Shoulder problems are rampant in modern society and are a common complaint of personal training clients. While shoulder impingement, rotator cuff syndrome, and tendonitis are common clinical diagnoses, most shoulder problems share a common etiology: poor scapulothoracic stabilization. Common treatments — including joint and soft tissue manipulation, stretching, medications, heat, and electrical muscle stimulation — rarely succeed in providing significant long-term benefits because they don’t address the underlying stability issues of the shoulder complex. Although it is rarely discussed when dealing with shoulder issues, the cervical spine is a large contributor to scapulothoracic instability.
This article will discuss the relevant anatomy as well as the relationship of the cervical spine to shoulder instability and identify some of the commonly overlooked signs of both cervical and scapulothoracic instability. Additionally, this article will define a corrective and progressive exercise strategy based upon the principles of the Integrated Movement System™ (IMS) that will give the fitness professional more confidence when working with clients with problematic shoulders.
Cervical and Scapulothoracic Dysfunction
The first step in gaining confidence when working with shoulder problems is to develop an understanding of the anatomy and kinesiology of the cervical and scapulothoracic regions. While they are not often discussed together, the cervical spine and shoulder complex are intimately related. The cervical spine is composed of seven vertebrae that blend into the thoracic region of the spine. It functions as a base for the head as well as an important attachment point for several of the muscles that support the scapulothoracic region. Several muscles of scapulothoracic complex, including the levator scapula, rhomboid minor, and fibers of the upper and middle trapezius each have attachments on both the cervical spine and scapula.
The C5-T1 cervical nerve roots form the brachial plexus as they exit the foramina. The brachial plexus exits the neck between the anterior and middle scalenes, travels underneath both the clavicle and the pectoralis minor prior to innervating the structures of the shoulder and upper extremity.
These relationships are important to understand, since dysfunctions in both postural support or proper movement patterns can have significant impact on the function of the shoulder complex. For example, disc herniations are a common cause of neck pain and dysfunction. Radicular symptoms such as numbness and tingling are usual symptoms of disc problems, but several other patterns often precede these symptoms. Decreases in internal shoulder range of motion and chronic trigger points in the levator scapula and rhomboid minor are two common early signs of irritation of the cervical nerve roots. While clients can experience problems at any disc level, C5-6 is the most common level for cervical disc bulges and herniations. Not so ironically, the nerve roots C5, 6, and 7 innervate the serratus anterior and disc irritations of the C5-6 level can be a cause of serratus anterior weakness and subsequent instability or winging of the scapulothoracic region.
This cervical instability must be improved when dealing with scapulothoracic dysfunction or there will be no long-term solution to these movement dysfunctions. While there are several causes of cervical instability, two of the more common ones include the forward head syndrome and downward scapular rotation syndrome. Their relation to scapulothoracic instability will be discussed below.
Forward Head Syndrome
The forward head posture is largely blamed on prolonged sitting and excessive time spent in front of computers, televisions, and video games. While each of these factors likely contributes to the problem, they are unlikely to be part of the driving force behind this problem. The forward head posture and subsequent hyperextension of the mid-cervical spine and anterior shear of the lower cervical spine (see arrow in Figure 1) are direct consequences of poor respiratory patterns. What is the relationship between the forward head posture and respiration? As the accessory muscles (scalenes, sternocleidomastoid, and pectoralis minor) assume the primary role of respiration, they subsequently pull the head and scapula into a forward position. This process leads to anterior shear of the lower cervical spine and compensatory hyperextension of the mid-cervical spine resulting in lower cervical instability and the subsequent lower cervical disc irritation that was discussed earlier.
Downward Rotation Scapular Syndrome
The “levator scapula sign” occurs when the scapula is insufficiently stabilized along its inferior border by the inferior fibers of the serratus anterior and lower trapezius. As the client performs a pushing or pulling pattern, rather than remaining stabilized, the superior angle of the scapula moves superior and medial on the thorax, and there is prominence of the levator scapula along the lateral aspect of the neck (see Figure 2). In addition to prominence of the levator scapula, hypertonicity can be palpated within the levator scapula as the client performs her patterns. Over-activation of the levator scapula also contributes to hyperextension of the mid-cervical spine as the levator scapula also functions as an extensor of the neck. This is a dysfunctional pattern that encourages downward rotation of the scapula especially when there is subsequent over use of the pectoralis minor as a primary respiratory muscle.
When there is over-activation of the downward rotators of the scapula (pectoralis minor, levator scapula, and rhomboids), it is common for clients to struggle with scapular stabilization. This patterning can be viewed in several upper extremity patterns however is easiest to see as the client returns their arm from the overhead position (see Figure 3). Notice how the inferior angle of the scapula moves away from the thoracic cage as the arm is lowered — and this is without any weight in the arm. It is important to look and/or palpate for this instability as this dysfunction will only be exacerbated as the arm is loaded. Improved scapular stabilization must be achieved prior to progressing the client to the fundamental pushing and pulling patterns, or the client will further ingrain these poor habits.
