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STRENGTHENING THE SHOULDER TO PREVENT INJURIES: Part 2

Dante Dettamanti BS, MS
Coached Stanford University to Eight NCAA Championships

Volume 1 Number 2 March 1, 2010
Water Polo Doesn't Come with an Instruction Book - That's Why We Have Coaches.
 

This is a second in a series of three articles about shoulder injuries in water polo, and exercises to help strengthen the shoulder muscles to help prevent injuries.
 
In weight training and athletics, the repetitive movements and daily stresses on the shoulder, forces the muscles of the rotator cuff to exert a greater force to stabilize the head of the humerus in the glenoid socket. The strength of these supporting structures is crucial; because as a muscle contracts, tightening of the shoulder capsule occurs, along with the tendons that connect the bones of the joint. This tension in the capsule holds the humeral head in the socket, providing the required stability to the shoulder joint.

Excessive stimulation from activity, over a long period of time, can begin a negative cycle that is very common among athletes in sports that stress repetitive arm motions and overhead activities. The combination of swimming the crawl stroke with the head out of the water, and the overhead motion of throwing and shooting a ball, tends to weaken the structure of the rotator cuff over time, and makes the water polo player a prime candidate for shoulder injuries.

The cycle usually starts with shoulder pain and the avoidance of certain movements, which causes atrophy of the involved musculature and eventually results in instability and possible impingement. Imbalances of strength and coordination occur from this continuous training, and are only reinforced as the athlete continues to perform these exercises. These imbalances are often the root of many training injuries and may predispose athletes to a greater risk of injury during further training and competition. We will look at a number of factors involved in producing shoulder injuries, and see if perhaps we can do something to prevent these kinds of injuries before they occur.

WHAT CAUSES INJURIES TO THE SHOULDERS OF WATER POLO PLAYERS?

COMPETITIVE SWIMMING:

Many water polo players, especially in this country, start out as competitive swimmers. Some start as early as five years old. It has been estimated that competitive swimmers can perform about 200,000 stroke cycles per year for age group and high school swimmers, and up to a million stroke cycles for elite level and older swimmers. Now multiply those numbers times the number of years in swimming before a player even begins to play water polo, and you can see the amount of wear and tear on the shoulder joint. Swimming the butterfly stroke adds even more stress to the shoulder, because both arms go forward at the same time, and there is no rotation of the shoulders to help relieve the stress.

It has been estimated that over 70% of competitive swimmers reported suffering from some type of shoulder injury at least once during their swimming careers. There are no statistics for water polo players; but shoulder injuries are also common in this sport as well. For the water polo player, there is added stress when swimming because of the wide, short and rapid sprint stroke that is required to keep the shoulders and head out of the water and maintain speed.

What is it about swimming that causes stress to the shoulders and possible injury? First is the undue stress that is put on the rotator cuff muscles that keep the shoulder stable. Every time the arm is lifted above the shoulder to take a stroke, the cuff muscles have to contract to keep the head of the humerus in the socket of the shoulder. After periods of many years, the tendons of the rotator cuff muscles become stretched out and loose, causing the humerous head to start to slip out and cause pain to the joint. This starts a cycle that can result in injuries and tears of the muscles.

An imbalance of the muscles surrounding the shoulder can also occur. During the power phase of swimming, when the hand is pulling through the water, it is the major muscles like the pecs (chest) and lats (back) that are used. The Pecs and Lats are strengthened more than the rotator cuff muscles, because they are used for the power phase of swimming; while the rotator cuff muscles are mainly used during the recovery phase, to lift the arm out of the water and to slow the arm down.

Since rotator cuff strengthening and rotator cuff exercises are not a very common practice among swimmers and water polo players, those muscles are underdeveloped. The larger upper body muscles of the chest and back are strengthened; but the swimmer probably neglects any rotator cuff strength exercises, or any exercises that work on stabilization. The combination of weaker rotator cuff muscles and over-developed shoulders, chest and arm muscles cause the muscle imbalances that can increase the likelihood of rotator cuff injury. There is a reason for that rounded-shoulder look of swimmers!

