Latest / The Driven Athlete / Decoding Shoulder Pain in Throwers- Evaluation, Mechanics, & Pain | Ep 82

Transcript

Decoding Shoulder Pain in Throwers- Evaluation, Mechanics, & Pain | Ep 82 · The Driven Athlete

• 0:00
  Speaker 1: If you're a driven, active person who wants to reach and pursue a higher quality life with some ambition, then guess what this podcast is for you.
• 0:07
  Speaker 1: This is the Driven Athlete Podcast.
• 0:10
  Speaker 1: What's up?
• 0:12
  Speaker 1: Y'all?
• 0:12
  Speaker 1: It's your man, dr Kyle.
• 0:13
  Speaker 1: Welcome back to the Driven Athlete Podcast.
• 0:15
  Speaker 1: Really interesting topic.
• 0:17
  Speaker 1: I feel like something that we have worked a lot on is shoulder pain with throwers, all right, so especially shoulder pain at layback, and that would be like when the arm is all the way rotated backwards about when they're about to throw, as they're loading to throw.
• 0:32
  Speaker 1: So it'd be like late cocking or layback is what that would be termed.
• 0:36
  Speaker 1: And if you ever look at like a picture of a major league baseball player or just a high level baseball player, when they're pitching or they're throwing, their arm is really far backwards, right, that's that full shoulder external rotation.
• 0:54
  Speaker 1: It's actually really important.
• 0:55
  Speaker 1: So, um, anyway, a common thing is pain and that position where it's like when I get all the way back to lay back, that's when it hurts.
• 1:02
  Speaker 1: And we're like when I get to like acceleration, mid acceleration, that's when it hurts.
• 1:05
  Speaker 1: And a super common uh, that's a really common thing.
• 1:08
  Speaker 1: And locations for that pain is oftentimes the front of the shoulder, the medial elbow and then sometimes the posterior shoulder.
• 1:18
  Speaker 1: Right, it's just in the shoulder.
• 1:19
  Speaker 1: So the things that we have to look at, that um are, uh, are differentially.
• 1:25
  Speaker 1: Diagnosis is like where's the pain and when does it occur, right?
• 1:30
  Speaker 1: So they say, hey, I'm a pitcher or I'm a volleyball player, I'm a swimmer, an overhead athlete.
• 1:36
  Speaker 1: We're going to stick with thrower just for the sake of this podcast, this topic.
• 1:39
  Speaker 1: And they say my arm hurts when I throw.
• 1:42
  Speaker 1: It's like all right, that's a common thing we hear.
• 1:46
  Speaker 1: Imagine going to just a standard doc's office.
• 1:50
  Speaker 1: They're going to say, all right, rest and just ice it down and then take some Advil, right?
• 1:56
  Speaker 1: They're not even going to ask, like, when in your throat does it hurt?
• 2:00
  Speaker 1: Right?
• 2:00
  Speaker 1: Like when, just it hurts when I throw?
• 2:02
  Speaker 1: Oh, standard rotator cuff involvement, right, let's start some imaging.
• 2:06
  Speaker 1: It's like, bro, we gotta look at other stuff and maybe ask a question of like when does it cause pain?
• 2:13
  Speaker 1: And then also, where it located in your shoulder, does it cause pain?
• 2:16
  Speaker 1: That totally changes the trajectory of our treatment protocol.
• 2:20
  Speaker 1: Maybe in the, the angry tissue, that what's?
• 2:23
  Speaker 1: What's, what's pissed off like, what's angry, what hurts, um.
• 2:27
  Speaker 1: And then, uh, what mechanics are causing that to be the problem?
• 2:30
  Speaker 1: Uh, how chronic has it been.
• 2:31
  Speaker 1: What's the age of the athlete like and their skill level, their, their development level.
• 2:36
  Speaker 1: But, um, that all that stuff totally changes the trajectory of like okay, how are we going to fix it Right, what manual therapy stuff are we going to involve to intervene with?
• 2:45
  Speaker 1: Um, and then, uh, what corrective exercises are going to involve?
• 2:50
  Speaker 1: That totally changes everything, man.
• 2:53
  Speaker 1: So it's just super important that you find a practitioner that's going to be like oh, it hurts when you throw.
• 2:58
  Speaker 1: Okay, tell me more, when.
