Keeping a neutral spine and not arching the lower back, you should be able to bring your upper arm past your ears. Keep your arms straight and your hands close together. Notice the lack of full flexion in the first picture and the lumbar extension/curvature in the middle picture. This is a good test/re-test for proper function of the shoulder complex.
If you previously read Part 1, you should have a pretty decent understanding of the shoulder complex and its biomechanics. You should also understand how the whole chain is interconnected and why we have to treat the whole chain, not just an individual part of it. If you haven’t read it, you should probably start there first.
Keep in mind that we’re talking about treating shoulder pain that is caused by impingement, referred to as Shoulder Impingement Syndrome (SIS). There can be other causes of shoulder pain but SIS is considered to be by far the most common.
To recap and summarize the treatment strategy for biomechanical shoulder pain and pathology, we have 4 areas to address:
- Thoracic Mobility
- extension
- rotation
- Rotator Cuff Musculature
- Supraspinatus
- Infraspinatus
- Teres Minor
- Subscapularis
- Scapulo-Thoracic Musculature
- Serratus Anterior (scapular protraction and upward rotation)
- Lower trapezius strength (scapular retraction, depression and upward rotation)
- Ratio of lower to upper trapezius strength
- Middle trapezius (scapular retraction)
- Posture
- It’s going to be much more difficult to prevent or treat shoulder impingement if consistent weak posture reinforces faulty movement patterns.
There are other things that can come into play but for simplicity, we won’t go into those areas.
There are a lot of treatment strategies and exercises to address shoulder impingement. There are many other exercises and treatments that could be potentially helpful. The goal and strategy of this post is to narrow our focus and utilize the biggest bang for your buck exercises based on the research.(1)
Thoracic Mobility:
It’s important to build our stability on a mobile base. This is how we first do it as infants.
Chiropractic adjustments to mobilize the thoracic spine joints are an effective way to restore proper joint motion.
Utilizing a foam roller can also be an effective way to mobilize the thoracic spine or reinforce the adjustment between treatments.
Another way to facilitate and reinforce thoracic mobility involves utilizing this rotation drill:
Strengthening the Rotator Cuff Musculature:
Subscapularis (internal rotation)
Probably the biggest bang for your buck exercise for the subscapularis is the Internal Rotation Diagonal exercise. It’s performed similar to a tennis swing:
Infraspinatus and Teres Minor (external rotators)
I would recommend holding a towel or something between your arm and ribcage to keep yourself from cheating or doing the movement improperly.
Supraspinatus (abduction of the arm)
We can use the same exercise to hit both the supraspinatus and the lower trapezius (as shown below)
Strengthening the Scapulo-Thoracic Musculature:
Lower Trapezius and Supraspinatus
We can use the “prone full can” exercise to facilitate strengthening the supraspinatus and lower trapezius. “Full Can” because your hand position is such that if you were holding a full can of “something” you wouldn’t pour it out. This exercise is also sometimes called a “Prone Y.”
You can do it laying face down on the floor or a bench. Remember to keep your shoulder blades down and back (i.e., don’t shrug)
Serratus Anterior
This muscle is a scapular protractor, upward rotator, and keeps the scapula pressed in good position against the thorax.
The Push-Up Plus is a great way to strengthen and facilitate this muscle.
Elevating your feet by placing them a foot or two off the ground is a great way to create a little extra activation of this muscle. If you need to make it a little easier, you can perform this exercise on your knees.
A combination that I really like is the Hand Release Push-Up Plus. To do this, you do a full push-up with the “plus” at the top. At the bottom, you come down to your chest and raise your palms off the ground. Raising the hands off the ground contracts the scapular retractors, making this a great overall exercise to hit a lot of the scapulo-thoracic muscles.
The last exercise is a big bang for your buck exercise called a Face Pull. It hits just about every muscle we want to hit to minimize impingement risk. You can use a band, TRX straps, a cable pulley system, or whatever you can find to simulate the exercise. Notice in the video below that these are performed with the palms facing each other. We want to do these with humeral external rotation to limit the impingement that takes place with internal rotation.
Remember to keep your scapula down and back (don’t shrug your shoulders upward during any part of the movement)
Posture:
Although I’m putting this at the end of the post, it may be the most important consideration of the four areas.
Notice that the how almost all the things we need to work on in preventing or treating shoulder impingement are displayed while sitting at a computer. Notice the arms internally rotated, the thoracic spine rounded forward, the pecs are in a shortened state, the scapular retractors and depressors are completely inactive, and often the shoulders will shrug up and the chin will jut forward. You don’t just have to be sitting at a computer to have bad posture. Those positions and habits can be perpetuated just as much while standing or doing various other things.
The body will adapt to the positions you consistently put it in. You can’t signal for your body to adapt to bad postures and movement patterns and then want it to perform well on occasion.
This shoulder strategy is a good place to start if you are having shoulder pain or want to prevent it. There can be other issues involved that I haven’t covered such as capsular tightness, muscular adhesions and trigger points, shortened muscles, cervical disc irritation, general lack of proper movement mechanics, and other possibilities. But this is a good strategy to start with in many cases involving shoulder pain and dysfunction.
References:
