Efficiency Is Key

Understanding the intricacies of throwing biomechanics and pitching performance is paramount to taking care of the baseball thrower pitcher. In an athletic training room, a critical aspect involves understanding injury patterns, workload tolerance, and objective markers that can aid in identifying predisposing factors to injury. After an injury, downtime from throwing coupled with a well-structured rehabilitation program can return many pitchers to the mound. However, the greater challenge is not only returning them to the previous level of performance but also preventing reinjury and maintaining pitcher durability. ^, Many potential factors have been implicated in shoulder and elbow injury including hip range of motion and strength, balance, core strength and lumbopelvic control, thoracic rotation, posture, scapular dyskinesis, shoulder range of motion, cervical range of motion, and muscle imbalance. ^, Organizing a structured evaluation and setting up an appropriate rehabilitation program with these factors in mind can be overwhelming. Therefore, an understanding of integrated kinetic chain function is important to skillfully and efficiently evaluate critical variables that determine joint range of motion, strength, and stability.

Common Things Are Common

Pitching requires a balance between mobility, stability, and end-range strength. The sequencing of events in the kinetic chain allows a smooth and efficient transfer of energy from the hips and legs, through the trunk, and out to the throwing arm. The arm must withstand “the big three” causative factors of injury during every pitch: high velocity, high forces, and extreme ranges of motion. Rotator cuff strength and scapular stability are critical components for protecting the throwing shoulder, but on their own, they may not be sufficient to prevent injury. Therefore, a more global and holistic approach is warranted. Understanding how individual segments work together in a concerted manner during the act of throwing is challenging, but imperative.

Pitching requires a certain degree of generalized movement patterning. Stride foot contact, late cocking, and release point are the critical points of focus for evaluating a baseball pitcher. These are the stages where transitions of movement and high forces occur during the act of throwing, making them the most likely points of potential injury. We can use this understanding to help guide the process of preventing and rehabilitating some of the most challenging athletic injuries.

This section highlights important concepts for designing and implementing an integrated “arm care system” that can be used in an athletic training setting. A significant emphasis will be placed on the hip, trunk, and cervical spine interactions in relation to the shoulder and elbow, rather than focusing solely on individual joints. Joint biomechanics, myofascial connections, segmented and integrated movements, and the coordination of systems to provide a strong, stable, and durable shoulder will be addressed.

Movements over Muscles

Pitching is a high velocity, high joint load dynamic movement sequence that can allow the throwing arm to rotate in excess of 6000 to 7000 deg/sec from maximal external rotation during late cocking to ball release. ^, In order for the shoulder to withstand the high torques associated with every pitch, a synergy of movement is necessary. This involves controlled end-range motion, a transient end range hold for stability, and a final transition phase (from external to internal rotation) that accelerates the throwing shoulder and arm to the point of ball release. ^{, ,}

Proper kinematic sequencing in a distal to proximal manner not only improves energy transfer to the throwing arm but may decrease normalized stress to the shoulder and the elbow. ^{, , , , , , ,} Increased complexity of movement requires an increased number of neural-mediated muscle synergies to be utilized for efficiency and repeatability of movement. Training a new skill causes a change in brain white matter architecture, and these changes happen as a result of time spent in training. Therefore, training may encourage development of new muscle synergies, change the structure of existing synergies, or change the way existing synergies are recruited. Thus, proper execution and movement competence must be a priority during injury prevention and rehabilitation programs to avoid compensatory patterns from developing, as neuromuscular adaptations can occur in conjunction with soft tissue changes or fatigue. ^,

Effectively understanding and evaluating common movement patterns in pitching is one of the cornerstones for identifying compensations, implementing important corrections, and protecting the pitcher from overuse and injury. It can also be used to detect subtle changes in recovery, manage workload, and gain an understanding of how to better manage daily throwing programs. Simplifying the complexities of kinetic chain function on the throwing motion can help give clinical insights into evaluating movement competency and aid in creating a more individualized program for injury prevention.

