As you probably have seen from perusing this site, we are big fans of giving you tools for you to do things on your own. The “prone series” is an excellent group of exercises to perform. Ideal candidates for these exercises are overhead athletes (swimming, tennis, baseball/softball, football quarterbacks, javelin throwers), particularly young athletes. These can be done anywhere at anytime with no equipment – just a rolled up towel to put your forehead on while performing. Additionally, they can be done on the floor. So no necessary trips to the sporting goods store to get a bench.

We suggest performing all three exercises “back to back to back.” Start with trying to do 5 repetitions of each, and then build up to 20. Once those get easy (and they will if you commit to this!), add light dumbbells. A can of soup will work just fine too. The key is that you can’t compensate by “hiking” your shoulders up to complete the repetitions or using momentum to raise your arms up. You should really “feel the burn”  between your shoulder blades and the back of the shoulder.

We caution you doing these three exercises if you have any range of motion restrictions in the shoulder, as in a post-operative shoulder or in one with arthritis. Inevitably, you will have to “cheat” to perform these and it will do more harm than good. In this case, it may be necessary to go see a physical therapist to get an assessment as to why you are having range of motion restrictions.

As stated previously, we LOVE these three exercises as a great starting point for young athletes. They’re easy to perform, require no fancy expensive equipment, can be done anywhere, and don’t require a lot of instruction. They are incredibly effective and results can be obtained quickly. You’ll know they’re working if your young athlete is having less pain when performing their overhead activity.

I was asked recently (and this isn’t the first time!) about shoulder exercises and strengthening for the female overhead athlete and if they should be different than males. Great question. Our anatomy is the same (well, except for that one part!) and the muscles work the same, but are there differences and other things we should consider? The answer in my opinion is yes and no.

First of all, for all females out there who are paranoid to do any strength training because it will make them look too big and “muscley” – it’s not going to happen. We’re trying to train small muscle groups so they can do their jobs. You only get that “muscley” look with heavy strength training or lots and lots of sets with fairly heavy weights to get that look. It’s an unfortunate misconception that has resulted in females, particularly young girls, to shy away from doing some of these exercises.

Many of the exercises that have been posted (and will continue to be posted) are great for everyone – male, female, young or old. The sets and repetition schemes are relatively the same too. That is where there isn’t much difference. Where there is a difference is twofold in my opinion. First of all, females tend to be “looser” than males are and more flexible. Previous studies have shown that males have “stiffer” hamstrings compared to females when it comes to ACL injuries in the knee. What that all means is that females may be more susceptible to shoulder instabilities. Additionally, because of the hormonal differences between males and females, females are more susceptible to ligament and joint capsule increases in extensibility with repeated movements. What that means is that females may need a little more emphasis on stabilization exercises. They should be done with the arm fixed on a surface as well as with the arm free to move in space. It’s best to get a PT or licensed athletic trainer (ATC/LAT) to help you with this.

I also would not do a lot of stretching in females for this very reason. Males sometimes tend to need more stretching, particularly in the front of the shoulder, because of the overemphasis on bench pressing and chest muscle development which leads to rounded, tight shoulders.

One more point about females: they really need lots of work on the gluteals for overall injury prevention. Remember, the extremities attach to the pelvis. If you have a strong base from which the extremities can act, the extremity will be that much more stable too. More on this to come later, but hopefully you see the point.

THERAPEUTIC ULTRASOUND IN THE TREATMENT OF SHOULDER CONDITIONS: IS THERE ANY EVIDENCE?

 Perhaps one of the most grossly overused and potentially misrepresented modalities used on patients is ultrasound.  Unfortunately, many of my PT colleagues use this a ton and the chiropractic community abuses it as well.  Little evidence supports its use.  The FDA has approved low intensity pulsed ultrasound for bone healing after fractures and I have seen this work.  Many studies have shown that pulsed ultrasound helps facilitate healing in injured medial collateral ligaments in the knee.  Studies on ultrasound are “all over the map” in regards to treatment parameters, treatment times, treatment size area, etc.  So what gives?

 First, ultrasound works in a few ways.  Continuous ultrasound is uses sound waves and heat to heat tissue.  The sound waves are proposed to help with increased collagen synthesis (the stuff that primarily makes up our organs, ligaments, joint capsules), improving bone healing and in some instances, break up bone in tissue that shouldn’t have it (read on).  Some have also proposed that it helps with nutrient diffusion in tissues because it essentially “opens up the cells” through the wave vibration which allows tissues to be penetrated with nutrient rich blood.  Again, these things are believed to happen, but they haven’t been proven unequivocally. 

