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      Mastering Shoulder Strength Training Session

       

      In this informative session, we will explore the essential aspects of Shoulder Strength Testing, including who it is designed for, what the testing process entails, and why it is a crucial component of physical assessment.

      Shoulder strength is vital for various activities, from everyday tasks to athletic performance, and understanding the factors that influence it can help in injury prevention and rehabilitation.

      Joining us is special guest Luke Nelson, Sports Chiropractor and an expert in sports science and rehabilitation, who will share his insights on the latest testing methodologies, common challenges, and actionable strategies to enhance shoulder strength. 

       

      A Criteria Based Approach For Overhead Athletes And Shoulder Injuries

      This framework uses criteria-based rather than purely time-based progression, ensuring adequate tissue healing and functional readiness before advancing.¹ Ongoing monitoring of psychological readiness—including fear or apprehension—remains crucial throughout². Approximate timelines vary by injury severity and whether or not any other complications are present:

      • Minor (e.g., mild impingement, Grade I strain): ~2–4 weeks total
      • Moderate (e.g., Grade II strain, small partial tears): ~4–8 (up to ~12) weeks
      • Severe or Post-Surgical (e.g., rotator cuff/labral repair): ~10–16+ weeks (some overhead repairs need ~6+ months)

      1. Phase One: Acute Protection & Healing

      Timeline

      • Minor: ~Week 0–2
      • Moderate: ~Week 0–4
      • Severe/Post-surgery: ~Week 0–6 (some protocols require extended immobilization)³

      Goals

      1. Protect injured tissues and respect surgical or conservative guidelines (e.g., sling after dislocation or repair).
      2. Control pain and inflammation.
      3. Preserve or gently restore pain-free range of motion (ROM) to prevent stiffness, as tolerated.
      4. Initiate isometric activations of the rotator cuff (RC) and scapular stabilizers if no contraindications exist.
      5. Maintain conditioning in the lower body and core while avoiding shoulder stress.

      Key Actions

      • Immobilization/Protection: Sling or brace for post-dislocation or post-op shoulders; avoid provocative arm positions (e.g., abduction + ER in anterior instability).⁷
      • Pain/Inflammation Management.
      • Passive or Assisted ROM: Exercises within pain-free limits and post-op restrictions if applicable.
      • Submaximal Isometrics: Light activation of the RC, scapular retractors, and depressors to reduce atrophy.
      • Overall Fitness: Stationary bike, core strengthening, and leg exercises modified to avoid shoulder aggravation.

      Criteria to Progress

      • Pain & Inflammation significantly reduced (little or no resting/night pain).
      • Tolerance for gentle PROM or AAROM at ~50% of normal range without sharp pain.
      • Stable Joint in safe positions (no re-dislocation episodes).
      • Basic Muscle Activation (RC/scapular isometrics) without pain.
      • For surgical or severe trauma: 4–6+ weeks of soft-tissue healing per surgeon’s guidance.³

      2. Phase Two: Restoring ROM & Early Strength

      Timeline

      • Minor: ~Weeks 2–4
      • Moderate: ~Weeks 4–8
      • Severe: ~Weeks 6–12 (once tissues have sufficiently healed to allow more active motion)¹

      Goals

      1. Restore pain-free ROM close to normal (or to surgeon-approved limits).
      2. Initiate low-intensity strengthening of rotator cuff and scapular stabilizers.
      3. Improve neuromuscular control through gentle proprioceptive drills.
      4. Correct early scapular dyskinesis and ensure scapulohumeral rhythm.

      Key Actions

      • Active-Assisted → Active ROM: Pulley exercises, table slides, wand-assisted flexion/abduction. Address posterior capsule tightness to reduce GIRD (Glenohumeral Internal Rotation Deficit) where relevant.¹
      • Joint Mobilizations: Grades I–IV as tolerated (avoid overstretching if post-op).
      • Light RC Strengthening: Elastic bands or light dumbbells for ER/IR at the side, scaption, biceps/triceps. Keep loads modest but consistent.⁴
      • Proprioception & Rhythmic Stabilization: Gentle perturbation drills in safe ranges (e.g., 45°–90° abduction).
      • Core & Lower Body: Continue comprehensive fitness; begin incorporating submaximal trunk rotation with arm movements.
      • Monitoring: Avoid pain or impingement signs. Modify if apprehension or instability emerges.

      Criteria to Progress

      • Near-Full, Pain-Free ROM (≥90–95% of uninjured side). Manage GIRD ≤15° in throwing shoulders.¹
      • Strength ~50–70% of contralateral side (manual or handheld dynamometry).⁵
      • Scapular Control: Minimal dyskinesis during active elevation.
      • No Pain with light daily tasks at or above shoulder height.
      • No Instability in mid-range arcs.