• 3:00
  Speaker 1: What's it feel like?
• 3:01
  Speaker 1: Where's it located in your shoulder?
• 3:03
  Speaker 1: How long has it been going on?
• 3:05
  Speaker 1: That totally changes everything.
• 3:07
  Speaker 1: So, anyway, so what we're going to look, we're going to ask, is when and where, what's it feel like?
• 3:13
  Speaker 1: And they say, let's say, for the example, it hurts at layback, at full backwards range of motion, or they call that full external rotation, and it hurts in the front of the shoulder.
• 3:23
  Speaker 1: Super common, all right, one of the first things we're going to look at for testing is the range of motion and pure external rotation.
• 3:31
  Speaker 1: All right.
• 3:32
  Speaker 1: So we're going to bring their arm up into their throwing angle, right, oh, sorry.
• 3:36
  Speaker 1: In addition to that, we're also going to ask like hey, show me your throw, because throwing mechanics are different for everybody and their arm angle, their arm slot is going to be different.
• 3:44
  Speaker 1: So, like some people have a very low arm slot where they're throwing more sidearm and then some people have a very high arm slot throwing more overhead, like a Ferris wheel versus like a merry-go-round, if you can visualize that.
• 3:54
  Speaker 1: So it's important to look at their mechanics right.
• 3:58
  Speaker 1: Like I'm not going to change their mechanics or like they're throwing if they're like a high level athlete and they're college or like a late high school, I'm not going to be like we need to totally change your throwing mechanics.
• 4:08
  Speaker 1: I'm not a pitching coach, but biomechanics and pain that's what I do.
• 4:11
  Speaker 1: And if they have pain and they're a younger kid and they're throwing two sidearm, we might suggest an influence.
• 4:16
  Speaker 1: But like it might be better for you to raise your arm slot a little bit, especially at this young age.
• 4:20
  Speaker 1: You're influenceable like that.
• 4:22
  Speaker 1: So that's what we're going to ask Show me your throwing form.
• 4:25
  Speaker 1: So they say you throw it and they say it hurts at the layback, at the very front of my shoulder.
• 4:32
  Speaker 1: We're going to check their shoulder.
• 4:34
  Speaker 1: Passive range of motion and pure external rotation.
• 4:37
  Speaker 1: Oftentimes throwers are limited in external rotation.
• 4:42
  Speaker 1: They have a lot right, but it's a natural accommodation for uh the athlete to be able to do that high level throw at that high level velocity in order to have, uh, the best mechanics possible and to spare their arm and the structures in their shoulder.
• 5:01
  Speaker 1: So it's super important that they have enough shoulder external rotation.
• 5:05
  Speaker 1: We find ourselves intervening to get more external rotation for them.
• 5:10
  Speaker 1: They're actually limited.
• 5:13
  Speaker 1: They need like 140 to 130 to 145, 150 degrees of pure external rotation in their shoulder.
• 5:22
  Speaker 1: It's like to get back there to have the right throwing mechanics that they need and spare their arm.
• 5:28
  Speaker 1: A lack of pure shoulder external rotation, it stresses other structures to overcompensate and that's what gets painful and that's why we're intervening with what we do right.
• 5:37
  Speaker 1: And oftentimes people ask like, okay, what hurts?
• 5:40
  Speaker 1: Well, with anterior front shoulder pain with a thrower at layback, it's very commonly the biceps tendon that's just irritated and painful.
• 5:51
  Speaker 1: It's getting chronically over-lengthened and it's chronically required too much stability of that structure when that's not really what it's designed to do and that causes pain right in the front of the shoulder.
• 6:04
  Speaker 1: So the long head of the biceps tendon traverses up the shoulder joint and attaches to the supraglenoid tubercle of your scapula and that is where the biceps anchor of the superior labrum is.
• 6:18
  Speaker 1: So your biceps tendon actually has an attachment to the superior labrum.
• 6:23
  Speaker 1: So if somebody has chronic biceps pain seems to be an increased risk of a slap tear in their labrum.
• 6:31
  Speaker 1: The slap tear means superior labrum, anterior to posterior SLAP slap and that's the connection with the biceps anchor to the labrum at the top of their shoulder joint all right and their shoulder glenoid.
• 6:45
  Speaker 1: So that's what that's the influence of the biceps tendon in the labrum and the slap tear All right.
