Physical Therapy

I think we can all agree that shoulder pain sucks. Personally, I use my arms all of the time. To put on clothes, shower, feed myself, drive, lift weights, do pushups, write this article, and a whole lot more. If you’re anything like me, you do too. There are a lot of possible causes of shoulder pain, but if you’re in a group of people diagnosed with scapular dyskinesis, scapular instability, or scapular dysfunction, which are essentially the same thing, I have something to tell you. It’s the truth, but I don’t know if you’re ready for it. Are you sure? Really really sure? Alright, you asked for it... There is no such thing as a dysfunctional scapula 😱 I know, you must be shook, but allow me to climb onto my soap box for a minute. I believe that the word “dysfunctional” has no place in a discussion about how bodies move. It reinforces unhelpful narratives around our bodies being fragile or broken, which can lead to hesitation, fear avoidance, and increased risk of repeat injuries. How? Our good friend Dumbledore said it best: (his beard is filled with wisdom) Using the word dysfunctional implies that there is a functional, normal, and/or correct way for a shoulder to move. Those who are dysfunctional are therefore abnormal, incorrect, and at risk for harming themselves. The terms dyskinesia, abnormal mechanics, and instability have similar issues. They’re binary. You’re either normal or abnormal with no room in the middle. It’s unintentional mental framing that leads to a self-limiting belief. People with these diagnoses commonly avoid activities out of a fear of making things worse, which in the end actually makes things worse! Just because your shoulder doesn’t work as well as you want doesn’t mean there’s something wrong with it. You just need to figure a few things out. The anatomy is important here. There are three main structures to consider when thinking about the shoulder: the ribcage, the scapula, and the humerus. The scapulo-thoracic joint is between the ribcage and scapula while the glenohumeral joint is between the scapula and the humerus. The scapula is responsible for about 30% of your total shoulder motion, and the scapulo-thoracic joint operates as a “floating” joint with no direct bone-to-bone attachment to the body. Your upper arm bone, the humerus, connects into a socket on the outside edge of the scapula. Your shoulder blade floats because as it moves so does the socket. It can therefore orient and position itself in a wide variety of ways, allowing you to get your hand into a lot of different positions. The shoulder has more range-of-motion than any other joint in the body. The more motion you have available the more complex movement becomes, and the harder it is to control. This is where the conversation of stability comes in. For the sake of this discussion I’m going to define stability as the ability to resist unwanted motion and/or to return to a desired state after being moved. This is why the common treatments for an “unstable” shoulder include activities like bosu planks, having your therapist slap your arm around while you hold it in one place, lifting and carrying weights hanging from bands, etc. The intent is good but the application is often poor, leading to inconsistent and incomplete results. These activities are complex, with a lot of variables to control. For someone who is already having issues, it’s a lot to ask. A better approach would be to start with development of passive motion, allowing access to the arm positions needed. Next step would be active motion within this newly acquired motion. From there we need to start producing force in all of these positions and developing both strength and consistency in the desired motor patterns. If the issue still exists at this point then, and only then, do we get into the fancy stuff. For example, I wouldn’t have a client do any form of an “unstable surface” pushup until they can clearly demonstrate 20 crisp and consistent repetitions of the strict pushup first. While complex, highly variable, dynamic activities might look sexy they are the top of the pyramid, not the bottom. You need to properly build the foundations before you get there. If you’ve been struggling to get your shoulders back to where you want them to be, and you feel like you’ve tried everything, I highly encourage you to go back and master your basics using the progression above. If you can’t figure it out, hire a skilled professional who truly understands the process. There’s nothing wrong with your shoulder, it’s just struggling to manage complexity.

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 our body adapts to the specific demands that are placed upon it.  Perform enough aerobic exercise and your heart adapts by increasing the size of the muscles in your left ventricle. This increases the amount of blood your heart can pump with every contraction, and your resting heart rate drops. The same adaptations effect the hormonal function of the nervous system and tend to decrease your resting blood pressure as well.1 The tendons of sprinters become increasingly stiffer as they train to be faster and faster. This is a positive adaptation – think of 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 (tendon) releases more energy when it is deformed (stretched) and makes the sprinter more likely to win his race.  When an injury is present, either to a muscle, or a tendon, or another part of the structure of the joint, this has happened because that area was applied a stress, or repeatedly more stress, than it could positively adapt to.  When you trip over something and roll your ankle in the classic position shown below in Image 1, you sprain the ligaments and strain the muscles on the outside of your ankle because you loaded them at a speed and magnitude in which they were not adapted for. Meanwhile, in the Far East, there are historical truths about mixed martial artist practitioners being able to break stone with their shins without hurting themselves, because they have repeatedly exposed their shins to those compressive forces by kicking trees and harder objects for years.  [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 though?  If we want to restore the function of someone’s shoulder to being able to tolerate more and more physical stress and use without a negative adaptation like injury, we must now follow the Goldilocks Principle of rehabilitation (image 2) and find a dose of stress that is “just right”: not so much to drive a negative adaptation, but enough of a stress to start to drive a positive adaptation.  When it comes to our ability to produce force or restore freedom of motion in a joint following injury, this chart below is a useful illustration of that Goldilocks principle.  Image 2:  Volume vs intensity threshold for gaining an adaptation. (Joel Jamieson’s “Ultimate MMA Conditioning”)  Resistance tubing, often used by the commercial brand name of “Theraband”, is one of the most common images conjured up when folks are asked what they think of physical therapy.  And despite the title of the article, I am not against the use of Theraband or tubing.  For people in the early stages of rehabilitation from a shoulder injury, resistance tubing can be a very useful tool for giving a low dose of resistance that may be enough of a challenge to recapture strength, or to give enough resistance through a range of motion to help someone improve their ability to control their arm in challenging positions.  