Shoulder problems are rampant in modern society and are a common complaint of clients I see regular. While shoulder impingement, rotator cuff syndrome, and tendonitis are common clinical diagnoses, most shoulder problems share a common etiology: poor scapulothoracic stabilization. Common treatments — including joint and soft tissue manipulation, stretching, medications, heat, and electrical muscle stimulation — rarely succeed in providing significant long-term benefits because they don’t address the underlying stability issues of the shoulder complex. Although it is rarely discussed when dealing with shoulder issues, the cervical spine is a large contributor to scapulothoracic instability.
This article will discuss the relevant anatomy as well as the relationship of the cervical spine to shoulder instability and identify some of the commonly overlooked signs of both cervical and scapulothoracic instability. Additionally, this article will define a corrective and progressive exercise strategy based upon the principles of the Integrated Movement System™ (IMS)
Cervical and Scapulothoracic Dysfunction
The first step in gaining confidence when working with shoulder problems is to develop an understanding of the anatomy and kinesiology of the cervical and scapulothoracic regions. While they are not often discussed together, the cervical spine and shoulder complex are intimately related. The cervical spine is composed of seven vertebrae that blend into the thoracic region of the spine. It functions as a base for the head as well as an important attachment point for several of the muscles that support the scapulothoracic region. Several muscles of scapulothoracic complex, including the levator scapula, rhomboid minor, and fibers of the upper and middle trapezius each have attachments on both the cervical spine and scapula.
The C5-T1 cervical nerve roots form the brachial plexus as they exit the foramina. The brachial plexus exits the neck between the anterior and middle scalene, travels underneath both the clavicle and the pectoralis minor prior to innervating the structures of the shoulder and upper extremity.
These relationships are important to understand, since dysfunctions in both postural support or proper movement patterns can have significant impact on the function of the shoulder complex. For example, disc herniations are a common cause of neck pain and dysfunction. Radicular symptoms such as numbness and tingling are usual symptoms of disc problems, but several other patterns often precede these symptoms. Decreases in internal shoulder range of motion and chronic trigger points in the levator scapula and rhomboid minor are two common early signs of irritation of the cervical nerve roots. While clients can experience problems at any disc level, C5-6 is the most common level for cervical disc bulges and herniations. Not so ironically, the nerve roots C5, 6, and 7 innervate the serratus anterior and disc irritations of the C5-6 level can be a cause of serratus anterior weakness and subsequent instability or winging of the scapulothoracic region.
This cervical instability must be improved when dealing with scapulothoracic dysfunction or there will be no long-term solution to these movement dysfunctions. While there are several causes of cervical instability, two of the more common ones include the forward head syndrome and downward scapular rotation syndrome. Their relation to scapulothoracic instability will be discussed below.
Forward Head Syndrome
Downward Rotation Scapular Syndrome
The “levator scapula sign” occurs when the scapula is insufficiently stabilized along its inferior border by the inferior fibers of the serratus anterior and lower trapezius. As the athlete performs a pushing or pulling pattern, rather than remaining stabilized, the superior angle of the scapula moves superior and medial on the thorax, and there is prominence of the levator scapula along the lateral aspect of the neck (see Figure 2). In addition to prominence of the levator scapula, hypertonicity can be palpated within the levator scapula as the athlete performs her patterns. Over-activation of the levator scapula also contributes to hyperextension of the mid-cervical spine as the levator scapula also functions as an extensor of the neck. This is a dysfunctional pattern that encourages downward rotation of the scapula especially when there is subsequent over use of the pectoralis minor as a primary respiratory muscle.When there is over-activation of the downward rotators of the scapula (pectoralis minor, levator scapula, and rhomboids), it is common for athletes to struggle with scapular stabilization. This patterning can be viewed in several upper extremity patterns however is easiest to see as the athlete returns their arm from the overhead position (see Figure 3). Notice how the inferior angle of the scapula moves away from the thoracic cage as the arm is lowered — and this is without any weight in the arm. It is important to look and/or palpate for this instability as this dysfunction will only be exacerbated as the arm is loaded. Improved scapular stabilization must be achieved prior to progressing the athlete to the fundamental pushing and pulling patterns or the athlete will further ingrain these poor habits.
These altered stabilization and movement patterns can lead to a host of additional shoulder and upper extremity conditions, including thoracic outlet syndrome, bicipital tendinopathies, and rotator cuff syndromes. Therefore, the corrective strategy for these conditions (as well as the forward head and downward rotation syndrome) is to improve respiration, stabilization, and integration of the fundamental movement patterns.
