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Shoulder Rehabilitation
by Dr. David T. Ryan,
Winner of the Cecil Award, National Arthritis Foundation
Introduction
The most common question that I get asked is how to strengthen an injured shoulder. Some athletes train around a shoulder injury for years, others try every insane treatment, including magnets and various injectables, instead of realizing they can correct the problem with proper training.
The shoulder is the most complicated joint in the body to rehabilitate. Why? It has more mobility and speed than any other joint in the body. The shoulder moves at 5730 degrees per second (dps), approximately 80% faster than the knee at top speed (2000 dps). Because of its seemingly complex nature, most individuals take up knitting or 12 ounce curls to avoiding training. Recently, I returned a professional hockey player to the ice in just 10 days with a shoulder separation. Previous attempts at shoulder surgery failed to provide shoulder stability, the injury was reviewed and an intense training schedule mixed with some ultrasound and medications was implemented. That's right, a step by step exercise program to increase flexibility and strength. Injuries to the shoulders supraspinatous muscle are the most common sports medical injury.
Many times the shoulder injury will have several additional components, including the back/neck/shoulder girdle, etc. Most good orthopedic surgeons are very reserved about attempting surgery unless there is a major tear, since there is a better chance to rehab the shoulder. For example, when trying to repair a torn pec tendon is associated with how it is made. Most tendons are very fibrous and thick, but the pec tendon looks like Jello flattened out by a rolling pin with parallel strings running through it. Your best chance at repairing partial tears is by rehabilitating the tissue and doing it the right way with plyometric/speed training.
This article will instruct you on how to increase range of motion and strengthen the shoulder area. This article will not allow you to begin diagnosing your lifting pals. It is best to see a chiropractic physician or a good orthopedic surgeon who specializes in shoulders. Beware that not all orthopedic surgeons or chiropractic physicians are created equally. A good general rule is if you don’t see improvement in a couple of weeks, then move on. Try another type of doctor or physical therapist or acupuncturist, etc.
Find a Chiropractic Physician at www.chiroweb.com
Find an Orthopedic Physician at http://www.aaos.org
When a doctor tells you to quit lifting and get on NSAIDS (Non Steroidal Anti-Inflammatory Drugs). Well, since over 16,500 people died in the US from reactions from those drugs you might want to consider using a non-drug approach. (British Medical Journal, June, 1999.) Short-term use of Advil, Aleve, Nuprin, Motrin, Asprin (white willow bark) and other NSAIDS (less than three weeks) are usually safe, but continued use will distroy your protective lining of your stomach and your heart. I have seen several athletes who have been unable to compete or came close to death with long term NSAID use. One of the best NSAIDs - Bextra is one of the safest anti-inflammatory drugs you can use, ask your doctor about it. It is 4000 times more selective, which means it leaves your heart and stomach alone.
Read this article and then take it to your healthcare professional and have them read it.
Please note that most physicians don’t have any training in rehabilitation. Some chiropractors do and most physical therapist are a good place to start then apply other references of this article to your training.
Take on the shoulder Step by Step. Try to workout without passing the 60% pain level. In time your strength will improve and your pain level will reduce.
One of the first steps to understanding shoulder rehabilitation is
learning anatomy. I know it might not be fun, but it is necessary.
BONES 1. Bones of the shoulder
A. Clavicle (Commonly known as the collar bone)
B. Scapula (Also known as the wing bone)
C. Humerus (The upper bone in your arm)
JOINTS 2. There are three joints (where bones come together) of the shoulder region.
The first two listed below make up the shoulder girdle.
A. Acromioclavicular (A-C joint) -- this joint is formed by the upper part of the scapula and the clavicle. Mainly it is active with shrugging movements. When this joint is injured a grading scale of 1 (minor) through 3 (severe) is used to evaluate the degree of separation as seen on a x-ray.
B. Glenohumeral -- the combination of the upper arm bone and the
outside area of the scapula make up this joint. This joint is responsible for most all the movements of the shoulder. Shoulder dislocation always refers to this joint. These can occur in any direction, but the anterior-inferior (forward and down) normally occurs the most frequent.
C. Sternoclavical -- composed of the clavicle (collar bone) and the
sternum (breast bone). This joint primarily operates during the shrugs, although, part of its function is to stabilize the shoulder girdle in place. Normally, this area becomes injured when the entire shoulder girdle is forced backwards or towards the center of the body (like getting slammed into the wall in Hockey).
MUSCLE 3. Muscles of the shoulder.
Here is a simple definition of what they do, in particular how they effect the more common movements such as the bench press.
The rotator cuff (SITS) Supraspinatus, Infraspinatus, Teres Minor, Subscapularis, others muscles of the shoulder include
the Teres Major, Latissimus Dorsi, Trapezius, Pectoriallis Major and Minor; corico- brachiallis, Biceps, Deltoid, Sternocleidomastoid, Rhomboid Minor and Major, Serratus Anterior.
SOME KINESIOLOGY WITH YOUR EGGS?
The humerus (your upper arm) is flexed (drawn forward, bench press) by the Pectoralis major, anterior fibers of the Deltoideus, Coracobachialis, and when the forearm is flexed, by the Biceps brachii; extended (drawn backward, bent-over rows) by the Latissimus Dorsi, Teres major, Posterior fibers of the Deltoideus and when the forearm is extended, by the Triceps brachii; it is abducted (arm drawn away from the body, lateral raises) by the Deltoideus and Supraspinatus; it is adducted (arm is drawn toward the side of the body, like one arm rows) by the Subscapularis, Pectoralis major, and by the weight of the limb; it is rotated outward /external rotation (similar to bent-over lateral raises) by the Infraspinatus and Teres Minor; and it is rotated inward /internal rotation (cable cross-overs) by the Subscapularis, Latissimus Dorsi, Teres major, Pectoralis major, and the anterior fibers of the Deltodeus.1 With the arm over head, any motion is stabilized or controlled by the Coracobachialis. Circumduction (similar to a underarm throw in fast pitch softball) is the combination of the above movements to allow the greatest degree of movement of any joint.
IMPORTANT POINTS ABOUT THESE MUSCLES
•Some muscles are major movers of the joints, others only stabilize.
•If you were to cut away the tendons of the rotator cuff, the
Glenohumeral joint goes from completely closed to a 2.5 cm gap. Now you can
understand how important the rotator cuff muscles are in stabilization of the
shoulder. Some of the research done by Dr. Richard Fisher at OSU (also
Director of Orthopedics, Arnold Fitness/Classic Expo) showed,
the more weight placed on the shoulder in the bench press resulted in a more
stablization of the glenohumeral joint. Less shifting with more weight!
•Muscles are accompanied by surrounding soft tissue, these include bursa sacs,
major ligaments, nerves and arteries. It is possible to have scar tissue associated on any of these structures. It may be necessary in some cases to have a surgical procedure to remove that scar tissue.
Now that we have a clear understanding of anatomy and how it works the next step is learning the steps to evaluating your problem.
Your physician/physical therapist must help you with this phase.
The First step: Find the limited movement.
