1. Who is he?

2. Hint?

3. Goal in Rehabilitation medicine?

4. Improve Functional ActivitiesImprove FIM score

5. Treatment, Prevention and Fitness

6. Function alone More harm than Good

7. Modifications of Traditional Exercises for Shoulder Rehabilitation and a Return to lifting Program

8. Goals Today • Safe Zone • Scapular plane • High Five

9. Running legend Dean Karnazes has run 262 miles-the equivalent of ten marathons-without rest. • He has run over mountains, across Death Valley, and to the South Pole-and is probably the first person to eat an entire pizza while running.

10. Weight lifting • Bench Press • Military press • Latsdorsi pull • Recreational wtlifters • Body builders • Competitive athletes

11. Unique anatomy of the shoulder vulnerable to injury • Exceed the mobility and stability of the shoulder • Many hope to return to wt lifting after injury • High resistance low reps are not part of a rehab program

12. Need Guidance • Overview the specific stresses on the shoulder during weightlifting • Provide modifications to protect the static and dynamic structures

13. Stresses on the Shoulder • Peak subacromium stress at 85 to 120 degrees • Peak forces at .42 times body weight or 10.2 times the weight of the upper extremity • Spurs, AC injury stresses are magnified

14. Shoulder Stresses • Large stresses on the anterior GH ligament complexes • Anterior band of the inferior GH ligament stabilizes • Stresses are increases if shoulder behind a coronal plane • End range of bench press • Behind the head lat pull downs or other exercises • High Five (abduction and ER position)

15. Anatomical and Biomechanics Rational for ROM limitations in Traditional UE Resistive Exercise

16. Stresses on the Shoulder of Traditional Upper Extremity Resistive Exercise • Many of the traditional overhead pushing and pulling lifts, pull downs, chin ups, cause an increase stress to the anterior portion of the GH ligament • Over head lifting movements increase stress to the status stabilizers while decreasing the mechanical efficiency of the dynamic stabilizers

17. Shoulder Stress • Scapular plane position which is 30 to 45 degrees anterior to the coronal plane • Reduces the capsule stress and created an optimal length tension relationship between the scapular and rotator cuff muscles

18. General Strategies to Protect the Shoulder During Weightlifting Exercises • Increase risk of injury if beyond the “safe zone” • Below shoulder level • Scapula plane (anterior to the coronal plane) • Widens subacromium space and reduces anterior ligament stress

19. Scapular Plane

20. Specific Concepts for Modification of Weightlifting Exercises • Hand spacing • Wider hand grip not recommended because of the increase torque stability needed • Hand spacing should be no more than 1.5 x biacromion width

21. Grip type (overhand, underhand, neutral) • Over hand grip removes the biceps tendon from under the acromion but the IR of the humerus increase the Supraspinatus tendon under the acromion causing tethering • Underhand grip (fully supinated forearm) allows the supraspinatus out from under the acromion but brings the long head of the biceps under the acromion

22. Hand positioning • Neutral hand (neutral pro and sup for forearm) position optimal relationship

23. Modifications of Specific Weightlifting Exercises • Resistance • Hand spacing • Grip selection • ROM in the GH joint

24. The Bench press • Light resistance high reps (12 to 15 RM) • Hand spacing should be slightly wider than shoulder width (1 to 1.5 x biacromial width) this narrow grip decreases impingement and lessens stress on the AC joint and reduces anterior capsular stress • Grip depending on the underlying path

25. Bench press • Wider grip increase shoulder torque by 1.5 • Wide grip increases the stress on the distal clavicle • Avoided with AC injuries

27. Bench press • Incline bench of 30 to 45 degrees • Wide grip • High five position (abd and ER)

28. Bench press on a swiss ball • Reduces the amount of extension and shoulder abduction

29. The Cable Fly, the Pec Deck, the Dumbbell Fly, and the Pushup • Unsafe zones because of excessive rom • Posterior to the coronal plane they place anterior stresses • Never exceed the coronal plane during these exercises • GH abd maintaining the elbow below the level of the shoulder (90) and avoiding IR which causes inpingement • Resistance at or below shoulder level

30. Pec deck machine • High five • Start 30 to 40 degrees anterior to the coronal plane

31. Dumbbell flies • Anterior to the coronal plane • Abduction angles between 45 to 70 degrees avoid impingement • Elbow flexion between 45 to 70 degrees • Flexion between 70 to 90 degrees

33. The Shoulder press • Behind the head not recommended because of the anterior shear with the high five position and increase impingement • Barbell is recommended to alter handgrip and shoulder flexion • Plane of the scapula • Neutral forearm position • Push to ¾ of the range to minimize GH impingement

35. LatissimusDorsi Pull Downs • Behind the neck pull down unnecessary exercise that should be avoided • Transient paralysis • Stress cuff muscles and capsular restraints

36. ModificationsFront lat pull down • Bar in front pull toward the chest • Body in a 30 degree recline • Grip width – 1.25 to 1.5 times the biacromion width • Greater scapular retraction and shoulder adduction

37. Behind the back squats avoid due to the “high five” position