Tips from an experienced strength and conditioning coach and personal trainer on shoulder health, rehabilitation, and development. Dynamic management of the shoulder is vital to help athletes reach their goals despite injuries.
By Matthew Morris, BA CSCS
The most mobile large joint in the human body and arguably the most susceptible to dysfunction is the shoulder. The shoulder is comprised of well over a dozen parts working together within a framework of bones, tendons, ligaments, and muscles. These all intersect to make a quasi-ball and socket joint that allows a wonderfully wide range of mobility, though perhaps at the expense of stability.
Nearly any arm movement involves the shoulder, brushing your teeth, combing your hair, holding your phone, and carrying a suitcase. Even sleeping requires a particular shoulder position. Athletic performance requires that shoulder function jumps to another level. The risk of acute injury also jumps just as high. Think about Olympic weightlifters holding hundreds of pounds overhead, football players smashing into one another, the repetitive range of motion (ROM) for baseball players, swimmers, and volleyball athletes.
Bigger, Faster, Stronger
Prolonged, high workload demands on the shoulder without preparation and maintenance via proper strength and conditioning has been shown to lead to injury and joint dysfunction. Perhaps a good analogy is having a race car you take to the track quite often, but you have no mechanic – not good. For instance, in the 1990’s and early 2000’s weightlifting for athletes (especially football) became mainstream and high school coaches across the United States bought in. Bigger Faster Stronger (BFS) weight training programs were leading the industry. Bench, squat, and deadlift! Add up your max weight of each lift and total the three and see if you’re in the 1,000 lb. club or even the 1,200 lb. club and beyond! The race was on.
Now, before I go on, I want to state my bias due to the fact I was an acting participant in these programs beginning when I was 14 in my 8th grade year in 1998. To this day, I’m a weight room junkie. These pioneering weight training programs set the foundation for the future of sports performance by way of resistance training applications for groups. But as with any developing program, it didn’t come without its lessons.
BFS and other programs of that day (and many still today) focus on core lifts focusing on muscle groups for absolute strength and power gains without a foundation of mobility principles and muscle balance. Back to the race car analogy, it would be like focusing on a bigger engine and not discussing the bent axle – again not good. The most likely thing that would happen is the dysfunctional axle, bearing way more power with the bigger engine, would fail. In the example of football, you push and or strike someone with your shoulders and arms (and head back then but that’s for another discussion) nearly every play so it made since to bench-press, bench-press, bench-press, in program defense that is sports specific training. So, hypertrophy was a result. What a wonderful thing as a 17-year-old looking in the mirror seeing your deltoids and chests growing larger and becoming more defined! We were hooked! We athletes, parents, and coaches didn’t yet understand the lessons we would slowly and sometimes painfully find out. This type of training creates an athlete that becomes muscle bound. The steady progress in size and strength of the anterior side of the athlete’s chest and shoulders slowly and slightly rolled the shoulders forward. It also presented a barely noticeable exaggeration in the curve of the thoracic spine. The grossly underdeveloped strength of the rotator cuff that resulted was out of sight and out of mind. It was also a beautiful catalyst for anterior shoulder dislocations.
A shoulder dislocation
It was a typical hard hitting fall football Tuesday when teams usually schedule all their inside runs and opposing defense works, smashing into them to stop them from moving the ball. I was a defensive end rushing off the edge and diving at the running back with an outreached left arm to strike at his legs with my forearm in hopes of possibly tripping him up. My chance to form-tackle him had passed. Between the body position at point of contact, the force generated, and my untrained rotator cuff, my shoulder girdle wasn’t able keep my humerus properly attached to my body and off my shoulder went. I suffered a textbook anterior shoulder dislocation. This was an incredibly painful injury as compared to bone breaks and ligament tears, all of which I’ve had the pleasure to experience for pain tolerance perspective experience (ha).
If that isn’t tough enough, this was unfortunately the beginning of an all too common and a much longer than it should be process of acute injury treatment to successfully reset a joint. The transport to the nearest emergency department was time-consuming and the triage wait for medical staff to put you back together was grudgingly long. In my case, morphine and Demerol helped the 3-4 hours go by before I saw a trio of medical staff off in the hallway reviewing a book on, you guessed it, how to reset a shoulder. Soon they entered the curtain-partitioned space I was in with a few towels and their newfound plan. One nurse who stood at my right side held a towel around my torso. This nurse resisted the force produced by the doc on my left side with a towel around my elbow which was held at 90 degrees. With the other nurse, the doc slowly pulled my arm away from my body and externally rotated my shoulder and… plop… It worked! The head of my humerus fell right back into place. What a relief. Off they went to treat the next patient.
