Shoulder pain and shoulder injuries are among the most common conditions within the general population and among athletes. Approximately 75 to 80% of these are caused by conditions related to the rotator cuff (1). The rotator cuff consists of four muscles, including the supraspinatus, infraspinatus, subscapularis and teres minor. These act to provide dynamic stability and control the position of the humeral head relative to the glenoid fossa during motions ranging from throwing to performing a push-up (2). There are many factors that can lead to shoulder pain and dysfunction, one being a muscular imbalance between the rotator cuff muscles and its relationship to the scapula and clavicle.
This two part series will describe the function of the rotator cuff and its synergistic relationship to the scapula and clavicle, while also providing exercises to strengthen the muscles of the shoulder complex. Correcting dysfunctional movement patterns of the shoulder complex typically requires a multifaceted approach including inhibiting, lengthening, and activating muscles whether the goal is preventative or rehabilitative. This part of the series will focus on corrective exercise strategies that inhibit and lengthen muscles by self-myofascial release in combination with static stretching. Part 2 of the series will provide you with corrective exercise protocols to stabilize and strengthen the rotator cuff muscles.
To understand how to implement corrective strategies we must first look at the anatomy and kinematics of the shoulder. The shoulder complex can be broken down into three distinct regions, the upper arm or humerus, scapula, and clavicle, which are working together providing movement in all three planes. These three regions create a mechanical linkage that is dependent upon one another for proper shoulder motion that is controlled by the upper trapezius, lower trapezius and serratus anterior.
Dysfunctional movement patterns are in part based on the concept of relative flexibility that suggests movement occurs through the pathway of least effort. For example, if hip movement is relatively stiff compared to that of the low back, then the movement is more likely to happen in the back (3). In the case of the shoulder, if the trapezius muscles are limiting proper scapula thoracic motion, the rotator cuff muscles will then compensate for this and become the “pathway of least effort” leading to compensation patterns. Therefore, inhibited or tight trapezius and serratus muscles will alter proper scapula motion. This results in improper clavicle movement due to these muscular imbalances ultimately affecting the rotator cuff.
In order to have properly working rotator cuff muscles, proper scapula thoracic motion must be established in order to maintain the correct length-tension ratio of the rotator cuff muscles. The motion of the scapula and upper arm is defined as a 2:1 movement ratio, meaning for every 2 degrees of upward humeral motion there is 1 degree of upward scapular motion. Muscles involved in creating this movement are the upper and lower trapezius and the serratus anterior. A change in scapula position or motion may cause an internal rotation of the humerus resulting in a shortened internal rotator muscle (subscapularis) and a stretched or weakened external rotator muscle (teres minor). Any dysfunction of these muscles will require opposing muscles acting on the shoulder complex to be affected due to their relationship with one another.
Proper shoulder motion and rotator cuff function are also dependent on clavicle movements that include protraction, retraction, elevation, depression and posterior rotation. As the scapula rotates upward the clavicle elevates up to 30 degrees at the acromioclavicular (AC) joint (4). Then as the arm elevates further the clavicle begins to rotate posteriorly along its axis allowing the scapula to further elevate upward.
This posterior clavicle rotation has been described in numerous studies including one by Ludewig and colleagues who performed a three dimensional analysis (5). Their findings indicate that as the arm elevates, 8 degrees of posterior rotation occurs when the arm is elevated to 110 degrees. Any loss of normal scapula motion will alter the clavicle motion and ultimately restrict the range of motion of the upper extremity. Therefore, prior to initiating any specific rotator cuff exercises it is imperative to restore the muscular function of the scapulothoracic, AC, and sternoclavicular (SC) joint regions.
In order to inhibit and lengthen these muscles a self-myofascial release (SMR) approach with either a foam roll or a tennis ball can be utilized. SMR using a foam roll has been shown to be effective for increasing flexibility when combined with static stretching. Mohr and colleagues demonstrated this when they compared foam rolling and static stretching of the hamstring muscles (6). Their study findings indicate using the foam roll for SMR in addition to static stretching is superior to either SMR or static stretching alone. Therefore, in order to maximize range of motion it is recommended to foam roll prior to static stretching.
