Last week I posted Part 1 of this article, which was about a gymnast I evaluated with hip mobility issues and ongoing right-sided hip/leg injuries. It was incredible to see such a huge response, with just about 14,000 views in a few days. In that article I talked about how in some circumstances you can improve hip mobility by not stretching and trying to tap into the nervous system. This week I wanted to discuss another aspect of this gymnast’s case that I see frequently related to missing overhead motion. Many times a gymnasts lacking overhead motion is only thought of as having “tight shoulders”. They often continue to either stretch their own shoulders or get their shoulders stretched pretty aggressively in hopes of gaining mobility. As you will see in her case below, stretching may not be the answer for all gymnasts with limited overhead motion. More importantly, continuing to aggressively stretch may lead to instability based shoulder pain.

IMG_6925

1. Missing Overhead Motion Due to Lacking Control, Not Mobility 

IMG_6777 IMG_6778IMG_6779IMG_6780

As you can see above, she clearly has a ton of passive motion but it is her active motion that was lacking. This shows that she doesn’t actually have a mobility problem, but more of an overhead control/strength problem. In her case, more shoulder stretching most likely won’t improve her overhead motion during skills. Not to mention, continuing to stretch her already crazy amount of passive shoulder motion is likely just torquing her shoulder joint, placing lots of strain on her passive shoulder structures (capsule, ligaments), and may contribute to developing instability based shoulder pain (more research here, herehere, here, and here ). I wrote about this concept in a popular article from a few months back that you can find here, (Overhead Mobility Problem or Overhead Control Problem?). I also posted a video of me lecturing about this at Region 6 Congress (find that here).

My opinion is that rather than stretch more, gymnasts who fall into this category needs to spend time developing control/strength in their full range to gain overhead motion. They can then work on skill specific motor control drills and loading of the movement pattern to make the motion stick in her nervous system. Due to her really having an overhead control/strength problem, I feel this is what will cause her “inflexible shoulders” to gain motion needed for gymnastics skills like tumbling and Tkachevs rather than more passive stretching.

To help with this I gave her this pattern assisted “Reach, Roll, and Lift” drill (forgot to film her sorry). I apply this concept of training overhead active control in the full range with some overhead stability exercises, loaded carries, certain strength conditioning, and FRC inspired drills like seen below in the second video. I think this concept alone is huge for the gymnastics community to understand. This is because I feel stretching already hypermobile shoulders is one big catalyst for many instability based shoulder problems I have seen in gymnasts.

 

2. Missing Thoracic Mobility

IMG_6782 IMG_6783

This wasn’t as pronounced as the first point, but when I tested her thoracic spine passively she was limited in extending and rotating for both directions (only active showed below but passive did not improve). The above picture may be enough for the average person to not have issues, but due the extreme mobility demands of gymnastics skills, I look for patients I work with to easily reach 60+ degrees of rotation while showing comfortable breathing patterns.

Missing thoracic motion is something I surprisingly see a lot of in gymnasts, and I think there are a few possible reasons behind it. One is because gymnasts spend so much time in a hollowed/rounded chest position for skills. This hollowing is crucial for skills, but a gymnast still needs to be able to access the other thoracic motions of extension and rotation to get their arms overhead. Another reason I think many gymnasts lose thoracic mobility is because of their constant high-toned sympathetic state, and faulty breathing patterns (more research here and here). This is especially true when we start to move into the realms of stress and fostering adaptation (More great research here and here). You can see below she breathes with an apical, upper chest dominated pattern and has little 3D lower rib/diaphragm movement.

If you combine lots of hollowing for skills, breathing issues, postural habits outside the gym (cell phone, sitting hunched over book for school, etc), and compensatory patterns of using a naturally mobile lower spine, it can quickly throw off a proper globally dispersed extension pattern. It can also compromise the thoracic mobility needed for overhead skills like handstands, tumbling, Yurchenko’s, and so more.

For this, I gave her this simple thoracic and breathing mobility drill (sorry again didn’t take video of her in clinic). You could argue this is stretch, but I still think it’s not the typical overhead shoulder stretching many use in gymnastics.  This was followed by the tall kneeling bend back drill I mentioned last week, in an effort to encourage use of her new overhead control/thoracic /hip motion in a pattern.

It wasn’t as significant as her hips last week but we were able to see some positive changes after.

IMG_6788 IMG_6789

Following this I really like using seated wall angels to work on this, which is the second video.

3. A Lack of Core Control

IMG_6770

This gymnast was ripped and had a 6 pack, but with extending (pictured above) she fell into a significant amount of lower back hyper extension and anterior pelvic tilt. As was seen last week, the main reason driving this issue was high anterior hip tone. Following correction of that, the gymnast must learn core control to not fall back into the faulty motor pattern of over extending. In her case (and many other gymnast’s cases), she had more than enough core strength. She just lacked motor control to use her core properly during dynamic movement and stabilize her spine against high force. I have said this before, but training core strength and core control are two very different things.

