T Nation

Scapular Dyskinesis and GIRD Rehab Advice


#1

I've been through a hell storm and back after hurting my shoulder lifting. My current situation and I believe the ROOT of the issue is I have scapular dyskinesis and glenohumeral internal rotation deficit. I've been doing a lot of reading, researching and talking with various therapists about how to tackle this issue so I can get back in the gym (finally).

Currently my symptoms are:

-intermittent lateral elbow pain on the left side. Same side that was operated on in April (sub-acromial decompression and removal of bone spur)

-pain from time to time in the posterior capsule on the left side and some tightness; evidence by the prominent GIRD on the left side

-winging in both sides, however worse on my right side

-left shoulder is anteriorly rotated and slightly lower than the right shoulder

Just saw my ortho last week and he has instructed me to work on doing the sleeper stretch at 70, 90 and 110 degrees several times a day and I'm seeing a therapist to get soft tissue work on the usual suspects (sub-scap, pec minor, lats).

My ortho said if this issue does not improve within 6-8 weeks of this plan, then he will recommend arthroscopic capsular release surgery.

I definitely want to do everything possible to avoid surgery and am coming to you guys for advice on what all I can do.

So far this is what I've been doing:

-Cross body adduction stretch against wall with scap fixed
-Sleeper stretch
-Serratus Protraction/Retraction
-Scapular Punches with 5 lb dumbbells
-Foam Roll Lats
-Pec Minor stretch and lacrosse ball work
-Scap Squeezes

Also just started doing another posterior capsule stretch at 30 degrees elevation in the scapular plane, which I liked a lot.

I know Mike Renoid and many others are not fans of the sleeper stretch and I am starting to feel that same way. When I do it (correctly, scap back and down), I get more of a stretch down in my arm on the outside part of my arm and don't' really feel much in the posterior capsule.

Anyways, I really REALLY would appreciate any help and advice as I tackle this issue. Its been a hell of a road for me and I've learned so much, but I'm ready to get my physique back!

All advice is welcomed!


#2

Just got back from therapy; my therapist worked on my lats, pec minor/major and a little bit on my sub-scap. He said that I'm not that tight in my sub-scap, it was more my lats, serratus and pecs. This could be because I did some rehab work on it a couple days ago.

As mentioned, I have prominent winging on my right side (good side) and he mentioned that I have total loss of serratus activation on that side. So I will start to address that as well with work on my pecs, serratus rehab, lats etc.

My main issue is a lack of inferior glide of the humerus when abducting my arm. Instead of depressing, my left shoulder just lifts up with my arm.

Anyone have any advice for getting that inferior glide back and regaining internal rotation?

Doing the sleeper stretch past 90 degrees doesn't work for me do to this lack of inferior glide. As mentioned I'm substituting the cross body adduction and 30 degrees elevated in the scapular plane stretch for the time being.


#3

i had a bad shoulder for years and best thing what help me was to do the kind of stuff your doing. i focussed working on posture, massage pec and front shoulder(medicine ball and criketball)strech pecs stregthen upper back with face pulls, chin ups( palms facing towards you)and front leaving training, (youtube this). all these exercises i could do with no pain

check out mobilitywod.com


#4

Most people with shoulder like yours need to strengthen the subscap. So, not surprisingly, you don't have tightness there. (TIght muscles are normally stronger muscles.)

How are you tight in your serratus? If your serratus isn't functioning, and your scap is winged, your serratus is likely excessively lengthened. It's very, very rare that someone has a tight serratus but a winged scap.

Regarding getting the inferior glide back: Getting that serratus to fire will help give more room for the humerus to move.

You have some great stuff going and I can tell you've done some homework, but, you need to have much more focus on improving how your shoulder moves. And you get better at moving in a particular way by practicing moving in a particular way.

All the other exercises like focused stretching makes moving the way you want easier, but, if you do all that stretching and continue to move in the same crappy way (no upward rotation, no inferior glide, etc.) your imbalances are going to remain.


#5


#6

Glad to hear things seem to be heading in the right direction!