THROWING AND SHOOTING A BALL

An example of a sport that places increased strain on the shoulder joint, would be any sport that involves a lot of throwing movements, such as baseball and water polo. The act of throwing is the most stressful motion on the shoulder and rotator cuff. Water polo players make a perfect example to show the importance of proper exercise form and increased stress from shooting a ball. The arm and the ball (resistance) are thrown forward at a tremendous velocity, anywhere from 30 to 50 miles per hour. The rotator cuff is responsible for decelerating the arm at the end of the shot, and holding the arm in the socket, along with the labrum.

Proper balance between the concentrically contracting muscles (they generate the force to bring the arm forward with the ball) and the eccentrically contracting muscles (they help stop the forward motion) that control movement is important. An imbalance can be created (similar to swimming) in which the power muscles of the chest and arm that bring the arm forward, are stronger than the muscles in the back of the arm that slow down and stabilize the shoulder joint. A rotator cuff tear can happen as the muscles in the rotator cuff contract to slow down the arm, more force is produced than the muscles can handle. This happens when the imbalance that is created between these opposing muscle groups results in overuse of muscles, and ultimately overuse injuries of the shoulder.

SHOULDER INSTABILITY

Shoulder instability that is caused by weak muscles or stretched ligaments can significantly add to the problems associated with repetitive overuse in swimming, and overhead motions of throwing the ball in water polo. Athletes with so called “loose” shoulders (because of stretched ligaments) are even more at risk of impingement and tears of the rotator cuff, than an athlete with more stable and stronger muscles and ligaments. This “laxity” of the shoulder cuff ligaments can be because of different reasons:

As a result, a vicious self-perpetuating cycle of instability, less use, more muscle weakness, and more instability is present. These athletes frequently have relative rotator cuff muscle weakness, particularly the external rotators and scapular stabilize.

THE EFFECT OF STRETCHING THE SHOULDER ON STABILITY AND INJURY

Stretching prior to a training session is still a common practice among swimmers and water polo players (See Pictures 1 & 2). The shoulder is the most frequently stretched joint among the swimming community. Athletes often stretch with the misconception that they will increase muscle flexibility, reduce the risk of skeletal muscle injury, and improve performance.

Accordingly, swimmers and water polo players and their coaches tend to devote a considerable time to stretching. However, there is little evidence to support the relationship between muscle stretching and a reduction in injury, increasing of flexibility, or improving performance in the water. In addition, pre-exercise stretching has been found to decrease muscle strength, power output and balance performance.        

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Picture 1 Picture 2

Pictures 1-2 depict self stretching of the shoulder joint. Do not perform these stretching exercises!

Recent research on swimmer’s flexibility suggests there is no indication that extraordinary shoulder joint motion or flexibility is necessary to achieve a fast, efficient stroke. Elite level competitive swimmers and water polo players are naturally selected to their sport. They are generally flexible and possess loose connective tissue (general joint laxity). No matter how hard they try, swimmers and water polo players who are not inherently flexible will never be able to achieve the flexibility of athletes who are naturally flexible. This certainly cannot be accomplished by stretching.

Because of their inherent laxity in the shoulder, swimmers should emphasize preserving the overall stability of the shoulder by strengthening the stabilizing muscles of the rotator cuff and the scapula. Adding together the effects of thousands of repetitive shoulder rotations every week, and hundreds of overhead throws, water polo players (especially those who have a swimming background) will stretch the tendons and ligaments of the shoulder over time: which leads to more instability of the shoulder joint.

In addition to normal wear and tear on the shoulder joint from overuse, stretching of these stabilizing muscles can result in even more looseness of the tendons that are associated with those muscles; adding even more instability to the joint.

Stretching exercises that put the shoulder joint in a vulnerable position, and pull the tendons of the shoulder beyond their normal range of motion (as shown in pictures 1-4 ), are all discouragedby US Swimming as being potentially dangerous to the stability of the shoulder joint.

03 04
Picture 3: Cross-arm assisted stretch Picture 4: Elbow pull -
back stretch

Pictures 1-4 above, show shoulder- stretching exercises that can cause loose tendons of the rotator cuff muscles, resulting in instability and possible injury. Do not perform these exercises.