The following protocol is based on the above-described findings and can be performed daily or at least 3 times per week. The SMR exercises are performed on the floor applying as much body weight pressure as can be comfortably tolerated for up to 1 minute at time.
- Trapezius and Rhomboid SMR
Begin seated on floor. Lie back placing foam roll across upper back. Cross arms in front, placing hands on shoulders. Lift hips off floor. Slowly massage upper back, rolling up and down as tolerated, for duration of 1 to 2 minutes. Maintain consistent pressure with foam roll. If a painful area is found, stop rolling and REST on the area for 30 seconds as tolerated, then continue.
- Posterior Shoulder Tennis Ball SMR
Begin lying on floor facing up. Place a tennis ball behind shoulder. Raise arm so elbow is at shoulder level and bent to 90°. Lift opposite shoulder slightly so that pressure is felt against tennis ball. Grasp wrist with opposite hand and move arm upward and downward massaging shoulder muscles. Perform massage for 1 to 2 minutes. Maintain consistent pressure with tennis ball. If a painful area is found, stop rolling and REST on the area for 30 seconds as tolerated, then continue.
- Pectoralis Major and Minor SMR with Tennis Ball
Begin lying face down with a yoga or tennis ball situated between the floor and below the clavicle with forearm flat on the ground. Applying constant pressure on the ball, slowly move forearm upwards, pause momentarily, and then slowly return to starting position.
Static stretching to compliment the SMR exercises can be performed daily or at least 3 times per week. It is recommended that each stretch is held for 30-60 seconds and repeated three times resting 30 seconds in between stretches. When stretching the posterior shoulder a cross body stretch is recommended as this was found to be more effective than the side lying sleeper stretch by McClure and colleagues (7).
- Cross Body Stretch
Begin seated or standing (ideally this is best done with the back against a wall to help stabilize the scapula and emphasize the stretch on the posterior shoulder). Extend one arm in front, and across body, at shoulder level. With opposite arm grasp arm above elbow and gently pull towards chest until a stretch is felt in the back of the shoulder. Hold for 20-30 seconds and repeat on opposite side.
- Static Foam Roll Chest Stretch
Begin by positioning yourself lying on foam roll with feet flat on floor. Foam roll should support the head and run along the spine down to pelvis. Place arms to sides. Bend both elbows to 90º at shoulder level with palm facing up. Relax as chest and shoulders stretch for 30-60 seconds. Do not try to force arms to floor.
All of the above displayed exercises are easy to execute and include minimal risks if performed as described. To achieve satisfying results it is important do them on a regular basis and for a minimum of 4 weeks.
References
(1) Clark, M.A., Lucett, S.C. (2014). NASM Essentials of Corrective Exercise Training. Burlington, MA. Jones & Bartlett Learning.
(2) Arnheim, D.D., Prentice, W.E. (2000). Principles of Athletic Training. Boston, MA. McGraw Hill.
(3) Lehtola et al. BMC Musculoskeletal Disorders 2012.
(4) Kisner, C., Colby, L.A. (2002). Therapeutic Exercise Foundations and Techniques. Philadelphia, PA. F.A. David Company.
(5) Ludewig, P., et al. (2004). Three-Dimensional Clavicular Motion Durning Arm Elevation: Reliability and Descriptive Data. Journal of Orthopaedic & Sports Physical Therapy, 34(3), 141-150.
(6) Mohr, A., et al. (2014) Effect of foam rolling and static stretching on passive hip-flexion range of motion. Journal of Sport Rehabilitation.
(7) McClure P, et al. (2007). A randomized controlled comparison of stretching procedures for
posterior shoulder tightness. Journal of Orthopaedic & Sports Physical Therapy 37:108-14.
