Modifications and Treatments for Subscapularis Pain

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty discusses treating the subscapularis muscle for the fitness athlete. Zach discusses modifications for pressing, pulling, and Olympic weightlifting. In addition, Zach discusses go-to exercises to use for HEP with these individuals.

Take a listen to the episode or check out the show notes at www.ptonice.com/blog

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EPISODE TRANSCRIPTION

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ZACH LONG Good morning, everybody. Welcome to the PT on Ice Daily Show, where it is not only the PT on Ice Daily Show, but it is the best day of the week here on the PT on Ice Daily Show, and that is Fitness Athlete Friday. I'm excited to be with you all this week. My name is Dr. Zach Long. I'm a faculty member inside of the Fitness Athlete Division, teaching both our live and advanced concepts course with the rest of the team there. Today, we are going to talk about subscapularis treatment with the fitness athlete. So the subscapularis muscle, I think, gets commonly overlooked in the fitness athlete's shoulder. Alan talked about it last week, so I'm going to follow up his discussion last week with a few other things. But like Alan said last week, this is the largest and strongest of the rotator cuff muscles, and I think it commonly gets overlooked when people are dealing with shoulder pain. And so we're gonna jump into kind of some of the different modifications and treatment strategies that I use when patients have subscapularis pain. Make sure you listen to last week's episode as well. A little quick recap of last week's for you just to set the stage here. SUBJECTIVE EXAM FOR THE SUBSCAPULARIS Subjectively, what I hear most frequently when people are dealing with subscapularis strains are that they have pain with dips, pushups, and the bench press, so with shoulder extension-based pushing motions. And then things like snatches, overhead squats, and kipping pull-ups, where their arms being really stretched overhead in that position. OBJECTIVE EXAM FOR THE SUBSCAPULARIS Alan talked quite a bit last week about testing positions for the subscapularis, and those were absolute gold for ruling in and out the subscapularis. I'm going to throw one more test at you before I move on to more of the treatment stuff. And I like this test because As Alan talked about last week, when you do like IR at neutral, the pecs are such a big muscle working right there that it's not going to be sensitive enough on your subscap. So that's why he talked about like the liftoff test in your arm. The one kind of issue that I have with the liftoff test, I use it with all my subscap people, is for those that are highly sensitive and you know that they're already really irritable, I find at times that just getting into that position really lights them up. So the test that I prefer to start with is that internal rotation at neutral, but we get rid of the pec involvement a little bit. So imagine somebody standing with their elbow right at their side, elbow bent to 90 degrees. You then put one of your hands outside of their lateral elbow and you have them push out like they're doing a lateral raise. You don't let them actually push away from their body, but they're trying to. And then you test internal rotation resistance with the other hand. And you'll find that that little lateral raise push gets rid of a lot of the peck involvement in there and will let you get a positive test for a lot of people that have a subscap strain that your standard IR at neutral would not. SUBSCAPULARIS TREATMENT So let's jump into treatment a little bit and modification. I'm going to say number one, from a manual perspective, like if you made me choose only one area of the body to needle for the rest of my life, and you said you can only needle one thing for forever, choose what muscle. Now this might just be because I treat primarily shoulders, hips, and knees in the clinic, but I would choose subscapularis dry needling over every other area of the body. It has just been the area that I find most frequently gets huge improvements in their symptoms after a quick dry needling session. So if you're not familiar with that, look up Paul iDryNeedle. Paul runs our dry needling division along with Ellie. and the great faculty that we're building over there, but check out their coursework. That is just a money technique to have. From a treatment perspective, so much of my treatment with this comes down to the combination of wanting to build the subscap up, but also wanting to make sure we're not continually overloading the subscap. So I have a lot of conversation with my patients on what sort of modifications they need to be making to their training to not further aggravate the subscapularis. And so, All of these are obviously based on somebody's irritability. So when they strain their subscap, if it's very, very minor, I'm not pulling all of these levers, but if it's very major, I might be. And as y'all know, our goal with the fitness athletes and all of our people in general is to keep them active. We don't want to tell them, stop benching, stop doing pushups, stop doing dips. We want to find ways for them to do those movements or similar movement patterns with less pain. So that's breakout kind of where I kind of go with modifications. MODIFYING HORIZONTAL PRESSING So if we start with like our horizontal pressing motions, which I think are the most common things that I hear people with subscap strains discuss subjectively, that's the dips, pushups, and bench