Sports Medicine Report: Make a stronger shoulder recovery
By Randi Meares (MFA, CCS, CPRS)


Damage to the shoulder, one of the joints most often injured in a young diver's career, can severely curtail, or even end, a diver's competitive career. Once a shoulder has been injured, appropriate rehabilitation, long-term monitoring and joint-specific strength training are essential if the diver is to compete successfully again.

The young divers I have come in contact with, or am currently training, have all experienced a shoulder dislocation. In some cases, they have dislocated not one shoulder, but both, and often more than once. Why does this happen? How can divers gain and maintain shoulder joint stability after suffering one or more dislocations?

This article attempts to answer those questions by outlining the steps required to ensure the fullest possible recovery from a shoulder injury, and by providing examples of specific exercises. The recommendations below are based on my own experiences in post-injury conditioning and the research of experts in the field.

Acute Injury Management Only the First Step
A shoulder dislocation occurs when the ball is suddenly and forcefully moved out of the socket. When an arm is forcefully hit while fully extended, the force radiates up to the shoulder joint, prying the ball out of the socket. Dislocation is common in many contact sports. In diving, the contact is with the water at speeds that can exceed 30 miles per hour. Eighty to ninety-five percent of all dislocations are front (anterior) dislocations in which the ball of the arm bone rips out through the front of the socket.

In diving, the dislocation might be posterior, depending on what type of dive is being performed and how the shoulder is aligned when the body enters the water. According to Southmayd, M.D. and Hoffman, in Sports Health: A Complete Book of Athletic Injuries (1988), "once an athlete dislocates a shoulder, statistics show there is a 95% chance of redislocation. This is due to the fact that the damaged lip to the shoulder has no blood supply, and therefore no way to heal itself. So the damage is permanent."

Athletes who dislocate a shoulder generally complete a physical therapy program with home exercises. Typically this program is recommended by an orthopedist and is aimed at restoring "normal" function, not competition readiness. After completion of that program, an athlete is medically cleared and free to resume his or her pre-injury training regimen. But frequently, the previously injured shoulder still feels weak; it aches and prematurely fatigues, leaving the athlete vulnerable to re-injury.

Post-Injury Conditioning
A post-rehabilitation conditioning program can help reduce the potential for re-injury. It is the next logical step in returning to optimal fitness and strength levels, covering the phase of the healing process between physical therapy, or acute injury management, and the return to competitive training.

The first step is to regain general strength in the shoulder area. According to Zachazewski, Magee and Quillen's text, Athletic Injuries and Rehabilitation (1996), "general strength, unlike sport-specific strength, must be accomplished through traditional [resistance and] weight-training exercises. General strength exercises do not necessarily need to mimic sport-specific skills, but are one of the first steps in rehabilitation conditioning."

Post-rehabilitation conditioning should be conducted by a coach, trainer, physical therapist or personal trainer certified in therapy conditioning. This professional should be able to slowly guide the athlete towards optimal sport-specific performance levels. Before starting a conditioning program, the athlete should have minimal to no pain from activities of daily living (ADL). If the athlete is still experiencing pain when bathing, dressing, driving, etc., these issues require a therapist's or doctor's reevaluation.

If the athlete has finished his or her physical therapy program and has no pain performing ADLs, it is safe to continue the conditioning program by maintaining and increasing stability in the shoulder joint, which is inherently a very mobile joint with a wide range of motion. Michael Kelley, MHSc, C-NMT, CSCS, CCS, PRCS, and Corporate Fitness Director at Sinai Wellbridge health facility in Baltimore, says that "in regards to dislocation of the humeral head, the primary focus is to increase stability, making sure the surrounding musculature stabilizes the joint. In this case the musculature would be the rotator cuff group." Kelley says it's imperative to understand that "the more mobility in a joint, the less stability that joint has, and vice-versa," The rotator cuff muscle group acts as stability for the shoulder, holding the head of the humerus in the glenoid cavity. The rotator cuff group consists of the teres minor and infraspinatus muscles, external rotators of the shoulder, the supraspinatus, a shoulder abductor, and the subscapularis, a primary mover for shoulder internal rotation. This muscle group helps to hold the head of the humerus in the shoulder joint. The supraspinatus also helps to prevent downward dislocation of the humerus.

As with any athletic performance program, strength training should have a planned progression in mind. A base of strength needs to be developed first, followed by dynamic concentric and eccentric training (the shortening and lengthening phases of a muscle contraction.). Sport-specific training comes next, along with exercises designed to work joint stabilizers while the athlete is simultaneously distracted. According to Jennifer M. Gamboa, MPT, owner of Body Dynamics Rehab Services, Inc., in Arlington, Va., the true test is whether the shoulder stabilizers can function while the athlete is concentrating on an additional motor skill.