• 6:51
  Speaker 1: That's where that comes from.
• 6:51
  Speaker 1: Interesting fact slap tears are really common in overhead athletes.
• 6:57
  Speaker 1: Like 80% of overhead athletes have some kind of a slap tear labrum involvement, if it's mild to moderate, some kind of level.
• 7:05
  Speaker 1: So it actually is really common.
• 7:07
  Speaker 1: But you don't see 80% of throwers having pain all the time.
• 7:11
  Speaker 1: So the structural abnormalities aren't always correlated with a lack of functionality and pain and the trajectory of like, their athletic career.
• 7:20
  Speaker 1: Slap tears are really common.
• 7:21
  Speaker 1: Just the same message as before.
• 7:23
  Speaker 1: As we talk about with like lumbar disc herniations or cervical disc herniations, there's plenty of people that have herniated discs and they have no pain and they're totally fine, right?
• 7:33
  Speaker 1: So there's a disconnect between imaging abnormalities, structural abnormalities found in the image and the actual pain and functionality and trajectory project prognosis for somebody.
• 7:46
  Speaker 1: But anyway, so that's the involvement and the correlation between the biceps tendon and the top part of the labrum.
• 7:55
  Speaker 1: So as somebody goes back into layback there's a lot of torque and rotation involved in the shoulder and tensile tension against the biceps tendon, against the biceps anchor labrum.
• 8:08
  Speaker 1: So if somebody's lacking pure shoulder external rotation at layback, there's going to be more anterior translation of the humeral head.
• 8:17
  Speaker 1: All right, the humeral head is going to slide forward excessively and there's only one major structure, one structure that's active, that prevents that on the anterior side and that's the subscapularis muscle.
• 8:33
  Speaker 1: All right, the biceps tendon traverses the front part and it contributes a little bit to anterior stability but that's not its main job and with the rotation component added into it, that just caused a lot of stretch strain and it can cause a lot of irritation to the biceps tendon.
• 8:47
  Speaker 1: So anyway, that's why it gets lit up.
• 8:49
  Speaker 1: It's hanging on for dear life and it's not supposed to be doing that kind of stability requirements for the anterior part of the shoulder, the front part of the shoulder at layback, the anterior capsule, the joint capsule also, is what gets irritated.
• 9:02
  Speaker 1: There's a ton of nerve endings in the joint capsule also is what gets irritated.
• 9:06
  Speaker 1: There's a ton of nerve endings in the joint capsule of the shoulder.
• 9:08
  Speaker 1: They're all joint capsules, all right, no-transcript.
• 9:11
  Speaker 1: And all those nerve endings are super sensitive and they get irritated.
• 9:14
  Speaker 1: So if the anterior capsule is getting chronically stretched and overly stretched and strained and it's overly stressed with that excessive anterior translation of the humeral head, the biceps tendon is going to get lit up and the anterior capsule is going to get lit up and that's why the front of the shoulder gets really tender and hurts.
• 9:31
  Speaker 1: That's where the pain comes from.
• 9:32
  Speaker 1: All right, but we're thinking like okay, why the biceps tendon is lit up, the anterior capsule is lit up.
• 9:38
  Speaker 1: I wouldn't be surprised if the supraspinatus, like part of the rotator cuff, is lit up too, because it's just overworking and overwhelmed.
• 9:44
  Speaker 1: That's a super common thing, it's almost understood.
• 9:47
  Speaker 1: I guess the rotator cuff is probably going to be involved in some capacity a little bit.
• 9:51
  Speaker 1: But anyway, the question we ask is why?
• 9:53
  Speaker 1: Why?
• 9:54
  Speaker 1: What is this thrower doing differently that's causing the biceps tendon and the anterior capsule get lit up?
• 9:59
  Speaker 1: We know what the angry tissue is.
• 10:01
  Speaker 1: It's not that hard to figure out.
• 10:02
  Speaker 1: But the question is like why, and as a biomechanics and pain experts, that we do with athletes.
• 10:07
  Speaker 1: That's what we're trying to figure out, because that's what we're going to fix.
• 10:09
  Speaker 1: What's the cause of the cause?
• 10:11
  Speaker 1: All right, so the anterior biceps, the biceps tendon, gets lit up, the anterior capsule gets lit up and it's from excessive anterior translation of the humeral head in the shoulder joint, in the shoulder girdle, in relation to the glenoid fossa, that's where it articulates with the scapula or the shoulder blade.
