I think we can all agree that shoulder pain is frustrating. Personally, I use my arms constantly. Getting dressed, showering, feeding myself, driving, lifting weights, doing pushups, writing this article, and a lot more all depend on healthy shoulder function. If you are anything like me, you rely on your shoulders every day too. There are many possible causes of shoulder pain, but if you have been told you have scapular dyskinesis, scapular instability, or scapular dysfunction, which are essentially different labels for the same idea, I have something important to tell you. It is the truth, but you might not be ready for it. Are you sure? Really sure? Alright, you asked for it. There is no such thing as a dysfunctional scapula. I know that may come as a surprise, but hear me out for a moment. I believe the word dysfunctional has no place in conversations about how bodies move. It reinforces the idea that our bodies are fragile or broken, which can lead to hesitation, fear avoidance, and an increased risk of recurring injuries. How does that happen? Our good friend Dumbledore summed it up well: (his beard is filled with wisdom) Calling a scapula dysfunctional implies that there is a single correct or normal way for a shoulder to move. Anyone labeled as dysfunctional is then seen as abnormal, incorrect, or at risk of hurting themselves. Terms like dyskinesia, abnormal mechanics, and instability create similar problems. They are binary. You are either normal or abnormal, with no room in between. This kind of mental framing often leads to self-limiting beliefs. People given these diagnoses frequently avoid activity out of fear of making things worse, which ironically tends to make things worse over time. Just because your shoulder is not working the way you want does not mean something is wrong with it. It simply means there are a few things that need to be addressed. To understand this better, we need to look at the anatomy of the shoulder. There are three main structures involved: the ribcage, the scapula, and the humerus. The scapulothoracic joint exists between the ribcage and the scapula, while the glenohumeral joint connects the scapula and the humerus. The scapula contributes roughly 30 percent of total shoulder motion and functions as a floating joint with no direct bone-to-bone attachment to the rest of the body. The upper arm bone, or humerus, sits in a socket on the outer edge of the scapula. As the scapula moves, the socket moves with it, allowing the shoulder to orient itself in many different positions. This is what lets you place your hand in such a wide variety of positions. The shoulder has more range of motion than any other joint in the body. With greater available motion comes greater complexity and a higher demand for control. This is where the discussion of stability usually enters the picture. For this discussion, stability means the ability to resist unwanted motion or return to a desired position after being moved. This definition explains why common treatments for an “unstable” shoulder often include exercises like BOSU planks, reactive drills where a therapist applies unpredictable forces, or lifting weights attached to bands. The intent behind these exercises is good, but the application is often flawed. These drills are complex and involve many variables. For someone already dealing with shoulder issues, that level of complexity can be overwhelming and lead to inconsistent results. A more effective approach is to start by developing passive motion so the shoulder has access to the positions it needs. The next step is active motion within that newly available range. From there, the focus should shift to producing force in those positions and building strength and consistency in the desired movement patterns. Only if the issue persists after these steps should more advanced and variable exercises be introduced. For example, I would not have a client perform any type of unstable surface pushup until they can clearly demonstrate twenty clean and consistent strict pushups first. Highly variable and dynamic exercises may look impressive, but they belong at the top of the pyramid, not the bottom. The foundation has to be built properly before progressing upward. If you have been struggling to get your shoulders back to where you want them to be and feel like you have tried everything, I strongly encourage you to return to the basics and master them using this progression. If you cannot sort it out on your own, working with a skilled professional who understands this process can make all the difference. There is nothing wrong with your shoulder. It is simply having difficulty managing complexity right now.

