When I was still in school an older doc gave me some good advice. “Learn the shoulder, because everyone you treat will have a shoulder problem. It doesn’t matter if they come in for back pain, knee pain, hip pain, headaches...they will also have a shoulder problem.” Turns out she was right!
Why are shoulder issues so prevalent? A lot of it has to do with posture. Stress is a factor as well. And, our natural tendency to curl into flexion and internal rotation doesn’t help the situation.
In a perfect world the shoulder and surrounding areas would function like this:
Great mobility in the thoracic spine (upper back)
A nice stable shoulder blade
A well-centered joint where all of the muscles are at their optimal length
...which all results in flawless mobility of the shoulder joint
What I see in the office:
Completely locked up and tight upper back
A shoulder blade that has slid forward and is unable to stabilize itself
Arms that have rotated inward
A joint where some muscles are tight and others are overstretched, leading to poor centration and muscle imbalances
A tendency to lead each arm movement with a shoulder shrug (which further crowds the joint and limits mobility)
How do we treat shoulders at Blue Sky?
First we perform orthopedic tests. This lets us know exactly what structures are involved.
Next, we test for compensations. Which muscles are overactive, which ones are underactive? Using NeuroKinetic Therapy we can quickly figure this out. Common compensations are overactive rhomboids / underactive lats; overactive subscapularis / underactive infraspinatous or overactive levator scraps / underactive serratus anterior.
While these are common patterns I have definitely found with NKT testing that sometimes these patterns are the opposite in some patients. This is why I love NKT, we can test instead of guessing. Precision matters.
Simple homework will clear out the compensations, and then we can work on bigger movement patterns. The first step is building awareness of what it feels like to not shrug the shoulders as part of your movement patterns. We work on scapular engagement and stability. Which sounds complicated, but can be achieved with two simple exercises that come from developmental patterns (Dynamic Neuromuscular Stabilization exercises).
At the same time as you are re-programming your movement patterns we also work on increasing mobility in your upper back with gentle adjusting and muscle work. Also, since the neck and shoulder share many common muscles, we make sure the neck is functioning at full mobility and stability.
Another key is releasing any neural tension in the shoulder. With Neural Manipulation (learned through the Barral Institute), I can gently release the suprascapular nerve, dorsal scapular nerve, and brachial plexus. It’s amazing how much more motion can be achieved after this gentle work.
While this all sounds rather lengthy and involved, I’ve found that (for folks who are committed to their homework) great results can be achieved in 1-3 visits. Precise bodywork and smart movement patterns can make all the difference in quickly digging out of pain.
I have pain with overhead movements. What's that all about?
This is commonly called impingement syndrome. What that means is that the supraspinatus tendon is getting pinched between your shoulder blade and your humerus (arm bone). Commonly folks with this will have what is called a “painful arc” where there is pain while lifting the arm to a certain angle, and then after that angle movement becomes pain-free again.
The key to fixing this is creating more room for the supraspinatus tendon with a combination of thoracic (upper back) mobilization, scapular stabilization, external rotation, and better movement patterns. Also, with NeuroKinetic Thearpy, we can check for compensations that may be leading to the poor movement patterns in the first place. That way the pain won’t keep coming back.
There are some great developmental movement patterns from the Prague School / Dynamic Neuromuscular Stabilization folks that teach the body to instinctively move the shoulder with the joint in perfect centration so that there is no longer any pinching. Plus, the movements are super fun!
I have pain on the front of my arm when I reach behind me.
The first thing I like to check with patients who have this pain pattern is their long head biceps tendon.
This tendon rests in a groove on the humerus. While the ligament that keeps it in place can completely rupture and cause some severe issues, for most folks the tendon is just rubbing along the lip of the groove. There’s a super simple 15 second NeuroKinetic test that I can use to determine if this is the issue. From there we work on getting the tendon back to a more central location, and keeping it there with good shoulder mechanics, with a focus on external rotation of the shoulder.
I’ve had patients plagued with this issue for years, and we were easily able to resolve it in a single visit.
Don’t even get me started on the rotator cuff
Telling a patient they have a “rotator cuff” problem is not an adequate diagnosis. The rotator cuff has four muscles. I want to find out exactly which of the four muscles are involved. Next, I want to know why that muscle is painful.
Is it tight and strong? Is it tight and weak? This is what will guide treatment.
Also, are cuff muscles doing too much work for bigger muscles that aren’t pulling their own weight?
The rotator cuff is there to center the arm into the shoulder joint. But often cuff muscles get stuck doing the job of the bigger “prime mover” muscles. That is a recipe for pain.
Think about arm abduction (moving your arm away from your body). The first 15 degrees of abduction is controlled by the supraspinatus (one of the cuff muscles) and the rest of the motion is controlled by the mid deltoid. Many times with NeuroKinetic testing we find that the big old deltoid is out to lunch, and the scrawny little supraspinatus is having to overwork as a result. Ouch! That is a recipe for pain.
Remember that the supraspinatus muscle is the one that is getting pinched in an impingement syndrome? So now it’s not only getting pinched but overworking as well. No wonder it hurts.
This is why I always check the Supra / delt relation in impingement syndromes.
Moral of the story
If you have shoulder pain please find someone that will take the time to figure out the EXACT structures involved and who will also work with you on your movement patterns. If they tell you it’s a “rotator cuff problem” but offer no more information than that, then keep looking. And, find someone that can teach you good shoulder patterns. If you don’t fix the underlying movement problems it’s like constantly picking a scab. The tissue will not be able to heal as it will constantly be irritated.