3 Reasons Why I Don’t Use the Sleeper Stretch and Why You Shouldn’t Either

sleeper stretchAh, the sleeper stretch.  Pretty popular right now, huh?  Seems like a ton of people are preaching the value of the sleeper stretch and why everyone needs to use it.  It’s so popular now that physicians are asking for it specifically.

I don’t like the sleeper stretch and I rarely use.

There, I said it, I felt like I really had the get that off my chest!  Every meeting I go to I see more and more people talking like the sleeper stretch is the next great king of all exercises.  Then I get up there and say I don’t use it and everyone looks at me like I have two heads!  Call me crazy, but I think we probably shouldn’t be using it as much as we do.

 

3 Reasons to Not Use the Sleeper Stretch

So why don’t I use the sleeper stretch?  There are actually a few reasons.  Let me describe each in detail.

1. It Stretches the Posterior Capsule

If you have heard me speak at any of my live or online courses, you know that I am not a believer in posterior capsule tightness in overhead athletes.  Maybe it happens, but I have to admit I rarely (if any) see it.  In fact, I see way more issues with posterior instability.  The last thing I want to do is make an already loose athlete looser by stretching a structure that is so thin and weak, yet so important in shoulder stability.

Urayama et al in JSES have shown that stretching the shoulder into internal rotation at 90 degrees of abduction in the scapular plane does not strain the posterior capsule.  However, by performing internal rotation at 90 degrees of abduction in the sagittal plane, like the sleeper stretch position, places significantly more strain on the posterior capsule.

 

2.  It is an Impingement Position

This one cracks me, check out the photos below, if you rotate a photo of the Hawkins-Kennedy impingement test 90 degrees it looks just like a sleeper stretch.  I personally try to avoid recreating provocative special tests as exercises.

sleeper stretch

 

 

3. People Get WAY too Aggressive

Despite the above two reasons, this may actually be the biggest reason that I don’t use the sleeper stretch – people just get way to aggressive with the stretch.  The whole “more is better” thought process.  Being too aggressive is only going to cause more strain on the posterior capsule and more impingement.  You may actually flare up the shoulder instead of make it better.

 

When the Sleeper Stretch is Appropriate

There are times when the sleeper stretch is probably appropriate.  I could see recommending it in two cases, in young overhead athletes that don’t have anyone that can stretch them and in people with tight posterior capsules (I’m not talking about overhead athletes, you know my thoughts on this, but more so the adhesive capsulitis patient).  But of course, there are good ways to perform the sleeper stretch and there are bad ways, technique is important.

For more information on how to correctly perform the sleeper stretch and some alternatives to the sleeper stretch, check out some of my other articles:

Together, these three articles should really help you understand the pros and cons of the sleeper stretch.

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41 Responses to “3 Reasons Why I Don’t Use the Sleeper Stretch and Why You Shouldn’t Either”

  1. Great points Mike. I am not sure why this stretch is still being used.

    I am curious how you are measuring or determining a true posterior capsular tightness. Is there any technique with any validity or interrater reliability??? I remember discussing a technique a while ago with Chris Johnson, where he said it can be measured in sidelying, similar to an OBERs test but I am not sure how valid this is for a true posterior capsular restriction. Thanks.
    -Joseph Brence, DPT

  2. Mike,

    What do you think about posterior shoulder glides? I use these a whole lot more than PC stretching, and while I’ve never been to one of his courses, I know that Kevin Wilk proposes these with slight distraction to clear the glenoid rim.

    Nick

  3. When this stretch is used, I often find an increase in associated tightess of IR and the pattern of reaching behind the back. What do you propose would be the reason if it’s not posterior tightness?

  4. Mike,

    I would be on the other side of the fence for that debate about the posterior capsule. In my recent paper (http://www.ncbi.nlm.nih.gov/pubmed/21167742) in JSES we found that there is an increased posterior capsule thickness and that correlated with GIRD and scapular upward rotation. Like most things I believe some posterior capsule thickness is beneficial however there is most likely a point when it becomes problematic. This research is in its infancy and there is a careers worth of research that is needed to be performed to better understand this adaptation. There has also been a publication that have found an immediate increase in internal rotation following a posterior capsule release (http://www.ncbi.nlm.nih.gov/pubmed/12671624). And another publication demonstrating posterior capsule thickness on MRI in throwers (http://www.ncbi.nlm.nih.gov/pubmed/17825744), however it wasn’t quantified. I also have another paper in JSES coming out any day now demonstrating a relationship between posterior capsule thickness and humeral retroversion. With that being said I don’t believe that GIRD is caused by a single factor. I believe it is multifactoral and is caused by humeral retroversion, rotator cuff tightness, and posterior capsule thickness.

