Athletes in any sport are at high risk for shoulder injuries, especially if they perform overhead movements. The common thought to rehabilitate shoulder injuries is to strengthen the rotator cuff musculature/shoulder girdle and upper extremities. A more modern suggestion is to strengthen the hips and lower extremities to support the upper body.  This does not mean to ignore training the shoulder girdle. However, traditional exercises such as standing external rotation or the same exercise at 90/90 position are becoming outdated, and there are other outside the box movements that will train the sling systems to support the shoulder and are more effective than isolation training. In weightlifting, force transmission is so high in the upper body that the lower body force has to match that strength so the athlete can avoid injury and complete the lift. To further understand how to train the lower body to provide upper extremity stability, we turn towards myofascial trains.
 
The Shoulder Joint
 
The shoulder joint sacrifices stability for mobility, offering close to 180 degrees of motion in most individuals. We need to be able to have this amount of motion to reach overhead, grab objects, reach into tight spaces, and, of course, for the snatch and clean and jerk! Despite an increased amount of motion, the shoulder can provide adequate stability when performing the aforementioned functional movements. Multiple joints and muscles have to coordinate to provide efficient biomechanical movement. Passive structures such as ligaments prevent excessive motion, and in some cases, help with carrying objects by your sides. Since the glenohumeral joint is somewhat analogous to a golf ball on a really big tee, there needs to be a structure to increase surface area of the joint, and that is what’s called the labrum. The labrum is connective tissue that surrounds the glenohumeral joint to increase surface area and provide a vacuum-like seal to further the stability of the joint.  The AC joint, SC joint, thoracic spine, scapula and glenohumeral joint all have to have the right amount of mobility and muscle control to produce adequate movement. If one or many of these joints is injured or does not have proper range of motion, poor mechanics can occur.
 
As mentioned, there are multiple muscles that work to move the shoulder. Perhaps the most influential for shoulder stability are the scapular muscles. The trapezius muscles have different orientations throughout your back that work as force couples to provide sufficient upward rotation, depression, and elevation of the scapula. Frequently, the upper trap is most dominant, with the lower trap being underdeveloped, causing increased shoulder elevation and impingement of some kind. The serratus anterior is responsible for protracting the shoulder blade as well as upward rotation. The inactivity of this muscle is also responsible for movement system impairments such as poor upward scapular rotation and anterior tilting of the scapula.
 
We also can’t talk about stability in the shoulder complex without talking about the rotator cuff musculature. The rotator cuff is significant in providing glenohumeral depression and dynamic stability (support while the shoulder joint is moving) of the glenohumeral joint. Although we are discussing lower extremity strength in the role of upper extremity stability, it’s important to train these muscles to enhance the integrity of the shoulder girdle and to have the mobility to complete the lift or perform regular activities of daily living.
 
All of the above structures discussed are significant in rehabilitating the shoulder and developing strength and power. However, with the role of force transmission being so large from the ground up, hip, thigh and leg strengthening exercises are imperative to provide stability and efficiency within any overhead injury rehabilitation or overhead athletic performance. Whenever a step is taken or a snatch is performed, ground reaction forces come through the ankle and all the way up into the upper body to get properly distributed along the path of passive and active structures like joints, ligaments and muscles/fascia, respectively. The gluteus group (maximus, minimus, and medius) is significant in providing hip and knee stability, but also in force transmission.  For example, when a squat is performed, if dynamic valgus occurs (the knee travels medially during the concentric or eccentric phase), we can hypothesize that hip stability is not sufficient, thus improper force transmission occurs making for an inefficient lift and puts the lifter at an increased risk for injury. (However, there are exceptions to the rule, give one Kendrick Farris, an incredible lifter, whose squats exhibit dynamic valgus at times.)
 
Many studies point to the thoracic spine as one of the main culprits to shoulder pain, with it being significant in end range shoulder motion. That said, a recent study concluded that thoracic spine manipulation does not alter the mechanics of the shoulder girdle, suggesting that pain re-mapping is occurring following manipulation. We need approximately 60 degrees of clavicular posterior rotation, 180 degrees of freedom within the glenohumeral joint, 60-70 degrees of scapular upward rotation, and a variance of degrees in the thoracic spine to complete efficient range of motion.   
 
