What most therapists don’t know about rehabilitating shoulders from injury

When it comes to rehabilitating shoulders after injury, Rob has a bit more insight than most. Having been through two almost identical shoulder operations in his late teens (thanks Rugby!) and experiencing two different approaches to rehab, he’s developed some insight in to what all the therapists he’s seen over the year’s always miss. And it’s nothing intention, it’s just that the majority of therapists haven’t experienced shoulder injuries to the extent that they need to start from the beginning again. And if you’re someone who’s reading this and is struggling with shoulder pain, chances are you won’t need all this information - but it’s certainly not going to do you any harm by going right back to basics.

The brain, the shoulder, and the why

Before we get stuck in to the exercises, it’s important to lay some groundwork down in terms of understanding what the shoulder is, and why we even have one. For the most part, the role of the shoulder joint is to help get our hand where it needs to go, and provide a stable base from which to leverage force to the hand, but also down to the feet (try running without your shoulders moving - I’ll put $100 on it that you can’t!). Now the brain is going to develop incredibly energy efficient ways to use the shoulders from a very young age, and we’ll generally retain those until something happens that results in a substantial change in how the shoulder needs to move, for example, you dislocate it, you run in to a wall, you take a fall and land hard on your shoulder - you get the picture. Once trauma occurs, the impacted area will freeze up a bit while it heals. But the show must go on, so the brain works around it, and often develops new ways to work that are more energy efficient than dealing with the traumatised injury site. Once this happens, we then start to get compensations. So now not only do we have a sore area, but we have other areas working over time in a role they aren’t designed for - which guaranteed will cause niggles in other areas, causing more compensations… you see where we’re going with this? It’s a mess?!

So what do we do?

First, let’s understand the anatomy. The should joint is made up of three bones - your collar bone, your shoulder blade, and your humorous bone. Now this all sit on top of the ribcage, kind of like a bird sitting on a branch. I like this analogy as it highlight that the bird (your shoulder) rest on the branch (your ribcage) because it’s stable. Equally, the bird has the ability to adjust it’s position to maintain balance and stability if the branch swings around on a windy day, just like the shoulder does when we’re doing movement. So the ribcage forms the base, and it’s main job is to protect the lungs, and is supported by the diaphragm - another very important muscle.

Then there are a bunch of support muscles the fine tune the movement of the shoulder blade and give it the freedom to slide around the back of the ribcage, my favourite of which is the Subscapularis, which sits between the shoulder blade and the ribcage, but also attaches on to the top of the humorous bone to roll it in. This guy is also super important as it very rarely gets any love from the therapy world, and it has the biggest impact on loosening the shoulder when it feels stiff.

The other big hitters of interest include the Serratus Anterior, which helps control the bottom of the shoulder blade; the Latissimus Dorsi which controls the side of the shoulder and ribcage; and the Pectoral muscles that control the front of the shoulder and arm. These are all very broad descriptions of the roles of those muscles, and the sticklers in the industry would say it isn’t very accurate - but for what we’re going to talk about, it won’t really matter.

The Big Mistakes Therapists Make

1) Rotator Cuff Obsessed

Made up for four muscles that attach in and around the shoulder blade, and assert their force on the top of the humorous bone. Their main job is to rotate the shoulder arm in it’s socket and time their actions in accordance with the larger muscles around the shoulder joint to provide precise action of the arm and hand. There are three smaller muscles that rotate the arm out (external rotators), and one that rotates it in (internal rotator) which is supported by larger muscles that also rotate the arm in - such as the Latissimus Dorsi. Because the there are only three smaller external rotators, most therapists think they need to provide specific strengthening exercises to beef them up a bit. In reality, that’s a terrible idea! They are little for a reason, and are generally plenty strong already and loading them more just fatigues them. The best thing to do is open up the internal rotators so they are happier to relax, making life easier on the external rotators. Think of trying to drive with all the brakes on? You might get somewhere, but not very fast and eventually something is going to break.

2) They don’t use the ribs

The ribcage forms the foundation upon which the shoulder sits. Each rib has little muscles between them, as well as muscles around the spine that control their movement, plus the diaphragm. When there is trauma to the shoulder, the muscles tighten up around it which also pulls on the ribs and tightens them up too. Most therapists don’t notice this, and will proceed straight to working on the shoulder with giving the ribs a look. Another critical mistake, as all their hard work on the shoulder will go wasted on a foundation that is no longer rock solid. Would you trust a builder who was happy to do house renovations on a foundation that has sunken in? Don’t think so!

