Don't Forget About The Scapula

It seems like the list of things that can go wrong with the shoulder joint is never ending: partial rotator cuff tears, full-thickness rotator cuff tears, labral tears, shoulder dislocations, internal/external impingement syndrome, etc… However, not all shoulder pain is caused by dysfunctions within the glenohumeral joint, sometimes the scapula can be the cause. This post will discuss the importance of the scapula on shoulder pain and function. 

When dealing with shoulder issues, the focus is usually on the rotator cuff. The rotator cuff is made by the combination of four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis. Together, these muscles blend into the glenohumeral capsule to help keep the humerus on the glenoid. The reason why the rotator cuff muscles are so important is because they stabilize this structurally unstable joint. The image used to describe the stability of the shoulder joint is a golf ball on a tee (the golf ball is the humerus and the tee is the glenoid of the scapula). Since the tee doesn't have enough surface area contacting the golf ball, the golf ball is easy to knockoff the tee. The rotator cuff muscles essentially surround the humerus and glenoid providing stability, similar to tightly wrapping a golf ball and a tee together with Saran wrap. 

The part of the shoulder complex that is frequently overlooked is the scapula. The scapula acts as the foundation for the glenohumeral joint, moving with the shoulder as it moves. The scapula is controlled mainly by three muscles: the upper trapezius, lower trapezius, and serratus anterior. These three muscles, when acting together, help rotate the scapula upwards when elevating the humerus. However, when there is an imbalance between the muscles attaching to the scapula, it can interfere with the biomechanics of the shoulder. 

For instance, if the levator scapula muscle is in spasm, it can cause a downward rotation of the scapula. This is problematic when dealing with overhead activities and overhead athletes because the foundation of the shoulder (the scapula) hasn’t moved enough for those activities leading to an impingement of the shoulder. Especially in overhead athletes, repetitive dysfunction of the shoulder complex will lead compensation. Common compensation patterns include increased mobility at the glenohumeral joint or increased tension of the upper trapezius muscle. These compensation patterns stress different structures which can lead to pain and injury.  

The first step to treating the shoulder is to figure out if the pain is a result of the glenohumeral joint, scapular dysfunction, or a combination of both. Once the faulty mechanics have been identified, treatment can begin. In this case, we are going to assume the scapula is the reason. 

Although there is no universal protocol for scapular dysfunction, the most common pattern is tightness in the levator scapula and upper trapezius muscles accompanied by weakness of the lower trapezius and serratus anterior. 

Soft tissue therapies such as Graston or manual therapy to the upper trapezius and levator scapula are usually beneficial in addressing the tightness in these muscles. These therapies provide a mechanical stimulus to the muscles that will neurologically alter the tissue tone, thus decreasing the tightness. 

There are many exercises that can be used to address the muscle weakness in the lower trapezius and serratus anterior. When addressing muscle weakness, it should be noted that we are not only discussing the strength of a muscle but also the ability to contract the muscle (motor control). You can have the strongest muscles in the world, but if the activation sequence is delayed it won't be of much benefit to your movement. Therefore, starting off with some basic activation exercises for the lower trapezius and serratus anterior such as wall walks and serratus punches can help build both strength and motor control.

 

Wall Slide Start and Finish Position

Wall Slide Start and Finish Position

Serratus Punch Start and Finish Position

Serratus Punch Start and Finish Position

Once proper scapular control has been established and there is sufficient strength, the final step is to do exercises that will integrate these proper shoulder mechanics. Shoulder presses and push ups are two great exercises that will further enforce the mechanics discussed above. 

If you are having shoulder issues, let us help figure out how to get you moving better. Schedule a free consultation with us here