Taking The Athlete from Rehab to Sports Specific Training

Pathophysiology and Mechanics Pathophysiology and Mechanics of the shoulder girdle and of the shoulder girdle and overuse overuse injuriesinjuries of the LE in the of the LE in the athleteathlete

Evaluation – Special tests for Evaluation – Special tests for the shoulder and the shoulder and LELE

Muscle PhysiologyMuscle Physiology- Anaerobic / - Anaerobic / AerobicAerobic

Keys to starting a strength Keys to starting a strength training programtraining program

Neuromuscular Training – Neuromuscular Training – Plyometrics-Plyometrics- Perturbation Perturbation

Robert Donatelli PhD PT OCSRobert Donatelli PhD PT OCS

Current Concepts in Shoulder Overuse Injuries Etiology & Rx

Core rotators of Glenohumeral & ScapulaCore rotators of Glenohumeral & Scapula Mechanics of Overhead ActivitiesMechanics of Overhead Activities Instability-Impingement-Rotator cuff tears Instability-Impingement-Rotator cuff tears

mechanics of dysfunctionmechanics of dysfunction Evaluation – Special TestsEvaluation – Special Tests Treatment – Restore mobility, Increase Treatment – Restore mobility, Increase

strength, Return to sporting activitiesstrength, Return to sporting activities

Core Muscles of the Shoulder

Glenohumeral RotatorsGlenohumeral Rotators Primary: Primary: Infraspinatus and Teres Minor, Infraspinatus and Teres Minor,

Subscapularis, Lats. Teres Major, Pect major and Subscapularis, Lats. Teres Major, Pect major and minor.minor.

Secondary: Supraspinatus, Deltoid and BicepsSecondary: Supraspinatus, Deltoid and Biceps Scapula RotatorsScapula Rotators

Upper, middle, lower trapsUpper, middle, lower traps Serratus anteriorSerratus anterior Rhomboids, levator scapulaeRhomboids, levator scapulae

Mechanics of Shoulder Elevation

Humeral head needs to be centered on the Humeral head needs to be centered on the glenoid humeral head arch of rotation 3mm.glenoid humeral head arch of rotation 3mm.

Muscle action pulls the humeral head inferior, Muscle action pulls the humeral head inferior, superior, anterior, and posterior. superior, anterior, and posterior.

Inferior – Lats, subscapularis, infraspinatus Inferior – Lats, subscapularis, infraspinatus and teres minor.and teres minor.

Superior – Deltoid, supraspinatusSuperior – Deltoid, supraspinatusAnterior- Ext rotators Posterior –Int. rotators Anterior- Ext rotators Posterior –Int. rotators

Elevation in the POS - Research

-Greenfield, Donatelli, et al. AJSM 1990-Greenfield, Donatelli, et al. AJSM 1990*External rotators significantly stronger *External rotators significantly stronger in the POS vs. Frontal Planein the POS vs. Frontal Plane

-Tata JOSPT 1993-Tata JOSPT 1993*Better ratio of external to internal rotators *Better ratio of external to internal rotators

(35 degrees anterior to frontal Plane)(35 degrees anterior to frontal Plane)-Overhead throwing athlete function in Frontal Plane-Overhead throwing athlete function in Frontal Plane

Humeral & Scapula Mechanics of Elevation

Critical Phase of elevation: Critical Phase of elevation: Donatelli Donatelli 60-140 degrees 60-140 degrees Max shearing forces, max depressive forcesMax shearing forces, max depressive forces Greatest amount of scapula rotation 80-140Greatest amount of scapula rotation 80-140 Greatest amount of humeral depressor activityGreatest amount of humeral depressor activity Rotation of the clavicle is complete 120-150Rotation of the clavicle is complete 120-150 ICR of scapula rotation shifts from SC to AC joint ICR of scapula rotation shifts from SC to AC joint

at 100 degrees of elevation at 100 degrees of elevation Bagg and Forrest 1988Bagg and Forrest 1988

External Rotation Importance

*Key component to elevation*Key component to elevationRajendran Singapore Med 1991Rajendran Singapore Med 1991

Prevents ImpingementPrevents ImpingementFaltow AJSM 1994Faltow AJSM 1994

Most Important movement to restore after Most Important movement to restore after total shoulder surgerytotal shoulder surgery Brems JBJS 1994 Brems JBJS 1994