3) Don’t release Subscapularis

The Subscapularis is the guide for how the shoulder blade moves on the back of the ribcage, and is also the rotator cuff muscle that rotates the shoulder internally. Because of it’s location, it’s not the easiest to get to or see, so it often doesn’t register with therapists. But which it becomes tight, it will restrict how much the shoulder blade can slide on the ribcage. Most therapists then blame a lazy Serratus Anterior which pushes the shoulder blade forward around the side of the ribs, but in reality, the serratus is fighting a losing battle against the Subscapularis and both then get jammed up and muscle tension follows - generally around the top of the shoulder blade at the base of your neck, and at the front of the chest and shoulder.

4) Don’t passively load the joint

Passive Range of Movement (ROM) is one of the most extraordinary things you can do for any part of the body to help develop confidence in the joint that it can move, and be pain free - this is key in rehabilitating injuries. But therapists get obsessed with this idea that everything must be strengthened and ‘active’ or it’s not going to do anything. In reality until you’re dead, everything is active and they needn’t worry about things not connecting properly. Relaxing a joint area, and showing that it can move will stimulate the internal sensory system and show it that it is okay, and gradually the muscles will relax to the point they can be taken to their normal resting length, ready to go when called upon for action.

The big corrections

1) Breathe

Learning to breathe deeply, and organise the full rib cage to expand and contract will start to organise the deepest layers of musculature around the shoulder, and begin to restore length to the tightened areas post-trauma. Try finding a comfortable position, and holding your stomach in while breathing deeply - keeping the stomach drawn in forces the ribs to expand to a greater capacity. Once they are moving, work on holding your breath for extended periods while trying to expand the ribs even more.

2) Massage

Releasing areas of tension is key to being able to helping the area have more space to move, upon which you can build better quality range of movement. You’re going to want to use a massage tool that is firm but forgiving, and allows you to apply pressure without taking your breathe away. Key massage areas are listed below - they are just guides and we’d recommend exploring the supporting tissues to see what you can find. Generally spend 30 seconds to 2 minutes on a single spot. Over time, they will get better and you won’t need to spend as long, or do as many spots

• Diaphragm

• Pectorals

• Ribcage and armpit from side

• Thoracic spine

• Shoulder blade

• Upper Trapezius

• Subscapularis

3) Passive Range of Movement

Using a small weight and an elevated surface can be really helpful here, so let the arm gently move through its ranges of movement without actively recruiting any muscles. As previously discussed, this is about showing the brain what’s possible for that joint, and building confidence that movement is possible without pain. Exercises outlined below are guides, but equally play around with different positions to see what works for you. As tolerance allows, gradually add more weight at the end of ranges to see if you can start to test out the strength of the joint again.

• Hand on a window sill - this provides an anchor for your hand, and then you can move your body around the hand any which way you want.

• Lying on a bench, letting your arm hang down towards the floor. You can do this on your front or back, and sometimes your side depending on your set up.

4) Strengthen the Internal Rotators

Contrary to what most therapists do, I find the most helpful thing I’ve done is learn to lengthen the internal rotators, and let external rotators take care of themselves. There are two key exercises I use, and both require light hand weights, and one will require a long foam roller or equivalent.

• Subscapularis lengthening: best done on an elevated surface, lie side on with the arm out 90 degrees from the chest, and the head supported on a cushion or equivalent. Ideally the elbow hangs off the edge of the surface, and bend the elbow to 90 degrees holding the hand weight. Rotate the arm on the spot to let the hand drop backwards and forward - go slowly to maintain control, but gently work to a stretch at each end of the movement.

• Lie lengthwise on the foam roller, with the hand weights in each hand. There are three positions, the first of which is elbows on the ground but close to the foam roller. Elbows bent to 90 degrees, and then let the arms rotate out towards the floor, then rotate back to the side of the body, 8-12 times. Second position is with the elbows 45 degrees out from the body, and the third is the elbows 90 degrees out from the body. The elbow is always bent to 90 degrees, so where the forearm goes will change with each position, with the last two positions also allowing for internal rotation.

If you can follow this corrections, they will help build the foundation upon which the normal therapeutic interventions will be more successful. Because they weren’t bad interventions, they just didn’t cover enough of the basics before they start getting focused on the big stuff, which ultimately will create other issues down the track. It’s taken Rob 10 years to figure out what the basic’s are, and they will help everyone who walks through our doors - even better if you can have them done before you come in for a session!

Credits

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