• 10:28
  Speaker 1: So that excessive anterior translation, we will call that anterior instability or anterior hypermobility.
• 10:35
  Speaker 1: Excessive anterior translation, we would call that anterior instability or anterior hypermobility.
• 10:38
  Speaker 1: So shoulder hypermobility, that's a standard, that's a common thing.
• 10:40
  Speaker 1: The shoulder joint is super hypermobile, it's very unstable, all right.
• 10:46
  Speaker 1: So that excessive anterior translation, that also can create posterior impingement, all right.
• 10:52
  Speaker 1: So if the front part of the shoulder joint is, somebody goes into layback like this and the shoulder joint glides excessively forward to overcompensate for a lack of shoulder pure external rotation range of motion, the posterior contents are going to abut against each other early or excessively.
• 11:10
  Speaker 1: And that abutment of the posterior rim, of the glenoid part, of the bone, of the scapula and the humeral head, that causes posterior impingement and that's why the posterior shoulder pain occurs commonly with this at layback.
• 11:26
  Speaker 1: When I go all the way back, it hurts in the back of my shoulder.
• 11:28
  Speaker 1: It's excessive anterior translation and anterior instability.
• 11:31
  Speaker 1: Hypermobility of the shoulder joint and the posterior contents are getting abutted into each other.
• 11:33
  Speaker 1: Andmobility of the shoulder joint, okay, and the posterior contents are getting abutted into each other, and that would be posterior impingement and the structures that get posterly impinged would be the infraspinatus and teres minor and the posterior capsule.
• 11:46
  Speaker 1: So those guys, those soft tissues, is what's getting angry and irritated and pinched or impinged upon with a lack with upon, with excessive anterior translation at the layback.
• 11:56
  Speaker 1: But why?
• 11:57
  Speaker 1: Again, it's because they're lacking pure external rotation.
• 12:01
  Speaker 1: We can always work on strength and stability, so we would call this it's an anterior shoulder stability problem.
• 12:08
  Speaker 1: All right, and there's one muscle that really stabilizes against this excessive translation anteriorly as they go back and lay back, and that muscle is one of the rotator cuff muscles and that's called your subscapularis.
• 12:21
  Speaker 1: The subscapularis rotator cuff muscle is located on the ventral side of the scapula and it spans across the anterior part of the shoulder joint, of the humeral head, and that's the only active tissue that's main job is to prevent excessive anterior translation.
• 12:37
  Speaker 1: So very commonly that thing's going to be tight and weak, it's going to be bound down or it's just not going to be active as best it could be and it's going to be inhibited.
• 12:45
  Speaker 1: It's not going to be super strong and recruitable.
• 12:48
  Speaker 1: So we have to activate that muscle more, get it stronger, get it more activated with functional movement overhead, especially external rotation, to allow the shoulder to rotate backwards and external rotation without excessively just shifting forward at the same time.
• 13:02
  Speaker 1: That takes just some time to work on right.
• 13:07
  Speaker 1: We also have to improve its pliability.
• 13:10
  Speaker 1: All right, we have to lengthen the muscle pliability.
• 13:13
  Speaker 1: We have to improve its pliability.
• 13:14
  Speaker 1: So we have to do a subscapularis release too.
• 13:18
  Speaker 1: That doesn't feel good.
• 13:19
  Speaker 1: Maybe even dry needle it as well, if someone's cool with that.
• 13:22
  Speaker 1: So we're going to dry needle, we're going to release and work on the pliability, extension, extension, pliability of the subscapularis with the flexibility, dry needle it and then also work on posterior capsule mobs of the humeral head to reseat it in a better position and re-educate it to rotate in a more established center of rotation.
• 13:51
  Speaker 1: We call that PICR path of instantaneous center of rotation and then also work on some posterior rotator cuff soft tissue work and then the subscap MET and then subscap exercises on the gym floor that we're going to do corrective exercises with overhead movement and with external rotation.
• 14:07
  Speaker 1: So anyway, that's where our head's at with that.
• 14:10
  Speaker 1: That's what our brains are thinking.
• 14:12
  Speaker 1: If somebody comes in with anterior shoulder pain as a thrower, one of the first things we're looking at is do they have enough pure external rotation?