 Well, a recent study in Physical Therapy investigated using ultrasound to treat shoulder conditions.  It was a systematic review, meaning that the authors essentially found every study possible and analyzed the data.  Researchers found that there were benefits in using ultrasound for calcific tendonitis and that in studies showing that it was of benefit, treatment times were longer and more energy delivered per session.  Basically, we need longer treatment times and a little more “juice” from the ultrasound. 

 For what it’s worth, calcific tendonitis is a process by which bony deposits form in the rotator cuff in response to injury.  It is painful and limits function because bony tissue is in what should be purely tendinous tissue.  Ultrasound may work by helping to break up the bony deposits through vibration of the sound waves.  Most of the studies showing poor results had short treatment times and weak intensity from the ultrasound.

 So what can you do if your therapist is using ultrasound to make sure it’s being used right?  First of all, don’t let them do it more than 5 treatments if you aren’t noticing any changes.  Secondly, and this is the key – make sure the treatment area is no larger that 2x the size of the ultrasound head!!  This is my biggest pet peeve with people that use ultrasound.  Intuitively, it should make sense to you that the larger the area treated, the more the wave diffuses and loses its effectiveness.  Third, I suggest that your therapist use the 3 MHz frequency instead of the 1 MHz.  Some studies have shown that 1 MHz actually results in less positive effects because so much of the wave is refracted off of the bone (1 MHz is used for deeper tissues historically).  Last, make sure your treatment time is roughly 10-15 minutes. 

Alexander LD et al, Phys Ther, 2010; 90: 14-25

 I have a good friend of mine who is in pretty good shape and has a long history of regular exercise.  Not a meathead by any means, just a guy that likes to workout regularly and stay in shape.  He said recently that he was having pain in his shoulder with bench pressing and that as he lowered the bar, he would get pain and some “popping” in the joint.  The pain and popping limited his power off of his chest, almost making him feel weaker.  He had no specific injury to speak of, and there was not one incident where he felt considerable pain or a “pop.”  He has no pain or issue with any other activities.  Well, what is it and what to do?

 It seems like I post these cases when I never actually get to evaluate the person.  That being said, I would say that about 90% of the time, I can figure out a reasonable hypothesis as to what’s going on and be in the ballpark on how to fix it without having to run to the physician or get expensive tests that may be unnecessary. 

 My thought with him is that he has a soft tissue injury in his shoulder, likely the labrum but the possibility exists as well for a rotator cuff strain.  In people who have a long history of weight training, the repetitive motions can cause some degenerative fraying of the labrum in the shoulder.  In fact, it is believed that many football players have asymptomatic labral tears in the shoulder just from attritional wear and tear from engaging opponents and from heavy bench pressing their whole life.  Usually, as long as you are not having constant pain or problems with day-to-day activities (dressing, changing clothes, work duties), then you should leave these alone.  The best thing to do is make modifications in your weight training programs.

 I instructed my friend to do a few things.  First of all, I told him to limit overhead pressing, like the military press.  The main reason I told him to do that is because as he presses overhead, the rotator cuff gets “pinched” between the roof of the shoulder and the humerus.  Over time, that can cause more fraying of the cuff and either worsen the tear or lead to one. Really, it’s an exercise that is steeped in tradition that really isn’t that functional.  He doesn’t have a job that requires him to lift overhead and he isn’t a professional Olympic weightlifter, so why do it?  There are other options to strengthen those muscles, and I encouraged him to do lateral and front raises with dumbbells.  Secondly, I told him that when doing bench press, push ups, or incline bench press to avoid letting the elbows drop below midline as he lowers the bar (midline being where your elbow meets your trunk).  As you drop below midline, it causes more stress to the front of the shoulder and the labrum and can further irritate the shoulder.  Using the golf ball and tee analogy of the shoulder, when the elbow drops below midline, the “ball is starting to roll off the tee”.  Because of this, it places unnecessary and potentially damaging stress on the anterior shoulder soft tissues.   The more you let “the ball roll off part of the tee”, the labrum can fray or have microtears that lead to a full tear.  Ways to ensure that you stay above midline are to roll up a towel and place it on your chest and touch that with the bar as you lower it as opposed to touching your chest.  Or, he can just avoid going all the way to his chest.  Amazing how just that little extra motion can cause so many problems. 