Focus 1: Three Primary Segments

Breaking the body into 3 primary segments (pelvis, trunk, and cervical spine) can assist with understanding kinetic chain interactions and allowing a more thorough and efficient evaluation of the throwing shoulder. Since a deficit (in movement, strength, or stability) in one joint can have far-reaching effects at other joints along the kinetic chain, it is imperative that the clinician identify these areas and make appropriate correctives. ^{, , , ,}

Stride foot contact is the critical “loading moment” for the pitching arm. ^{, , , , , ,} At the hip, stride length, direction, strength, and stability are all key pieces that allow safe loading of the shoulder. ^{, , , , ,} An appropriate stride length increases drive leg propulsion time by increasing the braking force of the stride leg. This, in turn, extends the double limb support time and the posterior braking force. Consequently, it delays the peak velocity of trunk rotation to coincide with arm’s horizontal adduction rotation peak velocity, providing protection against hyper angulation. ^, A shorter stride length may decrease momentum transfer between the trunk and throwing arm, leading to “arm lag.” ^,

The hips, trunk, and cervical spine must rotate in a counterclockwise–clockwise–counterclockwise repeatable pattern (in a right-handed pitcher). During stride foot contact phase, the drive leg generates and transfers linear energy to the pelvis and trunk while the stride leg transfers energy distally to provide a stable base. ^{, , ,} This acts as a braking force to change linear momentum into rotational power that is subsequently transferred to the trunk. Specifically, peak ground reaction force of the stride leg ^{, ,} and maximum trunk rotation and rotational power have been shown to be strong predictors of energy transfer to the throwing arm.

Therefore, stride foot contact may be the critical phase for evaluating and improving movement synergies of pitching. Evaluating stride foot contact may also give the clinician important insights to movement competence, energy transfer, and overall ability to safely load the throwing shoulder. ^, Stride length and direction, trunk rotation, and hip–shoulder separation set the platform for the throwing shoulder to safely and efficiently load during the cocking phase. ^{, , ,}

During stride foot contact, a sequential reversal of trunk loading (rotation and extension to the arm side) to unloading (rotation and flexion toward home plate) occurs, forcing the scapula to end-range positions in both the sagittal (posterior tilt or extension) and transverse planes (retraction). Coordinated transverse plane motion of the scapulothoracic and glenohumeral joints enables the humerus to remain aligned with the spine of the scapula during stride foot contact, maximal external rotation phases. ^{, , ,} This kinematic sequence highlights several important interactions to consider during hip and trunk separation. If trunk rotation is restricted and unable to attain end-range motion, the scapula will not be able to achieve end range retraction, resulting in relative early protraction. Similarly, if end-range trunk rotation is halted prematurely due to limited hip or cervical rotation, the scapular transition from retraction to protraction will also happen too early in the pitch cycle. These restrictions in motion can lead to heightened horizontal abduction, ^{, ,} increased shoulder internal rotation torque, ^{, ,} and elbow varus moments, ^, potentially elevating the risk of injury.

Many factors can limit thoracic spine rotation, and once identified, must be addressed. As motor development advances to skill acquisition, pitchers who load the trunk more effectively will decrease positional and kinematic variability in the throwing arm. ^, Decreased hip abduction strength and decreased lumbopelvic control in the stride leg may affect the amount of trunk tilt at stride foot contact. ^, Increased trunk tilt may limit both pelvis and trunk rotation ^, which has been demonstrated to increase shoulder internal rotation and elbow valgus torques. Together, hip and lumbopelvic stability may improve stride hip–shoulder separation at foot contact to load the trunk and shoulder more efficiently. ^{, ,} If the trunk loads more efficiently, the pitchers’ arm slot may become more repeatable. If the trunk is unable to fully load into rotation during stride foot contact, the arm will still attempt to achieve end-range position in order to maintain throwing velocity. However, this is often through compensated movement or varied muscle synergy utilization. In this instance, pitching is a double-ended closed kinetic chain, where the foot is fixed on the ground, and the throwing arm is “fixed” in its necessary end-range position. Even though the trunk and scapula are unable to attain end-range motion necessary to allow safe positioning and loading of the shoulder, the humerus still gets forced to end range due to inertial and centripetal forces. Therefore, thoracic rotation and scapular end-range positions are critical factors to assess and address during the evaluation and rehabilitation process. ^,