      3. Phase Three: Strengthening & Neuromuscular Control

      Timeline

      • Minor: ~Weeks 4–6+
      • Moderate: ~Weeks 8–12+
      • Severe/Post-surgery: ~Weeks 12–16+ (once cleared for progressive strengthening and stability)

      Goals

      1. Build RC and scapular strength/endurance near pre-injury levels.⁵
      2. Develop dynamic stability in end-range positions (crucial for overhead athletes).
      3. Correct External Rotation:Internal Rotation strength ratios 
      4. Integrate kinetic chain movements at moderate intensity (legs, core, shoulder synergy).

      Key Actions

      • Progressive RC Strength: Increase band or weight loads, add eccentric training and resistance. Emphasize external rotators (often weaker in overhead athletes).⁶
      • Scapular Stability/Endurance: Weighted prone Ts/Ys, push-up progressions, row variations.
      • Neuromuscular Drills: Bodyblade or perturbation training in multiple arm positions, moderate med ball tosses.
      • Functional Integration: Submaximal sport-specific patterns (mock throws, partial swim strokes, controlled overhead hits) focusing on proper form.
      • Endurance Sets: 15–20 reps or timed intervals for RC and scapular stabilizers.
      • Flexibility Maintenance: Posterior capsule stretches if needed; address any tight pec minor.
      • Technique Feedback: Video or mirror feedback to prevent scapular hiking or trunk compensation.

      • ASH Test on Force Plates 

        • Once the athlete can perform moderate-load pressing movements pain-free, introduce an ASH Test for upper-limb force and Rate of Force Development (RFD).

        • Compare peak force, time to peak force, and RFD to the contralateral side to identify deficits (>20% difference is notable).

      • Isometric Dynamometry for RFD

        • Evaluate peak force and RFD in external/internal rotation at various angles (e.g., 90° abduction).

        • If improvements in RFD align with strength gains (~80% of contralateral), the athlete is typically ready for Phase 4’s explosive demands.

      Criteria to Progress

      • Full, Pain-Free ROM in all relevant planes (equal to uninjured side).
      • Strength ≥80% of contralateral side in key cuff/scapular muscles.⁵
      • Stable Scapular Mechanics under moderate load/fatigue.
      • Functional Tests ~80–90% Symmetry (e.g., medicine ball shot put distance, closed-chain stability tests, ASH Test).
      • No Impingement or Instability on clinical exam.
      • Psychological Readiness: Comfortable with higher-level strengthening.

      4. Phase Four: Advanced Sport-Specific Training

      Timeline

      • Minor: ~Weeks 6–8+
      • Moderate: ~Weeks 12–16+
      • Severe/Post-surgery: ~Weeks 16–24+ (throwers may need 6+ months)³ ⁴

      Goals

      1. Develop high-velocity strength, power, and agility in the shoulder complex.
      2. Reintroduce explosive overhead/throwing drills safely (throwing, serving, smashing).
      3. Ensure dynamic stability at end-range velocities (e.g., late-cocking phase for baseball pitchers).
      4. Attain sport-specific mechanics near full intensity.
      5. Build confidence in overhead actions via progressive exposure.

      Key Actions

      • Plyometric Shoulder Exercises: Med ball throws (chest pass, overhead slam, side toss), plyometric 90/90 catch drills, or clap push-ups if stable.
      • Interval Throwing Program (ITP): Gradual progression (distance, speed, volume). Similar approach for tennis serves, volleyball spikes, or swimming yardage.⁴
      • Advanced Strength & Eccentric RC Work: Emphasize deceleration capacity (posterior cuff, scapular retractors). Continue pushing scapular endurance (push-ups, rows) under heavier loads.

      • Plyometric Push-Up on Force Plates: Once the athlete tolerates advanced plyometrics (clap push-ups, med ball throws), you can use force plates under each hand to measure:

          • Peak Force (compare left vs. right)

          • Rate of Force Development (RFD)

          • Landing Force upon returning to the plate

        • Aim for minimal side-to-side asymmetry (<10–15%). If symmetrical and pain-free, it strongly indicates readiness for near-max overhead tasks.

      • Sport-Specific Drills:
        • Throwing practice.
        • Tennis: Serve progressions (mini-court → baseline → full power).
        • Volleyball: Hitting/serving drills with increasing jump intensity.
        • Swimming: Increase laps/interval pace, ensuring proper stroke mechanics.
      • Fatigue Drills: Simulate late-game conditions (intense cardio → overhead tasks).
      • Team Practice Integration: Gradual re-entry into practice scrimmages at partial, then full capacity.
      • Psychological Support: Address fear of re-injury with graded, successful trials.

