How important is the shoulder joint in your sport? Whether you use it for propelling the arms in running activities, throwing a ball, punching an opponent or hitting a ball with a racquet, it is essential to have stability and strength in the shoulder.

The gleno-humeral (shoulder) joint is very complex. To allow for a large range of movement in many directions, there is only a shallow socket (glenoid fossa) for the ball (head of the humerus). Stability within the joint is provided by the muscles, with some support from the ligaments.⁽¹⁾

The four relatively small muscles predominantly responsible for stabilising the shoulder – teres minor, infraspinatous, supraspinatous and sucscapularous – are known collectively as the ‘rotator cuff’. They share the role of rotating the head of the humerus as well as ensuring joint congruence.

Traumatic injuries to the shoulder are relatively rare, although a poor rugby tackle, for example, can cause immediate damage to the rotator cuff and possible dislocation of the shoulder. More common are overuse injuries, especially in sports like swimming and karate.⁽²⁾

Longstanding poor mechanics and posture around the shoulder are usually a factor in such injuries, causing adverse strains and stresses in the rotator cuff.⁽³⁾

Athletes tend to complain initially of a ‘niggle’ at the shoulder. Without physiotherapy such a symptom may progress rapidly to outright pain, which acts as a muscle inhibitor, causing further atrophy and mechanical dysfunction.

The initial treatment of rotator cuff injuries often consists of rest, ice and anti-inflammatories. However, the athlete can still remain in the gym environment, working on the cardiovascular system, lower limb and trunk strength as well as the non-injured arm. Physiotherapy may help to alleviate pain and inflammation as well as identifying predisposing factors and getting the rehabilitation process off the ground.

In the early stages, rehabilitative exercises will tend to be single plane movements and should be pain free. They can be carried out using a variety of tools, including dumbbells, water bottles, disks and cable columns.

A word of warning is needed here about the popular use of therabands – pieces of rubber which offer resistance when stretched – as a rehab tool. Force development requires a high activation of motor control units within the muscles at the beginning of the movement,⁽⁴⁾ and traditional exercises, such as the bench press, allow for this. Therabands, however, are quite non-functional as they develop greater resistance the further away from the body the arm moves, thus requiring higher utilisation of motor units later on in the movement.

As time goes on and selective strength develops, the rotator cuff will need to be worked in a sport-specific way. It must be retrained to work on demand and in conjunction with the surrounding musculature, so enabling efficient and specific movements to be produced. In a study on baseball pitchers, an increase in proprioception of the rotator cuff was shown to increase the stability of the shoulder joint;⁽⁵⁾ (proprioception is the neural feedback mechanism that allows muscles to work in conjunction with each other). Unfortunately, though, this later stage of rehab is often neglected.

An emphasis on sport-specific training does not mean that the athlete is ready to return to his sport; indeed, if he did, there would be a high risk of reinjury as the shoulder would not yet be strong enough to cope with the demands of the sport. Progress should be assessed by means of functional testing, with results compared to those of pre-season and pre-injury tests.⁽⁶⁾

Meanwhile, rehab should progress in the following ways:

• From simple, single-plane movements to complex, multi-plane movements, such as press-ups, seated row and rotations. Such movements are more effective than single-joint exercises for increasing rotator cuff strength;⁽⁷⁾
• From slow speed to full speed – eg bowling action for cricket first with no ball, then with a tennis ball, then with a cricket ball;
• From bilateral exercises to unilateral – eg stability press using a medicine ball against the wall first with two hands, then with one.

Once strength has been established, dynamic exercises requiring balance should be used, such as press-ups with one hand on a medicine ball, or walking forwards/sideways in the press-up position. These help prepare the joint for a return to sport.

The following example shows what such a rehab programme might look like for a karateka – a karate performer. Karate is a martial art that requires the use of the shoulder joint in blocks, strikes, punches and some grabs. Common training methods involve controlled and free sparring against opponents with contact to the body, as well as the use of punchbags and more traditional striking posts.