 I am happy to say that he is pleased with these modifications and now has no pain or popping in his shoulder when he lifts.  He has resumed his normal training and has reduced the amount of overhead activity that he was doing previously.

 I recently got asked these two questions over the phone by people.  These are always tricky questions to answer because there are several things that it could be.  First of all with the steering, more than likely the rotator cuff is jamming into the roof of the shoulder and is irritating the bursa, which is the fluid filled sac between the rotator cuff and the bony roof that makes up the clavicle (collar bone) and the acromion.  You may have a rotator cuff tear that’s causing the humerus to “ride high”, but if you are able to raise your arm without a lot of difficulty, then you likely don’t have a tear.  You may also have pain if you rest your body weight on your elbows.  It is also possible that you have bone spurs poking down into the cuff from the undersurface of the roof.  If that is the case, there is less room for the cuff and bursae to move without getting irritated.  If that is the case, an X-ray will usually let you know.  Surgery is only necessary if pain is limiting your function or if even after therapy and activity modification, you are still miserable.   Bottom line is that you don’t need surgery or injections just yet – contact a physical therapist to try and fix it.  A good PT can take care of this in 6-10 visits or so (less if you are self-motivated and don’t need a lot of supervision).

 Now as far as the tucking in of the shirt…well, you may see from my other posts that frozen shoulder is a possibility.  If that’s the case, your shoulder motion is globally restricted.  You may also have tightness from a previous surgery that hasn’t been addressed.  Finally, you may have some arthritis in your shoulder (yes, your shoulder can get it too!).  If that is the case, the analogy I like to use is from the sport of hockey.  Have you ever seen the ice after the Zamboni cleans it?  It’s nice and smooth like glass and the puck will glide forever.  Now think of how the ice will be after playing a full game with no cleanings between periods.  The puck won’t move and the ice will be really chopped up.  That’s kind of what it’s like in an arthritic joint (if you have no idea about hockey, think about it as a lubed up wheel versus a rusty wheel).  Motion gets really restricted and painful because the shoulder can’t roll, slide, and glide like it should and instead ends up grinding like a mortar and pestle.  Again, if you are having trouble with these things, a physical therapist can help you out.  They should be able to take care of this in no more than 6-10 visits.

 It’s in the DNA of athletic trainers that when they see an injury on TV they have an inherent need to diagnose it.  I am certainly guilty of that.  First of all, let me say that I really felt bad for Colt McCoy on many levels.  From afar, he strikes me as a solid kid who is well spoken, a leader, and someone who is faithful.  Nowadays, people who are faithful are constantly being bashed in the media, particularly Christians.  I admire his courage in not being shy about his beliefs.  The same goes for Florida QB Tim Tebow…anyway, injuries are nonetheless part of the game, but it’s hard to see a kid lose an opportunity to compete in the final game of his collegiate career in potentially the biggest game of his life.  I can’t imagine how he must have felt on that sideline watching the game unfold.  I hope he makes a speedy recovery and I look forward to see what happens at the next level for him. 

 Initially when I saw the hit in slow motion, a few hypotheses ran threw my head.  I wondered if there was an fracture of his scapula, which is pretty rare in football.  I also thought he may have had an axillary nerve palsy.  The axillary nerve is right about where he appeared to get hit and it innervates two muscles in the shoulder, mainly the big deltoid.  I also wondered if he had a concussion because the blow he sustained caused his head to “whip” in the opposite direction and he seemed a little dazed after the play.  As the game progressed and I read the reports on ESPN (not necessarily the most accurate source on injuries, but hey, it’s all we have!) it sounded like that he had no pain, but couldn’t feel his arm.  If that is the case, he definitely suffered a nerve injury.  Based on the fact that his head went to the side like that, I imagine he suffered what is commonly known as a “stinger” or a “burner”.  In fancy medical lingo, it’s known as transient cervical neurapraxia. 

