Lat Stretches to Improve Overhead Mobility

The length of the lats, or latissimus dorsi muscle, affects the ability to raise the arms overhead.  Shortened lats restrict overhead mobility.  Short or overactive lats also pull the shoulders inward and can increase compressive forces on the low back.  This commonly occurs with aging and those with a rounded shoulder posture.  Performing lat stretches can reverse this problem.

The latissimus dorsi is the largest muscle of the upper body.  It is a long broad muscle that originates in the low back.  It spans the upper back and passes under the armpit to attaché onto the upper arm.  The lats function to pull the arm down and across the body.  It also rotates the arm inward toward the middle of the body.   Common exercises which include these movements and strengthen the lats are pull-ups, pull downs, and rows.   It is also highly active during other common exercises such as presses, squats, deadlifts, and planks.

Many exercises performed in the gym require full overhead mobility.  Also, many of us perform daily activities which require overhead reaching.  When lats are short or overactive, the brain will take the path of least resistance and figure out a way to compensate.  This often manifests by excessively arching the low back when reaching overhead.  The following four exercises are examples of stretches for the lats.  Performing these regularly can improve overhead shoulder mobility and spare your low back from unnecessary stress.

Foam Rolling the Lats

Brief periods of foam rolling can reduce overactivity or tension in the lats.  This is a nice way to prepare the lats for the next two stretches.  Performing about 30 seconds of foam rolling is usually adequate.  Longer periods are rarely needed.   Lie on your side with the foam roll positioned in the area of your armpit.  Bend your bottom leg and straighten the top leg.  The palm should be positioned facing up to rotate the upper arm.  Engage the abdominals slightly to maintain a tilt of the pelvis.  Slowly roll up and down covering an area of about 6 to 12 inches.  Gentle pressure is all that is needed.  Aggressive pressure or foam rolling often increases tension in the lats.

Active Lat Stretch in Quadruped

Assume a kneeling position with both elbows resting on the floor.  Reach up and across the body with the side to be stretched.  Also, rotate the palm upwards.  Slightly sit back on the heels to increase the stretch felt in the upper back or armpit.  Engage the abdominals slightly to maintain a tilt of the pelvis.  Hold this position for 10 to 30 seconds.  Deep breathing can be incorporated to relax and further stretch the muscle.  Gentle stretching is all that is needed.

Supine Flexion

By lying on the back and flexing the arms overhead, shoulder flexion is assisted by gravity.  To increase the stretch to the lats, position the palms up.  As you gain mobility, move the hands closer together.  You can also perform the exercise lying on a bench to allow for greater range of motion overhead.  Be sure to keep the abs engaged and low back flat to avoid compensations.

Bench T-Spine Mobilization

This is my favorite exercise for restoring thoracic spine extension and stretching the lats.  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.  Engage your abdominal muscles to maintain a slight tilt of the pelvis.  You shoulder feel a nice stretch in your upper back or arm pit.  For an added stretch you can bend your elbows further past your head.  Hold this position for a few seconds, and exhale fully.  Reverse the motion to return to the start and repeat the desired number of repetitions.

Closing Thoughts

Improving the length of the lats takes patience and persistence.  This is a big strong muscle that is prone to overactivity and tightness.  Stretching 3 to 4 times per week for several weeks is needed to see any meaningful improvements.   Increase your chance of success by also performing abdominal and thoracic spine mobility exercises.  With consistency, you will see a payoff in your ability to perform overhead movements.   If you are unsure about how to get started, meet with a physical therapist.

Frozen Shoulder: Exercises to Restore Mobility

Stiffness from frozen shoulder can last 1 to 3 years.  Performing regular home exercise can expedite recovery.  As mentioned in a previous article, the exercise program must be individually tailored and match the stage of the disorder.  Gentle exercise with minimal pain is recommended early during the freezing stage.  The vigor and volume of stretching can be increased during the frozen stage but the pain must be respected.  During the thawing stage, pain during exercise is expected provided it dissipates soon afterward.  The exercises which follow in this article are a few examples of those commonly prescribed by physical therapists.  The effectiveness of these exercises can be enhanced by combining them with manual physical therapy.

