How to Stabilize the Scapula During Shoulder Elevation

One of the most common compensations we see with people with limited overhead shoulder elevation is lateral winging of the scapula.  Anytime you have limited glenohumeral joint mobility, your scapulothoracic joint is going to try to pick up the slack to raise your arm overhead.

This is common in postoperative patients, but also anyone with limited shoulder elevation.

Stabilizing the scapula during range of motion is often recommended to focus your mobility more on the shoulder than the scapula.  As with everything else, as simple as this seems, there is right way, a wrong way, and a better way to stabilize the scapula during shoulder elevation.

In this video, I demonstrate the correct way to stabilize the scapula, and show some common errors that I often see.

 

How to Stabilize the Scapula During Shoulder Elevation

 

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Is GIRD Really the Reason Why Baseball Pitchers Get Hurt?

Today’s guest post comes from Lenny Macrina, my good friend and co-owner of Champion PT and Performance.  We work with a lot of baseball players at Champion, which makes us really understand one thing – baseball pitchers are unique!  Many of our athletes come to us after going elsewhere for care but not making the progress they want.  I don’t think we are special, we just see a lot of baseball injuries, so we know what to look for in these athletes.  

Lenny does a great job here discussing a very common misconception about pitching injuries and GIRD.  Honestly, GIRD is kind of outdated.  

Lenny has conducted a ton of research on this topic and wanted to share his results.  You MUST understand the science and not get caught up in all the hype on the internet!  Read below and learn more!


 

Baseball pitchers tend to have unique amounts of mobility of their shoulders. Because of this, throwing generates tremendous forces on the shoulder.  This is important to consider when evaluating and treating baseball injuries.

All of this fancy talk basically says that throwing a baseball is technically bad for your body, and many times we see baseball pitchers with hurt shoulders and elbows.

But why?

We believe there are many reasons, but as physical therapists who have to assess and treat these baseball players, we must be aware of their unique presentation and act accordingly.

It has been well established in the literature that pitchers exhibit adaptations to their shoulder mobility from the act of throwing.   Generally, the thrower’s shoulder exhibits less internal rotation but greater external rotation compared to non-throwing side. There are many proposed reasons for these shoulder mobility changes, including bony adaptations, muscular tightness, shoulder blade position, and capsular restrictions.

This loss of internal rotation has received a lot of attention and has even been referred to as glenohumeral joint internal rotation deficit (GIRD).

 

Is GIRD really the reason why baseball pitchers get hurt?

Several authors have stated that GIRD may increase the risk of shoulder injuries in baseball pitchers. This has caused everyone to assume this and treat accordingly.

Our initial research, that we published in 2011, showed pitchers with GIRD had a 1.8 times increased risk of shoulder injury. But it was NOT statistically significant. Since then, we have published more data that shows similar trends, specifically in our paper looking at 8 consecutive seasons of injury data.

While pitchers with measured GIRD had a slightly higher rate of shoulder injury during that season, the relationship was not statistically significant and GIRD did not correlate with shoulder injuries.

Essentially, we have not shown that GIRD correlates to pitching injuries.

 

Total Motion May Be More of the Issue

Perhaps the issue really isn’t GIRD?  A more important measurement to consider in the overhead thrower is total rotational range of motion. Total rotation is defined as the sum of external rotation and internal rotation.

 

Total Rotational Range of Motion

Rather than look at internal rotation by itself, it may be more valuable to look at the combined total rotational motion of both external and internal rotation together.

In fact, we showed that pitchers with greater than a 5 degree deficit in total rotational range of motion displayed a greater risk of injury. In one study, this was a statistically significant 2.6 times increased risk of shoulder injury.

 

What About External Rotation and Shoulder Injuries?

Does GIRD Cause Baseball Pitching InjuriesCuriously enough, we also have shown a relationship between loss of external rotation mobility and shoulder injuries.  Pitchers with external rotation insufficiency were more likely to undergo surgery, 2.2 times more likely be placed on the DL for a shoulder injury, and 4.0 times more likely to undergo shoulder surgery.

Wow!  At first you would think, let’s stretch these guys out and gain external rotation. But hold on one second and let’s get a grip!

If you remember our study from 2011, we showed a high preponderance for shoulder injuries especially in the pitchers whose total motion was greater than 187 degrees.  You don’t want too little or too much motion!

So, as I always tell my students, athletes and fellow clinicians: We’re always walking a fine line between too much and not enough mobility.

 

What About Shoulder Flexion?

While internal and external rotation get all the exposure, shoulder flexion may actually be an area we see tight the most.

I think one interesting finding of our recent research has been the relationship between the shoulder flexion deficit and injury.  Pitchers with a deficit of greater than or equal to 5° in shoulder flexion of the throwing shoulder had a 2.8 times greater risk for elbow injury.

