From an upcoming, much longer, post detailing my visit to Stanford University’s Clinical Anatomy Lab, where I worked with cadavers:
Two common ways people go about alleviating shoulder pain is 1) Pulling the shoulders down and back and 2) Working the arms in the scapular plane. I’ve indirectly covered why the “Down and back” cue is poor. Examples here and here, and I’ll write directly about it in the future.
The instructor and I went over the scapula and the planes of motion, and something else regarding these cues clicked in my brain. In a normal scapular alignment, the scapular plane is 30 degrees from the midline. Essentially, you lift your arms in a V motion.
However, focus on pulling your shoulders down and back and you change where the scapular plane is. It moves from 30 degrees to however far back you’re pulling your scapulae.
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“Shoulders back.”
Per the links above, most people don’t need more scapular retraction, which is what happens when people pull their shoulders back. Next, the combination of telling people to pull their shoulders back and work them in the scapular plane is likely causing the person to not work the arm in the scapular plane, because you’re changing where their scapular plane is.
Keshava
December 30, 2013
It’s a common plan of many trainers to use a safety-first approach to shoulder pain when pressing overhead or pulling. The problem is many trainers focus exclusively on the OSTEOKINEMATICS (gross motor function at joint) but pay little, if any, heed to the corresponding ARTHROKINEMATICS (small movements of bones at joints surface). I speak to many of the trainers where I work and discuss elements of movement at the joint surface like gliding, rolling and spinning. Therefore we need a strategy to create space at the shoulder joint by using scapular action smartly.
A simple (but by no means exhaustive) plan for movement at the shoulder is to educate the client on the motor patterns relevant for anterior/posterior glide of the scapula, which in turn has a feed forward effect on anterior/posterior humeral glide. Then an analysis of the muscular actions and tensions that may allow/prevent such actions from happening, such as hypertonic subscapularis shifting the posterior glide responsibility to the lats and pecs, etc. Light cable work, soft tissue work and motor control exercises can then be graded to work the continuum from rehab to prehab to training, and is the start point I use to help people with chins/rings work/handstands etc.
By utilising this concept of varying kinematics on a joint, we can then make sense of ideas like joint centration and cues which allow the individual athlete/client to create the motor pattern in a way that is systematically consistent. So perhaps an interesting cue could be when pulling (row, chin, etc) to “posteriorly glide scapula while centering humerus in articular capsule”. Of course we would need to make the above comment a bit more user friendly! 🙂
Great sparks as always for discussion, keep up the great work, very much enjoy reading your discoveries and the exploratory nature of your work.
Many thanks,
Keshava
reddyb
January 3, 2014
Hey Kesh,
Thanks for the thoughtful comment.
I think a lot of what you’re getting at is it’s often not what you do, but how you’re doing it. If you keep certain principles or cues in mind -whatever is most poignant for the person- the person can do quite a bit of things. That said, certain exercises can only be modified so much.
An example I went over with someone yesterday is they have issues with anterior glide when their humerus goes into extension. To simplify, when their elbow goes behind their shoulder. This tends to be when they get pain. Now, while you could cue this person to somehow posteriorly glide the humerus back during humeral extension, you’re really playing with fire. To me, it’s just not worth it. At least until the person’s symptoms calm down, and their imbalances start to iron out.
The person asked me about doing push-ups. I reminded them to not get hung up on certain exercises, but how they do those certain exercises. They thought about it and went, “Ah, my elbows will go behind my shoulders.” For this person, even if I try to get them to posteriorly glide during a push-up, they just aren’t able to modify it enough as the elbow is going so far behind the shoulder, that humerus is going to anteriorly glide.
Going with a graded approach: I might have her do nothing into humeral extension for a while, then allow her arm to move through extension but only to a certain point (like a half push-up, floor press, chin-up), then progress to full extension in something like a push-up.
Did you make it to Canada? If so, how has it been going?
Keshava
January 3, 2014
Hey thanks for your response, very much agree with your stance. As always with the wonderful world of movement and the human body it is very important we as trainers/educators make it very clear to our clientele that we are not omniscient beings with all the answers. Facilitating movement and getting the person to take responsibility for their health is so vital, not painting ourselves as gurus, which is why I like your approach a lot.
Very much the point I was hoping to get across is that rather than pigeon-holing movement into one cue and have the person follow it mindlessly, we should provide a general template within which movement can take place, more philosophy than dictate if you will! Then as they understand more, the complexity of the movement can increase while staying true to some basic principles.
Of course all the necessary precautions vis-a-vis pain, not just forcing a range of movement because someone somewhere said its ‘optimal’ have to be taken. What you bring up is another, closely related point about regression/progression of movement. By working together with our client and getting them to dial into what they FEEL as opposed to what they think we want them to do, we start to create the range of movement that’s optimal for them, as well as the appropriate complexity of movement.
Building back the relationship of feeling what our body tells us, moving into new ranges carefully, building motor control patterns and mobilising + stretching effectively are things you speak about very eloquently. I would indeed follow a similar line to yours with your example, but always looking for a generalist approach to allow their own specific movement to develop naturally as they improved.
Am in Vancouver at the minute, am going back to London end of Jan to put on a movement seminar, then back to Vancouver and am busy building my website + getting ready for an action packed 2014!
Happy New Year my friend, hope you go from strength to strength and am looking forward to the day our paths cross!
Cheers,
Keshava
reddyb
January 6, 2014
Well said.
If you don’t mind, I’m curious how you’ve gone about starting things in Vancouver? I’m always interested in how people go about the beginning phase. If you’d rather, feel free to email me: b-reddy@hotmail.com
Happy New Year to you too !
Fred
April 2, 2014
Hi Brian,
I have very forward shoulders. I do some amateur gymnastics and rock climbing, which as you can imagine are quite lat and pec dominant (often in gymnastics you ‘hollow’ and protract the scapula as much as possible, such as during a planche). I wanted to tell you a bit about my routine to fix this and see if you had any comments. Of course, I’ve started to focus on sitting up straight and keeping my shoulders neutral.
Currently 4x per week I’m performing the overhead lat stretch you write about, scapular wall slides (back against the wall, focusing on retracting the shoulder blades), and push-up pluses (I assume that’s where you’re in a pushup position and continually retract then protract your scapula). For my overhead work, I focus on handstands while shrugging the shoulders up as much as possible.
A lot of handstand accessory work focuses on shoulder dislocates to ‘open up’ the shoulder – I’m concerned this will make things worse as I think it stretches the front of the shoulder. Also, would the cross-body stretch be any help? I believe it stretches the posterior shoulder capsule.
Best,
Fred
reddyb
April 4, 2014
Hey Fred,
It’s quite rare I ever implement scapular retraction work (in someone who is trying to improve their shoulder health). Especially when you’re doing such a high volume of downward rotation work.
I’d take a look at the overhead work I outline here: http://b-reddy.org/2013/09/05/a-progression-to-lifting-your-arms-overhead-pain-free/
I also talk about the push up plus, and why I avoid it, here: http://b-reddy.org/2013/07/25/musings-on-scapular-winging-anatomy-muscular-and-nerve-causes-and-exercise-considerations/
The shoulder dislocates can be ok, as long as you don’t go nuts with them. Cross body stretch is alright. Nothing bad about it; nothing great about it.