What’s in a shoulder?
To take a step back your shoulder is the joint that is formed by your upper arm bone, (humerus) and a triangular shaped bone sitting on your rib cage which we call the shoulder blade or scapula.
This complex of the two bones and the muscles working off it allow the shoulder to be the most mobile joint in the body.
Here’s a quick video to demonstrate the movements of the scapula.
There are muscles working from the scapula to the rib cage, scapula to humerus and scapula to the neck.
This dynamic complex allows us to move our arm and hand in space in a wide arc and acts as a force transmitter for the upper limb.
It also provides part of the platform for our neck to move on and is therefore really important in successful neck rehab.
How does the scapula influence your shoulder or neck pain ?
Here in lies an issue that has to be dealt with. There is no doubt that shoulder pain and neck pain can be caused or at least affected by the movement of the scapula or starting position of the scapula .
It can be related to one or a mix of the following factors:
- Muscular weakness
- tightness in the muscles
- Poor movement control of the scapula.
These factors then lead to changes in how the shoulder moves that can result in irritation in the soft tissue structures in the shoulder such as tendons or bursa.
Since some of the neck muscles attach onto the scapula any alteration in strength or movement in this region can alter forces and movements at the neck possibly contributing to neck pain.
Types of dysfunction of the scapula
Type 1 Scapular dyskinesis
This is the most common presentation of the scapula.
It is characterised by anterior tilting of scapula resulting in the lower part of the scapula, (Inferior angle) being more prominent. This may be accentuated if you put your hands on your pelvis and push into the hips. This is termed pseudo winging.
More often than note this is associated with “myofascial restrictions” around the scapula. The most likely culprits are;
- Pectoralis minor
- posterior rotator cuff and posterior capsule.
Type 2 scapular dyskinesis
Sometimes you may have heard the term winging scapula. This refers to when the long / medial border of the scapula appears to came away from the thoracic wall with movement or when the shoulder is lifting a weight.
Here is a great example of winged scapula in an individual.
It can be caused by the nerve that supplies some of the scapular muscles : the long thoracic nerve or weakness of the serratus anterior muscle and in some cases portion of the trapezius muscle.
This type of presentation is more likely to be helped with a strengthening and movement control type approach.
Alternatively there is another observation called pseudo winging, which is effectively the inferior angle of the shoulder blade becoming more prominent. This is probably more an issue with overactivity of pec minor and the posterior rotator cuff and may respond better to a stretching type program
However just because winging or pseudo winging are present it does not mean that it is the primary issue in your shoulder pain or neck pain.
Type 3 scapular dyskinesis
This is characterised by Upper and medial border of the scapula being more prominent and can give the appearance of having a long neck.
This is often the result of:
- tight levator scapula and rhomboid muscles.
- Weakness in mid to lower trapezius.
Which of these is most important in shoulder or neck pain ?
The most important factor is to Identify what activities are aggravating your shoulder or neck and see if changing how your scapula moves influences the pain. This could be related to one or a combination of the following isues:
- The postural position of the scapula relevant to the thorax and upper arm.
- The strength of scapular muscles.
- How the scapula moves in relation to arm movements
- Relative tightness of the muscles around the scapula.
The answers to these questions will let us know where we should start and what we should be looking at to improve your shoulder or neck pain.
If you can change your shoulder or neck pain by correcting scapular movements then it’s odds on favourite the scapula is a significant villain in the story.
So if you have a winged or pseudo winged scapula and pain is abolished by taping or correcting it by your therapist assistance then it probably needs addressing.
If however there is no change to the pain or function at the shoulder or neck then I’d be hunting for another culprit to address. It may still be a factor in the overall management but not the primary one.
How do I strengthen the scapular muscles ?
One of the persisting myths of scapular strengthening is the technique of tucking the shoulder blades down to the opposite hip. The theory being that this assists with downward rotation of the scapula by activating the lower fibres of trapezius.
That may be fine if those muscles are the issue , but not so effective if your problem is more related to weak upper traps or tightness in the posterior cuff.
Here are some examples we use for strengthening the scapular muscles depending on the presentation.
For these types of exercises we are focusing more on strength endurance rather than absolute strength.
3-5 sets of 10-20 reps should do the trick.
A scapular summary
Some shoulders need the scapula addressed and some don’t . It’s just got to be relevant to you and your problem , not a one size fits all approach .
By looking at these points above we can devise the best, most effective long lasting solution for you and your shoulder.
Thanks for reading, if you have any shoulder or neck issues you can book in to see us here