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Shoulder Health: Mobility vs. Stability

You Care Too Much About Shoulder Mobility and Not Enough About Stability

 

“Mobility.” It’s one of everybody’s current favorite fitness buzzwords, right up there with “functional.” Don’t even get me started on that word. Look anywhere in the heath and fitness blogosphere and you’re bound to find articles, products, and videos to improve your mobility. Hell, I’ve even written about it myself. For the most part, this focus on reaching increased ranges of motion and improving movement quality has been a good thing. Athletes who can adequately move through more ranges of motion generally seem to have lower rates of injury and perform better in the long term. However, like most things humans are involved in, we have taken the whole “mobility” thing too far. Color me shocked. With various movements reserved for emaciated and highly skilled yogis, overcomplicated warmup protocols, and torture devices designed smashing and bruising already inflamed muscles, we have placed mobility on a pedestal that most athletes not only can’t achieve, but often injure themselves doing so.

 

What in Kazmaier’s name is “mobility” anyways? That’s a good question. For the purposes of this discussion, I will define mobility as “the ability to comfortably reach the required range of motion to accomplish a task.” However, in the realm of biomechanics, there isn’t a unifying definition. Ask 20 different “experts” (and I use that term very loosely) in the field and maybe if you’re lucky, two of them will have the same answer. Since physical therapists and exercise physiologists can’t agree on what mobility is, how can any good data be gathered on what kind and how much of it is important? Truthfully, it can’t. The amount of mobility required for a specific movement is going to be dependent on the individual lever lengths, muscle origins and insertions, and joint anatomy of the individual athlete. Not to mention the fact that there isn’t necessarily a direct correlation between increased levels of mobility and sport performance! Provided one can achieve the necessary positioning required for their sport, is any range of motion further than that truly beneficial?

 

As is the answer to most questions about sports science and medicine, it depends. In this case, it depends on one thing: STABILITY. If one is unstable in any position, they are at greater risk of injury, regardless of how long they spent foam rolling that day (which may not even have any actual benefit, but that is a discussion for another time). Take, for example, the softball pitcher. She has tremendous mobility of the shoulder and elbow and can achieve all the positions required by her sport, but still blows out her elbow out and needs Tommy John’s surgery. What exercises are primarily performed during her rehabilitation protocol? Those that stabilize the elbow joint. Does the improved shoulder mobility of a quarterback over a lineman prevent him from dislocating his shoulder when he gets slammed on the ground? Not likely. These athletes have prioritized mobility over stability, as is required by the demands of their respective sports, but it has left them vulnerable. And vulnerable, unstable joints are not something we want as strength athletes. Even for your run of the mill office worker, stabilization exercises have been shown to reduce shoulder pain, and they don’t put their shoulders through nearly the beating that we do!

 

To achieve stability, we must first define it. Fortunately, the biomechanics literature actually does this, defining stability as “the ability to resist perturbation.” Get your minds out of the gutter and focus. This means that if a joint is stable, it can resist outside forces that compromise its integrity. Does this sound like something you might want when picking up heavy stuff? You’re damn right it does. Now I know you’ve got your fancy shoulder mobility routine that allows you to twist your arms behind you like a pretzel while standing on your head or some such nonsense, but can those same shoulders support a heavy barbell overhead, especially when you get out of position? GOOD LUCK. You’ve spent so much time trying to get into unnecessary positions that you have mixed up your priorities and are unable to perform what you’re actually training for. Don’t worry; I’ve got you. It’s time to get solid in those positions you’ve worked so hard to achieve.

 

Since I discussed trunk stabilization at length in Part I , we are going to focus on my favorite (or least favorite? I can’t decide) joint in Part II: the shoulder. We’ll skip the anatomy lesson for today, since I’ve written about shoulder and thoracic anatomy in the past, and just focus on the meat and potatoes of improving your shoulder stability. This is an issue I have worked through personally after having shoulder surgery last year. My labrum was torn in two places along with my supraspinatus, so needless to say, both my mobility and stability were compromised. Lucky for me, my range of motion came back rather quickly during my post-operative physical therapy. However, the pain just wouldn’t go away, and I just didn’t feel comfortable with weight overhead, regardless of how strong I felt and how solid my orthopedic surgeon kept telling me the shoulder was. The basic musculoskeletal literature wasn’t much help, so I started doing some outside reading and contacting providers more well-versed in shoulder rehab than I was at the time. It turned out my scapular kinematics (the movement of the scapula across the ribs in support of the shoulder) were totally out of whack and my shoulder joint was very unstable, despite the fresh hardware  inside of it. It wasn’t until I focused directly on scapular and shoulder stabilization movements that I became pain-free and started putting bigger weights over my head.