Integrating the Respiratory, Stabilization and Movement Systems
To specifically address the three most common causes of movement dysfunction — poor respiratory patterns, poor stabilization, and improper progressions of the fundamental patterns — the fitness professional must focus on improving the three principles of human function:
Respiration must be optimized; otherwise, no other movement can be optimal. Proper diaphragmatic respiration must be established to ensure both optimal oxygenation as well as proper stabilization of the spine and thorax. In fact, faulty respiratory patterns have been linked to overall poor health in addition to poor stabilization of the trunk and spine. The diaphragm has been shown to have a role in both respiration and stabilization (Richards et al., 2004) and faulty patterning of the diaphragm has been indicated in dysfunctional stabilization of the trunk and spine (Hodges et al., 2001; Kolar, 2009).
Once optimal respiratory patterns and core activation have been established, the athlete can be progressed to restoring optimal scapular mechanics. Recall that stabilization of the scapula against the thorax and control of upward rotation must be established prior to loading the upper extremity. Research has demonstrated that the push-up plus (push-up with an additional protraction component) and dynamic hug (fly pattern performed with resistive tubing or cables) patterns are two exercises that effectively activate both the serratus anterior and subscapularis, two muscles that have been linked to shoulder instability (McClure, 2006). In reviewing the literature, it would be logical to include these two exercises in a corrective exercise routine for athletes with scapulothoracic or glenohumeral instability. However, when reviewing research it is important to understand EMG studies are limited in that an EMG only records muscle activity, not whether or not the muscle is actually being activated to perform optimally. This is where the athlete must be diligent in understanding both the research as well as the optimum functional kinesiology of a muscle prior to instituting a corrective exercise program.
There is no arguing the fact that the serratus anterior is heavily recruited during a push-up plus motion. In addition to its stabilization function, the serratus anterior functions as a strong protractor of the scapula. However, the serratus anterior must also adhere the scapula to the thorax cage and decelerate the humerus as the arm returns from overhead motion, two functions that are not guaranteed during the push up plus. Yes, it is maximally recruited during a push up plus, but does this prove that the scapula is under any better neuromuscular control than in other functional positions? Unfortunately, it does not. This is not to say that the push-up plus cannot be an effective exercise as part of a progressive rehabilitative program but rather point out its limitations if used early in the rehabilitative process.
Recall that most shoulder problems — as well as problems in the low back, neck, etc. — are not strength issues; they are motor control issues. Applying more strength will only benefit the athlete who has a defined weakness and who possesses optimal neuromotor programs. Adding strength does not ensure anything except that a athlete will get stronger. Adding strength to a client with poor neuromuscular patterns only ensures that the athlete will continue to compensate and use the same patterns they have habitually used.
The following series of exercises is key in establishing both optimal stabilization as well as movement awareness of the scapulothoracic and glenohumeral regions. Movement awareness is the most overlooked component to corrective exercise as the client must be made aware of how they are currently moving as well as what ideal patterns look and feel like. These patterns include the quadruped with arm reach, the wall plank with arm reach, and shoulder rotation patterns. It is important to remember that the goal of these patterns is to improve neuromuscular control of the scapulae and spine stabilizers, so it is important that the early phases of corrective exercise emphasize this point.
The wall plank is an excellent pattern to establish both optimal scapular and spine alignment, as well as activation of the deep intrinsic stabilizers of both regions. In Figure 4, the athlete stands approximately one foot away from the wall and assumes an elbow plank position against the wall. Her upper arms are positioned level with the shoulders and she is cued into a neutral spine and scapular positions. These cues include:
She slides one arm up the wall while stabilizing the opposite side and returns to the starting position. She repeats on the other side for the desired number of reps. It is important that the athlete controls the lowering of her arm (eccentric control) as she returns to the starting position. Equally important is that she maintains stability in the stationary arm, as the goal is to improve the stabilization function of the scapular stabilizers. Be sure to monitor for excessive levator scapula activity by observing the lateral aspect of the athlete’s neck.
Quadruped with Arm Reach
As shown in Figure 5, the quadruped pattern begins with the athlete positioned in a quadruped posture with her elbows shoulder-width apart. She establishes neutral spine posture and the image of a long spine (as if someone is pulling her head by a string). She activates her serratus anterior and lower trapezius and maintains this activation throughout the pattern. She reaches one arm out as far as she can without losing scapular or spine position and returns to the starting position. She repeats on the other side, alternating each side until completed the desired number of reps. As with the wall plank, it is just as important to maintain stability in the stationary arm as the goal is to improve the isometric function of the scapular stabilizers. Be sure to monitor for excessive levator scapula activity by observing the lateral neck.