      Criteria to Progress – Clearance for Full Return

      • Completion of Sport-Specific Progression (e.g., entire throwing or serving program) with no pain/setback.⁴
      • ≥90–100% Symmetry: On functional tests (medicine ball throw, isometric testing, plyometric rebound).
      • No Clinical Instability (negative apprehension signs) or impingement.
      • Proficiency at Near-Full Speed: Coach/therapist confirms technique is normal at game-like intensity.
      • Psychological Readiness: High self-reported confidence (e.g., KJOC score >90 in throwers).
      • Medical Clearance: For severe/post-surgical cases (rotator cuff, labral repair).

      5. Phase Five: Return to Sport & Ongoing Maintenance

      Timeline

      • Minor: ~4–8 weeks total
      • Moderate: ~8–12+ weeks total
      • Severe/Post-surgery: ~16–24+ weeks or more (some overhead athletes 6+ months)

      Goals

      1. Full competition at or above pre-injury level.
      2. Prevent re-injury via workload monitoring and ongoing maintenance.⁶
      3. Maintain confidence under real-game demands.

      Key Actions

      • Gradual Increase in Competition Load: Monitor pitch counts, overhead reps, serving volume, etc.
      • Maintenance Program: Rotator cuff and scapular exercises (e.g., “Thrower’s Ten”) 2–3x/week.⁴ ⁵

      • Periodic Force-Plate Re-Test: Re-check ASH test or Plyometric Push-Up metrics each month/quarter to ensure the athlete retains symmetrical force/RFD. Any significant drop in RFD or side-to-side symmetry can signal overuse, fatigue, or a need to reintroduce more targeted strength work.

      • Warm-Up & Cool-Down: Dynamic cuff activation pre-game, stretching/ice post-game.
      • Workload Management: Track session RPE, avoid sudden spikes in volume or intensity.⁸
      • Technique Monitoring: Ensure correct biomechanics (no “arm drop” or altered angles under fatigue).
      • Psychological Support: Continued reassurance, addressing any lingering apprehension.
      • Plan for Minor Flare-Ups: Temporary reduction in overhead load, reintroduce specific rehab exercises as needed.

      Final Outcomes

      • Sustained, Pain-Free Performance: Athlete matches or surpasses pre-injury metrics (throw velocity, serve speed, stroke power).
      • No Recurrent Instability or major pain episodes; only normal muscle soreness is expected.
      • Ongoing Maintenance: Shoulder-specific exercises and good posture mechanics remain a routine.
      • High Confidence: Athlete fully trusts the shoulder under all sport demands.

      References

      ¹ van der Hoeven H, Kibler WB. Shoulder injuries in tennis players. Br J Sports Med. 2006;40(5):435–440.
      ² Kibler WB, Sciascia A. Current concepts: scapular dyskinesis and its relation to shoulder injury. Br J Sports Med. 2013;47(14):875–882.
      ³ Wilk KE, Arrigo CA. Rehabilitation of the overhead throwing athlete: there is more to it than just external rotation/internal rotation strengthening. Phys Sportsmed. 2017;45(2):105–118.
      ⁴ Wilk KE, Macrina LC, Fleisig GS, Porterfield R, Simpson CD. The importance of glenohumeral internal rotation in overhead athletes. J Orthop Sports Phys Ther. 2015;45(4):241–251.
      ⁵ Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009;39(2):105–117.
      ⁶ Cools AM, Johansson FR, Borms D, Maenhout A. Prevention of shoulder injuries in overhead athletes: a science-based approach. Braz J Phys Ther. 2015;19(5):331–339.
      ⁷ Reiser M, Lynall RC, Riemann BL. The effect of recurrent glenohumeral joint instability on dynamic stabilizing muscle activation: a systematic review. Clin Biomech. 2020;76:105020.
      ⁸ Clarsen B, Bahr R, Myklebust G, Andersson SH, Docking S, Essendrop M, et al. Improved reporting of overuse injuries and health problems in sport: an update of the Oslo Sport Trauma Research Center questionnaires. Br J Sports Med. 2020;54(7):390–396.

      Key Takeaways

      • Criteria-Based Progression: Move forward only after meeting milestones (e.g., ROM, strength symmetry, stable scapular control) rather than by rigid timelines.
      • Scapular & Kinetic Chain Emphasis: Proper scapular stabilization and lower-body/core strength reduce stress on the shoulder.
      • Sport-Specific Interval Programs: Gradually reintroduce overhead actions (e.g., throwing, serving) to restore power safely.
      • Psychological Readiness: Confidence is crucial; use graded exposure to high-velocity activities.
      • Maintenance & Prevention: Even post-return, continue targeted exercises and workload management to minimize re-injury risk.