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How to Prepare Before You Throw – Part 1: Prepare Your Body

Working with so many injured pitchers over my career, one common theme that I often hear when players describe how they got hurt was that they did not properly warm up and prepare themselves to throw.  I’m not sure if this is always the true cause of the players’ injuries, however, I hear it often enough that it has to have some significance.

throwing long toss programThis seems to make sense, though.  Throwing is very dynamic and aggressive on the body.  In fact, it is the fastest known motion that the human body performs!  If it could, your shoulder would rotate a full 360 degrees around up to 27 times in 1 second!  That is unbelievable.

I often say injury is just a simple physics equation.  Force = mass x acceleration.  The faster your body moves and the harder you throw, the more forceful it is on your body.

Because of this, you can see how just grabbing a baseball and starting to throw can be stressful on the body.  Throwing is so dynamic and forceful that you want to do your best to put yourself in a position to succeed before you start throwing.  This will help foster a long and healthy career.

To prepare before your throwing program, you really need to do two things: 1) Prepare your body and 2) Prepare your throwing.  In this two part article I will discuss both.

 

How to Prepare Before Your Throwing Program – Part 1 – Prepare Your Body

It’s funny how common sense tells us to prepare our body for common athletic activities, like running and jumping, yet people often neglect throwing.  The first three steps to prepare before your throwing program involve getting your body ready.

 

Prepare to Throw Step 1 – Get Loose

The first step in preparing your body to throw is to get loose and work on your mobility.  We’ve studied 1000’s of baseball pitchers and have found a few things when it comes to throwing a baseball:

  1. Throwing a baseball causes your muscles to tighten and you loose mobility of your shoulder and elbow
  2. Not addressing this becomes cumulative and you eventually get a little tighter and tighter over the course of a season
  3. Working to maintain your motion is effective and can prevent lose of motion

One of the phrases I use a lot with my athletes is “I want you to be you BEFORE you pick up a ball.”  What that means is, if you just threw 100 pitches yesterday in a game, I know you are tight.  If you ignore it and pick up and ball and try to throw, you are setting yourself up for trauma.  Throwing will loosen you up (before you tighten up again), but it’s a much more aggressive way to get your mobility back.

Rather, perform some self-myofascial release by using a foam roller, massage stick, and baseball ball.  Here are the ones I use the most on Amazon and because the foam roller is hollow, you can put your other tools inside and all fit nicely in your gear bag:

  • Foam roller – One of the best and hollow to put your other tools in it in your gear bag.
  • Massage stick – The best one on the market, the other more popular ones don’t compare.
  • Trigger point ball – You can use a baseball, but I also like the reaction balls.  The nubs help you get in there and hold it in position on the wall.

How to prepare before your throwing programYou should focus on the entire body with particular emphasis on your lat, back of the shoulder, rotator cuff, pec, biceps, and forearm.  You should avoid the front of your shoulder.  There really aren’t a lot of muscles there and your just smashing your rotator cuff and biceps tendons.

Hit each spot for 30-60 seconds and hold on any really tender spots for 10 seconds.

Notice how I intentionally didn’t say to “stretch” your arm or perform a “sleeper stretch” (here is why you shouldn’t perform the sleeper stretch).  Most baseball pitchers are too loose to stretch effectively and they end up torquing themselves too much and making things worse.  There is a difference between muscles and joints, it’s possible to have tight muscles and loose joints.

There is one shoulder stretch that is effective on the muscles and not too aggressive on the joint, the cross body stretch I call the Genie Stretch.  This can be enhanced even more by using a trigger point ball in the posterior shoulder muscles.  You can and should stretch your forearm, you can’t really hurt yourself here.

 

Prepare to Throw Step 2 – Warm-Up Your Muscles

Now that you have worked on restoring mobility back to your baseline BEFORE you throw, it is time to get your muscles ready to throw.  In the strength and conditioning world, we refer to this as “activating” the muscles.

You want to hit all the muscles and movement patterns that are need to accelerate and decelerate your arm.  These essentially include the scapula and rotator cuff muscles.  By turning on these muscles, the body will be better prepared for the upcoming activities and throwing.

Shoulder activation throwing programThe simplest way to do this is with resistance tubing.  We use a combination of tools at Champion, but tubing is quick, easy, and portable.