Reversed Rotator Cuff Patterns
The closed chain rotator cuff pattern is an excellent pattern to incorporate the scapular stabilizers as well as the muscles of the rotator cuff, specifically the subscapularis. Most rehabilitation exercises for the rotator cuff begin with fixation of the trunk and rotation of the humerus on the scapula, which is in direct contrast to the patterns that occur during development. As the child learns to crawl, he moves the scapula over a fixated humerus thereby developing optimal rotator cuff function. This concept will be used to incorporate rotator cuff function with scapulothoracic stability. Please note that because this is a higher-level pattern, it must only be performed by athletes that have established optimal stability of the cervical, scapulothoracic, and glenohumeral regions.
The athlete should begin by holding onto a barbell secured to a power rack before progressing to the TRX version — both are demonstrated below. The athlete begins with a very shallow angle of incline and then lowers his body as he develop stability and strength. The athlete grasps the bar or handles (see Figures 6 and 7) and stabilizes his scapula and spine. He reaches to the side with his free arm without losing the scapular control of the fixed arm or alignment of the spine. He rotates back to the starting position and repeats for the desired number of repetitions on each side. The rotation occurs around the glenohumeral joint making these patterns essentially a reversed rotator cuff exercise for the stationary arm.
Sets, Reps, and Tempo
Quality over quantity should always be
stressed whenever attempting to improve motor patterns. The first two patterns
— the wall plank-reach and the quadruped reach — are designed to improve
stabilization and motor control and are generally not taxing to the endocrine
or nervous systems. Therefore, these patterns need to be performed every day to
improve motor control as well as awareness and can be done so without much worry
of over-training. The athlete will perform these patterns 2 times per day for
5-10 reps per arm with a 2 second concentric and 2 second eccentric phase. This
is a great posture relief exercise for athletes who work long hours at a desk
The reverse rotator cuff pattern is a higher level pattern and can easily lead to an over-trained or fatigued rotator cuff. This pattern will be performed 2-3 times per week for 2-3 sets of 8-12 repetitions.
Once an athlete achieves optimal respiration and stabilization, they must be taught how to integrate these into the fundamental movement patterns including pushing and pulling patterns. During pushing and pulling patterns, the scapulae must remain stabilized on the thorax. As the arm is lowered from overhead, the scapula must be eccentrically controlled throughout the entire motion. This same eccentric control must be adhered to during the eccentric phase of the dumbbell or cable chest press.
The one thing that all upper extremity syndromes — including thoracic outlet, carpal tunnel, and rotator cuff — have in common: they are all a result of poor stabilization and/or movement patterns. Therefore, passive therapies, medications, or surgery are rarely a long-term solution because none of these options address the underlying stabilization or movement issues. To be a part of the long-term solution, fitness athletes must understand and be able to educate themselves about the proper methods of respiration, stabilization, and movement integration. This article described several common movement impairments that lead to scapulothoracic dysfunction and introduced the key components of integrating the respiratory, stabilization, and movement systems as a means of improving movement patterns. Hiring a sport therapist can greatly help improve and monitor these patterns, the sports therapist can become an important part of an athletes health care team and become part of the solution to the health care crisis.
Decker, D.J., Tokish, J.M., Ellis, H.B.,
Torry, M.R., Hawkins, R.J. (2003). Subscapularis Muscle Activity During
Selected Rehabilitation Exercises; The
Journal of Sports Medicine
Hodges, P.W., Heijnen, I., Gandevia, S.C. (2001). Postural activity of the diaphragm is reduced in humans when respiratory demand increases; Journal of Physiology ; 537(3): 999–1008.
Kolar, P., Holubcova, Z., Frank, C., Liebenson, C., Kobesova, A. (2009). Exercise & the Athlete: Reflexive, Rudimentary & Fundamental Strategies. International Society of Clinical Rehabilitation Specialists – course handouts, Chicago, IL.
Kolar, P., Kobesova, A., Holubcova, Z. (2009). Dynamic Neuromuscular Stabilization: A Developmental Kinesiology Approach. Rehabilitation Institute of Chicago – course handouts, Chicago, IL.