Supine Shoulder Flexion

Performing stretching exercises in the lying position will minimize the effects of gravity.  This results in less pain and improved range of motion.  Begin lying on the back with the hips and knees bent.  With the uninvolved hand grasp the wrist of the involved side.  Use the uninvolved arm to passively lift the involved arm overhead.  Maintain a straight elbow.  At the onset of mild discomfort or a stretch, pause for 5 to 10 seconds.  Perform 10 repetitions.  This exercise is typically prescribed during the freezing stage of frozen shoulder.  As pain begins to diminish the exercise can be progressed by increasing the duration of the stretch up to 30 seconds.

Supine Shoulder External Rotation

Begin lying on the back with a small pillow or towel roll under the upper arm.  Hold a cane, golf club, or similar object with both hands.  Use the uninvolved arm to passively rotate the involved arm out to the side.  The elbow of the involved arm should be maintained at a 90-degree angle throughout the exercise.  At the onset of mild discomfort or a stretch, pause for 5 to 10 seconds.  Perform 10 repetitions.  This exercise is typically prescribed during the freezing stage of frozen shoulder.  As pain begins to diminish the exercise can be progressed by increasing the duration of the stretch up to 30 seconds.

Standing Shoulder Extension

Restoring the ability to reach behind the body is important for people with frozen shoulder.  This takes repetition and time.  Be patient.  Standing shoulder extension with a cane or golf club is a great starting point.  Stand tall holding the cane behind the body with the arms straight.  Maintain both elbows straight and lift the cane backward until mild discomfort, or a stretch is felt.  Pause in this position for 5 to 10 seconds.  Perform 10 repetitions.  This exercise is typically prescribed during the freezing stage of frozen shoulder.  As pain begins to diminish the exercise can be progressed to the cross body or sleep stretch described below.

Cross Body Stretch

This stretch addresses the posterior shoulder joint and muscles which are prone tightness in those with frozen shoulder.   It is most appropriate for those in the frozen and thawing stages of frozen shoulder.  This stretch is performed lying on the involved side with hips and knees bent.  The involved shoulder and elbow are positioned in 90 degrees of flexion.  The hand of the uninvolved arm grasps the elbow of the involved arm and gently pulls it across the body.  Once a mild stretch is felt on the outside or back of the shoulder, this position is held for approximately 30 seconds.  The stretch is typically performed 2-3 times each session.

Sleeper Stretch

The sleeper stretch is effective for improving the ability to reach behind the back.  Difficulty with dressing behind the back is a common complaint about those with frozen shoulder.  For this stretch, the same starting position as the cross body stretch is assumed.  However, with the sleeper stretch, the wrist and forearm of the involved arm are gently moved down towards the table.  Once a mild stretch is felt on the outside or back of the shoulder, this position is held for approximately 30 seconds.  The stretch is typically performed 2-3 times each session.   This stretch is most appropriate for those in the thawing stage of frozen shoulder.

Closing Comments

Patience and persistence are the keys to success with these exercises.  The rate of recovery from frozen shoulder can only be increased to a certain point.  Overly aggressive stretching early when pain levels are high can prolong recovery.  Conversely, infrequent or painless stretching, later on, can result in incomplete recovery.  Dealing with frozen shoulder is a marathon, not a sprint.  Team up with a physical therapist so can plan the exercise strategy which is best for you.

 

Frozen Shoulder: What is it and What Can Be Done?

Frozen shoulder, also known as adhesive capsulitis, is characterized by tightening and contracture of the shoulder joint capsule and surrounding ligaments.  The inner lining of the shoulder joint called the synovium, and the surrounding muscles are also affected.  In the majority of cases, pain and loss of motion occur without any specific injury.  Sometimes only a minor trivial incident, such as bumping the shoulder against a wall, can be recalled by the patient.