Movement of a joint is called Range Of Motion (ROM). There are standards or normal movement ranges. Comparing the normal side to the damaged side is an easy way to determine your limits. Some individuals who have injuries on both sides must have a physician or physical therapists assist them in discovering their limits of motion.
There are two forms of ROM:
ACTIVE (AROM)--where you move the joint.
PASSIVE (PROM)--where the doctor moves the joint for you while you relax.
NOTE WHERE THE PAIN OCCURS DURING THE RANGE OF MOTION TESTING, RECORD THAT FOR COMPARISON LATER.
The ranges of motion to be examined are:
• Abduction and Adduction: With the arms straight at your side
raise the arms over your head. (Fig. 1)
• External rotation and Abduction: reach behind your head and
touch the top of the opposite scapula.
• Adduction and Internal rotation: reach in front of your head
and touch the opposite shoulder.
• Internal rotation and Adduction: reach behind your lower back
and raise the arm to the bottom of the scapula.
• Scapular movement: 2:1 ratio of arm abduction to scapular
movement. For every 2° of arm abduction 1° of scapular
movement should also occur. This important area is commonly
overlooked during examination. Frozen shoulder syndrome starts here.
There are other areas of ROM, but these will be uncovered during the next section of muscle testing.
Note any deficiencies or improvement in your journal. Check your progress in the future by comparing your good side to your injured side in a mirror.
The Second step: Begin testing your muscles in particular movements. Realize some of your strength testing can be done in the gym during your workout. You may need to adapt your exercises and use dumbbells to compare one side to the other; However, during rehabilitation bilateral movements (using a barbell) promotes faster strength gains.
The nine motions we are going to test are: Flexion, extension, abduction, adduction, external rotation, internal rotation, scapular elevation (shoulder shrug), scapular retraction (position of attention), shoulder protraction (reaching) and overhead flexion (throwing a ball).
Test these movements with the following exercises
Flexion & scapular protraction: Reverse grip-bench press.
Extension: One-arm bent over rows
Abduction & external rotation: Lateral shoulder raises
Adduction & internal rotation: Cable cross-overs/ Dips
Scapular elevation & retraction: Dumbbell shrugs up and back
Overhead flexion: One-arm dumbbell pull-overs.
Another excellent exercise to consider is the "Rotator Cuff Shoulder Roll." Performed with your arm holding a dumbbell, elbow bent at 90 degrees, upper arm perpendicular to the bench, midway down on a flat bench, only the shoulder blade (Scapula) touching the bench; keep your thumb pointing to the ground as you move the dumbbell from above your head to below your shoulder. (SEE ILLUSTRATION-1) A more advanced way to do this exercise is with a barbell. Grab the barbell a little wider than shoulder width with palms facing inward. Now raise your elbows (keeping your upper arm only rolling- your upper arm is parallel with the ground) start with your forearms pointing down to the ground (like a scar crow). Now raise the forearm in a circular motion, in that you rotate the upper arm, making a half circle as you raise the bar over your head. Keep your elbow at the same height throughout the movement. (SEE ILLUSTRATION-2)
I would strongly discourage you from doing any behind the neck military presses below the earlobe. They tend to separate the shoulder joint to an abnormal degree. Do military presses in front of the neck and not lower than the earlobe.
STAY BALANCED
With all your exercises work on balancing the strength of the joint equally in all directions. An unbalanced joint, especially the shoulder, will eventually cause further injury or ligamentous laxity and osteoarthritis. The head of the humerous will wear on the ball and socket joint and eventually tear the Teflon-like covering in joint called the glenoid labrum.
Write Down your weaknesses in a journal and we’ll cover the correct exercises to
The Third Step: Work on increasing your range of motion.
When your tissue is injured it heals with scar tissue, not fresh new cells, just protein branches called collagen. For about the first three weeks scar tissue is forming therefore, lifting weight too early is counter productive; however, it is quite essential to work on passive then active ROM. You should be aware that once the scar tissue has stabilized you must begin exercising the area with weights as soon as possible. Please note that some research has shown that use of NSAIDS on a repetitive basis results in additional scar tissue formation. Additional research indicates that cross frictional massage and deep tissue massage to the tendon, helps promote new blood vessel growth and speed healing.
INJURY EVALUATION
At this point you should be past the initial 48 hours of ice treatment. Also, you should have been seen by a health care professional to properly assess your injury. After that point, we will discuss each level relative to your range of motion improvement. In other words the more movement without pain the better you are. Your Physician will usually grade your injury as severe, moderate or mild. Remember any NUMBNESS should be evaluated by a doctor immediately. Long term radiating pain or numbness (over six weeks) should be evaluated by a Neurologist prior to exercise. Never train with pain greater than 6 on a scale of 0-no pain to 10-worst pain possible.
Many doctors use several evaluating levels to rate your injury.
If your injury is rated as:
Severe: (As evaluated by a professional).
If this is your diagnosis discuss your use of:
Passive Range of Motion (PROM): Injured joint is moved through a painful range of motion by another person, usually a licensed Physical Therapist. PROM is done for three weeks. Do not lift on that joint for three weeks. You may even need to get manipulated under anesthesia. You can still do isometric exercises twice a day. Contract the muscle for 12 seconds at 60% of your maximum ability for 6 sets. Do 6 different positions in the range of movement.
Then re-evaluate, if your PROM is within 80% when compared to your uninjured side you can begin speed training, if not, you must complete two more weeks of PROM and isometrics until you meet that 80% range. Then move on to speed training.
Moderate: (As evaluated by a professional).
Passive Range of Motion (PROM) for two weeks. You can still do isometric exercises twice a day. Contract the muscle for 12 seconds at 60% of your maximum ability for 6 sets. Do 6 different positions in the range of movement.
Then re-evaluate, if your PROM is within 80% when compared to your uninjured side you can begin speed training, if not, you must complete two more weeks of PROM and isometrics until you meet that 80% range. Then move on to speed training.
Mild: (As evaluated by a professional).
PROM for one week: You should be within 80% of the unaffected side. You should continue to lift, but not if your pain is greater than 6 (scale 0-10) Once your range of motion has returned to normal compared to the opposite side, it is time to begin the speed program.
Keep in mind you are still healing so you need to continue stretching (after a workout is best since the area is warm). The stretch should be held steady for 15-20 seconds and repeated three times. Continued three times a week for the rest of your life. Yes, the rest of your life. When you injure the ligament and muscle, these areas heal with scar tissue. That scar tissue needs to be kept mobile. Over time, with inactivity, the scar tissue will form adhesions and loose what little blood supply it has. Flexibility is just like strength, it is easier to keep the flexibility than trying to regain range of motion. Manipulation or chiropractic adjustments provide maximum full range of motion in the spine and/or extremities, but are no substitute for the athlete doing self-stretching.
Always continue to train the opposite side even though you can't train the injured side. This actually helps you recover the injured side quicker. 4
STRETCHING REHAB
Various forms of stretching are rather aggressive. Propreoceptive Neurofacilitation (PNF) is one of the best ways to overcome many chronic limited range of motion. This is a type of stretch where you contract the muscle very hard to cause it to fatique and then you use the antognistic reflex to allow the muscle to lengthen. Sound confusing? There are two references at the end of the article for text on stretching; get them, read them, do them. More than half of the chronic athletic injuries out there could be helped by simply having the person begin a prescriptive PNF stretching program.