These altered stabilization and movement patterns can lead to a host of additional shoulder and upper extremity conditions, including thoracic outlet syndrome, bicipital tendinopathies, and rotator cuff syndromes. Therefore, the corrective strategy for these conditions (as well as the forward head and downward rotation syndrome) is to improve respiration, stabilization, and integration of the fundamental movement patterns.
Integrating the Respiratory, Stabilization and Movement Systems
To specifically address the three most common causes of movement dysfunction — poor respiratory patterns, poor stabilization, and improper progressions of the fundamental patterns — the fitness professional must focus on improving the three principles of human function:
- respiration prior to stabilization
- stabilization prior to integration
- integration prior to progressions
Respiration must be optimized; otherwise, no other movement can be optimal. Proper diaphragmatic respiration must be established to ensure both optimal oxygenation as well as proper stabilization of the spine and thorax. In fact, faulty respiratory patterns have been linked to overall poor health in addition to poor stabilization of the trunk and spine. The diaphragm has been shown to have a role in both respiration and stabilization (Richards et al., 2004) and faulty patterning of the diaphragm has been indicated in dysfunctional stabilization of the trunk and spine (Hodges et al., 2001; Kolar, 2009). A previous two-part article on PTontheNet, “ Assessing the Fundamentals: The Thoracic Connection ” (Osar, 2010) provides more information on improving respiration and coordination with trunk stabilization. Readers are encouraged to review these mechanics, since they are the integral first step in improving movement patterns in the IMS.
Once optimal respiratory patterns and core activation have been established, the client can be progressed to restoring optimal scapular mechanics. Recall that stabilization of the scapula against the thorax and control of upward rotation must be established prior to loading the upper extremity. Research has demonstrated that the push-up plus (push-up with an additional protraction component) and dynamic hug (fly pattern performed with resistive tubing or cables) patterns are two exercises that effectively activate both the serratus anterior and subscapularis, two muscles that have been linked to shoulder instability (McClure, 2006). In reviewing the literature, it would be logical to include these two exercises in a corrective exercise routine for clients with a scapulothoracic or glenohumeral instability. However, when reviewing research it is important to understand EMG studies are limited in that an EMG only records muscle activity, not whether or not the muscle is actually being activated to perform optimally. This is where the fitness professional must be diligent in understanding both the research as well as the optimum functional kinesiology of a muscle prior to instituting a corrective exercise program.
There is no arguing the fact that the serratus anterior is heavily recruited during a push-up plus motion. In addition to its stabilization function, the serratus anterior functions as a strong protractor of the scapula. However, the serratus anterior must also adhere the scapula to the thorax cage and decelerate the humerus as the arm returns from overhead motion, two functions that are not guaranteed during the push up plus. Yes, it is maximally recruited during a push up plus, but does this prove that the scapula is under any better neuromuscular control than in other functional positions? Unfortunately, it does not. This is not to say that the push-up plus cannot be an effective exercise as part of a progressive rehabilitative program but rather point out its limitations if used early in the rehabilitative process.
Recall that most shoulder problems — as well as problems in the low back, neck, etc. — are not strength issues; they are motor control issues. Applying more strength will only benefit the client who has a defined weakness and who possesses optimal neuromotor programs. Adding strength does not ensure anything except that a client will get stronger. Adding strength to a client with poor neuromuscular patterns only ensures that the client will continue to compensate and use the same patterns they have habitually used.
The following series of exercises is key in establishing both optimal stabilization as well as movement awareness of the scapulothoracic and glenohumeral regions. Movement awareness is the most overlooked component to corrective exercise as the client must be made aware of how they are currently moving as well as what ideal patterns look and feel like. These patterns include the quadruped with arm reach, the wall plank with arm reach, and shoulder rotation patterns. It is important to remember that the goal of these patterns is to improve neuromuscular control of the scapulae and spine stabilizers, so it is important that the early phases of corrective exercise emphasize this point.
The wall plank is an excellent pattern to establish both optimal scapular and spine alignment, as well as activation of the deep intrinsic stabilizers of both regions. In Figure 4, the client stands approximately one foot away from the wall and assumes an elbow plank position against the wall. Her upper arms are positioned level with the shoulders and she is cued into a neutral spine and scapular positions. These cues include:
- a long spine posture – the deep neck flexors are activated, the spine is in neutral posture;
- the scapula are positioned into upward rotation — the serratus anterior and lower trapezius are activated;
- the core is activated and the client maintains diaphragmatic respiration.
