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Shoulder Rehab Part III

May31st 2013

In part I of this series I discussed how traditional physical therapy exercises for the rotator cuff often miss the mark, and then in part II how dysfunction and a lack of motor control in other areas of the body can significantly affect the shoulder and cause pain.  Be sure to read those, if you haven’t already, as this article will make much more sense.

In part III I want to talk about another concept that has taken the therapy world by storm – Scapular Retraction.

In a nutshell, scapular retraction means pulling the scapula (shoulder blade) closer to the spine, and often times the cuing from the therapist or physician is to pull the shoulder blades down and back (or “put your shoulder blades in your back pockets”).  Check out the picture below:

“Shoulder Blades down and back”

Now I’m not going to sit here and say that good things can’t happen from doing this, or deny that I used to buy this approach.  Some folks are just stuck with their shoulder girdle forward and scapulae protracted (spread apart) so far that they create a shoulder impingement with that faulty posture.  Working on scapular retraction can work in the short term in these cases, but I certainly don’t think it’s a permanent fix.  There are many therapists and physicians that feel this strategy will help in all cases.  Here are some reasons why it will not:

1)  The scapula is most cases just needs to be posteriorly tilted (or tipped).  Check out the photo below to get the visual, but the jist of it is that this creates more space in the glenohumeral (shoulder) joint to decrease impingement while also allowing for greater freedom of movement at the shoulder.

Try lifting your arm overhead maintaining your scapulae down and back like in the picture above.  It isn’t going to happen.  The scapulae are meant to upwardly rotate when going overhead to maintain the joint space and prevent impingement.  Too much ‘down and back’ will actually create more downward rotation and greater impingement (see picture above in the upper left).  Strike 1!

Scapular Reduction Test – the scapula is gently posteriorly tilted. This will often clear an impingement with shoulder elevation. Notice he is not pulling the scapula closer to the spine!

2)  Too much scapular retraction with common exercises like rows and pull-downs can result in an anterior glide of the humeral head.  Fancy term for the ‘ball’ of the shoulder sitting too far forward in the socket.  This can also lead to greater impingement, and for someone with the very common condition of bicipital tendinosis can be quite painful.

The top hand is palpating the borders of the scapula, while the bottom hand is palpating the front and back of the humeral head. Her humerus is seated anterior in the socket on both sides, but much more pronounced on the L shoulder. This is actually very common.

I’ve seen quite a few patients with this type of shoulder positioning fail miserably with scapular retraction programs.  You’re literally pulling the scapulae back and leaving the humeral head protruding even more to the front creating great impingement.  Strike 2!

3)  Remember in part II when I talked about regional interdependence?  Anything you do to the scapula could create a reaction somewhere else.  In the majority of cases the patient will overdo it, and you’ll end up with negative compensations elsewhere in the body.  Check out the picture below.  This is one of my all-time favorites, and I use this as a teaching tool with my students.

I know they say the picture on the right is ‘correct’, but look at what he had to do to his neck and back to get there (the arrows are mine).  He had to jack his neck and back into more extension, and over recruit his upper traps just to get there.  Nothing like creating a neck and back problem while trying to fix the shoulder.  It’s easy enough to do and I’ve seen many a therapist and trainer let this go.  Strike 3!

So what to do about this?

There is nothing wrong with a little scapular retraction to reposition the scapula on the thorax, but if some other issues are cleared up first this may just happen naturally.

1)  Cervical mobility – the neck should move freely and without pain.  I gave a great example of this in part II.  There are a number of muscles running between the neck and shoulder girdle so any tension resulting in cervical restrictions can alter scapular position.

2)  Thoracic mobility – the scapulae sit on the thorax so positioning and movement of the thoracic spine will definitely affect scapular positioning.  Poor mobility creates an inability to adjust the posture to the activity, and poor scapular mechanics result.

3)  Poor motor control – once mobility issues have been corrected (and it’s not just the cervical and thoracic spines), then scapular and spinal motor control often improve automatically.  Scapular retraction exercises aim to strengthen the scapular muscles, but motor control basically means the muscles are positioning and moving the scapula the right way at the right time.  See part 2 again for a more in-depth explanation.

This is by no means an exhaustive list of possible solutions, but it’s a start.

I plan on posting a couple videos next week showing how to perform pushing and pulling exercises correctly.  I’m on my way to Chicago right now for a Graston Technique training so those will have to wait until I get back.  Keep an eye out for those and part 4 – correcting scapular winging.

As always feel free to email any questions to me:  joe@elitepttc.com

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