The functional training programme progresses along three lines:

• Stabilisation – to ensure that the shoulder joint can remain stable under increased work loads;
• Strength – to make the shoulder strong in all the degrees of movement, concentrating on gymbased exercises;
• Function – enhancing the shoulder’s ability to cope with the demands of the sport.

Stabilisation exercises

The following exercises, which are progressively more challenging, should be performed with equal stability in both rotator cuffs. If you feel you are off balance, do not progress to the next level until you are stable:

• two-handed press-up hold against the wall;
• two-handed kneeling press-up hold position;
• two-handed press-up position hold;
• two-handed press-up hold against Swiss ball on wall;
• two-handed press-up against a wall;
• two-handed kneeling press-up;
• press-up position, one hand on medicine ball;
• two-handed press-up;
• press-up, one hand on medicine ball.

Strength exercises

Work on four sets of five good quality repetitions to gain strength in each movement. Stage 1 includes the following single joint exercises:

• Seated row shrug – on the seated row machine, shrug your shoulders to the rear with straight arms, keeping your back straight;
• Lat pull-down shrug – shrug your shoulders downwards, keeping arms and back straight throughout the movement;
• Shoulder raises using dumbbells or other equipment, like water bottles. Perform the movement in a controlled fashion, without momentum. Keeping the arm straight, move the weight to shoulder height to the front, side and rear of the body.

Stage 2 includes the following multi-joint exercises:

• Seated row – as above, but pull with the arms after the rearward movement of the shoulders;
• Lat pull down – first reverse shrug the shoulders, then use the arms to pull down;
• Dips – on a bench or on parallel bars;
• Chins – perform either under a bar with feet on the floor, pulling chest to the bar, or on an overhead bar, pulling chin over bar.

Stage 3 includes the following multi-joint advanced exercises:

• Walking in press-up position – moving forwards, sideways and backwards about 3m in each direction. Repeat two or three times;
• Wheelbarrows – as above, but with a partner holding your ankles;
• Malcolms – run forwards 5m, then drop down onto floor, initially with knees hitting the floor first, then dropping straight down onto hands, absorbing the impact by bending arms. Repeat for 20-30m, then repeat whole exercise twice more.

Sporting progression

As with stabilisation exercises, progress through these in order, as you feel able to:

• Slow block/punch movements, emphasising form, no tension at end;
• As above, but with tension at end of movement;
• Punch slowly against a stationary target;
• Punch quickly against a stationery target;
• Controlled sparring, with announced attacks, one block and counter punch;
• Free sparring with unannounced attacks.

Progression at all stages should only be made with correct movement, and if there are no adverse effects within 24 hours of the previous training session. Progression within the sport is best developed by frequency – rather than duration or intensity – of the training sessions.

As the rehab programme develops, the coach should become more involved in the technical sessions, keeping the physiotherapist and conditioning coach on hand to make sure the stability and strength of the joint is not compromised. Competitive training can thus be gradually reinstated, reducing the risk of further injury and enabling the athlete to perform to his or her desired level.

James Marshall

References

1. Norkin, C & Levangie, P, Joint Structure and Function. Philadelphia: FA Davis, 1992
2. Solomon, L, Warwick, D & Nayagam, S, Apley’s System of Orthopaedics and Fractures. London: Arnold Press, 2001
3. Sports Medicine 16, 1993, 57-61
4. Baechle, TR & Earle, RW, Essentials of Strength Training and Conditioning. Champaign, Illinois: Human Kinetics. 2000, pp 9-10
5. J Shoulder Elbow Surgery 10(5) 2001, 483-444
6. Tippett, SR & Voigt, ML, Functional Progressions for Sport Rehabilitation. Champaign, Illinois: Human Kinetics, 1995, pp29-30
7. JSCR, 18, 1, 2004. p144-148