STRENGTH REHAB
Strength: (Rehabilitation) To begin only after a professional consultation and return to exercise has been approved by your physician. ROM should be 80% of the unaffected side or of normal range of motion.
PUTTING IT ALL TOGETHER
Now, if you thought the previous part was tough, get up, pour a glass of filtered water with ice and get ready. With rehabilitation various parameters of the lift allows you to control the level of rehabilitation you are in. These parameters include:
1. Frequency: How often you lift.
2. Sets: A group of repetitions.
3. Repetitions: Lifting through a range of motions and return to the starting position.
4. Weight: Using less is better. Better to contract the muscles in the shoulder while performing the
movement.
5. Speed of movement: Speed of reps. Slower is better in the early phase.
Increased speed must be explosive as you progress.
6. Rest period: Time between sets. More rest between sets at the early phase, less at the end.
7. Amount of movement (Range of motion): Detailed later in this article
8. Intensity: How hard you try
The most common mistake that everybody makes is lifting too much weight too early and doing reps too fast. We will review the two most commonly misused parameters for rehabilitation with weights; speed and ROM. Follow the advice to the letter if you want to continue to improve your strength. If you don't follow the protocol, you will eventually plateau off in your strength prior to your maximum pre-injury strength. If you have already plateaued in lifting strength, start by dropping your weight in half and follow one of the following protocols to regain and improve your strength. Just a brief mention to you employers out there: (QUICK HINT) Have some type of light duty work available to your workers, it allows them to return to full duty quicker.
REHAB LEVEL ONE – RANGE OF MOTION (ROM)
The first variable we will adapt is the ROM. When an injury occurs the body splints the area with muscle spasm to prevent further injury. This spasm restricts the range of motion. You must regain as much joint mobility as possible after an injury to prevent the onset of arthritis and/or athropy. Osteoarthritis (Os-tea-O-arth-ri-tis) is the most common form of arthritis. It is merely the body forming calcium growths to stabilize an unstable area. Arthritic changes can begin as early as one week after an injury. Unnecessary immobilization of the shoulder can arthritic changes as quickly as two days. 5
Most physical therapists recognize five phases of rehabilitation. Range of motion is closely coordinated with the progression of exercise.
Phase 1: Forming complete passive range of motion
Phase 2: Initiating movement, muscular contraction
Phase 3: Initiating movement with full active range of motion
Phase 4: Strengthening with full range of motion
Phase 5: Functional rehabilitation: The special action of retraining the athlete to their level of previous competition speed.
REHAB LEVEL TWO – SPEED OF MOVEMENT
As range of motion improves, you will need to improve the joints speed of improvement without pain. As movement begins with weight we usually follow these steps:
Phase 1-3 Slow - partial movement (isometric)
Avoid training painful areas with weight. Begin by contracting the muscle (isometrically) for six seconds at 60% (a little more than half of what you can do before you feel pain begin). Repeat for 6 sets resting one minute between sets. Train around the painful area of movement. By training around the areas of pain this allows you to actually effect the injured area since there is a physiologic overlap of about 15 degrees beyond the ROM, to each side of the area you training. 6 Once you have obtained 80% of your AROM most physicians will instruct you to proceed to the next phase.
Phase 4 Slow - complete movement (isotonic)
Fast - partial movement (isokinetic)
Slow movement with weight, full range of motion. Then shorter movements with quick contractions in the middle of the ROM.
See illustration (a picture here of a curl with the whole ROM in blue, like a sweep, with a middle range of motion in red would-demonstraighting movement in the center about 60 degrees, would be easiest to understand)
Phase 5 Fast - complete movement (isokinetic)
Special machines called Orthotrons (Orth-o-trons) are designed to allow you to exercise over a particular range of motion at a particular speed. This is where the value of a well equipped rehab facility and a well trained physical therapist is judged. You aren’t likely to find machines like this in a gym, they are very expensive.
Slow movement (six seconds concentric-up, six seconds eccentric-down).
mid-Fast movement (two seconds concentric, two seconds eccentric).
Fast movement (less than one second concentric, less than one second eccentric).
~~Wondering if the slow movement (Constant motion-NO SHOCK) really works, Joe Montana returned to the football field very quickly when it was used on his lower back injury. ~~
Eventually you want to move explosively fast, slowly increase your speed as well. This helps coordinate the muscles to work together at faster speeds which resembles true athletic activity and causes the muscles to grow in a way that strengthens there connective tissue. Realistically, you should train like this at least once a month for the rest of your life to work on only explosive (plyometric) movements. For example if you typically bench 315 then you should try doing 135 for 8 sets of 8 reps with only 30 seconds between sets. Moving the bench press so fast that you are doing about two reps per second. This plyometric training thickens the ligaments and tendons. It is necessary to do this to improve the strength of the area. You can also judge it by doing a push up and trying to clap your hands after you have pushed yourself off the ground. As you improve you can try to clap your hands twice before lowering back to the ground. I have never seen a shoulder problem exist after an athlete can clap twice on a push up for 25 reps.
USING STRAPS FOR SPEED
Training with rubber straps will allow for constant tension during high speed training. You must have some experience using them and one of the best groups around to explain this is Westside Barbell and Elete Fitness Systems. Look you can either buy the straps for less than a hundred bucks or buy an Orthotron machine starting around $200,000.
Contact them at http://elitefitnesssystems.com/
Lastly, the importance of training for speed is involved with the speed of the shoulder. You need to coordinate your muscles to work at higher speeds. Explosiveness is more important than strength in any sport. Ever try to stop a tiny “speeding” bullet?
Putting together your functional rehabilitation program
Weight, Sets and Reps: Get out the calculator and the pencil cause here comes the math. Start with how often you should train an injured joint? In a study done by Matthews in 1957 and redone in 1981, research found that if you rehabilitate 5 days a week is more beneficial than only training 4 or 3 days a week. Both studies only used a five day work week not a six or seven day program (couldn’t get the researchers to work weekends). Since Dr. Don Matthews was a professor and friend of mine, I feel that I can extrapolate off this study and suggest that you work the injured area 7 days a week until you reach phase 5, then reduce to 3 then 2 days a week. You can train more frequent due to the reduced intensity of rehabilitation and your body will recover much faster than doing high intensity body- building.
More technical stuff
Zinovieff, DeLorme-Watkin and McQueen are just a few of the techniques that explain how many Sets, Reps and the amount of weight you should use. They all base their principles on the progressive resistive theory. In general, most recommend ten repetition maximum. As far as how much weight to use? Enough to just get ten reps! Real tough, Huh? Some of the best results increase the number of sets you perform as your shoulder strengthens. In other words, you start with doing 3 sets, once you are able to perform 11 reps on your last set, simply add a set until you are doing 5 sets. When you can perform 11 reps on your last set, then add 1 to 1.5 pounds and drop your sets back to 3. This allows you to work on strength first and then develop speed and endurance. One of the important factors in healing an injury is to promote increased circulation in the scar tissue. Remember, if you are board with your rehab program, you are probably right on track. You should always leave and feel that you could do more.
