Shoulder Stability in the Overhead Athlete
Shoulder pain is a commonly occurring musculoskeletal complaint, second only to back pain ( Ginn 1997 ). Overhand sports such as swimming, tennis, cricket and softball require extremes in shoulder range of motion. To achieve peak performance in the athletic shoulder there must be an optimal balance between mobility and stability.
Excessive range of motion and the repetitive nature of the majority of these sports challenges the shoulder complex stability. The want of mobility in the athlete often disrupts the need for stability. Carter Rowe likens the head of the humerus in relation to the glenoid, to a seal balancing a ball off his nose!
The trade off of mobility at the expense of stability is the issue at stake in the overhead athletes, which is different to the older non athletic population whom are often dealing with degenerative processes such as spur formation and decreased subacromial space (Jobe, Pink 1991 ). One of the major implications of these modifications in athletes to increase mobility is that the shoulder region relies on muscles, more than any other region of the body, to provide adequate stability. There are 26 muscle groups controlling the shoulder girdle, with the four rotator cuff muscles playing a significant role in the dynamic stability of the glenohumeral joint ( Carr 1996 ). The repetitive nature of these activities leads to microtrauma which in turn results in instability. In the majority of athletes this instability leads to an anterior subluxation which in turn causes an impingement of the rotator cuff tendons against the coracoacromial arch. Thus the instability continuum is born ( Jobe, Pink 1991 ).
overuse ® microtrauma ® instability ® subluxation
® impingement ® rotator cuff tear
This instability must be stopped and balance restored before anatomical damage occurs. The stable base must be provided by the scapular musculature as well as the rotator cuff muscles.
Marilyn Pink, Frank Jobe and colleagues from Inglewood , California preformed two studys to determine which exercises most effectively used the scapular and glenohumeral muscles. As a result of this study these authors came up with core of exercises to provide a shoulder girdle strengthening programme.
This research proposes to investigate if there is a difference in improved shoulder function following the prescription of this core exercise programme as compared to a control group.
The proposed purpose of this research is to investigate if the exercise programme as described by Pink et al improves the functional scores in the shoulders of a group of high performance overhead athletes with shoulder pain, as compared to a control group whom also have pain, but will continue doing what they usually do. This will be measured by a shoulder function assessment.
The hypothesis is that there will be a significant improvement in the shoulder function of the athletes following the exercise programmes. And secondly, that the group utilising the strengthening exercises will be significantly better than the control group.
There are numerous shoulder problems in athletes, which the literature largely reports as a result of glenohumeral and scapular instability. Shoulder pain affects the ability of athletes to perform, and can also affect the ability of the wider community to work or function independently. Effective treatment of shoulder disorders could reduce the time out of the competitive field for the athlete, or time lost from work in the non athlete -which has important socioeconomic implications.
There are very few well designed clinical studies that evaluate the efficacy of physiotherapy in the treatment of individuals with shoulder pain. A recent review identified eighteen randomised, controlled clinical trials of physiotherapy for shoulder pain. Only one of these trials demonstrated that physiotherapy was effective. However, the reviewers concluded that because of the poor quality of these studies, the effectiveness of physiotherapy for the painful shoulder could not be accurately assessed (Ginn 1997 ).
The core shoulder programme as described by Pink et al is very easily demonstrated and utilised within the clinical practise of any physiotherapist. These exercise do not require expensive, specialist equipment and can be easily done as a home programme. The exercise are easy for athletes and their coaches to understand, and can also be modified for particularly acute situations or progressed as maintenance programmes.
The proposed study aims to help qualify the appropriateness and success of the core exercise programme, that Pink and colleagues claims to have close to 100% success rate (Pink et al 1991 ). This study could then lead on to further studies to develop the optimal protocol based on the findings of this study.
This study will be aimed at the overhead athlete with shoulder dysfunction, and in particular instability. The main focus is to see if consistent use of the core exercises in the athletes training programme will reduce the incidence and intensity of shoulder pain.