You do need to be careful of your volume of exercises.  These warm-ups are designed to prepare the muscle, not fatigue them, and are not a substitute for strengthening the muscles.  That is a completely different program to be performed at a different time.  We use tubing to simply activate the muscles with low volume sets and reps of 2×10

I use Theraband tubing with handles.  They are the best and far superior to the cheap bands you can buy at the local stores, which have odd resistance and can lose resistance over time.  They are even ~$15 on Amazon.  You can attach the band to a fence or post, or take turns holding with a partner.

I like the tubing with handles and want you to have to grip the tubing, rather that velcro strap them around your wrist.  Grip the tubing helps warm up your grip and forearm muscles and also has a reflexive stimulus to your rotator cuff to engage.

Here is a link to Amazon.com to purchase the Theraband Exercise Tubing I use in the video at the end of this article.  I recommend the green band for Little League age, the blue band for middle school and early high school age, and the black band for the older or experienced pitcher:

 

Prepare to Throw Step 3 – Getting Moving

The third step to prepare to throw now involves dynamic movements.  You can see that we are building on a logical progression here: restore mobility, activate the muscles, and perform dynamic mobility exercises for movement prep.

Throwing is a very dynamic activity, obviously, that needs elasticity of the muscles.  Stretching and mobility work alone will not turn on the elastic components of your muscles.  Similar to my comments above on stretching, I don’t want a baseball being the first elastic stimulus your body faces.  I want to slowly work up to that so it is less traumatic and aggressive of a jump in stress on the tissue.

We want to dynamically move the joints and have the muscles produce quick contractions,.  This helps prepare the muscle for  by improving mobility and activation.

At Champion, our athletes have a whole portion of their program dedicated to these three steps and assuring that the entire body is prepared to throw, however, I demonstrate a simple arm version of this in the video below.  Perform this and you’ll be head and shoulders above most other athletes.

For pitchers, we use movement prep exercises that mobilize and activate the muscles groups needed to throw, like the chest, posterior shoulder, and rotator cuff.  It doesn’t take a lot of repetitions to prepare the body.

 

My Warmup Program Before Throwing

Perform this 3-minute arm warm up program prior to starting your throwing program for the day.  This is our bare minimum program that we teach our athletes that are new to the concepts of preparing their body before throwing.  As you can see, you don’t need dozens of exercises or many sets and reps, even just performing this quick warm-up will put you in a more advantageous position to throw than most other athletes.

It is quick and easy and can be performed on the field before practice.  Look out into the bullpen next time you are at a MLB game and you’ll see many players performing this during the game.

I’ve adjusted the order of how I prepare the body a little bit since the filming of this video, so it is a little out of order per the above information, but serves as a great example of a quick and easy 3-minute warm up to be performed after your self-myofascial release and before throwing.

 

In part 2, I will discuss the next three steps involved in preparing to throw and how I actually start off my throwing programs.

 

Want to Learn More?

 

I also have a free 45-minute video on How Baseball Players Can Safely Enhance Performance While Reducing Injuries.  Enter your name and email below and I will send you access to the video as well as a handout of the above arm care warm-up exercises that you can take to the field:

How to Cue the Scapula During Shoulder Exercises

In today’s video, I share my thoughts on the common cue of retracting your scapulae together while performing shoulder exercises.  I’m not sure this is the most advantageous cue, despite it’s popularity.  Instead, I focus on facilitating normal scapulohumeral motion.  I don’t want to restrict the scapula while moving the arm.

Learn more about how to cue the scapula during shoulder exercises in the video below.

 

How to Cue the Scapula During Shoulder Exercises

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Learn How I Evaluate and Treat the Shoulder

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ShoulderSeminar.com is on sale this month for $150 off.  This huge sale goes until the end of October 31st at midnight EST.  Sign up today and also get access to RehabWebinars.com for free for 1-month.  Click here to enroll in the program today, the sale ends at the end of the month!

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The Influence of Pain on Shoulder Biomechanics

The influence of pain on how well the shoulder moves and functions has been researched several times in the past.  It is often though that impaired movement patterns may lead to pain the shoulder.

A recent two part study published in JOSPT analyzed the biomechanics of the shoulder, scapula, and clavicle in people with and without shoulder pain to determine in differences existed between the groups.  Part one assessed the scapula and clavicle.  Part two assess the shoulder.

