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Stabilizing the Shoulder Blade & Joint

ahorschig

Welcome back to Squat University. Last week I introduced a blog series on improving shoulder stability by addressing a weak serratus anterior muscle. This week we’re going to move on and discuss a few other important muscles: the rotator cuff, rhomboids and trapezius.

Today I want to share with you a few exercises that will help address deficits in strength, endurance and coordination of these muscles that lead to instability and poor mechanics of the shoulder.

Many of the exercises discussed today will be performed with a paused hold at certain ranges of the movement. This action allows you to emphasize shoulder stability. Remember strength is not the same as stability.

Strength is your ability to produce force whereas stability is your ability to limit excessive or unwanted motion. If a muscle is strong but can’t maintain adequate tension and work in coordination with the other surrounding muscles, joint mechanics will breakdown and injury can ensue.

Stability also requires muscular endurance. This is why many corrective exercises to enhance stability are performed with high repetition sets at first. This will help build the capacity of these muscles to “turn on” and maintain adequate stability for your first to last sets in a training session, as well as during the everyday movements outside of the gym thereafter. A lack of endurance to create sufficient stability is a reason why many injuries occur in the 2nd half or later portion of many athletic matches (such as a soccer or football game).

Side-Lying External Rotation  

Research has shown that the posterior rotator cuff muscles (infraspinatus and teres minor) are most efficiently activated with the simple side-lying external rotation exercise.1,2 These two muscles keep the humerus bone compressed and centered in the joint socket during arm movement (keeping the golf ball centered on the golf tee).

Assume a side-lying position with a towel roll pinned between your top side arm and rib cage (this will help place your arm in the optimal position).1 Start with your arm parallel to the floor and shoulder blade pulled back and down (scapular retraction and depression). Without allowing your shoulder blade to move, pull your hand up towards the sky (the motion of external rotation) before returning back down.

Recommended sets/reps: 2-3 sets of 15-20 reps

Depending on your current level of strength you may need to perform this exercise at first with no weight. Once you are able to perform the recommended sets and reps without significant fatigue or pain, start adding weight.

If you are unable to externally rotate through a full range of motion due to shoulder pain, you can start with partial reps within a pain free zone. These “short arc” motions will allow you still benefit without furthering the injury process and increasing symptoms. As pain subsides, continue to progress how far you can externally rotate without pain as you increase the resistance.

Banded “W” 

One of my favorite exercises that I perform on a daily basis during my own warm-ups (regardless if I’m performing any of the Olympic lifts or squatting) is the Banded “W.” This progression from the previous Side-Lying External Rotation exercise not only addresses rotator cuff strength and stability but also activates the often underutilized lower portion of the trapezius muscle.3

One of the most common imbalances seen in athletes is between the upper and lower trapezius muscle fibers. The upper traps are highly active during movements such as the pulling motion of the clean and snatch and therefore have a tendency to become over dominant and can lead to poor mechanics of the shoulder complex. Research has shown that performing the Banded “W” is one of the best exercises for concentrating on the lower traps to address this imbalance.3

Start by grabbing an elastic band in both hands with your arms held by your side and elbows bent to a 90-degree “L” position. Your thumbs can be facing upward or out away from your body. As you pull your hands out to the side against the band resistance (the motion of external rotation) make sure your elbows remain in the same bent position by your ribs.

Hold the end position for 5-10 seconds before returning back to the start.

Recommended sets/reps: 2-3 sets of 15-20 reps

External Rotation Press

While the prior two exercises are great at strengthening the posterior rotator cuff, many of the movements an athlete performs in a training session take place above shoulder height in positions where the joint is more vulnerable to instability and injury. For this reason, corrective exercises to enhance shoulder stability must also be performed at different angles of shoulder elevation.

Start by grabbing a resistance band tied around a rig or rack. Pull the band towards you in a rowing motion. Your hand should finish directly in front of your elbow with your arm parallel to the ground. This will lock your shoulder blade into a good position by activating muscles like the rhomboids and middle portions of the trapezius.2 Hold this position for 3 seconds.