Just as hip–trunk separation is critical for loading the arm efficiently, cervical-trunk separation and cervical-scapular dissociation may be just as vital. Specifically, the cervical spine and trunk must rotate independently of one another and achieve full range of motion (ROM) without compensation at the scapula (increased tone or loss of end-range position). For example, if the cervical spine is unable to fully rotate to the nondominant side (to allow the eyes to look toward home plate), compensation elsewhere can occur. The trunk may be forced to rotate early, preventing the scapula from reaching end-range retraction and posterior tilt. This has the same detrimental effects as limited hip–trunk separation as previously discussed.

Devaney and colleagues emphasized the importance of cervical range of motion for protecting the throwing shoulder. Specifically, they noted that pitchers with decreased cervical flexion and rotation to the dominant side had a 9x greater risk of shoulder or elbow injury than those with more cervical mobility. A torsional upper crossed imbalance of cervical, scapular, and thoracic positional asymmetry may indeed cause secondary movement compensation with apparent full cervical rotation toward the nondominant arm and limitation to the throwing side. This study highlights the importance of cervical range of motion and the potential impacts on arm health.

Posture and scapulothoracic muscle imbalance can alter scapular position and allowable movement potential. Specifically, a shortened pectoralis minor muscle and upper trapezius have been shown to account for 58% of the variance in scapular dyskinesis. Thigpen and colleagues demonstrated that a forward head rounded shoulder position increased scapular protraction and anterior tilt. A shortened pectoralis minor muscle or weak serratus anterior resulted in similar outcomes. ^, The implications of these deficits are that the scapula will be in a position that functionally limits the humerus in horizontal abduction and external rotation. Scapular retraction and end-range posterior tilting is necessary to allow enough clearance for the eccentrically moving humerus to attain end ranges during stride foot contact and late cocking phases of pitching. Failure to reach scapular end ranges may result in hyper angulation and a “wringing out” effect on the rotator cuff, biceps tendon, and anterior capsule. Additionally, bony abutment of the humeral head and posterior superior glenoid and labrum may occur during the late cocking phases. ^, The scapula and humerus move in opposite directions during load–unload transitions of the trunk, scapula, and humerus. In essence, the scapula is not able to “get out of the way” of the humerus during pitching, leading to internal impingement and associated sequelae. During clinical examination, the combination of horizontal abduction and external rotation end-range isometric holds must be pain free to indicate proper scapular position.

In summary, sequential loading of the hips, trunk, and cervical spine during stride foot contact phase sets the stage for efficiently loading the throwing arm during the late cocking and acceleration phases of throwing. Understanding this phase of throwing may give valuable insights into efficiently evaluating the kinetic chain and designing and implementing thorough preventive and rehabilitation programs.

Focus 2: Myofascial Kinetic Chains

The abovementioned discussion highlighted important considerations for movement function or dysfunction within a 3 segmented kinetic chain. This section adds to this with a brief overview of myofascial chains that dynamically interconnect these segments.