The subjects with pain were not in acute pain, but rather had chronic issues with their shoulders for an average of 10 years.  The authors used electromagnetic sensors that were rigidly fixed to transcortical bone screws and inserted into each of the bones to accurately track motion analysis.

The studies were interesting and worth a full read, but I wanted to discuss some of the highlights.

 

The Influence of Pain on Shoulder Biomechanics

In regard to the scapula, the authors found:

  • Upward rotation of the scapula less in subjects with pain
  • This decrease in upward rotation was present at lower angles of elevation, not in the overhead position

It is important to assess scapular upward rotation in people with shoulder pain, particularly emphasizing the beginning of motion.  Realize that no differences were observed in upward rotation past 60 degrees of elevation, implying that the symptomatic group’s upward rotation caught up to the asymptomatic group.  This may imply that there is a timing issue, more than a true lack of scapular upward elevation issue.  They are upwardly rotating, but perhaps just too late?

The study also found the following in regard to shoulder motion:

  • Shoulder elevation was greater in subjects with pain
  • This increase in shoulder elevation was present at lower angles of elevation, not in the overhead position

Noticed how I intentionally presented it similar to the scapula findings?  if you put the two finings together, it appears that people with shoulder pain have a higher ratio of shoulder movement in comparison to scapular movement at the beginning of arm elevation.  The shoulder caught up again overhead, so it appears that the timing between shoulder and scapular movement may have an impact.

The Influence of Pain on Shoulder Mechanics

As you can see, it is important to assess both shoulder and scapular movement together, and not in isolation, as movement impairments at one join likely influence the other.  The brain is exceptionally good at getting from point A to point B and finding the path of least resistance to get there.

I should note that in studies like this, it is impossible to tell if the pain caused the movement changes or the movement changes caused the pain.  So keep that in mind.  Regardless of causation, our treatment programs should be designed with these findings in mind.

There are so many other great findings in the study that I encourage everyone to explore these further, but I thought these findings were worth discussing.  Based on these findings, it appears worthwhile to assess the relative contribution of scapular and shoulder movement during the initial phases of shoulder elevation.

Interested in advancing your understanding of the shoulder?  My extensive online program teaching you exactly how I evaluate and treat the shoulder at ShoulderSeminar.com is on sale now for $150 off!  That is a huge discount that you don’t want to miss!  Click here to enroll in the program today, the sale ends at the end of the month!

ShoulderSeminar.com

 

 

 

Great Exercise to Enhance Posterior Shoulder Strength, Endurance, and Overhead Stability

I wanted to share an exercise I have been incorporating into my programs lately to develop posterior shoulder strength, endurance, and overhead stability.  I call it the ER Press as it combines shoulder external rotation in an abducted position with an overhead press.  When performed with exercise tubing, it provides an anterior force that the posterior musculature must resist during the movement.  The key is to resist the pull of the band while you press overhead.

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I use this drill a lot with my baseball players and overhead athletes.  I think it’s a great drill that hits many of the areas that I focus on when training a strong posterior chain of the trunk and arm.

It’s also becoming a favorite of my Crossfit and olympic lifting athletes, who are reporting that they feel more comfortable overhead and have more stability with their snatches and overhead squats.

There are numerous progressions that can be performed by simply changing the position the athlete is in, including tall kneeling, half kneel, and split squat stances.  You can also perform some rhythmic stabilizations at the top range of motion once to increase the challenge.

 

How to Enhance Your Success After Rotator Cuff Repair Surgery

Rotator cuff tears are very common injuries for people of all ages.  Depending on the study you read, it has been reported that 13% of people over the age of 50 years and 50% of people over the age of 80 years will have a rotator cuff tear.  Naturally, rotator cuff repair surgery has become equally as common.  Over the last several decades we have made great progress in our rotator cuff repair surgical techniques, transitioning from an open procedure, to a less invasive “mini-open” procedure, and now full arthroscopic.

arthroscopic rotator cuff repairThe newer arthroscopic rotator cuff repairs tend to less painful and allow people to do more sooner.  However, one mild little fact that we often do not hear about is that the failure rate after rotator cuff repair surgery is still too high.

Past studies have shown up to 75% of people following a rotator cuff repair will technically “fail” if you define surgical failure as the cuff is not intact again after surgery.  A recent systematic review published in JOSPT reported a failure rate between 18% and 40% over 10 different research reports.

