Hey there, it’s your friendly neighborhood holistic functional rehab expert and movement specialist Dr. Ken! I don’t know how many of you know, but I’ve had a history of a long term relationship with shoulder pain starting back in the late 90s in my high school career. As a pretty bad-ass athlete (in my own eyes at least 🙂 ) , I tried my hand at playing baseball where I was probably maybe at least a half-decent player that used my shoulders to throw a lot, along with the countless reps during practice and in the weight room training.
I thought that it was just a right of passage for the sport. But what I didn’t realize was, as I got to college and grad school, I discovered that my fellow classmates, friends, professors, parents, and family members strikingly all complained of the same types of shoulder pain. And most of them did not play a shoulder intensive sport like I did. How could this be?!
I used to think exactly like those people. I figured I just had “bad shoulders,” and tried to learn to modify my life and live with it. Little did I know, learning to ‘live with it’ put me on the fast track to being trapped in a physical prison being restricted in the things that I really wanted to do! Did I really just have this plain bad luck that I was not genetically blessed with “good shoulders”.
Shoulder problems make you feel fragile, weak, stuck, and very likely confused. Confused because of how complicated the “shoulder joint” is.
The lack of understanding when it comes to shoulder function makes it so people actually create MORE DAMAGE when they are trying to rehab the shoulder.. New doctors, clinicians, and trainers merely concentrate on the shoulder joint itself. What’s worse is that conventional wisdom says if you have a messed up shoulder, you should stretch it, and increase mobility so it will function better. I mean logically, it kinda makes sense right..? But boy was that thinking just a small piece of the whole story!
If you’re tired of trying to “Live with it…” keep reading.. B/C it gets better.
I thought that after I got my clinical doctorate in PT school from Seton Hall University, I was now fully certified to finally “fix” people. Boy was I wrong! After watching and hearing the same ol’ “I have a rotator cuff tear, I have a labral tear, I have shoulder all the itisis (arthritis, bursitis, tendinitis) the Orthopedic doctors often recommended pain med, caustic multiple cortisone injections, and oftentimes unnecessary surgeries. In fact, I myself had an arthroscopic surgery for a torn rotator cuff and labrum, went through the traditional routes of PT and did I feel better?!
In fact yes, but only for about a year b/c I had to stop doing everything that I loved in order to give time to recover and heal. On the same note, I was told to avoid throwing, no heavy lifting and to avoid overhead exercises if I did not want these problems to come back..! So as a good ol’ patient, I complied and went through 6 months of therapy and thought, “I’m kinda back baby.”
Little did I know, my next 10 years was my true soul search to really find what the “ROOT CAUSES” of my shoulder issues really were only to find out that many other people have gone through similar journeys as me, if not in whole, at least in similar parts of my shoulder struggles.
Slowly returning back to working out at the gym, playing golf instead of baseball now, and I promised myself I wouldn’t throw hard playing in my adult Co-Ed softball league. And of course I’d keep up with my PT TheraBand exercises and rotator cuff and shoulder blade exercises.. Bore! I could tell it still wasn’t the same.. My mind was still in an avoidant fragility mindset that it could just be anything that could cause it to go “bad” again. As I tried to get back to my previous levels of fitness and sports, the same twinging pain, feeling stiff and achy, and soon enough the tightness came back. How could a “fixed” shoulder with all this work and rehab still not be good, especially when I’ve dedicated this much time and effort into trying to get it good again?
After over a couple of decades of researching and reading, and learning from the best in the field from top baseball throwing coaches and trainers, top researchers, and renowned rehab specialists and doctors, we have finally broken the code!
The Code is what we preach everyday at SJPT that everything is connected!
In fact to such a deep level, there would not be enough time to cover in this article itself but let’s just say, a shoulder joint is never just a shoulder joint. In fact we purposely call it the Shneck (shoulder is connected to the neck) to intrigue more thought provoking curiosity for you, our clients and our clinicians, and hopefully many more readers like you.
The shoulder in this particular blog, but really it extends to every “joint” we treat is made up of FIVE KEY COMPONENTS–and if ALL 5 of these regions are not functioning properly, you’ll have very slim chances at solving your problem(s).
Not only do you need to address these FIVE areas, but you need to address them IN PROPER ANATOMICAL ORDER.
The Five Key Components
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Graph of Amount of Emphasis and Level of Importance
In my 13 + years in training and as a professional rehab expert, I have seen so many failed attempts at shoulder rehabilitation and strengthening. Hell, I went through it myself. There is nothing more frustrating than doing everything in your power, dedicating lots of time and energy, and achieving insignificant results, or sometimes even negative ones.