Liebenson, C. (2007). Rehabilitation of the Spine: a Practitioner's Manual . 2nd ed. Lippincott Williams & Wilkins, Philadelphia, PA.
McClure, P.W., Michener, L.A., Karduna, A.R. (2006). Shoulder Function and 3-Dimensional Scapular Kinematics in People With and Without Shoulder Impingement Syndrome; Physical Therapy; 86(8):1075-1090.
Osar, E. (2010). Assessing the Fundamentals-The Thoracic Connection- part 1. PTontheNet. Retrieved from http://www.ptonthenet.com/articles/assessing-the-fundamentals-the-thoracic-connection-part-1-3286 .
Osar, E. (2010). Assessing the Fundamentals-The Thoracic Connection- part 2. PTontheNet. Retrieved from http://www.ptonthenet.com/articles/assessing-the-fundamentals-the-thoracic-connection-part-2-3302 , June 9, 2010.
Osar, E. (2007). Improving Shoulder Function-Part 1. PTontheNet. Retrieved from http://www.ptonthenet.com/articles/Improving-Shoulder-Function---Part-1-2965 .
Osar, E. (2008). Improving Shoulder Function-Part 2. PTontheNet. Retrieved from http://www.ptonthenet.com/articles/Improving-Shoulder-Function---Part-2-3046 .
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Richardson, C., Hides, J., Hodges, P.W. (2004). Therapeutic Exercise for Lumbopelvic Stabilization: a Motor Control Approach for the Treatment and Prevention of Low Back Pain. 2nd Ed . u.a.: Churchill Livingstone, Edinburgh.
Sahrmann, S. (2002). Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, St. Louis, MO.
Article taken from PTontheNet and adapted by Apache Brave Sports Therapies
What if we told you that top athletes suffer from the same thing as you do? Inflammation happens to everyone; it is part of our body’s natural response to training and damaged tissues and also plays a role in the immune system response. With modern day advances in sport science we are now able to see just how much inflammation you’re likely to feel from a strenuous bout of activity through the analysis of your genes.
A DNA Kit test will look at four genetic inflammatory markers - IL6, IL6R, CRP and TNF. Variations in these genes give us a clue if you are predisposed to suffer significantly higher levels or slightly lower levels of inflammation. Knowing your predisposition of this biological phenomenon can make big alteration to your training and even more so to your recovery strategies which dictate your training schedule and ultimately your goals.
Acute inflammation is important for healing; however excessive inflammation can result in prolonged feelings of soreness, tenderness, swelling, and also in a loss of function (reduces ROM or range of motion) and could even result in allergies and chronic diseases. There are various strategies that can be used to help decrease acute and chronic inflammation like sports massage therapy , but for the purpose of today's blog we will be looking at foods that can help in the role of decreasing inflammation in our body:
For those people who know me will tell you I am the most skeptical person out there when it comes to new products and fad diets to aid fitness training and weight management. I go to lots of trade fairs and seminars and see lots of new products, most of the time I have made my mind up within 20 seconds. Science has to prove it works for me to believe in something, it’s the way I run my business as a sports therapist and the way I train myself.
I first saw the DNA fitness tests in 2013 at a trade show; it was not something I was not interested in at the time so I walked on by. However, after seeing these tests repeatedly pop up on trade and fitness magazines I started to take more of an interest.
Over the years I’ve personally battled with injuries from playing sport and had to deal with my own weight issues while being off sport recovering from injury. It’s what got me in to my now profession as a sports therapist; I help many athletes recover, prepare and condition their bodies ready for their events.
As a sports person you are always looking for that extra legal edge, that extra bit that will gain you a few seconds off your personal best or just be able to train and diet better for a healthier lifestyle. So I felt that taking the DNA Diet Fitness Pro test was really worthwhile.
The reports included an abundance of manageable and easily understandable information about my DNA and also provided focused and implementable advice, which wasn’t just based on eating less and exercising more. I was particularly impressed with the strength of the connections DNAFit made between my genetics and the practical implications the results might have in terms of my diet and fitness.
I would recommend this test to anyone interested in improving their health and fitness, regardless of whether you’re a complete beginner or training for a marathon.
There has been a huge increase in interest in cycling over recent years as more people become aware of the health and fitness benefits’ cycling achieves, as well as its advantages as a fast and economical means of transport. Studio cycling has also grown and has been identified as one of the most popular group exercise formats in clubs worldwide.
