Often with shoulder pain the injury can be influenced by restrictions and muscular tension further down the 'chain of muscular activity'. With any single contraction there are a number of synergists or ‘helpers’ along with antagonists (muscles that act against the contraction) and stabilisers. Focussing beyond the initial elements, are muscles concerned with peripheral skeletal elements that act along with the nominated joint to assist fluid and functional movement. For example, a wrist can influence how the shoulder moves, if you are picking up a heavy object. So let’s look at some of the other contributors that can add or subtract from shoulder pain.
Often as a therapist when looking at the shoulder, I look at the ribs and thoracic cage as a clue to what may be contributing to poor movement. In overhead extension of the shoulder, the ribs can be restricted by intercostal muscles (muscles in between each individual rib) which create bio-mechanical adaptions decreasing the ability of the shoulder and in particular the scapula, to retract and rotate downwards which is vital for joint movement. Restriction in the ribs does not allow for lumbar extension that will assist the shoulder and scapula to extend and perform the overhead movement. Alleviating tension here can make this movement not only easier, but also more efficient. This is particularly relevant to Olympic Lifters or Power Lifters performing overhead movements. Rib cage flexibility is most important to performing the overhead press or snatch lift.
The Biceps Brachii can contribute to forward rotation of the scapula due to it’s insertion point at the coracoid process. Issues here can result in impingement which was discussed in our first article on Shoulder Pain. If the Biceps Brachii is tight or restricted (particularly the short head) this can pull on the coracoid process which encourages a forward rotation of the scapula and a ‘rounding’ appearance of the pectoral girdle. The ability of the scapula to retract is vital for any movement involving pushing or lifting. Draining through the biceps tendon can be an effective way to assist with retraction of the scapula as well as lateral rotation of the humeral head and re-gaining pain free movement.
Similarly the Supinator muscle (muscle on the inside of the elbow) which laterally rotates the forearm against the humerus, can contribute to inward rotation of the arm at the elbow which can restrict flexion of the shoulder. The Supinator along with Brachioradialis (elbow flexor located near the elbow) can contribute to restricted action of the shoulder particularly when the elbow is fully extended. Brachioradialis is very paticular here as it is one ofthe primary elbow flexors and can influence the load on biceps brachii and the shoulder as a stabiliser. This is particularly relevant when performing the standard Biceps Curl, the inability to open the forearm can result in an internal rotation of the humerus and consequently the shoulder can be internally rotated at the joint. Releasing at both these muscles can assist with the efficient use of other muscles (such as the Coracobrachialis) which act on the shoulder.
Of course these types of issues are secondary to the primary problems associated with shoulder flexion/extension but often, as a therapist, working along these lines is where we can reinforce efficient and better technique in the movement of the shoulder. They are also advantageous when you are in the secondary stage of rehabilitation where acute pain is donwgraded, but functional movement is still restricted. Detailed work here can contribute to effective bio-mechanics of the joint for future pain free movement.
Looking beyond the issues of the joint itself can often lead to better response, particularly where a long term or chronic condition has led to bio-mechanical adaption. Any movement involves a ‘chain’ of muscles that act to support and assist the joints concerned. These can be traced from the most distant part of the skeleton back to the origin of the joint and thus have a major role in helping to retrain and re-establish efficient movement and function. Sometimes looking further afield can bring about results that enable movement.
If we look along another line of influence issues in the shoulder can also be found in the neck. With the humeral head being somewhat 'dislocated' the arm appears to fall away from the shoulder, which has a major influence on the alignment of the neck. The head sits on top of a triangle formed by the clavicle in the front and the scapula in the back. So any issue which affects the alignment of the scapula is going to have an ongoing issue further up the chain, ie in the muscles of the neck. (more on this is Wry Neck Syndrome). So you can imagine how messy the whole process becomes with each seperate issue contributing to the other.
This is a common problem with treating shoulder issues. Once you evaluate a cause and treat it, you can then become aware of other issues that are deeper, or hiding behind the previous issue. That 'push/pull' principle brings into play so many muscles that you can't attend to one and not address the other. They are all finely tuned to each other and like a series of elastic bands pulling on a teacup balanced in the middle, tension release too much in one direction results in the whole balancing act tipping over.
So in analysing what issue is presenting in your shoulder, there is always the other side of the coin in what 'you' the athlete can do. If you aren't doing your 'homework exercises' you are only contributing to the injury. There are a whole range of exercises that need to be administered and also in the right combination. This is where it gets very tricky, analysing which injury is most primary and accordingly prescribing the most appropriate exercises to get the shoulder working well.^ We will talk about this more in detail later in the series.
Often you will find with shoulder pain that you need to 'chase it around' a little. If it moves slightly from the front to the back, you can see how you must address different types of exercises and accents to ensure you are constantly getting that balance right. Upward motion, downward rotation, internal and external rotation, internal and external rotation WITH flexion... the list goes on. And we will talk more about these later.
It is a slow process and takes time, but if you follow the treatment plan and are regular with your own homework, this condition can be alleviated WITHOUT SURGERY. Full recovery doesn't occur in the clinic alone, it needs to come from those all important exercises and conditioning which all TAKE TIME. So be diligent and consistent.
As with most injuries but especially with the shoulder, it is not a case of a blanket approach. There are specific issues that can mask or hide the underlying cause of pain and injury. A good assessment is key to identifying the primary cause, and continual assessment in this case is particularly advised. The shoulder is the most flexible joint in the skeletal structure and as such, relies on a multitude of various contributing factors to achieve complete, pain free movement. So always seek the advice of your therapist and have a targeted approach to your program.
*supraspinatus/infraspinatus/ teres minor/ subscapularis