If there are positive outcomes with this study these exercise could be used both in the rehabilitation and prophylactic phases for athletes.
Review of Literature
In order to investigate the usage of strengthening exercises around the shoulder girdle in the rehabilitation of shoulder pain the following areas will be reviewed:
1/ The normal shoulder complex.
2/ The overhead athletes shoulder.
3/ Mechanisms of shoulder instability.
4/ Review of shoulder rehabilitation protocols.
5/ Core exercises as described by Marilyn Pink et al.
The Normal Shoulder Complex
The glenohumeral joint is highly mobile, and this mobility is particularly evident in the overhead athletes. This mobility requires a stable base, and the success of this shoulder complex is largely dependent on the relationship of the scapula and the humerus. The stability is provided by a complex interaction of the static stabilisers (non contractile elements ) and the dynamic stabilisers ( contractile elements ).
a) Static Stabilisers
These include the capsule, ligaments labrum and to small degree bony constraints. The glenohumeral ligaments are thickenings in the capsule, and Turkel et al, 1981, have shown that the inferior ligament is the primary restraint to excessive anterior translation of the humerus on the glenoid with 90 degrees abduction and maximal external rotation. The coracohumeral ligament plays a role in controlling the extent of inferior translation of the adducted arm.
Vangsness et al, 1995, have documented the presence of neuroreceptors in the glenohumeral ligaments, and in the unstable shoulder there is loss of proprioceptor and joint position sense.
Recent studies have described the role of negative intra-articular pressure in maintaining joint stability. Habermyer et al have shown a negative pressure of approximately 30 mmHg exists in a stable shoulder, providing a suction cup effect.
The glenoid labrum is a fibrocartilaginous structure, with a primary function of circumferentially deepening the socket, effectively increasing the stability by elevating the glenoid rim. The second function is to act as the anchor of the capsular ligaments to the glenoid rim.
Articulation between the humeral head and the glenoid fossa is highly conforming, yet allows for substantial mobility while offering little inherent stability (Ticker 1995 ). Kelkar et al demonstrated that the motion of the glenohumeral joint may be described as a ball and socket articulation with small translation of the humeral head center through the large range of shoulder motion. In this conformation, contact on the glenoid surface remains relatively uniform, whereas contact on the humeral head is focal and migrates over its surface during joint motion (Bigliani 1996 ).
The exact roles of ligaments, labrum and intra-articular pressure on maintaining glenohumeral joint stability remains controversial. However, there are clear indications that injury to the inferior ligament complex disrupts these mechanisms causing instability.
b) Dynamic Stabilisers
The static restraints are generally lax during motion in functional ranges and the dynamic stabilisers maintain stability. Dynamic stabilisers primarily include the muscles of the rotator cuff and the long head of biceps. They function to provide maximal range of motion during overhead activity within the range of glenohumeral stability. The rotator cuff muscle – tendon unit provides stability to the shoulder by providing a dynamic compressive load to the shoulder joint. The supraspinatus acts to maintain the humeral head centred in the glenoid, serving as a dynamic stabiliser against superior translation of the humeral head. The infraspinatus and teres minor complex, the primary external rotators of the humerus, assist in maintaining and stabilising the glenohumeral articulation by pulling the humeral head posteriorly. The subscapularis muscle, the internal rotator of the cuff, functions in the anterior direction, but is less effective if the arm is in 90 degrees of abduction. The long head of biceps plays a role as a humeral head depressor ( Ticker 1995).
At extremes of motion, when the ligaments and capsule become taut, both the static and dynamic restraints function to maintain glenohumeral stability. When the static stabilisers are disrupted, the rotator cuff muscles can in some circumstances maintain joint stability. Scapular stabilisers also play an important role in providing a stable base for the shoulder girdle and provide optimal orientation for the glenoid in overhead activities (Shea 1996 ).
