Constructing a shoulder rehab routine

[Fryk]

A shoulder rehab routine

My question is this: How to construct a shoulder rehab routine.

The basic problem is: I know which muscles to train, and which to ignore. There is no shortage of exercises being suggested, but I have found little on how to put it together. Which exercises to choose before others, which to ignore, totalvolume, frequency etc?

The real question is how to plan the specific shoulder rehab. Also I am not sure how brilliant the core conditioning is, however that is less of an issue.

I have been â€diagnosed†with subacromial impingement, and have a partial thickness tear of the supraspinatus.

My focus is to do what I can. Doing a bunch of core work, and specific shoulder rehab exercises. (4x /week).

I am working with a PT. Mostly he is doing mobilization of the T-spine and trigger point work.

On top of this and my rehab program there is a bunch of daily mobility work: stretching, lacrosse balling etc.. (Inspiration is from http://www.Mobilitywod.com primarily)

Also trying hard to improve my posture in every imaginable way. Primarily: Esther Gokhale – 8 Steps to pain free back.

I have gotten good advice on the forum on my injury(ies) previously, but with progress new questions arise.

Previous thread: http://www.gymnasticbodies.com/forum/viewtopic.php?f=17&t=3803

However it seems to be a different topic all together also my Google / Search magic has not been able to turn up what I am looking for. If all of this has been covered previously, please point me in the right direction.

I have found some sources on shoulder rehab I thought I'd post in this context, most has already appeared on the forum in various threads.

Cressey: Shoulder Savers: http://www.t-nation.com/free_online_article/sports_body_training_performance_repair/shoulder_savers_part_i

Robertson: Push up, face pulls and shrugs: http://robertsontrainingsystems.com/blog/push-ups-face-pulls-and-shrugs/

Diesel Crew: Shoulder rehab protocol: http://www.dieselcrew.com/how-to-shoulder-rehab

There is of course Idos stuff: http://idoportal.blogspot.com/2009/07/scapula-mobilization-and-sequences.html

Anything by Robertson, Cressey and Reinold I have found to be good advice see:http://www.mikereinold.com/

My current template

4x / week (Mon, Tue, Thur, Fri)

Pre work out stretching

Infraspinatus (Sleeper stretch) 2 x 60s

Wall pec stretch 2 x 60s

Warm up: Jump rope: 5 minutes

FSP

1. Superman → 2x45s

2. Hollow → 3xMax (30, 20, 20-ish at the moment),

3. Reverse Plank: 60 s

4. Plank: 60 s

5. Chin Up Hold → NO WAY JOSE

6. Parallel bar support → NO WAY JOSE

7. German Hangs → 3x30s with feet support

Pre-hab:

1. Wrist routine

2. Planche Lean 30s

Alternating between A and B. Mostly done as circuit with rest between rounds.

#1A. â€Set the scapulaâ€

1.Bulgarian XR Rows (5 x 5 )

2. Stability Ball rolls (3-5 x 10)

3. V-ups ( 3-5 x 5 )

#1B. â€Set the scapulaâ€.

1. Side planks lifts, one legged (3 x 8 )

2. Body Lever negatives (5x1)

3. Hip Lift / Raise (3x 10)

4. Hip Thrusts (3 x 20)

# 2. Remember to â€set scapula†Done as a circuit. Rest between rounds.

1. Scapular Pushups, feet elevated – 5 x Full ROM, 5 x Top part of the movement

2. Trap 3 Raises – 2-3 kg – 3x10

3. Rear delt flyes – 3kg – 3x 10

4. Sidelying rotations – 2-3kg - 3x10

Finish with:

2x 10 - Band dislocates

1 x 10 - Wall slides

End template,

best regards

Fryk

[Cole Dano]

There is an awful lot in that post, i won't attempt to answer it all.

One 'positive' thing with impingement / rotator cuff issues is that they give very clear feed back. I'm happy to see you have a couple of No Way Jose's, it means you are listening to the feedback.

Above strength and even mobility is listening to the way the shoulders work, and using that pain feedback to tweak your movement patterns to better ones.

Impingement can be a structural issue, bet more often than not its failure to keep the head of the humerus down away from the acromion anode or coracoid process. This is one reason way rotator cuff exercises are prescribed. Its job is to keep the ball centered on the glenoid fossa.

That all sounds technical, but just think of a ball at the end of a stick moving on a saucer. You have to some how keep it on the saucer as you roll it.

Now normally the lat is not considered to be part of the rotator cuff but functionally many, including myself do.

If your pulling is poor, as was mine, it can mean the lat is also under activated. When i started doing my therapeutic work, i found that to be the main issue, get the lat to fire, and then learn to coordinate so it all fires smoothly.

I'll let others expand on any particulars.....

Take care!

[Fryk]

Thank you for the answer.

About the "No Way Jose" that is my PT that has banned these exercises for the time being. I am probably not good enough at listening to my body.

Yes, I know about the impingement and the rotator cuffs function in that regard. As you mention there is also the possibility of a type 3 acromion, which is something I dread to think about.

[Joshua Naterman]

Yet he ok'd planche lean?!?! That doesn't make sense to me.