Despite these “failure” rates, most research studies have shown that patient satisfaction after surgery is still very high.  This tells me that the rehabilitation process may be far more important than the actual surgery.  That is great news, even if the rotator cuff is found to not be intact again after surgery, pain, motion, strength, function, and satisfaction can all still be improved significantly.

Regardless, we should all be doing everything we can to maximize your success after rotator cuff repair surgery.

A recent systematic literature review publish in JOSPT sought to determine the prognostic factors associated with a successful recover following arthroscopic rotator cuff repair surgery.  Based on this paper, we can identify several factors that can help maximize your outcomes following surgery.  While, not all of these factors are easily addressed, many are, and it is always my goal to assure you put yourself in the best position to succeed.

 

Factors Associated with Successful Recovery Following Rotator Cuff Repair

The review focused on 10 papers that met the authors’ strict guidelines for inclusion.  Based on these 10 papers, they were able to identify 12 factors that were correlated to better outcomes following rotator cuff repair surgery.  These 12 factors were divided into 4 categories: demographic factors, clinical factors, factors related to the rotator cuff integrity, and factors related to the surgical procedure.

I am going to discuss the first 3 as they relate to things we may be able (or not able) to do to enhance outcomes following rotator cuff surgery.  In regard to surgical factors, one study showed that performing additional procedures to the biceps or acromioclavicular joint was associated with poorer outcomes.  We can’t really control the surgical procedures, but perhaps this information may be beneficial to the surgeons.

 

Demographic Factors

The most significant finding in regard to general demographics was related to patient age at the time of surgery.  Older age had a negative effect on recovery.

The studies demonstrated that the older you are, the less your chance of tendon healing.  Those under the age of 55 years have the best outcomes with between 88-95% chance of tendon healing.  In contrast, people aged over 60 years had between 43-65% chance of tendon healing.

While you can’t control when your rotator cuff becomes troublesome, these results do imply that we should not ignore symptoms and allow your shoulder and rotator cuff to gradually become more degenerative.  Addressing issues earlier should help with outcomes.  We have all seen it, most people put off addressing their shoulder soreness for years, attempting to work through the discomfort.  We don’t usually seek help until our functional level is significantly impaired.

 

Clinical Factors

Not surprising, bone mineral density and diabetes were both associated with poorer tissue healing.  Obesity was also associated with less successful outcomes.  People that were considered obese had a 12% less chance of successful outcomes.

I thought a very interesting finding involved your activity level prior to surgery.  People who rarely participated in physical activities had poorer outcomes that those that participated in medium- and high-intensity sports, such as golf, swimming, cycling, running, and tennis.

In regard to strength and motion, it was determined that the best predictor of final strength was initial strength.  Preoperative should stiffness also had a negative effect on recovery time, delaying return to activity.

While some of these factors, like bone mineral density and diabetes, may not be avoided, you can assure that these are under control medically before surgery.  However, factors such as obesity, activity level, strength, and mobility are all likely related and can be addressed prior to surgery.  This underscores the importance of performing physical therapy PRIOR to surgery.  I always say, the better you look going into the surgery, the better you’ll look coming out of surgery.

 

Rotator Cuff Integrity Factors

rotator cuff tear retractionThere were 4 factors in regard to the integrity of the rotator cuff that related to poor outcomes: tear size, the number of rotator cuff muscles involved, the amount of tendon retraction, and the amount of fatty infiltration.  These factors are all associated with tissue degeneration, and perhaps even associated with age.

Essentially, the more degenerative the tissue, the worse the outcomes.  Over time, your cuff tear will progress in size, potentially start to pull off the bone (retract), and become weak.

These factors are probably more associated with my comments on age above.  Perhaps we should be more proactive with our decisions regarding taking care of our shoulders prior to the tear becoming more involved and the tissue more degenerative.  Something to consider, repair of a small rotator cuff tear had a 96.7% chance of healing after surgery in comparison to a 58.8% chance if that tear becomes large.