 So what is that?  Well, anytime you hit your funny bone, that is essentially a transient neurapraxia.  Transient because it is only temporary.  In his case, the nerves to all arm muscles come out of the neck.  As his head whipped to the side, I think the nerves got stretched, which caused the symptoms down the arm.  If you are an experienced couch potato on Sundays, you may have seen football players with them.  The classic sign is that they run off the field and the arm looks dead.  Colt did a good job covering that up as far as I can recall.  Anyway, the time it takes to go away can certainly vary.  Unfortunately for him, it just took too long.  I have no idea if he’s experienced these before, but usually if you have a history of them, you are at risk for them to happen again and over time, the symptoms tend to last longer when you get them. 

 Could anything have been done to “get him through?”  The short answer to that is no.  Plain and simple.  There isn’t a magic exercise or massage technique or any fancy toy available that would take care of that.  I suppose that answer may seem obvious because if there was they would have done it, but unfortunately, this world is full of everyone who’s got great ideas that have no substance.  His injury was just an unfortunate thing and part of the game. 

 Now, there can be some rehab done on these.  First of all, strengthening of the neck muscles, upper trapezii, and the scapular stabilizers is a great start.  In Colt’s case, I think he got it from the stretch of the muscles in the neck from it whipping to the side.  Commonly, “stingers” happen this way, but usually the shoulder depresses too, causing further stretch.  Most of the time, these happen as athletes make contact with an opposing player with their shoulder (for example, a running back lowering his shoulder to make contact with a defensive player).  Because of the scapular depression, that’s why we need to also strengthen the scapular stabilizers.  Position players can use neck rolls or “cowboy collars” to limit the sideflexion of the head, but that is not an option for him because he needs full head motion because of his position.

ANOTHER COMMENT ABOUT THE COLT MCCOY INJURY BUT IT HAS NOTHING TO DO WITH THE SHOULDER…

If any of you have been to the doctor, I am sure you have at some point, had to sign the HIPAA (Health Insurance Portability and Accountability Act) form.   You know, the one that keeps all your information private.  It drives me nuts that in professional sports and in big time college sports that cameras are hovering over the medical staffs as they evaluate injuries and right over the top of the staff when they evaluate people on the bench.  Where’s their privacy?  I know millions are watching and saw the injury happen, but why is it any of our business what it is?  They should just tell people that they will or will not be returning due to an injury.  It seemed like every two minutes during the national championship game they were commenting on it or getting updates.  Believe me, I get it that it’s a huge game and he’s arguably the MVP for the Longhorns, but it’s a bit ridiculous that student athletic trainers and other staff have to hold up towels to keep the cameras from being in people’s faces.  It’s just not necessary.  It reminds me of those parasite paparazzi that hassle celebrities…

 They have also got to do away with those cameras during injury evaluations.  This actually came up when I was at the NFL Combine a few years back during my days with the Kansas City Chiefs.  I understand that the NFL is trying to enhance the fan experience, but injuries and their evaluation should not be a part of this.  I hope changes are made in this.  It’s not fair to the injured athlete, and it’s certainly not fair to the medical staffs.  I wonder if someday we’ll see someone try and bring litigation on a staff for how they treated an injury.  Funny how everyone’s an expert from afar but have no idea how to respond if they are actually in that situation. 

Hopefully, that makes sense.  I hope he has a speedy recovery.

 Much like the comparative anatomy stuff, I love history.  I find it interesting and enlightening to read old anatomy texts and journals to see what the forefathers in medicine did and how our field has evolved.  I read a book once called “The Knife Man”, a novel about the first known surgeon out of England.  The book was fascinating to say the least, and some may argue it is a little macabre.  It discussed primitive surgical procedures and how they evolved.  And remember, these are the days BEFORE anaesthesia and sterile fields!!  At any rate, one entry astounded me – the physician the book was about actually inoculated himself with syphilis to see how to treat it!! Now THAT is sacrificing oneself for the good of the profession!

 Anyway, I digress…talk to any physician or any therapist for that matter and one of the most basic exercises for the shoulder, particularly post-operative ones, is “Codman’s exercises.”  Codman was a physician who published lots of works on the shoulder in the early 20^th century until the 1940’s or so (that I am aware of!) and popularized exercises bearing his namesake, as well as the term “scapulohumeral rhythm,” which is always discussed in nearly every work on the shoulder.  He is without question one of the “grandfathers” of the shoulder.   Another patriarch of the shoulder (well, orthopedics in general!) is Dr. Verne Inman.  His article from the Journal of Bone and Joint Surgery in 1944 is an absolute classic in my world, a virtual goldmine on the shoulder.   

