One thing I always found to be crazy is that we were given a body but have no clue how to use it. I had to wait 15 years, take driver’s ed, and pass an exam to get a license to drive. And when I got a car, there’s a book in the glove box that tells me the basics on how the car operates. That doesn’t exist for the body. You just get it, then good luck. This is my first installment of that owner’s manual that we never received. Today I’m going to cover the shoulder. This is more basic than my previous post, which can be found here.
The Shoulder Owner’s Manual
SHOULDER PATHOLOGY
If you throw a rock, you’ll likely hit someone who’s been diagnosed with shoulder pain, shoulder impingement, or a rotator cuff tear by a medical provider or by Dr. Google. Unless it is traumatic, shoulder problems usually start because of some repetitive motion that creates a shoulder blade “dysfunction” with some associated muscle length impairments. The term dyskinesia, which just means faulty movement, is applied to the shoulder blade. This can lead to shoulder impingement, which I consider less of a medical diagnosis and more of an insurance billing code. Over time, this can lead to a rotator cuff tear.
Many people over the age of 40 have a rotator cuff tear that is not painful. I’ve met people with complete tears of the rotator cuff that have no pain at all. There arm doesn’t work very well, but it never hurts. Because of how common rotator cuff tears are, they are probably considered “normal,” and the extent of the tear has to reach a certain threshold before someone starts to lose function or experience pain. That threshold is highly variable person-to-person and likely activity dependent. Other structures around the shoulder can be injured, but rotator cuff problems are more common. And despite the injured structure, the treatment typically doesn’t change.
One note on shoulder pain. The intensity of pain in the shoulder (or anywhere in the body) has little to do with whatever structural things may be going on and more so to do with how dangerous your brain THINKS a specific activity is. Upgrading the parts and improving the efficiency of movement in the shoulder can help reduce the INTENSITY of pain.
SHOULDER FUNCTION
The shoulder is a ball and socket joint, and is best described as a golf ball on a tee. Here is a basic diagram (source) showing that concept and then the overlying tissues as you move left to right. The “tee” is the socket and connected to the scapula (shoulder blade). It is 3-5x bigger than the “ball,” which is the end of the humerus (upper arm bone).
As you move your arm through space, the goal is to keep the golf ball on the tee. As you can see in the picture to the left, as the arm is raised, the entire shoulder blade has to rotate UPWARD to keep the ball on the tee. The golf ball coming off the tee isn’t necessarily bad, but it is inefficient. Quite often upward rotation limitations progress to shoulder dysfunction because of excessive movement of the ball coming off the tee.
The most efficient position for raising your arm is the scapular plane (picture on left). Additionally, the tee isn’t on the side of the body, it is slightly angled forward. So the farther back your arms goes, towards the frontal plane, the easier it is for the golf ball to come off the tee. If your shoulder is sensitive, this position may be painful.
Many complain of shoulder pain when reaching into the back seat of the car, which looks like #1 in the following video. Usually the arm is going behind the body, which is the golf ball coming off the tee. There isn’t anything inherently “wrong” with #1, it just may hurt, more so if you are trying to pick something up. A better strategy is to turn the body as well, like #2 in the video, which helps keep the golf ball on the tee.
COMMON SHOULDER LIMITATIONS
Elevation – the ability to raise your arms over your head
A quick test: Back-to-wall shoulder flexion – stand against a wall with your low back flat against the wall. You may have to bend the knees to get the low back flat. Full range of motion would be getting the thumbs to the wall without the low back coming off the wall. If you can’t reach the wall, move your hands farther apart. You will probably instantly get more motion. Also, this test is also a good drill to improve your motion. How much you need depends on the tasks you need to complete.
Thoracic spine range of motion.
Movement of the thoracic spine is pretty important. It helps you stand upright and helps you look behind you. It also is required in order to fully elevate your arms over your head. This video shows why. You can’t fully lift your arms if you are hunched forward.
Here is an easy way to assess your own thoracic spine range of motion:
Normal thoracic rotation ROM is 50 degrees. The edges of the box make a 45 degree angle relative to the body. The stick should be beyond the box edge of the side you are rotating towards. You will notice in the video that Alex is more limited to the left.
Here is a great drill to improve thoracic mobility:
If you don’t have a foam roller, you can use a pillow. If you have enough hip mobility and it doesn’t bother your back, you can just put that top knee on the ground. This is a good drill to prep yourself for lifting weights overhead, or to just move through some ranges of motion you never move through. A retest to see if it helped can be the thoracic rotation assessment, the back to wall shoulder flexion, or just seeing if your arms move higher. You don’t even having to be missing anything, sometimes these just feel good.
Shoulder rotation
Most arm movements have a rotational component to it. Shoulder elevation is caused by the shoulder blade rotating up and the golf ball rotating out. Reaching in the back seat or scratching your back requires internal rotation and shoulder extension. Here is a test and treatment to improve rotation range of motion.
So there you have it, basic function and some self care strategies for the shoulders. Congratulations if you made it this far. Feel free to keep this in your glove box.
Summary
- Rotator cuff tears seem to be “normal.”
- Routinely move your arms and body through large ranges of motion.
- Maintaining the rotational component to your upper back and shoulder joint usually is helpful for overall shoulder function.
- The drills listed may give you a temporary change, but you have to continually practices activities that you want to be good at/maintain.
3FN 