press. I think the reason why those hurt so much is as we take the shoulder into extension, I think you can appreciate as your shoulder goes into extension that you're gonna create a little bit of compression on that anterior shoulder. And as we know, tendons don't like compression. So I think that's why extension is so irritable for these individuals. So one thing that I find myself doing more than anything else in people with subscapularis strains is I actually have them stop doing dips. And we end up replacing dips with, with push-ups or banded push-ups or some variation that doesn't take the shoulder into quite as much extension. When push-ups are pain-free, then we start moving back to dips. But generally, I find that dips are going to be really painful if the push-ups still hurt at all. So that's kind of a general rule of thumb for progression there on the dips. In terms of the pushup and bench press, I find that the most valuable thing we can do for people in terms of modifying is to just adjust the range of motion a little bit. So for the pushup, kind of the two modification, three modifications I make there are a lot of times I have individuals do a pushup down to an ab mat. So that ab mat's just gonna, they touch their chest to the ab mat instead of the floor. We reduce that range of motion, maybe an inch and a half or so with the ab mat there. And so frequently that is enough that we can now still do the prescribed workout with just that slight modification to the range of motion. Other times I find that having them really torque their hands into the ground or keep those elbows close to their side and making it a little bit more like a close grip pushup can help them out quite a bit. From a bench press perspective, very similar. So maybe instead of bench pressing, we do a floor press or a board press. So a floor press is simply a bench press where we're laying on the ground. So when the elbows get to our side, they hit the ground and you can't actually take the arm into extension. That can usually be enough that people can still press really heavy. The floor press is one of the best exercises you can do by far to improve your bench press strength, so it's a great modification in this time period. We can also do a board press where they're on a bench, but they go down and they touch one, two, or three 2x4 boards that are placed on their chest to reduce the range of motion. And then very frequently I also have, especially with more like my power lifters or people that care about bench pressing a lot, I'll use accommodating resistance. So maybe with a lightweight, they can touch their chest and not have that much pain, but if it's really heavy and they touch your chest, they get pain. So that's resist the bench press with bands so that at the bottom, those bands are unloaded a little bit, and then that weight increases as they go towards lockout. So that's a great way to really challenge the lockout, still train full range of motion, but not irritate that already irritated subscapularis. So the big key there is to probably reduce the range of motion a little bit and play with some of those variations to see if you can get people to not continually aggravate the subscapularis but still get in that horizontal pressing stimulus. MODIFYING KIPPING When it comes to kipping-based movements, so toes-to-bars are one that really tend to aggravate the subscapularis, I see quite a bit. I will Usually prefer to just get people to do a really tight kip where they maintain a lot of tension and they don't go into as aggressive an arch position. That is actually a performance advantage in the toes to bar. People will cycle their toes to bar reps a lot faster. So this is a great time to make people do smaller sets because a lot of times they'll fatigue more rapidly with this. but to actually work on a technique improvement that will help them out long-term. So those quick cycled reps with a little bit more tension. If it's more irritated, then we might just do an active hang, knee raise of some sort so that we're still getting the hanging stimulus. We're still getting the ab stimulus, but we're just reducing a little bit of the shoulder demands. And then when it comes to things like kipping pull-ups, if it's highly irritable and I don't feel like kipping is in their best benefit right now, we just turn that into strict band-assisted pull-ups that we maintain that high volume of the vertical pulling stimulus. We maintain those fast reps that keep our cardiovascular system up if we're talking about prescribing kipping pull-ups in a Metcon, but it will unload the shoulder just a little bit to do a strict band-assisted pull-ups versus kipping when somebody has a subscapularis strain. MODIFYING OLYMPIC LIFTING And then the final thing that I often modify is their snatches. So frequently, it's the turnover and the catch of the snatch that really irritate these individual symptoms. So at times, that just means we move to variations where we're not doing the turnover or the catch. So we're doing snatch grip deadlifts, snatch grip high pulls, snatch grip pulls, exercises like that. So we're still building their technique. and working on things that will help their snatch overall. But again, we're just not adding more fuel to the fire there. So that's the main modifications that I make when somebody has subscapularis pain. TREATING THE SUBSCAPULARIS: LESS IS MORE Let's jump now into treatment. And I think from a home exercise perspective, one thing that I'm really big on is that less for your HEP is more. We don't want to overload our patients. So a huge percentage of my