Myofascial Trains
 
Myofascial trains, also known as sling systems, are groups of muscles that connect together via fascia. Fascia is similar in texture to plastic wrap that encompasses muscles, bones, joints, nerves, and ligaments. Fascia has tone, and it can be tight and restricted. (This is the reason why I do not advocate static stretching most of the time.) These sling systems provide a great way to encompass lower extremity training in shoulder rehabilitation. The sling systems that we will discuss below include the posterior, lateral and spiral lines.
 
To further understand the role of fascia, let’s look at a very simple and commonly used myofascial train, the posterior sling system. The posterior sling system is comprised of the latissimus dorsi, the thoracolumbar fascia (a group of fascia that encompasses the lumbar spine and lower thoracic spine), and the contralateral (opposing) gluteus maximus. The latissimus dorsi has been thought of to provide the scapula with a depression mechanic, thereby increasing shoulder efficiency. Also, this system provides the lumbopelvic area with a tremendous amount of stability by way of the very thick and sturdy thoracolumbar fascia.
 
Why is this area significant for shoulder stability? Force transmission! If the lumbopelvic area is not stable enough, and hips are not strong enough, proper force transmission cannot be accomplished. This will put excess pressure on the upper extremities when overhead lifts are performed, and even the power lifts such as the back/front squat, deadlift, and bench press. The posterior sling system provides all of these functions, and also can decrease hamstring dominance, another culprit in the improper distribution of force. One common theme throughout this discussion is that the body works together to perform all movements. So-called isolation exercises are impossible and are most often inefficient when trying to provide overall stability to the body. This is not to say that bodybuilding training does not help in strength training. It most absolutely does, but when talking specifically about providing stability in weightlifting and the overhead athlete, its significance is minimal.
 
The spiral line is another sling system that is inherently valuable in discussing. This is using another diagonal pattern like the posterior sling system. It is composed of lateral muscles on the right leg, and lateral muscles of the contralateral upper extremity (biceps femoris, left internal oblique, left multifidi/paraspinals, lower trap). Diagonal patterns are inherently important in providing upper extremity stability; diagonal patterns are how we move (reaching for a glass, bending to pick something up), especially in the overhead lifts. The internal oblique and multifidi/paraspinals are important in providing the lumbopelvic area with stability.
 
The lateral line is another commonly used sling system to provide shoulder stability using muscles from the lower extremity. This tract begins with muscles of the lateral leg called the fibularis muscles, and it continues into the lateral tract of the thigh, which includes the abductors and IT band.  The superior fibers of the gluteus maximus begin the next phase, extending through the tensor fascia latae, lateral abdominal obliques, external and internal intercostals, all the way up to the sternocleidomastoid and splenius capitis. Providing lower extremity strength by way of the hip abductors and gluteus maximus, this sling system can aid in preventing dynamic valgus, and again absorb ground reaction forces, thus taking them away from the upper extremity, decreasing injury risk.
 
Sling systems are very complex and are a huge topic in the physiotherapy community. To learn more about anatomy trains and their role in corrective exercise and neuromuscular re-education, check out Thomas Myers’ great book.
 
Closed Chain Vs. Open Chain Movements
 
It is important to understand the difference between closed chain and open chain exercise since this is a basic foundational concept that will help comprehend on how to train these sling systems. Closed chain exercise is when the terminal joint is connected to a surface, thus closing the chain. Open chain is the exact opposite, leaving the terminal joint not connected to a surface, leaving the chain open. For example, a push-up is a closed chain exercise, and a bicep curl is an open chain exercise.
 
Closed chain exercises are superior for various reasons. They’re better at muscle recruitment, joint compression, and an increased amount of proprioception (the body’s ability to recognize where joints are without using visual dependence). Since as humans we operate in closed chain (squatting, walking, stair negotiation, hip hinging, and weightlifting!) closed chain exercise and training will benefit us the most.  When training these sling systems, preference is towards closed chain. The way we do that is using a system called RedCord. RedCord is a system designed to train these sling systems, using slings and bungee cords. RedCord began in Norway, invented by an individual with multiple careers. This system was introduced to the United States approximately 10-15 years ago, so this is a fairly new system considering that it takes 17 years for medical changes to occur (scary).
 
