Sometimes our Problems Reside Beyond our Pain Part II: Rotator Cuff and Shoulder Girdle Dysfunctions
Continuing from my previous post, the rotator cuff muscles (supraspinatus, infraspinatus, subscapularis, and teres minor) and shoulder girdle (clavicle and scapula bones) should not be examined without understanding the hip and ankle complex (Please Read "Sometimes our Problems Reside Beyond our Pain: Ankle Mobility & Hip Dysfunction"). It is a common belief in my field that many shoulder injuries excluding blunt trauma (a sudden hit) begin at the ankle or hip, which in turn limits motion and control of the shoulder girdle, thus impacting the rotator cuff and connecting glenohumeral joint.
During hip extension, which is movement performed throughout the day, the scapula retracts and enhances shoulder flexion on the same side. The opposite is true for hip flexion; the scapula protracts and enhances shoulder extension. Similar scenarios exist for hip adduction and scapula adduction on the same side. Relationships between the hips such as these are why many shoulder impingement injuries stem from poor posture. An example is excessive forward leaning. As you lean forward, the scapula protracts and the acromion process pinches in the glenoid fossa, leading to shoulder impingement.
If we want to remedy shoulder injuries, we need to examine hip and ankle motion. We examine the ankle because of its role in hip mobility. With that said, plenty of injuries effecting the shoulder originated at the shoulder joint. These injuries can often be explained through lack of thoracic, scapula, and clavicular mobility, as well as a buildup of scar tissue or dehydrated fascia limiting the scapula’s ability to glide over the thoracic spine properly. Dehydrated fascia is simply fascia that is less mobile because it has been less mobile. It’s one of those use it or lose it things. If we are immobile in a joint for as little as 24 hours, we begin building what Dr. Gill Hedley refers to as “fuzz.” Fuzz is simply a thickening of connective tissue limiting mobility. Fuzz is not a good thing and can be remedied through manual therapy such as massage and movement drills.
When examining the shoulder joint, I generally look for scapula mobility over the thoracic spine. If there is a scapula restriction and manually assisting the scapula in movement as the arm goes through a full range of motion helps, then the scapula may be the culprit, but if there is still discomfort or dysfunction when manually assisting in scapula motion, then I will look to the glenohumeral and elbow joint for restrictions. Beyond that, I assess how the hips, ankles, and spine react as the arm goes through a full range of motion.
Another common issue in the rotator cuff is an anterior positioning of the humorous in the glenoid fossa (shoulder joint) causing impingement. An overactive latissimus dorsi and teres major can be pulling the humorous anteriorly (forward) if the subscapularis is too weak to keep the joint in its proper position.
There are countless exercises for treating these dysfunctions, but with so much more going on for the shoulder than the hip, I feel a proper biometric analysis by a professional should be performed. With that said, one exercise that I have made a staple of my workouts is a dumbbell pullback into spinal extension with a slight twist of the spine towards the forward knee. It’s a modified lawnmower exercise. I first saw the exercise performed by Chuck Wolf, and I have seen tremendous results as a general hip, spine, and shoulder mobility drill bringing the entire system into sync.
Walking away from this, the key takeaway is movement is unbelievably integrated. Isolated exercises have their place in immediate acute physical therapy, but should be replaced by integrated movement patterns as soon as the body is ready. Most chronic injuries have a foundation in areas foreign to the pain and we must integrate whole body movements in order to correct posture and gait and keep the dysfunction from returning.