Shoulder pain is a common complaint that we see at Back to Function. Shoulder pain may originate in the joint itself, or from any of the many surrounding muscles, ligaments, tendons and fascia. Shoulder pain usually worsens with activities or movement of your arm or shoulder.

At Back to Function, we make sure to evaluate the position of the rib cage when presented with a client with shoulder pain. This is important because rib cage mechanics influence the position of the shoulder blade. The position of the shoulder blade ultimately dictates the action of the rotator cuff muscles which can cause some people to become prone to shoulder pain.

Anatomy of the shoulder joint

The humerus (arm bone), scapula (shoulder blade), acromion (point of shoulder), clavicle (collar bone) and surrounding soft tissues make up the shoulder. There are three significant articulations: the sternoclavicular joint, the acromioclavicular (AC) joint and the glenohumeral joint.

Ligaments and surrounding musculature, including the rotator cuff muscles, contribute to shoulder joint stability. The rotator cuff is comprised of four muscles: supraspinatus, infraspinatus, teres minor and subscapularis that interlock to function as one unit. These muscles help with internal and external rotation of the shoulder and depress the humeral head against the glenoid of the scapula as the arm is elevated. Fascia is the connective tissue that surrounds all the other soft tissues and allows them to work as an integrated unit. The tendons join together to form one common tendon, the rotator cuff tendon. This common tendon passes through the subacromial space. The subacromial bursa, which has a large number of pain sensors, fills the space between the acromion and the rotator cuff tendon.

At Back to Function we use a postural approach to evaluating musculoskeletal shoulder pain. Two of the most common shoulder issues we see are shoulder impingement and bicipital tendinitis.

Shoulder impingement

Shoulder impingement is a common cause of shoulder pain. It occurs when there is impingement of tendons or bursa in the shoulder from the bones of the shoulder. Overhead activity of the shoulder, especially repeated activity, is a risk factor for shoulder impingement. Examples include: painting, lifting, swimming, tennis, and other overhead sports.

With impingement syndrome, pain is persistent and affects everyday activities. Motions such as reaching up behind the back or reaching up overhead to put on a coat or shirt, for example, may cause pain.

Over time, impingement syndrome can lead to inflammation of the rotator cuff tendons (tendinitis) and bursa (bursitis). If not treated appropriately, the rotator cuff tendons can start to thin and tear.

BTF shoulder evaluation

When evaluating a client with shoulder pain, the typical pattern we see is a right oriented pelvis with a compensatory trunk rotation to the left which results in the left ribs being externally rotated and the right ribs internally rotated. This has a tendency to direct the right shoulder blade into a protracted position (winging scapula). With the shoulder blade winging, the muscles that stabilize the shoulder blade cannot operate effectively (lower trapezius, rhomboids, serratus anterior and subscapularis). This altered positon of the shoulder blade can lead to upper trapezius tightness as well as overload of the anterior shoulder structures (pectoralis minor, biceps and anterior capsule).

From a postural perspective, the most common mechanical issues contributing to shoulder impingement are:

• Poor ability to expand the rib cage with diaphragmatic breathing
• Poor ability to co-contract abdominals upon inhalation
• Weak lower trapezius and long head of the triceps (usually on the right) resulting in winging and anterior tipping of the shoulder blade

Note that all 3 of these causes contribute to weakness of the scapular muscles.

At Back to Function we use our unique functional screen to determine if your shoulder pain is being caused by these mechanical issues related to rib cage and shoulder blade position. Once we determine the cause of your shoulder pain, we provide treatment that incorporates soft tissue therapy that helps inhibit overactive muscles that are contributing to faulty position. It is also important to establish optimal pelvis, rib cage and shoulder blade position.

Here are some examples of re-positioning exercises that we use at Back to Function to help alleviate shoulder impingement.

In order to train the left diaphragm and restore a neutral rib cage position with right serratus anterior facilitation:

90-90 Hip Lift with Left Pelvic Shift & Right Arm Reach with Balloon

Why the balloon?

Performing maximal exhalation, particularly against positive air pressure like a partially inflated balloon, is a great retraining technique that can be used to facilitate the diaphragm and pull the elevated externally rotated ribcage down into internal rotation with maximum recruitment of the abdominal muscles. This positions the ribcage appropriately under the shoulder blade which improves overall shoulder function.

In order to facilitate the lower trapezius and triceps muscles needed for shoulder blade stabilization:

Long Seated Supported Press Downs

Standing Resisted Triceps Pulldowns

The third training focus should integrate shoulder internal and external rotation provided by subscapularis activity with integrated shoulder blade stability:

Supine Resisted Right Triceps Extension with Right HGIR

Bicipital tendinitis

Biceps tendinitis is an inflammation or irritation of the upper biceps tendon. Also called the long head of the biceps tendon, this strong, cord-like structure connects the biceps muscle to the bones in the shoulder. Pain in the front of the shoulder and weakness are common symptoms of biceps tendinitis.

From a postural perspective, the most common mechanical issues contributing to bicipital tendinitis are:

• Decreased ability to rotate trunk or chest wall to the right
• Decreased ability to externally rotate (usually on the right) secondary to forward shoulder position and weak serratus anterior muscle
• Overuse of the latissimus dorsi muscle for arm internal rotation secondary to poor shoulder blade positon and subscapularis muscle function

Here are some examples of repositioning exercises that we use at Back to Function to help alleviate bicipital tendinitis.

In order to activate the left abdominal wall musculature with right trunk rotation:

Standing Supported Passive Left AFIR with Right Trunk Rotation

In order to facilitate the serratus anterior musculature:

Left Sidelying Resisted Right Serratus Punch with Right Trunk Rotation

In order to activate the subscapularis muscle while inhibiting the lats:

Left Sidelying Resisted Right HGIR

As with any painful body part, it is prudent to be properly evaluated by a healthcare professional prior to starting an exercise/rehabilitation program. The doctors at Back to Function can evaluate your shoulder pain and decide whether you need imaging or a referral to an orthopedic surgeon if necessary. You don’t have to live with your shoulder pain any longer. To feel and perform better please contact us at 310-534-1900, or by email at [email protected] today.