RESISTANCE TRAINING:

Swimmers and water polo players have a tendency to strengthen the power muscles in the chest, shoulder and arms and ignore the smaller stabilizing muscles of the shoulder and back. There's a lot more to a good dry-land training program than doing lots of push-ups. In fact, too many push-ups, along with pull-ups, lat pull-downs and a litany of other drills that target the chest, lats and front deltoids (shoulders), can actually increase your chances of developing a shoulder injury over time!

Granted, these are some of the most important muscles responsible for propelling the swimmer and water polo player through the water, so it does make at least some sense to keep them strong. However, when your strengthening program either minimizes the importance of, or completely neglects the opposing muscles that are responsible for shoulder and scapular stabilization, it's a recipe for trouble.

PROPER FORM

Proper form when lifting weights is also important. If decelerating a player’s arm when shooting and throwing (the arm doesn’t weigh that much) produces enough force to tear the rotator cuff, it should be obvious to see what a 50-60 pound barbell can do. In order to prevent rotator cuff injury when performing resistance exercises, the athlete must lower the weights under control.

For instance, when lifting a weight during an arm curl, the bicep muscle contracts and is said to undergo “concentric” contraction. When the weight is lowered, the muscle undergoes “eccentric” contraction that helps control the decent. The eccentric, or negative part of the repetition, is when the rotator cuff accepts the most force. If you do not slow the weight down with larger muscles, you put the rotator cuff at risk for tears and rotator cuff impingement syndrome. Always lower the weights under complete control.

In exercises where the arms are straight, do not "lock" the elbows. Your elbows should be slightly bent. This makes the muscles work harder to increase the effectiveness of the exercise. Locking a joint while exercising also increases the chances of injuring the joint.
Move slowly and smoothly. Do not jerk. Move slowly and steadily to use the muscles, not momentum, to complete the exercises. For exercises involving lifting or pulling, take two- three seconds to lift or pull, hold for one second, and take three seconds to lower or return.

Certain resistance exercises with heavy weights can put too much stress on the shoulder, mainly because they put the shoulder in a vulnerable position that could encourage impingement, or result in tears of the rotator cup. Weight exercises that need to be avoided or modified include: 1) Perform the bench press with a narrow grip on the bar that is no wider than the width of the shoulders, 2) Avoid pullover exercises (laying on back and pulling weight from behind head and over the top of the head to the chest).

 3) Avoid fly exercises where the athlete lays on his back and extends the arms down and out the side, and then with a straight arm brings the weights together and up to a position over the chest. It is best to perform this exercise with a machine that can be adjusted so that the hands start in a position that is slightly behind the shoulders, rather than a position that is overstretched to the maximum behind the shoulder. 4) Avoid lat pull-downs and military press exercises that start and finish behind the head rather than pulling down or pushing up from the chest. 

Be patient and build up strength slowly. Doing too much too soon can cause overuse injuries. Strengthening a group of muscles should only be done every second day to give the muscles a chance to heal, unless otherwise instructed by a physician or physical therapist. Strengthening exercises load the muscles slightly beyond their limits and cause microscopic tears. If given a proper chance to heal, muscles become stronger. If not given a chance to heal, chronic inflammation and problems may develop.

PROPER WARM UP

Warming muscles and tendons before performing any activity, will improve range of motion and help decrease the risk of injury. This is especially true for warming up the shoulders of water polo players for swimming and throwing the ball. The best way to warm up for any activity is to start out performing that activity at a slow pace, and then as the muscles get warmer and looser, to gradually increase the intensity of the activity. A good way for a water polo player to warm-up is to swim slowly for about 10-15 minutes, changing strokes as you go along; so that all of the muscles will be used. Then gradually increase your speed.

The same thing goes for warming up the legs for the eggbeater kick, and warming up the arm and shoulder for passing and shooting. Start slowly at first and then gradually increase the intensity of the activity, before going all out and risking injury.
Note: Stretching before performing an activity does nothing to warm up the muscles and joints of the body. Warming up can only occur by performing the activity and contracting the muscles that will be used in that activity. This prepares the body for exercise by increasing heart rate and breathing rate, and increasing blood flow to the muscles, and raising body temperature. Trying to swim fast or shoot a ball, without warming up the shoulder muscles and joints, is a recipe for injury to the rotator cuff muscles and ligaments.