Regarding the drooped shoulder: Do you have any history of throwing or anything where you predominantly used the right arm?


#7

Me too bro me too! The mental anguish I have been through, far exceeds the pain post op, the confusing look my old ortho would give me when I told him how much medial elbow pain I still had etc etc.

Its actually the left shoulder; which is my dominant arm. My history is years and years of basketball (left handed) and solid 10 years of serious lifting. I did play baseball as a kid for 2 years, but was a 2nd baseman and outfielder, no pitching.

Just got back from therapy, I've got my follow up visit with my doctor tmmrw.

Now that my motion has improved, I'm getting the humerus to drop upon abduction, we are both thinking I will get clearance to begin strengthening. Which I couldn't be happier about! Miss the feeling of lifting something!

I do have some AC joint clicking up abduction, which I'm going to have my doctor look at, its a slight concern for me right now.

We looked out strengthen on adduction (scapular retraction), which showed very weak mid and lower traps, which isn't surprising in the least bit. Serratus is firing as mentioned on the left side, but due to the weak mid/low traps and rhomboids its somewhat tight. Right side has terrible winging, however the scapula sits at the proper position at rest. The winging on that side it only prominent as I'm lowering my arm around 110-100 degrees. However, I'm completely asymptomatic on that side.

Will update tmmrw after the doctor's visit and I'm extremely optimistic that after another month or two of strengthening I might be in the clear.

Thx for the thoughts and advice so far.


#8

I was a pitcher for 8 years and now have a drooped, painful shoulder for a while now What exercises/stretches should I be doing?


#9

A low shoulder is a very common phenomenon in an arm with some throwing or overhead motion history.

Keep in mind that it's very, very UNcommon to have weak rhomboids. ESPECIALLY if the serratus has been weak. They are linked. One is weak, the other is strong and vice versa.

However, it is very, very common to have weak mid/lower traps but tight rhomboids.

Check out this video of a client of mine. You can see the rhomboid dominance in her left shoulder: http://www.youtube.com/watch?v=r1zul4Uylfg&feature=g-upl

And then check these two videos out. You can see the rhomboid dominance in the first video and then you can see the correction in the second video where the upward rotators (which the serratus and lower trap are part of) are doing their job much more effectively:

Better: http://www.youtube.com/watch?v=IrOlWaeeRtU&feature=g-upl

Might be an exercise worth adding to your arsenal. It had done wonders for many of my clients with shoulder issues.


#10

Check out the above videos. They should help you out.


#11

Great video and perfect examples! Very familiar with the wall slides, at my previous PT, they had me working on all serratus strengthening and mid/lower trap stuff (crab walks, protraction/retraction, wall slides, reverse wall slides, quad rocks etc). Only problem is they never caught the severe GIRD, so the loss of motion was the primary factor I needed addressed, since we all know mobility before strength.

I start the strengthen phase of rehab tmmrw and will be focusing primarily on the serratus and lower trap area. These should pull the shoulder back and into place.

Breddy, wanted to ask you, upon abduction of the left shoulder I get a click in my shoulder area. My therapist said he thought it might be some AC Joint crepitus? Was suppose to ask my doc this morning but totally forgot.

My doctor's appt went very well. He said I have completely eliminated the prominent GIRD I displayed the first time he saw me and was impressed at how quickly I improved from doing the sleeper stretch and its variations religiously everyday.

The plan now is to strengthen for the next 4-8 weeks and if all goes well I will be good to go.

I asked him if I still needed to do the sleeper stretch and he told me only as needed. My plan is to continue with it a few times a week, but most likely not everyday as I had been. Don't want to over stretch the capsule since I know that could cause issues.


#12

Great to hear. Things seem to be coming together.

Regarding the click during abduction, is it painful at all?

You may have, or had, too much superior glide of the humerus. This is pretty common in those with lack of inferior / posterior capsule mobility. Pain with abduction is pretty consistent with superior glide as well. If you have pain. Where as pure flexion pain is more consistent with anterior glide. At least in my experience.


