The shoulder is a very complex joint with endless things that can potentially cause injury or pain. I wrote the bulk of this article years ago, while I was attending a Crossfit gym and had become a bit surprised at the number of shoulder injuries (shoulder pain) I was seeing. This is an article detailing the top 4 structural problems I see with the shoulder. I also describe some of the take home work needed to balance the shoulder after the neurology has been restored. Enjoy!
TOP 4 CAUSES OF SHOULDER PROBLEMS (seen in my office)
1. The Neck: If the neck is out of alignment this can have a devastating effect on the shoulder. If you look up the maps of the cervical plexus (and while your there, look up the brachial plexus) you will see the cervical nerve roots. These nerves innervate the arm muscles. The specifics aren't needed for this. What you need to know is if the neck is imbalanced, it can place pressure on the nerves; proper nerve function is needed for muscles to activate and function properly. If the neck is not structurally balanced, the arm muscles can be improperly activated (or shut off completely), and this includes any one of the many different muscles acting on the shoulder. Imbalance leads to dysfunction and pain. This is the primary starting point. Any of the following injuries can stem from the neck therefore, ALWAYS CHECK THE NECK.
2. AC Joint: Before we get into the actual AC joint we need to look at the deltoid. The deltoid is the muscle that covers the whole shoulder. It is also notoriously weak in people, both strength wise and neurologically. The unique thing about the deltoid is it antagonizes itself. That means when the anterior deltoid is firing the posterior deltoid is not and vice versa. Another example of muscles that antagonize each other are the biceps and triceps. When you flex your bicep you can't flex your triceps. It is deactivated. Now the deltoid is unique in that it does this with itself. When using Applied Kinesiolgy (neurologic testing) I find that when a muscle is spasmed or chronically tightened (muscle fibers shortened) it can inhibit the muscle opposing/antagonizing it. The 2 most common are the anterior deltoid being shortened or neurologically activated and deactivating the rear deltoid, and the psoas muscle being shortened or neurologically activated thus deactivating the gluteus maximus muscles. (Interestingly, both are ball and socket joints.)
What does this all have to do with the AC joint? Everything! The rear deltoid muscle stabilizes the AC joint. So think about it. The anterior deltoid is chronically tight, a strength imbalance develops in the deltoid, and the rear deltoid becomes weak and inhibited. Where does that stress from the imbalances go? The AC joint. If this problem persists for too long the stress can become too great and a diagnosable AC injury or separation occurs.
3. Biceps Tendon Injuries: This is a fairly complex condition, often called biceps tendonitis among other things by medical doctors, that can affect a number of different joints from the neck to the wrist and can be hard to find if you don't see someone who uses Applied Kinesiology. Applied Kinesiology is neurologic testing. Simply stated, and when used correctly, tests the neurologic integrity of the body. If a muscle is not responding appropriately to stimuli it leads to imbalance. It is the practitioner's job to create the correct stimuli in order to test. Imbalance leads to pain and dysfunction and eventually serious injury.
Some anatomy about this injury you need to know to fully understand the injury includes the bicipital groove of the humerus, the subscapularis, the long head of the biceps, and surrounding musculature. If you do not have a good understanding of anatomy please look up for better understanding. The long head of the biceps moves up the arm and attaches to the glenoid labrum. The problem mostly arrises in the area of the the bicipital groove. This is a valley in the humerus which houses the biceps tendon. Simply stated, irritation happens to this area and the tendon moves medially. The subscapularis is an internal rotator of the shoulder. It attaches to the transverse ligament, which is the ligament that houses the bicipital groove holding the biceps tendon in place.
The problem: As we slouch, create muscular imbalances from certain types of training, have too much focus on internal rotation of the shoulder, weak extensors, etc. the subscapularis will tighten and create a lot of strain on the transverse ligament of the bicipital groove. This is turn puts strain on the biceps tendon and the biceps function as a whole. This leads to major imbalances in the shoulder and elbow. The shoulder, being a more mobile and vulnerable joint, bares most of the stress and becomes injured.