    In terms of posterior instability I have also seen posterior labral tears in athletes with a thick posterior capsule. This may be caused by the altered arthokinematics of the shoulder during the late cocking phase. This would position the humeral head very posterior and potentially cause a tear of the labral due to large sheer stress.

    I do agree with you that the sleeper stretch is in an impingement position. If we are stretching in a preventative manner then this will not cause pain because they don’t have impingement. In an athlete that is injured and does have impingement the sleeper stretch can cause pain. My approach is that if the sleeper stretch is causing anterior shoulder pain during stretching then you can lower the abduction angle to 70 degrees and normally that alleviates the anterior pain during stretching and it still addresses the capsular and rotator cuff adaptation.

    Again this is an area that requires much more research however I believe there is more evidence supporting posterior capsule thickness compared to research disproving it.

    • Stephen, thanks for your excellent comments. Big question I have is does thickness = tightness. Your study in JSES is great. It shows PC thickness on the throwing side and a decrease in IR on the throwing side (of course). We know IR is reduced due to bone adaptations and I could see the posterior capsule being thicker, but is the thickness the reason why IR is less? I don’t know if he study answers that. Now if you also showed that retroversion was EQUAL side to side then I would think there was a correlation.

      Your other study showing a correlation between PC thickness and retroversion I think falls into the same category, both are present in the throwers shoulder but does one cause the other? I don’t think we have that answer.

      Regardless, this isn’t about PC tightness, this is about the sleeper stretch. Hey, I know there are times when it can be OK, I’m just saying I don’t use it and don’t think I need it. But, more importantly, I write these articles to stimulate thought and discussion! Thank you for contributing.

      • Mike that is a good point. My study did find a correlation between thickness and IR. However, there are other variables that also correlate with IR (humeral retrovserion). So to prove that thickness equals tightness, longitudinal research is required. This will determine if thickness increases overtime, IR decreases, and retroversion stays the same. This would then prove causality.

        What we do know is that more GIRD and total motion difference leads to more shoulder and elbow injuries. Therefore, any stretching or mobilization techniques that decrease GIRD may help prevent injuries in overhead athletes. I agree that it is best to stick with what you are most comfortable with and what has worked for you in the past.

        This is a great forum to discuss current ideas and theories. Keep up the good work!

        • Mark Rice. MS, ATC Reply July 12, 2011 at 3:11 pm

          Great points made by all. However, I do tend to agree with Steve. But I will say this, having utilized the sleeper, I have seen my baseball players over do it when left to their own devices. Point, Mike.

          One spin on it that I have used in the past is to gently apply pressure to the vertebral border of the scapula prior to patient applying the stretch. This will allow a couple things to happen while stretching:
          1. Preventing scapula internal rotation and anterior tilting leading to impingement while stretching
          2. It may conceivably allow the posterior capsule to be isolated a bit more now that the scapula, and the glenoid in turn, are more stabilized.

          If the scapula isn’t stabilized during the treatment, accessory motion is ALWAYS going to occur. When the accessory motions are eliminated, chances are the patient should be able to perform the sleeper stretch pain free.

          We are truly on the frontside of this whole debate. It’s going to be years before this topic is settled. If ever. Great conversation everybody.

  5. Trevor Winnegge DPT,MS,OCS,CSCS Reply July 11, 2011 at 7:28 pm

    This is certainly an interesting post. I tend to agree with Stephen regarding changing angles if pain. I use sleeper stretch for adhesive capsulitis patients, post operative shoulders and some impingmenet patients. I initiate around week 6 in post ops and find it helps improve IR better than other alternatives (although I am interested in Mikes alternate techniques). I find it to be well tolerated, provided patients are well positioned and instructed in the “less is more” approach to get the “more is more” mentality out. One point I disagree with you Mike on is its correlation to Hawkins test. I agree the end position is essentially the same, however I feel the echanics are different. In Hawkins, you have the patient holding the arm up andassisting in rotation. I have never had a patient be able to do this 100% passive. Therefore you are activating deltoid and cuff in the impingement position. I feel the sleeper stretch position helps decrease deltoid activity by supporting scap and shoulder. There is a small degree of weight beaing in sleeper stretch but if done properly I find this minimal. Too many people do it lying completely on involved limb instead of rotating the truck bac, as in your picture. Perhaps a future EMG study can be done comparing he two. Until then, I am going with my theory. I have found it to be successful and helpful with most, but not all, patients. I certainly am selective on who gets it. @Nick, Posteror glides do stretch post capsule and are excellent manual techniques in the right patients. Sleeper stretch and other alternatives are more for HEP stretching. For a patient to do a self post mob, it is difficult, often painful and in my opinion, not worth prescribing. Thoughts anyone?