#13

Hey Brian,

The click is not painful at all, just sometimes its rather loud and it slightly concerns me. I'm going to ask my sports med doc about it, but most of the people I have talked to have said its not something to worry about.

So as mentioned I got the go ahead to start strengthening and most of the stuff I'm doing right now is all body weight stuff. Both my doctor and my therapist have told me that my serratus and lower trap are especially weak on the left side and I wanted to ask you for some recommendations on what strengthening exercises I could get started on. Keep in mind the left scapula is sitting off and to the left. I'm consciously keeping my shoulder back on that side, to help strengthen those muscles to help get rid of the anteriorly rotated shoulder (drooping).

This is my program so far:

sleeper stretch: just once a day now instead of 3x a day, mainly as needed.

planks: I do 3 sets holding from 1-1:30 minutes, will progress as I get endurance

scapular wall slides sitting against the wall: keeping elbows, hands pinned to the wall and knees bent towards chest to avoid low back compensation

isometric protraction/retraction against the wall for serratus

thoracic mobility on foam roller

pec minor stretch on foam roller

-external rotation with arms bent at 90 degrees, no resistance, but 5 seconds holds for 2 x 15

-scap squeezes; again holding for 5-7 seconds for high reps

-chin tucks

My therapist wanted me to also start doing W, Y's and T's on a stability ball, but I'm not a big fan of them on the ball for someone like myself who has severe weakness in those muscles. I agree more with Renoid on this one to do them isometrically on a bench or table with a light weight. I'm also doing W's, but simply standing without any weight at the moment.

Let me know what you think and I'm open to suggestions. I do have prominent winging on the right side, where as the left side has very very little. Right side wings bad when bringing the arm down from flexion overhead.

Thx so much and the video's on your blog page were awesome and helpful.


#14

Thanks for the words on the blog. Glad they were of some use to you.

If you've read a good amount of Reinold you may have come across his dislike of the sleeper stretch. I'm with him on this one. It's not that it's a bad stretch it's just that nobody can do it properly. After a couple years I have basically given up trying to use it anymore. Even if somebody gets it right with me, sure enough their next session they are doing it wrong.

Ironically, the people who can do it are typically the people who don't need it!

Doesn't mean you shouldn't do it. Just really, really make sure you're doing it properly. If you aren't you could be making things worse.

Are you doing the scapular wall slides where the emphasis is on the downward portion? If so, when it comes to strengthening the serratus and lower traps, I shy away from this as well. This is because the serratus and lower traps are upward rotators and scapular wall slides emphasize the downward motion. That is, it emphasizes the downward rotators of the scapula. I much, much prefer the videos I sent you. Especially if you have a drooped shoulder the upper trap probably needs some work.

(Remember that Cressey and Reinold's stuff are typically geared towards baseball players. Baseball players are expected to have a drooped shoulder. It becomes part of their anatomy. For your regular, non throwing regularly person, you don't want this. )

The great thing about the shrug exercise I showed you is that because you have your arms pushed against the wall the wall provides an inferior and posterior glide of the humerus. Which is exactly what you're trying to accomplish with the sleeper stretch. So, the exercise is strengthening the upward rotators (serratus and lower trap) AND loosening up the inferior/posterior capsule. I have actually given people that single exercise for their shoulder and it worked wonders.

Let me know what you think.

Also, check these out. These have some more videos that I think might help you out.

This one has a before and after of a client with scapular wining (sorry if I sent this to you already): http://b-reddy.org/2011/06/02/example-of-impaired-movement-causing-pain/

Then number two in this talks about a drooped shoulder and correcting it: http://b-reddy.org/2011/07/21/just-because-it-feels-tight-doesnt-mean-it-is/

And then this is about humeral anterior glide. This is very, very common in the people I've seen with a winging scap/ low shoulder. You might just want to watch the videos. Not sure if you'd be into all the details and technical jargon. The cuff exercise for the subscap is my favorite cuff exercise. It also helps improve internal rotation while strengthening at the same time. This is in contrast to the sleeper stretch which only stretches: http://b-reddy.org/2011/06/19/best-exercises-for-the-subscapularis/

Sorry to just tell you to read so much. I think the videos will really help you out though. You especially see the progress in the girl who had the winging scap.

