most active during the transition from the stride to the arm cocking phase. This muscle centers the ball within the socket as the arm is being raised. The infraspinatus muscle is most active during the arm cocking phase as the shoulder maximally externally rotates. The teres minor’s primary role is to assist with decelerating the arm after ball release. And finally, the subscapularis is highly active as it contributes to arm acceleration.

 

Phases of Baseball Pitching

The Rotator Cuff and Injuries in Baseball

Numerous studies have proved an association between rotator cuff weakness and injury in baseball players. A 2015 study showed baseball players with ulnar collateral ligament injuries had significantly less rotator cuff strength compared to healthy pitchers. An earlier study found high school baseball players with pre-season supraspinatus weakness were more likely to sustain arm injuries during the regular season. Research performed in Japan found rotator cuff imbalances were associated with shoulder and elbow injuries in high school pitchers. Finally, research on professional pitchers shows pre-season weakness of the supraspinatus and infraspinatus muscles are associated with in-season injuries requiring surgery.

Rotator Cuff Exercises for Baseball

For good reason, baseball players are encouraged to perform regular rotator cuff exercises as part of a year-round arm care program. The specific exercises performed are based on the scientific research showing which exercises elicit the highest activation of the rotator cuff. Baseball players are also creatures of habit and routine. The individual preferences of the athlete should always be considered when selecting exercises. Some athletes prefer exercising with resistance bands while others prefer more traditional free weights. The 4 exercises which follow can be performed with light dumbbells, usually between 2 to 8 pounds. In part 2 of this article, we will cover some of the most beneficial resistance band exercises for the rotator cuff.

Closing Thoughts on Rotator Cuff Exercises for Baseball Players

Arm overuse throwing injuries for the baseball player can be debilitating and derail a career. These 4 exercises are only a small sample of rotator cuff exercises for baseball players which can be helpful. They can be performed during any part of a year-round training program. Your physical therapist can perform an individual assessment and design an exercise program based on your deficiencies and goals. The objective is to increase the baseball player’s likelihood of a long injury-free and successful career. Contact us today if you questions about which exercises are right for you.

 

How to Achieve the Best Outcome after Rotator Cuff Surgery

It is estimated that nearly 1 of every 4 rotator cuff repairs will re-tear within 6 months of surgery.  Overly aggressive rehabilitation or inappropriate use of the involved arm can increase this risk.  Based on my 15-plus years of experience as a physical therapist, this is the time when patients are tempted to progress themselves too quickly.  Don’t take the chance.  If you want to achieve the best outcome from rotator cuff surgery, perform your rehabilitation under the guidance of your physical therapist.

Rotator cuff tendon healing is considered sufficient to begin gentle strengthening exercises between the 12th and 16th week after surgery.   After restoring range of motion, it is important that resistance is gradually introduced and progressed.  The purpose of this article is to highlight several key exercises which are utilized during the later phases of rehabilitation after rotator cuff surgery.  Your physical therapist will help you develop the best-individualized plan based on your surgery and long-term goals.

Strengthening Exercise after Rotator Cuff Surgery

Strengthening exercises for the rotator cuff is initiated below–chest level with exercises such as internal and external rotation.  During active-assisted arm elevation exercises, it is important that you maintain appropriate exercise form in order to minimize the risk of developing compensations.  A common compensation is to “shrug” the entire shoulder when attempting to raise the arm overhead.  When you can perform a press-up exercise overhead without compensation, you are ready to progress to performing the full-can scaption with a light dumbbell.  The level of resistance is generally kept low (1 to 2 pounds) but may be increased based on your functional demands.

External Rotation in Side-Lying

This exercise is ideal for strengthening two of the rotator cuff muscles, the infraspinatus and teres minor.  Begin lying on the side with the involved arm on top.  The elbow remains bent at 90 degrees throughout the exercise.  Rotate the arm upwards through a full range of motion while keeping the elbow tucked to the side of the body.  Hold the top position for 2 to 3 seconds before slowly lowering back to the starting position.  Typically 2 to 3 sets of 10 to 20 repetitions are performed.

Band Internal Rotation @ 0 Degrees

This exercise is ideal for strengthening the subscapularis muscle of the rotator cuff.  Begin standing with the involved arm closest to where the resistance band is anchored.  The elbow remains bent at 90 degrees throughout the exercise.  Rotate the arm inwards through a full range of motion while keeping the elbow tucked to the side of the body.  Hold the top position for 2 to 3 seconds before slowly returning back to the starting position.  Typically 2 to 3 sets of 10 to 20 repetitions are performed.

Wand-Assisted Flexion in Standing

This exercise is helpful for transitioning back to full overhead reaching activities.  Stand holding a wand or cane in both hands.  The uninvolved arm will assist in elevating the involved arm overhead.  The elbow remains straight with a thumb-up position throughout the exercise.  The thumb-up position increases rotator activation and minimizes the risk for shoulder impingement when the arm is raised.  It is important to slowly control the lowering of the arm using as much of the musculature on the involved side as possible.  Hold the top position for 2 to 3 seconds.  Typically 2 to 3 sets of 10 repetitions are performed.

 Serratus Punch

 This exercise activates the rotator cuff and shoulder blade muscles while incorporating a more functional reaching movement.  Begin with a resistance band anchored behind you.  The hand starts close to the body with the elbow bent.  A punching movement is performed with a slight upwards inclination.  Hold the top position for 2 to 3 seconds before slowly returning back to the starting position.  Typically 2 to 3 sets of 10 to 20 repetitions are performed.