Achieving full range of motion is crucial for evaluation and rehabilitation purposes. However, the ability to control motion and facilitate smooth transitions into and out of end ranges is equally critical. ^{, ,} Stability must be dynamic in nature to allow the center of mass to change position or orientation relative to movement demands. In a baseball pitcher, stability refers to the ability to facilitate smooth movement transitions into and out of end-range positions. This requires myofascial kinetic chains that link segments to allow for coordinated, repeatable movement patterns. ^,

Continuity between the stride hip, trunk, and deep core can be made via myofascial interconnectivity of the adductor magnus, the pelvic floor, and the diaphragm muscles. The deep core is further connected to the cervical spine via fascial attachments that envelope the deep cervical and scalene muscles. ^, In general, this can be thought of as the “stabilizing line.”

The spiral line connects the stride hip, ipsilateral internal oblique, contralateral external oblique, and serratus anterior and rhomboid muscles along the front of the trunk wrapping around to the posterior spine. Hip rotation, trunk rotation, and scapular position are a functional unit that allows trunk loading during the stride foot contact phase. ^{, ,} Stride hip stability must be present to maintain stride length and allow maximum eccentric length of the obliques and serratus anterior to properly load the trunk and scapula. ^, This is one example of many in the human body, describing how stability and mobility are interdependent. In general, this can be thought of as the “loading line.”

A functional anatomic unit for scapular positioning in the transverse plane is the balance of the subscapularis, the serratus anterior, and the pectoralis major. This can be thought of as one of the functional triangles in the body that must work in concert to provide smooth efficient movement at a joint ( Fig. 1 ). The importance of the eccentric length of the serratus is evident in maintaining scapular position and end-range stability, influencing subscapularis length, and contributing to full shoulder external rotation.

Axial cross section of the scapulothoracic articulation demonstrating the functional triangle involving the subscapularis, the serratus anterior, and the pectoralis major.

( Adapted from Kuhn JE, Hawkins J. Evaluation and treatment of scapular disorders. In: Warne JJP, Iannotti JP, Gerber C, eds. Complex and Revision Problems in Shoulder Surgery. Philadelphia: Lippincott-Raven; 1997:357-375.)

The last muscle to highlight is the latissimus dorsi and describes its far-reaching functional role. From a myofascial perspective, the latissimus dorsi attaches at the proximal humerus and travels obliquely along the lumbar spine to the contralateral pelvis via the thoracolumbar fascia. The thoracolumbar fascia connects with the internal oblique and transverse abdominis at the lateral raphe ^, and indirectly attaches to the diaphragm portion of the deep core. Therefore, the latissimus dorsi not only has an influence on the hip, core, trunk, and shoulder, but its overall function may be influenced by any of these segments as well. Therefore, the adductor magnus, the deep core, and the latissimus dorsi may represent an important hip–trunk–shoulder functional synergy for the throwing shoulder.

Focus 3: Movement, Loading, and Transitions

Efficient loading of the shoulder during pitching requires full joint motion, proper segmental sequencing, and effective control of these movements by the neural and myofascial systems. ^{, , , , , ,} Even though many kinetic and kinematic variables can be evaluated during late cocking and acceleration phases, ^{, , ,} (high force, high velocity phases), it is challenging to make corrections in movement dysfunction that happen during this part of the cycle. Thus, it must be reiterated that stride foot contact (hip, trunk, scapula, cervical loading phase) may be the most important and influential phase to understand in more detail. ^{, , , , ,}

It has been discussed how each of the 3 segments interact and how changes in one segment can affect the others. Large joint loads and high velocity of movement at end range make injury common during maximal external rotation. ^{, , ,} As foot contact occurs, the stride hip stabilizes, ^, and energy is transferred to the counter-rotating trunk. ^{, , ,} Full trunk rotation enables scapulothoracic end-range positions and serves as a prerequisite for both shoulder range of motion and the glenohumeral stability required during late cocking and acceleration. ^{, , ,} As the trunk unloads, the shoulder lags behind, forcing it into maximum external rotation. During this phase, the shoulder decelerates “into” external rotation, transiently stops, and then changes direction to accelerate forward into internal rotation to ball release. ^, This “transition phase” is a critical point in the throwing cycle, as the shoulder must optimally function at end ranges, under high load. ^{, , ,} It is during this moment that eccentric control is paramount to prevent injury. Controlling the rate and force of movement to maintain stability during the eccentric–concentric transition is critical and can have profound implications to the learning, execution, and rehabilitation of natural movements. Range of motion deficits, muscle imbalance, or joint instability at any segment in the kinetic chain may alter the timing or sequencing of movement. ^{, ,} Over time, shoulder or elbow injury may occur from fatigue, compensation, or overuse.

