четверг, 31 марта 2016 г.

Артроз акромиально-ключичного сустава





Некоторые суставы тела склонны к изнашиванию вследствие нагрузки в большей степени, чем другие. При этом происходит дегенерация хряща, в результате чего хрящевая часть сустава изнашивается. Этот процесс называется артрозом.
Акромиально-ключичный сустав – сустав в поясе верхней конечности, который чаще всего поражается этим процессом. Артроз развивается преимущественно у пациентов среднего возраста. Поражение акромиально-ключичного сустава вызывает боль и может значительно снижать качество жизни у активных пациентов среднего возраста.

Анатомия плечевого сустава

Причины
Часть лопатки, образующая крышу плечевого сустава и соединяющаяся с ключицей, называется акромион. Сустав, в котором акромион сочленяется с ключицей, называется акромиально-ключичным. Сочленяющиеся поверхности акромиона и ключицы покрыты суставным хрящом. Суставной хрящ имеет гладкую, эластичную поверхность, что позволяет костям скользить друг по другу, когда Вы двигаете рукой. Кроме того, хрящ обладает амортизирующими свойствами.
Акромиально-ключичный сустав отличается от таких суставов, как коленный или голеностопный, тем, что диапазон движений в нём очень небольшой. Во время движений в плечевом суставе в акромиально-ключичном суставе происходят небольшие “сдвиги”. Эти движения в суставе необходимы для нормального функционирования плеча.
Наш плечевой сустав работает постоянно. Непрерывная нагрузка на акромиально-ключичный сустав делает его восприимчивым к такому заболеванию, как остеоартроз. Нагрузка на акромиально-ключичный сустав особенно большая, когда руки подняты кверху. Штангисты и другие люди, которые часто поднимают тяжелые предметы, как правило, имеют повышенную склонность к данному заболеванию. Часто это состояние возникает в молодом возрасте.
Артроз акромиально-ключичного сустава часто развивается после травмы сустава, особенно после вывиха акромиального конца ключицы. Это довольно распространённая травма. Вывих обычно возникает в результате падения на плечо. Вывих устраняют, проводят соответствующее лечение, однако в результате дегенеративных изменений много лет спустя развивается артроз акромиально-ключичного сустава.

Симптомы
На ранних стадиях артроз акромиально-ключичного сустава, как правило, вызывает боль и напряжённость в передних отделах плечевого сустава. Боль более выражена, когда руку удерживаешь на груди, так как в этом положении увеличивается нагрузка на акромиально-ключичный сустав. Болезненным может быть не только место в области сустава, но и распространяться на плечо, переднюю часть грудной клетки и шею. Если раньше была травма сустава, сустав может выглядеть не так, как здоровый. При движениях могут слышаться хруст или щелчки.

Диагноз
Ваш врач подробно расспросит, как развивалась Ваша болезнь, а также, как она проявляется в настоящее время. Вам нужно будет обязательно указать все травмы плечевого сустава в прошлом. Вас могут попросить оценить Вашу боль в баллах по шкале от одного до десяти. Ваш доктор также уточнит, насколько боль влияет на Вашу повседневную деятельность.
Диагностика артроза акромиально-ключичного сустава, как правило, основывается на данных медицинского осмотра. При исследовании определяется боль и напряжённость. Одним из ключевых признаков является боль при выполнении определённых движений: в ходе исследования доктор плавно тянет Вашу руку, лежащую поперек груди. Ваш врач может вводить местные анестетики, например, лидокаин, в сустав. Если проблема в акромиально-ключичном суставе, инъекции будут временно уменьшать боль.
Доктор может назначить рентгеновское исследование акромиально-ключичного сустава. Рентген покажет сужение суставной щели и наличие костной шпоры вокруг сустава, а также другие признаки.

Лечение

Консервативное лечение
Основное лечение для артроза акромиально-ключичного сустава обычно состоит в обеспечении «покоя» и назначении противовоспалительных препаратов, таких, как аспирин или ибупрофен. Если боль не проходит, может помочь инъекция кортизона в сустав. Кортизон - сильный препарат, который уменьшает воспаление и боль. Эффект кортизона часто является временным. С целью реабилитации показано занятие лечебной физкультурой (ЛФК). Врач ЛФК поможет Вам подобрать программу занятий.