The Overhead Athletes Shoulder
Athletes often demand maximum function, both mobility and stability, as well as placing extraordinary stresses on the glenohumeral joint. Participants in sports such as baseball, tennis or golf require similar motions in the overhead position. The throwing motion can be divided into five phases; wind up, early cocking, late cocking, acceleration and follow through. During early cocking abduction and external rotation begins, with this maximising at late cocking. Significant torques and forces are placed on the shoulder restraints at this extreme range of motion. Electromyography studies have shown peak activity of the rotator cuff to both externally rotate and stabilise the humeral head, while studies of the inferior glenohumeral complex using strain gauges have demonstrated its important function in similar positions (Ticker 1995 ). Acceleration is generated by the contraction of the internal rotators while follow through is characterised by the deceleration of the arm and body. All the major muscles are involved eccentrically to accomplish this deceleration. Swimming involves a similar overhead movement, albeit with reduced velocity.
Isokinetic shoulder muscle strength has been evaluated in pain free overhead athletes and it has been reported that the ratio between external and internal rotational strength based on concentric isokenetic strength testing is 0.75 in control subjects and 0.64 in swimmers. (This is a statistically significant difference.). Whether the imbalance is associated with injury or is a normal result of excessive overhead activity remains unknown ( Bak 1997 ).
Several studies have shown that overhead athletes exhibit increased external rotation at the expense of internal rotation as compared with normalised data. Warner et al, 1990, found anterior instability was associated with excessive external rotation and decreased internal rotation. Limited internal rotation is thought to be a consequence of posterior capsular or cuff tightness, but the relationship of pain to changes in range of motion remains controversial.
The shoulder joint of the swimmer must withstand repetitive microtrauma and is subject to overuse syndromes. There are three unavoidable factors influencing swimmers shoulders for all ages and levels;
- extremely high rate of shoulder revolutions
- swimming takes shoulder to extremes of range of motion
- swimming requires generation of high muscular forces on the shoulder
Other factors that literature has implicated include; breathing side, hand paddles, increased intensity or volume.
Fine wire EMG studies have demonstrated the contribution of various shoulder muscles to the swimming stroke. Similar to non-aquatic overhead athletes, swimmers demonstrated shifts in the ratios of rotator cuff coupled muscles. The adaptive shifts resulted in a dominance of adduction and internal rotation. In athletes with a stable shoulder, these normal adaptations appear to be well tolerated ( McMasters 1996 ).
Competitive swimmers cover 10-14kms per day, 6-7 days per week. This equates to 16,000 shoulder revolutions per week. Comparably, there are approximately 1000 revolutions per week for a professional tennis player or baseball pitcher, 300 revolutions for a javelin thrower and 200 for professional golfer. Shoulder problems are reported in 66% of elite swimmers, 57% professional pitchers, 44% college volleyball players, 29% javelin throwers and 7% of professional golfers (Johnson 1988 ).
Mechanisms of Shoulder Instability
Glenohumeral instability represents a spectrum of disorders, from shoulder subluxation which is the symptomatic translation of the humeral head relative to the glenoid, to a dislocation, which is translation to the point of complete separation of articular surfaces (Allen 1995 ).
The term minor instability refers to a condition in which chronic microtrauma involving the stabilising mechanisms of the glenohumeral joint leads to subluxation of the humeral head ( O’Brien 1989 ). This condition is commonly associated with athletes involved in repetitive, high velocity activities such as throwing or swimming. The condition may be the result of altered structural integrity or to muscle imbalance or inco-ordination of the glenohumeral and scapulothoracic complex. This all leads to inadequate maintenance of the position of the humeral head against the glenoid during activity (Magaary 1992 ).
Recurrent shoulder instability usually develops after an initial traumatic anterior dislocation or subluxation. In others the initial dislocation may be less traumatic and may occur during activities such as swimming, volleyball or weight lifting. In each situation the arm is abducted and externally rotated to the point that the glenohumeral ligaments tear and the shoulder either subluxates or dislocates.