Gamboa believes that "an athlete's strengthening program ultimately needs to incorporate multidimensional stability exercises, so that the diver can withstand unpredictable forces from any direction. You can strengthen someone's rotator cuff until the cows come home, but if you don't address its role in function, the rotator cuff will not adequately stabilize the joint during the high demands of diving." She added that it is important to get the shoulder stabilizers to function from the cognitive phase to the automatic phase, so that when the diver hits the water unpredictably, those stabilizer muscles will do their job.

Specific Exercises
Rotator cuff conditioning should concentrate on strengthening with internal and external rotation exercises. Have the athlete lie on one side, with the free shoulder in neutral position and the elbow close to the torso, flexed at a 90-degree angle. Lift a small hand weight while externally rotating the shoulder for 10 repetitions. Perform the repetitions with little or no movement in the elbow. Slowly increase repetitions to 15 before moving up in weight. Then increase the weight by 1/2- to 1-pound increments.

The subscapularis, located in front of anterior to the scapula, can be similarly isolated with internal rotation exercises. From a standing position, reverse the rotation from lateral to medial, following the same protocol as previously mentioned. The supraspinatus can be isolated by having the athlete lie on one side and raise the arm in a 20- to 30-degree arc.

The next area on which to concentrate is the posterior shoulder girdle. These muscles help stabilize the shoulder joint, as well as stabilize and control movements of the scapula. Muscles in this group include the posterior deltoid, rhomboids, upper and middle fibers of the trapezius and the levator scapulae. Scott Ackerman (CCS, CPRS, MES), is a NFL assistant strength coach for the Washington Redskins organization and owner of Elite Fitness Concepts training facility in Great Falls, Va. "We see a lot of shoulder dislocations in the NFL, though obviously not for the same reasons as divers, and we focus on strengthening the external rotators and the posterior shoulder girdle.

"Seated machine rows, cable rows, and rear deltoid raises, executed with dumbbells, are great for targeting this area," maintains Ackerman. "With cable rows, you can really focus in on retracting the scapula by bringing the elbows all the way back and squeezing the shoulder blades together. The athlete should work at about 50-60% of their maximum output, or whatever weight you can manage 12-15 repetitions at. Then drop the weight down and without any rest after finishing the first set, finish off with partial reps, or 1/2 reps. This is where you start with a partial or modified rep range and just work the small range of motion to full contraction." Ackerman emphasizes that dropping the weight, after the back is pre-fatigued, really targets the rhomboids and upper portion of the trapezius.

Aiding in posterior shoulder girdle strength is the latissimus dorsi, the large back muscle that makes up most of the middle back, and its sister muscle, the teres major. The latissimus dorsi is the prime mover of shoulder extension and adduction; it medially rotates the humerus and depresses the scapula. The teres major assists the latissimus dorsi in these functions. Some of the exercises designed to strengthen the posterior shoulder girdle also target the lats.

Once the athlete has made initial strength gains, traditional shoulder exercises can be introduced as tolerated. These exercises should target the three heads of the deltoid muscle along with the pectoralis major. A prime mover of shoulder flexion (in transverse plane), the pectoralis major works as a shoulder adductor and medial rotator of the humerus. Exercises can include pectoral flys, bench press, at shoulder height and below, and front, side and rear deltoid raises. Exercises that move overhead, or above shoulder height, like the military press and incline bench press, should be avoided until the shoulder musculature is strong enough to withstand more advanced training levels.

References
1 Sports Health: The Complete Book of Athletic Injuries; Southmayd, William, M.D., Hoffman; Marshall. New York, N.Y.: Putnam Publishing Group, 1981
2 Pre/Post-Rehabilitation Certification Manual; Philbin, John C., pres., Broderick; Jack, course director. Gaithersburg, MD: National Strength Professionals Association, 1991.
3 Athletic Injuries and Rehabilitation; Zachazewski, James E., Magee, David J., Quillen; William S. Philadelphia, PA: W.B. Saunders, 1996.
4 Conditioning Specialist Certification Manual; Philbin, John C., pres. Broderick, Jack, course director. Gaithersburg, MD: National Strength Professionals Association, 1996.

Randi Meares is a certified conditioning specialist and post-rehabilitation specialist based in the Washington metropolitan area. She trained for these certifications under the direction of John Philbin, Washington Redskins strength coach and former coach of the U.S. Olympic Bobsled team. A former professional dancer, Meares holds a masters degree in fine arts and has taught at several colleges and universities, including George Washington University and Brigham Young University.