Next, rotate the shoulder backwards (the motion of external rotation). This will activate the posterior rotator cuff (particularly the infraspinatus) in a similar manner to the turnover catch phase of a snatch.13Your hand should now be facing the ceiling with your elbow bent to 90 degrees like an “L”. Make sure the shoulder blade does not move at all during this rotation and again hold this end position for 3 seconds.

Last, push your hand overhead and hold in this end position for another 3 seconds (if you perform the Olympic lifts, your hand should be ideally stacked directly over the back of your head to mimic the barbell jerk). With your arm extended the muscles that stabilize the shoulder blade will be working hard against the band resistance to keep your arm from falling forward. Interestingly enough, this exercise not only recruits the rotator cuff but also produces a high degree of serratus anterior activation in order to help stabilize the shoulder blade against the rib cage.2,4

After the small hold, reverse the pattern with the same pauses in each position as you return to the start. Lower the arm to the “L” position. Rotate forward until your arm is parallel to the ground. Finally, press your arm forward to end the movement.

Recommended Sets/Reps: 2-3 sets of 10 repetitions

Prone Lateral Raise

As I mentioned before, one of the most common muscular imbalances athletes present with is upper trap dominance. Another great exercise to strengthen the lower and middle portions of the trapezius muscle is the prone lateral raise.

Start by lying on your stomach with your arm hanging off a bed or bench. With your elbow locked in a straight position raise your arm to the side, ending with it parallel to the ground (as if making one side of a “T”). As you raise your arm, think about simultaneously pulling your shoulder blade in towards your spine (the motion of scapular retraction). You can perform this exercise with your palm facing the ground or with your thumb pointed towards the ceiling (the motion of shoulder of external rotation) for added difficulty. Hold the end position for 3-5 seconds before lowering back down.

Recommended sets/reps: 2-3 sets of 15-20 reps

Prone Floor Angel

Start by lying on your stomach with your hands positioned by your hips and palms facing down. With your elbows locked in a straight position, pull your hands off the ground as you simultaneously squeeze your shoulder blades together. This motion of shoulder extension is great at activating the rhomboid muscles of your mid back that help control your shoulder blade.2

While keeping your shoulder blades pulled together and depressed, rotate your hands upward into what will end up looking like a back squat hold position. Next, push your hands above your head as far as you can (this will mimic the motion of a standing barbell press). Once your arms are fully extended, rotate your arms upward so that your palms are now facing towards the sky.

From this position, raise both arms off the ground as far as you can (making sure your elbows remain straight).  After holding for 3 seconds, lower your arms back down before rotating them to the original palms-down position and then returning back to the hips.

Recommended sets/ reps: 2-3 sets of 10 reps

Rhythmic Stabilizations

Muscle fatigue not only affects your ability to create stability but also your awareness of how your body is positioned and moving (called proprioception).5The more fatigued you become, the less control you have on your body and form/technique may break down. This is why fatigue combined with poor muscular stability leads to a cascade of events that creates eventual joint instability and injury.

A common method of improving the body’s ability to sense joint position (enhancing proprioception) is with rhythmic stabilization exercises. The goal with these exercises is to improve muscular co-contraction (the ability to coordinate stability around a joint during active movements by turning on all of the surrounding muscles simultaneously).12 If you have a friend nearby, try this exercise.

Lie on your back with your arm extended straight out in front of you toward the sky. Have a friend try to push your arm over in different random directions while you try to maintain it from moving. Have your friend perform these pushes lightly at first before speeding them up and applying more force as you improve the control of your arm. If you’re doing these with the right amount of force, your shoulder should be fairly fatigued after 20 seconds.

Recommended sets/reps: 4-5 sets of 20 seconds

These rhythmic stabilization exercises can be performed in a number of different positions such as against a kickball or swiss ball (or any other unstable surface) with your arm extended against a wall.11 Explore a number of different positions and try to perform these rhythmic stabilizations in the one you find most unstable.

Bottoms Up Kettle Bell Press

The bottoms up kettle bell press is one of my favorite stability based exercises for the shoulder as it directly carries over to many of the movements we perform as strength athletes. Start in a half kneeling position with your legs fairly narrow so we can simultaneously challenge your core control. With your wrist in a straight position (knuckles up) hold a kettle bell upside down. Press the weight above your head and hold it for 5 seconds before slowly coming back down. The pressing motion should be performed in the scapular plane which means your elbow is positioned around 30 degrees to the side (not straight forward or completely out to the side).