When an athlete sustains an initial episode of instability, permanent damage to the inferior glenohumeral ligament complex is likely to occur, through a stretching or lengthening mechanism, resulting in recurrent instability. Bigliani et al suggests additional elongation of this ligament may occur with each subsequent episode of instability. Thus, the instability can become progressively worse. Epidemiological studies have shown that in active athletes, the incidence of recurrent instability after an initial anterior shoulder dislocation is between 90-95%.
The traditional classification of shoulder instability is based on the direction, degree, frequency and cause of glenohumeral instability. The degree of instability can reflect the pathology at the tissues. A dislocation results from high loads and usually requires manipulation to reduce. Subluxation is characterised by abnormal translation of the humeral head on the glenoid, and is increasingly being recognised in the overhead athlete.
Repetitive microtrauma to the soft tissues restraints can lead to instability. If any of the restraints are unable to function correctly because of stretching or damage, excessive translation can occur and result in injury.
Evidence suggests that instability is a common denominator in a variety of athletic shoulder complaints, including tear of the glenoid labrum ( Bankart lesion ), sub acromial bursitis and rotator cuff tendonitis associated with impingement syndrome. Impingement may result in tendonitis, and simply treating this without addressing the underlying instability is futile. In the unstable shoulder the external rotators will be required to do additional work to restrain the humeral head against anterior translation, leading to an overload fatigue and secondary inflammation. This may account for the common complaint of posterior pain.
Review of Rehabilitation Programmes
The primary goal of shoulder rehabilitation programmes for the overhead athlete is to return the athlete to pain free function in the shortest time period, allowing them to maximise performance and avoid future problems.
Rehabilitation of the athletes shoulder involves a number of steps. In the acute phase following injury pain and inflammation must be adequately controlled before the athlete can progress in the programme. If there has been a dislocation or a severe subluxation a period of immobility may be necessary to allow healing of the capsular tissue. Without going into specific details, strengthening of the internal and external rotators should start with the arm in low levels of abduction, positions that avoid impingement, and then progress to 90 degrees of abduction.
Once a certain amount of strength is gained by the rotator cuff muscles the prime movers eg. deltoid, latisumus dorsi and pectorals are strengthened, starting with the most posterior component and then progressing anterior. In this way the weaker external rotators that are located posteriorly are protected until muscle balance and glenohumeral stability are achieved ( Ticker 1995 ). Functional training, specific movement patterns and proprioceptive training are incorporated in the later stages of the programme as certain milestones are achieved.
Multidirectional instability rehabilitation focuses on the strengthening and improving the endurance of the dynamic stabilisers and scapular musculature. These scapular muscles stabilise the scapular on the thorax and provide a stable platform for the humerus. A rehabilitation programme can be designed working from positions in which control is maintained with progression to more difficult positions ( Magery and Jones 1992 ). Using wobble boards and Swiss balls through weight bearing positions of the arm help to facilitate stability and kinaesthetic sense.
For the overhead athlete that is involved in throwing and swinging, attention of the overall conditioning of the accessory muscles such as abdominals, gluts and paraspinal muscles should take place ( Bak 1997 ).
The rehabilitation programme will not only involve strengthening exercises but also some stretching exercises. For swimmers maintaining adequate flexibility is necessary since it permits maximal stroke efficiency, however caution should be implemented so as to not overstretch, especially in the anterior capsule of the shoulder. Coaches and athletes should steer clear of the notion that greater flexibility will guarantee injury free swimming and adhere to the idea that mobility must strike a balance with stability ( Stocker 1995 ).
Core Exercises as Described by Marilyn Pink et al.
In 1991 and 1992 Marilyn Pink and others including the likes of Frank Jobe and Bruce Moseley did two electromyography analysis of the glenohumeral and scapular muscles during a shoulder rehabilitation programme. One study concentrated on how the muscles responsible for humeral motion can best be exercised in a rehabilitation programme for the throwing athlete, and the other study was designed to determine which exercises most effectively used the scapular muscles.
