Does the hypermobile shoulder need mobility? That depends on how you define mobility. Most people who have hypermobility issues describe a feeling of tightness. Where do you find them? In the corner with a band and a ball, stretching the crap out of their shoulders and rolling away. Or getting manual therapy on a weekly basis.
Of course, most of these people have the firm belief that either their pain or their difficulty with overhead movement is due to tightness and lack of mobility. Unfortunately, this is further encouraged by the immediate effects of manual therapy, which I have mentioned in previous articles, makes them FEEL better. However, the problem is that it does not get them better.
The terms hypermobility and instability are often used interchangeably, and even I am guilty of that at times. In my practice, if I am treating someone for a hypermobile shoulder, it is because that hypermobility results in instability. If it did not, they would likely not be in my office.
Let’s remember that hypermobility, while it can result in instability, does not necessarily mean instability. From a functional standpoint, mobility and stability are not opposites, as mobility can be demonstrated in stable states.
HYPERMOBILITY VS INSTABILITY
A more appropriate term for someone who has a lot of joint range of motion is laxity. Joint laxity is normal and different people have different degrees of laxity, but we typically term people who have a lot of laxity as hypermobile. But technically, hypermobility is not a syndrome or dysfunction. Instability is.
Shoulder stability is a function of your static stabilizing system: joint capsule, glenohumeral ligaments, glenoid labrum; and your dynamic stabilizing system, which involves the muscles of the shoulder girdle, yes, but most importantly their appropriate neuromuscular control. This dynamic stability could be further divided into glenohumeral and scapulothoracic stability.
Simply put, we can view hypermobility as a quantitative measure and instability as a qualitative measure.
Shoulder instability can manifest itself in many ways. In my practice, I work with a lot of CrossFit athletes, recreational as well as elite, and I see two typical hypermobility scenarios:
- The previously sedentary hypermobile individual: This individual has now become involved in a high-demand overhead activity and does not have the dynamic stability specific to this new demand. Their hypermobility in itself was not a problem before but now results in excessive multidirectional glenohumeral translation during movement and secondary rotator cuff impingement.
- The more seasoned CrossFit athlete: High-demand overhead athletes often sustain chronic injury to the passive restraints (labrum, ligaments) leading to subtle, directional instability. Over time, this excessive translation of the humeral head can lead to rotator cuff impingement.
Of course, I also sometimes see cases of acute shoulder injury resulting in ligamentous laxity, but this is not the major portion of my shoulder cases.
As I mentioned before, most of these people will come to me complaining of tightness and stiffness and believe that either their pain or their difficulty with overhead positions is due to a lack of mobility. Typically, the only treatment they have had is manual therapy to “release their tight muscles”.
“MOBILITY” WORK FOR THE HYPERMOBILE SHOULDER
What is mobility work for the hypermobile shoulder? At first glance, this question seems like an oxymoron. Should people who have instability be releasing their tight muscles? Well, only if you plan on doing something to improve stability afterwards.
Many people with shoulder instability complain of tightness in their upper traps, which for the record is usually actually the result of a hypertonic levator scap. That said, people often present with trigger points in the upper and lower traps. This is why most people seek recourse via manual therapy treatments, which as I have mentioned in a previous article, makes the FEEL better but does not GET them better. If you’re interested in my thoughts on this, read There is More to Rehab than Manual Therapy.
That said, if we hope to get people moving better, we need to remove the barriers to movement. How an individual feels is one of these barriers. If people feel better, it will help them move better. As such the mobilization sequence for the hypermobile shoulder (unstable shoulder, oops I did it again…) can start with down-regulating muscles or treating myofascial trigger points, but that should not be the whole of the treatment.
Dynamic stabilization exercises are used to restore the force couples needed to balance joint forces and reduce excessive movement. For the unstable shoulder, this starts with placing the shoulder in a vulnerable position and challenging that position under controlled conditions.
Proprioceptive neuromuscular facilitation (PNF) techniques have long been used in the rehabilitation setting. The principles underlying these techniques can be credited to the work of Sherrington (1947).
Rhythmic stabilization is a proprioceptive neuromuscular facilitation technique PNF) that uses as isometric contraction of the agonist followed by an isometric contraction of the antagonist to produce co-contraction. The goal is to increase the strength of the holding power so that the position cannot be broken.
Slow reversals are also a PNF technique, but they utilize isotonic contractions of the agonist and antagonist through the range of motion.
To see how these techniques are performed, watch the main video of this article.
AN EFFICIENT STRATEGY
According to Prentice (2011), four basic elements are crucial to reestablishing neuromuscular control and functional stability: (1) proprioception and kinesthetic sensation, (2) dynamic joint stabilization, (3) reactive neuromuscular control, and (4) functional motor patterns.
We have already discussed how the Mobilization sequence can involve releasing myofascial triggers points and alleviating muscle tension to help the individual feel better. Rolling and other soft-tissue mobilizations also have the advantage of stimulating proprioception.
Following this through with a dynamic stabilization exercise and increasing the challenge of this exercise by changing the direction of resistance quickly and unexpectedly can help improve reactive neuromuscular control. Watch the main video of this article to see how these exercises are done.
In the Activation sequence, it is usually helpful to work on scapulothoracic stability, bringing awareness to scapular positioning and control. In last week’s article, I discuss how an understanding and awareness of scapular positioning is important for functional stability of the shoulder.
The Integration sequence is all about motor patterns: integrating the functional stability work to movement-specific demands. It is also important because most of the exercises above do not provide sufficient intensity to result in improved capacity under load. The integration sequence ensures strength in the continuum of care by allowing us to continue to load our clients in positions that are safe and prevent compensation.
An emphasis on slow eccentrics is an excellent tool in this sequence. Eccentric movements are more difficult to control, and greater voluntary effort is required to perform a motor task that is more difficult to control. As such, eccentrics may improve neuromuscular control by targeting specific motor pathways in the brain.
A hypermobile shoulder has a lot of mobility but can also have a lot of dynamic stability. As such, it would be wrong to qualify this as “too mobile”. However, if you combine a hypermobile shoulder with a lack of dynamic stability, then there will be excessive movement that can lead to pain, tightness, stiffness and some degree of functional impairment.
Addressing this excessive movement is the basis of “mobility” work for the hypermobile shoulder, or as we should say, the unstable shoulder.
REFERENCES Prentice, W. (2011). Rehabilitation techniques for sports medicine and athletic training (5th ed.). New York: McGraw-Hill. Sherrington, C. (1973). The integrative action of the nervous system. New York: Arno Press.