If a gymnast spends years relying on their hypermobile lower back for extending skills, without using their full overhead shoulder mobility, it may create a situation where the nervous system neglects it.  She first needs to learn how to coordinate her breathing and core control together. Then she must develop the motor control to put it all transfer it to skills, both protecting her spine and utilize the full range of overhead shoulder motion.  To teach this, I like to use the breathing and motor control drill in the first video below.  You can elevate them on a trapezoid to get more overhead motion. I also think flipping someone over and doing a slow, breathing cycle paced bear crawl can foster this core control very well.

Why This Matters

Just like I mentioned last week, I think these ideas have very important training implications related to shoulder flexibility and gaining overhead mobility for skills. For this gymnast (and a few other gymnasts I have treated this year), assuming overhead mobility issues and stretching more can lead to hypermobile shoulders that may not carry over to skills and also quickly become painful (more here). If the mobility issue is really in the thoracic spine, and if the overhead motion that is missing is really due to lacking control, aggressive shoulder stretching may do more harm than good.

I will say I have treated gymnasts with shoulder problems that are really related to mobility issues and limited soft tissue extensibility.  Restrictions in the latissimus, pec major, pec minor, teres major, posterior shoulder, triceps, or other tissues can be the reason behind their limited motion. Gymnasts can fall into both categories, mobility or more motor control/strength oriented. Even in those mobility circumstances, I usually approach these issues with some similar methods to last weeks post using breathing and adjunctive manual therapy to manage the increase tone. When mobility changes are seen, I then again try to teach the nervous system how to use it so it can change skills. With that said, a movement evaluation and test-restest model must be used rather than assuming its the lats or pecs only.

Concluding Thoughts

The take away point from this post is that there are many possible reasons to why a gymnast can’t get their arms overhead. This is true both in the motor control and mobility department. This was just one case, but I have seen a few different combinations of shoulder/thoracic/lumbar spine issues in gymnasts.  We need to make sure we are ruling in the reason for their lacking overhead motion, and using the appropriate interventions to deal with it. I suggest coaches and gymnasts look to find a movement professional who can help sort out these issues. This can help narrow in on the problem, and also avoid using certain methods that are both efficient and safe. I hope this last two articles on this case study were helpful! Take care,

Dr. Dave

References

  • Payne, P., Godreau MA. The preperatory set: A novel approach to understanding stress, trauma, and the bodymind therapies. Front. Hum. Neurosci., 01 April 2015
  • Ramsay, DS. Woods, SC.Clarifying the Roles of Homeostasis and Allostasis in Physiological Regulation. Psychol Rev. 2014 April ; 121(2): 225–247
  • Porges, S. The polyvagal theory: New insights into adaptive reactions of the autonomic nervous system. Cleve Clin J Med. 2009 Apr; 76(Suppl 2): S86–S90. 
  • Bradley, H. and Esformes, J. Breathing Pattern Disorders and Functional Movement. Int J Sports Phys Ther. 2014 Feb; 9(1): 28–39.
  • Boyle, KL. Olinick, J., Lewis, C.  The value of Blowing Up A Balloon. N Am J Sports Phys Ther. 2010 Sep; 5(3): 179–188.
  • Andrews, J., Reinold, M., Wilk, K. The ATHLETE’s Shoulder. Second EDITION, 2009
  • Wilk KE, Macrina LC, Reinold MM.  Nonoperative rehabilitation for traumatic and atraumatic glenohumeral instability.  North Am J Sports Phys Ther 1(1):16-31, 2006.
  • Wilk KE, Arrigo CA, Andrews JR.  Current concepts: The stabilizing structures of the glenohumeral joint.  J Orthop Sports Phys Ther 25(6):364-79, 1997.
  • Wilk KE, Andrews JR, Arrigo CA.  The physical examination of the glenohumeral joint: Emphasis on the stabilizing structures.  J Orthop Sports Phys Ther 25:380-9, 1997.
  • Cordasco FA. Understanding multidirectional instability of the shoulder. J Athl Training 35(3):278-285, 2000.
  • Reinold M., Wilk K: Treatment Of The Shoulder: Principles of Dynamic Stabilization DVD
  • Manske R., et al. Current Concepts In Shoulder Examination of The Overhead Athlete. IJSPT Oct 2013; 8(5): 554 – 578
  • Andrews, J., Reinold, M., Wilk, K. Current Concepts in the Evaluation and Treatment of the Shoulder inOverhead Throwing ATHLETES, Part 2: Injury Prevention and Treatment. Sports Health: A Multidisciplinary Approach 2(2) 2010
  • Paine, R., Voight, M. The Role of The Scapula. IJSPT: 8(5): 617 – 629; 2013
  • Caine D., et al. The Handbook of Sports Medicine In Gymnastics. First Edition. John Wiley and Sons, 2013Cook G., et al.