Full joint motion, segmental interactions, and myofascial connections allow for efficient hip, trunk, and shoulder loading. It is important that rehabilitation specialists and those that work with the throwing athlete understand these concepts. Identifying and correcting dysfunctional movement, improving movement symmetry, and enhancing stability during the loading phase can assist the clinician in the design and implementation of effective arm care and rehabilitation strategies. The overall goal is to prevent injury and improve return to play outcome measures. If we can teach the shoulder to load efficiently, the shoulder will unload safely.

Concept 1: Posture and Breathing

One of the challenges of taking care of pitchers is maintaining symmetric range of motion and preventing scapulothoracic, cervical, and associated postural asymmetries and muscle imbalances from developing due to the unilateral and torsional demands of throwing. ^{, , ,} Pelvis orientation, thoracic rotation, shoulder and cervical range of motion are some of the most important variables that need to be assessed often, so that appropriate intervention can be done to keep the kinetic chain functioning at a high level.

The center of mass plays a key role in determining whole body movement, limb movement, and largely determines functional range of motion of joints. The lack of core stability or inability to control movement into and out of end ranges can have impacts on hip, trunk, scapula, and shoulder health. ^{, ,} Therefore, it is important to improve or maintain high-level function of the deep core: the thoracic diaphragm, the pelvic floor, and transverse abdominis. When balanced and working optimally, these muscles can help maintain or restore thoracic symmetry, enhance scapular position and stability, and help make the shoulder more resilient to injury.

Breathing can be an important staple in arm care to address many of these variables. Understanding basic osteokinematics of the costovertebral joints and diaphragmatic influences on rib and thoracic spine position and movement can be an important factor in improving postural asymmetry and core stability. ^, The autonomically controlled eccentric–concentric reciprocal interactions between the diaphragm, pelvic floor, and transverse abdominis can have a dramatic effect on postural symmetry, deep core stability, and overall movement competence of the hip, thoracic and cervical spine, and scapula. When working optimally, these muscles can help safely load the trunk and position the scapula into retraction, upward rotation, and posterior tilt during stride foot contact and maximal external rotation phases. ^{, ,}

Concept 2: Assessing and Improving Active Range of Motion

Shoulder range of motion receives a great deal of attention in the literature. ^, Even small deficits may predispose the shoulder and elbow to increased injury risk. ^{, , , ,} Extreme range of motion is required during various phases of the pitching cycle, and optimum health and function of the shoulder is dependent on maintaining full range of motion.

Possible causes for lost range of motion include postural faults, compensatory movement patterns, muscle fatigue, eccentric overload, and injury. ^{, , ,} Trying to determine and address, the true cause of motion loss is challenging and most likely multifactorial. Thus, being able to assess and correct multiple variables simultaneously during an evaluation or rehabilitation program can be efficient and give a more complete understanding of how an individual joint functions within the larger movement pattern in the kinetic chain. ^{, ,} Decreased hip or trunk range of motion, poor core stability and trunk control, and scapular malposition may not allow the shoulder to load properly, setting the stage for muscle imbalance, decreased shoulder stability, and ultimately overuse, muscle guarding, compensated movement strategies, and injury. ^{, , , , , , , , ,} It is possible that decreased shoulder range of motion is merely an “effect” of an issue more proximally.