  6. Mike,
    I too do Hawkins passive and i should be done passive, but my point was, is it really passive? most patients are apprehensive about you recreating pain, tend to guard or help. I don’t think it is ever truly passive!

  7. Funny that the first new patient I had after reading your post was a collegiate baseball player with the Dx of posterior capsulitis with especific instructions to perform the sleeper stretch. I had never had a prescription for the sleeper stretch before. Such coincidence.

  8. Living in the northwest, I have found orthopedists very dubious of the sleeper stretch technique. Your reasoning is very solid. However, I have found posterior glide as a safe and effective technique for adhesive capsulitis followed by patient exercise with close attendion to positioning. I look forward to your followup posts.

  9. Mike,

    AWESOME POST!!! I completely agree that this is an overused and potentially deleterious stretch in the context of an incomplete evaluation and even then the stretch technique is bastardized in the vast majority of cases. I have data that I will submit for publication regarding forward shoulder position and an associated loss of internal rotation such that the more protracted the shoulder, the greater the loss of internal rotation ROM. Anecdotally, I find that internal rotation often improves by resolving forward shoulder position which leads me to believe that this is the place to start rather than cranking on the shoulder via the sleeper stretch. Its reassuring to read this post Mike and I hope that it has a broad reach!

  10. Hi Mike,
    Im a big fan and spread the good word about your site to my students and clients here in UK.

    However, I have to raise a few points regarding posterior capsule tightness.

    1) leaving OH athletes out, its very common to get posterior tightness in everyday folk and even more so in anterior chain dominant ones. Why? Well just consider Jandas upper cross. When the scapula migrates anteriorly on the thoracic wall, the orientation of the glenohumeral joint is changed and in order to keep the limb functional in a position where the lower arm is in front of the body rather than across it, the humerous is effectively at end of range lateral rotation.

    With me so far?

    And if you stay in upper cross posture with an effectively laterally rotated humerus, the posterior capsule is constantly held in a shortened position and it gets shorter and inflexible. Ultimately feeding into a secondary impingement.

    Personally I find that by using ART or some other release on the posterior capsule, I can immediately reduce the pain and increase the rang of any of my clients presenting with a secondary impingement.

    2) Hawkins test is only positive if there is pathology, if not, its just a stretch. Lets not be afraid of end of range stretches, yoga been doing that for centuries. But not if pathology right!

    Thanks Mike.
    Keep up the excellent work!

    • Paris, great points. Agree that everyday people can get posterior capsule tightness, I see it common in post op and adhesive capsulitis patients. I dont think I see it as much in other groups but it does happen and what you describe makes sense.

      However, I would argue your ART technique is actually improving posterior musculature mobility, not the capsule, just my opinion.

      In regard to the Hawkins test, it actual does cause impingement every time. You are symptomatic if you are also inflamed and irritated, otherwise impingement is actually a normal occurrence in us all. The sleeper stretch causes impingement of the coracoacromial arch. You can flare up the shoulder by doing this:

      1) Too often
      2) Too aggressively
      3) or with poor mechanics.

      Thanks for your input!

  11. Jennifer Johndrow PT, OCS Reply July 14, 2011 at 7:50 pm

    Thanks for this very interesting post and follow up comments. I had begun to really like the sleeper stretch for gaining IR range of motion, particularly after you posted about the behind the back strech being a least favorite exercise. I was looking for a good IR stretch the patient could do on their own at home. However, you do make excellent points about what’s wrong with the sleeper stretch, and I look forward to your additional posts about this! Thank you, I can usually find good info from your site when I am looking for it!

  12. Ravi Lescher,MPT Reply July 23, 2011 at 10:52 pm

    Let’s not forget to think functionally here folks. For the vast majority of “average” patientes, they perform IR and flexion on a repetitive basis with reaching/lifting/carring/etc, which causes impingement with tissue irritation anteriorly. These are NOT the folks you want to stretch into IR (I agree that if you work the scapula/rows you reset the glenohumeral head posteriorly and MAGICALLY get full IR ROM often). Functionally, if you have a pitcher or other person repeatedly ER their shoulder then OF COURSE a posterior capsule stretch makes sense… I think where we get into trouble as a profession is when we are rushed or have a poorly trained aide who has a “here, do this” approach and doesn’t monitor if a patients symptomatic areas are aggravated with the exercise. Again…common sense. Thanks Mike for the great post! It is always refreshing to see my treatment approaches validated here when I see some wacky things going on in the clinic :)

  13. Mike,

    Sensible advice. I personally do not like the sleeper either for the exact reasons that you outlined. Especially your second point illustrates how the collective clinical “groupthink” can blatantly mislead generations and perpetuate some pretty average results around the world for decades and decades.

