CASE STUDY: Kerri Walsh + SHOULDER injury = fixed
OK so if you remember from one of my SHOULDER blogs (HERE), I said I'll do a case study on an internationally known athlete demonstrating how someone could hurt their shoulder. Well, here it is...introducing Kerri Walsh.
If you are an "OVERHEAD ATHLETE," this should be on your priority read list. For the past two months or so, shoulder injuries hit an all-time high, particularly for professional < recreational overhead athletes. So I feel the need to drill this material into your heads.
Who are OVERHEAD ATHLETES?
(Reading pointers): Don't worry too much about the lingo, all you need to take from this is to understand what muscles and joints are affected, and what times of exercises can help rectify those affected muscles. Once you understand this, you can do them on your own. I've designed a few really effective programs to help with shoulder impairments. I'll post a few youtube videos that will demo the program in better detail.
Subject: Kerri Walsh
Past Medical History: right rotator cuff pathology and 2 shoulder surgeries over her career.
Sport: Pro-Beach Volleyball Athlete
Assessment based on observation:
* Upper Crossed Syndrom
* Forward head carriage
* Bilateral Rounded Shoulders
According to Borsa, Laudner, and Sauers (2008), volleyball players are overhead athletes who have consistently reported altered mobility patterns in the dominant shoulder (5). Elite beach volleyball players like Kerri Walsh do not fall far from the tree. With her dominant right rotator cuff pathology and two shoulder surgeries over her career clearly demonstrates this finding to be true. Borsa et at. (2008) further explain how mobility concerns of the overhead athlete can be either hypermobile or hypermobile. Apparently, researchers debate "whether altered shoulder mobility is inherent or acquired through adaptive change to joint structures" (Borsa, Laudner & Sauers, 2008). Looking back at Kerri Walsh's early collegiate career, we can better understand whether or not her chronic shoulder conditions are anatomically inherited anomalies or adaptive through progressive changes to joint structures. Reportedly, has a history of congenital severe shoulder injuries dating back to her high school years and college career (1). One particular shoulder injury hindered her senior collegiate career (1). Interestingly enough, Walsh still is one of the most-honored players in NCAA history. Considering the ability to personally evaluate and question the Olympic medalist is not an option, it is safe to assume that rectifying structural damages to the glenohumeral joint capsule, ligaments, glenoid labrum, or rotator cuff musculatures might be something she will need to address her entire life.
Joshi et al. (2011) designed an external rotation fatigue protocol to conclude that lower trapezius weakness might alter the scapular position and affect the length-tension relationship for the infraspinatus. Further stating that overactivity of the "infraspinatus might be a compensatory mechanism to maintain force production despite altered scapular position" (Joshi et al., 2011). In other words, if the lower trapezius is weak it will fatigue faster and alters the scapular position, progressively increasing infraspinatus activity which means, possible shoulder injury.
For example, spiking a volleyball can be defined as a frontal plane movement with peak moment force anteriorly applied, shoulder abduction and internal rotation thrust (descending movement). The subscapularis with the help of its eccentric copilot the infraspinatus, internally rotate the shoulder while the lower trapezius depresses and stabilizes the scapula. Also, the infraspinatus plays a major role as the external rotator. Therefore, if Kerri Walsh cranks back her right shoulder to gather full momentum for the spike, but the lower trapezius is weak and ineffective to maintain the scapula in the right position, the infraspinatus will be forced to pick up the slack and eventually becomes vulnerable to injury.
Finally, restricted Cervical spine mobility (or lack of stability) caused by apparent and assumed dysfunctions such as her Upper Crossed Syndrom, rounded shoulders and forward head carriage will eventually equate to musculoskeletal abnormalities that can lead to potential pathologies of the shoulder complex (2). Moreover, according to the dysfunctions mentions, the abnormalities and asymmetry of the trapezius, levator scapulae, sternocleidomastoid, deep cervical extensors and flexors, latisimuss dorsi and serratus anterior can altered the uniform posture of the cervical spine leading to scapulothoracic dysfunction (Clark, Lucett & Sutton 2014).
If the Serratus Anterior and Lower Trapezius muscles are proven weak; the Serratus Anterior Punch, Dynamic Hug, Knee Push-up Plus, and Push-up Plus exercises have been suggested by Decker et al. (1999) to consistently evoke the Serratus Anterior muscle activity greater than 20% Maximal Voluntary Contractions MVC. A study in 2007 by McCabe and his colleagues supported the notion of Press-Ups as a notable exercise to engage the Lower Trapezius muscle fully. According to McCabe et al. (2007) The press-up exercise elicited marked lower trapezius EMG activity, moderate upper trapezius EMG activity, and a high ratio of lower trapezius to upper trapezius EMG activity (6). "Scapular retraction produced marked EMG activity of both the lower and upper trapezius and moderate activity of the middle trapezius. Bilateral shoulder external rotation generated moderate lower trapezius EMG activity, minimal upper trapezius activity, and the highest ratio of lower trapezius to upper trapezius EMG activity" (McCabe RA, Orishimo KF, McHugh MP, & Nicholas SJ. 2007). Lastly, I do not have any peer-reviewed evidence to support my hypothesis. However, I have gathered evidence from personal clinical experience, that by applying tempered ischemic compression (with the use of Thera-Cane) to the attachment sites of underactive muscles such as the Serratus Anterior and lower trapezius helps improve scapulothoracic rhythm. Is it possible that these muscles possess tight enough lateral fibers to alter the suppressing the scapular position and preventing proper scapulothoracic rhythm?
1. Susan Slusser. (1999). Winning Kills the Pain / Bad shoulder and all, volleyball star Walsh is Stanford's mainstay. San Francisco Chronicle Staff Writer. Source found on http://www.sfgate.com/sports/article/Winning-Kills-the-Pain-Bad-shoulder-and-all-2891268.php
2. Sahrmann, S. (2001). Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis, MO: Mosby.
3. Joshi, M., Thigpen, CA., Bunn, K., Karas, SP., Padua, DA. (2011). Shoulder External Rotation Fatigue and Scapular Muscle Activation and Kinematics in Overhead Athletes. Journal of Athletic Training: 46(4):349–357. www.nata.org/jat.
4. Clark, M., Lucett, S & Sutton, B. (2014). NASM Essentials of corrective exercise training. Jones & Bartlett Learning, Burlington, MA. p.102-103
5. Paul A. Borsa, Kevin G. Laudner and Eric L. Sauers. (2008). Mobility and Stability Adaptations in the Shoulder of the Overhead Athlete A Theoretical and Evidence-Based Perspective. Sports Med; 38 (1): 17-36 0112-1642/08/0001-0017/