Here is an example of how a program should progress:
Exercises: Dips, cable cross-overs, reverse bench press and Pullovers.
Day 1 2 3 4 5 6 7
Weight (#'s) 10 10 10 10 11 11 11
Sets 3 4 4 5 3 3 4
Reps 10-10-11 10-10-10-8 10-10-10-10 10-10-10-10-11 10-10-8 10-10-10 10-10-10-10
Speed slow slow slow slow faster fast fast
OTHER EXERCISES THAT ARE USEFUL ARE:
Floor Presses are done by lying on the floor with your legs straight, lowering the weight and resting/relaxing on the elbows for a second then pushing the weight up. Similar to box squats. It is sort of a plyometric training that allows for increased coordination of the muscles and increased fiber recruitment. This exercise can be modified by returning to the bench and placing various thickness of boards on your chest and resting the weight on the board, then quickly pressing the weight off. This technique is commonly used by the members of Lou Simmons's West Side Barbell (Where most world record holders train), who also constantly vary their grip. Simply find your weak point in the movement of the bench press or military press and work on the plyometric program from there. This is also sometimes referred to as pin presses however the use of a cage and pins is not as realistic as the free form bench press movement. Remember that this is a quick movement and requires you to be in the Phase 5 level of rehab. You must lower the weight slowly to the floor and then explode the weight to the top. This is great for a majority of injuries such as the Torn Pec, separated A-C, rotator cuff tear, etc.
Use bands to train
Pullovers- (Straight Arm) exercise works the coricobachialis, which is responsible for a majority of the stabilization of the A-C joint.
Bicep Curls- should be modified to bring the bar to your forehead at the end of the movement. The bicep helps stabilize the A-C joint better when the arc of the movement ends with the bar at your eyebrows.
Rotator Cuff Roll - see prior description in this article.
Reverse grip Bench press-Like it says your grip is backwards, this forces you to keep your elbows in to your sides and lower the bar to your stomach, (hint, this movement will help you overcome bad bench techniques which halt your progress) varied width is also used on this movement.
Dumbbell Fly/Press- which ever hurts the most.
Once your strength is approximately 80% of your preinjury strength it is time to increase your speed of movement (phase 4).
Partial movements/Lock-outs Bench press- by simply holding more weight than you normally bench as a PR, you build psychological confidence and you will stabilize the golgi-tendon organs (little switches located in your tendons that tell your brain that the weight is to heavy and cause your muscle to let go). It is very important to overload after an injury since the golgi-tendon organ is very hypersensitive to weight.
That's it No tricks, No gimmicks, just hard work and lots of it. Each program requires some modification so check with your physician if you note any of the following:
•Pain in the chest (clutching-type pain)
•Radiating pain in the arms, wrist or hands.
•Any numbness
•If your strength doesn't increase 14% in 4 weeks
Continue utilizing the suggested exercises until you die or the take the evening news off the air, which ever comes first. You may be avoiding Bench day or hate shoulder day since the strength is gone or the pain is too much. Try the above stated program in its entirety; you have a lot to lose if you don't. Many of the principles explained will apply to the rehabilitation of all the joints after injury. I recommend that you discuss you progress with your physician to best accommodate your exercise program.
Working out with less pain
Several other medical approaches may assist with a more painless workout.
Arthroscopic surgery-is a simple technique of cleaning off the rough edges on the tissues to allow them to work with less friction. Recovery is quick and usually uncomplicated.
Acupuncture – needles!!!! Calm down, it is painless, this technique uses the stimulation of some nerves to calm others down, this is a retraining treatment and requires several visits to work; however, you should see some improvement within a few visits. A word of caution, states vary in their requirements for license. Some of the best training is with Doctors of Oriental Medicine (DOM) and MD or DO and DC’s. Several Medical schools are beginning to teach this technique. Remember the Chinese have used this as a main form of medicine for over 11,000 years.
Supplements-Most effective from the literature and my personal experience are products with Glucosamine Sulfate and Chondrotin Sulfate and MSM (Organic Sulfur). Now please note you shouldn’t take herbs with medications unless you check with your pharmacists. Not your doctor-your pharmacist. Also note that taking NSAID’s (Advil, Motrin, Ibuprophin-containing drugs) will lower your Sulfur content and cause more scar tissue to form and also lower the effectiveness of the aforementioned chemicals. Note also that the Center for Disease Control, Atlanta, GA. Indicated that in 1998, that 16,500 deaths were associated with the use of NSAID’s. Bextra is a newer NSAID that is out, which is 4000 times more selective, meaning that it leaves your heart and stomach alone.
Bio
Dr. David Ryan, practices in Columbus, Ohio at the Columbus Chiropractic Centers and was a team physician for three of the capital cities' pro teams. Medical Director, Arnold Classic and Fitness Expo, the 1994/1995 WPC World Powerlifting Championships. Ring side Physician USA BOXING. Former assistant Strength Coach, Ohio State University. In 1994 the Arthritis Foundation honored him with a national award. He also works with professional football, basketball, rodeo and various professional and Olympic athletes. Send questions in a self addressed/stamped envelope to 5870 Cleveland Ave. Columbus, Ohio 43231
Dr. Richard Fisher (Orthopedic Surgeon) practices in Columbus, Ohio (again, thank god) he is the orthopedic director of the Arnold Classic/Expo.
Bibliography
1. Gray, H., Goss, C.M. (Ed.): GRAY'S ANATOMY, PHILADELPHIA,
PENNSYLVANIA: Lea & Frebiger, 1976.
2. O'Donaghue, D.: TREATMENT OF INJURIES TO ATHLETES,
PHILADELPHIA, PENNSYLVANIA: W.B. Saunders, 1976.
3. Hellerbandt, F.A., et al: Influence of Bilateral Exercise on
Unilateral Work Capacity. Journal of Applied Physiology, 2:
446-452, 1950.
4. Moore, J.: Excitation Overflow; An Electomyographic Investigation
Archives of Physical Medicine and Rehabilitation, 56:115-
120,1975.
5. Videman, T.: Experimental Models of Osteorthritis: Role of
Immobilization. Clinical Biomechanics, 2: 223-229, 1987
6. Davies, G.J.: Compendium of Isokinetics, S & S Publishers, 1984.
Suggested Reading
Voss. D., et al: Proprioceptive Neurofacilitation: Patterns &
Techniques. PHILADELPHIA, PENNSYLVANIA: Harper & Rowe, 1985.
Glossary
Tendon-The tissue the connects the muscle to the bone.
Rehabilitation-Scientifically designed exercise program for injuries or illnesses.
Arthritis-Deterioration of cartilage and general wear on the joint surfaces, due to a ligament's instability.
Atrophy-Shrinking of tissues like muscles.
Range of motion-The distance that a joint allows the bones to move in.
PNF- Proprioceptive Neurofacilitation, a complex stretching technique (read the book).
