As discussed in my last post, I treat my shoulder patients differently now compared to a few years ago. When I say ‘shoulder problem’, let’s get specific. There can be a ton of things happening in the shoulder and discussing every possibility is way beyond the scope of this blog post. In my practice the most common shoulder problem I have seen so far is shoulder impingement with a gradual and insidious onset of symptoms rather than traumatic episodes (also very common- rotator cuff issues in overhead athletes). Let’s discuss shoulder impingement briefly. It is simply pinching of the rotator cuff muscles, tendons and bursa between the upper end of the arm bone (head of humerus) and the tip of shoulder blade called acromion especially with arm elevation or overhead activity.
Common patterns I find in these patients-
1. The typical upper crossed posture– I place this on my número uno common pattern for shoulder dysfunction because I see this all to often and I have ignored this in the past. Now who doesn’t have a rounded upper back with shoulders rolled in and forward neck posture. After all we live in this posture, sitting in our chairs in front of the computers, TV’s etc. Now over a period of time the thoracic spine gets quite stiff and you will observe lack of thoracic spine extension. So a stiff thoracic spine will affect the scapulo-thoracic joint causing the scapula to be stuck in a more protracted, downward rotated and anteriorly tilted position causing compression of the sub acromion space as your patient moves his arm up causing impingement. This brings me to my favorite point, Often the cause of pain might be away from the site of pain and needs to be worked on equally or more even though the patient has no complains there. While they might question your actions initially (patient education), we should know better than to run after symptoms.
2. Posterior rotator cuff weakness– think teres minor and infraspinatus vs deltoid, think small vs big, David vs Goliath (may be an exaggeration in some cases or may not). One of the actions of the deltoid apart from abduction is superior translation of the humeral head. To counter that the primary action of the rotator cuff muscles is holding the head of the humerus into the glenoid cavity. If the posterior cuff is weak and is already small it will not be able to counteract the superior pull of the bigger deltoid on the humerus head causing it to jam into the sub acromiom space causing – impingement. Ever had novice bodybuilding enthusiasts come to you complaining of pain in the shoulder with overhead press. Ask them their shoulder routine and you will tend to find a lot of military press and side flies for deltoid hypertrophy with very little or no external rotation exercises for teres minor and infraspinatus. So while they might feel they are working on shoulder strengthening, it might be feeding into the dysfunction. This picture sums the force vector of the above muscles well. (While the figure shows only supraspinatus, we know the force vector is same for the rotator cuff. Remember primary action is not rotation at the shoulder but holding the humeral head in the cavity)
3. Upper to lower trap imbalances– as we all know most of us have this dysfunction where the upper trap is over active and the lower trap lies in dormant hibernation. What results is inability to posteriorly tilt the scapula during elevation (blame weak lower trap) leading to the anteriorly tipped acromion (blame overactive upper trap) compressing the sub acromion space causing – impingement. Take the example of the body builder again, does he do shoulder shrugs on “shoulder day”. Hell ya he does and can you blame him? The ladies love it!! Incorporating a lower trap corrective exercise drill is paramount in these cases.
4. The evil Pec. Minor– pec minor tightness and upper crossed syndrome often go hand in hand like peanut butter and jelly or ‘Vikram-Betaal’ (this weird analogy may or may not resonate with you, but I write this after a long day at work and late into the night). A tight pec minor exerts a medial pull on the long head of the bicep tendon sometimes pulling it out of the bicipital groove. Now going back to anatomy, the long head of the bicep attaches to the glenoid labrum and a positional dysfunction in this muscle can most definitely cause shoulder discomfort. Those who know me from my college days know I was a very big proponent of the MULLIGAN CONCEPT (still am) and the posterio-lateral MWM’s glide to the shoulder has provided me excellent results in the past. However, those familiar with Brian Mulligan’s work know that his concept does not explain very well why the therapy works the way it does sometimes giving the impression of ‘voodoo witchcraft’ which is great; but I have had some of my patients return after a week with reoccurrence of some discomfort and pain. I am no longer contend with this explanation and I feel we might not just be placing the shoulder in a retracted position but also might be unintentional placing the tendon back in the groove with the lateral push (think of the hand grip, it’s very close to the tendon. Thoughts??). While this approach is downright awesome to perform it makes me wonder; am I chasing symptoms again?? Hence, pectoralis minor soft tissue release is always on my agenda (so common in geriatric patients!!).
While there are a lot of other issues that could cause the dysfunction and this is not the complete picture, these are some of the very common patterns that I find and address with my impingement patients. Part 2 of the blog will be my first video blog where I will perform some corrective exercises mentioned above and post the videos. I will make this into a social experiment partly on myself as I find myself often falling into the dreaded excessive thoracic flexion.
For those already doing this, I’m sure their patients are thanking them, for those who haven’t, I urge you to think out of the box. My days of only ultrasound, ESTIM, coddman’s exercises (yawn), finger ladder and that gigantic wheel on the clinic wall(can’t even remember it’s name) are long over. Treating pain and not the underlying cause is a great disservice in my opinion and I will be the first to admit on this blog that I was guilty of it. Like my mentor said in one of the courses I took a few months ago, “If you did it unintentional and did not know better you are excused, but from this day onwards if you still do the same thing, you are only pretending to help”!! Let’s not be that person. Comments are welcome.
Abhijit Minhas PT