Identify root causes of dysfunction and help clients return to function and good form.
Movie stars, athletes and brides-to-be work hard to develop shoulders that are aesthetically pleasing, and shoulders are an integral part of the big somatic “picture.” However, there is much more going on in this area than meets the eye. The shoulder complex involves more than one joint, and healthy, functional shoulders are more desirable than ones that merely look good on camera. After all, looking good for the wedding is great, but not being able to carry your luggage on your honeymoon is not.
We use our shoulders a tremendous amount every day. Simple tasks like pouring milk for a bowl of cereal, doing a downward-facing dog or holding ourselves upright in indoor cycling class all require us to use our shoulders. Functional movements like walking, pressing and pulling are influenced by the shoulder joint, and a tender rotator cuff or inflamed bursa sac can make those activities—and even sleeping—almost unbearable.
Shoulder pain is prevalent in approximately 21% of the population, and dysfunction is common. Forty percent of reported pain lasts at least a year (Clark & Lucett 2012). Injuries can shelve clients for a month or more and, if not rehabilitated properly, can lead to chronic instability. This article discusses what’s happening in the shoulder complex and offers suggestions on how to assemble a sound corrective exercise program.
Tissues and Movement
Before focusing on the shoulder itself, let’s take a broad look at the human movement system. Keep in mind that this is an overview; trainers need a more in-depth review before programming corrective exercise routines for clients with shoulder impairments.
Connective tissue has viscoelastic properties, is either dense or loose and is designed to respond to everyday stresses. Under normal circumstances, it reacts to load or stress in various ways, depending on the rate at which force is applied, the magnitude of the load and its duration (Magee et al. 2007).
Each type of tissue has its own jobs and unique capabilities. Dense connective tissue—found in bones, ligaments, tendons and aponeuroses—is stiffer and can lengthen only 10% before tearing. Because it is relatively inflexible, dense tissue protects end ranges of motion, but injuries to this tissue are common. Loose connective tissue is a lot more forgiving. Found in joint capsules, muscles, nerves and elsewhere, it can lengthen up to 80% or more of its resting length without experiencing tension buildup (Magee et al. 2007). This is critical for the fitness professional to understand because, once you get to the point where the load has shifted primarily to the more densely wound connective tissue, any errors in technique or inability to handle load will be magnified.
A tissue becomes injured when it can no longer tolerate the load and deformation caused by a force’s velocity, angle, duration or frequency. Prior to experiencing a very common repetitive-stress shoulder injury like bursitis or tendonitis, movement impairments are routinely present. An effective personal trainer will be able to identify such impairments before they translate to an injury. Then it is possible to harness therapeutic exercises and help correct faulty movement patterns (Sahrmann 2001).
Shoulder Anatomy and the Passive System
The shoulder is much more than a single joint. The entire kinetic chain is connected “from toes to nose,” and listing all the interconnections is impossible here. However, as we look at the shoulder, we’ll include some of its broader connections to the rest of the body.
The human movement system incorporates the articular, nervous and muscular systems (Clark & Lucett 2010). For our purposes, we’ll refer to the articular system—which includes bones, joints and ligaments—as the “passive system,” and we’ll call the muscular system the “active system.”
The passive system provides anchor points, support and leverage for the muscular system. Traditionally, the major bones of the shoulder girdle are the humerus, scapula and clavicle. The shoulder complex extends to the rib cage and the thoracic and cervical spines. You can make a case to include the lumbar spine and pelvis as well, because of muscular and fascial connections. When the passive system is out of alignment, it can produce contraction in the active system, leading to lower work capacity, reduced endurance and greater risk of injury (Travell & Simons 1983).
The joints most closely associated with the shoulder include the glenohumeral (GH) joint, the acromioclavicular (AC) joint, the sternoclavicular (SC) joint and the scapulothoracic (ST) joint. While an in-depth exploration of these joints is beyond the scope of this article, personal trainers must educate themselves thoroughly on these joints before designing programs for clients.
The ST joint is considered a false joint because it lacks a true bony articulation. The scapula (shoulder blade) simply floats on the thorax; however, due to its importance in the shoulder’s functionality, it must be included. The intervertebral and costovertebral joints associated with the thoracic spine can influence both local and global musculature (Epstein et al. 1993). Although small, these joints are integral details of the thorax.
When bones are in ideal alignment, full range of motion becomes possible in the joints. For example, the GH joint should be able to fully flex, extend, abduct, adduct, internally rotate, externally rotate and circumduct. This joint is highly mobile and can move through large ranges of motion. To allow for that mobility, there must be a low degree of stability. The ST musculature helps decelerate movements like throwing, since it anchors the shoulder blade to the thorax and the humerus to the scapula via the glenoid.
The scapula sets the platform for the humerus. If the scapula is out of alignment, the humerus will follow (Sahrmann 2001). The scapula should be able to elevate, depress, protract, retract, upwardly rotate and downwardly rotate. It is said to “tilt” anteriorly and posteriorly as well. The acromion process of the scapula attaches to the clavicle at the AC joint.