DAVID CRUZ, DC, CSCS, FMS, SFMA
Dr. David Cruz practiced as a sports chiropractor for 18 years treating athletic injuries, from weekend warriors to professional athletes. He received his bachelor’s of science degree in athletic training and has completed graduate course work in kinesiology. He is a Certified Strength and Conditioning Specialist (CSCS) as well as having both FMS and SFMA certifications. The combination of his background in sports medicine and interest in technology made him passionate about bringing these two worlds closer together, resulting in the foundation of his company WebExercises in 2005.
WebExercises is an end-to-end solution for exercise rehabilitation professionals and is currently integrated with several EHR companies. In addition to WebExercises, Dr. Cruz is co-founder and partner of two other software businesses within the health care and technology industry.
We all know that our clients are doing good things for their bodies while we are with them, but probably not during the other hours of the week. Especially the prolonged time they potentially spend sitting, now considered detrimental to overall health. We see the effects of this everyday in the form of poor posture, and we continue to overlook it as something benign that naturally occurs over time without consequences. According to the American Journal of Pain Management “Posture effects and moderates every physiological function from breathing to hormonal production. Spinal pain, headache, mood, blood pressure, pulse, and lung capacity are among the functions most easily influenced by posture.” 1 There is also evidence that poor thoracic posture shows “a trend towards greater mortality” as discussed in a study by the Journal of the American Geriatrics Society. 2
Another fairly new risk factor that is starting to become more common is excessive usage of mobile phones, tablets and PCs. Over the past seven years mobile device usage has grown from .3 hours a day to 2.8 hours a day for the average adult. Comparatively, our computer use has remained about the same over the same time period at 2.4 hours per day. 3 A recent article by Kenneth Hansraj, MD, the chief of Spine Surgery at New York Spine Surgery and Rehabilitation, describes that as the head tilts forward its weight effectively goes from 10 to 12 pounds in the neutral position to as much as 60 pounds at 60 degrees of flexion, which is the typical position that we have while using a mobile device. 4
Over time this forward head position leads to ligamentous creep deformation having lasting neurophysiological effects. This was demonstrated with a feline study that found the creep deformation that occurred over the first 30 minutes did not recover with 10 minutes of rest and was present up to seven hours later. 5 The other finding of this research was even more alarming: the primary risk factor was not the load but rather the duration of the load. The implication of this is concerning given we spend an average of 2.8 hours a day using our mobile device.
In addition to the ligamentous deformation, muscle adaptations occur resulting in the Upper Cross Syndrome (UCS) as described by Janda. The UCS is characterized by tightness of the upper trapezius, levator scapula and pectoral muscles along with weakness of the deep cervical flexors and middle to lower trapezius muscles.
As these postural changes occur with the neck and upper body, our lower body becomes susceptible to adaptions as well. These include weakened back muscles as evident in a study by Sanches-Zuriaga that found a decrease in low back muscle activation after soft tissue creep, suggesting that prolonged or repeated flexion could increase the risk of injury. 6 These findings support the fact that prolonged sitting should be interrupted with breaks in order to decrease this risk along with exercise intervention.
For the purpose of this article the focus will be on the Active Subsystem (spinal muscles) as described by Panjabi in his spinal stability system model. The following five exercises can be used for most clients, requiring minimal time and no equipment. These exercises will not only help with preventing the above-described deformation and adaptation risks, but also encourage clients to stand up regularly and perform mini-exercise breaks throughout the day.
We will start with the forward head posture as described by Harman and colleagues who found that this position is associated with weakness of the deep cervical flexor and mid thoracic scapular retraction muscles. 7 Additionally, shortening of the opposing cervical extensors and pectoral muscles was also noted. A combination of strengthening exercises for the deep cervical flexors and scapular retraction muscles coupled with stretching of the cervical extensor and pectoral muscles was performed for 10 weeks. The findings of the study demonstrated that a short, home-based targeted exercise program can improve the postural alignment related to forward head posture.
Based on the above findings, the following three upper body exercises are suggested as they are ‘low-barrier’ homework for clients that they can perform daily without any equipment.