From the information on the functioning of the shoulder complex it is well established that both the glenohumeral joint and the scapular thoracic complex are crucial in the performance of overhead activities.
a) In the glenohumeral muscle study, dynamic, fine wire, intramuscular electromyography was carried out in 15 normal male volunteers performing 17 shoulder exercises derived from a shoulder rehabilitation programme used from professional baseball clubs. The four rotator cuff muscles were studied, as well as the pectoralis major, latissimus dorsi and the three portions of the deltoid. The EMG activity was synchronised with cinematography and averaged over 30 degree arcs of motion. An exercise was considered to be a significant challenge for a muscle if it generated at least 50% of it’s predetermined maximal contraction over 90 degrees. Four exercises were consistently found to be among the most challenging exercises for every muscle. These shoulder exercises consisted of; 1/ elevation in the scapular plane with internal rotation 2/ flexion in the sagittal plane, 3/ horizontal abduction with external rotation and 4/ press up.
This study concluded that these exercise would be a minimum for an effective rehabilitation for the glenohumeral muscles.
b) In the scapular muscles study, 8 muscles in 9 subjects were studied in a similar way while performing 16 exercises. The muscles included; upper, middle and lower trapezius, levator scapula, rhomboids, pectoralis minor and middle and lower serratus anterior. A group of 4 exercises were shown to make up the core of a scapular muscle strengthening programme. These included; 1/ scaption ( scapular plane elevation), 2/ rowing, 3/ push up with a plus and 4/ press up.
From these two studies a combination of a rehabilitation programme for the scapular and glenohumeral musculature could be developed. This would include the exercise;
1/ Scaption – with internal rotation
2/ Scaption – with external rotation
3/ Horizontal abduction with external rotation
5/ Push-up with a plus
6/ Press up
Literature Review Summary
The shoulder complex is characterised foremost by its mobility and ability to perform activities in several planes for activities of daily life as well as the extreme demands of high performance overhead athletes such as swimmers and throwers. This mobility comes at a cost of instability, and the key in optimal performance is the balance of the two. In the absence of bony congruency capsular ligaments are heavily relied on for static stability while the musculature of the rotator cuff are imperative in providing the dynamic stability. This dynamic stability becomes increasingly important in the athlete who through microtrauma may have developed capsular laxity. This stability requires a stable base and is largely dependent on the relationship of the scapular and the humerus.
Until recently most of the information available on how to exercise specific shoulder girdle musculature has been based on anatomical and biomechanical knowledge, rather than quantifiable data such as electromyography. Through EMG analysis a core exercise programme for the rehabilitation of the glenohumeral and scapular musculature has been developed by Marilyn Pink and colleagues.
Using this type of strengthening programme along with additional functional and proprioceptive training, literature suggests shoulder function can be restored and maintained in the overhead athletes.
Given this information from the literature reveiw with regards to the importance of the dynamic stabilisers of the shoulder complex, the optimal regime to strengthen these structures has great significance to the athletes as well as the greater community.
This is to be a prospective, randomised clinical trial over an 8 week period. This design will be single blinded.
40 male or female overhead athletes with a history of unilateral shoulder pain will be used. These athletes will be taken from a sample of convenience from advertising at local swimming, cricket, athletics, golf and racket clubs on the North Shore.
The inclusion criteria will be as follows:
- Over 15 years of age
- Competing at top club or district level, (at minimum)
- No present treatment being received
- Consent given by Coach to partake in trial
Subjects will be excluded if the shoulder pain is due acute inflammation or neoplastic disorders, pain was referred from vertebral column structures, pain was due to trauma within the previous 4 weeks or was bilateral. Subjects will also be excluded if they experience moderate to high irritability with the execution of the exercises.
Subjects will be specifically instructed not to alter any of their training regimes while participating in this study.