The acromion is a thick, ridge-like bone that can have three different shapes. These shapes—classified as flat (type 1), smoothly curved (type 2) and hooked (type 3)—determine how much space the rotator cuff, biceps brachii tendons and bursa sacs have to operate in. Abnormalities in the acromion are congenital, and all the corrective exercise in the world will not create more space. A type 3, or hooked, acromion is associated with a greater incidence of rotator cuff tears (62%) and impingement (30%) (Epstein et al. 1993).
It can be difficult to assess alignment and functionality of the SC and ST joints. Maintaining their subtle actions will foster shoulder health and function. If you suspect that either joint is dysfunctional, refer out to a licensed medical professional for examination (Lee 2003).
Thoracic spinal alignment and function are often overlooked. In people who are very sedentary, the thoracic spine is often stuck in flexion and has limited extension and rotation. An overly kyphotic posture decreases the effectiveness of the scapular stabilizers and rotator cuff musculature (Clark & Lucett 2010). Scapular malalignment is reason enough to assess and address thoracic mobility.
The shoulder’s ligamentous structure is of particular interest. Ligaments aren’t just flat, straight guy wires that provide static support to joints. They can twist and turn like an intricately wound rope. At end ranges of motion, ligamentous tension increases—as does support from the joint capsule—in an attempt to prevent injury. Ligaments also serve a proprioceptive function, providing the nervous system with valuable feedback about joint position and tension (Osar 2012).
Cartilage provides smooth surfaces for joints to interact with. Faulty arthrokinematics and osteokinematics (movement of the joints and bones) will wear this tissue down over time. When cartilage breaks down, pain and inflammation soon follow.
The subacromial, ST and subdeltoid bursa sacs reduce friction in the shoulder joint. The subacromial bursa is most frequently inflamed after repeated impingement between the humerus and acromion.
Repetitive stress breaks down the active system more quickly than it does the passive system. If a client is experiencing pain as a result of an insult to the passive system, a movement impairment has likely been present for a period of time. The active system is more easily disturbed. It doesn’t take long for tendonitis to occur when someone exhibits poor posture and form, loaded repeatedly.
The Shoulder and the Active System
Muscles can be grouped into local stabilizers and global movers (Clark & Lucett 2010). That is not to say that a muscle only stabilizes or only creates global movements, but many muscles have characteristics that lend themselves to one category versus the other. Local stabilizers are composed mostly of type I muscle fibers, are single-joint muscles and are prone to inhibition. Global movers contain a higher percentage of type II muscle fibers, cross more than one joint and are prone to tightness (Clark & Lucett 2010).
In 1987, Vladimir Janda introduced a categorization system for muscles based on their phylogenetic development (evolutionary history) (Janda 2013). Tonic muscles are associated with flexion and are developmentally “older.” Phasic muscles are “extensors” and develop shortly after birth. Think of a baby snuggled up in a ball, pulling his bottle to his mouth. The feet and knees come in with the bottle. A flexor synergy is already built in, but the baby can’t yet achieve hip, knee and ankle extension; the central nervous system needs time to develop. So what does this have to do with the shoulder? When we experience pain or stress or are chronically sedentary, we tend to default to the flexion pattern, which over time can set up muscle imbalances.
The ST and thoracohumeral muscles are among those potentially affected by these imbalances. Even in their size, the tonic muscles have an unfair advantage (Sahrmann 2001). The pectoralis major and latissimus dorsi dwarf the trapezius, serratus anterior and rhomboids. As the rhomboids—along with the latissimus dorsi and levator scapulae—downwardly rotate the scapula, they often betray their phasic counterparts (Sahrmann 2001). The serratus anterior and lower and upper trapezius upwardly rotate the scapula and can’t overcome the poor posture and domination created by the downward rotators (Muscolino 2008; Sahrmann 2001). A flexed thoracic spine also contributes to scapular dyskinesis (poor movement).
Fascial lines also need to be taken into consideration. Among other things, fascia is responsible for support, proprioception and force transmission (Myers 2001; Schleip 2003). Fascia and related connective tissue form “tracks” throughout the body, and these can be mapped and assessed (Myers 2001). Locally, the arm lines run from various aspects of the shoulder area down to the attachment points around the hand. These fascial lines can temper range of motion at the shoulder girdle. For more information about fascial lines, read “Whole-Body Strength Training Using Myofascial Lines,” by Derrick Price, MS, in the April 2012 issue of IDEA Fitness Journal.