Sounds complicated, but treatment is usually pretty straight forward (at least in my office). Identify what is happening with the muscles. Find the neurologic imbalance, and treat that imbalance. Thy human body is very intelligent. When you work on compromised areas with the right treatments, the body gets better very quickly. Sometimes years of pain vanishes on the spot. Treating an area that is not neurologically compromised typically yields minimal to no results. If your doctor is not treating the neurologically compromised areas, they aren't treating the problem. It isn't rocket science!!! (As in, your doctor should know how to treat this. If they don't, FIND A NEW DOCTOR!)
4. Infraspinatus injury: The infraspinatus muscle is one of the main external rotators of the shoulder. This muscle is notorious for becoming injured, and I believe it is because of the heavy amount of internal rotation today's life requires. This muscle has to be addressed in all shoulder injuries for the shoulder to become fully functional. That usually entails muscle work, muscle lengthening, and neck adjustments. If you don't address an infraspinatus injury, the shoulder will NOT get better.
You may be thinking what about the supraspinatus tendon. This is a common shoulder injury, the result of years of wear and tear (major imbalance and dysfunction) culminating in the tendon tearing. I am not a surgeon and don't treat supraspinatus tears specifically in my office. I do have patients with them as secondary complains and miraculously some of them have skipped surgery and have better shoulder function after seeing me (once we have balanced overall shoulder function). This is because when the shoulder is balanced, there is no added stress on the ligaments and joints, and injuries heal.
TAKE HOME EXERCISES:
The posture stretch: Take a 3 foot foam roller. Lay on it so your whole spine is on top of the roller. Pelvis to head. Lay your arms on the ground, perpendicular to your body and the fam roller beneath it, thumbs pointed toward your head, at a 45 degree angle. Feel the stretch and inch your hands up toward your head, over the course of 15 minutes. Do this everyday until you no longer feel an intense stretch with your hands at 90 degrees or greater. (hint: should look like a cross position.)
Rotator cuff workout:
Can be done as a workout by itself or after a workout.
A1: 30 degree incline prone trap raise 3 x 10-12 (3 second eccentric phase) 10 sec rest
A2: Elbow on knee DB external rotation 3 x 10-12 (3 second eccentric phase) 10 sec rest
A3: Low pulley external rotation at 30 degress 3 x 10-12 (2 second eccentric phase) 60 sec rest
This is a super set workout. For more info on what this means, eccentric phase, timing and any lifting questions I encourage you to visit StrengthSensei.com for more info. Charles Poliquin is a wealth of information and has a great website detailing training and health information. Below is the link to an article detailing tempo training.
Tempo Training - StrengthSensei.com
Posterior Deltoid workout:
The rear/posterior delts should be worked on a minimum of once a week. It should be noted that shoulders can be a whole day at the gym themselves, and I personally have been working shoulders out extensively for years, as a day of their own. So you may have to have separate shoulder days for a while in order to do this.
A1: Bent over rows elbows 90 degrees 3 x 6-8 (3 second eccentric phase) 10 sec rest
A2: Seated cable rows to belly button 3 x 8-10 (2 second eccentric phase) 10 sec rest
A3: Face Pulls to forehead with rope 3 x 10-12 (4 sec eccentric phase) 60 sec rest
It should be noted that I have adapted these workouts from the shoulder workouts of Charles Poliquin.
This article has been fun for me to write and I hope very informative for you all. I hope the information has brought a new level of understanding of the shoulder and the common injuries associated with it. If you have pain or shoulder dysfunction odds are you fit into 1 or more of the categories in this article. If your doctor is not addressing the things listed, they do not have the understanding or expertise to be properly treating a shoulder injury. My best advice would be to find a new doctor. If you are in the Tri-State area, (NY, NJ, CT) contact my office, Bluestone Health Group, and we will surely see what we can do.
Netter FH. Atlas of Human Anatomy. 4th Ed. 2006. (Textbook)
Rakowski Bob. Kinesiology Applied to Functional Medicine. Seminar Series 2010-2012. Minneapolis MN. (itsdrbob.com is his website) (favorite teacher/seminar instructor/mentor/doctor check his seminars and info out!)
Charles Poliquin. www.strengthsensei.com