The foremost principle that guides rehabilitation is the SAID Principle, or Specific Adaptations to Imposed Demands. Simply put, this principle of physiology tells us that the body adapts to the specific demands placed upon it. Perform enough aerobic exercise and your heart adapts by increasing the size of the muscles in the left ventricle. This allows more blood to be pumped with each contraction, lowering resting heart rate over time. Similar adaptations occur within the nervous and hormonal systems and often lead to decreases in resting blood pressure as well.¹ The tendons of sprinters become increasingly stiff as they train to run faster. This is a positive adaptation. Think about the last time you struggled to change the roll of bathroom tissue because the spring was stiff and kept snapping back quickly. A stiffer spring, much like a stiffer tendon, releases more energy when stretched and recoils, helping the sprinter move faster and more efficiently. When an injury occurs to a muscle, tendon, or another joint structure, it is usually because that tissue was exposed to a level of stress that exceeded its ability to adapt positively. When you trip and roll your ankle in the classic position shown below in Image 1, the ligaments and muscles on the outside of the ankle are injured because they were loaded too quickly and with too much force for what they were prepared to handle. Meanwhile, there are well documented examples of martial artists being able to break stone with their shins without injury because they have spent years gradually adapting their bodies to those compressive forces. [caption id="" align="aligncenter" width="652"] Image 1: Despite this being Klay Thompson of the Golden State Warriors, my left ankle was in this same exact situation about a year ago. Source: https://i2.wp.com/b-reddy.org/wp-content/uploads/2016/07/klay-thompson-right-ankle-sprain.jpg?ssl=1[/caption] How does this relate to a shoulder injury? If we want to restore shoulder function and allow the joint to tolerate increasing physical stress without negative adaptations like pain or injury, we need to apply the Goldilocks Principle of rehabilitation shown in Image 2. The stress must be just right. Too little will not create change, and too much will drive setbacks. The chart below is a helpful way to visualize this concept when restoring strength and range of motion following injury. Image 2:  Volume vs intensity threshold for gaining an adaptation. (Joel Jamieson’s “Ultimate MMA Conditioning”)  Resistance tubing, often referred to by the commercial name Theraband, is one of the most common tools people associate with physical therapy. Despite the title of this article, I am not against the use of resistance bands. For individuals in the early stages of shoulder rehabilitation, tubing can be extremely useful. It provides a low level of resistance that may be enough to rebuild initial strength or improve control of the arm through a safe range of motion. Bands can also help provide external feedback so you can better feel your shoulder moving into different positions, which can be valuable when restoring range of motion. However, if the goal is to build a shoulder that can produce and absorb meaningful force, bands alone are often not enough. At some point, greater resistance is needed to apply the appropriate combination of volume and intensity required for long term strength gains.   Sidelying Kettlebell Arm Bar Exercises like the kettlebell or dumbbell arm bar are an excellent entry point for retraining shoulder rotation with heavier loads. They also help retrain coordinated movement of the shoulder blade, allowing smoother and more controlled motion of the arm. Hooklying Dumbbell Pullover The hooklying dumbbell pullover is another effective way to improve overhead range of motion while building strength through a large arc of movement. This exercise is commonly used to help clients regain overhead motion without compensating through excessive lower back arching. It also builds confidence when holding weight overhead. Staggered Stance Landmine Press Landmine pressing is a highly effective way to load the muscles around the shoulder with progressively heavier resistance. This variation also allows easy modification to train coordination between ribcage rotation and shoulder movement, which is critical for many athletic and daily activities. If you are returning from a shoulder injury, it is important to understand the purpose behind each exercise you choose. Not all rehabilitation needs to look like bands and two pound weights. Your program should be challenging enough to prepare your shoulder for the real world demands you place on it. Make sure the time you invest in rehabilitation is producing the adaptations your shoulder actually needs. References Farrell C, Turgeon DR. Normal Versus Chronic Adaptations To Aerobic Exercise. [Updated 2021 Jul 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572066/