The correlation between shoulder flexion deficit and elbow injury may represent a lack of tissue mobility and overall flexibility (possibly to the latissimus dorsi) in injury-prone subjects.

The baseball pitcher has a unique mobility of the arm.  We need to be careful assuming that these abnormalities and asymmetries correlate to injury.  They often do not.

The challenge is figuring this out and keeping up with the research…as it is always evolving!  The more you work with baseball pitchers the more you appreciate these subtleties.  These are the subtleties that make them unique, and effective as athletes.

 

So, what does all of this mean?

  • Assess motion
  • GIRD not necessarily bad (actually pretty normal)
  • Lacking ER may increase risk of injury
  • Total range of motion deficits increase risk of injury
  • Shoulder flexion deficits increased elbow injury risks
  • Assess and never assume!

GIRD is not as evil as everyone makes it out to be.  Treating them unnecessarily and trying to gain internal rotation may actually make them worse.  Don’t treat without thoroughly assessing, and don’t assume GIRD is the reason why baseball pitchers get injured.

 

 

Assessing the Shoulder Shrug Sign

The latest Inner Circle webinar recording on Assessing the Shoulder Shrug Sign is now available.

Assessing the Shoulder Shrug Sign

Assessing_the_Shoulder_Shrug_SignIn this inservice recording, I overview the two main types of shoulder shrug signs that I see.  The classic shrug sign typically involves either a rotator cuff injury or significant capsular hypomobility.  However, we also see shrugs in people that have poor overhead mobility.

This webinar will cover:

  • What are the different types of shoulder shrug signs?
  • How to tell if you have a mobility or motor control issue
  • The sequence I follow to determine what to choose for my treatments

To access this webinar:

Assessing for Lat and Teres Tightness with Overhead Shoulder Mobility

Limitations in overhead shoulder mobility are common and often a frequent source of nagging shoulder pain and decreased performance.  Any loss of shoulder elevation mobility can be an issue with both fitness enthusiasts and athletes.  Just look at all the exercises that require a good amount of shoulder mobility in the fitness, Crossfit, and sports performance worlds.  Overhead press, thrusters, overhead squats, and snatches are some of the most obvious, put even exercises like pullups, handstands, wall balls, and hanging knee and toe ups can be problematic, especially when combined with speed and force such as during a kipping pull up.

Assessing for Lat and Teres Tightness with Overhead Shoulder MobilityWhen assessing for limitations in overhead shoulder elevation, there are several things you need to evaluate.  I’ve discussed many of these in several past blog posts and Inner Circle webinars on How to Assess Overhead Shoulder Mobility.

I am worried about what I am seeing on the internet right now.

I feel like the mobility trends I am seeing are focused on torquing the shoulder joint to try to improve overhead mobility.  Remember, the shoulder is a VERY mobile joint that tends to run into trouble from a lack of stability.  Trying to stretch out the joint or shoulder capsule should never be the first thing you attempt with self mobilization techniques.  In fact, I have found it causes way more problems than it solves.

Think about it for a second…

If your shoulder can’t fully elevate, jamming it into more elevation is only going to cause more issues. Find the cause. [Click to Tweet]

In my experience, the focus should be on the soft tissue around the joint, not the shoulder joint itself.  The muscles tend to be more of the mobility issue from my experience than the joint.  Just think about all the chronic adaptations that occur from out postures and habits throughout the date.

Two of the most muscles that I see causing limitations in overhead shoulder mobility at the latissimus dorsi and the teres major.

Here’s a quick and easy way to assess the lat and teres during arm elevation.

 

Assessing and Improving Overhead Shoulder Mobility

For those interested in learning more, I have a few Inner Circle webinars on how to assess and improve overhead shoulder mobility:

 

 

How to Assess Overhead Shoulder Mobility

The latest Inner Circle webinar recording on How to Assess Overhead Shoulder Mobility is now available.

How to Assess Overhead Shoulder Mobility

How to assess overhead shoulder mobilityThis month’s Inner Circle webinar is a live demonstration of How to Assess Overhead Shoulder Mobility .  In this recording of a live student inservice from Champion, I overview my process for assessing loss of overhead mobility.  This is a very common occurrence at Champion and something we do all day.  Many people don’t even realize they have a mild loss of mobility.

In this webinar, I’ll cover:

  • Why you must look at the shoulder, scapula, thoracic spine, and lumbar spine
  • What to look for during active elevation
  • How to assess for passive loss of motion
  • A couple of easy tweaks to assess if loss of mobility is coming from the joint or soft tissue
  • How to teach someone self assessments so they can monitor themselves

To access this webinar:

 

 

 

How to Assess the Scapula

The latest Inner Circle webinar recording on How to Assess the Scapula is now available.