RESISTANCE TRAINING PROGRAM FOR THE SHOULDERS

PROGRAM FOR THE MAJOR POWER MUSCLES OF THE SHOULDER

The power muscles of the chest, back and shoulder area are important to water polo, and should be part of an overall strength program. The pecs (chest) and lats (back) are the major muscles that are involved in the power phase of the swimming stroke, and the power phase of the shooting and throwing motion of the arm. Other major muscles involved, but to a lesser extent, are the deltoids (shoulder), rhomboids (shoulder neck) and trapezius (upper back and shoulder).

Strengthening all of these muscles should be done 2-3 days a week during the season as well as the off-season. Resistance can be provided by free or machine weights, body weight, or resistance bands with handles (stretch cords). The advantage of using bands is that the motions of water polo can be more closely duplicated. The advantage of using weights is that they can create more resistance than bands. In general, the heavier the resistance with fewer repetitions (weights), the more bulk (strength) is added to the muscles; and the lighter the resistance with greater reps (bands and body weight) has both a strength and endurance component. Recommended for high-school and college age players are 3-sets at 8-12 repetitions for each exercise, using machine or free weights. For younger players, perform strength exercises using body weight (push-ups) and resistance bands in a circuit training format that allows players to rotate after each exercise.

Some coaches will do more high resistance exercises during the off-season using free and machine weights, and more lower resistance exercises during the season, using body weight and stretch bands. They feel that it is not necessary to add extra bulk during the season. The exercises during the season are simply a maintenance program for the strength that was built up during the off-season. In addition, more time is needed during the season to prepare and practice for games; making less time available for resistance training. (Resistance training exercises for water polo major muscle groups will be covered in a future Water Polo Planet twice-monthly series)   

Overdoing chest exercises like the bench press, without strengthening the other muscles surrounding the shoulder, causes an imbalance between the front and the back of the shoulder that can lead to shoulder injuries. To correct the imbalance, players should add back and shoulder exercises to their routine, such as front, narrow and wide-grip lat pull downs and lat pullovers (Lats), seated rows, or horizontal rows laying on an inclined bench (Trapezius and Rhomboids), and back, side, and front arm raises (Deltoids). It is recommended by therapists and exercise physiologists, that there be a TWO TO ONE RATIO  of the number of back-of-the shoulder exercises to the number of front-of-the shoulder exercises.

THE IMPORTANCE OF STRENGTHENING THE STABILIZER MUSCLES OF THE SHOULDER.

As mentioned above, an emphasis on strengthening the major power muscles of the shoulder, back and chest, while ignoring the stabilizing muscles of the rotator cuff and the scapula, can cause an imbalance that can lead to injuries to those muscles. 

Because most strength training programs do not focus on the shoulder muscles that provide stability to the shoulder, overuse can exaggerate the injury even more. Strengthening the muscles surrounding the shoulder, before injuries occur, can help prevent many of the injuries that are common in water polo.

Many muscles are involved in shoulder movement, and all work together. Given that the rotator cuff works to stabilize the shoulder joint, it stands to reason that the muscles of the rotator cuff will come into play whenever the larger muscles that work across the shoulder joint are exercised. However, a system is only as strong as its weakest link.  In the shoulders the weakest link is the stabilization system, the rotator cuff.

The rotator cuff is the main stabilizer of the shoulder joint during movement of the shoulder. If the ball of the upper arm is not kept centered, abnormal stress is placed on surrounding tissue and may cause gradual injury. The preferable way to prevent a shoulder impingement or muscle tear is through an exercise program to strengthen the rotator cuff muscles sufficiently so that the head of the shoulder is held firmly in place and will not slip out of the socket. With no slipping, the tendons will no longer be inflamed or irritated.

If you are regularly involved in activities such as swimming and water polo, that repeatedly put an abnormal amount of stress on the shoulder joint and the muscles of the rotator cuff, then it would definitely be worth your while to do some specific rotator cuff exercises. Doing this will ensure your shoulder joint stays strong and decrease the likelihood of incurring an injury.