Direct correlation between increase in passive Direct correlation between increase in passive external rotation and active elevation in the external rotation and active elevation in the POS Donatelli et al POS Donatelli et al

The relevance of moment arm of shoulder muscles with axial rotn

Kuechle, Newman et al, Clin Biomech 2000Kuechle, Newman et al, Clin Biomech 2000 Motion studies included axial rotation with the Motion studies included axial rotation with the

humerus elevated 90 degrees in the frontal, sagittal, humerus elevated 90 degrees in the frontal, sagittal, scapular planes and neutral position (add) scapular planes and neutral position (add)

Results indicated most powerful ext rotator – Results indicated most powerful ext rotator – infraspinatus, followed by the teres minor and post. infraspinatus, followed by the teres minor and post. DeltoidDeltoid

Most powerful int rotn subscapularis & pect majorMost powerful int rotn subscapularis & pect major Largest moment arms in ext. rot, infraspinatus, teres Largest moment arms in ext. rot, infraspinatus, teres

minor and the subscapularis for int. rotnminor and the subscapularis for int. rotn

Glenohumeral Elevation StudiesIn Three Dimensions

Browne etal JBJS 1990Browne etal JBJS 1990 External rotation is necessary to allow External rotation is necessary to allow

maximum elevation anterior to the frontal maximum elevation anterior to the frontal plane. (average plane 23 deg./ 35 deg ext)plane. (average plane 23 deg./ 35 deg ext)

Internal rotation is necessary to allow Internal rotation is necessary to allow maximum elevation posterior to the frontal maximum elevation posterior to the frontal plane. (average plane 31 deg/ further plane. (average plane 31 deg/ further posterior 60 deg. Int rotn. necessary)posterior 60 deg. Int rotn. necessary)

Dynamic and Static Forces of Subacromial Impingement

GH joint Muscles that act parallel to GH joint Muscles that act parallel to the. Provide the. Provide compressive compressive forces – forces – Subsapularis-lats-infraspinatus, Subsapularis-lats-infraspinatus, teres minor – Design to counter-teres minor – Design to counter-balance the Deltoidbalance the Deltoid

Muscles acting perpendicular to the Muscles acting perpendicular to the GH joint Provide GH joint Provide shearing shearing forces - forces - Deltoid Deltoid

The Resultant Force is from all the The Resultant Force is from all the muscles producing compressive muscles producing compressive and shearing – the vector direction and shearing – the vector direction of the total force Payne AJSM 1997of the total force Payne AJSM 1997

Muscle forces and Acromial Pressure During Elevation

Payne et al Am J Sports Payne et al Am J Sports Med 1997Med 1997

Biceps 10% reduction in Biceps 10% reduction in 6 of the 10 shoulders 6 of the 10 shoulders 34% reduction34% reduction

RC reduces 52% without RC reduces 52% without supraspinatus simulationsupraspinatus simulation

Deltoid abduction force Deltoid abduction force is increased 17% and the is increased 17% and the average pressure inc. average pressure inc. 1240% without RC1240% without RC

Dynamic Stability of G-H Joint in Overhead throwing Activities

Balance of Rotator Cuff and Scapula Balance of Rotator Cuff and Scapula rotatorsrotators

Force Couple of the Scapula and HumerusForce Couple of the Scapula and Humerus Joint compressionJoint compression Short and Long head of Biceps stabilizes Short and Long head of Biceps stabilizes

the anterior capsule.the anterior capsule. Stable Scapula BaseStable Scapula Base

Role of the Biceps

The long head of the biceps at The long head of the biceps at 60 & 90 degrees of abduction 60 & 90 degrees of abduction and external rotation is an and external rotation is an important stabilizer to the important stabilizer to the anterioranterior capsulecapsule Itio et al JBJS Itio et al JBJS 19931993

During internal and external During internal and external rotation the long head of the rotation the long head of the biceps produces compressive biceps produces compressive forces to the humeral head forces to the humeral head and controls translations and controls translations Abboud Clin Ortho Rel Res Abboud Clin Ortho Rel Res 20022002

Overhead Throwing Athletes

Assessment of Shoulder Assessment of Shoulder Strength in Professional Strength in Professional Baseball Pitchers Baseball Pitchers Donatelli, Ellenbecker, Donatelli, Ellenbecker, et al. JOSPT Sept 2000et al. JOSPT Sept 2000

Significant deficit of the Significant deficit of the external rotators external rotators

Significant increase in Significant increase in strength of the lower strength of the lower trapstraps..