 Inman and others manuscript in JBJS was aptly entitled “Observations on the function of the shoulder joint.”  What fascinates me about these guys is that they did all this before the days of MRI’s, CT scans, bone scans, and all the other imaging technologies that we have at our fingertips (and take for granted!) today.  We are forever indebted to these people for their foresight and curiosity. 

 Moving along, they just discussed how anatomy dictates function in the shoulder, and even touched on some comparative anatomy.   Some of the more interesting points from their review are as follows:

1. The teres minor is morphologically a portion of the deltoid muscle.  This is important because it’s always been puzzling why the deltoid and teres minor share the same nerve innervation (the axillary nerve), but they have different functions.   In more primitive mammalian species, it’s one large muscle.  Because our scapulae (shoulder blades) are structured differently and the muscle is needed for different purposes, it separates from the deltoid to become a distinct muscle.  Cool huh?
2. The subscapularis, teres minor, and infraspinatus (3 of the 4 rotator cuff muscles) function as depressors and rotators of the humerus. 
3. The latissimus dorsi and the teres major are most massive in climbing species.  Inman and colleagues seem to think that it doesn’t serve a significant purpose in humans. 
4. The deltoid has its greatest activity between 90-180° of abduction, reaching its peak at 110°.  For rehab professionals, this means that 110° is a great position to work on neuromuscular stabilization and proprioception because the deltoid is at its greatest mechanical advantage. 
5. The supraspinatus reaches its peak at 100° of abduction.  That being said, they also report that by far, the supraspinatus’ greatest role is in humeral head depression so the deltoid can raise the arm.
6. Infraspinatus reaches its peak at 180°.  Although it’s considered primarily an external rotator, it’s clear that this muscle should be worked at full elevation as well.
7. The teres minor peaks at 120° of abduction.  Again, its primarily an external rotator but we should do elevation exercises to 120° to maximally train the teres minor. 

Inman VT et al, J Bone Joint Surg, 1944.

SLAP stands for Superior Labrum Anterior-Posterior. You may recall (if you’ve read my other posts) that the shoulder is like a golf ball on a tee, and the tee has a washer on it, which is the labrum. Well, if we imagine that we’re looking at the top of the golf tee and imagine it being a clock, the bicep tendon actually goes into the shoulder joint and attaches to the labrum at the 12 o’clock position. The reason why this is a problem, especially with overhead athletes, is that every time an athlete goes through their sport motion, the bicep tendon “tugs” on the labrum and over time, pulls the labrum away from the glenoid (the golf tee). Perhaps the best analogy I can provide is from the American Sports Medicine Institute in Alabama – they said it’s like pulling a pesky weed out of the ground. To do so, you typically pull back and forth repeatedly until it eventually pulls away from the ground.

There are many types of SLAP tears and it’s beyond the scope of what I’m trying to do here on this site. I suggest that it’s important for you to know that the severity of tears vary from simple degenerative fraying to full tears either labrum and bicep together or pulled separately from each other.

What are the symptoms then? Well, first and foremost, if you are an overhead athlete you are at risk. Typically, they are in younger (<40 years) athletes, but certainly if you are an active older athlete, it is possible. If you are older, chances are it was a traumatic injury that caused it. Second, people typically complain of pain that is “deep” in the shoulder, making it difficult to localize. People aren’t typically point tender with these either. Pain is most often felt in the “late cocking” phase of throwing, but certainly can be felt during acceleration or follow through. You may experience a “clunk” or “click” in the shoulder as you move it through rotary motions. There are a litany of special tests that either your orthopedic physician or physical therapist can take you through to determine if you have a SLAP tear, but many are unreliable. It’s usually a combination of those tests and the subjective complaints that you have.

Interesting story about these…back in the 1970’s, pitchers would complain of pain in the shoulder with progressive decreases in velocity and eventually a “dead arm” feeling in the throwing shoulder. It was really known as the “kiss of death” in baseball pitchers. Physicians had no idea what the injury was because “it saw them but they didn’t see it”, so they just assumed that the athlete was either faking it or they just weren’t tough!! As more and more athletes came forward with these complaints, it led to the discovery of this condition.

What to do about these? If it’s your throwing shoulder, you definitely need to have surgery on this. It will not heal on its own. If you just have some degenerative fraying and you’re not a thrower or intend on stopping, you might be able to get by. However, if you have any intention of doing overhead activity, even rec league softball, you should get this fixed. If its in your nondominant arm, you also may be able to get by.

