The shoulder joint can be an admittedly difficult structure to assess and rehabilitate. Shoulder pain can come from a myriad of problems, so figuring out where to start is tough. Before diving into how to assess the shoulder though, let’s define what exactly the shoulder girdle consists of.
The shoulder girdle is composed of the clavicle, scapula, and humerus. The clavicle, or collar bone, sits on top of the rib cage and connects the sternum to the scapula via the acromion, which forms the “roof” of the shoulder. The scapula, or shoulder blade, rests on the back of the rib cage and provides a surface for the humerus to glide on; the glenohumeral joint. In order the maximize the mobility and function of the humerus, the clavicle and scapula need to start in a good position to allow for proper scapulohumeral rhythm.
When assessing the shoulder there are lots of factors that need to be considered, but a good place to start is resting scapular positioning. “Ideal” scapular position is debated but large deviations from what is considered “normal” should raise some concerns. There are four general guidelines I follow when looking at resting scapular position:
· Superior-medial border in-line with 2nd thoracic vertebrae
· 3 inches between spine and medial border of the scapula
· 5° resting scapular upward rotation
· Scapula snug against the rib cage
Implications of Scapular Depression
The resting elevation of the scapula can give insights into what muscles are more dominant in the individual being evaluated. One way to check for “normal” scapular elevation, as mentioned earlier, is to see if the superior-medial border of the scapula rests in-line the 2nd thoracic vertebrae. Personally though, I believe it is easier to assess clavicular angle when determining the resting level of the scapula. Ideally, we want to see the lateral aspect of the clavicle about 1 inch higher than the medial aspect. A flat clavicle may indicate scapular depression due to a latissimus dorsi dominance. This is a very common posture seen when evaluating overhead throwers, as the latissimus dorsi is a powerful internal rotator. Unfortunately, resting scapular depression can impede the ability of the scapula and clavicle to upwardly rotate, making shoulder flexion difficult and increasing the risk for impingement, among other pathologies.
In this population, choosing what exercises to avoid can be just as important as choosing what exercises to emphasize. Because the scapula is already resting in depression, I tend to shy away from exercises that reinforce this aberrant posture in clients who are symptomatic, such as farmer carries, pull downs, or trap bar deadlifts. Instead, I put an emphasis on exercises that promote scapular elevation and upward rotation. Some of my favorite exercises for individuals who sit in scapular depression include waiter carries, landmine presses, and KB bottom up presses.
The Rhombo-Serratus Muscle
In the textbook “Anatomy Trains,” Thomas Myers introduces the idea of a Scapular “X” relationship that exists within our shoulder girdle. The first leg of the Scapular “X” is composed of the rhombo-serratus muscle. The rhomboids begin at the spinous processes of C7-T5 and attach to the inferior aspect of the medial border of the scapula. At the medial border of the scapula the rhomboids are picked up by the serratus anterior, on the anterior surface of the scapula, before attaching to ribs 1-8/9. When one of these muscles is short, you will often find that the opposite is long.
Ideally, we want to see the medial border of the scapula resting about 3 inches from the spinous processes with 5° of resting scapular upward rotation. In athletes who possess a “military posture,” you will notice a decrease in space between the medial border of the scapula and the spinous processes. This compensation can often be linked to shortened rhomboids. Strengthening, or shortening, the serratus anterior muscle can help to improve this posture. One of my favorite ways to encourage scapular protraction and upward rotation is by performing a simple push-up. Landmine presses and KB bottoms up presses can be great options here as well.
But what if the medial border of the scapula is well over 3 inches from the spine? In these athletes we should consider that the rhomboids may need to be strengthened in order to create a better starting position. Row variations are a great option for encouraging this adaptation.
Lower Trapezius and Pectoralis Minor Balance
The second leg of the Scapular “X” consists of the lower trapezius and the pectoralis minor muscles. The lower trapezius muscle begins at the spinous processes of T4-12 and attaches to the spine of the scapula. The pectoralis minor runs from the coracoid process to ribs 3-5 and is responsible for anteriorly tilting the scapula. A common presentation we see is an anterior tilt of the scapula, where the inferior-medial border is elevated rather than the scapula being snug against the rib cage. An athlete with this presentation may benefit from lengthening the pectoralis minor and strengthening the lower trapezius.
One of my favorite ways to decrease tone in the pectoralis minor is by using a pin-and-stretch technique. Start by taking a lacrosse ball and placing it between your pectoralis minor and the corner of a wall. Hold this position for about 10-20 seconds then raise your arm to shoulder height about 10 times, pinning and stretching the pectoralis minor.
The prone trap raise is one of my favorite ways to strengthen the lower trapezius. I will defer to Eric Cressey for an explanation on how to perform this commonly butchered exercise:
The shoulder can be a difficult joint to rehabilitate and train due to the number of muscles that must coordinate with one another to create clean movement. By no means is this a comprehensive approach to assessing the shoulder, but hopefully this gives you a good idea of where to start.