    When I train clinicians, I often go through common rehab exercises on flashcards and we discuss the true indications, and true precautions of those exercises. My students actually get a ton out of doing this and are frequently relieved to not have to give “standard exercises that they know are not helping.

  14. Hello, Mike,
    Would you please comment on the use of the “shoulder horn”. Do you recommend against using this device?
    Thanks,
    Phil

  15. hi I’m new..I wanted to share the results of a study done by Balaicuis McClure that compared the effects of two stretches on gaining internal ROM. They compared the sleeper stretch and cross-body stretch in athletes (some of who had sig glenohumeral IR ROM deficiency) over a four week period. They acutally found that the group who did the cross-body stretch had significantly greater gains in IR than the sleeper stretch group. Purely just food for thought!!!!

    • My bad….i just finished reading the rest of this. Here I was thinking I was adding new advice….ignore my comment.

  16. Nicholas St John Rheault Reply February 8, 2012 at 1:00 am

    Good morning Mr. Reinolds,

    I’m a big fan of your work and the works of Eric Cressey (to name just a few). I have seen/watched the 11/2009 Optimal Shoulder Performance that you guys did jointly. Great stuff. I’m interested as in why you’re not a fan of the “sleeper” stretch. Does it matter on the Type I, II or III, which could/would factor into posterosuperior impingement and or poor scapular stability, etc…..

  17. nice and informative blog thanks for sharing keep on posting like this

  18. nice info to all thanks for sharing
    keep on posting like this

  19. I feel very glad to post my message to this blog and we are very thank ful to the blogger who post this info

  20. New to inner circle, I agree with you Mike. I have thought myself if we are putting people in an impingement position and stretching we need to be careful and be educating our patient and what they should be feeling. I try to position the patient so they do feel it in the posterior shoulder and not anterior. Thanks, and looking forward to cont reading and input.

  21. Mike, my 9 year old was doing this unmonitored (I was not aware he was doing this) and he seems to have strained something. Can someone help me understand what he might have done, what I should do to confirm or help, and whether I should be overly concerned. He complains the back part of his arm (upper tricep, shoulder muscle) hurts. HELP!! :(

    • Jack, hard to tell over the web. Plus, perhaps he was doing the stretch because he was sore already? I would just get checked out, are you anywhere near Boston?!

  22. What would you recommend for young high school baseball players with GIRD, who’s families cant afford skilled PT/OT and have limited access to ATC s at their schools

  23. “I humbly disagree. When reactive synovitis is present I think sleeper stretches can be problematic but GIRD happens in OHA commonly. The stretch works as borne out by studies by Wilk and others in keeping pitchers off the DL. I use it and recommend it when the PC is tight.”

    • I guess it is just how you define GIRD, I think this is over-diagnosed. Yes IR is less in the throwing shoulder, but this is from boney adaptations that cause a shift in their total rotational motion. If you have someone that is equal with total motion bilaterally, and then aggressively treat for GIRD, you will increase their overall motion and create less static stability. You may be interpreting the Wilk studies wrong, Kevin never looked at the sleeper stretch. They showed that the less IR you have the greater your chances of injury may be (their study wasn’t overwhelming and standard deviations were high). What they didn’t say was that when you have a loss of IR, you have a gain of ER. Perhaps that gain of ER is why they are getting injured?

      I know this isn’t what is being preached right now, I’m just sharing my experience. Maybe I am wrong.

  24. Loved reading this. I have two youth baseball players and as a physical therapist also a heightened sense of injury and the need for prevention, but I have never understood the sleeper stretch since as you pointed out it puts the shoulder into the “impingement” position. I have never personally been able to perform the sleeper stretch without pain. But, you hear it over and over, how important it is.

    Your explanation makes perfect sense, though. Obviously if a pitcher is losing IR after a pitching session, it isn’t a capsular issue at least not at first.

    And as you also point out, if the overall total motion is the same between sides, one has to wonder what the advantage of increasing IR will be if you are not also decreasing ER at the same time. It seems to me that the increasing ER is a natural adaptation to the throwing demands and as such is advantageous to the athlete (or at least his/her throwing) even if it may predispose the shoulder to injury. The knee-jerk reaction to simply stretch the posterior capsule and “restore” IR seems somewhat short-sighted/simplistic.

    I’ve always wondered how things like thoracic mobility or even mobility throughout the rest of the lower body impacts this issue. I have no real basis for this (other than instinct), but it seems to me maximizing mobility in other joints could/would potentially decrease the increase in ER and thus the decrease in IR…and be a far more logical/preventive approach…but maybe I’m way off base.

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