Today I’m going to clue you in on how the shoulder ACTUALLY works, what the key players are, and how to approach strengthening it to a level that is bullet proof!
The Secret to this method is the systematic correction of the key players, and the smooth reintegration into the ideal compound movements. Then, the safe and progressive climb toward more advanced strength and mobility training exercises.
ALL of these players play a vital role in shoulder health and strength. If you have a dysfunction in one of these areas, you are going to have a shoulder problem–guaranteed!
The most common mistake a person can make (and boy do a lot of people make this one) is to focus on cranking and stretching the “tight” glenohumeral joint only.
This is a MAJOR PROBLEM.
The Glenohumeral Joint is already the MOST MOBILE JOINT IN YOUR ENTIRE BODY…so what happens when you try to stretch it MORE? You actually create what’s called joint instability. You see, your joints actually require two things–Mobility AND Stability.
Stretching the hell out of the most mobile joint in your body is going to cause more pain and suffering–and in some cases, this process isn’t reversible–because you aren’t stretching muscle here–you are stretching what’s called the capsule which are fibrous like ligaments around any joint. Capsular tissues and ligaments don’t stretch like a rubber band, the way muscles do. Ligaments stretch more like silly putty–you can’t shove it back together once you overstretch it.
So don’t just stretch your damn gleno-humeral joint! (unless you really know what you’re doing of course)
Not only do you need to address the function in all these five critical areas, but the ORDER that you address them in is critical!
In fact, many traditional PTs already know that you need to have a functional scapula and a mobile thoracic spine (middle back) in order for your glenohumeral joint to work well.
BUT…
If you don’t address the BREATHING, and core strength FIRST, all the shoulder rehab in the world isn’t going to fix the problem.
Just to reiterate: you need to address the key players, in this particular sequential order.
Key Component #1: BREATHING
Every time I mention this, I secretly fear that people, like I initially did, will roll their eyes and think, “I can already breathe, I’ve been doing this for my entire living existence.”
How does this even relate to my shoulder function..?”
But breathing dysfunction, to my own surprise as well, is Extremely COMMON! It in turn, causes a massive snowball effect throughout the whole body, especially the rib cage, which is the main foundation to pretty much each of our 5 key components that we are talking about!
First understand that the very first movement in life that we ever had to master when we are first born is to wail and cry, to start your Diaphragm up to breathe. Breathing drives all other physiological processes..
“Breathing is life, and breathing is the driver of all movement”
-Fore-Fathers of Functional Rehabilitation: Vaclav Vojta, Karel Lewit, Vladimir Janda, and Frantisek Vele.
Unfortunately, for many, many, many reasons; people start using the wrong muscles to drive breathing, and this is commonly referred to as Chest Breathing. In this dysfunctional form of breathing, people drive lung expansion using their neck and shoulder muscles ( our Shneck ) excessively causing improper muscle tension in these areas.
Proper muscle tension during rest and during activation creates something called Joint Centration where the ball lives happily in the center of the socket in the gleno-humeral joint aka the shoulder joint.
You see your body is designed in a rather masterful way. The structure is set up for your joints to have an ideal mechanical advantage for movement. The only way that your joints maintain this ideal position is if the muscles acting on a joint have the correct amount of tension. Not enough tension and you lose STABILITY–too much and you lose MOBILITY.
Optimal breathing is a perfect sequence of the diaphragm driving the movement, and the accessory muscles assisting the movement.
When your breathing patterns are not functioning properly, it is going to make some muscles hang on too tight, and it will make others take a vacation and become too relaxed.
Fortunately, these issues can be fixed with just a couple minutes of breathing exercises everyday! This is one example from our Optimal Bullet Proof Shoulder Manual.
It really is a magical thing! Upon our discovery about 6 and a ½ years ago, my own shoulder pinching and pain has gone away but more drastically our clients with years, sometimes even decades of shoulder pain even after their surgeries who still had pain and degenerative arthritis were all able to become pain-free and getting back to nearly EVERYTHING they could ever have imagined wanting to do.!
Our patients Mark V, and David S who both had bilateral (both right and left) shoulders impingement with tears in the rotator cuff and labrum who both were desperate to get back to the active lifestyles had surgeries to “fix” their tears, but yet low behold, still have pain years after. Both had terrible ability to raise their arms up above their heads and severely restricted what they did due to their surgeons suggesting to pretty much abstain from doing anything overhead! How absurd! (Pretty much good luck and you’ll just have to live with it.)
Here at South Jersey Physical Therapy, we have a systematic sequenced approach in getting your brain and your respiratory muscles to realize what sequence of engagement, diaphragm as the primary driver, and where air should be drawn from and where it should go in order to normalize optimal breathing mechanics and how to integrate this knowledge back into your daily lives. