Shoulder Injury

I can certainly resonate with the agenda of MOVE – as a Physiotherapist, I am a passionate student of movement. And working with Dr. John Randle, an orthopaedic surgeon whose entire elective practice is dedicated to the shoulder, I am totally fascinated by the shoulder joint’s complicated movement nature. The postural analysis, the range of motion, and the investigation of both the stabilization and the strength capacity of the shoulder require both a keen attention to detail and an ability to look at the big picture.

It doesn’t matter if you are rehabilitating a painful shoulder, an injured shoulder, a surgical shoulder, or training a healthy shoulder for sport. A healthy shoulder is foremost one with a postural foundation that is supportive, thus having the potential for optimal mobility, stability and strength. To borrow one of Dr. Randle’s favourite lines (and his stipulation for return to work and sport), a healthy shoulder is “unconsciously competent. This is shoulder function that is, easy, effortless, and trained to be anticipatory, efficient and effective.

Good posture. Simple right? Stop slouching and sit tall, pull your shoulders back, pinch your shoulder blades together, tuck your chin in, pull your belly in. This is all awesome, but couldn’t it be also more specific? The postural foundation should be specific in terms of alignment and function, by incorporating the individual’s unique starting point to apply the appropriate corrections.

When addressing the shoulder (and for simplicity, let’s assume the lumbar spine is fine) the starting point for analysis becomes the thoracic spine. Once overlooked, the thorax is now much more appreciated in terms of its role with the shoulder girdle.

First, consider the individual with a flexed, kyphotic thoracic posture.  Forward head position, rounded thoracic spine, abducted scapulae, and forward/internally rotated shoulder joints.  When trying to correct the posture, the kyphosis prevents the scapula and therefore the shoulder joint from attaining an optimal alignment.  With movement of the shoulder joint – especially elevation – the kyphosis prevents the normal upward rotation and posterior tipping of the scapula on the thorax creating a dysfunctional movement pattern of the shoulder with potential for future pain and pathology.

Kyphosis includes tightness of the pectorals, anterior deltoid, subscapularis and biceps, restriction of the posterior shoulder (capsule and myofascial components) and poor stabilization function of the scapular and rotator cuff muscles will present as a movement restriction in the very least.  Rotator cuff tendinopathy may result as the cuff is unable to stabilize the shoulder joint.  As long as this thoracic kyphosis isn’t fixed, it can respond well to traditional mobilization of the thoracic spine, improving the mobility and balance of the anterior chest/shoulder and posterior shoulder tissue, as well as improving the function o f the scapulothoracic and scapulohumeral muscles along with the rotator cuff.

Second, consider the opposite extreme of thoracic posture: an individual with a thoracic spine that is flat (or extended).  These individuals will try find optimal alignment with an “over correction” of their posture – jamming their scapula back into retraction (further extending the thoracic spine) and correcting their forward head posture by forcing cervical retraction – but still leaving the shoulder joint forward and/or internally rotated.

An exaggerated postural correction with flatness of the thoracic spine and forced scapular retraction:

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The humeral head is still forward, and the natural thoracic curve is flattened:

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With movement of the shoulder into elevation, the thoracic spine essentially hinges and extends over the lumbar spine, and the front ribs become elevated or “popped anteriorly”.  This anterior elongation makes it extremely difficult to keep the anterior core/abdominal muscles engaged, further preventing the thorax from remaining level. The scapula elevates and the shoulder joint remains forward in an attempt to keep vertical. With this pattern, it is also extremely difficult to engage the appropriate coupling of the scapular muscles, with the mid/lower trapezius and serratus anterior muscles losing effectiveness.

Shoulder elevation with a schematic representation of the anterior rib elevation and change in thoracic posture:

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Once loaded, the scapula then loses stabilization on the thorax (winging), further stressing the shoulder joint by reinforcing the forward humeral head in the socket.  Although for different reasons than the thoracic kyphosis, dysfunction and pathology will still result, even if the individuals are able to “muscle through” using this strategy.

The scapular winging on a flat thoracic spine is obvious in the high plank position here:

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The pectorals and anterior structures, the posterior shoulder complex, and the latissimus dorsi may need mobilization. However, in comparison to the kyphotic posture, the flat, extended thoracic spine requires significant retraining to find the normal alignment of the thoracic spine both statically and dynamically.

When working with patients or clients in the gym, look at the big picture – then get into the details! Investigate how the shoulder girdle is dynamically supported through the postural alignment on the thorax. By integrating the role of the thoracic spine with function of the shoulder, we can expect greater gains and move towards healthy, happy shoulders. How to address the posture, the mobility, the strength and stability? How to become unconsciously competent? Let’s continue with that conversation soon!

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