Оперативное лечение

Если консервативное лечение не в состоянии облегчить вашу боль, Ваш врач может порекомендовать операцию.

Резекционная артропластика акромиально-ключичного сустава
Резекционная артропластика заключается в удалении акромиального конца ключицы на протяжении 2-2,5 см. Затем рубцовая ткань заполняет пространство между ключицей и акромионом, и формируется ложный сустав, связывающий ключицу и акромион. После данной операции акромиальный конец ключицы и акромион не испытывают избыточной нагрузки. Эта процедура обычно делается через небольшой разрез кожи над суставом.

В некоторых случаях операция может быть выполнена с помощью артроскопа. Артроскоп представляет собой инструмент с крошечной видеокамерой на конце, что позволяет хирургу работать в суставе через небольшие разрезы.

Реабилитация
Реабилитация после консервативного лечения
Если Вы не нуждаетесь в хирургическом лечении, упражнения должны быть направлены на облегчение боли, а затем на укрепление мышц. Сначала выполняются упражнения, когда руки удерживаются ниже уровня плеч. Начальная программа включает силовые упражнения для вращательной манжеты плеча и мышц плеча. Целью является добиться плавности движений и научиться контролировать симптомы. Программа обычно рассчитана на 4-6 недель.

Реабилитация после операции

Ваш врач, возможно, порекомендует Вам ношение повязки для поддержки и защиты плеча в течение нескольких дней. Врач ЛФК предложит Вам программу восстановления. Первое время терапия будет направлена на контроль боли и уменьшение отека после операции. Может помочь холод и электрическая стимуляция мышц. Ваш врач также может использовать массаж и другие виды процедур для облегчения спазмов мышц и боли, если нет противопоказаний.
Восстановление может проходить быстрее после артроскопической резекции. Лечение начинают с упражнений, направленных на увеличение диапазона движений в плечевом суставе. Далее назначаются упражнения для увеличения активных движений и укрепления мышц. Вам нужно избегать слишком быстрого восстановления и придерживаться программы реабилитации.
Реабилитация проходит медленнее после операций, когда доступ производился через мышцы. Врачи, как правило, ждут не менее двух недель, прежде чем начать упражнения. Вы начнете с выполнения пассивных упражнений, во время которых осуществляются движения в плечевом суставе, а Ваши мышцы остаются расслабленными. Инструктор проконтролирует правильность выполнения этих упражнений. Вас могут научить, как выполнять пассивные упражнения дома.
Активная терапия начинается не ранее четырех-шести недель. Активные упражнения помогут Вам восстановить движения в плечевом суставе, используя силу Ваших мышц. Можно начать с изометрических упражнений. Смысл их в том, чтобы напрягать мышцы, избегая движений в суставах.
Примерно через шесть недель Вы начнете выполнять более сложные упражнения, которые будут сосредоточены на увеличении силы и контроля за мышцами вращательной манжеты плеча и мышцами лопатки. Ваш врач поможет Вам восстановить эти мышцы правильным образом. Главной целью является синхронное восстановление мышц вращательной манжеты плеча, которые удерживают головку плеча в центре суставной впадины лопатки при любых движениях.
Упражнения разработаны таким образом, чтобы быстрее вернуться к занятиям спортом и повседневной деятельности. Ваш доктор покажет Вам, как в будущем уменьшить нагрузку на поражённый сустав.

среда, 30 марта 2016 г.

Lifter's Shoulder: The Cause & The Cure

 

Lifters-shoulder-cause-and-cure

Here's what you need to know...

  1. If you're an athlete or a lifter, chances are your shoulders have given you some trouble. In fact, no other body part is as prone to dysfunction.
  2. Movement is king. Where crisp, clean movement is found, the ability to train without pain is soon to follow.
  3. You can access your own movement with self-diagnostic testing, then rid your shoulders of nagging pain.

The Shoulder Complex is... Complex

When it comes to strength training and fitness, there may be no region in the body that's as chronically dysfunctional and painful as the shoulder complex.
Simply put, the four joints comprising the shoulder girdle are battle-tested on a daily basis, not only in training but also sports like desk jockeying and frantic finger pounding into your smart phone (which are both up for review to be added to the 2020 Olympic Games.)
This region is termed the shoulder "complex" for a reason – mostly due to the insane complexity of the soft tissues that encompass multiple joints all working together to elicit smooth and powerful movements in coordination with the rest of the body.
Even with advanced orthopedic evaluation, the likelihood of even the most talented sports medicine specialist pinpointing the exact origins of pain with palpation alone is about as likely as that snowball's chance in hell you've heard about.
One thing holds true: Movement is, and will always be, king. Where crisp, clean movement is found, the ability to train without feeling like you're being impaled by ice picks every time you bench is soon to follow.