STABILIZING THE SHOULDER BLADE

Strengthening exercises for the muscles that control the shoulder blade are also important, as the shoulder blade (scapula) helps the rotator cuff to stabilize the shoulder while in motion. The rotator cuff muscles arise from the scapula and attach to the head of the upper arm bone. If the shoulder blade is not stable, undue pressure may be placed on the rotator cuff. Shoulder shrugs, rowing (seated rows, bent-over rows, etc.), bent over side lateral raises, and reverse flys target the major scapular stabilizers, trapezius, levator scapulae, and rhomboids. (See Pictures 5-10 below and on next page). Since these are larger muscles that are also used during the power phase of swimming and shooting, the water polo player should use moderate to heavy weights that can be lifted for 2-3 sets of 8-12 repetitions.

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Picture 5 Picture 6

Pictures 5-6: Seated Row-Pull handle back to chest. Roll shoulders back to squeeze shoulder blades together.

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Picture 7 Picture 8

Pictures 7-8: Reverse fly.

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Picture 9 Picture 10

Pictures 9-10: Bent-over side lateral raises.

ROTATOR CUFF AND SCAPULAR STABELIZER EXERCISES

In addition to strengthening the major movement muscles of the shoulder, specific exercises that strengthen the rotator cuff and scapular stabilizer muscles can be done about three days a week, using resistance bands, and all year around as an injury preventative. To insure that every member of the team strengthens these important muscles, about 10-15 minutes per day of shoulder stabilizer exercises can be added to the team’s normal weight-training program.

WHERE AND WHEN TO MAINTAIN THE SHOULDER

Depending on an athlete’s training cycle, shoulder maintenance can be done within a strength session, while resting or waiting a turn in practice at the side of the pool, or as a detailed workout that specifically focuses on an athlete’s rotator cuff and scapular stabilizers. These workouts can also be designed for off days, travel days, alternate days (not performing strength training), or active rest days as a means of recovery.

As a coach, you will not be happy when one of the players on your team comes up with a shoulder injury that prevents him from playing, or limits his shooting power and ability. These kinds of injuries are common among water polo players; but can be prevented with proper strengthening of the stabilizer muscles. Do not wait for an injury to occur before you start a rotator cuff strengthening program for your team. The most important concept is to prevent and maintain this unique joint, before the problem becomes an issue that cannot be resolved.

WHAT EQUIPMENT SHOULD I USE?

Strengthening exercise can be performed with light-weights (dumbbells) or stretch-resistance cords that provide resistance when stretched. Unlike heavy weights, stretch-resistance cords are easy to transport and can be used anywhere. Players can take stretch cords with them and perform many of the exercises at home. Resistance cords come in a variety of thicknesses to provide different levels of resistance, and are usually color-coded. Resistance bands are attached to a door-knob, or other immovable object, or the athlete can stand on the cord to anchor it down. When using resistance bands, increasing the distance you stand away from where the cord is attached increases the resistance.

ENDURANCE WORK- LOW REISTANCE, HIGH REPETITION 

Although the majority of movements in the weight room and athletic realm involve short bursts of medium to high intensity, endurance is also required to both resist the onset of fatigue and aid in the recovery between bouts. Doing high-rep, low-resistance exercises with a stretch-resistance cord is the best way to gain endurance in the muscles. Shoulder instability often occurs when these rotator cuff and scapular muscles become fatigued. The high-volume work associated with endurance is also the best method for improving tendon and ligament strength. The goal of this program is to prepare water polo players for the nature of intense activity, and these high-speed exercises are more sports specific than normal resistance training using weights.

Sets of 25-30 repetitions for each exercise is a good place to start to develop both the strength and endurance aspects of the shoulder muscles. The athlete should start feeling fatigue in the muscles as he approaches the last several repetitions. If 25-30 repetitions is too easy, then the athlete should get a heavier resistance cord, increase the resistance by holding the cord closer to where it is attached, or stand further away from the attachment. If he can only do 10 repetitions before fatigue sets in, then he should obtain a lighter resistance cord.

