Got Shoulder Pain?

If you have shoulder pain, you are not alone:

  • Shoulder pain is reported to occur in up to 20% of the general population, with 40% persisting for at least 1 year (Annual cost is about $39 billion)
  • Shoulder impingement is the most prevalent diagnosis, followed by traumatic injuries
  • Altered mechanics at the shoulder joint make it susceptible to degenerative changes
  • Degenerative changes can further alter posture and kinematics locally and at neighboring joints, due to muscle imbalances, joint dysfunction  and movement compensations/impairments

Review of Shoulder Functional Anatomy

The shoulder is a unique joint that requires mobility and stability though the interplay of dynamic and static structures.

Stability is derived from muscles, whereas mobility is permitted from the relatively loose capsule and ligamentous structures.

Bones and Joints

The shoulder girdle is made up of articulations between the:

  • Humerus (arm bone)
  • Scapula (shoulder blade)
  • Clavicle (collar bone)
  • Sternum (breast bone)
  • Ribs


The are 4 primary joints that make up the shoulder:

  1. Glenohumeral
  2. Acromioclavicular
  3. Sternoclavicular
  4. Scapulothoracic


It is also important to note that because of the attachments of the latissimus dorsi muscle to both the shoulder locally and to the lumbo-pelvic-hip complex (LPHC) distally, that dysfunction in the  LPHC can affect proper shoulder function.

There are a number of muscles associated with the shoulder joint:


Rotator Cuff/Local Muscles     Other muscles
  • Supraspinatus
  • Subscapularus
  • Infraspinatus
  • Teres major and minor
  • Deltoid
  • Pectoralis muscles
  • Latissimus dorsi
  • Rhomboids
  • Trapezius
  • Levator scapulae
  • Serratus


The rotator cuff muscles act primarily as a steering mechanism. Both the rotator cuff and other muscles provide static and dynamic stability.

Common Injuries Associated with the Shoulder Injuries:


Local Injuries Above The Shoulder  * Injuries Below The Shoulder *
  • Rotator cuff strains
  • Shoulder impingement
  • Tendinopathies of the rotator cuff and biceps tendon (75-80% of shoulder injuries)
  • Instability
  • Cervical spine injuries
  • Headaches
  • Low back pain
  • SI joint dysfunction
  • Hamstring, quadricep and groin strains
  • IT- Band syndrome
  • Plantar Fasciitis
  • Achilles Tendinitis


*The neighboring joints above and below the shoulder are interconnected through the Kinetic Chain. These areas should be considered in the assessment and treatment process for shoulder conditions.

Other than obvious trauma through contact or strain, many shoulder injuries are due to a combination of:

  1. Abnormal length-tension relationships of soft-tissue structures (muscles, tendons, fascia)
  2. Abnormal joint function locally, proximally and distally
  3. Abnormal/compensatory movement as a result of the above


These dysfunctions are commonly seen in the Upper Crossed Syndrome.

The Upper Crossed Syndrome

The Upper Crossed Syndrome (UCS) was first described by the  Czech physician Janda.  The UCS is also referred to as proximal or shoulder girdle crossed syndrome.

In UCS, tightness of the upper trapezius and levator scapula on the dorsal (back) side crosses with tightness of the pectoralis major and minor on the anterior (front) side. Weakness of the deep cervical flexors ventrally (front) crosses with weakness of the middle and lower trapezius (Back). This pattern of imbalance creates joint dysfunction, particularly at  C1-C2, C4-C5 segments, cervicothoracic joint, glenohumeral joint, and T4-T5 segments. 

Specific postural changes are seen in UCS, including forward head posture, increased cervical lordosis and thoracic kyphosis, elevated and protracted shoulders, and rotation or abduction and winging of the scapulae.


These postural changes also decrease glenohumeral stability  and result in winging of the scapulae.

In addition, this loss of stability results in compensatory tightening of  the levator scapula and upper trapezius to maintain glenohumeral centration (optimal joint position).


Sample Shoulder Assessment Process


Assessment Observation
Static Posture Upper Crossed Syndrome (see above)
Overhead Squat Arms fall forward

Low back arches

Horizontal abduction wall test Elbows flex

Shoulders elevate

Shoulder flexion wall test Shoulders elevate

Low back arches

Pushing, Pulling, Pressing Shoulder elevate

Forward head

Scapular winging (pushing)

Range of motion Shoulder flexion

Glenohumeral internal and external rotation

Strength Middle and lower trapezius, rhomboids, rotator cuff muscles, serratus anterior


Systematic Corrective Strategies For Shoulder Impairments


Phase Modality Muscles Acute Variables
Inhibit Dry Needling

Soft tissue manipulation

Foam Roller

Upper Trapezius

Levator scapulae

Latissimus Dorsi

Pectoralis Muscles


Cervical and Thoracic

Varies with technique

Foam Roller- Gently roll to tender spot(s) and hold position 30-60 seconds

Lengthen Static stretch Upper Trapezius

Levator scapulae

Latissimus Dorsi

Pectoralis Muscles


Cervical and Thoracic

30 second hold
Mobilize Mobilization


with movement





Cervical spine

Thoracic spine

Lumbar spine

SI Joints


Pain free mobilization with movement
Repetitions based on response
High Velocity/Low Amplitude
Activate Isolated Exercises


Middle and Lower Trapezius


Deep neck flexors

Core Stabilizers

10-15 reps

4/2/1 Tempo

4 reps

Increasing intensity (25%. 50%, 75%. 100%)

Integrate Integrated Dynamic Movements Squat to Row

Single Leg Romanian Dead-lift w/PNF pattern

Push-up Plus

10-15 reps
4/2/1 Tempo

Key Points


  • Shoulder pain is reported to occur in up to 20% of the general population and can impact quality of life as well as limit participation in athletics
  • The shoulder is a complex joint that is impacted by the neighboring joints above and below
  • Many shoulder injuries are due to a combination of:


Abnormal length-tension relationships of soft-tissue structures (muscles, tendons, fascia)

Abnormal joint function locally, proximally and distally

Abnormal/compensatory movement

  • A comprehensive shoulder evaluation should include

Static posture assessment

Dynamic movement screen

Range of Motion Testing

Manual Muscle Testing

Joint palpation

  • Systematic corrective strategies for shoulder impairments should include:

Inhibiting and lengthening overactive muscles

Activating underactive muscle with isolation exercises

Integrating compound, functional, total body exercises


Got Shoulder Pain?


Clark, M., & Lucett, S. (Eds.). (2010). NASM essentials of corrective exercise training. Lippincott Williams & Wilkins.


Page, P., Frank, C., & Lardner, R. (2010). Assessment and treatment of muscle imbalance: the Janda approach. Human Kinetics.


Scapular Dyskinesis

A Kinetic Chain Approach to Shoulder Problems



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About the Author

Dr. Geoff LecovinNaturopathic Physician/Chiropractor/Acupuncturist/Certified Strength and Conditioning Specialist/Corrective Exercise Specialist/Performance Enhancement Specialist/Certified Sports Nutritionist/View all posts by Dr. Geoff Lecovin