 

Let’s start with the scapula.  The movement of this bone across the ribs and as a part of the shoulder joint is extremely important for both mobility and stability of the shoulder. I won’t delve into the nitty gritty of its functional anatomy and biomechanics, but it attaches to the clavicle, the humerus, and the axial skeleton, essentially serving as the anchor for one’s upper extremity. When this moves improperly or is easily fatigued (poor scapular kinematics a.k.a scapular dyskinesia), it compromises the integrity of the entire shoulder joint. In fact, it can actually decrease rotator cuff strength, meaning that even if your cuff muscles are strong, scapular dyskinesia can result in an unstable shoulder. All the banded external rotations (which I still recommend for rotator cuff strength) in the world won’t save you if you are unable to stabilize your scapula. Since it is likely that your anterior and lateral deltoids, pecs, lats, and traps are already plenty developed, I won’t tell you how to strengthen those. They can help stabilize the scapula, but without the smaller stabilizers, they can actually worsen your scapular kinematics.

 

Looks like I do have to get into a little anatomy and biomechanics. You don’t like it? Too bad. Go get hurt and have a weak press. Anyways, the smaller muscles of scapular stabilization are designed to prevent scapular winging and scapular malposition, also known as SICK scapula syndrome (SICK stands for Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement). You can see in these images that these are clearly not good positions to support heavy weights. The primary muscles implicated in these pathologies are the rhomboids, levator scapulae, serratus anterior, and to some degree the infraspinatus, lower trapezius, and posterior head of the deltoid. As a strength athlete, unless you’ve had a nerve injury, there’s no excuse for these muscles to be underdeveloped. Lucky for you, they aren’t overly complicated to strengthen and hypertrophy. But first, a disclaimer: if you have a shoulder that dislocates or feels significantly unstable, please get it evaluated by a medical professional prior to performing these exercises. You may be doing more harm than good if your joint is already in bad shape.

There are many ways to achieve this, but I am partial to easy stuff that anyone can do with some basic equipment. I’ll first detail some introductory movements before going into more complex and integrated stabilization strategies. Band pull-aparts are one of my favorite movements for developing the rhomboids and levator scapulae, and there are videos all over YouTube on how to perform them properly. They also hit the posterior deltoids to a reasonable degree. I have three major pointers for that exercise, however. One: be sure to let your scapulae fully protract forward and fully retract backwards during the movement. Partial reps aren’t helping anybody. Two: focus on pulling with your mid back; don’t rely on your lats, arms or traps for the movement. Think of drawing your scapulae down and towards your ribs when you pull. And three: do TONS of reps. Light weights and high reps are what will hypertrophy these muscles and make them  resistant to fatigue. I never do pull-aparts for sets of less than 20, and it’s usually more than that. You can use the same band and the same principles for face pulls on top of the pull-aparts. These will hit the traps, lats, and posterior deltoids to a greater degree than pull-aparts, but that’s okay. All of these muscles will need to work in concert for you to be successful.

 

Another easy exercise that assists in the development of scapular stabilization is the “scap push-up,” which focuses primarily on serratus anterior. To perform these, get into a push-up position, and while maintaining a tight core and completely extended elbows, try to push yourself away from the floor using just your shoulders. This is done by protracting your scapulae. Hold that position for 1-2 seconds, then retract your scapulae to return to your starting position. This does not need to be performed with added weight, but you should feel a solid contraction for at least 10 reps.  Accompanying the scap push-up is the “scap pull-up.” Perform this exercise hanging from a pull-up bar with arms completely extended overhead. Without bending your elbows, pull your body towards the bar by retracting your scapulae together and down towards your feet. Hold this contraction for 1-2 seconds, then return to your starting position of a dead hang; repeat 10 times. This also has the added benefit of stretching the lats and improving your grip strength.