Movement: It's Kind of a Big Deal

CrossFit Movement
These days, assessing posture in my physical therapy practice has become a useless waste of time. No matter if we're evaluating an elite overhead athlete that cashes million dollar checks or an overweight mother of four, one thing holds true: their postures are atrocious.
Computers and smart phones aren't going anywhere soon. The posture of the general public is going to get worse. But athletes, lifters, and fitness fanatics are still going to move.
Assessing shoulder mobility and movement patterns with just a few simple screens can largely influence whether they move well while continuing to move often.
All you need is your own body, a mirror, and the willingness to stare at yourself shirtless without a pump.

Isolated Movements of the Shoulder

Shoulder X-Ray
The ball and socket type shoulder complex has the ability to move within the three cardinal planes of motion, making it one of the most mobile joints in the body.
Wide ranges of movement capabilities also make the shoulder joint more susceptible to injury, especially when lifters are pushing their bodies to the absolute limits in both hypertrophy and strength.
It's important to know and appreciate the movements of the shoulder joint in order to screen yourself for possible mobility impairments and movement dysfunctions. Here are the three cardinal planes of motion and the movements the shoulder is capable of using within these planes:

Sagittal Plane: Flexion

Flexion

Sagittal Plane: Extension

Extension

Frontal Plane: Abduction

Abduction

Frontal Plane: Adduction

Adduction

Transverse Plane: External Rotation

External Rotation

Transverse Plane: Internal Rotation

Internal Rotation

Transverse Plane: Horizontal Abduction

Horizontal Abduction

Transverse Plane: Horizontal Adduction

Horizontal Adduction
Remember, we aren't cyber-kinetic organisms. We have the capability to coordinate smooth movements in all planes of motion simultaneously.
This makes the isolated shoulder movements described above all but obsolete, especially for assessing your own movement with self-diagnostic testing with goals of corrective movement and ridding your shoulders of nagging pain.

Multi-Articulated Movements of the Shoulder

Screening functional internal and external rotation of the shoulder joint can play a huge role in not only identifying mobility deficits, but also identifying painful local areas within the shoulder complex.
The term "functional" doesn't mean we're going to test mobility while flailing around on a physio-ball. It simply refers to a combination movement that correlates more specifically to coordinated movements of the shoulder complex as a whole.
Functional internal and external rotation can be described as the combination of three distinct shoulder movements all performed in conjunction with smooth and rhythmical movement patterns in a certain range of motion.
Here are the breakdowns of both of these functional mobility tests:

Functional Internal Rotation = Internal Rotation + Extension + Adduction

Functional Internal Rotation

Functional External Rotation = External Rotation + Flexion + Abduction

Functional External Rotation

Shoulder Mobility Screen

These movements can be tested unilaterally or in reciprocal fashion. First thing's first: Get both arms moving simultaneously while in a standing position.
The Apley's Scratch Test will show how both shoulder girdles work in coordinated movement along with mobility capabilities of each of the shoulder girdles separately.
The right will be moving into functional internal rotation while the left is moving into functional external rotation all at the same time. The goal is to try and approximate the fingertips of each hand to touch behind your back while being symmetrical from shoulder-to-shoulder when both sides are tested.
No cheating on this one by breaking neutral posture at the spine or ratcheting your hand up your back little by little.
Take into account the distance between your hands for both sides moving through functional internal rotation and external rotation at the same time. Also note any pain or movement differences from side to side.
What you feel internally is the most important aspect of this test, with the coordinated dual shoulder range of motion a close second.