Holding the kettle bell upside down places the weight’s center of gravity further away from your hand (as compared to a standard dumbbell). If your body is unable to meet the stability demands by holding the kettle bell in this unbalanced position, the kettlebell will end up falling over.

You can increase the difficulty of this exercise by adding in a resistance band across your wrist pulling in towards the midline of your body. You can attach the band to a rig or have a partner hold the other end of the band. This will require your lateral and posterior shoulder muscles to work even harder to maintain balance and coordination of the kettle bell.

Recommended sets/reps: 2-3 sets of 10 reps

Kettle Bell Turkish Get-Ups

The Get-Up takes the prior kettle bell exercise one step further and requires you to move your body (and therefore shoulder complex) through a variety of different positions. During each transition, every muscle that stabilizes the arm must work to keep the weight from falling forward or backwards.

Start by lying on your back. Your left leg should be straight with your right knee bent. Hold a small weight with your right hand with your arm extended towards the sky. Next, twist your upper body onto your left side, propping yourself onto your elbow. Try to keep your left foot from coming off the ground during this transition.

Next, push yourself upwards into a side plank. Pause during this transition and feel for the position of your scapula and work to keep the weight from falling forward! To help with this, imagine yourself balancing a glass of water with the hand that is holding the weight. If your arm falls forward, the water will spill from the glass.

Pull your left foot under your body and shift your weight onto your left knee. Pause in this position for a few seconds. Next, twist forward into a split kneeling position before pausing for a few seconds. Feel the muscles in the back of your shoulder working hard.Last, stand straight up, keeping your arm locked out above your head. Reverse this same order of movements until you are lying again on the ground.

To progress this exercise, you can use a heavier kettle bell or barbell, perform longer duration holds at the end of each transition, or hold the kettle bell in the upside down position.

During this movement I want you to look straight forward rather than up at the kettle bell (how some coaches traditionally teach this exercise). The goal with any corrective exercise is to have sufficient carry over to the barbell exercises we will then perform in training or competition. Because there is not a single exercise that ends with you staring upwards at the barbell, the corrective exercises must reflect this and train your ability to sense joint position and stability without the need to see the weight as it moves above your head.

Recommended Sets/Reps: 2-3 sets of 10 repetitions

“Empty Can” versus “Full Can”  

Traditionally there are two exercises that are performed to target the supraspinatus muscle of the rotator cuff. Both are performed with the arms extended and elevated in a scapular plane (about 30 degrees away from the front of the body). The difference between the two are how the arms are positioned.

The “empty can” is performed with the thumbs pointed towards the ground (as if pouring liquid out from a can). The “full can” is performed in the opposite manner with the thumbs pointed towards the sky.

While the “empty can” is often used as a clinically as a test by medical professionals to rule in or out a shoulder impingement injury, suggestions to use the “empty can” as an exercise can be traced back as far as the early 1980’s.6 While this exercise may activate the supraspinatus just as much as the “full can” version, it also simultaneous brings out a high amount of activation in the deltoid muscle. This is problematic for two reasons.

Trying to strengthen a weak rotator cuff with exercises that also produce high levels of deltoid activation can lead to unfavorable joint mechanics. For example, the “empty can” exercise creates more upward pull on the humerus (compared to the “full can”) leading to a greater risk of joint impingement.7 This is why the “empty can” movement often elicits pain in athletes currently dealing with a shoulder injury.

It is also common to see scapular winging during the internally rotated “empty can” exercise compared to the “full can.”8 When the shoulder blade wings out to the side (the movement of protraction and anterior tilting) it closes off the available space deep inside the shoulder joint for the humerus to move, increasing risk for impingement to occur. In contrast, pulling your shoulder blades together (retraction) as you perform the “full can” exercise in combination with the externally rotated thumbs-up position increases this joint space and allows you to strengthen the rotator cuff in a mechanically efficient position.

To perform the “full can” exercise, raise your arms in an extended position to shoulder height. Hold this position for 3-5 seconds before lowering back down. Think about keeping your shoulder blades pinned together during the entire motion.