- Head Retraction
Begin seated, or standing, looking forward with shoulders back, neutral posture. Activate core muscles. Attempt to draw head directly backwards. Maintain level head position. Do not tilt head up or down. Hold for two seconds. Return to start position. Beginners should start with 3 sets of 10 repetitions.
- Shoulder Retraction
Begin standing with good posture. Shoulders should be back and head up. Bend elbows to 90 degrees and keep elbows near sides. While maintaining good posture, draw shoulders back squeezing shoulder blades together. A stretch may be felt in the chest and front of shoulder. Do not allow shoulders to raise upward. Hold for 5-10 seconds. Beginners should start with 3 sets of 5 repetitions.
- Doorway Chest Stretch
Place forearm on wall, or doorway, with elbow bent at 90º. Elbows should be slightly below shoulder level. While maintaining forearm contact, lean body into doorway until gentle stretch is felt in the chest and shoulder. Hold for 20-30 seconds. Beginners should start with 3 repetitions on each side.
As described earlier, prolonged sitting and its effect on posture is not limited to the upper body alone but also affects the lower body. Tightness of the hip flexors along with an inhibition of the extensor muscles can lead to an aberrant motor pattern know as “gluteal amnesia” according to McGill. 8 He recommends exercises to enhance gluteal muscle function to unload the back in addition to hip flexor mobility with specific psoas muscle targeting.
Here are two very effective and easy to perform exercises that clients can do during short exercise breaks throughout the day.
- Standing Hip Flexor Stretch
Begin standing in front of a chair about 18 inches away. Place one foot flat on the chair seat. Slowly allow hips to glide slightly forward until a gentle stretch is felt on the front of straight leg. Hold for 20-30 seconds. Beginners should aim for 3 sets each per side.
- Glute Hip Bridge
Begin lying on floor, facing up. Bend knees so feet are firmly on floor and arms extended. Activate core muscles. Lift hips off floor to attain a bridge position with knees, hips, and shoulders in alignment. Slowly return to start position. Initially, some cramping in the back of the thigh may develop. A simple hamstring stretch, before and after, may prevent this from occurring. Beginners should aim for 3 sets of 10 repetitions.
All of the above exercises are easy to execute and include minimal risks. Most important here is the regular execution and mid- to long-term adherence to the program. A calendar that reminds clients of the exercises and allows them to check off performed sets and reps could be a motivational tool for them and helps you track their compliance.
References
(1) Lennon et al. (1994). Posture and Respiratory Modulation of Autonomic Function, Pain, and Health. American Journal of Pain Management. 4 (36-39).
(2) Kado et al. (2004). Hyperkyphotic Posture Predicts Mortality in Older Community Dwelling Men and Women: A Prospective Study. Journal of the American Geriatrics Society. Volume 52 (10) 1662.
(3) Bosomworth, D. Mobile Marketing Statistics 2015. Retrieved from: http://www.smartinsights.com/mobile-marketing/mobile-marketing-analytics/mobile-marketing-statistics/
(4) Hansraj, K. (2014). Assessment of Stresses in the Cervical Spine Caused by Posture and Position of the Head. Surg Technol Int. Nov;25:277-9.
(5) Jam, B. (2005). The Neurophysiological Effects of the Creep Phenomenon and its Relation to Mechanical Low Back Pain.
(6) Sanchez-Zuriaga, D. (2010). Is Activation of the Back Muscles Impaired by Creep or Muscle Fatigue? Spine. Vol 35, (5) 517–525.
(7) Harman, K. (2005). Effectiveness of an Exercise Program to Improve Forward Head Posture in Normal Adults: A Randomized, Controlled 10-Week Trial. The Journal of Manual & Manipulative Therapy. Vol. 13 (3) 263-176.
(8) McGill, S. (2010). Core Training: Evidence Translating to Better Performance and Injury Prevention. Strength and Conditioning Journal. Vol. 32 (3) 33-46.
