photo credit: http://pacificcoastchirowellness.com/shoulder-pain/
Check out my first post on 3 Ways to Get Out of Shoulder Pain if you haven't already.
People from all walks of life can and do suffer from shoulder pain. Whether someone is a professional athlete who operates overhead for their respective sport or a mother of 3 young children, shoulder pain can be present in any population.
In Part 1, we discussed many reasons why someone may have shoulder pain. Check out part 1 and give that a read first.
Three reasons we discussed in part 1 were soft tissue restrictions, scapulo-humeral rhythm, and breathing patterns.
Today, in Part 2, we will discuss the effect of:
on shoulder pain. The reasons mentioned above as well as the reasons mentioned in part 1 are all important to consider with a client or patient who is experiencing shoulder pain.
Now, before people start sending me hate mail on why poor posture is not correlated with shoulder pain, posture is only the piece of the puzzle and there is no cause and effect relationship or strong correlation between posture and shoulder pain.
Posture is one of those topics that has been discussed for years on what is proper posture and what is not. You can have someone who presents with "poor posture" and have no complaints of shoulder pain. On the other hand, someone could walk in with "perfect posture" and have 9/10 shoulder pain.
My thought process is that we need to consider all possible factors that may be contributing to someone's pain and/or dysfunction. If someone sits at a desk all day for 10+ hours with "poor posture," then we may want to address this issue.
photo credit: http://www.fitnessmash.com/2011/12/do-we-really-need-to-stretch/desk-jockey/
If we don't address this particular issue and educate our clients and patients on this particular factors, then we are doing them a disservice. It's only a piece of the puzzle.
Here is a picture of "normal" resting posture:
Here are two pictures of "not-so-normal" resting posture:
With the first picture, we ideally like to see an imaginary line going from the ears, down through the shoulders, hips, knees, and ankles that would represent an ideal resting posture position.
As shown in the other 2 pictures, this is not the case.
In picture #2, the person's head and shoulders are translating forward and they are rounding through their upper back. This is something we typically see in a population who tends to sit or work at a computer the majority of the day.
In picture #3, the person is in a gross extension pattern, where they are extending through their lumbar spine/TL junction and in turn placing the scapula into a depressed position. This is typically seen in a population who either stands throughout the day AND/OR partakes in weight training, etc. I am not saying everyone who lifts weights looks like this, but in my experience, this is what we typically see.
We can do all the rows, correctives, pec stretching, etc. we want to try to remedy this, but first and foremost, we need to educate the patient or client on how they are currently positioned and how it may be better to be in a different position.
In my opinion and I'm sure other people will echo my sentiments, posture is dynamic.
What does this mean!?
Well, as I sit here typing this, I could have the most atrocious looking posture. Then 1-2 minutes later, I could have textbook looking posture. Just because someone has a certain posture for a brief period of time, doesn't mean they are going to have lifelong issues related to how they sit or stand.
Posture is one of those things that is always adjusting and changing. We are human beings and are moving throughout our day. If someone maintains a prolonged position, whether it be sitting at a desk throughout the day as shown in picture #2 above OR if they are standing throughout the day hanging out in extension as shown in #3, THEN this is where it could be problematic.
We want to educate our patients and clients on remaining mobile throughout many varying positions throughout their day. Going from a sitting to standing position, 1/2 kneeling to tall kneeling, etc., these varying positions can help anyone to fend off the poor posture bug.
Here are a couple of quick fixes if you sit all day:
Here are a couple of quick fixes if you stand for prolonged periods of time:
2. Lifting Technique
Time and time again, I speak to my clients about how their lifting mechanics and form can either help to support or trump what we are doing in the treatment room. Someone who exhibits proper lifting technique can recover from an injury quicker. Conversely, someone who is consistently performing lifts with poor technique will continue to exacerbate their shoulder/knee/low back, etc. pain and dysfunction.
When my clients are with me in a session, I want their form to be pristine. If not, then we are going to coach them into the proper position. When they are on their own performing a particular corrective or strength exercise, I expect the same. Now, I know when people don't have a coach around to cue them, their form may not be as good as with someone watching.
If another trainer, coach, or physical therapist was watching your patient or client exercise or perform their home exercise program, what would they say?
Would they say, "Wow, that form looks pristine! They must have someone who has coached them on the form and technique."
"Wow, it must be their 1st day in the gym. Maybe I should go over there and help them with that exercise?"
