The Fultz Fix: Why a shooting coach is not the answer to Markelle's problems

When I first heard about the Fultz story in 2018, I was captivated. The headline played back in my head like a summary of my life, and I couldn’t look away.

When I looked at Fultz’ shot, I had this visceral feeling that we had the same injury. I continued to watch, and saw an eerily familiar timeline, starting with a sudden onset of shoulder weakness and inability to elevate the arm, followed by shoulder pain with activity, a physician’s vague diagnosis of scapular dyskinesis, and a lack of progress with months of intervention.
What struck me the most, was the assertion by many that he must be having a case of the “yips,” and that nothing was physically wrong with Fultz. I could relate, as this was what I heard circulating in the background when I had my injury. But I knew that Fultz’ struggles were physical, and luckily Dr. Julius Irving was on the same page.

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What did I see?

I immediately took to watching countless video clips, of the Fultz of old and the Fultz of new.

What I first noticed was that his shoulder blade was lacking the ability to move into its full range, and he seemed to be compensating for this inability by hitching his body backward into an extended position. The visual evidence, coupled with the lack of improvement, and Fultz’ recounting that he was “literally unable to life [his] arm,” when the injury first occurred led me to the conclusion that the muscles in his shoulder blade must not be performing their job properly.

How could this be? A shoulder blade so weak on an NBA first round pick? It doesn’t seem to make any sense. What could have made his shoulder so weak?

Could it be an acute injury to a shoulder muscle or tendon, producing a pain response that inhibited muscle activity? Perhaps, but the timeline reflected that he did not receive a shoulder injection until much later, and after his injection, he still failed to improve his scapular movement.

After the shoulder was determined to be clean on imaging, he went out and continued to struggle.

At this point, I was convinced. I took to the interweb (something I have rarely done in the past), and opened a blog page and a twitter account for the sole purpose of discussing the Fultz situation. I knew what was going on, I knew he wasn’t getting the help he needed, and I knew how to fix it.

My initial Fultz post, complete with markup.

After all, after years of dysfunction, I went from not being able to lift my arm above my shoulder, to lifting it with minimal compensation within a 6-8 week timeframe. I realized that the movement compensation I had adopted to allow myself to function at a high level had severely impacted the function of almost every segment in my body, and I developed a program aimed at specifically targeting compensatory movement at each segment, and retraining it. The progress I made in a year was like Ferris Bueller turning back the odometer on my life about 8 years.

I pushed my take on the story for about a week, without much response. Then Patrick Kelly of the Phifth Quarter Podcast reached out to me to have me on the show to discuss what I thought was going on. We talked for a few minutes, ending our conversation with a question about what Fultz’ timeline for recovery would be. My assertion was that he could take 1-2 years to get back to his prior level, to which Kelly and crew were in disbelief.

Go check these guys out! Link above.

However, I have changed my mind about what is happening with Fultz. Let me explain.

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The timeline of my first theory reads like this:

1. Nerve injury to scapular muscles →

2. Decreased function of scapula and shoulder →

3. Shoulder pain →

4. Compensatory movement strategy of the ribcage and back into extension
   

However, there’s an alternative view we could take that is equally plausible. We could easily replace this timeline with this one:

1. Decreased neural drive of scapular muscles (due to some underlying movement strategy)→

2. Decreased function of scapula and shoulder →

3. Shoulder pain →

4. Compensatory movement strategy of the ribcage and back into extension

Or we could replace it with a timeline that reads like this:

1. Baseline movement strategy of the ribcage and back into extension →

2. Altered position of the interface of the ribcage and scapular →

3. Decreased neural drive of scapular muscles →  

4. Decreased function of the scapula and shoulder

My initial reaction was so strong, that I was convinced given Fultz’ early report and the lack of progress, that it was the first theory that was correct, rather than any of the alternates. And while I may have been correct, there’s hardly any way to know. As an insult may have occurred to the nerve initially, which could have kicked off a chain of compensatory events, and by now the nerve itself could be long healed, but Fultz’ still left to deal with the compensatory movement strategies, thus limiting his performance moving forward. Or not.

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What does this all mean?

Regardless of the fact that I have to walk back the veracity of my initial reaction of what could be going on with Fultz, the observations that I made in my initial post are still all problems that need to be addressed.

Here’s a summary of the key observations:

1. Inability to fully upwardly rotate shoulder blade during shooting

2. Tendency toward excessive shoulder medial rotation during shooting

3. Tendency toward excessive back and ribcage extension (generally) and during shooting

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Why are these findings problematic?

Let’s start from the bottom and work our way up.

As someone who works a lot with clients and patients that are athletes and performers, I can tell you that all these individuals have one thing in common. They are very good at extending their bodies, and they love to do it. Whether it’s the basketball player or ballerina, these folks spend most of their life in an extended position. Given the underlying neural underpinning of human beings, this is a problem.

In the past 15-20 years, there has been a wealth of information regarding movement pattern dysfunction, rehabilitation, and training. Whether you look at Shirley Sahrmann’s Movement System Impairment Model, Gray Cook’s Selective Functional Movement Assessment, or Ron Hruska’s Postural Restoration Institute approach, you will find that these leaders in the fields of movement, rehab, and training, all identify a common trend, that would read something like this:

“the most common movement pattern dysfunctions occur when individuals become too extended on one or both sides of their body
”

— Greg

For more information on these systems, check out:

-Shirley Sahrmann: Diagnosis and Treatment of Movement Impairment Syndromes

-Gray Cook: Movement

-Ron Hruska: https://www.posturalrestoration.com

In the case of Fultz, his natural proclivity towards extension may have caused the scapular dyskinesis that has plagued his shot.

