25 May 2019
This is such an important and timely topic… regardless of the species. I could likely write it off the cuff. However, I was inspired by a great blog on the topic.
It contains five of the most common errors seen when trying to return back to training following shoulder injury. I think contains wisdom that transcends human-canine barriers! So, let’s dive in!
1.Rapidly Increasing Workload When Pain is Gone, or When Athletes are “Cleared”. Here it is emphasized that client education must occur early in the rehab process. The absence of pain does not mean things are better or that activity can be resumed. Progressive loading is still the key to success. It also serves to minimize flare ups when returning to training.
In our canine population, it is so important to educate the handlers of the dogs. It is very typical for owners of the canine athletes to push their dogs faster than what was prescribed. I now come to expect it. So, if there is something that I am quite fearful of, I will spend more time educating the owner on WHY I am adding that restriction, or limiting the progression to just one or two things. The ‘why’ seems to minimize leniencies or overly exuberant training. (Note I said minimize, not resolve!)
2.Not Restoring Unilateral Strength Symmetry Before Bilaterally Loading the Shoulder. Okay, so dogs and people all have a dominant arm. That, likely needs to be taken into consideration. Additionally, almost all shoulder injuries or pain comes from protective inhibition and some degree of minor disuse atrophy. This is without considering that there may have been unilateral imbalances (right to the left) or training imbalances (push to pull ratios) that may have contributed to the injury in the first place. So before engaging in bilateral shoulder training, ensure that the ‘affected’ shoulder has an 85% - 90% symmetry index.
This is going to be harder to assess on a dog, or any quadruped for that matter. However, we should think about this factor before engaging in therapeutic exercises such as push-ups. I’d suggest lots of 3-legged or diagonal leg balancing activities using the affected limb, and comparing to the opposite side / diagonal with the various progressions as you progress through rehab. Side stepping and lateralized exercises can be used and again compared. I’d also employ the use of a Stance Analyzer or two digital scales to evaluate static weight bearing throughout rehab as well. Additionally, I’m thinking that there should be a way of doing a push up that challenges one side more than the other (one foot elevated on a book perhaps) as a way to test and train one shoulder more than the other. Food for thought!
3.Treating the Cause of Shoulder Pain, Not Only the Site of Pain. With any injury, the therapist should ask him/herself, “Have I considered all of the variables that may have contributed to this shoulder injury in the first place?”
I don’t think that we think of this often enough in our canine population. Are there factors that have made this leg the dominant leg? (i.e. Contralateral carpal arthritis? A rear end injury? Neck, thoracic spine, or rib dysfunction? A soft tissue or fascial restriction?) This is why it’s so important to evaluate the whole dog during your initial assessment.
4. Medical Providers Not Creating Individualized, Objective, Return to Fitness Programs. From this perspective, it is best start with a conversation on the primary goals or when the athlete desires to be back to sport. From that date, you can reverse engineer the progressions in training needed to aim for that end goal. You can create a progression of exercises, sets, repetitions, and metabolic work in a periodized fashion. The exercises, sets, reps, and progression rate can be adjusted based on the injury type, client, and training age. As well, ensure that your client knows that your first program is just your first best guess, and that it is likely to change throughout your therapy as needed.
For canine athletes, this holds true as well. Sometimes you will test an exercise and it might flare up the patient, other times you don’t see the desired result with the exercise chosen. However, if you come at your program with an end goal in mind and a desired time limit… then you know how fast you need to progress. If all goes well, the patient meets each challenge and strengthens accordingly. If not, then you reset the goal or change the plan. There is no cookbook!
5.Not Continuing Basic Soft Tissue and Cuff Care for Maintenance. Athletes and coaches must remember that just because there is no pain, doesn’t mean the shoulder is back to full function. As athletes train more, they naturally acquire soft tissue stiffness, fatigue, and imbalances around their shoulder joint. It’s important to address these factors before pain creeps back in. Regular soft tissue management, strength balance work and high-level cuff strength should be part of the maintenance regimen for the athlete.
I am now on record as saying that I believe that almost all (if not all) agility dogs have some degree of medial shoulder hypermobility. It’s what is being asked of them, and the shoulder accommodates to the pressures (sometimes functionally, and sometimes pathologically). So, I too think that some soft tissue work on a regular basis is imperative. Stretch the scalenes. Mobilize the shoulder joint. Keep the supraspinatus and biceps tendons strong. Check and address those ‘other areas’ of pain.
In getting the shoulder patient back to competition, not only should you have a plan, but you should also communicate your plan and your thoughts along the way. Be transparent. Answer questions. Be honest about the ups and downs for returning to training and sport as well as the possible positive or negative consequences that come with big decisions.
There you go… some juicy, informative stuff you can take away from human physical therapy practice! Go forth and help those canine athletes!
Tags: shoulder , glenohumeral , return to sport
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