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)
The are 4 primary joints that make up the shoulder:
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|
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 *|
*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:
- Abnormal length-tension relationships of soft-tissue structures (muscles, tendons, fascia)
- Abnormal joint function locally, proximally and distally
- 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
|Static Posture||Upper Crossed Syndrome (see above)|
|Overhead Squat||Arms fall forward
Low back arches
|Horizontal abduction wall test||Elbows flex
|Shoulder flexion wall test||Shoulders elevate
Low back arches
|Pushing, Pulling, Pressing||Shoulder elevate
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
Soft tissue manipulation
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
Cervical and Thoracic
|30 second hold|
|Pain free mobilization with movement
Repetitions based on response
High Velocity/Low Amplitude
|Middle and Lower Trapezius
Deep neck flexors
Increasing intensity (25%. 50%, 75%. 100%)
|Integrate||Integrated Dynamic Movements||Squat to Row
Single Leg Romanian Dead-lift w/PNF pattern
- 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
- A comprehensive shoulder evaluation should include
Static posture assessment
Dynamic movement screen
Range of Motion Testing
Manual Muscle Testing
- 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.
A Kinetic Chain Approach to Shoulder Problems
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