Shoulder Rehabilitation
by Dr. David T. Ryan,
Winner of the Cecil Award, National Arthritis Foundation
Introduction
The most common question that I get asked is how to strengthen an injured shoulder. Some athletes train around a shoulder injury for years, others try every insane treatment, including magnets and various injectables, instead of realizing they can correct the problem with proper training.
The shoulder is the most complicated joint in the body to rehabilitate. Why? It has more mobility and speed than any other joint in the body. The shoulder moves at 5730 degrees per second (dps), approximately 80% faster than the knee at top speed (2000 dps). Because of its seemingly complex nature, most individuals take up knitting or 12 ounce curls to avoiding training. Recently, I returned a professional hockey player to the ice in just 10 days with a shoulder separation. Previous attempts at shoulder surgery failed to provide shoulder stability, the injury was reviewed and an intense training schedule mixed with some ultrasound and medications was implemented. That's right, a step by step exercise program to increase flexibility and strength. Injuries to the shoulders supraspinatous muscle are the most common sports medical injury.
Many times the shoulder injury will have several additional components, including the back/neck/shoulder girdle, etc. Most good orthopedic surgeons are very reserved about attempting surgery unless there is a major tear, since there is a better chance to rehab the shoulder. For example, when trying to repair a torn pec tendon is associated with how it is made. Most tendons are very fibrous and thick, but the pec tendon looks like Jello flattened out by a rolling pin with parallel strings running through it. Your best chance at repairing partial tears is by rehabilitating the tissue and doing it the right way with plyometric/speed training.
This article will instruct you on how to increase range of motion and strengthen the shoulder area. This article will not allow you to begin diagnosing your lifting pals. It is best to see a chiropractic physician or a good orthopedic surgeon who specializes in shoulders. Beware that not all orthopedic surgeons or chiropractic physicians are created equally. A good general rule is if you don’t see improvement in a couple of weeks, then move on. Try another type of doctor or physical therapist or acupuncturist, etc.
Find a Chiropractic Physician at www.chiroweb.com
Find an Orthopedic Physician at http://www.aaos.org
When a doctor tells you to quit lifting and get on NSAIDS (Non Steroidal Anti-Inflammatory Drugs). Well, since over 16,500 people died in the US from reactions from those drugs you might want to consider using a non-drug approach. (British Medical Journal, June, 1999.) Short-term use of Advil, Aleve, Nuprin, Motrin, Asprin (white willow bark) and other NSAIDS (less than three weeks) are usually safe, but continued use will distroy your protective lining of your stomach and your heart. I have seen several athletes who have been unable to compete or came close to death with long term NSAID use. One of the best NSAIDs - Bextra is one of the safest anti-inflammatory drugs you can use, ask your doctor about it. It is 4000 times more selective, which means it leaves your heart and stomach alone.
Read this article and then take it to your healthcare professional and have them read it.
Please note that most physicians don’t have any training in rehabilitation. Some chiropractors do and most physical therapist are a good place to start then apply other references of this article to your training.
Take on the shoulder Step by Step. Try to workout without passing the 60% pain level. In time your strength will improve and your pain level will reduce.
One of the first steps to understanding shoulder rehabilitation is
learning anatomy. I know it might not be fun, but it is necessary.
BONES 1. Bones of the shoulder
A. Clavicle (Commonly known as the collar bone)
B. Scapula (Also known as the wing bone)
C. Humerus (The upper bone in your arm)
JOINTS 2. There are three joints (where bones come together) of the shoulder region.
The first two listed below make up the shoulder girdle.
A. Acromioclavicular (A-C joint) -- this joint is formed by the upper part of the scapula and the clavicle. Mainly it is active with shrugging movements. When this joint is injured a grading scale of 1 (minor) through 3 (severe) is used to evaluate the degree of separation as seen on a x-ray.
B. Glenohumeral -- the combination of the upper arm bone and the
outside area of the scapula make up this joint. This joint is responsible for most all the movements of the shoulder. Shoulder dislocation always refers to this joint. These can occur in any direction, but the anterior-inferior (forward and down) normally occurs the most frequent.
C. Sternoclavical -- composed of the clavicle (collar bone) and the
sternum (breast bone). This joint primarily operates during the shrugs, although, part of its function is to stabilize the shoulder girdle in place. Normally, this area becomes injured when the entire shoulder girdle is forced backwards or towards the center of the body (like getting slammed into the wall in Hockey).
MUSCLE 3. Muscles of the shoulder.
Here is a simple definition of what they do, in particular how they effect the more common movements such as the bench press.
The rotator cuff (SITS) Supraspinatus, Infraspinatus, Teres Minor, Subscapularis, others muscles of the shoulder include
the Teres Major, Latissimus Dorsi, Trapezius, Pectoriallis Major and Minor; corico- brachiallis, Biceps, Deltoid, Sternocleidomastoid, Rhomboid Minor and Major, Serratus Anterior.
SOME KINESIOLOGY WITH YOUR EGGS?
The humerus (your upper arm) is flexed (drawn forward, bench press) by the Pectoralis major, anterior fibers of the Deltoideus, Coracobachialis, and when the forearm is flexed, by the Biceps brachii; extended (drawn backward, bent-over rows) by the Latissimus Dorsi, Teres major, Posterior fibers of the Deltoideus and when the forearm is extended, by the Triceps brachii; it is abducted (arm drawn away from the body, lateral raises) by the Deltoideus and Supraspinatus; it is adducted (arm is drawn toward the side of the body, like one arm rows) by the Subscapularis, Pectoralis major, and by the weight of the limb; it is rotated outward /external rotation (similar to bent-over lateral raises) by the Infraspinatus and Teres Minor; and it is rotated inward /internal rotation (cable cross-overs) by the Subscapularis, Latissimus Dorsi, Teres major, Pectoralis major, and the anterior fibers of the Deltodeus.1 With the arm over head, any motion is stabilized or controlled by the Coracobachialis. Circumduction (similar to a underarm throw in fast pitch softball) is the combination of the above movements to allow the greatest degree of movement of any joint.
IMPORTANT POINTS ABOUT THESE MUSCLES
•Some muscles are major movers of the joints, others only stabilize.
•If you were to cut away the tendons of the rotator cuff, the
Glenohumeral joint goes from completely closed to a 2.5 cm gap. Now you can
understand how important the rotator cuff muscles are in stabilization of the
shoulder. Some of the research done by Dr. Richard Fisher at OSU (also
Director of Orthopedics, Arnold Fitness/Classic Expo) showed,
the more weight placed on the shoulder in the bench press resulted in a more
stablization of the glenohumeral joint. Less shifting with more weight!
•Muscles are accompanied by surrounding soft tissue, these include bursa sacs,
major ligaments, nerves and arteries. It is possible to have scar tissue associated on any of these structures. It may be necessary in some cases to have a surgical procedure to remove that scar tissue.
Now that we have a clear understanding of anatomy and how it works the next step is learning the steps to evaluating your problem.
Your physician/physical therapist must help you with this phase.
The First step: Find the limited movement.
