Blending Neurological and Biological Inputs
Neurological tightness in a tennis player’s shoulder joint.
Due to various nagging dings and injuries over the last 4 years, my client has not played tennis. We have spent the last several years treating and training everything from his lumbar spine, hips, knees, shoulders, elbows, adductors, pelvic floor dysfunction, and more.
As of late he feels he is ready to get back on the court and start playing tennis, so we circled back to his dominant arm and serving arm.
Upon his local Functional Range Assessment (FRA) of the shoulder joint, we found neurological tightness (NT) almost immediately in the zone of internal rotation (IR). And here is where our journey begins.
Given the mechanism of neurological tightness, our inputs need to be neurological in nature—active inputs. We use positional isometrics beginning at the point where we find the NT and joint coupling of the scapula, whereby the scapula elevates and protracts to compensate for the shoulder joint’s inability to IR.
Positional isometrics allow us to target the CNS, specifically the motor units and muscle fibers they innervate.
We began by testing the smaller motor units using low-level isometrics. We started here for two reasons: first, to prime the CNS, and second, to test whether or not the small MUs were the primary drivers of the NT. We got negative feedback when trying this strategy, meaning we did not improve our range of motion.
Our next strategy was to increase the effort to 70% or greater for about 8 to 10 seconds. This strategy gave a positive test (also called a positive PAILs test) and improved ROM into IR. We continued this strategy until the client experienced a stretch in the joint capsule, and I no longer felt the joint coupling effect.
Once this finding is evident, meaning the client is experiencing a stretch of the shoulder joint capsule, the strategy immediately switches to one that is biological in nature. We targeted the connective tissue architecture (CTA) of the shoulder joint capsule. We held a stretch for 3+ minutes to apply a stimulating input into that specific architecture. Bear in mind that this is an area of tissue that my client has not had access to in some time, so this was fairly uncomfortable and fatiguing.
Following this architectural input, we then went right into passive range holds. Having the client use the internal rotators of the shoulder joint to hold and control this newly found joint and capsular space. These holds were roughly 20 to 30 seconds.
We tried applying more load externally to the regressive tissue and internal rotators with my manual pressure, but he could only produce enough strength to maintain the hold, as it was too much too soon. So we kept training that input to train the muscles responsible for IR.
Before moving into his joint workspace work doing controlled articular rotations (CARs), the total time in this treatment mode was roughly 15-18 minutes. This really emphasizes to the CNS what we want. In other words, from the time we did our first set of low-level isometrics to the time his holds were done, I did not take him out of IR for a rest, we spent 15-18 minutes under tension and work.
Lastly, we did one set of level 2 CARs, where I acted as the block and controlled the movement, specifically hammering home the rotation from the shoulder joint into all that new “stuff” we just created.
His training until the next session is as follows:
[In the Sleeper Position]
Higher intensity PAILs 70%+ > increase ROM
Repeat until stretch is achieved
Stretch for 3 minutes
Passive Range Hold 1-2 sets x 20sec
Level 2 CARs 1x2 in each direction
Frequency 1-3x per week