You can progress this exercise two ways. The first is by either adding weight and/or a resistance band loop across your wrists. The second is to hold one arm in the elevated position while the other arm performs the movement of raising and lowering the arm. For example, the right arm would be held elevated at shoulder height while the left arm performs the “full can” for 20 reps before switching and holding the left arm at shoulder height while the right arm performs the movement.

Recommended reps/sets: 2 sets of 15-20 reps. As you progress with strength you can increase resistance and drop to 3-4 sets of 10 reps.

It’s Okay to Go Heavy

Have you heard the line, “Don’t use heavy weights when doing corrective exercises for your rotator cuff or else your larger deltoids will kick on and take over?” This is a common misconception that has made its way unfortunately to the rehabilitation profession.

The origin of this thought process likely has its roots in good intentions. Often athletes with weak rotator cuff muscles like to compensate by relying on stronger more powerful muscles (like the deltoids and trapezius) in order to accomplish whatever movement they’re trying to perform. The more weight you give that person, the more compensation they will likely show.

Recent research has looked into the activation levels of the smaller rotator cuff and larger deltoid muscles during common rehabilitation exercises and found they increased the same amount as more and more weight was used.9 This means larger muscles (like the deltoids, pecs, or lats) do not overpower smaller muscles (like the rotator cuff) just because more weight is used. If a strong athlete can use good technique during a “full can” exercise with 10-15 lbs, there’s nothing wrong with it! The amount of weight you use for each corrective exercise must be based on your ability to perform that exercise with good technique, without pain and to meet your individual goals with rehab and performance.

Final Thoughts

It doesn’t matter if you are an elite Olympic weightlifter or an average gym-goer, these exercises can benefit you if you have shoulder pain. Even if you don’t have pain, these exercises are great for warm ups prior to workouts. An ounce of prevention is worth a pound of cure.

Until next time,

Dr. Aaron Horschig, PT, DPT, CSCS, USAW

With

Dr. Kevin Sonthana, PT, DPT, CSCS

References

  1. Reinold MM, Wilk KE, Fleisig GS, et al. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. J Orthop Sports Phys Ther. 2004;34:385-394.
  2. Reinold MM, Escamilla R, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009;39:105-117
  3. McCabe RA. Surface electromyographic analysis of the lower trapezius muscle during exercises performed below ninety degrees of shoulder elevation in healthy subjects. N Am J Sports Phys Ther. 2007;2:23-43
  4. Myers JB, Pasquale MR, Laudner KG, Sell TC, et al. On-the-field resistance-tubing exercises for throwers: an electromyographic analysis. J Athl Train. 2005;40(1):15-22
  5. Myers JB & Lephart SM. The role of the sensoriomotor system in the athletic shoulder. J Athl Train. 2000;35(3):351-363
  6. Jobe FW, Moynes DR. Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries. Am J Sports Med. 1982;10:336-339
  7. Poppen NK, Walker PS. Forces at the glenohumeral joint in abduction. Clin Orthop Relat Res. 1978;165-170
  8. Thigpen CA, Padua DA, Morgan N, Kreps C, Karas SC. Scapular kinematics during supraspinatus rehabilitation exercise: a comparison of full-can versus empty-can techniques. Am J Sports Med. 2006;34:644-652
  9. Alpert SW, Pink MM, Jobe FW, McMahon PJ, et al. Electromyographic analysis of deltoid and rotator cuff function under varying loads and speeds. J Shoulder Elbow Surg. 2000;9:47-58
  10. Dark A, Ginn KA, Halaki M. Shoulder muscle recruitment patterns during commonly used rotator cuff exercise: an electromyographic study. Phys Ther. 2007;87:1039-1046
  11. Reinold MM, Gill TJ, Wilk KE, Andrews JR. Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes, part 2: injury prevention and treatment. Sports Health. 2010;2(2)”101-114
  12. Wilk KE, Marcina LC, Reinold MM. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. N Am J Sports Phys Ther. 2006;1(1):16-31
  13. Ernst AT, Jensen RL. Rotator cuff activation during the Olympic snatch under various loading conditions. In Proceedings of XXXIII Congress of the International Society of Biomechanics in Sports (Colloud, F, Domalian, M, & Monnet, T; Editors). 2015;670-673

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