Movement of a joint is called Range Of Motion (ROM). There are standards or normal movement ranges. Comparing the normal side to the damaged side is an easy way to determine your limits. Some individuals who have injuries on both sides must have a physician or physical therapists assist them in discovering their limits of motion.
There are two forms of ROM:
ACTIVE (AROM)--where you move the joint.
PASSIVE (PROM)--where the doctor moves the joint for you while you relax.
NOTE WHERE THE PAIN OCCURS DURING THE RANGE OF MOTION TESTING, RECORD THAT FOR COMPARISON LATER.
The ranges of motion to be examined are:
• Abduction and Adduction: With the arms straight at your side
raise the arms over your head. (Fig. 1)
• External rotation and Abduction: reach behind your head and
touch the top of the opposite scapula.
• Adduction and Internal rotation: reach in front of your head
and touch the opposite shoulder.
• Internal rotation and Adduction: reach behind your lower back
and raise the arm to the bottom of the scapula.
• Scapular movement: 2:1 ratio of arm abduction to scapular
movement. For every 2° of arm abduction 1° of scapular
movement should also occur. This important area is commonly
overlooked during examination. Frozen shoulder syndrome starts here.
There are other areas of ROM, but these will be uncovered during the next section of muscle testing.
Note any deficiencies or improvement in your journal. Check your progress in the future by comparing your good side to your injured side in a mirror.
The Second step: Begin testing your muscles in particular movements. Realize some of your strength testing can be done in the gym during your workout. You may need to adapt your exercises and use dumbbells to compare one side to the other; However, during rehabilitation bilateral movements (using a barbell) promotes faster strength gains.
The nine motions we are going to test are: Flexion, extension, abduction, adduction, external rotation, internal rotation, scapular elevation (shoulder shrug), scapular retraction (position of attention), shoulder protraction (reaching) and overhead flexion (throwing a ball).
Test these movements with the following exercises
Flexion & scapular protraction: Reverse grip-bench press.
Extension: One-arm bent over rows
Abduction & external rotation: Lateral shoulder raises
Adduction & internal rotation: Cable cross-overs/ Dips
Scapular elevation & retraction: Dumbbell shrugs up and back
Overhead flexion: One-arm dumbbell pull-overs.
Another excellent exercise to consider is the "Rotator Cuff Shoulder Roll." Performed with your arm holding a dumbbell, elbow bent at 90 degrees, upper arm perpendicular to the bench, midway down on a flat bench, only the shoulder blade (Scapula) touching the bench; keep your thumb pointing to the ground as you move the dumbbell from above your head to below your shoulder. (SEE ILLUSTRATION-1) A more advanced way to do this exercise is with a barbell. Grab the barbell a little wider than shoulder width with palms facing inward. Now raise your elbows (keeping your upper arm only rolling- your upper arm is parallel with the ground) start with your forearms pointing down to the ground (like a scar crow). Now raise the forearm in a circular motion, in that you rotate the upper arm, making a half circle as you raise the bar over your head. Keep your elbow at the same height throughout the movement. (SEE ILLUSTRATION-2)
I would strongly discourage you from doing any behind the neck military presses below the earlobe. They tend to separate the shoulder joint to an abnormal degree. Do military presses in front of the neck and not lower than the earlobe.
STAY BALANCED
With all your exercises work on balancing the strength of the joint equally in all directions. An unbalanced joint, especially the shoulder, will eventually cause further injury or ligamentous laxity and osteoarthritis. The head of the humerous will wear on the ball and socket joint and eventually tear the Teflon-like covering in joint called the glenoid labrum.
Write Down your weaknesses in a journal and we’ll cover the correct exercises to
The Third Step: Work on increasing your range of motion.
When your tissue is injured it heals with scar tissue, not fresh new cells, just protein branches called collagen. For about the first three weeks scar tissue is forming therefore, lifting weight too early is counter productive; however, it is quite essential to work on passive then active ROM. You should be aware that once the scar tissue has stabilized you must begin exercising the area with weights as soon as possible. Please note that some research has shown that use of NSAIDS on a repetitive basis results in additional scar tissue formation. Additional research indicates that cross frictional massage and deep tissue massage to the tendon, helps promote new blood vessel growth and speed healing.
INJURY EVALUATION
At this point you should be past the initial 48 hours of ice treatment. Also, you should have been seen by a health care professional to properly assess your injury. After that point, we will discuss each level relative to your range of motion improvement. In other words the more movement without pain the better you are. Your Physician will usually grade your injury as severe, moderate or mild. Remember any NUMBNESS should be evaluated by a doctor immediately. Long term radiating pain or numbness (over six weeks) should be evaluated by a Neurologist prior to exercise. Never train with pain greater than 6 on a scale of 0-no pain to 10-worst pain possible.
Many doctors use several evaluating levels to rate your injury.
If your injury is rated as:
Severe: (As evaluated by a professional).
If this is your diagnosis discuss your use of:
Passive Range of Motion (PROM): Injured joint is moved through a painful range of motion by another person, usually a licensed Physical Therapist. PROM is done for three weeks. Do not lift on that joint for three weeks. You may even need to get manipulated under anesthesia. You can still do isometric exercises twice a day. Contract the muscle for 12 seconds at 60% of your maximum ability for 6 sets. Do 6 different positions in the range of movement.
Then re-evaluate, if your PROM is within 80% when compared to your uninjured side you can begin speed training, if not, you must complete two more weeks of PROM and isometrics until you meet that 80% range. Then move on to speed training.
Moderate: (As evaluated by a professional).
Passive Range of Motion (PROM) for two weeks. You can still do isometric exercises twice a day. Contract the muscle for 12 seconds at 60% of your maximum ability for 6 sets. Do 6 different positions in the range of movement.
Then re-evaluate, if your PROM is within 80% when compared to your uninjured side you can begin speed training, if not, you must complete two more weeks of PROM and isometrics until you meet that 80% range. Then move on to speed training.
Mild: (As evaluated by a professional).
PROM for one week: You should be within 80% of the unaffected side. You should continue to lift, but not if your pain is greater than 6 (scale 0-10) Once your range of motion has returned to normal compared to the opposite side, it is time to begin the speed program.
Keep in mind you are still healing so you need to continue stretching (after a workout is best since the area is warm). The stretch should be held steady for 15-20 seconds and repeated three times. Continued three times a week for the rest of your life. Yes, the rest of your life. When you injure the ligament and muscle, these areas heal with scar tissue. That scar tissue needs to be kept mobile. Over time, with inactivity, the scar tissue will form adhesions and loose what little blood supply it has. Flexibility is just like strength, it is easier to keep the flexibility than trying to regain range of motion. Manipulation or chiropractic adjustments provide maximum full range of motion in the spine and/or extremities, but are no substitute for the athlete doing self-stretching.
Always continue to train the opposite side even though you can't train the injured side. This actually helps you recover the injured side quicker. 4
STRETCHING REHAB
Various forms of stretching are rather aggressive. Propreoceptive Neurofacilitation (PNF) is one of the best ways to overcome many chronic limited range of motion. This is a type of stretch where you contract the muscle very hard to cause it to fatique and then you use the antognistic reflex to allow the muscle to lengthen. Sound confusing? There are two references at the end of the article for text on stretching; get them, read them, do them. More than half of the chronic athletic injuries out there could be helped by simply having the person begin a prescriptive PNF stretching program.