She slides one arm up the wall while stabilizing the opposite side and returns to the starting position. She repeats on the other side for the desired number of reps. It is important that the client controls the lowering of her arm (eccentric control) as she returns to the starting position. Equally important is that she maintains stability in the stationary arm, as the goal is to improve the stabilization function of the scapular stabilizers. Be sure to monitor for excessive levator scapula activity by observing and palpating the lateral aspect of the client’s neck.
Figure 4: Wall plank with arm slide: start (left); finish (right). The client maintains stability of her right scapula as the left arm reaches up the wall. Her deep neck flexors are activated and she maintains this long spine position throughout the pattern.
Quadruped with Arm Reach
As shown in Figure 5, the quadruped pattern begins with the client positioned in a quadruped posture with her elbows shoulder-width apart. She establishes neutral spine posture and the image of a long spine (as if someone is pulling her head by a string). She activates her serratus anterior and lower trapezius and maintains this activation throughout the pattern. She reaches one arm out as far as she can without losing scapular or spine position and returns to the starting position. She repeats on the other side, alternating each side until completed the desired number of reps. As with the wall plank, it is just as important to maintain stability in the stationary arm as the goal is to improve the isometric function of the scapular stabilizers. Be sure to monitor for excessive levator scapula activity by observing and palpating the client’s lateral neck.
Figure 5: Quadruped with arm reach: start (left); finish (right). The client activates her deep neck flexors and core stabilizers and reaches out with one arm without any shifting or loss of alignment.
Reversed Rotator Cuff Patterns
The closed chain rotator cuff pattern is an excellent pattern to incorporate the scapular stabilizers as well as the muscles of the rotator cuff, specifically the subscapularis. Most rehabilitation exercises for the rotator cuff begin with fixation of the trunk and rotation of the humerus on the scapula, which is in direct contrast to the patterns that occur during development. As the child learns to crawl, he moves the scapula over a fixated humerus thereby developing optimal rotator cuff function. This concept will be used to incorporate rotator cuff function with scapulothoracic stability. Please note that because this is a higher-level pattern, it must only be performed by clients that have established optimal stability of the cervical, scapulothoracic, and glenohumeral regions.
The client should begin by holding onto a barbell secured to a power rack before progressing to the TRX version — both are demonstrated below. The client begins with a very shallow angle of incline and then lowers his body as he develop stability and strength. The client grasps the bar or handles (see Figures 6 and 7) and stabilizes his scapula and spine. He reaches to the side with his free arm without losing the scapular control of the fixed arm or alignment of the spine. He rotates back to the starting position and repeats for the desired number of repetitions on each side. The rotation occurs around the glenohumeral joint making this pattern essentially a reversed rotator cuff exercise for the stationary arm.
Figure 6: Reverse rotator cuff pattern – basic version: start (left); finish (right). The cervical spine, thoracic spine, and scapulothoracic must remain stabilized as the trunk rotates around the fixated arm.
Figure 7 : Reverse rotator cuff pattern – advanced version: start (left); finish (right)
Sets, Reps, and Tempo
Quality over quantity should always be stressed whenever attempting to improve motor patterns. The first two patterns — the wall plank-reach and the quadrupedreach — are designed to improve stabilization and motor control and are generally not taxing to the endocrine or nervous systems. Therefore, these patterns need to be performed every day to improve motor control as well as awareness and can be done so without much worry of over-training. The client will perform these patterns 2 times per day for 5-10 reps per arm with a 2 second concentric and 2 second eccentric phase. This is a great posture relief exercise for clients who work long hours at a desk or computer.
The reverse rotator cuff pattern is a higher level pattern and can easily lead to an over-trained or fatigued rotator cuff. This pattern will be performed 2-3 times per week for 2-3 sets of 8-12 repetitions.
Once clients achieve optimal respiration and stabilization, they must be taught how to integrate these into the fundamental movement patterns including pushing and pulling patterns. During pushing and pulling patterns, the scapulae must remain stabilized on the thorax. As the arm is lowered from overhead, the scapula must be eccentrically controlled throughout the entire motion. This same eccentric control must be adhered to during the eccentric phase of the dumbbell or cable chest press. Readers can review the optimal scapular mechanics of both pushing and pulling patterns in the two-part article on PTontheNet, " Improving Shoulder Function " (Osar 2007 and Osar 2008).
The one thing that all upper extremity syndromes — including thoracic outlet, carpal tunnel, and rotator cuff — have in common: they are all a result of poor stabilization and/or movement patterns. Therefore, passive therapies, medications, or surgery are rarely a long-term solution because none of these options address the underlying stabilization or movement issues. To be a part of the long-term solution, fitness professionals must understand and be able to educate their clients about the proper methods of respiration, stabilization, and movement integration. This article described several common movement impairments that lead to scapulothoracic dysfunction and introduced the key components of integrating the respiratory, stabilization, and movement systems as a means of improving a client's movement patterns. By improving these patterns, the fitness professional can become an important part of a client’s health care team and become part of the solution to the health care crisis rather than part of the problem.
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