Press-Up in Standing

This exercise is a progression of wand-assisted flexion in standing.  Initially, the exercise is performed without any weight.  As the strength of the rotator cuff improves, 1 to 2 pounds is added to the movement.  In a standing position, start with the hand close to the body with the elbow bent.  A pressing movement is performed overhead.  The elbow straightens as the arm passes overhead.  The top position is held for 2 to 3 seconds before slowly lowering the arm back down to the starting position. Typically 2 to 3 sets of 10 repetitions are performed.   It is important to avoid “shrugging” the shoulder or arching of the low back.

Full-Can Scaption

Once the press-up exercise can be performed properly without compensation, the full-can exercise is added to improve rotator cuff strength.  This exercise specifically targets the supraspinatus muscle which is the most commonly torn tendon of the rotator cuff.  The exercise starts from a standing position with the elbow straight and thumbs pointing up.  The arms are elevated from an angle midway between the front and side of the body.  The top position is held for 2 to 3 seconds before slowly lowering the arm back down to the starting position. Typically 2 to 3 sets of 10 repetitions are performed.   It is important to avoid “shrugging” the shoulder or arching of the low back.

Final Thoughts on Rotator Cuff Surgery Rehabilitation

Rehabilitation after rotator cuff surgery is a slow progression lasting anywhere from 3 to 6 months.  Your physical therapist will be your guide through the process.  You will be safely progressed in the most effective manner based on your own healing capabilities and long-term goalsYour physical therapist will know when to ramp things up and when to slow things down.  In the end, you will feel like a new person.   Contact your physical therapist if you have questions or are ready to get started with your rehabilitation.

Rotator Cuff Surgery: Phase 2 Exercises

Rotator cuff surgery rehabilitation is a marathon, not a sprint.  You must remain patient throughout the process in order to achieve the best long-term outcome.  Rotator cuff repairs involve stitching tendon back to tendon or tendon back to the bone.  This requires caution for the first 3 to 6 months after surgery while the repair is vulnerable to re-tearing.  Overly aggressive stretching or lifting of the arm can damage the repaired tendon.   The exercises included in this article are a progression of the early phase range of motion exercises done during the first 2 to 6 weeks after surgery.

This second phase of rehabilitation typically begins 6 weeks after surgery.  However, these exercises may be delayed for an additional 2 to 4 weeks for larger tears which require greater protection.  Phase 2 exercises utilize less external assistance than those performed in phase 1.  Also, these exercises are progressed by being done against gravity.  These factors contribute to slightly greater activation of the rotator cuff muscles but do so in a protected fashion.  The goals of phase 2 are to restore range of motion and prepare the shoulder muscles for gentle strengthening exercises during phase 3.

Incline Table Slides

This exercise is a progression of the table slide exercise performed in the early phases of rehabilitation.  Begin standing, holding a towel with the hand of the involved arm resting on a surface inclined 45 degrees.  Relax the shoulder and neck muscles.  Actively, slide the hand up the incline.   At the top, hold the position for 2 to 3 seconds.  Typically, 10 to 15 repetitions are performed for 2 to 3 sets.

Wall Slides

This exercise is a progression of the incline table slide.  The goal is to transition towards raising the arm overhead against gravity without assistance.  Begin standing, holding a towel with the elbow bent.  Relax the shoulder and neck muscles.  Actively, slide the hand up the wall.  At the top, hold the position for 2 to 3 seconds.  Lower the arm under control by slowly sliding back down the wall.  Initially, the uninvolved hand can be used to assist the movement.  As pain decreases and strength improves, perform the exercise unassisted.

Active Press-Up in Supine

Lie on your back with the knees bent.  The involved arm begins at the side with the elbow bent.  Actively lift the arm straight up to the ceiling.  When the elbow reaches full extension, pause and hold the position for 2 to 3 seconds.  Typically, 10 to 15 repetitions are performed for 2 to 3 sets.  This exercise can be safely progressed by performing it in a slightly reclined position and eventually in standing.

Wand-Assisted Flexion in Supine

Begin on the back holding a cane, wand, or similar straight object in each hand.  The hands are spaced slightly wider than shoulder-width.  The cane or wand is grasped between the thumb and index finger assuming a thumb-up position.  The thumb-up position will maximize movement at the shoulder joint.  With both elbows straight, lift the arms overhead until a mild to moderate stretch is felt.  Hold this position for 5 to 10 seconds.  Then slowly lower back to the start position.  Typically 10 to 20 repetitions are performed.

Resistance Band Elevation in Supine

Performing exercises lying on the back minimizes the effect of gravity.  This makes it ideal to begin exercising with light resistance while protecting the healing rotator cuff repair.  To perform band elevation in supine, begin on the back holding a resistance band in the hand of the uninvolved side at waist level. The involved side shoulder starts flexed 90° with the elbow straight holding the band in a thumb-up position. Minimal tension is placed on the band in this starting position.  Actively lift the arm into forward elevation to approximately 160°, thereby lengthening the band.   Pause 2 to 3 seconds at the top, then lower slowly back to the starting position.  Typically, 10 to 15 repetitions are performed for 2 to 3 sets.

Closing Thoughts on Rotator Cuff Surgery

From the 6 to 12-week point after rotator cuff surgery, most patients feel much less pain.  This can provide a false sense of security.  The repaired tendon is still at only approximately 25% to 50% normal strength during this time period.   Exercise must still be applied cautiously during this phase of rehabilitation.  Your physical therapist and surgeon will communicate with each other to determine the optimal rate of progression for you.  Those patients who remain patient and consistent with their exercises usually achieve the best long-term outcomes.