Unilateral Functional Internal/External Rotation Testing

Shoulder Pain Center
If after completing the Apley's Scratch Test and finding asymmetrical movement, pain, or notable mobility deficits (your fingers not even close to touching), it's time to break the functional movements down to identify where the faulty movement is originating.
By moving one arm at a time, the thoracic spine and ribcage are largely taken out of the mobility equation.
While moving both arms reciprocally during the Apley's Scratch Test, the thoracic spine is also being tested in how well it's able to coordinate a stable extended position while the shoulder girdles are approximating end-range motion. This leaves us able to focus in on the shoulder movement itself.
Screen one shoulder at a time in both functional internal and external rotation. While moving into functional external rotation, the goal is to be able to touch your fingertips to the bony spine of the contralateral shoulder blade.
As for the functional internal rotation screen, touching your fingers to the inferior angle of the shoulder blade on the opposite side shows normal mobility within that pattern.
The testing positions are the same as the pictures above showing proper functional internal and external rotation.

Thoracic Spine Mobility Deficit?

Chances are, when you broke down the test into one shoulder moving at a time, your range of motion, along with the rhythm of the movement, was notably better. If so, your shoulder pain may be secondary to poor thoracic spine mobility.
This is a great finding because you're well on your way towards taking action steps in your p/rehabilitation program. Focus on these three thoracic spine mobility drills before and after your training:

Gleno-Humeral Rhyme and Rhythm

Now that we have some metrics on the amount our shoulders are moving through functional internal rotation both reciprocally and unilaterally, it's time to assess rhythm and coordination.
As your shoulder moves into elevation, a few things must happen in order to complete a full and pain-free range of motion to end range. First, all joints of the shoulder complex must be working together, but also kicking in at advantageous times.
An asymptomatic shoulder joint with normal range is usually able to get to about 180 degrees of motion at end range. Obviously every shoulder girdle is as unique as the person it's connected to, so this is a ballpark number.
For the shoulder to move through this range without compensation patterns dominating the movement, the shoulder blade and humerus (bone of the upper arm) must be moving in synergistic and rhythmical fashion. We call this scapula-humeral rhythm.
Pristine scapula-humeral rhythm simply means that for every 2 degrees of motion the humerus moves into elevation, the shoulder blade must upwardly rotate 1 degree of motion to achieve end range.
However, the numbers don't tell the entire story. The point at which the shoulder blade starts to kick in is also very important.

Testing Scapulo-Humeral Rhythm

When assessing your own scapula-humeral rhythm, it's important to not only look at ranges of motion, but also when the shoulder blade starts to move.
At approximately 120 degrees of upper arm elevation, the shoulder blade should just be starting to upwardly rotate. If you find your shoulder blades become highly visible at the sides of your body before 120 degrees while slowly moving your arms into elevation, this is indicative of posterior shoulder soft tissue tone and tightness.
Also, assess the symmetry of the movement from left to right. Are your shoulder blades starting to rotate at the same times, or is the rhythm off and asymmetrical?
If your rhythm is off, your best course of action is to start in on a posterior shoulder girdle soft tissue and mobility program.
This can simply be movement targeting the latissimus dorsi and other surrounding muscles with foam rolling or Hands-On SMR, or mobility focused movements such as loaded stretches into your programming.
The choice is yours, and the only wrong decision is to not address these issues at all.

The Painful Arc of the Shoulder

Finally, if you nerd out on mechanics of human movement and dysfunction, you most likely want to figure out what exact anatomic location in the shoulder complex is causing you discomfort every time you hit the gym.
Let's go back to the scapula-humeral rhythm testing position and switch our focus on pain provocation.
The most commonly injured sites in the shoulder girdle are the gleno-humeral joint (GH-Joint) and the acromio-clavicular joint (AC-Joint). Though these two joints work together in upper extremity function, they're responsible for playing in primary movements at different points of the movement arc into shoulder elevation.
Arc
The painful arc of the shoulder states that if pain in the shoulder is present when your upper arm is within 45-120 degrees of motion, the most likely culprit causing pain is within the GH-Joint.
On the other side of the arc, if pain in the shoulder is only present at end range shoulder elevation, between 170-180 degrees, the AC-Joint is likely the portion of the shoulder complex that isn't functioning correctly.
If your own self-diagnostic findings point to GH-Joint pain and dysfunction, enhancing your dynamic and static shoulder positioning, especially under load, is going to be the one of the most efficient ways to leave pain in the dust while continuing to train hard.
As for the AC-Joint, relieving unwanted joint stresses at end range can be avoided by decreasing the tone of the muscles and structures of the posterior shoulder girdle, allowing better tracking patterns of the scapula and shoulder joint as a whole.

