Shoulder / ПЛЕЧИ: Rotator cuff strength or scapular stability…What comes first?

http://jessephysio.com/2013/01/02/rotator-cuff-strength-or-scapular-stability-what-comes-first/

Just like a house, which requires a strong foundation to stay supported, so does the glenohumeral joint of the shoulder complex. Although a thorough anatomy review is beyond the scope of this blog, I feel a few key concepts need to be reviewed. The only thing connecting the shoulder complex to the rest of the body is the scapula via the acromioclavicular joint. Some argue that the scapulothoracic complex is a joint but I will argue that is it most definitely not! It’s just a bone (the scapula) sitting on top of the ribs…no joint there. Anyways…

Since the scapula is the only thing connecting the shoulder to the rest of the body, it only stands to reason that it is the foundation from which the shoulder can function optimally. Therefore, I see very little use in training the rotator cuff muscles without first addressing scapular stability AND mobility. Too many clinicians focus on just scapular strengthening exercises without addressing scapular mobility first when they have a client with shoulder pain. For example, if levator scapula is tight, what will it do? It will downwardly rotate the scapula placing it in a disadvantageous position for glenohumeral joint mobility. If pec minor is tight (and who’s isn’t?) what will it do? It will anteriorly tip the scapula lifting the inferior angle off the ribs creating issues for lower fibers of trapezius to aid in upward rotation. Therefore strengthening lower fibers of trap without FIRST addressing pec minor tightness is less than ideal. You will never be able to achieve strength goals until the scapula is sitting flat against the ribcage with the spine of the scapula at around 15 degrees of inclination.

Furthermore, thoracic spine position is critical to scapulohumeral rhythm. An article was just published in the latest JOSPT (December addition) that dealt with the beneficial affects of thoracic spine manipulation on rotator cuff tendinopathy/pain. It only stands to reason that if the upper back is moving better, the scapula can move better, therefore allowing the rotator cuff to act as a humeral head stabilizer instead of a prime mover…which it often has to do in the case of kyphotic postures. So, hypothetically if the thoracic spine is mobile and upright, the tendons of the rotator cuff can “relax” and thus decreasing the inflammatory response due to impingement or overuse.

The beautiful thing about this model is that is applies to so many “shoulder related’ conditions. Thoracic outlet syndrome (TOS) is a function of muscle imbalances and posture. Studies are showing that cervical radiulopathy is also a function of thoracic spine and scapular positioning. Even distal conditions like carpal tunnel syndrome and tennis elbow can be traced back to shoulder positioning (not all the time, but it’s always something a prudent clinician should check).

Conditions such as rotator cuff or long head of biceps tendonosis, upper limb nerve entrapments, and even labral tears can usually be traced back to scapular positioning. But what can we do about this? How do we train the scapula more optimally? Here is the key: STOP doing external rotation exercises for the rotator cuff to fix scapular positioning I see it all the time and it drives me nuts.

Now I will outline a summery of what I feel needs to be done to addresses many shoulder- related issues:

We all know that we should balance our pushes and pulls, especially with regards to our bench pressing and rowing, right? But what if it’s not so simple a relationship?

In essence, what we’re looking at here is balancing our ability to protract and retract the scapulae. Bench pressing is a horizontal pushing movement that you’d think normally produces protraction (forward movement of the scapula around the ribcage) and trains the muscle that cause protraction, a.k.a. the serratus anterior. The logical opposing movement would be a row of some sort. Balanced, right? Wrong.

Question: What’s the most effective scapular position to maximize bench press performance?

Answer: Retraction and depression

Question: What scapular position is achieved in the contracted phase of a rowing movement?

Answer: Retraction and depression

Balanced? Nope.

Get it? What looks good on the outside, feeds an imbalance on the inside. Serratus anterior becomes ineffective as a protractor, stabilizer, and upward rotator. Then there’s an added bonus. But first a quick anatomy lesson.

Next time you’re cutting on a cadaver (What? Doesn’t everyone?), check out the serratus anterior and the rhomboid. What you’ll find is that because of the fascia that covers everything in the body, they’re essentially the same muscle with the scapula kinda stuck in the middle.

So if the serratus anterior isn’t fully effective at producing an upward rotation force and the rhomboid (a downward rotator) is getting trained with both pushes and pulls, then guess who wins the tug-o-war with the scapula.

Correct! The rhomboids and downward rotation. This means you’re more likely to experience shoulder impingement. (thank you Mike Roberson for that great example!)

It becomes clear that one of the best ways to train the shoulder is…the PUSH-UP!!! This classic exercise is fantastic at activating and strengthening the serratus anterior as an upward rotator of the scapula. It also acts to counteract the forces of pec minor by flattening the scapula against the rib cage (fighting that anterior tilt a tight pec minor exerts on the scapula).

Lear and Gross determined that push-ups performed with the feet on an elevated surface significantly increased the activation of the serratus anterior compared to traditional push-up variations. If it’s been a while since you performed traditional push-ups, it would be a good idea to start with basic variations, but elevating the feet is a viable progression if your primary goal is improved serratus function.
(J Orthop Sports Phys Ther. 1998 Sep;28(3):146-57.)

Another clutch exercise for optimal shoulder health is the Face-Pull. This exercise works to strengthen the scapular retractors…but the beauty of this exercise is that is does so with the scapula pre-set in an upwardly rotated position. We must be careful here..too much posterior deltoid activity is no good…we want pure scapular retraction occurring with minimal humeral head elevation.

Another not so popular exercise that is often forgotten for shoulder health in the Standing Straight-arm pulldown. I love this exercise because it is dead easy to preform and coaching for it is a breeze. Very little that can go wrong here. This exercise is fantastic because it teaches the latissmus dorsi muscle to work to depress the humeral head in the glenoid without activating the deltoid. This will prevent excessive humeral head elevation with overhead reaching…a common source of pain in shoulder pathology patients.

Besides exercise, I will ALWAYS employ manual therapy to help with scapular positioning. Here is what I do:

Pec Minor soft tissue release (I would say ART but I’m not allowed…it’s like $2500 for a weekend ART course…are they serious?!?!) I digress… I pin the muscle just at its origin on the coricoid processes and passively or actively flex the arm in the plain of the scapula to release this muscle. I then do manual stretching to aid in loosening it up.