The true underlying pathology of frozen shoulder is not well-understood.   Some reports show the lining of the shoulder joint becomes inflamed while other studies show a lack of inflammation.  Changes in blood flow and nerve sensitivity have also been found.  However, it is well known that the outer capsule of the joint shrinks and thickens leading to significant pain and loss of motion.

adhesive capsulitis

Who is most commonly affected?

Frozen shoulder affects between 2% to 5% of the population.  The disorder most commonly affects women between the ages of 40 and 65 years old.  It often occurs in both arms several years apart.  It is also more common in those with certain diseases such as diabetes and thyroid disorders.

Signs and Symptoms

Patients with frozen shoulder often have pain at rest which is worsened at night and with movement.  As the disorder progresses, the range of motion becomes more and more restricted.  Pain typically begins to subside during this time but function can remain extremely limited due to stiffness.  The inability to reach overhead and behind the back are hallmark signs.

The Course of Frozen Shoulder

Frozen shoulder progresses through stages over the course of 1 to 3 years.  The first stage, called the “Freezing Stage” is characterized primarily by increasing pain with some loss of motion.  As the disorder progresses into the “Frozen Stage”, pain begins to subside but significant stiffness is present.  During the “Thawing Stage”, pain continues to diminish and range of motion slowly improves.

adhesive Capsulitis

Previously, it was believed that frozen shoulder would resolve on its own by waiting 12 to 18 months.  However, several studies show persistent loss of motion and limited function for up to 3 years.  Therefore, it is important to take an active approach in order to avoid a delayed recovery.  Three of the most common treatment options include physical therapy, corticosteroid injection, and manipulation under anesthesia.

Physical Therapy for Frozen Shoulder

Range of motion and stretching exercises can be an effective treatment option for people with frozen shoulder.  However, it is important that the exercise program matches the stage of the disorder.  Overly aggressive stretching performed in the “freezing stage” can result in increased pain and delayed recovery.   Exercise is carefully prescribed by the physical therapist in order to meet the individual’s goals.

Frozen shoulder

Manual physical therapy can also be an effective treatment for people with frozen shoulder.  In particular, joint mobilization and passive stretching techniques are useful in the later stages when pain is minimal.  The effects of manual therapy are always enhanced when patients perform regular home exercises.

Corticosteroid Injection

Injections can be particularly helpful during the early “freezing stages” of frozen shoulder.  They can help reduce some of the acute pain which occurs at night and while at rest.  Research shows combining injections with 4 to 6 weeks of daily home stretching can significantly improve pain and function.  Caution should be used for those with diabetes, as steroid injections can acutely influence blood sugar levels.  You can discuss this with your doctor to determine the best course of action.

adhesive capsulitis

Manipulation under Anesthesia

Manipulation of the shoulder joint by a physician while under anesthesia may be considered in cases where stiffness is not resolving.  This is often used during the later stages of frozen shoulder.  There may be some short-term increase in pain for several days.  However, when combined with regular home exercise and supervised physical therapy, manipulation under anesthesia can be very effective for improving function.

Frozen shoulder

Conclusion

Frozen shoulder can be very frustrating for people because of the prolonged recovery.  However, there are effective treatments which can reduce pain, disability, and in some cases speed up recovery.  If you are suffering from frozen shoulder, discuss these treatment options with your physician.  In upcoming articles, we will go into more detail about physical therapy’s role in your recovery.

Bodyblade Shoulder Rehabilitation Exercises

Proper coordination between different parts of the body is required to maintain normal shoulder function.  As mentioned in previous articles, the lower body, trunk, shoulder and arm muscles function together.  These body segments are links in a chain.  If one link is not functioning properly, the entire kinetic chain suffers.  The kinetic chain approach to shoulder rehabilitation is based on control of the shoulder blade and coordinated stabilization of the trunk.  The Bodyblade is a rehabilitation tool which can be used to train these links of the kinetic chain to function in a coordinated fashion.