What you have is ok, and if jumping rope isn't bothering you then what you've got going on may not be too bad. You need to add lower trap work, diesel crew should be able to show you that. Make sure the scapula are set down and back. Retraction + depression the whole time.

2: Go to an ART practitioner.

3: if 2 is impossible for some reason, do this. You will need help for areas you can not reach. Grab fistfulls or large pinches of skin. Pull away from body. While pulling, move in circles. As you can imagine, this will be slightly uncomfortable. You will be quite surprised at the amount of relief this gives you. Your back will have to be done by someone else. I suggest being freshly showered so that your skin is less slippery, and I also recommend that the skin pincher chalk his/her hands. For the front of the body, do your chest from bottom to top, moving an inch at a time. 5-10 1 second circles in each direction should be plenty per spot. You don't have to do it all in one go, though it is a very good idea to. This will re-set a lot of fascial tension. It will not be terribly comfortable, especially around the inner arm and armpit. The back actually feels pretty good.

You need to hit the entire upper body from hips to shoulders and from at least the shoulders to the elbows on the arms. This won't fix it by itself but this will be a big step forward, especially after someone has done your back. Pullers will have to be aggressive with what they are doing, sub-dermal fascia is tough stuff.

[Fryk]

About the "planche leans" I have not discussed that particular exercise with my PT, though it should be noted that is in fact not a planche lean. Merely something I regard as progression toward that end goal.

What I do is, I sit with my elbows pointing forward, fingers pointing back, feet on the floor, knees pressing on the elbows. Like the start position for the frog. I rock forward creating further extension in the elbows - I do not lift my feet of the floor, just working the elbows slightly. I do not know what this is called, hence the why I called it planche leans - just to remind myself.

I do not think ART is possible, I will however try the suggested technique.

For specific lower trapezius work would it not be sufficient to do trap3 raises and wall slides?

[Donar]

Fryk,

what are your actual symptoms right now? During what movements do you have pain?

What exactly is your physical therapist doing? What muscles is he treating?

How is your breathing? Do you breath with your diaphragm?

[Fryk]

I have no pain at the moment, neither during movements.

My inferior angle of the right scapula is however winging a bit. My PT thinks it has to do with a shortened (pissed off?) infraspinatus, which is keeping the serratus anterior from firing properly.

The PT is working on the rhomboids, and the external rotators primarily.

The breathing is most likely not sufficiently diaphragmatic. I have read that doing 5 minute of breathing daily with a book on the stomach, while lying face up should be a good way to re-engage the diaphragm.

Besides the routine, I am daily doing: SMR (Lacrosse balling), stretching, ART (as per Slizzardmans recommendation), diaphragmatic breathing exercises and posture work. Which is alot of work.

My main concern is what rehab exercise routine should look like.

[Rafael David]

What you have is ok, and if jumping rope isn't bothering you then what you've got going on may not be too bad. You need to add lower trap work, diesel crew should be able to show you that. Make sure the scapula are set down and back. Retraction + depression the whole time.

this is nice for WU, right ? i do this instead of ido's band because i don't have bands...

[Cole Dano]

Its a nice routine, i think for rehab higher reps may be in order though.

[Donar]

I have no pain at the moment, neither during movements.

My inferior angle of the right scapula is however winging a bit. My PT thinks it has to do with a shortened (pissed off?) infraspinatus, which is keeping the serratus anterior from firing properly.

The PT is working on the rhomboids, and the external rotators primarily.

The breathing is most likely not sufficiently diaphragmatic. I have read that doing 5 minute of breathing daily with a book on the stomach, while lying face up should be a good way to re-engage the diaphragm.

Besides the routine, I am daily doing: SMR (Lacrosse balling), stretching, ART (as per Slizzardmans recommendation), diaphragmatic breathing exercises and posture work. Which is alot of work.

My main concern is what rehab exercise routine should look like.

Tell your PT to work on your pectoralis minor as well.

For the breathing, I would suggest doing it four times per day: 3 mins after you wake up (lying down), 3 mins at some point during the day (standing), 3 mins at another point during the day (sitting), 3 mins before you go to bed (lying down).

Make sure when you do SMR, you focus on all the upper body muscles (most importantly: pectoralis minor, latissimus dorsi, pectoralis major, all 4 rotator cuff muscles, upper trapezius, levator scapulae, maybe serratus anterior (could be inhibited due to trigger points), maybe diaphragm (could be inhibited due to trigger points).

Do not limit yourself to the lacrosse ball. Some spots, like the subscapularis, are impossible to get with a lacrosse ball.

On your routine:

- Don't overdo it on infraspinatus stretches

- Perform subscapularis stretches as well

Here are some other good exercises you could add to your routine:

- dumbbell incline scapular shrugs (like this but with a db:

)

- reach roll and lift:

Eventually, you could add in turkish get ups, and chop and lifts (in all 4 directions), as well.

[Joshua Naterman]

Tell your PT to work on your pectoralis minor as well.