How to Build Bulletproof Shoulders

 

Shoulder

Here's what you need to know...

  1. Landmine presses are an effective "middle of the road"exercise between overhead work and true horizontal pressing exercises.
  2. If you're dead-set on returning to barbell overhead pressing as you come back from a shoulder injury, test the waters with a bottoms-up kettlebell variation first.
  3. Athletes need to earn the right to train lats. You aren't allowed to do pull-ups or pulldowns until you pass the back-to-wall shoulder flexion test. No exceptions allowed.
  4. Don't train the rotator cuff to failure. Fatigue is your enemy when you're trying to establish a strong and effective rotator cuff.
A lot of athletes refer to me as the "Shoulder Guy." This is probably because I've personally evaluated more than 3,000 shoulders. With that experience comes a lot of new expertise in the shoulder arena. Below, you'll find three examples of new things we're doing to keep shoulders healthy and performing at high levels.

1 – Bottoms-up kettlebell overhead drills are a great early stage, return-to-overhead-pressing progression.

My role of the "shoulder guy" was actually born out of necessity, as I have a right shoulder that's structurally a mess. Still, I've managed to work around it to move some solid weight for a guy my size, and it doesn't give me any problems at rest unless I do something stupid – most notably overhead pressing and even incline pressing.
Still, I miss my overhead work, so I tinker and experiment with things quite a bit to see what works. For instance, landmine presses are an effective "middle of the road" exercise between overhead work and true horizontal pressing exercises.
If you really think about the arm path, this isn't much different than an incline press, so why does the incline press often cause people more shoulder problems than landmine work? I suspect it has to do with the fact that having the upper back pinned against a bench limits the ability of the shoulder blades to freely rotate upward; they get stuck down into scapular downward rotation.
This year, to build on the "how you can overhead press without really overhead pressing" theme, I experimented with a lot with bottoms-up kettlebell overhead carries and pressing. I like the idea of starting with a carry because it teaches people where an appropriate "finish" position is, and then you can work backwards from it.
If you've successfully completed overhead carries, you can go to a 1-arm bottoms-up kettlebell military press:
The bottoms-up setup is more shoulder friendly because the unstable environment shifts more of the muscular contribution to joint stability than actual force production. In this regard, it's very similar to doing a push-up on an unstable surface. So, if you're dead-set on returning to barbell overhead pressing as you come back from a shoulder injury, test the waters with a bottoms-up kettlebell variation first.

2 – Athletes need to earn the right to train the lats.

Posture
I have a true love/hate relationship with the lats. On one hand, lats are awesome in that they make you look jacked and contribute to high performance on a number of athletic fronts, from sprinting speed to throwing velocity. On the other hand, athletes love to use them to excess for other actions like breathing and core stability, and they shouldn't be doing that much work. The end result? A lot of aberrant postures that look like this:
This guy uses his lats to do absolutely everything. Notice the crazy arching of his lower back, and the fact that his elbows sit about four feet behind his shoulders at rest. Additionally, most guys who overuse the lats will have heavily downsloped shoulder girdles (scapular depression), as well as limited shoulder flexion, as becomes apparent if you test them on their backs. To give you an idea of what I'm talking about, the upper arms in the picture below should actually make contact with the table:
Nowadays, we spend a lot of time trying to teach athletes how to shut lats off when they shouldn't be on. However, I know we aren't going to talk you out of trying to develop that V-shaped torso with lat work, so what are some guidelines?
First, you aren't allowed to do pull-ups or pulldowns until you pass the back-to-wall shoulder flexion test. No exceptions allowed.
If you can't pass the test, make sure you're foam rolling and stretching your lats out regularly, and practice this drill:
Second, if you find that your posture is like the one above, work hard to get out of extension on a daily basis. In other words, you likely need to posteriorly tilt the pelvis and flatten the lower back a bit – and then try to maintain this during your exercises. Yes, it sounds silly, but you might actually need to flex more and stop arching your back to improve your deadlift and squat technique.
Third, make sure you're doubling up on the volume of overhead reaching in your program in order to iron out the top-to-bottom imbalance at your shoulder girdle. Good additions to your program would be wall slide variations, overhead carries and presses, and overhead reaching during warm-up drills.
Let's say you're doing four sets of six weighted chin-ups for a total of 24 reps. How would you get 48 reps of overhead reaching in during your training session?
Warm-ups:
1 Set Dead Bugs 8 reps/side
1 Set Wall Slides with Upward Rotation 8 reps
1 Set Overhead Lunge Walk 4 reps/leg
1 Set Alternating Lateral Lunge Walk with Overhead Reach 4 reps/leg
Training Session:
3 Sets Overhead Variation 3 x 6 reps = 18 reps
It's pretty simple, and it makes you realize that simply getting the arms overhead more – and with a neutral core posture – can easily shift your program back into balance. Remember, though, you have to earn the right to even train lats in the first place!