STRENGTH REHAB
Strength: (Rehabilitation) To begin only after a professional consultation and return to exercise has been approved by your physician. ROM should be 80% of the unaffected side or of normal range of motion.
PUTTING IT ALL TOGETHER
Now, if you thought the previous part was tough, get up, pour a glass of filtered water with ice and get ready. With rehabilitation various parameters of the lift allows you to control the level of rehabilitation you are in. These parameters include:
1. Frequency: How often you lift.
2. Sets: A group of repetitions.
3. Repetitions: Lifting through a range of motions and return to the starting position.
4. Weight: Using less is better. Better to contract the muscles in the shoulder while performing the
movement.
5. Speed of movement: Speed of reps. Slower is better in the early phase.
Increased speed must be explosive as you progress.
6. Rest period: Time between sets. More rest between sets at the early phase, less at the end.
7. Amount of movement (Range of motion): Detailed later in this article
8. Intensity: How hard you try
The most common mistake that everybody makes is lifting too much weight too early and doing reps too fast. We will review the two most commonly misused parameters for rehabilitation with weights; speed and ROM. Follow the advice to the letter if you want to continue to improve your strength. If you don't follow the protocol, you will eventually plateau off in your strength prior to your maximum pre-injury strength. If you have already plateaued in lifting strength, start by dropping your weight in half and follow one of the following protocols to regain and improve your strength. Just a brief mention to you employers out there: (QUICK HINT) Have some type of light duty work available to your workers, it allows them to return to full duty quicker.
REHAB LEVEL ONE – RANGE OF MOTION (ROM)
The first variable we will adapt is the ROM. When an injury occurs the body splints the area with muscle spasm to prevent further injury. This spasm restricts the range of motion. You must regain as much joint mobility as possible after an injury to prevent the onset of arthritis and/or athropy. Osteoarthritis (Os-tea-O-arth-ri-tis) is the most common form of arthritis. It is merely the body forming calcium growths to stabilize an unstable area. Arthritic changes can begin as early as one week after an injury. Unnecessary immobilization of the shoulder can arthritic changes as quickly as two days. 5
Most physical therapists recognize five phases of rehabilitation. Range of motion is closely coordinated with the progression of exercise.
Phase 1: Forming complete passive range of motion
Phase 2: Initiating movement, muscular contraction
Phase 3: Initiating movement with full active range of motion
Phase 4: Strengthening with full range of motion
Phase 5: Functional rehabilitation: The special action of retraining the athlete to their level of previous competition speed.
REHAB LEVEL TWO – SPEED OF MOVEMENT
As range of motion improves, you will need to improve the joints speed of improvement without pain. As movement begins with weight we usually follow these steps:
Phase 1-3 Slow - partial movement (isometric)
Avoid training painful areas with weight. Begin by contracting the muscle (isometrically) for six seconds at 60% (a little more than half of what you can do before you feel pain begin). Repeat for 6 sets resting one minute between sets. Train around the painful area of movement. By training around the areas of pain this allows you to actually effect the injured area since there is a physiologic overlap of about 15 degrees beyond the ROM, to each side of the area you training. 6 Once you have obtained 80% of your AROM most physicians will instruct you to proceed to the next phase.
Phase 4 Slow - complete movement (isotonic)
Fast - partial movement (isokinetic)
Slow movement with weight, full range of motion. Then shorter movements with quick contractions in the middle of the ROM.
See illustration (a picture here of a curl with the whole ROM in blue, like a sweep, with a middle range of motion in red would-demonstraighting movement in the center about 60 degrees, would be easiest to understand)
Phase 5 Fast - complete movement (isokinetic)
Special machines called Orthotrons (Orth-o-trons) are designed to allow you to exercise over a particular range of motion at a particular speed. This is where the value of a well equipped rehab facility and a well trained physical therapist is judged. You aren’t likely to find machines like this in a gym, they are very expensive.
Slow movement (six seconds concentric-up, six seconds eccentric-down).
mid-Fast movement (two seconds concentric, two seconds eccentric).
Fast movement (less than one second concentric, less than one second eccentric).
~~Wondering if the slow movement (Constant motion-NO SHOCK) really works, Joe Montana returned to the football field very quickly when it was used on his lower back injury. ~~
Eventually you want to move explosively fast, slowly increase your speed as well. This helps coordinate the muscles to work together at faster speeds which resembles true athletic activity and causes the muscles to grow in a way that strengthens there connective tissue. Realistically, you should train like this at least once a month for the rest of your life to work on only explosive (plyometric) movements. For example if you typically bench 315 then you should try doing 135 for 8 sets of 8 reps with only 30 seconds between sets. Moving the bench press so fast that you are doing about two reps per second. This plyometric training thickens the ligaments and tendons. It is necessary to do this to improve the strength of the area. You can also judge it by doing a push up and trying to clap your hands after you have pushed yourself off the ground. As you improve you can try to clap your hands twice before lowering back to the ground. I have never seen a shoulder problem exist after an athlete can clap twice on a push up for 25 reps.
USING STRAPS FOR SPEED
Training with rubber straps will allow for constant tension during high speed training. You must have some experience using them and one of the best groups around to explain this is Westside Barbell and Elete Fitness Systems. Look you can either buy the straps for less than a hundred bucks or buy an Orthotron machine starting around $200,000.
Contact them at http://elitefitnesssystems.com/
Lastly, the importance of training for speed is involved with the speed of the shoulder. You need to coordinate your muscles to work at higher speeds. Explosiveness is more important than strength in any sport. Ever try to stop a tiny “speeding” bullet?
Putting together your functional rehabilitation program
Weight, Sets and Reps: Get out the calculator and the pencil cause here comes the math. Start with how often you should train an injured joint? In a study done by Matthews in 1957 and redone in 1981, research found that if you rehabilitate 5 days a week is more beneficial than only training 4 or 3 days a week. Both studies only used a five day work week not a six or seven day program (couldn’t get the researchers to work weekends). Since Dr. Don Matthews was a professor and friend of mine, I feel that I can extrapolate off this study and suggest that you work the injured area 7 days a week until you reach phase 5, then reduce to 3 then 2 days a week. You can train more frequent due to the reduced intensity of rehabilitation and your body will recover much faster than doing high intensity body- building.
More technical stuff
Zinovieff, DeLorme-Watkin and McQueen are just a few of the techniques that explain how many Sets, Reps and the amount of weight you should use. They all base their principles on the progressive resistive theory. In general, most recommend ten repetition maximum. As far as how much weight to use? Enough to just get ten reps! Real tough, Huh? Some of the best results increase the number of sets you perform as your shoulder strengthens. In other words, you start with doing 3 sets, once you are able to perform 11 reps on your last set, simply add a set until you are doing 5 sets. When you can perform 11 reps on your last set, then add 1 to 1.5 pounds and drop your sets back to 3. This allows you to work on strength first and then develop speed and endurance. One of the important factors in healing an injury is to promote increased circulation in the scar tissue. Remember, if you are board with your rehab program, you are probably right on track. You should always leave and feel that you could do more.