YES. A tight pec minor can and will pull the scapula out of position. Getting direct ART or other manual therapy on pec minor will hurt like hell but take a lot of pressure off. Another thing that tends to get missed is coracobrachialis. It goes from the middle of the upper arm to the coracoid process and can also cause issues, though they tend to be at the front of the shoulder. Still, never skip anything. Treat EVERYTHING that attaches to the upper arm and/or the scapula.

[Fryk]

My PT have worked on the pec minor, it is however not sore. I can however find some ugly stuff in the external rotators with a lacrosse ball, with out much effort - the pec minor not as bad. My PT said something I thought was interesting, that it is not even certain that the poor position of my right shoulder can be "fixed" all together. The real goal is to make sure that there is proper stability in movement.

The suggested soft tissue work, breathing work etc. has been noted.

Though my main question is still how to construct what I consider the rehab exercise routine itself:

- How many rehab exercises per day, for instance?

- Which muscle groups / exericses to hit every workout, which to hit every second workout?

- How many reps to shoot for, difference between exercises etc?

[Joshua Naterman]

Never reach fatigue and always have good form with zero pain. Within those guidelines, the more volume you can do the better.

[Fryk]

Okey, that is simple enough.

Since I there is quite a number of exercises suggested, would it be best to focus on a limited number or just to rotate through a larger number of exercises?

[Joshua Naterman]

Hit the same muscles with different exercises. Nothing wrong with that! Or you can repeat, it's all up to you. I end up doing a lot of the same stuff because it is convenient, and because there's only so much variety you can put in place at home without getting inconvenient.

When it comes to shoulder rehab you need to do the most functional stuff your shoulder can handle and do it as often as possible, within the confines of the limitations discussed and your schedule.

[Fryk]

It even sounds logical, and also a call for KISS. (Keep it simple stupid). In this context functional would be the bodyweight movements right? eg. scap push ups preferred over dumbbell protractions.

[Archbishop o balance]

What you have is ok, and if jumping rope isn't bothering you then what you've got going on may not be too bad. You need to add lower trap work, diesel crew should be able to show you that. Make sure the scapula are set down and back. Retraction + depression the whole time.

this is nice for WU, right ? i do this instead of ido's band because i don't have bands...

I don't have much experience with these exercises, but but I just read an interesting article by Mike Reinolds on why the YTWL exercises probably aren't that benificial for improving scapular function and lower:upper trapezius activation ratio when done in the ordinary fashion. What do you guys think?

http://www.mikereinold.com/2011/05/why- ... cises.html

[Joshua Naterman]

That's the basic matrix, but I do not like how they are usually shown. Basics are what make you strong, but you have to do them right. I have also found that YTA is more effective than YTWL as well as quite a bit faster.

This article fails in a number of areas, though it is a great example of a well-thought out argument. For one thing, Our bodies work as a unit. The rear deltoids are external rotators and stabilizers, and when done properly these actually help you DISENGAGE the upper traps WHILE learning to use the lower traps. This is key. Isolation is almost never the right thing to do. Sometimes in the early stages of rehab you need to "isolate" just so that you aren't teaching a compensation pattern, but as soon as possible you want to be working the rear delts, infraspinatus, teres minor, and lower traps together. They all work together in real movements, and you still need upper traps to work too. You just don't want them trying to do things alone. That's my bone to pick with that article.

Aside from the, athlete experience is more important than biomechanical supposition. When your intellect tells you something isn't that great but athlete experience is clearly showing otherwise, it's time to rethink your position. Having said that, it is fair to say that YTWL-type exercises are often more useful for teaching activation and movement patterns than for directly building strength.

Proper form with shoulder width chin ups is great for building lower trap and read delt strength directly. External rotation work like seated and side lying external rotations build infraspinatus and teres minor strength while tying in rear delts if done correctly, and also teach the lower traps to stabilize the scapula during the motion. YTWL tends to be an excellent assessment and a reasonable teaching tool for recruitment, but since they are such a challenging series of positions to perform correctly in they are by nature not the best way to directly build strength.

[Archbishop o balance]

You have a knack for putting things into perspective and explaining them for the less educated, Slizzardman Thank you for your answer. What kind of education have you got?

[Joshua Naterman]

A combination of formal and self-taught. I'm in the exercise science program at Georgia State University, carrying a 4.08 or something like that GPA. However, this stuff comes from reading anatomy books, learning what is where, and then looking at the body as a single unit and observing how things work. I have been trained to be very good at practical thinking. Most of that training was self-taught. I don't know if that answers your questions, but that's the truth.

I had to learn because I couldn't afford to just keep going around paying people to try and apply what they knew, especially since no one could really give me good results. Knowing what I know now things are quite a bit simpler, but it took a LONG time to develop this understanding. I do believe that I am capable of passing on my knowledge in a much, much shorter period of time than it took me to build it up.

I am almost 100% certain that I will be going to Osteopathy school for my post-graduate education, as they are basically a chiropractor AND an MD. but with a blend of wellness and disease model perspectives. I like how the school near me sounds, they teach things in a very integrated fashion so that you learn how to interact with patients AS you learn and see them as people, not paychecks. It should be interesting, that's for sure.