Hope this stuff helps you out!


#15

Awesome post thx so much! Remember I'm a pre-PT student, so I love reading! haha

I hear you on the wall slides and I'll cut those from my program, that was something I added in thinking it would help, but totally makes sense that I'm def squeezing on the way down and training more of the downward rotators than the weak upward ones.

That row exercise you were having your female client do looked a little different from a traditional row since it looks like the pulley was off to the left?

I like the idea of the high ER, my lats aren't that tight, but pec minor usually is. However ever since I've been consciously pulling that shoulder back and down since I got rid of the GIRD, my therapist has said the pec is a lot looser.

I saw a video of a guy doing a one handed row behind his back, where the pulley was off to left and he was positioned in a similar fashion to your female client. Except as mentioned it was single arm and was specific for the lower traps. Would this one be rehab movement? I'll try and find the video for it.

Was also thinking Push Up Plus, Face-pulls and then the single handed W's and T's and Y's.

The left barely wings as mentioned, but the right one looks freakish like your female client when I'm coming down from flexion. I'll check if it does it when I do a rowing motion and let you know as well.


#16

One thing I do with scapular wall slides, if I do use them, is I have the person have a big emphasis on terminal FLexion as well as the downward movement as well. This assures me that the person is working on upward rotation and can still get the benefits of a pec minor stretch at the bottom.

The exercise she is doing is actually a kneeling pallof press. It's primarily an abdominal exercise. I videoed that exercise to show that every single movement you do is a chance to improve how you're moving, at every joint. So, even for an ab exercise she has to be extremely cognizant of what her shoulder is doing. Otherwise she is just adding to her issue. My approach is that for someone with a serious issue, like to the degree that girl's shoulder blade was winging, I view every exercise as a therapy exercise, if that makes sense.

In her case her scap was winging during pretty much everything. From her daily life to every exercise. Thus, I tried to get her to make sure it didn't wing during anything, from her daily life to every exercise. For example, in the pallof press I would actually have her add a terminal shrug when her arms were fully extended. Adding even more work for the upward rotators.

If you're talking about the video of the cuff exercise I was actually using that for high Internal rotation. When pec major (and pec minor like you said) is tight / overactive, it can take over internal rotation from the subscapularis. Putting the elbow up high, and making sure the humerus stays nice and snug can help make sure the subscap is working and not just pec major. A strong subscap will pull the humerus posteriorly and inferiorly into the capsule. A strong subscap can then almost act as an inferior/posterior capsule stretch in itself.

I think what I'm getting at is, for the people I've worked with, a lot of these other issues, such as loss of internal rotation, weak subscap, weak serratus, etc. are normally secondary issues. While it's great to work on these issues, if you don't find the root cause, pain may still persist. I find that typically the root cause of issues in the people I work with are depressed shoulders and a lack of upward rotation.

I'm not sure if you've read Shirley's Sahrmann's work yet but this is consistent with her approach. Downardly rotated scaps and depressed shoulders and are the most common things she finds with her patients. In her book she states that if there are associated issues, such as a winging scap, the primary diagnosis refers back to downwardly rotated scaps. It's not that you don't treat the winging scap, but the lack of upward rotation always takes precedent over the winging in that specific example. The rationale being the downwardly rotated scap occurred first, causing the winging scap later on at some point.

Correct the lack of upward rotation and you correct the downwardly rotated scap AND the winging scap at the same time. Correct the winging scap only though and you may still have issues.

Keep in mind this is with the people I deal with, which is much more of everyday people as opposed to your athletic demographic. However, I've found this holds true more often than not, regardless of the demographic. I have yet to see someone who needed to work on their downward rotators. Nearly every person I come across has forward head posture (indicative of overactive levator scap, which is a downard rotator), tight lats (a rarely talked about downward rotator), pec minor and rhomboids.

