The Foundations To
Maintaining A Healthy Shoulder
By Vicki Darlington OTR/L,CHT,CLT
Bardmoor Outpatient Rehab Center
The Shoulder joint is the most
mobile joint of the body.
 It is described as the “shoulder girdle” due to multiple
ligament, muscles, tendons and articulations that
attach the upper limb to the body.
 The shoulder must be mobile enough to allow a wide
range of actions of the arm and hand, but also stable
enough to allow for activities that require lifting,
pushing, pulling and weight bearing.
 The rotator cuff muscles are the arm elevators and
rotators placing your arm in specific positions to perform
over head activities in stabilizing and mobilizing
positions.
 The structures within the sub-acromial space are the
 Sub-acromial bursa
 The Rotator cuff tendons( Supraspinatus,Infraspinatus,Teres
Minor and Subscapularis)
 The long head of the Biceps1
SHOULDER IMPINGEMENT
 Shoulder Impingement Syndrome is the most common
shoulder diagnosis that occurs in middle age and older
adults. It can progress to rotator cuff tears as well as
glenohumeral joint instability and adhesive capsulitis .3
Types of Shoulder
Impingement
 Impingement is a broad non-descript term.
 Advancement in basic scientific research in the areas
of anatomy and the biomechanics of the human
shoulder, has led to the identification of multiple types
of impingement as well as other causes of rotator cuff
pathology, including instability and intrinsic tendon
overload.3
 Primary Impingement-Compression of the rotator cuff tendons
between the humeral head and the overlying anterior third of the
acromion, coracoacromial ligament, coracoid or acromial clavicular
joint.
 Secondary Impingement- Underlying instability of the glenohumeral joint due to attenuation of static stabilizers (capsular
ligaments,Labrum. Usually seen in athletes or overhead activities.)
 Internal Impingement-or undersurface impingement. The 90*
ABD/90*ER positioning causes Supraspinatus and Infraspinatus to
rotate posteriorly so the undersurface of the tendon rubs on the
posterior-superior glenoid lip.5
SCAPULAR KINEMATICS
 There is a growing body of literature associating
abnormal scapular positions and motions with a variety
of shoulder pathology.2
 This not only involves the rotator cuff muscles but other
large and small muscles that glide as well as stabilize
the scapula on the rib cage during arm motions.
Scapular Dyskinesis
 Scapular Dyskinesis is characterized by a lack of
upward rotation, a lack of posterior tilting and increased
internal or medial rotation of the scapula.6
 This can be attributed to altered recruitment patterns,
muscle weakness in the scapular stabilizers but also
soft tissue flexibility deficits restricting normal ROM
during activities of daily living as well as in sports
related activities.
Scapular Kinematics During Arm
Elevation
 The scapular position on the thorax and control during
motion is the critical component of normal shoulder
function.
 During elevation of the arm over head, the scapula
should upwardly rotate and posteriorly tilt on the thorax.
Overall, the evidence for scapular kinematic alterations in patients
with impingement or rotator cuff symptoms is substantial, with the
majority demonstrating lack of upward rotation, posterior tilt and
internal rotation of the scapula.3
Scapular motions
LUDEWIG and REYNOLDS
Page 21
NIH-PA Author Manuscript
NIH-PA Aut
FIGURE.
Scapular motions from (A) posterior (upward/downward rotation), (B) superior (internal/
external rotation), and (C) lateral (anterior/posterior tilting) views. Axes of rotation are
indicated as black dots. Reprinted with permission from Borich et al. 2
Clinical Presentation
Elevation: upper trap & levator
Depression: pec minor lower traps
Protraction: Pec minor and serratus
Retraction: middle traps and rhomboids
Up(lateral) rotation: Upper traps,lower traps,serratus
Down (medial rotation): levator,rhomboids and pec minor
11
Occupational and Physical Therapists treating patients
with shoulder impingement or rotator cuff injuries should
assess:

Age, history of present condition; traumatic,
insidious, overuse?
 Pain, ROM, flexibility, hypermobility and posture.
 Consider leisure pursuits, sitting positions, overhead
reaching involved in occupation as well as home
management tasks.
 Consider exercise history ,type of exercises
performed.
 As therapists we have a role to educate our patients on
body mechanics and postural correction in their daily
activities and exercise regimes.
 These are just as important as strengthening, ROM,
flexibility and stretching.
 Form, technique and core involvement integrated into
your training techniques are crucial to successful
outcomes.
Postural Re-education
 Posture can be assessed in standing.
 Look for slumped ,rounded shoulders, head forward
positioning, and internally rotated hands.
 This creates excessive thoracic spine kyphosis and the
scapula will be positioned in a downwardly tilted
position and increased upper trapezius activation.7
 This creates reduced ROM and impingement.
Poor Posture
Citing numerous studies, shoulder
range of motion is less when head is
forward, shoulder is internally rotated
and cervical and thoracic spine is in a
kyphotic posture.3,6,7
Keeping the shoulder externally rotated
or in a “thumbs up” position when
reaching over head or performing
overhead activities and exercises can
prevent impingement.
Good Posture
Correcting posture can increase
posterior scapular tilt, creating a
relative increase in the sub-acromial
space, improving shoulder flexion
range of motion.