3 – Get rid of the YTWL series.

You're probably familiar with the YTWL series that has gained a lot of popularity over the past decade or so. It's particularly common among strength and conditioning coaches who want to train a bunch of shoulder functions in a short amount of time so that they can get to the "big bang" stuff. Effectively, you take four exercises and do them in order with no rest – each for 8-12 reps.
The theories are admirable: healthy shoulders and training economy. Unfortunately, the outcomes are not. I can honestly say that I've never seen an athlete perfectly execute all of these movements on his first day – much less under the conditions of fatigue you'd get with a longer series like this.
That said, I love the Y; it's awesome for developing lower trapezius control, which allows us to get appropriate upward rotation with plenty of scapular posterior tilt.
I also love the T; it helps us to recruit both middle trapezius and the posterior rotator cuff and deltoid – while making sure that the humeral head (ball) doesn't glide forward on the glenoid socket.
The W is a great exercise, too, as it trains the ability to differentiate between movement of the glenohumeral joint (ball-and-socket) and that of the scapulothoracic joint (shoulder blade on the rib cage). You want the former, not the latter, and making sure that takes place means you're getting great rotator cuff recruitment without "tugging" with the lats.
To be honest, I don't particularly care for the L, as it's too lat dominant. Still, even if I did like it, it wouldn't matter because most athletes have butchered all three other drills by the time they even get to it!
Beyond the lack of technical coaching most athletes receive on these exercises, the problems are magnified by the presence of fatigue. The research is pretty clear that the best way to train the rotator cuff for high performance is perfect technique, but not even coming close to failure. Fatigue might be your friend when you're doing a drop set for your quads or biceps, but it's your enemy when you're trying to establish a strong and effective rotator cuff. The ball just rattles around the socket instead of staying nice and centered.
The solution is very simple: replace the series with the individual parts spread out through the week. We might do a Y (prone 1-arm trap raise) on Mondays and Thursdays during lower-body days, and the T (prone horizontal abduction) and W (external rotation) on Tuesdays and Fridays on our upper body days.

Prone 1-Arm Trap Raise (Y)

Prone Horizontal Abduction (T)

Cable External Rotation at 90 Degrees, Scapular Plane (W)

You can sum this entire point up as, "Do things correctly before you do them a lot or under fatigue."

4 Easy Ways to Fix Shoulder Pain

A Guide to Smooth, Powerful Shoulder Movement

The-cure-for-sticky-shoulders
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Let's start out with a list of some common things that contribute to soft tissue problems in the shoulders and some suggestions for minimizing them. Then we'll finish off with four moves that'll heal your shoulders up fast.

Five Reasons Why Your Shoulders Hurt

1 – Barbells

Barbells fix our shoulders in position and don't allow them to rotate or use shoulder-friendly grips. To make matters worse, we typically press bars with a pronated (overhand, palms facing away) grip, which is a position of loaded internal rotation for the shoulder. This can promote existing rotator cuff/shoulder girdle imbalances. Also, if you have weakness in one shoulder, it can't be addressed with a bar that distributes the load evenly across both shoulders.
If you have shoulder pain, keep barbell use to one day a week per upper body movement (preferably for horizontal pressing as opposed to vertical). Limit barbell use to short, heavy sets and switch between a pronated and supinated grip from time to time.

2 – Body-Part Splits

If you're going to use body-part training splits, you need to make sure that you're balancing your ratio of pushing and pulling. People balance horizontal push and pull all the time (think bench press and row), but it's all too easy to neglect to balance vertical pushing and pulling (think overhead press and pulldown.) Things like cleans, shrugs and overhead pressing must be balanced with things like chin-ups and pulldowns at different angles. Organize your program to keep a 2:2 ratio of vertical pulling/pressing to horizontal pulling/pressing.