Just me rambling :).


#17

thx for the thoughts, its helpful.

Had my therapist look at my flexion and abduction today since I've gotten rid of the GIRD.

Winging is pretty much gone on the left side (bad side), but lower traps are especially weak and serratus needs to get stronger too. The right side is still a mess, since we haven't addressed it yet. Upon flexion/abduction the scap wings slightly out to side, before I thought it was only when I was coming down from flexion, but its pretty much right from the start. So sounds like I might be fairly similar to your female client in the video who just loses the control right from the start. Was she also upper trap dominant and weak in the lower traps and serratus? I'm guessing she was

With that in mind I had him take a look at me doing those reverse wall slides and just as you thought, he said I'm upper trap dominant on that left side. So although I do a good job of keeping the elbows and hands pinned to the wall, I don't have the lower trap strength to do the movement correctly.

So I need to regress from that, he side a corner wall slide unilaterally with a towel in hand would be a good one. The wall acting as a barrier to keep the upper trap from elevating so much.

He also had me use a pulley with cables and just working on the eccentric movement from a lat pull down. Also said it wouldn't be a bad idea to have someone depress my GH joint and work on flexion, abduction in front of a mirror.

With all that said, and now knowing my specific issue with the left side. What else can you suggest for regaining that eccentric control and strengthening those lower traps.

Right now I'm thinking:

Push up Plus
Planks
Unilateral T's Y's
W's with a thera-band

and I'm guessing regular old low rows wouldn't hurt either.

Let me know what you think and again thx so much for your input and your excellent blog.


#18

Sorry it took me so long to reply. Been out of commission lately with ACL surgery.

How things been going?


#19

Damn that stinks! Hope your feeling better and I'm sure the fun is about to start with your rehab.

For the past two weeks I've been going back to the gym and doing my strengthening routine a couple times a week.

Push Up Plus
Prone T's, Y's W's
Rows
Lats

However, when I go into therapy the day after I rehab at the gym he's noticing that my posterior capsule feels tight again and that humerus will fall back into internal rotation?

After some thinking we both agreed that perhaps the Push Up Plus for serratus is some how aggravating me for some reason. Which ultimately worries me because there could be something else going on.

I've been extremely diligent with my rehab and might be asking my doctor for an MRI next week just to make sure I don't have anything else going on. Lord knows its been a long harsh road and at times I get discouraged and feel like I'll never get better. Then other times I feel like I'm getting there. I'm sure you know what I mean.

Infraspinatus is very tender when he works on it in general and then esp after rehab. I know my original MRI prior to my surgery mentioned partial cuff tears, but my previous surgeon said that those were simply an artifact of the MRI? He also said I have an abnormally larger space around my labrum which might be wear the clicking I get comes from.

I laid off rehab work yesterday and today and it feels decent to good. So something is aggravating it and when that happens, then the original elbow pain comes back a little bit since the bicep tendon is getting over-loaded and I get achy in my posterior shoulder/cuff area along with lats too.


#20

So after talking with my doc and therapist, I'm going to get an MRI with arthrogram this Friday to make sure there isn't any soft tissue stuff that is going on in that posterior left shoulder area.

At the moment my lats on the left side are chronically tight. Its suspected that it is due to lower trap and serratus weakness. The tight lats are also contributing to my left shoulder sitting in anterior rotation and slightly drooped.

Getting the MRI to ensure that there's no labral, or rotator cuff tear. My previous MRI prior to surgery showed partial cuff tear, some AC joint inflammation and severe tendonitiis of the supraspinatus. When my previous doc did my surgery he said all of that was an artifact of the MRI and that my cuff muscles were in great shape. This same doctor although very nice couldn't even diagnosis the very obvious and severe scapular winging I had on both sides and he calls himself a shoulder specialist! Yikes!

Will keep this thread posted on the results when I get them back probably sometime next week. Bracing myself to hope nothing is wrong, since I really don't want to get a second surgery on that side.