Strong shoulder muscles, such as the trapezius, serratus anterior, and rotator cuff provide a base of support to stabilize the scapula and optimize arm function.  Also, normal movement patterns of the upper body require lower body and trunk muscle activation before upper extremity movement occurs.  The Bodyblade is an oscillatory device which requires co-activation of these body segments.  The Bodyblade trains muscular strength, endurance, and coordination through the co-contraction of several important muscle groups.

Bodyblade Exercises

Shoulder rehabilitation programs using the Bodyblade can take on different forms.  Different exercises can target different links in the chain such as the glutes, core, scapular muscles, or rotator cuff.  The three exercises included in this article are a few examples which can be used for patients recovering from a shoulder injury.   These exercises are typically performed for a period of time (i.e., 30 seconds) or repetitions (6-10 repetitions) using multiple sets (i.e., 2-4 sets).  Your physical therapist can help you design a program which is best for you.

Closing Thoughts

Shoulder rehabilitation has become more of a total body rehabilitation approach versus focusing solely on the shoulder.   The Bodyblade is a device which facilitates co-contraction of muscles in the shoulder and throughout the body.  This is characteristic of how the body functions in everyday life and sports.  For people experiencing shoulder pain, the Bodyblade can be an effective adjunct to other foundational shoulder strengthening exercises.

Kinetic Chain Exercises Linking the Shoulder and Hip

Overhead activities such as throwing require proper sequencing of different body parts.   The lower body, trunk, shoulder, arm, and hands are considered links in a chain.  If any of these links are not functioning properly, the chain is compromised.  Effectively using the body as a kinetic chain maximizes overhead athletic performance and reduces injury risk.  Shoulder rehabilitation programs now integrate the kinetic chain theory for a broader approach versus focusing only on isolated muscles.

Exercises targeting the shoulder muscles receive a great deal of attention in overhead athletes and rightfully so.  The rotator cuff and scapular muscles are important for dissipating high forces created from throwing.  However, most of the energy created during throwing occurs from the lower body and trunk.  Weak links in the lower body often result in additional stress to the shoulder and elbow during throwing.  Therefore, including exercises that incorporate all links of the kinetic chain are beneficial.

lower body strength throwing

 

Lower body exercises such as the squat and lunge can be integrated with common shoulder rehabilitation exercises.  Total body exercises which incorporate resistance bands or tubing are ideal for integrating links of the kinetic chain.  This article described only 3 exercise examples.  However, there are many other variations which can be developed based on the athlete’s profile and goals.

Overhead Squat with “Y”

Stand holding a resistance band in both hands with the shoulders flexed and elbows straight.  Perform an overhead “Y” by raising both hands with the elbows straight.   Maintain this overhead “Y” position as you perform an overhead squat.  Try to reach a maximum depth of the squat without compromising the upper-body position.  Maintain the overhead “Y” until completion of the set.  Perform 8 to 10 repetitions per set.  This exercise integrates the gluteus maximus, rotator cuff, low back muscles, and trapezius.

Lunge with “T”

Stand holding a resistance band in both hands with the shoulders flexed and elbows straight.  Perform a “T” with both arms by pulling the hands and shoulder blades back with the elbow straight.   Once in the “T” position, perform a reverse lunge with one leg.  The “T” position is maintained until one alternating repetition is performed on each leg.  Reset the “T” before completing the next repetition.  Perform 6 to 8 slow and controlled repetitions on each side.  This exercise activates the gluteus medius, gluteus maximus, lats, and trapezius.

Lateral Band Walk with “W”

Perform an exaggerated sideways walk with a resistance band just above the knees. Remain in an athletic position keeping the toes pointed straight ahead.  It is important to push the knees apart against the resistance band in order to activate the hip muscles.  The shoulder blade and rotator cuff muscles are activated by using a second resistance band in the hands.  Make a “W” with the elbows in order to achieve scapular retraction.  Take 3 steps to the right followed by 3 steps back to the starting position.   Also, think about pulling the elbows to the opposite back pocket.  Perform 6 to 8 slow and controlled repetitions to each side.  This exercise activates the gluteus medius, gluteus maximus, rotator cuff, and lower trapezius.

