Working in a collision sport environment there are always going to be shoulder injuries, from pec tears, torn rotator cuffs or shoulder dislocations. The growing question is how do we progress them in their journey and how do we quantify this?
There has been some great work in this area carried out by the likes of Ben Ashworth with his ASH test (Force awakens: a new hope for athletic shoulder strength testing) and Edel Fanning at the Sport Surgery Clinic in Dublin applying lower body jump testing to the upper body (The Young Contact Athlete Post Latarjet), while Myles Murphy has showcased a real world example from the elite environment of how accelerated rehabilitation can be carried out following a Latarjet procedure (Eight-Week Return to Play Following Latarjet Shoulder Reconstruction in an Australian Football Player: A Case Report).
During my time at the South Sydney Rabbitohs we had two shoulder reconstructions and one Latarjet repair and inspired in part by the great work carried out by the practitioners mentioned above, the rehab physio and I set out to develop a return to falling and return to contact framework.
In my final year at the club we successfully managed to rehab the 2 shoulder injuries from the season before and return them to full, unrestricted training during the pre-season. One of these injuries was general wear and tear with no one incident of trauma while the other athlete was injured whilst being tackled at the start of the year and superbly managed nonoperatively throughout the season by the medical staff before having surgery in the off season. Neither of these injuries occured whilst making a tackle.
Part of this thought process came about when discussing the return to contact markers for an athlete recovering from Pec surgery. Before we had begun to develop this framework, a bench press of 30kg for 10 reps had been the main marker for progressing athletes.
Now instinctively as S&C coaches and physios working in rehab we tend to work through a continuum from unloaded to loaded, from simple to complex. Naturally we may assume a normal push up would be less load than a loaded exercise such as a DB Bench press. However in this instance when the athlete weighed 120kg and with about 66% of your bodyweight passing through your arms on a push up, one push up equated to a total load of 80 kg or 40 kg passing through each arm (surpassing the 30 kg bench press marker), not to mention this athlete bench pressed 120kg for 6 before this injury.
This post is rooted in the original framework but it is also an extension of it with further development of these ideas as well as my current access to dual force plates which we did not have access to at the time.
So where do loading and falling exercises best fit on a rehab continuum?
From static to dynamic.
From low load to high load.
Starting with closed chain exercises before open chain.
Building through small ranges of motion to larger ranges of motion.
Falling also works along a continuum, from static to dynamic. From band assisted to loaded. From absorbing to sticking or rebounding.
This is an N = 1 exploration of falling progressions with a healthy subject. It will not explore asymmetries or LSI but instead look quantify the load of falling progressions along a continuum.
Our first step at the club was to quantify forces through the shoulder at various ranges using the ASH test so I will begin here.
It is a static test and can be progressive but it will require adequate shoulder flexion and abduction. It is however a comfortable way to begin to measure shoulder strength in a rehabbing athlete.
The Athletic Shoulder (ASH) test: reliability of a novel upper body isometric strength test in elite rugby players
An added area of interest for me is the exploration of the “L” position. This position seems to be more relatable to making a normal tackle with shoulder and elbow flexion compared to the “Y” or “T” position which are more likely to represent a tackle gone wrong and possibly result in a tackle related shoulder injury. As I write this now I think a “W” position would be better still.
The next area of interest was to explore a bilateral testing position. Anyone who has seen a countermovement jump would likely agree it looks better than its single leg counterpart, likely as a result of greater stability throughout the test.
Having carried out several ASH tests I have seen a large variance in how athletes have approached this and I have often wondered if providing greater stability through a bilateral test would provide better results.
Due to limitations with the force plates cable connection I was only able to explore the “II”, “YY” and “LL” positions.
As we can see here the “LL” and “YY” positions result in a greater output compared to their single limb variants while the “I” position remains stronger than the “II” position. This isn’t surprising though as the “I” position is by far the most stable position in the original ASH test and by removing some level of stability the output goes down. Add stability to the more unstable “Y” position and output goes up. It would be interesting to see how a “TT” test would respond. Whether or not the bilateral testing would result in more reliable measures remains to be seen, especially given the original ASH test’s high reliability (ICC = 0.94 – 0.98).
If we extrapolate the data from Ben’s ASH reliability paper we will see scores ranging from 1.1 – 1.9 N.KG. In this data set the range is slightly lower 0.97 – 1.7 N.KG. As you will see as you work through the progressions is that these forces can increase up to 25 N.KG. For now the ASH tests starts as a nice entry point to to measure and monitor shoulder strength.
Push Up Variants
By using the Hawkin Dynamic system during certain tests I was able to dive deeper in to the metrics and explore peak force throughout the different phases of the movement, be it braking, propulsive or landing forces.
From the graph above we can see the maximum force exerted throughout the movements along the continuum. It does not distinguish whether the force was a landing force or propulsive force as this will be explored below. Each exercise classification has been colour coded and what we can see is that depending on the exercise modification something like a banded kneeling fall (Fall) can have a lower force requirement than a clap push up (CM) and can allow athletes to work on multiple movement threads earlier on in the continuum.
-Quadruped – 1 arm lift
Quadruped – 1 leg lift
– Banded Push Up – Chest
– Banded Push Up – across
– Banded Push Up – Waist
Feet elevated Push Up
– Push up
– Double Clap Push Up
– Clap Push Up – Absorb
– Clap Push Up – Stick
– Countermovement Push Up
– Countermovement rebound
– Concentric Push Up
– Countermovement Push Up to Box
– Concentric Push Up to Box
– Box Drop Absorb
– Box Drop Return
– Box Drop Rebound
– Box Drop Stick
-Banded kneeling fall absorb
-Banded kneeling fall and stick
– Kneeling fall absorb
– Kneeling fall and stick
– Kneeling fall rebound
Standing fall and absorb
Standing fall and stick
It is very hard not to cheat on a standing fall and this is where adding rolling elements may be useful as well as integrating being tackled by a static, kneeling defender.
From exploring these different falling progressions it became apparent that technique and coaching can impact the load.
For example cueing an athlete to absorb the force rather than stick the landing will decrease the landing force while although not presented here but by having an athlete leave their feet on the floor during the kneeling falling progressions will increase the landing forces.
This blog was not meant as an exhaustive list of falling progressions, it was simply meant to explore various movement types and the associated load. Further work in rehabbing athletes would be worth exploring how asymmetries present themselves as the athlete moves along the continuum.