Assessments provide you with the requisite information to individualize a program. Proper implementation is a separate article in itself; invest in the proper education so that you thoroughly understand assessment protocols. Correlate results from a series of assessments (cluster testing) to provide you with an accurate representation of the alignment, structure and function of the shoulder complex. The following assessments are recommended (Clark & Lucett 2010):
- static postural assessments
- transitional assessments
- dynamic movement assessments
When performing static postural assessments, observe all five major load-bearing joints from the anterior, lateral and posterior views. Look at the feet, knees, pelvis, shoulders and head—the five kinetic-chain checkpoints. Simple transitional assessments like Appley’s Scratch Test or a shoulder rotation test can help pinpoint asymmetries in range of motion, as well as provide some insight into thoracic mobility (Clark & Lucett 2010; Cook et al. 2010).
Other transitional assessments—such as the overhead squat, push-up or pressing test and the pull-up or pulling test—demonstrate how the shoulder complex integrates with the rest of the kinetic chain (Clark & Lucett 2012). When you are conducting an overhead squat assessment, have the client start in neutral alignment, and observe 5–10 repetitions from the anterior, lateral and posterior views. Also look for asymmetries and movement compensations elsewhere in the kinetic chain.
Every assessment is an exercise, and every exercise is an assessment. Observe your client during pressing and pulling movements like the standing cable chest press or split-stance tubing row. Change your view every few repetitions, and monitor all five checkpoints. Watch for shoulder elevation, thoracic flexion, cervical extension or arching in the low back. If a client is executing the movement with good form and has the requisite stability and mobility, progress the exercise. For more detailed information about shoulder assessments, see the sidebar “Assessment and Corrective Exercise Clinic.”
Corrective Exercise Programming
Once you’ve identified postural faults or movement compensations, you’re ready to create a corrective exercise program to restore alignment and function. Corrective exercise programs may last 10–60 minutes, depending on the severity of the movement impairment and the client’s current capacity for exercise. These programs follow a specific methodology or school of thought. While there are multiple systems and approaches, these points apply somewhat universally:
- Research by Bang and Deyle suggests that supervised corrective exercise programs are more advantageous than unsupervised workouts (Bang & Deyle 2000). Make sure clients use optimal form as often as possible. Stacking strength on top of dysfunction is a recipe for disaster (Cook et al. 2010).
- Self-massage techniques help clients “normalize” soft tissue. Dysfunctional tissue may lack extensibility, be neurally overactive or have developed trigger points. Trigger points are hyperirritable points within muscle tissue that, when stimulated, can produce local or referred autonomic nervous system sensations such as pain, tightness, inhibitions or even goose bumps (Travell & Simons 1983). It is important to restore proper tone and tissue extensibility before implementing any other corrective strategy. A muscle that has been very overused or is wrought with adhesions won’t allow a joint to move freely or an antagonist to activate properly. Self myofascial release, trigger point therapy, active release and many other techniques can help clients with this stage.
- Joint mobilization exercises, which include gentle, repetitive and even oscillatory movements, encourage joints to move through all three planes of motion. Poor joint movement can lead to local and systemic dysfunction. It is not within a personal trainer’s scope of practice to manually facilitate joint mobility by placing hands on a client. This is reserved for licensed manual therapists. Save stretching for muscles that are chronically shortened. There is a time and place for static, active, muscle energy and dynamic techniques. Fitness level and stage of training will guide you in selecting the most appropriate technique for each client.
- Lengthened or weak muscles can lead to negative postural changes and joint instability (Sahrmann 2001). Developing proper neuromuscular activation in inhibited muscles is necessary. Activation techniques include manual therapy (refer out), isolated isometrics, eccentric and concentric muscular actions and targeted movement patterns. The client’s joint mobility, core stability and coordination will help you select the most pertinent technique for restoring neural activation.
- Addressing proper breathing mechanics is also important. Dysfunctional breathing patterns can exacerbate upper crossed syndrome (Clark & Lucett 2010). Taking the time to educate clients on how to breathe well from different positions will not only enhance functional capacity but also help restore healthy length–tension relationships and quality of movement to the shoulder complex. Teaching diaphragmatic breathing during the activation portion of the workout may be particularly rewarding and can help decrease sympathetic tone in tonic muscles (Osar 2012).
- Neuromuscular reeducation exercises help clients ingrain new movement patterns into their central nervous systems. Disuse and overuse can lead to poor movement quality. Corrective exercise seeks to reteach fundamental movement patterns used in work, sport and life. Exercises performed in the standing position using multiple joints can help develop functional strength and coordination. While it can be difficult to gauge the correct number of sets and exercises for a corrective exercise program, the strengthening protocols typically follow a low- to moderate-volume approach of 2–3 sets with 8–15 repetitions. However, your assessment and the individual’s specific needs will determine the program. Build a repertoire that will challenge and fatigue the client, but make sure he or she can complete it with good form.
Critical Link in the Chain
A critical region of the kinetic chain, the shoulder complex is often misused and abused. Providing effective corrective exercise programs to minimize shoulder impairments can help you stand out from the competition and lead to referral streams from your existing client base and medical professionals. A good trainer can help a client come back from an injury; a great trainer will spot dysfunction before it turns into an injury and know how to program correctly for it.