Today, I got into a discussion with a new client who has a history of severe shoulder problems. A former competitive Junior B hockey player who has dislocated both shoulders more times than he can count, resulting in a complete inability to properly get his arms overhead without compensation and moderate to severe pain with any pressing movements. I figured this would be a perfect time to write a blog in respect to treating the cause of his problem instead of the symptoms of his injury (this will be elaborated in my upcoming blog post, Assessing and Fixing Asymmetries Part 2).
Let’s start at the beginning. In order to truly treat the cause of injury instead of simply treating the symptoms, you need to assess. At first glance, it’s not hard to see that this client sits into severe scapular depression (downward sloped shoulders, indicated by the red lines), caused by his scapula sitting too low on the rib cage.
The fact that his scapula are sitting too low is a result of overactive lats, and underactive/lengthened upper traps. Because he isn’t sitting in a neutral posture, step #1 of his rehab is going to involve getting him back to a neutral posture (indicated by the yellow lines). Furthermore, it’s not enough to simply analyze the resting posture visually. Upon palpation, it was easy to feel that this client is also present with slight scapular winging and lack of lower traps/serratus anterior strength, which will also affect his ability to get overhead properly.
Take Home Point from Screen #1: Promote scapular elevation, shut off the lats, promote scapular posterior tilt.
Sure, we can start by giving him some functional upper trap activation work, work on lengthening his lats, and promoting lower traps activation, but that is treating only ONE of the causes of his discomfort. In order to truly get this client functioning optimally, we need to assess with various movements in all 3 planes of motion.
When we put this client into a supine position and assess his shoulder asymmetry in the frontal plane, it can easily be seen that his right shoulder is elevated much higher off of the ground then his left shoulder (this can be seen by the height discrepancy, as well as the amount of shadow under each shoulder).
This is a common sign of pectoralis minor and coracobrachialis contracture, which is pulling his right shoulder into adduction, internal rotation, and protraction. Because both the lats and coracobrachialis promote internal rotation of the humerus, there is some hand-in-hand connection with Take Home Point #1 that we previously discussed. Hammering out these overactive muscles is imperative to getting his scapula sitting in the proper position. If we would have stopped at screen #1 taken in the sagittal plane, chances are he would be at a stand-still because stretching out his lats would only get him so far if these other structures still remained short and stiff. We must look at the entire picture.
Take Home Point from Screen #2: Correct pec minor/coracobrachialis shortness to promote optimal alignment.
Now that we have assessed the resting posture pictures, it’s time to assess some of the problematic movements. With a standing shoulder flexion test, it’s not only visible that this client lacks full shoulder flexion ROM, but he also lacks full scapular upward rotation in both shoulders (he is literally unable to touch the palms of his hands together even when asked on an abduction test).
The black lines represent the spine and where his scapula sit at the end of shoulder flexion, whereas the red lines represent where his scapula should be sitting at the end of the movement. He is missing a solid 15-20 degrees of upward rotation in both scapula. Not only will this impede his normal scapulothoracic rhythm, but without the optimal upward rotation it will result in impingement like symptoms, lumbar compensation patterns, and ultimately pain. The lack of full shoulder flexion, as witnessed by his inability to get his hands fully overhead without compensation (lumbar hyperextension and elbow flexion), also ties into the overactive lats issue presented earlier, and will play into his inability to achieve sufficient thoracic extension.
Take Home Point #3: Correct lat tightness, promote thoracic extension.
Now, let’s look at the three key take home points for this client:
- Promote scapular elevation, shut off the lats, promote scapular posterior tilt.
- Correct pec minor/coracobrachialis shortness to promote optimal alignment.
- Correct lat tightness, promote thoracic extension.
As we can see, while some of the major findings correlate with one another, there is a myriad of issues that must be addressed from years of compensation and patterns going uncorrected. First, the lack of scapular upward rotation needed for pain free movement is predominantly caused from tight/overactive lats pulling down on the shoulder girdle. The tight/overactive pec minor and coracobrachialis are pulling him into adduction and internal rotation (meaning he is already ‘behind the start line’ and not starting from a neutral position). The thoracic extension and scapular posterior tilt go hand-in-hand, and are predominantly controlled by the lower traps. However, if the lats/pec minor/coracobrachialis are all tight and pulling the shoulder in different directions, how do you expect to strengthen the lower traps, serratus anterior and upper back mobility if the muscular tightness goes unaddressed? He is already at a significant disadvantage. Simply treating the symptoms without correcting the muscular imbalances in the first place will do nothing but pull this client further into distortion.
Plan of Action:
In order to truly assist this client, there isn’t one single magic exercise we can give him. Soft tissue work must be done faithfully in order to eliminate any muscular tightness contributing to his problems. Shutting off overactive muscles and turning on the right muscles is imperative. Get him back into a neutral alignment with proper activation and mobility drills. Focus on individualized exercises that will improve his performance and shoulder health. Simply massaging, foam rolling, applying ice/heat, or placing acupuncture to the area without re-activating and promoting the proper structures afterwards is simply treating the symptoms and not the cause. Be proactive, make mobility and prehab a habit.
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