Soft tissue Restrictions Overhead Throwing Athletes

Subscapularis tightness restricted ext. rotation at neutralSubscapularis tightness restricted ext. rotation at neutral Capsular restrictionsCapsular restrictions Rotator cuff Imbalances External rotator weaknessRotator cuff Imbalances External rotator weakness Scapula asymmetryScapula asymmetry Scapula rotator weakness: Serratus, Mid and lower Scapula rotator weakness: Serratus, Mid and lower

trapstraps* Stress to the arm (wrist, elbow, humeral shaft, * Stress to the arm (wrist, elbow, humeral shaft,

peripheral nerves)peripheral nerves)

Subscapularis Syndrome

SignsSigns-Limited passive external rotation -Limited passive external rotation

in the adducted position (neutral)in the adducted position (neutral) -Lack of disassociation of the scapula -Lack of disassociation of the scapula

from the humerus during elevationfrom the humerus during elevation -Impingement signs Positive-Impingement signs Positive -Asymmetry of the scapula – poor length -Asymmetry of the scapula – poor length

tension of supraspinatus, infraspinatustension of supraspinatus, infraspinatus

Stabilizing Mechanics of the G-H Joint

Turkel JBJS 1981Turkel JBJS 1981 Passive external rotation in Passive external rotation in

neutral – subscapularis neutral – subscapularis muscle is the most muscle is the most stabilizing tissuestabilizing tissue

At 45 degrees of abduction At 45 degrees of abduction – subscapularis and – subscapularis and superior/anterior capsulesuperior/anterior capsule

At 90 degrees of abduction At 90 degrees of abduction – inferior glenohumeral – inferior glenohumeral ligamentous complexligamentous complex

Rotator Cuff - Imbalances

Shoulder Strength and ROM in Symptomatic & Shoulder Strength and ROM in Symptomatic & Pain-free Elite SwimmersPain-free Elite Swimmers Bak & Magnusson Bak & Magnusson AJSM 1997AJSM 1997

Painful shoulders have inc. ER:IR ratios of Painful shoulders have inc. ER:IR ratios of concentric and eccentric strength – implications concentric and eccentric strength – implications strengthen internal rotatorsstrengthen internal rotators

Normal and Painful shoulders during breaststroke Normal and Painful shoulders during breaststroke AJSM 1994 Jobe, Pink, PerryAJSM 1994 Jobe, Pink, Perry

Painful shoulders inc. activity of internal rotators Painful shoulders inc. activity of internal rotators dec. teres minor, supraspinatusdec. teres minor, supraspinatus

Role of G-H Ligaments and Capsule in Overhead Throwing Athletes

O’Brien Am J Sports Med O’Brien Am J Sports Med 1990 Capsule is shortened 1990 Capsule is shortened with Rotationwith Rotation

Ext. Rotation at 90E abd. Ext. Rotation at 90E abd. Is supported by the Is supported by the anterior band of the anterior band of the inferior G-H lig. Posterior inferior G-H lig. Posterior band of the inferior G-H is band of the inferior G-H is under the humeral head under the humeral head resisting inferior resisting inferior displacementdisplacement

Translations of Humeral head

Harryman JBJS 1990Harryman JBJS 1990 Translations of the Translations of the

humeral head occurs humeral head occurs because the capsule is because the capsule is asymmetrically tight asymmetrically tight

Surgically tightened Surgically tightened posterior capsule and posterior capsule and found inc. anterior found inc. anterior humeral head humeral head translation with translation with add,flexion, int. rotnadd,flexion, int. rotn

3-Dimensional Studies-Scapula Movement analysis

Ludewig et al. JOSPT 1996Ludewig et al. JOSPT 1996 Lakasiewicz et al JOSPT 1999. Lakasiewicz et al JOSPT 1999. During POS elevation shown general pattern During POS elevation shown general pattern

of:of: 1. increased posterior-tilt angle1. increased posterior-tilt angle 2. 2. increased upward-rotation angleincreased upward-rotation angle 3.increased 3.increased external-rotation angle external-rotation angle

Serratus - progressive inc. activity 90-140Serratus - progressive inc. activity 90-140