3 – "Chewing"

The tendons at the front of the shoulder can get "chewed up." These tendons protect the shoulders by keeping the humeral head from translating too far forward in the glenoid fossa (the socket). This forward or anterior translation is referred to as "anterior humeral glide" and can lead to chronic connective tissue irritation and lingering pain and soreness, especially after pressing workouts.
It can be made worse with tight lats that pull our humeral head forward. This is seen in people who perform rowing/pulling reps that end with the elbows in retroversion way behind the rib cage and with the top of their humerus jutting out in front of their pecs. If this is you, shorten your range of motion when doing pulling exercises. Focus on getting a good scapulae squeeze/retraction and stop there. It'll help to restore the tissue quality of these abused supportive structures.

4 – Gunky Ground Substances

Ground substances are basically what lubricate our individual muscle fibers and allow them to smoothly cooperate and glide over one another. They're composed of water and other entities known as glycosaminoglycons (GAGs). GAGs are amino groups containing polysaccharides that, combined with water, support the connective tissue (like collagen and elastin) and help it to remain moist.
GAGs act as a medium of exchange for oxygen and nutrients and also allow for removal of cellular waste. They therefore play a major role in the work capacity, health, and daily function of our muscle fibers and are as crucial for hypertrophy and performance as fascia and muscles themselves.
With chronic stress, immobility, and injury, these substances can change from being water-like to becoming viscous, hindering our movement. Then they become solid and gunky, restricting our movement. This last stage is where problems like painful, frozen shoulders come into play. Self-myofascial release (SMR) and other restoration methods will keep our ground substances watery and in their natural state.

5 – Movement Bias

Our joints are subjected to the same loading patterns over and over again without the ameliorating effects offered by performing movements that are altogether different from what your joints are accustomed to. To help deal with this, be more disciplined in the daily management of your soft tissue.

How to Fix Your Shoulders

Here's a simple rehab protocol to help your soft tissues return to normal and get your scapulae moving properly again.

1 – Medicine Ball Tack and Floss

Med balls can be great tools for self-myofascial release. Due to their shape, they're often better than foam rollers. Balls can really get into the nooks and crannies. Many med ball are harder too, with a tackier surface which increases friction and makes it easier to maintain contact with you and the floor.
To use the tack and floss with a med ball, find a knot or sore spot. Pin the sore spot down and actively go through a full and varied range of motion. This is a great way to knead the tissue from the point of pressure outward, tenderizing the tense tissue and gradually decreasing the layer of adhesions and dysfunction that have built up. It'll also re-mobilize ground substances, help the fascial layers to glide smoothly on top of one another, and mobilize any scars.
Perform the tack and floss with two movements and two progressions using the wall and then the floor. For the wall, place a small or medium-sized med ball between the wall and the area under your collarbone – in and around the pec and anterior deltoid – and lean against it. To get the pec minor, get your feet back and really lean in. Maintain a rigid anterior core and a slight posterior pelvic tilt to protect your posture.

Tack and Floss, Anterior 1

Get your arm into a position of full internal rotation – back of the hand placed at the top of the butt or as close to it as you can get – and slowly rotate it counter-clockwise all the way up overhead and then back to the starting position.
Be sure to also rotate the hand and wrist to access and release the maximum amount of fibers in the shoulder girdle. You can also raise your upper arm to shoulder height and flex the elbow to 90-degrees and go through an internal/external rotation pattern.

Tack and Floss, Anterior 2

The more you perform this, the better your tissue quality will become and the more pressure you'll be able to apply against the ball. Eventually you'll be able to move to the final progression, which is on the floor.

Tack and Floss, Anterior 3

This final position will provide a much fuller release of the shoulder girdle by adding in a sideways rotation to include the release of the superior attachment of the lats, the teres major and minor, the infraspinatus, and the long head of the triceps.
Perform the same movements on the posterior (back) region of the shoulder girdle. The floor works best here.

Tack and Floss, Posterior 1

Tack and Floss, Posterior 2

Do two sets of ten before moving on to exercise two of the series.