Closing Thoughts

Combining lower body exercises with traditional shoulder rehabilitation exercises is beneficial for overhead athletes.  Muscles throughout the entire body function in a coordinated sequence during baseball and softball throwing.  Resistance bands have gained popularity in the baseball and softball communities as part of pre-throwing routines and strength and conditioning programs. These shoulder-focused exercises train only a limited number of links in the kinetic chain.   A wiser approach is to integrate upper body resistance band exercises with dynamic, full-body exercises.  Talk to your physical therapist if you are unsure about which exercises are best for you.

 

 

Closed Kinetic Chain Shoulder Rehabilitation Exercises

In order for the arm and shoulder to optimally function, muscles of the entire body must contribute.   During most dynamic activities in everyday life and sport, the lower body creates most of the needed energy.  Energy is transferred from the lower half of the body up through the trunk and finally to the arm.  The important links in this sequence are the core and shoulder blade muscles.  Shoulder strengthening exercises which focus on the rotator cuff are usually only partially effective for patients with shoulder pain.  Muscles do not function in isolation.  The brain programs movement as patterns, not individual muscles.  Therefore, shoulder rehabilitation programs should include exercises which integrate the entire kinetic chain including the core and shoulder blade.

These same rehabilitation exercises can also be utilized as part of a dynamic warm-up for athletes.  Ideally, muscles throughout the body are involved in the pre-game warm-up for baseball and other overhead sports such as tennis and swimming.   These exercises have the potential to improve strength, performance and reduce the risk of injury.  The 5 closed kinetic chain exercises included in this article activate the core muscles along with the trapezius and serratus anterior.   Closed kinetic chain exercises involve bearing weight through the arms and hands.

Quadruped Band Series

Begin in the quadruped position with the hands positioned under the shoulders and knees under the hips.  Maintain a neutral spine and pelvis.  Loop a resistance band around the wrists.  Next, reach 6-8 inches to the side with one arm.  The hand is placed down on the floor for 2 seconds before returning to the start position.   Typically, 8 repetitions are performed on one side then repeated on the opposite side.  This exercise activates the serratus anterior muscle.   To keep these muscles highly activated, push the upper back up toward the ceiling throughout the exercise.

High Plank on Balance Board

This exercise is performed in a push-up position with the hands on a balance board or BOSU.  The hands are positioned below the shoulders with the pelvis in a neutral position.  From this position, move the board in a circular fashion by touching the edges of the board to the floor.   Perform 30 seconds in one direction.  After a brief rest period, repeat the same sequence moving the board in the opposite direction.   This exercise activates the serratus anterior muscle.

Shoulder Taps

Begin in a push-up position with the hands under the shoulders.  Maintain a neutral spine and pelvis.  Perform the exercise by alternately touching the opposite shoulder with the opposing hands while maintaining a pelvic neutral plank position.   Perform 8 to 10 slow touches to each shoulder.  This exercise highly activates the serratus anterior muscle and to a lesser degree the lower trapezius.  To keep the serratus anterior highly activated, push the upper back up toward the ceiling throughout the exercise.

Ball Walkouts

Begin by lying over an exercise ball with both hands on the floor.  Walk your hands and body out from the ball.  Maintain a neutral spine and pelvis as you walk out from the ball.  Pause and hold the end position for 10 seconds.  Then walk back to the starting position.  Perform 8 repetitions is a slow and controlled fashion.

Bear Crawls

Assume an all-4’s position with the hands shoulder-width apart and the knees under the hips.  Elevate the knees 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.  To increase the challenge, crawl in both a forward and backward direction.

Final Thoughts

The 5 exercises shown in this article integrate the lower body, core, and upper body.  More specifically, these exercises challenge the rotator cuff and scapular muscles while simultaneously activating the core.  This is similar to how we function in sport and everyday life.   Closed-chain exercises are excellent for improving the coordination between muscles and adjacent body regions.  Integrate these exercises into a warm-up or as part of a stand-alone exercise program.  If you have questions, contact your physical therapist for help.