Total range of motion and differences between the contralateral shoulder are frequently used to assess shoulder health and readiness for throwing. Owing to the multisegmented functional chains involved with throwing, isolating a single joint or plane of motion may not be the most holistic approach for assessing functional range of motion or uncovering cause–effect relationships that contribute to motion losses. Incorporating various body positions that maximally lengthen muscle chains or to challenge stability requirements are strategies that can be utilized to help clinical decision-making.

Understanding how shoulder function varies across different positions–supine, half kneeling, and standing–with varying degrees of hip or trunk rotation and stability can provide insight into whether changes in range of motion result from inadequate tissue extensibility or poor motor control strategies stemming from the hip, core, and trunk. A structured and progressive kinetic chain evaluation and rehabilitation strategy is more likely to discover the root cause of movement limitation or dysfunction. Motor control and motor learning sequences have been developed for this purpose. ^, Incorporating shoulder range of motion within one of these movement paradigms can be useful for evaluating a movement pattern or a preferred movement strategy. This can uncover underlying proximal dysfunction, movement or strength imbalance, or instability that can be contributing to suboptimal shoulder function.

Concept 3: Get Motion, Hold Motion, and Transition Motion

Functional movement requires two phases of load–unload sequences. Eccentric–concentric movement transitions require full range of motion, strength, and neurologic control to maintain stability and overall joint integrity. ^, Assessing range of motion would not be complete without evaluating the different pieces that make up a functional movement strategy. Transitions at end ranges from late cocking to acceleration are where most shoulder and elbow injuries happen. ^,

Specifically, during throwing, the shoulder is first eccentrically loaded into external rotation and then concentrically unloaded during the acceleration phase to the point of ball release. Once ball release occurs, the shoulder undergoes a second phase of eccentric loading of the posterior chain decelerators followed by a concentric unloading to return the shoulder back to a neutral position. ^{, ,} Maximum shoulder and elbow forces occur during eccentric loading phases of throwing, coupled with high velocity of movement at supramaximal ranges, making injury common at these critical instances. ^{, , ,} Helping athletes remain injury free begins with training range of motion in a manner that mimics functional demand. This also allows the clinician to assess important transition phases of throwing and evaluate change of direction tolerance, compensated muscle utilization, or pain prior to allowing a return to interval throwing programs.

The basic strategy for range of motion acquisition and maintenance is summarized using shoulder elevation as the example.

• 1.
  

  Eccentric movement into flexion (antagonist eccentric contraction)

  
  
  
  
  • a.
    

    Brief hold of agonist (scapular stabilizers)

  
  
  
  
• 2.
  

  Concentric movement out of flexion (antagonist concentric contraction)

  
  
• 3.
  

  From full flexion eccentric movement into extension (agonist eccentric contraction)

  
  
  
  
  • b.
    

    Brief hold of antagonist into extension

  
  
  
  
• 4.
  

  Concentric contraction into flexion

The brief hold in 1a is to allow assessment of scapular end-range holding capacity. If the scapula cannot attain and hold end range, this must be improved prior to step 2 or range of motion may not be as easily maintained. As the arm moves against resistance, a loss of scapular stability may allow the scapula to be “pulled” along with the humerus, hindering the effective functioning of muscle force couples. During the “hold” phase of movement, the clinician can evaluate for scapular strength at end range, stability (onset and timing of contraction), and transition tolerance (ability to prevent glenohumeral shear) during the eccentric–concentric phase. Any deficit in scapular end-range strength, stability, or transition tolerance is an indicator of overall shoulder girdle instability. It can be objectively assessed, and improvements can be observed, measured, and felt by the clinician and athlete.

Once the first phase of eccentric–concentric movement (steps 1–2) becomes competent, the process is repeated with steps 3 to 4. These steps can be integrated within different motor development positions to better understand kinetic chain shoulder function and further guide clinical decision-making during the rehabilitation and return to throwing process.