Therefore, whether someone is being coached in person, via the internet, or are all alone and doing the exercise by themselves, technique is of utmost importance.
Now, don't get me wrong, someone may be able to get away with poor form for a long time and not have any pain and/or dysfunction. The human body is resilient and can handle amazing amounts of stress time and time again before we start to notice it causing any type of damage.
Eventually, sub-par technique will catch up with you. Here are 3 exercises that are performed with ideal technique:
1-Arm Cable Row
DB Bench Press
Here are some exercises being performed with "not-so-ideal" technique:
1-Arm Cable Row
What is wrong with this technique?
DB Bench Press
What is wrong here?
We see that the humerus is translating anteriorly in relation to the glenoid (shoulder). There is minimal scapular retraction/protraction. By allowing the humerus to translate anteriorly, this places increased stress on the passive restraints of the shoulder (biceps tendon, anterior capsule, labrum, rotator cuff).
Also, there is an increased amount of lumbar lordosis seen with the big low back arch and rib flare.
Here we see:
There is excessive arching of the low back/rib flare at the end of the pressing motion. Also, there is excessive translation of the cervical spine and head anteriorly at the end of the pressing motion as well.
Instead of trying to increase the weight on exercises week after week after week, drop the weight a little bit and focus on the technique. In the short term, your ego may take a hit, but in the long term, you will be stronger and remain in the iron game.
3. Core Instability
This point somewhat goes hand in hand with lifting technique, but we will discuss how impaired core stability will affect the shoulder.
First, an example. Would you build a house on a solid foundation or a "suspect" foundation?
The same goes for the human body, specifically the core/trunk region. If you don't provide a stable base by putting the core in a good position, this will in turn alter the position of the lumbar spine and the thoracic spine. Once the thoracic spine is in a poor position, this alters the position of the ribs and ribcage. Once the ribs and ribcage are malaligned, this will dictate the position of the scapula and in turn the glenoid (shoulder).
Many times if we affect the position of the trunk, this can cause immediate changes in the position of the joints above it.
So, to improve core stability, this doesn't mean doing crunches or sit-ups.
If anything, we want to train our core to maintain a neutral position. One way to find out what a neutral spine position feels like is by standing with your back to a wall as shown in the picture below. Your heels should be approximately 6 inches away from the bottom of the wall.
We ideally would like to be able to slide our hand between the wall and our back. You should feel both the wall and your low back.
If you can't slide your hand through, as shown below:
You might be in a slightly flexed lumbar spine position.
On the opposite end of the spectrum, you could have too much space (more than 1 hand width) between your low back and the wall. See below.
Both of these two scenarios, too much or too little space between the wall and low back, can cause issues at the shoulder.
For the sake of this post, we will focus on too much space between the low back and the wall. What this typically means is that the person is "hanging out in extension" or has increased extension in their lumbar spine.
This is typically accompanied with a rib flare. When the low back arches, the ribs will have a tendency to drift up and out, in a superior and anterior direction. This is a classic sign of someone exhibiting an extended posture.
photo credit: teamchiroames.com
In turn, this will cause the scapula to tilt forward and protract due to the compensation by the upper rib cage to counteract the extension moment. When the scapula tilts forward, this will limit the amount of glenohumeral range of motion and can cause varying issues from the neck/shoulder to the lumbar spine and hips.
As seen in the previous post regarding shoulder pain here, breathing patterns can contribute to this extended, rib flare posture position. When we breathe predominantly from the accessory musculature (scalenes, pec minor, SCMs), this can cause an extended posture by pulling up on the rib cage and placing it into extension.
It can also send a signal to the brain indicating that there is a threat due to the abnormal breathing pattern. The brain will then send a signal to the body to be on "high alert" and will engage accessory extensor tone in the paraspinals in the thoracic and lumbar spine. In turn, this can compound the extension posture/rib flare.
The Postural Restoration Institute (PRI) goes into great detail about this. Check out their website for more information.
So, if we have a tendency to start off a lift or exercise in this position, we may have a tendency to perform the exercise in an extended posture. When placing strength on top of dysfunction in this extended posture, it is increasing the risk for injury.
Whether it be a DB Bench Press, cable row, or overhead press as shown above, if we maintain a neutral spine, "ribs down" position, this will allow all the moving parts in the kinetic chain to work and function properly.
Let me know if you have any questions!
Here I will be writing and posting about topics ranging from physical therapy, injury prevention/reduction, and strength and conditioning.