 

What You Can Do to Enhance Outcome Following Rotator Cuff Repair Surgery

I feel like this study shed some light on several things we can do to enhance your outcomes following rotator cuff repair surgery:

  • Do not unnecessarily put off surgery as outcomes are less successful the older you are at the time of surgery.
  • In regard to the above, also consider that putting off surgery may allow the rotator cuff to become degenerative.  The larger the tear and the more degenerative the tissue, the less successful the outcome.
  • Being physically active and losing weight are both associated with better outcomes.  Get off your butt.
  • Begin physical therapy prior to surgery.  The stronger and more mobile your shoulder is at the time of surgery, the better off you’ll be after surgery.  You’ll be stronger and return to activities sooner.  Plus, some studies have shown that physical therapy can help you avoid rotator cuff surgery.
  • Assure that medical conditions, such as bone mineral density and diabetes, are being addressed and under control prior to surgery.

For the clinicians reading this, we can also use this information to determine our rate of progression during rotator cuff repair rehabilitation.  The more prognostic factors that your patient may have indicating a less successful outcome, the more conservative you may need to progress.

Would you progress some that is a 52 years old physical active person with a small rotator cuff tear and no other health issues at the same pace as a 74 year old with a large tear, weakness, and diabetes?  Of course not.  We can’t just blindly follow a protocol.  Protocols are useful and necessary, but they just provide structure that you adjust if factors dictate that you should be more conservative.

There are ways to enhance your success after rotator cuff repair surgery, many of which are controllable.  Use these findings to help you or your client’s maximize your outcomes following surgery.

 

 

Hip Rotator Cuff

Hip Rotator CuffThe latest Inner Circle webinar recording on the Hip Rotator Cuff is now available.

Hip Rotator Cuff

This month’s Inner Circle webinar on the rotator cuff of the hip was great.  We discussed how our knowledge of the hip has continued to increase over the last decade and has resulted in a much better understanding of how the hip is involved in the mechanics of the lower body and stabilization in multiple planes of motion.  We then broke down the hip musculature as either prime movers or prime stabilizers, and discussed how different positions and exercises impact both of these different muscles groups.

If this sounds familiar, it is, we use the analogy of the shoulder to show the similarities between the hip and the shoulder.

To access the webinar, please be sure you are logged in and are a member 0f the Inner Circle program.

Kevin Wilk’s New Rotator Cuff Injury DVD

I am excited to announce that AdvancedCEU has just released Kevin Wilk’s brand new DVD on the Current Concepts in the Treatment of Rotator Cuff Injuries.

Kevin Wilk Rotator Cuff DVD

If you follow me and my website, then I am sure you know Kevin well.  Kevin has an amazing ability to take a ton of research and apply it to what we need to know clinically.

This is the second in a series of new DVDs from Kevin that are dedicated to specific clinical pathologies, he previously released a DVD on Shoulder Instability last spring.

 

Current Concepts in the Treatment of Rotator Cuff Injuries

There are 3-DVDs of almost 4 hours of content from Kevin Wilk, one of the leading clinicians when it comes to treating disorders of the shoulder.  This DVD set is great in that it reviews the most current concepts, techniques, and specific principles associated with both nonoperative and postoperative rehabilitation of rotator cuff injuries.

The DVDs were recorded during a recent live seminar, which I love because you get to see Kevin teaching in action.  This is where he is at his best, interacting with a group of people.

The DVD is regularly priced at $79.95 but is on sale for the release for only $69.95 this week ONLY (until end of day Sunday January 26th at midnight EST).  You can also save another $20 by purchasing both DVDs together.

Click below for more information, Kevin’s new DVD:

Kevin Wilk Shoulder DVDsClick Here –> Kevin Wilk DVD – Current Concepts in the Treatment of Rotator Cuff Injuries

Act now, the special $69.95 sale price only lasts until Sunday January 26th!

 

 

Can Physical Therapy for Rotator Cuff Tears Prevent Surgery?

Rotator cuff repair surgery and postoperative rehabilitation continue to be some of the most debated topics on the shoulder at orthopedic and physical therapy conferences.  Numerous studies have been published showing the failure rate of rotator cuff repair surgery ranges anywhere from 25-90%.

rotator cuff tearWhile this failure rate is certainly alarming, the term “failure” must be defined.  In traditional study models, success is defined as an intact rotator cuff, which makes sense.  However, one of the more interesting findings in most of these studies is that despite the “failed” repair, most patients are quite satisfied with their functional status and outcome.  This really does have to make you question how we define “failure” as patient outcomes and satisfaction seems more important than radiological findings.