patient population at this time are people that are seeing me for a second opinion. And I kind of see three things most commonly pop up when people see me as a second opinion. Number one, they were just underloaded. They didn't get a sufficient enough stimulus, their therapist was on the right diagnosis, but they didn't challenge them enough to actually build tissue strength up. Number two is they're on the wrong diagnosis, which we all see all the time. Somebody thought, you know, that because this person's pain was on the back of their shoulder radiating down to the tricep, they assumed that it was a posterior rotator cuff pain and they didn't do a great job screening out the subscapularis with the tests that Alan talked about last week and I talked about earlier. And so they're treating posterior rotator cuff when it's really the subscapularis instead. And then the third thing is people come in and they have an HEP list of eight exercises that they're doing for three sets. And I look at that and I'm like, man, that's going to take 40 minutes to get done. Less is more here, folks. So the rule of thumb I have here is that my goal, sort of like your post-op ACL that needs a full strength program, My goal with most of my individuals is to try to limit their HEP to 10 or 15 minutes or less, four-ish days a week. I think that that's pretty manageable for most of our people. It gets really crazy when you're asking people to do 30 minutes of work every single day. So to get this done in 10 minutes or less, that usually means that I'm trying to stick to three exercises, maybe four. So in the subscapularis, maybe they do some soft tissue work on their subscapularis. That's one minute. And then we do a nine minute EMOP. So that's 10 total minutes of work. We add in grabbing equipment. They get this done in less than 15 minutes. Less is more with these individuals. Try to really stick to that. And I think you'll see your HEP compliance go up quite a bit. So three exercises, less than 15 minutes, preferably less than 10 minutes is my goal. When I'm looking for exercises, I kind of have four different exercises that we might have in those three of their HEP. Number one is going to be obvious. Like if they have a subscapular strain, we're doing something to try to build that muscle and tendon backup. It would be way too hard for me to really describe these exercises here on the podcast, but if you go to my YouTube channel, Barbell Physio, you can search for all of these exercises. But kind of my general progression here, highly irritable. I'm doing internal rotation at neutral, but I'm going to do it similar to how I did the testing. So I take one band and I'll put it around their arms. So one big resistance band going around both arms. So they have to do that little lateral raise before they do the internal rotation. I'll find that that again isolates the subscap a little bit more than the pecs. Progress that to an IR punch. Progress that to an IR diagonal. Progress that to IR at 90 degrees. That's my general philosophies there. So number one, load the subscap. Number two thing to have in that HEP is to look at any mobility limitations that they might have. Like is their overhead positioning stiff? Is their Tyler test for that posterior shoulder capsule stiff? Do they lack shoulder extension? Does their thoracic spine suck? Does something as far away as their ankle mobility suck? And that's putting them in suboptimal positions for things like overhead squats or snatches. So the second component there is to dial in their mobility, The third component is lat strength. So the subscap and lats have a lot of similarities in terms of their function, but I'd say overall for the athlete doing rig-based gymnastic skills, when they have lat weakness on board, the rotator cuff ends up taking on more of the stress of those movements. I call the lats the glutes of the upper extremity. What happens when somebody has weak glutes in athletic performance? They strain their hamstrings more. They tweak their back a little bit more. Their performance overall goes down. Strong lats are so important to the fitness athlete population. So make sure you're thinking of that with individuals. That's number three on people with subscap strains is to load their lats up. 4. Something to pump a ton of blood into the shoulder tendinopathy, whatever you want to call it. And lateral raises don't bother their shoulders. So we do something like an internal rotation diagonal to directly load the subscapularis. Now lateral raises don't hurt, but we know lateral raises are going to challenge the deltoid quite a bit. They're going to challenge the supraspinatus. Those muscles are all around the subscapularis. So if I then have them do a set of 15 to 20 lateral raises, I'm going to pump a bunch of blood to the shoulder. What happens when we pump blood to an area that's currently injured? We help with inflammatory chemicals that are sitting out in that area. We help with, you know, an overall endorphin release. We just make everything feel better when we add a little bit of blood pump to an irritated area. So that's make that be our final exercise in that little EMOM for them. So I hope those modifications and HEP discussion help you out a little bit more when you see subscaps. Again, make sure you go back and check out Alan's episode. He did a great job discussing internal rotation and shoulder extension and why that's so important in this population as well. Hope y'all have a great Friday and a great weekend, and we'll see you here next time.

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