• 14:19
  Speaker 1: Having enough pure external rotation is going to solve all those problems.
• 14:22
  Speaker 1: It's going to prevent a lot of those problems.
• 14:26
  Speaker 1: That's the best recipe.
• 14:28
  Speaker 1: So an interesting thing with that is GERD.
• 14:31
  Speaker 1: If y'all have ever heard of GERD, g-i-r-d glenohumeral internal rotation deficit.
• 14:37
  Speaker 1: So the shoulder joint rotates right like this, okay, and if it has excessive amounts of external rotation, the thought is they're lacking internal rotation because the shoulder joint has developed and proliferated into accommodating more pure external rotation.
• 14:54
  Speaker 1: So the thought would be like they're lacking internal rotation.
• 14:58
  Speaker 1: Well, that's accepted, that is understood to be the case.
• 15:02
  Speaker 1: That's that's going to be totally understood, expected, right.
• 15:07
  Speaker 1: But I'm not going to work on more internal rotation.
• 15:11
  Speaker 1: All right, gerd is actually a good thing for shoulder overhead throwers like baseball players.
• 15:19
  Speaker 1: All right, gerd is a good thing.
• 15:20
  Speaker 1: It's an accommodation that they need to throw well and have the best mechanics possible with that high velocity, high torque, rotation, throwing motion.
• 15:31
  Speaker 1: It's an adaptation of three things.
• 15:34
  Speaker 1: It's a bony adaptation where the humeral head actually develops more in a retroverted position.
• 15:41
  Speaker 1: So that's going to be a comment.
• 15:46
  Speaker 1: Imagine like a young kid who throws and plays baseball a lot.
• 15:49
  Speaker 1: I mean all the thousands and thousands of throws they've done.
• 15:51
  Speaker 1: That influence.
• 15:54
  Speaker 1: And torque influences the growth of the bone over through adolescence.
• 15:58
  Speaker 1: So I imagine something like goes through adolescence years and puberty, like as they learn how to throw Like a 10, like maybe it's like an eight-year-old who then throws for their whole life.
• 16:08
  Speaker 1: And now that they're in college at 22, right, that's a long time.
• 16:11
  Speaker 1: Right, that's what.
• 16:13
  Speaker 1: 14 years, right, that's a long time.
• 16:18
  Speaker 1: Right, that's what 14 years.
• 16:19
  Speaker 1: So, so bony changes get influenced in that direction.
• 16:20
  Speaker 1: Is to accommodate all the stress they've been going through, all right, um.
• 16:22
  Speaker 1: The other one is soft tissue development.
• 16:25
  Speaker 1: So like the joint capsule itself, um develops to get more lax and and the uh, the anterior direction, and that bounds gets bounded down in the anterior direction.
• 16:34
  Speaker 1: And it gets bounded down in the posterior direction, I'm sorry, yeah, in the opposite direction, the posterior structures.
• 16:40
  Speaker 1: That's to accommodate more external rotation, again, all right.
• 16:44
  Speaker 1: And then the other one is just muscular.
• 16:45
  Speaker 1: So the muscles get more developed and tight with the posterior structures and then also in the anterior ones they get more pliable and lax.
• 16:56
  Speaker 1: But over time compensation patterns happen and maybe throwing mechanics change and over over, overly doing, uh overtraining can happen, like I totally.
• 17:04
  Speaker 1: At some point you gotta, you gotta, modify training right.
• 17:08
  Speaker 1: Overtraining is uh always going to be a concern.
• 17:12
  Speaker 1: Um, but at some point got to back it down a little bit right, even point got to back it down a little bit right.
• 17:15
  Speaker 1: Even the pro athletes will back it down a little bit to allow things to settle down.
• 17:18
  Speaker 1: It wouldn't be smart to just train through, but anyway.
• 17:22
  Speaker 1: So GERD, glenohumeral internal rotation deficit is actually an expected good thing for throwers.
• 17:28
  Speaker 1: We're not going to work on more internal rotation.
• 17:30
  Speaker 1: So, as an example, I'm not going to do sleeper stretch with with athletes, I'm not going to do the behind the back rope pull with athletes or the elbow forward stretch with athletes or with these throwers.
• 17:39
  Speaker 1: We're going to work on more external rotation actually, and that's going to prevent a lot of future issues and resolve their pain right.