Prior to participation, each subject will read and sign a written informed consent form approved by the ethics committee of AIT. Along with the informed consent form will be a detailed description of the research protocol and the reason for the research. Each subject will be fully aware that when they enter the research there will be a 50% chance that they be in a group which does not receive any form of rehabilitation. It will be made clear to the subjects that they can leave the study at any time and no discriminatory action will be taken against them.
Procedures and Equipment
All 40 subjects will undergo a standardised Constant and Murley Functional Shoulder Assessment ( Constant and Murley 1985 ) with one slight adjustment in the strength/power assessment. This is scored out of 25 points and instead of using 25 pounds as the maximum amount it would be better to use the non painful shoulder to determine the maximum amount and then get a percentage of this to get a score out of 25 for the painful shoulder. This will be evaluated by an independent post graduate physiotherapist that is familiar with this assessment. Concluding this each subject will have functional rating out of 100 points for their painful shoulder.
Reliability and Validity
The Constant and Murley Functional Shoulder Assessment is applicable irrespective of the pathology and provides an overall clinical functional assessment. It is accurately reproducible by different observers and is sufficiently sensitive to reveal even small changes in function. The method is easy to perform and requires minimal amount of time or specialist equipment ( Constant and Murley 1985 ). In the article describing this method, the authors discuss both the validity and reliability of this measure. For further information this original article should be sourced.
Following the assessment, each of the subjects will be allocated to either the control group or the experimental group. This will be done randomly by placing 20 labels marked “control” and 20 labels marked “experimental” into a hat, and having each subject pull out a lable. The hat will be shaken between each selection.
a) Control Group
These subjects will be told to continue doing exactly whatever it is they are currently doing over the next 8 week period.
b) Experimental Group
These subjects will be given a teaching session on how to perform each of the 6 exercises as described by Marilyn Pink;
1/ Scaption – with internal rotation
2/ Scaption – with external rotation
3/ Horizontal abduction with external rotation
5/ Push-up with a plus
6/ Press up
Each subject would not leave this teaching session until the instructor was satisfied they understood, and they were able perform these exercises in their home or training environment. A weight would be established for each of the exercises for each individual by the instructor during this teaching session.
Subjects were instructed to do these 6 exercises Monday, Wednesday, Friday and once in the weekend, giving a total of 4 times each week. Each exercise was to be done using 3 sets of 10 reps with 60-90 seconds rest between each set. No particular order was determined.
After 4 weeks the experimental group returned to confirm they were doing the exercises correctly and progress the loads as the instructor and subject saw fit.
At the end of the 8 week period all 40 subjects would return and be re-evaluated by the same physiotherapist that evaluated them in the initial stage, using the same functional scoring assessment. This therapist would be blinded to the fact whether the subject was in the experimental or control group.
The resultant scores out of 100 in the functional assessment pre and post the experimental time frame would be compared for each of the 40 subjects. This would be done via a paired t test, whereby the difference would be tested by a one sample t test.
The t test would be applied to the experimental group and the control group. From this, with alpha at 0.05, would could test the hypothesis that there is no difference between pre and post values of all subjects.
We would then do an independent t-test on the difference means by group ( control or experimental). This would test the hypothesis that there is no difference between each of the control and experimental groups.
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Katrina is a NZ trained physio holding a Masters degree. She is one of the few qualified Manipulative Physiotherapists on the beautiful Sunshine Coast in Australia.
Still a strong All Blacks New Zealand Rugby supporter, (we will forgive her for that!!) Katrina enjoys what the coast offers, paddling and swimming regularly with the Maroochydore SLSC. As a former international athlete (1992 World Surf Ski Champion), a national kayak coach and a recent finisher of the Coolangatta Gold, Katrina has a very good understanding of the athletic body and the need to keep training. Kat’s passion is her two dogs, Mana and Kia. Her canine and physio interests combined in completing a Level 1 Canine Physio course last year, and she is very happy to exchange ideas about your four legged family members.
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