Good bacteria can help you lose weight
For every probiotic evangelist there are several that sneered at the idea that these ‘good bacteria’ products did anything other than leave a big whole in your pocket. But according to a recent study, probiotics are very much more than a health food gimmick.
Probiotics, which are available as yoghurts, drinks and pills, contain so called ‘good’ bacteria that manufacturers claim aid digestive health and boost the immune system.
But the jury remained out – until now when a study has found that they do have many health benefits, including proving effective medicines and helping to control weight.
But you need to need to use the probiotics every day to see any benefits and you should be mindful of the sugar content (it’s best to opt for a pill over yoghurt) which will negate any of the benefits.
The definition of motivation is that which gives the impetus to behaviour by arousing, sustaining and directing it towards the successful attainment of goals. Abraham Maslow (1954) proposed that we all have a hierarchy of needs, the most basic being physiological needs such as food, and the highest needs being those related to self-fulfillment. Motivation directs behaviour – it organizes behaviour towards a particular goal state. It maintains behaviour until that goal is achieved.
The marathon is a long-distance running event with an official distance of 26 miles and 385 yards that is usually run as a road race. The marathon was one of the original modern Olympic events in 1896, though the distance did not become standardized until 1921. More than 500 marathons are contested throughout the world each year, with the vast majority of competitors being recreational athletes. Larger marathons can have tens of thousands of participants.
Although, all of the information that is presented in this article is geared toward the benefits and/or effectiveness of anaerobic high intensity interval training (HIIT) vs. low intensity aerobic training with regards to fat utilization, there is an understanding that some reasons for aerobic training supersede the outcomes. For the sake of pure enjoyment, personal goal setting (training for a triathlon, marathon, road race, etc), and the challenge of competition are all viable and respectable reasons for interacting with long slow distance (LSD) activities. For many people these types of activities are suitable for their lifestyle and enjoyable means of living an active life. The goal of this article is not to discount or diminish the value of physical activity in all its modalities, but to merely present data with regards to optimum fat loss, hormonal indicators, and other factors of cardiovascular and cardio respiratory markers as they pertain to exercise intensity prescription.
In the world of endurance, it seems that you cannot discuss fitness without discussing VO2 max. Ask any endurance athlete about it, and you will hear epic stories with names like Indurain, and LeMond. Many of you, however, may find yourselves wondering what exactly VO2 max is and why is it so important. To better understand this concept; let’s take a little trip back to school, specifically back to physiology class. According to the Essentials of Strength Training and Conditioning textbook, VO2 max is the maximum amount of oxygen in millilitres one can use in one minute per kilogram of body weight (ml/kg/min). In other words, maximal oxygen uptake (VO2 max) is the greatest amount of oxygen that can be used at the cellular level for the entire body. VO2 max has been found to correlate well with an individual’s degree of physical conditioning and has been accepted as an index of total body fitness. Numerous studies show that one can increase his/her VO2 max by working out at an intensity that raises the heart rate to between 65 and 85 percent of its maximum, for at least 20 minutes, three to five times per week. The estimated mean value of VO2 max for male athletes is about 3.5 liters/minute and for female athletes is about 2.7 liters/minute.
It is ironic that in this age of information, people continue to be confused about supplements. While in The UK alone, billions of pounds sterling are spent annually on vitamins, minerals, herbs, amino acids and other nutritional products, studies still show that people in all walks of life (including fitness professionals) need a good foundation in basic supplement information to help them make informed decisions about which products might best suit their individual needs. Because of this, the following is a list of what I feel are the top 10 supplements facts that can help save you time and money - and get the most out of the products you use.
Caffeine is one of the most heavily researched and beneficial ergogenic aids available. It is mostly consumed in coffee, with 1 cup containing around 75mg of caffeine. The understanding of the performance effect of caffeine has increased and this has widened its use. Most people know that “caffeine may improve performance” but what does it actually do and how can we make the most of caffeine?
Caffeine is classified as a stimulant and is the most common drug used in the world. Caffeine crosses the membranes of all the body's tissues. It can wield effects on the central nervous system and the peripheral tissues that result in physiological effects. Studies have shown that caffeine can help an athlete perform better. It has been shown to be a powerful ergogenic aid that is beneficial in athletic performance and training. Caffeine has been shown to increase speed and power output, improve the length an athlete can train, and assist the athlete in resisting fatigue. Caffeine has also been proven to stimulate the brain which contributes to an athlete's clearer thinking and ability to concentrate harder on the task at hand.