• 17:50
  Speaker 1: That's what the ultimate goal is.
• 17:52
  Speaker 1: So what happens if somebody lacks a periaxial rotation?
• 17:55
  Speaker 1: Well, they have more anterior translation or anterior shifting of the shoulder joint.
• 17:59
  Speaker 1: They have more hyperangulation at layback.
• 18:02
  Speaker 1: So that'd be like the W posture, the W throwing position, so like if somebody throws and their arms out, like this, they're going to retract their scapulas more and they're going to horizontally abduct All right, they're going to horizontally abduct their shoulder and that just creates even more anterior shift of their shoulder joint and that's no bueno.
• 18:23
  Speaker 1: Steven Strasburg was really he's a, he was a pro pitcher and he was really known to have that W posture.
• 18:29
  Speaker 1: The thought would be like that hyperangulation position.
• 18:32
  Speaker 1: It just creates more anterior shift and more stress and strain on the anterior structures of the shoulder joint.
• 18:41
  Speaker 1: That has been also correlated with medial elbow stress.
• 18:45
  Speaker 1: So medial elbow stress, as an example, like Tommy John issues, that's the anterior band of the UCL ligament in the elbow, so the owner collateral ligament and there's an anterior band of the owner collateral ligament and that guy gets overly stretched and strained with a lot of valgus forces, which would be this position here where imagine, like shifting your arm inwards all the time and your elbow goes forward.
• 19:08
  Speaker 1: Where imagine, like shifting your arm inwards all the time and your elbow goes forward, that valgus stress on the elbow stretches and stresses the anterior band of the UCL.
• 19:17
  Speaker 1: And imagine doing that a thousand, thousands and thousands of times at high velocity.
• 19:21
  Speaker 1: But it's gonna cause some changes and maybe some issues and then it can cause a ligament injury at the UCL and that surgical repair is called Tommy John surgery.
• 19:30
  Speaker 1: All right, so a lack of pure external rotation seems to be just a foundation for a lot of these issues to develop Biceps tendon pain, anterior capsule pain, an excessive anterior shift of the shoulder joint.
• 19:46
  Speaker 1: Anterior translation is what we would call that Hyperangulation at the shoulder, with throw at layback with that W position, creates even more anterior shift and then more medial elbow stress.
• 19:59
  Speaker 1: And the last one is oftentimes athletes will hyperextend their low back.
• 20:02
  Speaker 1: So like lumbar hyperextension and hyperextension rotation.
• 20:06
  Speaker 1: So another common thing for athletes is with throwers is they get back pain right.
• 20:09
  Speaker 1: They excessively hyperextension rotation.
• 20:10
  Speaker 1: So another common thing for athletes with throwers is they get back pain right.
• 20:12
  Speaker 1: They excessively hyperextend their lumbar spine and hyperextend, rotate their lumbar spine with the throw motion.
• 20:20
  Speaker 1: It's because they're overcompensating to get back far enough as they need to.
• 20:25
  Speaker 1: And the thing we're going to check out if an athlete is their shoulder rotation, their pure external rotation range of motion, even for an athlete coming in with back pain.
• 20:36
  Speaker 1: If a pitcher comes in with back pain, we're checking out their shoulder for sure.
• 20:40
  Speaker 1: That's what they do, right, their shoulder is their main driver and the torque that they do with their throw.
• 20:46
  Speaker 1: And if their back hurts with throwing, we're definitely checking out pure external rotation range of motion for their back pain.
• 20:53
  Speaker 1: So it's just a compensation.
• 20:54
  Speaker 1: It's interesting how these like these compensation patterns lead to manifestations of pain elsewhere.
• 21:01
  Speaker 1: So that's just where our brain's at and looking at that stuff.
• 21:05
  Speaker 1: So the other things that include.
• 21:08
  Speaker 1: Here's the last thing I was going to talk about.
• 21:09
  Speaker 1: The other thing that is important to investigate is, with a lack of pure external rotation, they're getting rotation somewhere.
• 21:21
  Speaker 1: If they're getting back there, the thoracic spine also needs to rotate and their scapula needs to retract in order to get up into full layback and their arm slot.
• 21:33
  Speaker 1: So their scapula retracts and their thoracic spine rotates and their shoulder joint externally rotates.