Tubing can also be very useful for helping to give you external resistance so you can feel your body and shoulder getting into different positions to help you restore range of motion (link to an article about “position restoring range of motion”).  If our goal is to build a shoulder capable of producing and absorbing significant forces, we need more force than just the band can provide, so that we can find the right dose of “volume and intensity” to help us get stronger.    Sidelying Kettlebell Arm Bar Activities like the kettlebell or dumbbell arm bar, shown above, are a great entrance point to retraining rotation at the shoulder with greater loads. They are also effective at retraining the ability for the shoulder blade to turn to accommodate improving smooth total movement of the arm.  Hooklying Dumbbell Pullover The hooklying dumbbell pullover is another way to improve range of motion, and strength across a whole range of motion. This is a way that I commonly help clients improve their ability to go overhead without using a substitution from their lower back, and to get them confident in keeping heavier objects overhead.  Staggered Stance Landmine Press Landmine pressing, shown above, is a great way to load all the muscles that work around the shoulder, and eventually with a substantial amount of load. Landmine pressing is easy to modify to train the timing of rotation of the ribcage with rotation of the shoulder and shoulder blade to improve different aspects of upper body performance.  If you’re returning from a shoulder injury, make sure that you’re aware of what you’re trying to accomplish with the exercises that you choose to do. Not all rehab has to look like bands and two-pound weights. It should be intense enough to prepare you above and beyond what you need your shoulder to do. Make sure you’re getting the adaptations your shoulder needs with the time you are investing in your rehab. 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 amongst the athlete and active adult population that we see. As therapists, we see traditional diagnoses such as shoulder impingement, tendonitis, and rotator cuff injuries daily. Traditionally, these common issues are blamed on weak rotator cuff muscles, scapular winging, imbalance of muscle activity, etc. One major thing to understand about these diagnoses is that they are not the actual problem…they are a result. A result of deeper-rooted movement habits and mechanics that usually go unaddressed in the traditional rehab process. Typical solutions for these “results” are equally short- sighted. Frequently these solutions, which include stretching, rotator cuff strengthening, and general strength training, miss the mark as far as resolving pain. Why? Because they are addressing symptoms and not the thing that has caused the faulty mechanics, the need to over- use certain musculature or orient musculature in a disadvantageous position. To truly understand what the biggest missing piece is in resolving these common shoulder issues we first need to understand how the shoulder behaves.  A Quick Anatomy Lesson of the Shoulder Complex  The shoulder complex is made up of 4 major components: The glenohumeral joint (ball and socket), the scapula (shoulder blade), the sternum and clavicle, and the rib cage. Shoulder movement in any direction requires rotation of the humeral head (ball) within the glenoid (socket).  Because the shoulder has so much freedom of movement, stability of the joint needs to be ensured. That is why every shoulder movement is accompanied by scapular movement. Since the actual socket of the shoulder joint is on the scapula, its movement is vital in maintaining the humeral head centered within the glenoid during shoulder movement. When the humeral head doesn’t stay centered within the socket is when things like shoulder impingement occur, proximal biceps tendonitis rotator cuff injuries occur For a shoulder joint to move well, you need a scapula that can move in congruence with the humerus. What allows the scapula to move? The scapula has a slight curvature to its shape. The scapula sits on a rib cage that has a roundness to it due to normal thoracic kyphosis or curvature of the upper back. The roundness of the upper rib cage and the curvature of the scapula allow the two to maintain congruency with each and allows the scapula to rotate about its normal motion in support of the humeral head. The position of the rib cage and its ability to expand appropriately to support the scapula is essential for normal scapular movement that allows for normal shoulder movement without compensation.  Rib Cage Position and Expansion  The rib cage, under normal circumstances should be able to expand circumferentially (360 degrees) during normal breathing. During every inhale, the lower ribs should move outward in what’s called bucket handle movement while the upper ribs and sternum move up and out in a pump handle movement. The backside of the rib cage should reflect a similar movement, especially in the upper rib cage. It is when the rib cage lacks these normal, requite movements that things like scapular position and as a direct result, shoulder mobility, are negatively affected.  For example, when the back side of the upper rib cage becomes too restricted in its movement or flattened due to chronic muscular tension in the upper back you will see a limitation in scapular movement. A curved scapula on a flat surface does not achieve the same movement and rotational capabilities as one that is on rounded, congruent surface. Remember, without scapular movement the shoulder joint either cannot access normal movement or will have to move through compensatory mechanics to get there. Chronically moving in to ranges that you don’t have access to or compensating for movement limitations is exactly what leads to frequent pressure and tension in the same area i.e., shoulder impingement, biceps tendonitis, wear and tear of rotator cuff tendons, etc. How does one lose normal rib cage mechanics? This is easiest to see in an activity like resistance training. Most movements in the gym emphasize “shoulder blades back and down” for “stability.” No matter whether you’re pushing or pulling, back squatting or deadlifting, the rib cage and scapular position are relatively the same. A similar effect occurs from the ill-fitted advice to pull your shoulder blades back and down for “good posture.” Chronically spending time in a scapular retracted position will both prevent normal scapular movement and flatten the upper rib cage resulting in the need to compensate to achieve the desired shoulder movements.  The Solution To truly resolve shoulder pain, you must start at the source. Yes, there are many other factors involved in shoulder pain; rotator cuff strength, dynamic stability, local tissue inflammation, etc. Regardless of these issues you must understand and resolve what lead to these issues in the first place, otherwise you are just treating a symptom. If your goal is to improve the mechanics and motion at the shoulder joint, you need to ensure proper scapular movement. To have normal scapular movement requires a rib cage that is positioned properly and can expand in all directions to provide a foundation and support for the scapula. Once you have established a proper foundation, all factors mentioned before 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]