 

It is appropriate to perform these movements every training session, but not required. They should definitely be worked in at least three times per week, though. Once you have developed strength and endurance in these exercises (at least 3 sets of each without breaking technique), we can move on to more advanced and integrated shoulder stability movements. If you have injuries elsewhere in your body, those may be affected by these movements, so use them carefully and accordingly. As always, safety comes first.

 

I’ll admit that I stole this next exercise from Chris Duffin (who you should definitely be paying attention to as any variety of strength athlete), but that only makes my recommendation for it even stronger. Using the same light band you had for the pull-aparts and face pulls, wrap it around a power rack or something else sturdy, then put your hands through the loop. Take a few steps away from the rack and extend your arms over your head. Now, this may be limited by inadequate shoulder mobility, so do the best you can at the start and work to improve that alongside your stability. It’s almost like both of those things are important! Make sure your scapulae are pulled back and down in a good position, and squat. Pause for a second at the bottom of each rep and try to keep your torso as upright as possible. In addition to stabilizing the shoulder girdle, these squats will help to open up the hips, shoulders, and thoracic spine. If you’re feeling extra spicy, put a short band or hip circle around your knees to really wake up your glutes as well. 2-4 sets of 15-20 reps before most training sessions is a good range to work with here.

 

Now we can move on to loaded shoulder stabilization movements. Unlike the prior movements, these can be a little challenging to learn and explain, so watching some videos can be helpful. The loaded movements also take a little more recovery, so they should not be performed every day. The first three can be used a progression, so scale them as needed when using them yourself or introducing them to your athletes. I really like kettlebells for these movements, but if you only have access to dumbbells, that’s okay too.

 

We will begin with a modified version of the kettlebell armbar. This version adds in protraction and retraction of the scapula in addition to the movement of the armbar and progresses from easier to more difficult positions. While laying supine with your knees and hips flexed and your spine in neutral (think of pushing your lower back into the floor), grab a light kettlebell and extend your arm upwards as if you were performing a floor press. Take a good diaphragmatic breath to stabilize your trunk, and protract your scapula, pushing the kettlebell away from your body (much like you did in the scap pushups). Hold this position for a one-count prior to returning to the starting position. Perform 10 reps per arm, 3 times per week. Once this has become an easy and comfortable movement, you can move onto the next progression, which is performed lying somewhat on your side with your knees and hips flexed in the same fashion as the first movement (think of a slightly less flexed fetal position. Perform 10 reps per side, 3 times per week yet again. Once this is easy, roll completely onto one side, extend the bottom leg, and bring the other leg across (think of how you would get your lower back to pop via the stretch we all learned in PE class). This is the more traditional KB armbar position for those of you familiar with the movement. The same rep scheme should be used for this. If none of that made sense, here’s a good video of a traditional kettlebell armbar, from which you can extrapolate the movements described above. Each of these positions is more difficult than the last, so start conservatively with the weight used. It’s not worth getting cocky and hurting yourself during pre-hab. That’s just dumb.

Once you’ve become comfortable with the armbars, we can transition to a more integrated movement: the Turkish get-up (or TGU). The stabilization principles are the same here, as we focus on the setting of the scapula prior to initiating movement. I won’t go through a complete explanation of how to perform a proper TGU here as there are plenty of places online with certified kettlebell coaches teaching the movement. I’d recommend trying to have someone teach you them in person, however, as the TGU can be a challenging movement to perform properly. When performed properly, though, it really improves movement quality, mobility, and stability of most of your body’s joints, chief among them the shoulder and the trunk. Moves like the TGU are also important from a medical perspective, as falls are such a major contributor to morbidity and mortality in the elderly. Every person, athlete or not, needs to have a good relationship with the ground and know how to pick him or herself off of it. We can probably tweak that to use it as an analogy for life too, but I’ll leave the motivational memes to somebody else. In any case, start conservative with the weight on TGUs too, because they are an incredibly humbling exercise if you have not performed them before. 2-3 sets of 5 reps per side twice per week is a good place to start.