• 21:39
  Speaker 1: We would call that the MER M-E-R, the max external rotation.
• 21:43
  Speaker 1: So when you see the poster or the picture of a pitcher in baseball when they're at their full stride and they're at full layback or late cocking position for the throw, they're like way back there.
• 21:55
  Speaker 1: Their shoulder isn't the only thing rotating.
• 21:57
  Speaker 1: Their thoracic spine needs to extend and rotate and their lumbar spine needs to extend and rotate.
• 22:01
  Speaker 1: But it's mainly we're going to look at the thoracic spine and then their scapula.
• 22:05
  Speaker 1: Their shoulder blade needs to retract and upwardly rotate.
• 22:08
  Speaker 1: So all those factors, those things need to be functioning well in order to get to a full layback position as best they can and as efficiently as they can and not have pain.
• 22:20
  Speaker 1: So we're also going to look at the scapula for sure and we also need to work at the thoracic spine rotation for sure.
• 22:24
  Speaker 1: It's not always T-spine extension rotation, sometimes it's flexion rotation, but for layback we need to look at the rotation range of motion for the thoracic spine and that would be the MER All right.
• 22:37
  Speaker 1: So exercises that we work on we need to work on their scapula, upward rotation and retraction, which is a tricky thing to work on.
• 22:47
  Speaker 1: It's not that it's just something that people don't consider which is a tricky thing to work on.
• 22:50
  Speaker 1: It's not that it's just something that people don't consider, but we've had really good results with athletes when we work on upward rotation and retraction at the same time and then also thoracic spine, and we can't neglect that.
• 23:00
  Speaker 1: Part of that is core stability, all right.
• 23:02
  Speaker 1: So it's just interesting to look at all these factors to help an athlete that has anterior shoulder pain, all these pieces to the puzzle that contribute, and we don't want to leave any stones unturned as to like why this athlete that developed shoulder pain like this, when the answer of just overtraining, that can be effective, for sure, but if that's just, it's just too much, take a break, you're working too much, just rest.
• 23:25
  Speaker 1: That's a that's a cop-out answer.
• 23:28
  Speaker 1: The reason is because all of his teammates pitcher teammates they're throwing at the same volume.
• 23:34
  Speaker 1: They don't have the same shoulder pain that this other athlete does.
• 23:37
  Speaker 1: So what is this athlete doing different?
• 23:38
  Speaker 1: Right?
• 23:39
  Speaker 1: They're all throwing the same amount.
• 23:40
  Speaker 1: Why don't they have shoulder pain?
• 23:42
  Speaker 1: The same way that this person has shoulder pain?
• 23:44
  Speaker 1: It's because this guy's doing something different and we have those compensation patterns we need to figure out and we need to work on.
• 23:49
  Speaker 1: Intervene that appropriately with a recipe of the purposeful manual therapy, some soft tissue work, muscle activation and recruitment, and then stability corrective exercises out in the gym, right, all those things.
• 24:02
  Speaker 1: That's the best recipe and that should translate to their functional throwing motion that we're going to, later stages, work on too, but that's the best recipe to actually fix shoulder pain at layback and that's what we have to investigate and differentially diagnose and it's going to totally change the trajectory for different people based on their shoulder pain and all the stuff I mentioned in the beginning.
• 24:23
  Speaker 1: So those are just things that we got to consider.
• 24:25
  Speaker 1: So that's just a little sneak peek and snapshot and like what's going on in our evaluative process differential diagnosis where our brains are thinking if somebody comes in with shoulder pain as a thrower.
• 24:36
  Speaker 1: So if any questions, don't hesitate to reach out.
• 24:37
  Speaker 1: We're always open to suggestions, comments, questions, concerns, conflicting opinions and if you have any questions yourself or you're battling pain, don't hesitate to give us a call.
• 24:48
  Speaker 1: Reach out on our website.
• 24:49
  Speaker 1: You can DM us on Instagram.
• 24:51
  Speaker 1: Our phone number is 561-899-8725.
• 24:56
  Speaker 1: Don't hesitate to reach out to us on our email.
• 24:58
  Speaker 1: The best email to reach us is team T-E-A-M team at athleteRCcom and we're always excited and optimistic to help people and open to having conversations.
• 25:11
  Speaker 1: So feel free to reach out and we'll catch you all next time.