Athletic Shoulder - Ian Horsley: Not the Shoulder!
Apr 21, 2025
Episode 184: In this episode of the Athletic Shoulder Podcast, powered by Inform Performance and hosted by Ben Ashworth, we’re joined by Hon. Professor Ian Horsley, a renowned Chartered Physiotherapist and Athlete Health Lead at the UK Sports Institute. With over 25 years of experience in elite sport, Ian has worked with England Rugby, Rugby League, professional football clubs, and was part of Team GB’s HQ physiotherapy team at four Olympic and two Commonwealth Games.
Ian is internationally recognized for his expertise in shoulder dysfunction, upper limb rehabilitation, and dysfunctional breathing. He also serves as Clinical Director at Back in Action Rehabilitation and holds an honorary professorship at the University of Salford, where he contributes to the MSc in Sports Rehabilitation program.
Topics Discussed:
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The importance of respiratory health in movement and rehab
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Assessing thoracic shape and breathing patterns to support shoulder function
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How cranial nerves and eye movements influence pain and range of motion
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Using the brain’s activation to enhance rehabilitation exercises
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Case studies from elite sport showcasing holistic assessment techniques
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The 'not the shoulder' approach to shoulder treatment
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The role of proprioception in athlete performance and recovery
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Innovative methods like sensory input and non-threatening assessments
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Gaps in current functional and overhead testing for athletes
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The value of collaborative research in advancing shoulder rehab
Key Points
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Respiratory assessment in high-performance athletes should include a detailed evaluation of thoracic shape and breathing mechanics, focusing on achieving 360-degree thoracic expansion during respiration. A cylindrical thorax with balanced pump-handle and bucket-handle rib movements is ideal, but many athletes present with flat or even lordotic thoracic spines, leading to suboptimal scapular positioning and altered shoulder mechanics.
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Dysfunctional breathing patterns, particularly those that restrict posterior mediastinal expansion (the area between the shoulder blades), can significantly limit shoulder mobility. Encouraging athletes to direct airflow into the posterior thorax—such as through specific breathing drills in positions like child’s pose—can quickly improve external rotation range if thoracic flatness is the limiting factor rather than capsular or structural restrictions.
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The relationship between thoracic posture and shoulder function is critical. A reduced thoracic kyphosis (flat spine) forces the scapula into greater external rotation to maintain congruence with the chest wall, resulting in compensatory humeral internal rotation. This altered alignment can limit functional range of motion and lead to false positives during scapular assessment, such as apparent scapular winging.
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Simple breathing interventions can be powerful adjuncts to traditional rehabilitation, particularly for athletes with restricted thoracic mobility. For example, targeted breathing exercises that expand the posterior thorax can result in immediate improvements in shoulder external rotation and thoracic rotation, which are vital for overhead athletes and swimmers.
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Assessing the infrasternal angle provides valuable insights into an athlete’s breathing mechanics and core muscle recruitment. A normal infrasternal angle is approximately 90 degrees; angles greater than 100 degrees indicate a wide angle, while less than 80 degrees is considered narrow. A narrow angle often results from over-recruitment of external obliques, which can restrict diaphragmatic movement and impact both respiratory and pelvic floor function.
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The synchrony between the respiratory diaphragm and pelvic floor is essential for optimal core stability and efficient movement. During inhalation, both diaphragms should descend in unison, and during exhalation, they should ascend. Disruptions in this coordination, often linked to altered infrasternal angles, can influence pelvic position, lumbar mechanics, and hip function, thereby affecting overall athletic performance.
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Objective improvements in force output, not just range of motion, can be achieved through respiratory interventions. For instance, altering breathing mechanics to improve thoracic mobility in Paralympic athletes has led to measurable increases in rotatory force production, directly translating to enhanced performance in sports such as swimming and canoeing.
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Integrating respiratory assessment into physiotherapy practice for athletes involves both static and dynamic evaluations. This includes observing thoracic expansion patterns, measuring infrasternal angles, and correlating these findings with shoulder and trunk movement assessments. Such an approach helps identify non-obvious contributors to movement dysfunction that may be missed with conventional musculoskeletal assessments alone.
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Brain training and neuroplasticity are increasingly recognized as central to rehabilitation. Emphasizing the coaching of the brain, rather than just muscles or movements, can unlock new avenues for athlete development. Techniques that stimulate neuroplastic changes, such as specific sensory or cranial nerve exercises, can complement traditional physiotherapy to enhance motor control and recovery.
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A comprehensive physiotherapy assessment in professional sport should move beyond the “usual suspects” of shoulder dysfunction and include respiratory mechanics and brain-based interventions. By considering how breathing patterns, thoracic mobility, and neural factors interact, practitioners can develop more holistic and effective rehabilitation and performance enhancement strategies for elite athletes.
Where you can find Ian:
Sponsors
VALD Performance, makers of the Nordbord, Forceframe, ForeDecks and HumanTrak. VALD Performance systems are built with the high-performance practitioner in mind, translating traditionally lab-based technologies into engaging, quick, easy-to-use tools for daily testing, monitoring and training
Hytro: The world’s leading Blood Flow Restriction (BFR) wearable, designed to accelerate recovery and maximise athletic potential using Hytro BFR for Professional Sport.