Scapula Movement

Retraction of the scapula with Retraction of the scapula with horizontal extension =horizontal extension = Middle Middle Trapezius & RhomboidsTrapezius & Rhomboids

Protraction of the scapula = Protraction of the scapula = upward rotation and lateral upward rotation and lateral movement - movement - Middle traps and Middle traps and rhomboids eccentric, Lower, rhomboids eccentric, Lower, upper traps and serratus rotate upper traps and serratus rotate (concentric) (concentric) serratus stabilizes serratus stabilizes scapula to chest wallscapula to chest wall

Elevation of the scapula =Elevation of the scapula = upper traps & elevatorupper traps & elevator

Scapula Rotators

Inferior angle of scapulaInferior angle of scapula

Overuse of Impingement

Ludewig JOSPT, 1996- Ludewig JOSPT, 1996- Impingement group Impingement group IInferior angle protrudes nferior angle protrudes more posterior then the more posterior then the spine of the scapula. Higher spine of the scapula. Higher scapula elevationscapula elevation

Ludewig & Cook Phy. Ludewig & Cook Phy. Therapy 2000 Therapy 2000

UUupward rotation upward rotation decreased 4 degreesdecreased 4 degrees Inc. Inc. activity of upper traps Dec. activity of upper traps Dec. anterior serratus activityanterior serratus activity

Scapula Rotators Effect on G-H

Serratus anterior and trapezius weakness Serratus anterior and trapezius weakness will reduce upward rotation of the scapula will reduce upward rotation of the scapula and increase risk of the RC and bicipital and increase risk of the RC and bicipital impingement impingement Devita et al Phy Therapy 1990Devita et al Phy Therapy 1990

Weakness of the scapula retractors will Weakness of the scapula retractors will result in excessive protraction and narrow result in excessive protraction and narrow the subacromial space the subacromial space McQuade et al Clin McQuade et al Clin Biomech 1995 and Kibler Am J Sports Med 1998Biomech 1995 and Kibler Am J Sports Med 1998

Scapular Dysfunction

Kebaetse et al Arch Phys Med Kebaetse et al Arch Phys Med Rehab 1999Rehab 1999 Thoracic Thoracic posture effects position of scapula posture effects position of scapula and ROM of the shoulder girdleand ROM of the shoulder girdle

Warner et al Clin Orth Rel Res Warner et al Clin Orth Rel Res 19921992 Asymmetry of the scapula in Asymmetry of the scapula in 32-57% of shoulder instability 32-57% of shoulder instability and impingement groups. and impingement groups.

Wadsworth & Bullock-Saxton Int Wadsworth & Bullock-Saxton Int J Sports MedJ Sports Med 97 97 Impingement Impingement shoulder shoulder -- serratus recruitment serratus recruitment delayed delayed

McMahon et al J Sh & Elbow McMahon et al J Sh & Elbow Surg supraspinatus/ serratus Surg supraspinatus/ serratus delayed activity-instabilitydelayed activity-instability

Scapula Rotators - Exercises

EMG analysis of Scapula EMG analysis of Scapula Stabilizing Synergists Stabilizing Synergists during push-up during push-up progressionprogression

Decker et al AJSM 1999– Decker et al AJSM 1999– Dynamic Hug greatest Dynamic Hug greatest EMG activity EMG activity

Lear and Gross JOSPT Lear and Gross JOSPT 1998 – Inc. EMG for 1998 – Inc. EMG for serratus and upper traps serratus and upper traps with push-up with a plus with push-up with a plus and elevation of feetand elevation of feet

Stretching and Strengthening exercises: Scapular kinematics

Wang CH, et al, Arch Phys Med Reh 1999Wang CH, et al, Arch Phys Med Reh 1999 20 asymptomatic subjects with forward shoulder 20 asymptomatic subjects with forward shoulder

posture posture Stretching for pects and resisted strengthening Stretching for pects and resisted strengthening

exercises for the scapular retractors were performed exercises for the scapular retractors were performed 3x week – 6wks3x week – 6wks

Strength of horizontal abduction and internal /ext Strength of horizontal abduction and internal /ext rotator increased (p<.01) rotator increased (p<.01)

Scapula showed less upward rotation and less Scapula showed less upward rotation and less superior translation after the exercise prog. (p<.01)superior translation after the exercise prog. (p<.01)