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To understand this, one must look at the relationships between the back, the ribcage, and the shoulder blade. To summarize the key points:

1. The back muscles change the position of the spine

2. The spine attaches to the ribcage, which therefore is also affected by action of the back muscles

3. The shoulder blade interfaces with the ribcage such that the underside of the shoulder blade is congruent with the surface of the ribcage

Note the natural curvature of the adjacent vertebrae, the attachment of the ribs to the vertebrae, and the congruency of the shoulder blade on the ribs:

Credit: Screenshot Essential Anatomy 5.0

However, when a person has an extension dominant pattern that goes unchecked, the position of the spine, and thus ribcage can become increasingly extended over time. This creates a ribcage that becomes oriented in such a way that disrupts the congruency of the shoulder blade, therefore resulting in inefficient movement of the shoulder blade and compensatory movement strategies.

-Over time, if the athlete does not learn how to inhibit the excessive action of the back muscles to correct the position of the rib-cage in order to restore the ability of the shoulder blade to interface in a way that is maximally congruous, the result is decreased neural input to the shoulder blade muscles.

-Once the shoulder blade muscles aren’t optimally functioning to promote proper movement with arm elevation, the athlete is then at an increased risk of suffering damage to the shoulder joint due to impingement of the shoulder on the shoulder blade.

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Why aren’t other players suffering a similar injury if they all have to perform the same sports-specific movements?

There are a couple of potential explanations here:

1. Fultz had a greater natural proclivity to extension throughout his early years, culminating in a straw that broke the camel’s back moment → these patterns are emphasized during the adolescent years (check PRI science)

2. Fultz was performing lifting techniques that emphasized extension or in a fashion that emphasized excessive extension (such as a deadlift with a hyperextended back, etc.)

3. Fultz has a shooting technique issue which further feeds his faulty pattern (this is less likely, more likely it is that other players that have a similar technique are better able to inhibit the firing of the extension-based muscles)

For example, check out Stephen Curry and Kevin Durant, when compared with Fultz.

1. Notice first the red lines, which I drew through each shoulder joint and across the pelvis at the level of the hip pointers (ASIS). Notice how Curry and Durant have nearly parallel lines between the shoulders and pelvis, and next notice how Fultz has a ribcage that is tilted up and to the left, characteristic of a unilateral extension pattern. (Check left AIC from PRI), or an explanation from Dr. Sarah Petrich.

2. Notice the blue arrow pointing to a prominent portion of Fultz’’ ribcage, which is being dissociated from his pelvis, indicating a lack of opposition of the left abdominal wall to the left back extensors/hip flexors.

Sources: Curry: Sports Illustrated, Fultz: Philly Voice, Durant: Mercury News

You might say, he was leaning to get out of the way of the hand of a defender, and maybe that is the case. But you’ll see that when Durant launches himself similarly, his left pelvis and ribcage do not dissociate and instead help maintain the balance necessary to execute a consistent shot.

To quote Curry,  "A lot of people focus on your hands with your jump shot but it starts with your feet being squared to the basket and having good balance." Fultz is certainly not the epitome of balance, especially when his shot looks ugly.

And if you are the type of person who needs more evidence than one picture, check this out:

Note the increased distance of the bottom left ribs from the line through his hip pointers, indicating dissociation of the rib-cage from the pelvis and excessive extension on the left.

So how do we fix this?

Before we can even start to fix Fultz’ shot, we need to acknowledge something. The movement strategies that are causing his performance to suffer are deeply ingrained at this point.

Whether he had a nerve injury to his shoulder, which led to compensatory movement strategies, or movement strategies that over time changed the position of his shoulder and predisposed it to injury, the solution is the same:

1. Restore rib-cage position by facilitating muscles that inhibit the activity of his back extensors and related extension-based muscle groups

2. Restore proper neural input and strength to the shoulder blade muscles that contribute to proper shoulder blade movement and performance

3. Integrate positional changes and corrected movement pattern function into progressive activities, without compensation to the preferred dysfunctional pattern

4. Lastly, resume sport-specific activities (practices, games, etc.)

This last point is key. Whether scenario A, B, or C created the dysfunction that has disrupted Fukltz’ performance, the fact is that he has been thrust back into practice and game scenarios where he continues to use the dysfunctional pattern that is at the root of his problems.

It will take time away from the game, with:

A) intentional prescription of corrective exercises, and

B) limitation of activities that perpetuate the pattern that has contributed to his dysfunction

The mistake that is easy to make when working with athletes, is that you should do everything you can to keep them playing, no matter what. After all, that is your job as a trainer, strength coach, physical therapist, or team physician. However, in situations where complete neural rewiring is the necessary solution, continuing to perform high-level tasks is most certainly a way to ensure that performance will continue to suffer. Trust me, I’ve done that and it doesn’t work.

Fultz doesn’t need a shot coach, a psychotherapist, or a shoulder injection. He simply needs to learn how to move.

If you enjoyed this post check out the video below, and leave me a comment.

Thanks for reading.

-Dr. Greg Chaplin, PT, DPT, CSCS