How to avoid busting your shoulder

Clearly prevention of a shoulder injury is preferable to trying to rehabilitate it. As I explained in the last article, often a vicious cycle develops where one injury to the shoulder ultimately leads to a complete dysfunction of the joint. Adding repetitive loads through continued practice and matches only exacerbates the problem, and it never settles. There are, however, a few simple things players can do to prevent injuries, as part of their normal training and/or warm-ups which don't require much more effort. The following exercises cover the areas of mobility, control and strength, and are suitable to keeping a throwing shoulder healthy. It is by no means a complete list, but a solid place to start. Common sense always applies, and any pain experienced should be checked out.

The upper quadrant of the body (arm, scapula, thoracic and cervical spines and skull) are all linked within a "kinetic chain" via extensive myofascial connections. A lack of mobility in any one of these areas can potentially result in compensation in another - hence the phrase "the weakest link in the chain". That is why appropriate flexibility must be developed first, before attempting to re-train and strengthen better function. Three key areas to target include thoracic spine extension, scapula and glenohumeral mobility.

A kyphotic or rounded upper back creates a challenge to positioning the scapula in an upwardly rotated and retracted position when lifting the arm. A simple way to see if you have adequate mobility is to take the combined elevation test: aim to lift both arms above the horizontal whilst lying face down and arms extended above the head (i.e. a superman position). Improve this mobility by lying supine over a bolster of some kind (eg foam roller, swiss ball, rolled bath towel etc) and mobilising/stretching gently into thoracic extension. This is especially important if one sits hunched all day at a desk then goes out to cricket practice.

This can be followed with a "kneeling cat" stretch, arms extended by the ears and dropping the chest down to the floor. Combine strengthening of the lower trapezius in this position here by keeping the thumbs pointing upwards and slowly lifting one arm whilst still keeping the elbow straight. The head is allowed to lift slightly as you lift the arm at the scapula, not the shoulder. This is also excellent for bowlers since a thoracic spine that extends well will also rotate well.

It is common for a thrower's dominant shoulder to develop a loss of rotation over time through a thickening and tightening of the capsule and muscles. Ideally, a 180° arc of total rotation should exist from the fully cocked external to fully internal rotated positions. In fact, if a cricketer has been throwing from a young age then it is also possible that some degree of osseous retro-torsion exists in the humerus or glenoid. This can account for an apparent loss of internal rotation. Whilst this cannot be changed, the tightening of the posterior shoulder soft tissues can be addressed. A useful method to improve mobility here is by using the "sleeper" stretch. Lie sideways to lock down the scapula and abduct the arm at 90° to the trunk. Stretch behind the shoulder joint by gently pushing the hand down toward the floor with the opposite hand. Rolling the trunk slightly toward the arm further winds up the tight posterior shoulder structures.

To help train the muscles responsible for scapular retraction you can begin by performing what I call "angel wings". Stand back against a wall, arms raised with both elbows and back of wrists touching the wall. Without allowing wrists to lift off, slowly slide the arms up and down the wall as far as possible. After a few repetitions you will feel a burn in upper back muscles you never knew existed. To progress, try doing the same movement prone on a gym bench or a Swiss ball with a 1-2kg dumbbell in each hand. Do not let the hands drop and avoid poking out the chin.

To target the deeper scapula stabilising muscles it is useful to use a "closed chain" exercise - where loading occurs through the entire arm. Stand approximately one metre from a wall with hands placed on it at shoulder level. Keeping the elbows straight, perform small wall press-offs using only the scapulae - drop the body down between the shoulders then press back as far as possible. Repeat this movement without shrugging, sticking the chin out or bending at the elbows. If easy then repeat the movement using a single arm. The aim is to challenge the scapula muscle called serratus anterior. Progress by finding increasingly more horizontal positions, which in turn adds increasing resistance.

Targeting the rotator cuff is next. To recap, this has the primary role of working together to dynamically stabilise the glenohumeral joint. But research has also shown us that deficits in the ratios between internal and external rotation strength are potential precursors to labral injury so strengthening the posterior cuff is essential to the thrower. The most convenient strengthening tool is with the use of a Theraband. Squeeze a towel between the elbow and side so that the deltoid muscle "softens". Slowly pull a Theraband across the body and out to the side as far as possible without twisting your body and without "switching on" your deltoid (feel with your opposite fingers).

International players generally use a blue Theraband to provide the most appropriate resistance, and its length at the start of the movement should be approximately forearm (lever) length and be on slight tension. If done properly the posterior cuff muscles will begin to burn after 10-12 reps.

The posterior cuff should also be targeted in an abducted shoulder position. In this case the Theraband can be anchored under the right foot so that the line of pull is parallel to the forearm (vertical). Starting with the shoulder internally rotated as far as possible, externally rotate the shoulder, ending with the band up against the front of the vertical forearm. It's important during this movement to ensure the scapula remains retracted and chest upright to avoid possible shoulder impingement.

So there you have it - a handful of simple exercises to target the mobility, strength and control of the shoulder complex. Performed on a regular basis I find that they go a long way in keeping the shoulder free from injury, or rather, allow it to function properly. These are a small part of the overall strength and conditioning of the player but I'll look at that aspect a bit later, including which exercises to avoid. Throwing and return to throwing will also be discussed from a physio's perspective.

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