Debridement of Partial-Thickness Tears RC without Acromioplasty Budoff, Nirschl et al, JBJS May 1998Budoff, Nirschl et al, JBJS May 1998 Supraspinatus is small and relatively weak Supraspinatus is small and relatively weak

susceptible to overuse and traumasusceptible to overuse and trauma Eccentric overload weakens musculotendinous Eccentric overload weakens musculotendinous

rotator cuff unit. rotator cuff unit. Unable to oppose the superior pull of the Unable to oppose the superior pull of the

Deltoid-inappropriate superior migrationDeltoid-inappropriate superior migration Continued superior migration causes secondary Continued superior migration causes secondary

impingement – RC & Grt Tuberosity abuts impingement – RC & Grt Tuberosity abuts

Pathological Changes Of Overuse

Deltoid retains strength longer than RC – loss of Deltoid retains strength longer than RC – loss of depressor effect on humeral head during elevationdepressor effect on humeral head during elevation

Reactive and degenerative osseous changes eg. Reactive and degenerative osseous changes eg. Osteophytic spurring causing a weakened cuff to Osteophytic spurring causing a weakened cuff to rupture – resulting from impingementrupture – resulting from impingement

Chronic tendinopathy or angiofibroblastic Chronic tendinopathy or angiofibroblastic hyperplasia degenerative tissue – tendinosis, no hyperplasia degenerative tissue – tendinosis, no inflammatory cells-degenerative tearing or inflammatory cells-degenerative tearing or avascularity, aging or overuse.avascularity, aging or overuse.

Outlet stenosis or G-H instability extrinsic factorsOutlet stenosis or G-H instability extrinsic factors

Pathology of RC tears

Ozaki et al, JBJS 1988Ozaki et al, JBJS 1988 Most tears of RC is a Most tears of RC is a

degenerative process that degenerative process that predates the formation of predates the formation of osteophytes and acromial osteophytes and acromial changes, result from changes, result from reactive osseous changes reactive osseous changes secondary to superior secondary to superior migration and humeral migration and humeral impingement rather than impingement rather than primary acromial primary acromial variantsvariants..

Rotator Cuff Pathology

Uhhtoff et al Internat Orthop 1988Uhhtoff et al Internat Orthop 1988 Ozaki et al, JBJS 1988Ozaki et al, JBJS 1988Cadaveric shoulders most partial thickness tears Cadaveric shoulders most partial thickness tears

– articular side supraspinatus near insertion – – articular side supraspinatus near insertion – hypovascular critical zonehypovascular critical zone

72% of RC tears are painless – degeneration 72% of RC tears are painless – degeneration occurs at a rate the body can absorb it, leaving occurs at a rate the body can absorb it, leaving a full thickness tear of RC a full thickness tear of RC

Function of the Arch

Harryman believes the function Harryman believes the function of the shoulder may eventually of the shoulder may eventually become dependent on the arch become dependent on the arch for functional stability. for functional stability. Contemp Contemp Orthop 1995Orthop 1995

Williams stated patients with a Williams stated patients with a marginally functional torn cuff marginally functional torn cuff need the coracoacromial arch. need the coracoacromial arch. If removed If removed shoulder shoulder may may become completely non-become completely non-functional.functional.

Franklin states the arch Franklin states the arch provides restraint to anterior provides restraint to anterior and anterosuperior migration and anterosuperior migration of humerusof humerus

Internal Impingement

Impingement of deep surface of the subscap tendon and Impingement of deep surface of the subscap tendon and the reflection pulley on the ant/sup glenoid rim: Gerber the reflection pulley on the ant/sup glenoid rim: Gerber et al J sh/elbow surgery 2000et al J sh/elbow surgery 2000

Increased internal rotation with 100 deg. Flexion Increased internal rotation with 100 deg. Flexion the lesser tuberosity and biceps tendon are brought the lesser tuberosity and biceps tendon are brought closer to the ant/sup glenoid rim and the superior closer to the ant/sup glenoid rim and the superior G-H lig. Becomes laxG-H lig. Becomes lax

At 90 deg flexion and internal rotation the deep At 90 deg flexion and internal rotation the deep surface of the subscap tendon is impinging against surface of the subscap tendon is impinging against glenoid rimglenoid rim