 

Kettlebell windmills are the movement I would suggest next. They aren’t necessarily more challenging to learn than TGUs, but they can require a little more stability in the shoulder and I’d argue that the positions are easier to get into after you’ve done some TGUs. Start with a light kettlebell over your head and your feet roughly shoulder width apart. Your off arm should be out to your side, and while keeping tight scapulae and a solid core (don’t forget your diaphragmatic breathing), rotate your body down and away from the kettlebell while it remains over your head. Shift your hips to the side of the KB and keep your knees straight (but not locked), touching your off hand to the ground. Then, bring yourself back to the starting position using your obliques. The name of the movement is appropriate; think of moving yourself like the arms of a windmill (sort of). Here’s a video in case that didn’t make sense. 2-4 sets of 5-10 reps is what I’d say you should shoot for.

 

One important thing to remember when performing all of these loaded exercises: DO NOT TAKE YOUR EYES OFF THE WEIGHT AT ANY TIME! You will not be the first or last person to lose your balance with the weight and smack yourself in the face. The goal here is to prevent injury, not cause it. This is especially important when you have developed enough grip strength and stability to perform these movements with a bottoms-up KB, which is a great goal to have. Bottoms-up kettlebell training improves shoulder stability even further by providing a significant increase in rotator cuff activation from standard training. If you’ve ever tried to perform a reasonably heavy bottoms-up KB press, this shouldn’t be a surprise.

 

I’d be remiss if I didn’t recommend overhead carries as an excellent method of improving shoulder and scapular stability. You can perform these with pretty much any implement you like, from kettlebells to dumbbells to logs to stones to sandbags to barbells to your significant other, for all I care. Each one is going to have a different feel and activate your muscles in a slightly different way. These carries can be extremely taxing on your trunk stabilizers and legs as well, so just be careful when performing them. My favorite among the overhead carry variations is the yoke. The way it swings and the sheer size and awkwardness of the implement makes it a challenge even with relatively light weights. Like any of the aforementioned movements, be sure to set your scapulae beforehand and keep them tight throughout.

 

That brings me to my final point. You can actually improve your overhead stability on your regular training movements without even adding any of this stuff in (you should still work on it, though). It all starts with your setup. By pulling your scapulae slightly down and together during setup, you set yourself with a good base to press, snatch, or overhead squat from. This will also get you in more thoracic extension, make external rotation of the shoulders easier and more comfortable, and open up your chest a bit. Couple this with squeezing the living hell out of the bar, which helps to activate your rotator cuff complex and improves neuromuscular coordination, and you’ve just increased your stability significantly without even performing any fancy new exercises. Add in proper diaphragmatic breathing, and you’re ready to toss some weight into the sky.

I hope this has been helpful to all you mobility freaks out there. None of this is to say that mobility exercises to achieve adequate and proper ranges of motion for your sport is bad. In fact, that is a wonderful idea. An immobile joint isn’t terribly useful either. Just don’t sacrifice your stability for mobility, especially in the shoulder. It can be pretty fragile, so protect it! Now get out there, improve your overhead stabilization, and set some scap-tacular PR’s! Stay strong and healthy!

 

P.S. Honorable mention integrated core/trunk stability movement (with coordination work as well) is the bear crawl. Try it both forwards and backwards with a short band around your wrists. This can be a conditioning killer as well, especially if you drag a sled or add a weighted vest. You can even reach back during your crawl and do 1 arm sled pulls. Play around with it and have some “functional” fun!

DISCLAIMER: None of this article is intended to be taken as medical advice. If you have any questions or health concerns, please contact your primary care physician. Always consult a physician before starting any diet or exercise program. These statements have been made by a private citizen and do not reflect the views or policies of the United States Navy.

Seth Larsen, DO (aka “Dr. Meathead”) is a Doctor of Osteopathic Medicine and resident physician in family medicine with an area of focus in musculoskeletal and sports medicine. He is also a former NCAA football player who now competes as a nationally-qualified lightweight (<200lb) strongman, elite-level deadlifter, and amateur highland games athlete. In addition to his residency, he is currently in the process of applying for a fellowship in primary care sports medicine and completing his CSCS. He runs www.drmeathead.com, an educational website promoting the integration of all aspects of modern medicine with performance nutrition and strength & conditioning.

 

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