Archive for the ‘Shoulder’ Category

Just like a house, which requires a strong foundation to stay supported, so does the glenohumeral joint of the shoulder complex. Although a thorough anatomy review is beyond the scope of this blog, I feel a few key concepts need to be reviewed. The only thing connecting the shoulder complex to the rest of the body is the scapula via the acromioclavicular joint. Some argue that the scapulothoracic complex is a joint but I will argue that is it most definitely not! It’s just a bone (the scapula) sitting on top of the ribs…no joint there. Anyways…

Since the scapula is the only thing connecting the shoulder to the rest of the body, it only stands to reason that it is the foundation from which the shoulder can function optimally. Therefore, I see very little use in training the rotator cuff muscles without first addressing scapular stability AND mobility. Too many clinicians focus on just scapular strengthening exercises without addressing scapular mobility first when they have a client with shoulder pain. For example, if levator scapula is tight, what will it do? It will downwardly rotate the scapula placing it in a disadvantageous position for glenohumeral joint mobility. If pec minor is tight (and who’s isn’t?) what will it do? It will anteriorly tip the scapula lifting the inferior angle off the ribs creating issues for lower fibers of trapezius to aid in upward rotation. Therefore strengthening lower fibers of trap without FIRST addressing pec minor tightness is less than ideal. You will never be able to achieve strength goals until the scapula is sitting flat against the ribcage with the spine of the scapula at around 15 degrees of inclination.

Furthermore, thoracic spine position is critical to scapulohumeral rhythm. An article was just published in the latest JOSPT (December addition) that dealt with the beneficial affects of thoracic spine manipulation on rotator cuff tendinopathy/pain. It only stands to reason that if the upper back is moving better, the scapula can move better, therefore allowing the rotator cuff to act as a humeral head stabilizer instead of a prime mover…which it often has to do in the case of kyphotic postures. So, hypothetically if the thoracic spine is mobile and upright, the tendons of the rotator cuff can “relax” and thus decreasing the inflammatory response due to impingement or overuse.

The beautiful thing about this model is that is applies to so many “shoulder related’ conditions. Thoracic outlet syndrome (TOS) is a function of muscle imbalances and posture. Studies are showing that cervical radiulopathy is also a function of thoracic spine and scapular positioning. Even distal conditions like carpal tunnel syndrome and tennis elbow can be traced back to shoulder positioning (not all the time, but it’s always something a prudent clinician should check).

Conditions such as rotator cuff or long head of biceps tendonosis, upper limb nerve entrapments, and even labral tears can usually be traced back to scapular positioning. But what can we do about this? How do we train the scapula more optimally? Here is the key: STOP doing external rotation exercises for the rotator cuff to fix scapular positioning  I see it all the time and it drives me nuts.

Now I will outline a summery of what I feel needs to be done to addresses many shoulder- related issues:

We all know that we should balance our pushes and pulls, especially with regards to our bench pressing and rowing, right? But what if it’s not so simple a relationship?

In essence, what we’re looking at here is balancing our ability to protract and retract the scapulae. Bench pressing is a horizontal pushing movement that you’d think normally produces protraction (forward movement of the scapula around the ribcage) and trains the muscle that cause protraction, a.k.a. the serratus anterior. The logical opposing movement would be a row of some sort. Balanced, right? Wrong.

Question: What’s the most effective scapular position to maximize bench press performance?

Answer: Retraction and depression

Question: What scapular position is achieved in the contracted phase of a rowing movement?

Answer: Retraction and depression

Balanced? Nope.

Get it? What looks good on the outside, feeds an imbalance on the inside. Serratus anterior becomes ineffective as a protractor, stabilizer, and upward rotator. Then there’s an added bonus. But first a quick anatomy lesson.

Next time you’re cutting on a cadaver (What? Doesn’t everyone?), check out the serratus anterior and the rhomboid. What you’ll find is that because of the fascia that covers everything in the body, they’re essentially the same muscle with the scapula kinda stuck in the middle.

So if the serratus anterior isn’t fully effective at producing an upward rotation force and the rhomboid (a downward rotator) is getting trained with both pushes and pulls, then guess who wins the tug-o-war with the scapula.