Are you Treating the Problem or The Result?  Shoulder problems are incredibly common among the athletes and active adults we see. As therapists, we regularly encounter diagnoses such as shoulder impingement, tendonitis, and rotator cuff injuries. These conditions are often blamed on weak rotator cuff muscles, scapular winging, or muscle imbalances. One major thing to understand about these diagnoses is that they are not the actual problem. They are the result. They are the result of deeper rooted movement habits and mechanics that often go unaddressed in traditional rehabilitation. Common solutions for these issues are often just as short sighted. Stretching, rotator cuff strengthening, and general strength training are frequently prescribed, yet they often miss the mark when it comes to truly resolving pain. Why? Because they address symptoms rather than the cause of the faulty mechanics, overuse of certain muscles, or positioning muscles in disadvantaged positions. To understand the biggest missing piece in resolving shoulder pain, we first need to understand how the shoulder actually works. A Quick Anatomy Lesson of the Shoulder Complex  The shoulder complex is made up of four major components: the glenohumeral joint, which is the ball and socket, the scapula or shoulder blade, the sternum and clavicle, and the rib cage. Shoulder movement in any direction requires rotation of the humeral head within the glenoid socket. Because the shoulder has so much freedom of movement, stability of the joint must be maintained. This is why every shoulder movement is accompanied by scapular movement. Since the socket of the shoulder joint is part of the scapula, its motion is essential for keeping the humeral head centered within the socket during movement. When the humeral head does not stay centered, issues such as shoulder impingement, proximal biceps tendonitis, and rotator cuff injuries can occur. For the shoulder to move well, the scapula must move in coordination with the humerus. The scapula has a natural curvature and sits on a rib cage that also has curvature due to normal thoracic spine shape. The rounded rib cage and curved scapula allow these structures to stay congruent and permit normal scapular rotation in support of shoulder movement. The position of the rib cage and its ability to expand properly to support the scapula is essential for normal shoulder motion without compensation. Rib Cage Position and Expansion  Under normal circumstances, the rib cage should be able to expand in all directions during breathing. With each inhale, the lower ribs should move outward in what is known as bucket handle motion, while the upper ribs and sternum move up and outward in a pump handle motion. The back side of the rib cage should demonstrate similar movement, particularly in the upper ribs. When the rib cage lacks these normal movements, scapular position and shoulder mobility are negatively affected. For example, when the back side of the upper rib cage becomes restricted or flattened due to chronic tension in the upper back, scapular movement becomes limited. A curved scapula resting on a flat surface cannot move or rotate the same way it would on a rounded, congruent rib cage. Without proper scapular movement, the shoulder either loses access to normal motion or must rely on compensatory mechanics. Repeatedly moving into ranges you do not truly have or compensating for restrictions is exactly what leads to repeated stress in the same tissues. This often shows up as shoulder impingement, biceps tendonitis, or gradual wear of the rotator cuff tendons. How Rib Cage Mechanics Are Lost Loss of normal rib cage mechanics is commonly seen in resistance training. Many gym movements emphasize pulling the shoulder blades back and down for stability. Whether pushing, pulling, squatting, or deadlifting, rib cage and scapular position often remain the same. A similar issue comes from the common advice to pull the shoulders back and down for good posture. Spending excessive time in a retracted scapular position limits normal scapular motion and flattens the upper rib cage. This forces the shoulder to compensate to achieve desired movements. The Solution To truly resolve shoulder pain, you must start at the source. While factors such as rotator cuff strength, dynamic stability, and local tissue irritation matter, they should not be addressed in isolation. If you do not resolve what led to these issues in the first place, you are simply treating symptoms. To improve shoulder joint mechanics and motion, proper scapular movement must be restored. Normal scapular movement depends on a rib cage that is positioned correctly and able to expand in all directions to provide a stable foundation. Once this foundation is in place, other components of shoulder rehabilitation can be addressed with much greater success. Below are 2 examples of drills to implement into your program to improve ribcage expansion: Seated Zercher Breathing Video [embed]https://www.youtube.com/watch?v=3CtDqIZnC_U[/embed] Seated Back Expansion Video  [embed]https://www.youtube.com/watch?v=24K6f7OMDXE[/embed]