Stretching and flexibility are
extremely important as scapular
dyskinesis is a direct result of soft
tissue tightness, most notably in
pectoralis minor, rhomboids and
levator scapulae. This leads to
excessive anterior tilt and a tight
posterior capsule.5
Rotational Range of Motion
Adaptation
 True gleno-humeral internal and external rotation
should be measured in supine with the joint at 90°of
abduction in the coronal plane, with additional
posteriorly directed force, this limits scapular
compensation.(see following fig)
 Bilateral comparisons should also be taken. Many
overhead athletes with shoulder impingement also
have increased dominant arm external rotation and
reduced dominant arm internal rotation.6
Range of Motion
Scapular Stabilization
 Borstad investigated the most effective pectoralis
minor stretches. He proposed a unilateral corner
stretch involving facing the corner of 2 walls, placing
the shoulder in 90° ABD position, then rotating the
torso away from wall until a gentle stretch is perceived.
This demonstrated the greatest length change followed
by supine manual stretch. 9
 However this wall stretch may place the shoulder into a
position of impingement . I advocate the supine
manual stretch to stretch the Pec minor and levator
scapulae.
Supine Manual Stretch
Place your hand on the
coracoid process and in a
scooping motion push the
shoulder blade down towards
the patient’s feet, upwardly
tilting the scapula.
Essential beginning exercises
1
3
Strengthening
 Strengthening of the serratus anterior and lower
trapezius muscles is vital to improving scapular
kinetics. Decker identified 3 exercises that produce
high EMG activity in the serratus, and several that
show high EMG in the lower traps. 10
 1.Wall slides-with elbows bent at 90° and shoulders at
90° flexion, lean into the wall and slide arms up the
wall equally , approximately 6 inches, then back down.
Placing Theraband around your wrist to encourage
external rotation makes the exercise more challenging.
Wall Slide
Push up Plus
Full scapular protraction occurs with
elbows extended with hands on
wall, shoulders at 90° flexion, then
retract scapulas. Performing a push
up plus with feet elevated, produced
significant greater serratus EMG
activity.10
Dynamic Hug
Is first performed without
Theraband . Look into a mirror,
making sure you are not hiking your
shoulder ,activating lower trapezius
and putting arms thumb up ,as if
hugging.
Can advance to Therabands
originating from below your waist.10
Middle and Lower
Trapezius
strengthening
This occurs in prone rowing and
scapular rows.
However poor technique can
promote anterior scapular tilt as the
rhomboids and levator scapulae
muscles are recruited, which can
lead to subacromial impingement.5
Better technique
Close attention is required to coach
the patient to maintain the scapula in
a back and downward position.
This position automatically calls for,
chin tucked, head in alignment, as in
postural alignment.
Long arm Adduction
Isometric
Sit at table with the affected arm
resting on table, thumb up towards
the ceiling ,hand and wrist on a
folded towel ,pinky side down. With
elbow straight, press down and hold
for 5 seconds. Feel the downward
contraction in the lower side back
area.11
PATIENT EDUCATION

ADL Strategies to Prevent Impingement
 Do not reach out to side with elbows extended ,arm
abducted for weighted objects.
 Do not reach behind your back and pull objects (which
internally rotates shoulder and causes head forward
posturing) as in retrieving objects from the back set of a
car.
 Do not reach overhead with shoulders internally rotated
and abducted to retrieve weighted objects ( as in higher
shelves in closets or cabinets).
PATIENT EDUCATION
 Do not carry boxes or objects with shoulders flexed and
elbows extended.
 If something is heavy, get your weight behind it and
push, rather than pull.
 When lifting objects or reaching overhead , try to keep
the shoulder externally rotated or in a thumb up
position to lessen the chance of impingement.
PATIENT EDUCATION
 Prior to exercise or work, massage the involved tendon or
muscle; follow with full range of motion, stretching of the
muscle and isometric resistance.
 Take breaks from activities if repetitive in nature. If
possible, alternate stressful, provoking activity with other
activities or patterns of motion.
 Prior to initiating a new activity or returning to an activity not
conditioned for, begin a strengthening program.
 If your shoulder is feeling better and you do lots of
activity(i.e. yardwork, housework, sports) ice your shoulder
after the activity and prior to sleeping.
PATIENT EDUCATION
 Maintain good postural alignment in all daily activities,
especially your computer terminal, phone use, texting
etc.
 Adapt seating or work station to minimize stress.
 If beginning sports related activity, seek coaching in
proper techniques or adapt equipment for safe
mechanics.
Exercise/Workout
Recommendations
 Over 40 years of age, performing military press with arms in
full external rotation/full abduction and weights over head is
just setting you up for injury.
 Do not strengthen pecs and biceps, ignoring posterior
rotator cuff and scapular stabilizers
 Do not lean forward during tricep dips.
 Engage core /abdominal muscles to set torso, and have
good base of support.
 Perform increased reps and more sets before going to
higher weights.
15
15
Solution for patient with Adhesive
Capsulitis: S/P Manipulation under
anesthesia
He travels with a laptop very frequently
to different offices all over the country.
I made recommendations ,gave him the
specs for a perfect work station.
He sent me this note and picture.
My portable laptop set-up: I have
many laptops and every one of them is
now configured to look straight
ahead...at eye level with a Bluetooth
keyboard and mouse. As an
experiment, one weekend I went back to
my old ways; the next day I had a stiff
neck and shoulder, and that was the end
of that experiment; this works....
16
WORK STATION
SET UP
In conclusion