Correct! The rhomboids and downward rotation. This means you’re more likely to experience shoulder impingement. (thank you Mike Roberson for that great example!)

It becomes clear that one of the best ways to train the shoulder is…the PUSH-UP!!! This classic exercise is fantastic at activating and strengthening the serratus anterior as an upward rotator of the scapula. It also acts to counteract  the forces of pec minor by flattening the scapula against the rib cage (fighting that anterior tilt a tight pec minor exerts on the scapula).


Lear and Gross determined that push-ups performed with the feet on an elevated surface significantly increased the activation of the serratus anterior compared to traditional push-up variations. If it’s been a while since you performed traditional push-ups, it would be a good idea to start with basic variations, but elevating the feet is a viable progression if your primary goal is improved serratus function.
(J Orthop Sports Phys Ther. 1998 Sep;28(3):146-57.)

Another clutch exercise for optimal shoulder health is the Face-Pull. This exercise works to strengthen the scapular retractors…but the beauty of this exercise is that is does so with the scapula pre-set in an upwardly rotated position.  We must be careful here..too much posterior deltoid activity is no good…we want pure scapular retraction occurring with minimal humeral head elevation.


Another not so popular exercise that is often forgotten for shoulder health in the Standing Straight-arm pulldown. I love this exercise because it is dead easy to preform and coaching for it is a breeze. Very little that can go wrong here. This exercise is fantastic because it teaches the latissmus dorsi muscle to work to depress the humeral head in the glenoid without activating the deltoid. This will prevent excessive humeral head elevation with overhead reaching…a common source of pain in shoulder pathology patients.


Besides exercise, I will ALWAYS employ manual therapy to help with scapular positioning. Here is what I do:

Pec Minor soft tissue release (I would say ART but I’m not allowed…it’s like $2500 for a weekend ART course…are they serious?!?!) I digress… I pin the muscle just at its origin on the coricoid processes and passively or actively flex the arm in the plain of the scapula to release this muscle. I then do manual stretching to aid in loosening it up.

Levator scapula/Upper trap stretching and soft tissue release

Passive side lying scapular mobs into elevation, depression, upward and downward rotation


Thoracic spine manipulation to aid in upper back mobility

(Not exactly how I do it, but you get the idea…you want more of a superior directed force as opposed to a straight anterior to posterior force)

So how do you make a rotator cuff happy?

1) Address upper back posture.

2) Maintain optimal balance of the muscles around the scapulae and the shoulder joint.

3) Then addresses rotator cuff muscle strength AND endurance (which is an entire post in itself!)

Happy new year!!

A face I’ve seen a lot lately

I personally have a love hate relationship with the shoulder joint. It’s a mysterious area with much interconnection with the rest of the body, yet there are multiple local factors that can make a good shoulder bad. Obviously there are the 4 muscles of the rotator cuff (supraspinatus, infraspinatus, teres minor, and subscapularus), the deltoid, teres major, trapezius….and then all the other muscles that attach from the ribs and neck to the shoulder blade….all of which can be pain generating sources.

Above all else though, at least over the past few months for me…has been the glenohumeral joint (GHJ) capsule. The GHJ capsule overlaps the joint providing an extra measure of stability to an otherwise very mobile joint. A tight capsule is one difficult entity to treat. Before I go on explaining why the joint capsule can suck to treat, let’s go through a basic arthrokinematic example talking about a tight capsule:

A tight anterior capsule will drive the humeral head POSTERIOR too soon with external rotation

A tight posterior capsule will drive the humeral head ANTERIOR too soon with internal rotation

A tight inferior capsule will drive the humeral head SUPERIOR too soon with abduction

A tight superior capsule will drive the humeral head SUPERIOR too soon with abduction (this one goes against the joint arthokinematics we learned in school)

I have had a recent influx of clients with chronic capsule tightness that borderlines on being diagnosed as frozen shoulder…but isn’t because they can still actively raise the arm up over 40-50 degrees in the scapular plane. A tight and fibrosed capsule is hard to treat because as a manual therapist, if can’t move their shoulder without pain, I can’t do a heck of a lot. One client I saw 2 weeks ago was so sore (for 8 months!!) that I couldn’t do PROM into ER or IR without a huge bout of rebound pain into the superior and anterior shoulder joint. In her case, both the anterior and posterior capsule was tight leading into multidirectional glenohumeral joint restriction. After clearing the cervical spine, I did tons of soft tissue work to the posterior capsule, quadrilateral space, pecs, lats, and traps…this helped with pain but unfortunately didn’t drastically change her AROM…she is possibly in the freezing stage of adhesive capsulitis.

