Reloading the Upper Extremity
The reload is the final step in Cook’s (2013) rehabilitation and exercise checklist. In the reload the goal of training interventions is to reinstate motor control, increase strength and power, and challenge a dysfunctional movement pattern the client has. The reload builds on the reset and reinforce, and supports the progress made in prior phases. The shoulder, the glenohumeral joint, is a very mobile joint that is inherently unstable. This happens when the head of the humerus moves excessively around the glenoid cavity, and the instability is a result of a muscle imbalance in the stabilizing musculature, such as weak rotator cuffs compared to the rest of the shoulder complex, and overuse (Murray, Goudie, Petrigliano, & Robinson, 2013)This hypothetical case study looks at a client with shoulder instability.
George is a 32-year-old warehouse worker. He wishes to improve his cardiovascular fitness, and his strength so he doesn’t get as tired performing manual labor. George is normal weight and has no serious history of injury. Some of his job responsibilities include lifting boxes and stacking them atop one another. This place a lot of stress on the glenohumeral joint, and George has recently begun complaining of non-specific pain in the shoulder that increases with activities where he lifts his arms above his head. His shoulder has large range of motion and complains of a “clicking” noise during lifting boxes.
In a postural examination George presents no abnormalities in the lower quarter. In the upper body he exhibits flattening of the infraspinous and supaspinous fossa of the scapula, which indicates weakness of the posterior rotator cuff (Page, Frank, & Lardner, 2010). George also displays medially rotated arms, meaning the pectorals and lattisimus dorsi are significantly stronger than the teres minor, infraspinatus ,supraspinatus, and deltoid. The push-up movement pattern test showed excessive scapular abduction while George lowered his body indicating weakness of the serratus anterior (Page et al., 2010). In the shoulder abduction test, George bent slightly at the side while initiating the arm raise. This indicates weakness of the rotator cuff, deltoid, and overactive trapezius and quadratus lumborum (Page et al., 2010). George’s reload should focus on strengthening the muscles of the rotator cuff, serratus anterior, and deltoid.
Exercise progressions should integrate the entire upper extremity and utilize hip and trunk stabilization strategies. Strong and stable hip and core musculature is important in shoulder motion, because initiation of shoulder movement is coupled with muscle activation of the core and lower extremity, and the muscles in the trunk and hip provide stability for the shoulder girdle (McMullen & Uhl, 2000). This will allow for maximal force transmission and stabilization between the arm and trunk. Also, since many multijoint exercises neglect the muscles of the rotator cuff, isolation single joint exercises are required to strengthen the rotator cuff (Page et al., 2010). George’s exercise program will include external rotation, farmer walks, and TRX push-ups.
Isolated shoulder rotation exercises emphasize recruitment of the rotator cuff muscles (Malliou, Giannakopoulos, Beneka, Gioftsidou, & Godolias, 2004). External rotation focuses on the teres minor, infraspinatus, and the rear deltoid, while internal rotation increases the strength of subscapularis. To perform an external rotation the George should use a dumbbell, cable, elastic band, or a partner giving slight resistance to perform the exercise. The weight should never be too heavy, as a rotator cuff tear is possible. The first progression is external rotation while lying on the side. George begins lying on his side with a towel between his upper arm and torso, with his arm abducted about 90° and a light weight in his hand (Liebenson, 2014). George should exhale, while externally rotating his forearm so that the dumbbell is lifted up in a semicircle motion as he maintains the right angle bend between the upper arms and the forearm. He will continue this external rotation until the forearm is aligned to the floor and the torso pointing towards the ceiling. While at the top he should the contraction for a second before inhaling and returning to the beginning position (Liebenson, 2014, pg. 306). George should perform 3 sets of 15 of side lying external rotation on each side. Internal rotation is done from the same position except George would be moving the resistance to his midline, instead of away from the body. These exercises can be progressed to standing and standing on one leg. Standing provides no added benefit to the rotator cuffs, but it forces George to engage his lower body a bit and may aid in a smoother transmission of force. Performing the exercise on one leg should increase postural awareness and stability.
The next exercise George will do is the kettlebell farmers walk. The farmer’s walk is a great exercise as not only does it increase the isometric contraction of the dynamic stabilizers of the shoulder, it builds stability in the hips and core (Liebenson, 2011). It also mimics George’s work tasks so it should have good transfer to his day to day life. To perform a basic farmer’s walk, George should begin by holding equal weight kettlebells in each hand with the arms extended by the side. He should walk about 20 steps while trying to minimize side to side swaying while walking (Liebenson, 2011, 544). He should perform 3 sets of farmers walk. To progress the movement, George can increase the weight of the kettlebells or increase the distance walked. Another progression is holding the kettlebell in a bottoms up position. This increases rotator cuff activation to keep the kettle bell stable (Haley, 2013). George should travel the same distance, but instead he holds one kettlebell at a time. In this variation George, holds the kettlebell upside down by the handle in front of the shoulder at about chin height. (View here: http://www.stack.com/a/bottoms-up-kettlebell-carry). George should walk about 20 steps with the kettlebell in one hand, while keeping his core tight and then should switch arms. Since the rotator cuff is really designed to provide stability, and not engage as prime movers, weighted carries, like the farmers walk, mimic the function of the rotator cuff through isometric stabilization.
The TRX push-up is a good push-up variation. A traditional pushup challenges the pectorals, deltoids, triceps bracchi, core, and serratus anterior. The TRX increases core musculature activation on during push-ups and can be easily modified to increase or decrease difficulty (Fong et al., 2015). To perform the exercise, George should begin in pushup position with the hands beneath the shoulders inside a TRX strap (Verstegen & Williams, 2015). The TRX should be hanging vertically and the feet should be about shoulder width apart. George should be positioned with a slight forward lean. While maintaining a straight line from the ears to ankles, George should then bend his elbows to lower the torso. When his elbows are bent to 90° he should push himself back to starting position (Verstegen & Williams, 2015, pg. 244). George should perform 3 sets of 10-15 repetitions. To progress or regress the exercise George can alter the angle of his elbows in the starting position. Gulmez (2017) found that the least amount of force is generated at a 45°angle whereas the most is generated at a 0°angle. George can regress by increasing the angle, and progress by decreasing the angle. Another progression for the TRX push-up is adding the plus maneuver at the top of the movement. By protracting the scapula, by lifting the upper back to the sky, serratus anterior and rotator cuff activation is increased and should aid in dynamic shoulder stabilization (Swanik, Bliven, & Swanik, 2011).
After a resetting the shoulder through a combination of foam rolling, mobilizations, and stretching, and reinforcing the shoulder through neuromuscular education, George is ready to reload the shoulder complex. The internal and external rotation, farmer’s walk, and TRX push-up strengthen the muscles of the rotator cuff, the serratus anterior and the deltoid. Their progressions involve training core and hip stability, which helps protect the shoulder by aiding in more efficient transfer of forces throughout the entire kinetic chain.
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