2 – Handcuff Drill

After releasing the soft tissue of the shoulder girdle that's been hindering movement, do the handcuff drill. This strengthens and promotes blood flow to the muscles of the scapula and humerus, which operate in a supportive function during pressing. The muscles you hit depend on whether you perform the exercise in protraction or retraction, so do both.

Handcuff Drill, Wall

Start in a full kneeling position close to the wall. Wrap a small, taut band over the wrists and place the hands against the wall with the wrists at shoulder height and the elbows locked. Now imagine a clock. Make small movements with each hand, alternating them one at a time toward 12, 3, and 5 with your right hand and 12, 9, and 7 with your left hand.
Progress the exercise by kneeling further from the wall, up to about a foot out from the original position. Then move to standing and progress it the same way. Once you can perform it standing far from the wall, progress to the floor (or on a slightly elevated surface) where you perform the exercise in a straight-arm plank.

Handcuff Drill, Floor

At first your shoulder girdle will quickly fatigue and burn. However, that feeling of fatiguing and burning (the build-up of metabolic waste) isn't the same thing as pain. If it hurts, stop and continue next time, building your way to the point of doing the entire exercise pain-free. You're not ready to move to the next position/progression of this exercise (moving further out from the wall) until you can complete two sets of the handcuff drill pain free, in both retraction and protraction, without taking a break between reps.
Perform two sets of ten in each position.

3 – Restoring Scapula Movement

The next exercise is all about obtaining vertical push/pull balance. This means coordinating the activity of the upper and lower fibers of the trapezius, as well as some of the lower fibers of the serratus anterior, all while keeping our scapulae in retraction.
This exercise can be done with both a cable (for passive activation of the upward rotators), or a kettlebell (for active activation of the upward rotators). While the kettlebell variation is great as a warm-up for performance, the cable variation is great as a more corrective measure to grant the user healthy lat-length (to prevent anterior humeral glide and a kyphotic posture) and long-head triceps length. This will loosen up the often stiff and gunky posterior capsule of the shoulder.
A stiff and immobile posterior capsule can force the humeral head to the front of the glenoid fossa and contribute to further anterior glide of the humerus and a lack of joint centration within the glenohumeral joint. The cable variation also gives us some vertical pulling at an atypical angle to hit fibers we normally wouldn't, and to promote that crucial vertical press/pull balance.

Restoring Scapula Movement, Cable

Do the cable variation by attaching a dual or single high-pulley to a moderate load and hinging backward at the hips. Simultaneously flex the shoulders overhead so that the bottom position has you at a 45-degree angle at the hip with the arms fully extended alongside the ears.
The hinge and the overhead flexion at the shoulder gives the lats and long head triceps a nice, long dynamic stretch and helps to provide the positional mobility and stability at both the lumbar and thoracic spine that's required when performing the kettlebell variation.
The kettlebell variation is performed by holding the kettlebell in a goblet while remaining in the bottom position of a hinge, and pressing it out overhead keeping the arms in-line with the ears. Start light!

Restoring Scapula Movement, Kettlebell

Do two sets of ten for each of the cable and kettlebell variations (in that order) before moving on to the final exercise.

4 – Rebuilding Your Overhead Press

The serratus press will get the shoulders re-acclimated to overhead pressing. The focus is to train the lower fibers of the serratus anterior to keep your scapula abducting and rotating snugly and efficiently along and against the ribcage, closely following the humeral head and maintaining proper congruency of the ball and socket.

Serratus Press, Foam Roller

For the first progression, take a foam roller and place it horizontally against the wall. Then get into either a wide or a staggered stance and lean against the roller with the distal portion of your forearms. With the arms bent to 90-degrees at the elbow and shoulder, protract the scapulae and press into the roller while simultaneously moving the arms overhead, gradually gliding the roller upwards. Keep the arms narrow, no more than shoulder distance apart. Once you can perform it pain free for three sets of ten, it's time to progress.

Serratus Press, Barbell

Set the pins at just below shoulder height in a power rack with an unloaded or very lightly loaded barbell and perform the same action. Slowly press the bar up while maintaining forward pressure against the rack. Don't progress to the power rack until you can do two to three pain-free sets with the foam roller. Remember, everything here is about progress. Don't rush. You may increase the load slightly with each set.

When to Do Them

Try these four exercises prior to training and also on your off-days. Once you heal up, keep doing these movements as a preventative care program to maintain shoulder health.