How to Assess the Scapula

How to assess scapular dyskinesisThis month’s Inner Circle webinar is a live demonstration of How to Assess the Scapula.  In this recording of a live student inservice from Champion, I overview everything you should (and shouldn’t) be looking for when assessing the scapula.  When someone has a big nerve injury with significant winging or scapular dyskinesis, the assessment of the scapula is pretty easy.  But how do you detect the subtle alterations in posture, position, and dynamic movement?  By being able to identify a few subtle findings, you can really enhance how you write a rehab or training program.

In this webinar, I’ll cover:

  • What to look for in regard to static posture and scapular position
  • How to check to see if static postural asymmetries really have an impact on dynamic scapular movement
  • What really is normal scapulothoracic rhythm (if there really is a such thing as normal!)?
  • How to reliably assess for scapular dyskinesis
  • How winging during the concentric and eccentric phases of movement changes my thought process
  • How to see if scapular position or movement is increasing shoulder pain
  • How to see if scapular position or movement is decreasing shoulder strength

To access this webinar:

 

 

 

A Simple Test for Scapular Dyskinesis You Must Use

A common part of my examinations includes assessing for abnormal scapular position and movement, which can simply be defined as scapular dyskinesis.  Scapular dyskinesis has long been theorized to predispose people to shoulder injuries, although the evidence has been conflicting.

Whenever data is conflicting in research articles, you need to closely scrutinize the methodology.  One particular flaw that I have noticed in some studies looking at the role of scapular dyskinesis in shoulder dysfunction has involved how the assess and define scapular dyskinesis.

Like anything else, when someone has a significant issue with scapular dyskinesis it is very apparent and obvious on examination.  But being able to detect subtle alterations in the movement of the scapula may be more clinically relevant.  There’s a big difference between someone that has a large amount of winging while concentrically elevating their arm versus someone that has a mild issues with control of the scapula while eccentrically lowering their arm.

Most people will not have a large winging of their scapula while elevating their arm.  This represents a more significant issue, such as a nerve injury.  However, a mild amount of scapular muscle weakness can change the way the scapula moves and make it difficult to control while lowering.

 

A Simple Test for Scapular Dyskinesis

One of the simplest assessments you can perform for scapular dyskinesis is watching the scapula move during shoulder flexion.  Performing visual assessment of the scapula during shoulder flexion has been shown to be a reliable and valid way to assess for abnormal scapular movement.

That’s it.  Crazy, right?  That simple!  Yet, I’m still amazed at how many times people tell me no one has ever looked at how well their scapula moves with their shirt off.

However, there is one little tweak you MUST do when performing this assessment…

You have to use a weight in their hand!

Here is a great example of someone’s scapular dyskinesis when performing shoulder flexion with and without an external load.  The photo on the left uses no weight, while the photo on the right uses a 4 pound dumbbell:

scapular dyskinesis

As you can see, the image on the right shows a striking increase in scapular dyskinesis.  I was skeptical after watching him lift his arm without weight in the photo on the left, however, everything became very clear when adding a light weight to the shoulder flexion movement.  With just a light load, the ability to prevent the scapula from winging while eccentrically lowering the arm becomes much more challenging.

I should also note that there was really no significant difference in scapular control or movement during the concentric portion of the motion raising his arms overhead:

scapular winging concentric

This person doesn’t have a significant issue or nerve damage, he simply just needs some strengthening of his scapular muscles.  But if you didn’t observe his scapula with his shirt off or with a dumbbell in his hand, you may have missed it!

 

How to Assess for Scapular Dyskinesis

In this month’s Inner Circle webinar, I am going to show you a live demonstration of how I assess scapular position and movement.  I’ve had past talks on how to assess scapular position and how to treat scapular dyskinesis, however I want to put it all together with a demonstration of exactly how I perform a full scapular movement assessment and go over things I am looking for during the examination.

I’ll be filming the video and posting later this month.  Inner Circle members will get an email when it is posted.

 

 

 

How to Coach and Perform Shoulder Program Exercises

The latest Inner Circle webinar recording on How to Coach and Perform Shoulder Program Exercises is now available.

How to Coach and Perform Shoulder Program Exercises

How to Coach and Perform Shoulder Program ExercisesThis month’s Inner Circle webinar is on How to Coach and Perform Shoulder Program Exercises.  While this seems like a simple topic, the concepts discussed here are key to enhancing shoulder and scapula function.  There are many little tweaks you can perform for shoulder exercises to make them more effective.  If you perform rotator cuff or scapula exercises poorly, you can be facilitating compensatory patterns.  In this webinar, we discuss:

  • How to correctly perform rotator cuff and scapula exercises
  • Coaching cues that you can use to assure proper technique
  • How to enhance exercises by paying attention to technique
  • How to avoid compensation patterns and assure shoulder program exercises are as effective as possible

To access this webinar:

 

 

 

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