Above all else, I feel one of the hardest parts of treating the shoulder has nothing to do with me at all. It has all to do with the patient. I often get fantastic results using manual therapy for some spinal conditions. However, the shoulder requires a lot of active care…meaning the patient can’t be lazy. Corrective and rehabilitative exercise is a MUST for the vast majority of shoulder problems. For athletes, this is great. But for a mother of 3 who works full time and barley has enough time in the day to eat, doing the required home exercise program is…well…hard. This is what they don’t tell you in school…they show you great exercises that get shoulders better…but they don’t tell you how hard it is to get clients to adhere to a graded home exercises program. Sometimes even giving 1 or 2 exercises is all I can do because giving all that is required to create needed mobility and strength in the shoulder is just too much.

So what’s the best way I have found to convince clients to do their exercises? You need to PROVE to them how important they are. Here is how I go about doing that:

1) Many clients with painful shoulders have a large kyphosis or sit in a hunched forward position (desk workers syndrome). This effectively closes off the subacromial space leading to impingement. Have the patient assume their normal poor posture position and tell them to maximally flex their arm. They will have decreased ROM with sooner onset of pain. Then have the client sit erect with scapula back and down and repeat shoulder flexion. This will produce increased ROM and later onset of pain (which hopefully is diminished in the new position). This teaches the patient how important it is to have good posture and strong scapular retractors….this proves to the client how important the exercises are.

2) I also do assisted scapular upward rotation to help clear the acromion and humeral head during arm elevation. If this diminishes or abolishes the shoulder pain I always tell the client that we have to make the muscles that my hands acting as to keep your shoulder feeling this good. Again, I’m proving to them how great they could feel if they put in the work.

A 2009 article from JOSPT did a great job of summarizing the proposed biomechanical mechanisms of scapular kinematic deviations. They are:

1) Inadequate serratus activation: Lesser scapular upward rotation and posterior tilt

2) Excess upper trap activation: Greater clavicular elevation

3) Posterior GHJ soft tissue tightness: Greater scapular anterior tilt and humeral head anterior translation

 4) Thoracic kyphosis or flexed posture: Greater scapular IR and anterior tilt with less upward rotation

(JOSPT Feb 2009: The Association of Scapular Kinematics and Glenohumeral Joint Pathologies)

So what do I do for painful shoulders? Here are some of the usual steps I take for most shoulders problems:

1) Address Thoracic kyphosis: Retraction and extension exercises, thoracic spine manipulation, soft tissue release, posture arch, spikey ball, posture education

 

2) Address scapular stabilizers: Strengthen serratus anterior (wall slides, push up plus, hugs, punches etc), lower traps (Y’s, Overhead pull aparts, chair dips), and rhomboids (rows and active scap squeezing)

 

3) Address soft tissue tightness (BIG ONE!!): Release levator scapula, scalenes, SCM, upper traps, QL space, subscap, pec minor, pec major, lats

 

4) Rotator cuff strengthening: Side lying ER, Isometric ER/IR, scapular plain abduction progressing to ER at various degrees of shoulder abduction, “W” squeezes ( a favourite of mine)

5) Capsular stretching: Door way ER stretch, horizontal adduction and sleeper stretch with PNF contractions being my favourites

Overall, the shoulder is a tough joint to treat because no one exercise or technique works for everyone. It’s a constant trial and error processes that is made easier by a good assessment that takes into account posture, the cervical spine, contractile and non-contractile tissue along with more distal and inter-systemic issues manifesting as shoulder problems. The one thing we as therapists need to remember is that non-acute shoulder dysfunction doesn’t happen overnight…it takes months of misuse before problems arise. Therefore, we shouldn’t expect shoulder problems to disappear instantly. It takes time, focus, and a considered effort on the clients part to get a shoulder healthy.

Do you have any tips for treating painful shoulders? What kinds of techniques do you use?

Have a great day!