5 Exercises to Improve Overhead Shoulder Mobility

Loss of overhead shoulder mobility can be subtle.  Often, this subtle loss of motion occurs slowly over time from our daily routines and habits.  Sitting at a desk for most of the day can result in postural changes and loss of shoulder mobility.  Over time, the small changes in shoulder mobility begin to accumulate.  Before you know it, the shoulder begins to feel a little tight and painful when reaching overhead.   Things can snowball from there.

Many people do not realize they have lost shoulder mobility until they begin or resume an exercise program.  Exercises which require overhead shoulder mobility include the shoulder press, push press, snatch, and pull-up.  There are many others.  These types of exercises are performed at or near end ranges of motion.  The shoulder can begin to break down weight, repetitions, and speed are added to the equation.

Overhead Mobility

The ability to function overhead requires mobility of the shoulder joint, the scapula, and thoracic spine.  The scapula must freely rotate and tilt in order to reach fully overhead.  Exercises which target the serratus anterior and lower trapezius are often helpful.  Also, the thoracic spine must be able to fully extend in order to achieve end range overhead positions.   Thoracic mobility drills are helpful here.

Shoulder Mobility Exercise

Full range of motion of the glenohumeral, or shoulder, joint is needed to function overhead.  Restrictions can be due to the joint capsule or the soft tissue (muscles and tendons) structures surrounding the joint.   Joint restrictions are treated best with manual therapy.  Soft tissue mobility restrictions are treated by combining soft tissue manual therapy techniques with mobility drills.  The remainder of this article describes 5 shoulder mobility drills.

Supine Flexion

By lying on the back and flexing the arms overhead, shoulder flexion is assisted by gravity.  To increase the stretch to the lats, position the palms up.  As you gain mobility move the hands closer together.  You can also perform the exercise lying on a bench to allow for greater range of motion overhead.  Be sure to keep the abs engaged and low back flat to avoid compensations.

Bench T-Spine Extension

This exercise improves thoracic spine extension.   It also provides a stretch to lats and triceps.  Both of these muscles can restrict overhead mobility.  By moving the hips back to heels lumbar spine flexion is created.  This adds to the stretch in the upper back and lats.

Floor Slides

Perform the floor slide with the hips and knees flexed.  This position facilitates a neutral low back position.  This is a great way to stretch tight pectoral muscles which contribute to rounded shoulders and limited overhead mobility.

Shoulder Flexion over Foam Roll

Lying over the foam roll helps maintain proper spine position when flexing the shoulder overhead.   It also facilitates stretching to the pectoralis major and minor muscles.  Adding a resistance band to the wrists engages the rotator cuff muscles.  Be sure to keep the abs engaged and low back flat to avoid compensations.

Prone Lifts

This is a challenging exercise but it can be very effective for restoring the last bit of shoulder mobility.  The prone position also facilitates posterior tilting of the scapula.  Tilting of the scapula is an important part of function overhead.  Be sure to keep the abs engaged to avoid compensations in the low back.   As you gain mobility move the hands closer together.

Final Thoughts

The shoulder is the most mobile joint in the body.  However, mobility problems are very common and can lead to pain and decreased function.  Performing any of these 5 mobility drills can combat and reverse loss of overhead shoulder mobility.  Don’t expect huge improvements after a few sessions.  Results can be expedited by combining these exercises with manual therapy performed by a physical therapist.   However, it takes consistent and disciplined performance to achieve the best long-term results.

 

Reverse Shoulder Arthroplasty (Replacement)

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.

Closing Thoughts

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.

  1. 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.
  2. 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.
  3. Boudreau S, Boudreau E, Higgins LD, Wilcox RB. Rehabilitation Following Reverse Total Shoulder Arthroplasty. J Orthop Sport Phys Ther. 2007;37(12):734–743.
  4. 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.
  5. 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

Rotator Cuff Tears: Management with Exercise

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.

Strengthening Exercise

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.

 

 

Closing Thoughts

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.

References

  1. 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.
  2. 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.

Strengthen the Shoulder to Manage Elbow Pain

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.

Closing Thoughts

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.

References

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.