Training the Myofascial Sling Systems
 
Now that we’ve discussed anatomy, biomechanics, and sling system anatomy, let’s talk about how to train these systems using RedCord, other systems, and without any equipment.  We tend to couple these movements with functional exercises such as overhead squats, squats, and hip hinges.
 
Let’s talk about training the posterior sling system. This can be done multiple ways; obviously, it depends on the level of the athlete. A movement called the supine pelvic lift can be performed using the RedCord system. The athlete would have a sling placed underneath their buttocks with bungees attached to the sling. This offloads the spine. More can be added if needed, depending on the pain level of the athlete. More slings would then be placed under one leg, or two. These slings would have no bungees. The athlete would then place both hands on the table and press in, activating the latissimus dorsi bilaterally. Specific cues such as “be long with your legs,” “press down into the slings with your legs,” “float hips up by tightening your glutes,” “belly button to spine, abdominal brace, and Kegel.” These cues are very specific to promote glute contractions, inhibit erector spinae involvement and posterior sling system activation. These cues are common amongst the RedCord system and can be used in any exercise outside of the theory as well. As described above, the latissimus dorsi and glute group are highly active, thus promoting posterior sling activation.
 
The forward lean is a closed chain upper extremity movement that will train the posterior sling system and anterior line.  The athlete grabs the hanging handles, pulls down into scapular depression, performs lumbopelvic contractions (belly button to spine, abdominal brace, Kegel) and then lean forward. The athlete then holds this movement for approximately three diaphragmatic breaths, then returns to the starting position. This can be made more difficult with an additional movement such as a march. This will activate that posterior sling system by the athlete pulling down on the contralateral arm and tightening the contralateral glute max. This movement also incorporates dynamic stability of the rotator cuff musculature. If athletes do not have the RedCord system available, a TRX is useful in performing both the supine pelvic lift (without slings) and the forward lean with a march.
 
Lateral line and spiral line training can be accomplished by a multitude of movements. The first of which is the side lying pelvic lift.  The athlete will be side lying with the forearm on the ground. The elbow will be pushed down into the ground, either with the athlete’s legs on a bench or using RedCord slings. The cues are very similar to the supine pelvic lift, being long with the legs and pushing down on the sling or bench, the athlete’s hips will raise. These cues will give bias to the gluteus medius and posterior fibers of the gluteus medius. If done incorrectly, the athlete will feel fatigue on the side of the abdomen, thus having increased activity in the quadratus lumborum, which is where we don’t want activity! This exercise incorporates closed chain activity of the serratus anterior, lower trapezius, internal obliques, and gluteus medius fibers, as well as numerous abductors. Alternate ways of training the lateral and spiral lines include different ways of carrying weight such as the Turkish get-up. By stabilizing a weight overhead and performing a “get-up” which will utilize all of the hip abductors and contralateral oblique muscles, the lateral and spiral line trains. Single leg stance with an overhead dumb bell press will also perform spiral/lateral line activation. The athlete has to use hip abductor strength to stabilize the lower extremities and absorb force, while simultaneously pressing overhead, thus contracting the lateral and spiral lines.
 
Exercise has three divisions: frequency, intensity, and volume. You can only have two at a time. Depending on the level of the athlete and whether or not they are in rehabilitation, the two divisions will change. For most of my patients, we typically perform high volume, high frequency movement secondary to attempting to make a neuromuscular/motor pattern change. However, in athletes who are not injured and are performing at a high intensity level, they may want to make modifications to these movements such as increasing the lever arm, which will require increased muscle recruitment to perform these movements. This is going to be highly variable from person to person, and the individual must be evaluated thoroughly to provide an adequate picture of what intensity, frequency or volume of exercise to perform.
 
The myofascial trains provide a superior way of providing stability to the upper extremity simply because of more muscles involved and more functional ways of training these muscles (as outlined above). The standard ways of stabilizing the shoulder in the rehabilitation world using TheraBands and standing external rotation exercises are becoming narrower in their thought.
 
The myofascial trains and RedCord system offer a new way to train the body for stability. We can be very creative in the exercises we give using this information and make our athletes better faster, and our overhead athletes more stable and confident in their sport.