Prevention is best
I could go on and perhaps will in the future about the physical therapy process that begins post injury as patients seek their return to full health. Approximately a quarter century later, I unfortunately watched one of my athletes go through nearly the identical process with a dislocated elbow. Why has this not changed? What could be done to reduce the time in which the joint is dislocated from its appropriate place in the body? Does prolonged muscle, tendon, and ligament deformation increase the damage of the injury and or lengthen recovery time? I have my assumptions.
“An ounce of prevention is worth a pound of cure.” It is easier to stop something from happening than repair the damage afterwards. I would argue more affordable too. Would an insurance agent agree? Time will tell. What if you were tasked with protecting the population you serve that were susceptible to shoulder dysfunction? Would you focus on prevention or repair? I would propose, for full contact athletes we’ll say, that they be involved in a shoulder injury preventive maintenance program that would measure upper extremity mobility via a Cook functional movement screening in addition to rotator cuff pre-habilitation prescriptions. Once the athlete can score high enough on the mobility screening and dysfunction has been corrected, he or she could be fully released to resume core lift strength training.
Scholastic budgets may not allow for athletic trainers, physical therapists, and strength and conditioning coaches. I’m in full support of increasing overall value to programs and as a business owner I understand bottom lines must work to sustain service. So, I would have an interest in comparing the salaries of the sports med positions mentioned next to the annual injury claims of a school. I would support the more cost-friendly model with a greater value add.
Rehabilitation Exercises
Understanding that very few of those preventative measures actively exist, let’s focus on repairing the damage. Below is a blueprint example for a shoulder rehabilitation exercise prescription. Once the patient is released from the physician and standing orders made clear we can get the injured back on track. The first stop more than likely is the physical therapist then to the athletic trainer before full release into 100% function and back to production!
A shoulder rehabilitation regimen
| Exercise | Repetitions |
| Phase 1 – Range of motion and re-introduction to movement | |
| Prone Pendulum | 2-5 sets of 20 second |
| Seated Isometric internal rotation | 2-5 sets of 20 second |
| Seated Isometric external rotation | 2-5 sets of 20 second |
| ROM McKenzie active assisted stretches | As tolerated |
| Phase 2– Increase resistance and mobility demand | |
| TheraBand or dumbbell protraction | 2-5 sets of 20-30 reps |
| TheraBand or dumbbell retraction | 2-5 sets of 20-30 reps |
| Standing Thera-band external rotation | 2-5 sets of 20-30 reps |
| Standing Thera-band internal rotation | 2-5 sets of 20-30 reps |
| Shoulder adduction + hand behind back towel assist | 2-5 sets of 10 reps |
| Phase 3 – Successful scapular mobilization in all planes | |
| DB lateral raise + external rotation | 2-5 sets of 10 reps |
| Prone T’s, I’s and Y’s | 2-5 sets of 5-10 reps |
| Hanging shoulder retraction | 2-5 sets of 20-30 reps |
| Weight resistance shoulder protraction | 2-5 sets of 20-30 reps |
Of course, depending on the patient, the therapists, facilities, etc. this model can vary in phase time, exercise and repetition schemes. In its theory the initial focus is regaining range of motion and subjecting the joint to training as well as identifying repair status and patient pain tolerance. Then onward to increasing workload and progression to full range of motion and strength of the joint. Healthy communication between the doctors, therapists and trainers can make for a smooth process resulting in the highest chances of creating happy, healthy patients that trust in you as a professional provider.
Conclusion
I have had the privilege of competing all the way up to the division 1 level as a football player and afterwards a strength coach from the scholastic to professional levels and then in the clinical setting. Some of those levels have the blessing of sports med staffs and others don’t. The value of having a model with sports med staff available to individuals is the closest a patient can get to a synergistic halo of health through proper comprehensive training. This is correcting dysfunction whether it being before and or after injury. This is performance enhancement.
The MDHI thanks guest contributor Matthew Morris for his expert guidance on shoulder rehabilitation!