Here is an example of how a program should progress:
Exercises: Dips, cable cross-overs, reverse bench press and Pullovers.
Day 1 2 3 4 5 6 7
Weight (#'s) 10 10 10 10 11 11 11
Sets 3 4 4 5 3 3 4
Reps 10-10-11 10-10-10-8 10-10-10-10 10-10-10-10-11 10-10-8 10-10-10 10-10-10-10
Speed slow slow slow slow faster fast fast
OTHER EXERCISES THAT ARE USEFUL ARE:
Floor Presses are done by lying on the floor with your legs straight, lowering the weight and resting/relaxing on the elbows for a second then pushing the weight up. Similar to box squats. It is sort of a plyometric training that allows for increased coordination of the muscles and increased fiber recruitment. This exercise can be modified by returning to the bench and placing various thickness of boards on your chest and resting the weight on the board, then quickly pressing the weight off. This technique is commonly used by the members of Lou Simmons's West Side Barbell (Where most world record holders train), who also constantly vary their grip. Simply find your weak point in the movement of the bench press or military press and work on the plyometric program from there. This is also sometimes referred to as pin presses however the use of a cage and pins is not as realistic as the free form bench press movement. Remember that this is a quick movement and requires you to be in the Phase 5 level of rehab. You must lower the weight slowly to the floor and then explode the weight to the top. This is great for a majority of injuries such as the Torn Pec, separated A-C, rotator cuff tear, etc.
Use bands to train
Pullovers- (Straight Arm) exercise works the coricobachialis, which is responsible for a majority of the stabilization of the A-C joint.
Bicep Curls- should be modified to bring the bar to your forehead at the end of the movement. The bicep helps stabilize the A-C joint better when the arc of the movement ends with the bar at your eyebrows.
Rotator Cuff Roll - see prior description in this article.
Reverse grip Bench press-Like it says your grip is backwards, this forces you to keep your elbows in to your sides and lower the bar to your stomach, (hint, this movement will help you overcome bad bench techniques which halt your progress) varied width is also used on this movement.
Dumbbell Fly/Press- which ever hurts the most.
Once your strength is approximately 80% of your preinjury strength it is time to increase your speed of movement (phase 4).
Partial movements/Lock-outs Bench press- by simply holding more weight than you normally bench as a PR, you build psychological confidence and you will stabilize the golgi-tendon organs (little switches located in your tendons that tell your brain that the weight is to heavy and cause your muscle to let go). It is very important to overload after an injury since the golgi-tendon organ is very hypersensitive to weight.
That's it No tricks, No gimmicks, just hard work and lots of it. Each program requires some modification so check with your physician if you note any of the following:
•Pain in the chest (clutching-type pain)
•Radiating pain in the arms, wrist or hands.
•Any numbness
•If your strength doesn't increase 14% in 4 weeks
Continue utilizing the suggested exercises until you die or the take the evening news off the air, which ever comes first. You may be avoiding Bench day or hate shoulder day since the strength is gone or the pain is too much. Try the above stated program in its entirety; you have a lot to lose if you don't. Many of the principles explained will apply to the rehabilitation of all the joints after injury. I recommend that you discuss you progress with your physician to best accommodate your exercise program.
Working out with less pain
Several other medical approaches may assist with a more painless workout.
Arthroscopic surgery-is a simple technique of cleaning off the rough edges on the tissues to allow them to work with less friction. Recovery is quick and usually uncomplicated.
Acupuncture – needles!!!! Calm down, it is painless, this technique uses the stimulation of some nerves to calm others down, this is a retraining treatment and requires several visits to work; however, you should see some improvement within a few visits. A word of caution, states vary in their requirements for license. Some of the best training is with Doctors of Oriental Medicine (DOM) and MD or DO and DC’s. Several Medical schools are beginning to teach this technique. Remember the Chinese have used this as a main form of medicine for over 11,000 years.
Supplements-Most effective from the literature and my personal experience are products with Glucosamine Sulfate and Chondrotin Sulfate and MSM (Organic Sulfur). Now please note you shouldn’t take herbs with medications unless you check with your pharmacists. Not your doctor-your pharmacist. Also note that taking NSAID’s (Advil, Motrin, Ibuprophin-containing drugs) will lower your Sulfur content and cause more scar tissue to form and also lower the effectiveness of the aforementioned chemicals. Note also that the Center for Disease Control, Atlanta, GA. Indicated that in 1998, that 16,500 deaths were associated with the use of NSAID’s. Bextra is a newer NSAID that is out, which is 4000 times more selective, meaning that it leaves your heart and stomach alone.
Bio
Dr. David Ryan, practices in Columbus, Ohio at the Columbus Chiropractic Centers and was a team physician for three of the capital cities' pro teams. Medical Director, Arnold Classic and Fitness Expo, the 1994/1995 WPC World Powerlifting Championships. Ring side Physician USA BOXING. Former assistant Strength Coach, Ohio State University. In 1994 the Arthritis Foundation honored him with a national award. He also works with professional football, basketball, rodeo and various professional and Olympic athletes. Send questions in a self addressed/stamped envelope to 5870 Cleveland Ave. Columbus, Ohio 43231
Dr. Richard Fisher (Orthopedic Surgeon) practices in Columbus, Ohio (again, thank god) he is the orthopedic director of the Arnold Classic/Expo.
Bibliography
1. Gray, H., Goss, C.M. (Ed.): GRAY'S ANATOMY, PHILADELPHIA,
PENNSYLVANIA: Lea & Frebiger, 1976.
2. O'Donaghue, D.: TREATMENT OF INJURIES TO ATHLETES,
PHILADELPHIA, PENNSYLVANIA: W.B. Saunders, 1976.
3. Hellerbandt, F.A., et al: Influence of Bilateral Exercise on
Unilateral Work Capacity. Journal of Applied Physiology, 2:
446-452, 1950.
4. Moore, J.: Excitation Overflow; An Electomyographic Investigation
Archives of Physical Medicine and Rehabilitation, 56:115-
120,1975.
5. Videman, T.: Experimental Models of Osteorthritis: Role of
Immobilization. Clinical Biomechanics, 2: 223-229, 1987
6. Davies, G.J.: Compendium of Isokinetics, S & S Publishers, 1984.
Suggested Reading
Voss. D., et al: Proprioceptive Neurofacilitation: Patterns &
Techniques. PHILADELPHIA, PENNSYLVANIA: Harper & Rowe, 1985.
Glossary
Tendon-The tissue the connects the muscle to the bone.
Rehabilitation-Scientifically designed exercise program for injuries or illnesses.
Arthritis-Deterioration of cartilage and general wear on the joint surfaces, due to a ligament's instability.
Atrophy-Shrinking of tissues like muscles.
Range of motion-The distance that a joint allows the bones to move in.
PNF- Proprioceptive Neurofacilitation, a complex stretching technique (read the book).