Well, a recent prospective study in the Journal of Bone and Joint Surgery (British) shed some light on this topic. The study compared outcomes with one-year follow up in a group of subjects who had rotator cuff repair or physical therapy in the treatment of small and medium-sized rotator cuff tears. Subjects in the repair group had either the mini-open or the open repair, which are still considered the “gold standard” (arthroscopic ones are gaining in evidence and popularity). Researchers were vague on patient demographics, so age of subjects was not highlighted (the only criteria is that none were younger than 18 years of age). Several different standardized outcome measures were used to assess the outcome between the two groups. There were some interesting findings here:
1. Nine patients (18%) in the PT group showed no improvement after a mean of 24 sessions and had surgery.
2. Shoulder function scores were significantly better in the surgical group. However, at 6 months, improvement was only significant in one of the two scores.
3. Patient satisfaction was higher in the surgical group and this was considered statistically significant.
4. Second look MRI at one year showed 76% of repairs were intact, while varying degrees of tears were found in the other ¼ of the remaining patients.

So what’s all this mean? Well, I wish the authors would have highlighted what was actually done in therapy. They were pretty vague on what they did. All that being said, the subjects in the surgical group were happier with their outcome. Does that mean it’s appropriate for everyone? Certainly not. In young patients (<35 years old), it is generally accepted that all patients should have a repair. However, deciding whether or not to repair is really a decision that should be between a patient and his/her doctor.

From my end, I advocate attempting conservative therapy for at least 3-4 weeks, but up to 6. Again, if you are a self-motivated person, going to supervised therapy is necessary once a week with consistent participation in a home program. I find that you’ll learn quickly if physical therapy gives you any shot at getting better. The bottom line is that it all comes down to whether or not you can do what you want to do. You should expect some pain, but if it becomes unbearable, then you should get a repair. If however, you are able to manage with only some modifications (i.e. reaching in a cupboard with your uninvolved arm to get a coffee cup), then surgery can probably be delayed.

Moosmayer et al, J Bone Joint Surg (Br) 2010; 92 (1): 83-91.

 I recently had a case where an elderly gentleman (late 60’s, early 70’s) had a confirmed rotator cuff tear on MRI but managed just fine with physical therapy.  This man tore his cuff while fly fishing.  He tripped on some rocks in the water and when he went to catch his balance with his right arm, he ended up tearing his rotator cuff.  He is right hand dominant.  He was having moderate pain with certain activities – raising his arm above his shoulders, putting his arm in his jacket, reaching behind.  Strength testing was pretty weak.  He also had pretty significant muscle atrophy of the posterior rotator cuff.  What I am saying here is that he was a pretty classic presentation. 

 Anyway, we tried about 6 weeks of therapy.  He got gradually better with some passive (I did the work) motion and gravity eliminated elevation exercises using a cane.  He was pretty motivated to get better so I only saw him once a week.  We then started some strengthening exercises as tolerated.  We did a lot of scapular work too to help his shoulder range of motion.  Long story short, he gradually got better and a little stronger, but undoubtedly had cuff weakness.  He really wanted to be able to golf and fish, and he was able to raise his arm symmetrically to his uninvolved.  He was pleased with his outcome and was able to do the things he wanted to do, so I discharged him.

 Without question, the challenge here is that although he was able to function as he desired with minor modifications, the cuff won’t heal on its own and he isn’t getting any younger.  It is highly likely that his tear will get worse over time.  Should he have got it repaired now?  Ideally yes, but realistically, no.  He’s doing what he wants to be able to do.  If it does decline to the point he can’t use it, total shoulder replacements are an option for him.   

 One thing worth mentioning about the older population – make sure you have your physical therapist work on your thoracic spine.  With age, the spine expectedly gets stiffer and loses mobility.  You must have thoracic spine mobility for the shoulder to work properly.  You don’t need any thrust mobilization treatments, but just mobility exercises.  Repeated, consistent exercise can help loosen up the soft tissues surrounding the spine, and non-thrust techniques can supplement these treatments to facilitate greater shoulder motion.  I did that with this gentleman and it certainly benefited him (he is a right handed golfer and had pain on follow through – I addressed his thoracic rotation mobility to help dissipate some force through his trunk as opposed to the back of the shoulder).