These studies have sparked debate over the role of postoperative physical therapy follow rotator cuff repair surgery, with many physicians becoming more conservative and slowing down their protocols.  This obviously implies that some physicians believe that early physical therapy is the reason why failures occur.  This thinking may be flawed and factors such as tissue quality, tear severity, patient selection, surgical technique, and others may be more likely related to ultimate failure rates.

Another perspective to consider is that despite having a failed rotator cuff repair, patient satisfactions were good.  From experience, I can tell you that patients are satisfied when they:

  1. Have less pain
  2. Regain their mobility
  3. Return to functional activities

So the question really should be asked – if there is up to a 90% surgical failure rate but significant increase in satisfaction and outcomes, can physical therapy for rotator cuff tears alone without surgery be just as beneficial at helping patients reduce pain, regain mobility, and return to their activities?

 

Can Physical Therapy for Rotator Cuff Tears Prevent the Need for Surgery?

A recent study in the Journal of Shoulder and Elbow Surgery looked at this exact question.  The MOON Shoulder Group, which is a multi-center network of research teams around the country, followed a group of 381 patients with atraumatic full-thickness tears of the rotator cuff for a minimum of two tears.  The mean age of the patients was 62 years with a range of 31-90 years.

The patients performed 6-12 weeks of nonoperative physical therapy focusing on basic rotator cuff strengthening, soft tissue mobilization, and joint mobilizations.

At the six-week mark, patients were assessed and 9% chose to have rotator cuff repair surgery.  Patients were again assessed and the 12-week mark.  At 12-weeks, an additional 6% chose to have surgery.  In total, 26% of patients decided to have surgery by the 2-year follow-up mark.  Statistical analysis revealed that if a patient does not choose to have surgery within the first 12-weeks of nonoperative rehabilitation, they are unlikely to need to surgery.

Nearly 75% of patients avoided rotator cuff repair surgery by performing physical therapy despite having full thickness cuff tears. [Click to Tweet]

That is a pretty significant finding.

 

Keys to Nonoperative Rotator Cuff Rehabilitation

The results of this study could have a large impact on how we treat rotator cuff tears.  Physical therapy should be attempted prior to surgery, even in the case of a full thickness tear.  To maxmize these outcomes, a comprehensive rehabilitation program should be developed.  When working on patients with rotator cuff tears, I tend to focus on 3 key areas.

Restore Shoulder Mobility

This includes both passive and active mobility.  For passive mobility, it seems to me that shoulder range of motion is gradually lost as the rotator cuff symptoms increase.   Perhaps it is a pain avoidance strategy, disuse, or some other factor.  You’ll often find glenohumeral joint capsule hypomobility and soft tissue restrictions.  Soft tissue mobilization, joint mobilizations, and range of motion exercises should be designed based on the specific loss of motion exhibited by the patient.

Restore The Ability of the Rotator Cuff to Dynamically Stabilize

This is essentially the same as restoring active mobility of the shoulder.  The rotator cuff has to function properly to allow active mobility without restrictions.  In a previous article, I discussed the suspension bridge concept and how you can have a rotator cuff tear without symptoms.  You can see in this diagram that if you have properly functioning anterior and posterior rotator cuff muscles, you can often still elevate the arm despite a tear to the supraspinatus.

rotator cuff suspension bridge concept

Exercises designed to enhance strength and dynamic stability of the shoulder should be incorporated.  In my experience external rotation strength tends to be the most limited and needs to most attention.

Reduce the Impact of the Kinetic Chain

In addition to restore mobility and stability of the shoulder, you should also consider the impact of the kinetic chain on shoulder function.  Read my past article on the different types of shoulder impingement to understand some of these concepts.  Any dysfunctions of the scapulothoracic joint, cervical spine, thoracic spine, and lumbopelvic complex should be assessed.  These areas all have a significant impact on the alignment, mobility, and stability of the glenohumeral joint.

If you want to learn more about how I perform nonoperative rehabilitation for rotator cuff tears, I have a past webinar on shoulder impingement that discusses many of the same keys to treatment.

Using these principles, you can formulate a rehabilitation program that could potentially save 75% of people with rotator cuff tears from needed rotator cuff repair surgery.  Hopefully studies like this will continue to shed light on the impact physical therapy can have on the satisfaction and outcomes of patients with rotator cuff tears, with or without surgery.