After several months of performing sets of 25-30 repetitions for each exercise, obtain a band with enough resistance so that the athlete can only perform 10-15 repetitions before tiring. Start the exercise by pulling the hand slowly to the final position, hold that position for several seconds, and then slowly return the hand to the starting position. Perform 10-12 repetitions of each exercise in this manner.

These high repetition sets are also recommended for the larger scapular stabilizers to help delay the onset of fatigue during activity. Therefore, the traditional strength exercises previously mentioned for the scapular stabilizers, such as rows, shrugs, reverse flys and bent over lateral raises, may be also be performed doing high repetition repeats with stretch cords on alternate days. Heavier resistance with weights on one day can be followed by high rep exercises with stretch cords or dumbbells on the next day.

ROTATOR CUFF EXERCISES USING STRETCH CORDS                                           

The most common rotator cuff exercises with stretch cords are internal and external rotation of both arms, arm abduction (moving arm away from mid-line of body), and the internal rotation and horizontal adduction (moving arm toward midline of body) of the arms. Variety is important to insure that all of the rotator cuff muscles are used; so choose one exercise in each category and perform those for several sessions, before switching to another exercise for the next few sessions. Following are common rotator cuff exercises:

INTERNAL/EXTERNAL ROTATION EXERCISES                                        

1. Internal/External Rotation-Elbow at side:                                                                          

Attach band to a door-knob. Stand sideways to the door. Grab the band with one hand with your elbow pinned to your side. Internal rotation consists of pulling the band towards your body, and external rotation consists of pulling the band away from your body. Remember to keep the elbow tucked into the side during the entire range of motion (See pictures 11-14 on next page)

2. 90-degree Internal/External Rotation:                                                                                     

 For external rotation, attach band in front of you at between waist and chest level. Grab the band with one hand, and raise your arm in the air forming a 90-dregree angle. Internal rotation consists of pulling the band down towards the ground (attach band behind you at shoulder level). (See pictures 15-18 below)

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Pictures 11 & 12: External Rotation
(elbow tucked)
Pictures 13 & 14: Internal Rotation

15 16 17 18
Pictures 15-16: External
Rotation-pull up
Pictures 17-18: Internal
Rotation-pull down

HORIZONTAL ADDUCTION/ ARM ROTATION EXERCISES

3. Crossovers:

Attach the band to something that is a few inches off the ground and directly in front of you. Using your left arm first, start with the band near your right hip. Keeping your arm straight for the whole movement, pull the band across your body until your arm is completely extended above your head on your left side. After completing the prescribed number of repetitions, start the band near your left hip and pull the band across your body until your arm is completely extended on the right side of your head. After completing repetitions with your left arm, perform the same two exercises with your right arm. (See pictures 19-22 below).

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Pictures 19-20: Crossover -
Right to left
Pictures 21-22: Crossover -
Left to Right

4. Lateral Raise with Internal Rotation using stretch cord or dumbbell (pouring can of coke):

Stand on cord. With arm at side and thumb pointed toward ground (shoulders internally rotated), slowly raise arm to the sides but slightly toward the front (at about a 30 degree angle to the front of the body) until above shoulder level. See Pictures 23-24 below)

While performing the "empty coke can" exercise, if the athlete experiences any pain in the shoulder area, then the exercise should be discontinued. An alternate exercise is to use a lighter dumbbell, or smaller resistance tubing. If pain still persists, then try holding the thumb in a "pointing up" position rather than pointing down. This can be called the "full coke can" position.

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Pictures 23-24: Pouring can of coke

5. Abduction- Standing Arm Abduction:

Grab elastic tubing with both hands about shoulder width apart. Arms are straight. Begin with the arms at various heights (below waist, above waist, shoulder height,)  Pull both hands away from his or her midline. Hold for a count of 5 seconds. (See pictures 25-30 below and below).  

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Pictures 25-27: Standing Arm Abduction -
Below waist and above waist

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Pictures 28-29: Standing Arm Abduction -
Shoulder height

SCAPULA (SHOULDER BLADE) STABILIZING EXERCISES

As described above using weights, the athlete can perform the same exercises; such as rowing exercises and bent-over side-lateral raises using stretch bands, and shoulder shrugs using dumbbells. 