Posterior G-H pain in Overhead Throwing athletes

Superior Glenoid Impingement Jobe Clin Orth 1996Superior Glenoid Impingement Jobe Clin Orth 1996 Ext. rotn 90 deg abduction and horizontal extension Ext. rotn 90 deg abduction and horizontal extension

(early part of acceleration)(early part of acceleration) Impingement of inner fibers of the RC & post. Sup Impingement of inner fibers of the RC & post. Sup

labrum between the grt tub and post superior labrum between the grt tub and post superior glenoid. Secondary to lack of resistance from glenoid. Secondary to lack of resistance from subscapularis muscle causing angulation of the subscapularis muscle causing angulation of the humeral head instead of translationhumeral head instead of translation

Walker ext. rotation necessary for the grt tub to clear Walker ext. rotation necessary for the grt tub to clear the glenoid - more cartilage contact for elevation. the glenoid - more cartilage contact for elevation.

SLAP Lesion in Overhead Throwing Athletes

Morgan and Burkhart Morgan and Burkhart Arthroscopy 1998Arthroscopy 1998

Mechanism of injury in overhead throwing Mechanism of injury in overhead throwing athletes is a torsional force the “peels back” the athletes is a torsional force the “peels back” the biceps and posterior labrum from the neck of biceps and posterior labrum from the neck of the glenoid.the glenoid.

External rotation and abduction twisting force External rotation and abduction twisting force is produced at the base of the biceps and this is produced at the base of the biceps and this transmits a torsional force to the posterior transmits a torsional force to the posterior superior labrumsuperior labrum

SLAP Lesion Normal anatomy

O’Briens’ test SLAP II

Rehabilitation of Shoulder Girdle

--Strength the Core Rotators Strength the Core Rotators of the glenohumeral and of the glenohumeral and scapulothoracicscapulothoracic

--Manual Therapy – Static Manual Therapy – Static progressive stretchprogressive stretch

-Scapula mobility-Scapula mobility – Dynamic – Dynamic StabilityStability

--Restore Rotation – Sleeper Restore Rotation – Sleeper stretch Int. Rotnstretch Int. Rotn

-E-Explosive weight training xplosive weight training and plyometricand plyometricss

-Medicine ball exercises -Medicine ball exercises

New Research EMG analysis muscle function during exercises

Richard Ekstrom – Dissertation Richard Ekstrom – Dissertation RMUofHPRMUofHP

Lower and Middle traps – Lower and Middle traps – Kendall position for manual Kendall position for manual muscle test – Prone muscle test – Prone 90 90 horizontal abdhorizontal abd thumb up thumb up

Upper traps and serratus not Upper traps and serratus not isolated well from other muscles isolated well from other muscles – Synergistic unit for elevation – Synergistic unit for elevation test position 125 POStest position 125 POS serratus serratus

Upper traps-shoulder shrugUpper traps-shoulder shrug LowerLower traps- horizontal abd traps- horizontal abd

with ext. rotation and prone with ext. rotation and prone horizontal abd 145 deghorizontal abd 145 deg

Impingement Syndrome

Bang Md & Deyle GD – Comparison of supervised Bang Md & Deyle GD – Comparison of supervised exercise with & without manual PT for patients with exercise with & without manual PT for patients with shoulder impingement syndrome JOSPT 2000 shoulder impingement syndrome JOSPT 2000

N=52 2x/wk 3 weeksN=52 2x/wk 3 weeks Both groups same exercise regimeBoth groups same exercise regime Manual therapy group – Maitland superior to Manual therapy group – Maitland superior to

exercise group onlyexercise group only Manual therapy group significant inc. strength, Manual therapy group significant inc. strength,

ROM, function and decreased painROM, function and decreased pain

Case Presentations

Baseball PlayerBaseball Player RC tear/repairRC tear/repair Scapula asymmetry Scapula asymmetry Scapula muscle weaknessScapula muscle weakness Pain with overhead movementsPain with overhead movements Restricted ext. rotation in Add.Restricted ext. rotation in Add. Lack of disassociation of scapula/humerusLack of disassociation of scapula/humerus

Asymmetry of the ScapulaBefore After

Tight Subscapularis

External Rotation WNL

Treatment RC, Serratus, LLPS

Baseball player-Elbow PainBefore After

Strength Training

Strength Training

Strength Training

Plyometrics

Advanced Trunk and Shoulder Strength / Stability

Football player Impingement Before After

Strengthening exercises

Strengthening Exercises