Off the Cuff

by Garret McElfresh

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Without a doubt the rotator cuff is as frustrating as it is beautiful. The
"beauty": four relatively small involuntary "postural"-type muscles deep to
the delts that strive to provide the dynamic stability required to allow you
to do, among other things, wave your hands in the air like you just don't
care. The "frustration": all of the above, with some velocity and
repetition thrown into the mix (most sports) and words like tendonitis,
impingement, and painful arc start coming to mind. How do we train the
rotator cuff the "right" way to avoid the usual pitfalls of racquet sports,
overhead work, swimming, etc.? Ahhhh, the eternal question. Now for the
eternal answer...another question. Does the rotator cuff really "fail" us?
Or is its true function usually overlooked or under-addressed in most
training? Hmmm. I think we have a new eternal question. And I think I
have at least a partial answer: Variable Velocity Diagonals.

Variable Velocity Diagonals is my free and easy steal from PNF
(Proprioceptive Neuromuscular Facilitation). Wow! That's, like, three
fifty-cent words all at once. PNF patterns incorporate common physiologic
movements in a diagonal for both the upper and lower extremity rehab,
typically for post-stroke and frozen shoulder therapy, among many others.
I'm simply going to take what applies to the shoulder/scapula, modify if for
whatever range-of-motion your sport requires, and render it down to a few
basic elements for short and sweet (and smart) cuff training. And hopefully
those PNF dudes won't come after me...although I figure if they do, by now I
can take em.

Just flat-out listing the traditional rotator cuff muscles...the
supraspinatus, infraspinatus, subscapularis, and teres minor...doesn't do a
whole lot since they work I concert with each other and with many bigger,
stronger muscles in and around the shoulder/arm. While these four muscles
cap the humeral head with a common tendon to initiate rotational and
elevational movements, they primarily exist to keep the socket "tight"; they
pull the humeral head "down and into" the glenoid fossa (socket) actively to
best center the humerus during arm movements. This allows for the best
biomechanical advantage of the arm during movements and, more importantly,
it keeps the rotator cuff tendon from getting constantly squashed (impinged)
between the humeral head and the acromion. Medically speaking, ouch! The
cartilaginous lip (labrum) of the shoulder socket is pretty shallow. We
really need the cuff to provide "dynamic stability" for the shoulder
unlike,say, the hip which is a veritable Fort Knox in terms of bony,
non-contractile joint stability...unless you skydive without a chute or
suffer a car wreck, or pull a Bo Jackson in the NFL, which is sort of like
getting paid to be in a big car wreck over and over and over.

The rotator cuff is a finesse muscle group typically abused and prone to
dysfunction in endurance situations, or a sudden extreme power moment.
Training the cuff is always supplemental to "sports-specific" mastery
training and its effects have to be automatic, instinctual. If I asked you,
right now, to flex your infraspinatus, could you? Probably not. If I asked
you, in the middle of a power tennis serve, to keep your "armpit tight"
throughout the movement, could you? I doubt it. We must train the muscles
and the joint position sense (proprioception) to intuitively know right from
wrong, kinesiologically speaking. In other words, we have to work the arm
and shoulder in the same way and at the same speeds (in varying percentages)
as our sport. How else can the cuff be prepared for battle? This is easier
said than done.

When you break down gross overhead movements, like a throw or serve, you
will find the shoulder rotation internally and externally, abducting and
adducting, and flexing and elevating, often in dizzying combinations. This
is biomechanically astounding. Typical cuff rehab ROM "ther ex" done with
Theraband is fine for waking up the cuff after an injury or surgery
(controlled injury), but is woefully inadequate for optimizing cuff function
in high speed sports moments. The same goes for the usual set-rep dosage
parameters: 2 or 3 sets carried to a gentle sense of fatigue is fine if all
you need to do is check your scalp for dandruff. For a sports-tough cuff I
would junk sets and reps and go for time instead. Deep into game time your
cuff will thank you for it.

Let me describe the one basic diagonal pattern that I feel will serve most
trainees. I call it "Excalibur" because the movement is pretty close to
pulling the sword from the stone. One land, one king! As long as the Queen
says so. Broken down the movement is as follows:
1. To start, right hand in front of left hip (across the body) shoulder in
full internal rotation, wrist pronated.
2. As you lift your arm up and across your body the arm naturally
externally rotates so that when your arm is fully up over you head and the
right shoulder will be fully externally rotated and your wrist supinated.
N.B. This is where you focus on keeping your shoulder blades "down and
back" - the humeral/scapular ratio will pretty much take care of itself in
due time.
3. Return the sword to its scabbard. You can start at the top and reverse
the move, or fix your resistance (if you're using bands...you can use no
weight, a soup can, a very light (1-3 lb dumbbell) or bands) behind or in
front for variety. You may have to angle yourself to avoid rubber burn.

You can experiment: bilateral or unilateral work depending on your needs.
Do both, however, just for balance and fun. Also feel free to shorten the
movement, working part of the ROM most relevant to your sport, especially
where speed is involved. This is where the cuff will suffer if you can't
stay tight automatically. It is a good idea to mix up short- and full-range
movements for overall joint health. Joints are creatures of habit and they
will adaptively shorten if allowed.

This kind of cuff work is obviously most important in the off- and
preseason. Once the season starts it should be used once a week as a
refresher or "active recovery." Too much cuff work done on top of hard
training is a recipe for disaster. Used judiciously, however, Variable
Velocity Diagonals can be a serious training tool.

Good luck!

Garrett McElfresh, PT