6. Shoulder Roll with dumbbells: (See pictures 31-34 below)

Stand, arms at side. Move shoulders forward, shrug shoulders up, and move shoulders backward - squeezing shoulder blades together, pull shoulders downward. Repeat 5 times.

Repeat shoulder roll 5 times in opposite direction - shoulders backward, shoulders up, shoulders forward, in one slow continuous circular motion.

As strength increases, add weight and extra sets. Rest 30-seconds between sets.

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Pictures 30-33: Forward shoulder roll

7. Shoulder Blade Squeeze:

Stand or sit, elbows at side,
Bend elbows at 90-degree angle,
Pull elbows back, squeezing shoulder blades together,
Hold for 10 seconds
Repeat 3 times.

8. Wall push-ups:

Stand about 18 inches away from wall.
Place hands on wall at shoulder level with arms straight.
Slowly lower yourself toward wall and return to starting position.
To make this exercise more difficult use progressively lower surfaces - counter top, coffee table, etc. (See Pictures 35-37 below)

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Pictures 34-36: Wall push-ups

9. Scapular Push-ups:

This exercise targets the serratus anterior muscle, a primary scapular stabilizer. Get in a prone pushup position with your body weight on your toes and forearms (instead of the hands). Holding your body in a straight line, lower your chest while maintaining the shoulder position and allowing your shoulder blades to pinch together. By rolling your shoulders, push your upper body upward. (See Pictures 38-39 below)

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Pictures 37-39: Scapular push-up

SPECIFIC ARM EXERCISES TO HELP STABILIZE THE THROWING MOTION

Many of the above exercises to strengthen the rotator cuff and scapular stabilizers, also help to stabilize the shoulder joint during overhead throwing and shooting motions. These muscles are required to stabilize the joint as the player brings the arm back and up in preparation for the shot, as he brings the arm forward at high speed, and finally to slow down or stop the motion of the arm at the end of the follow thru.

See next months article on “ANALYSIS OF THROWING A WATER POLO BALL AND EXERCISES TO STRENGTHEN THE MUSCLES INVOLVED” for additional exercises for strengthening the shooting muscles and the shoulder stabilizing muscles.

PREVENTION IS GREAT: BUT WHAT IF I ALREADY HAVE AN INJURY?

If you have or suspect a rotator cuff type of shoulder injury, you should not try to diagnose it yourself. You can, however, try to reduce the inflammation and pain by using ice, medication like ibuprofin, and rest. Rest may include not performing any exercise at all, or just not performing the exercise that is painful when you do it. Unfortunately, this may mean taking some downtime from the pool as well. It makes little sense to continue with the same activity that brought the condition on in the first place,

 If your shoulder only hurts when you are shooting the ball, then do not take shots for a few days. This is a great time to work on shooting and passing with your non-dominant arm and improving the legs with extra training. It is better to take a few days off and rest the shoulder, then continue playing and further aggravate the injury; or cause further injury that might require surgery to repair.  If the pain persists after a few days of ice, medication and rest, then it will be necessary to consult a trainer (if your school has one), or a doctor or physical therapist; if you have not already done so.

The amount of time to rest an injured shoulder before starting rehabilitative exercises depends upon how quickly one heals, and the type and severity of the injury.

Rotator cuff injuries can be very persistent and easily aggravated if you do the wrong kind of exercise or too much. Strengthening exercises done too soon may cause further damage. If you are suffering an existing injury to your rotator cuff that is not so major as to require surgery, then a doctor or physical therapist may recommend some specific rotator cuff exercises and range of motion exercises to help speed up the recovery, and strengthen the injured joint. Three out of four rotator cuff injuries can be cured with simple exercises. Do not attempt to perform these exercises without consulting a doctor first, as you may do more damage than you already have.

The water polo athlete should never try to diagnose or treat any injury in the shoulder area by himself/herself. A trainer should be consulted (if your school has one) immediately when pain, or any of the above symptoms are noticed. If conservative treatment of ice, medication and rest does not solve the problem, then a doctor should be consulted.

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