Stability Point 1: Full Range of Motion of the Humerus Must be Present

Pain, guarding, or compensation is common signs of limited range of motion. If inflammation is present, muscle strength may be decreased, resulting in inadequate dynamic joint centration. ^, Guarding is frequently observed in the presence of fatigue or pain and can result in altered kinematics along with a subsequent increase in joint kinetics. ^{, , ,} This imparts even more joint stress to already painful soft tissue structures. Movement compensation can be from any of the aforementioned causes in an athlete’s attempt to continue pitching by avoiding certain painful or weak positions or patterns. ^{, ,} This usually only exacerbates the current injury or creates a “new” injury by transmitting force to a new area in the shoulder or more distally to the elbow.

Stability Point 2: Scapular End Range Is a Prerequisite for Humeral End Ranges of Motion

The scapula cannot attain full range of motion without a symmetric posture to allow maximum surface contact with the ribs. Rib position and thoracic spine position are interdependent, each influencing the other. The shoulder must be “allowed” to get to end range safely by the trunk and scapula. If these components are out of sync during pitching, the shoulder may still reach end range, but inefficient movement strategies and compensation may occur, potentially resulting in pain and subsequent pathology. ^{, , , , , ,} Therefore, thoracic spine and scapular position and overall posture can have a dramatic impact on shoulder range of motion and stability. ^{, , , , ,} Improving and maintaining symmetric posture can set the foundation for creating a strong, stable shoulder that can get into end ranges efficiently, and out of end range safely.

Stability Point 3: Transitions Are Critical for Shoulder Stability

Eccentric loading to end range followed by concentric return is a critical piece to attain or regain shoulder stability. ^, Pitching can magnify instability due to the extreme ranges of motion required coupled with high joint loads and velocity of movement. ^{, ,} Therefore, creating an environment that allows the shoulder to attain full range of motion through controlled eccentric and concentric movements is mandatory. While pitching, the humerus will attain end ranges, whether the supporting structures are able to support this movement or not. As the humerus moves into end ranges, scapular position can influence range of motion as well as force of area of contact of the humerus with the posterior–superior glenoid, labrum, and rotator cuff. ^,

Similarly, posture can have a negative influence on shoulder function by prepositioning the trunk, scapula, and humerus into habitual non-neutral positions. ^{, , ,} If scapular dysfunction is noted, improving postural symmetry can assist with regaining full trunk and shoulder range of motion, allowing better mechanical advantage of both dynamic movers and stabilizers. ^, Shoulder joint centration and overall dynamic stability and strength can help prevent high shear forces from occurring. ^, In our clinical experience, shoulder range of motion will not be lost if improved postural symmetry is achieved, and thoracic rotation and scapular end-range stability is maintained.

Posture/Activating Deep Core

The thoracic spine, ribs, and scapula must function in synergy to provide a stable platform for optimal shoulder function. Scapular protraction with anterior tilt or various degrees of downward rotation or winging can be present. Increased thoracic kyphosis with accompanying forward head posture can lead to limited shoulder range of motion. A flattened thoracic spine can lead to increased scapular static or dynamic winging. Thus, addressing posture and activating the deep core can have a positive influence on overall shoulder function by improving vertebral alignment, increasing scapulothoracic contact area and stability, and improving shoulder range of motion and strength.

Movement Building Blocks and Progressions

Once posture has been restored and movement allowance has been attained in an eccentric–concentric manner, basic movement competency can now be established and progressed using motor learning positions and strategies. This can further elucidate functional or dysfunctional interactions between mobility, end-range strength, and stability requirements. In general, lower level stable positions can be used to improve mobility and should be the first positions used. Higher level developmental positions can be utilized to observe how the shoulder functions in a more dynamic environment and to assess how the shoulder functions within a larger movement pattern. If range of motion decreases, or movement compensation is now observed from one position to the next, instability or motor control deficit is the most likely source. Exercises used in basic arm care are shown in Figs. 2–10 .

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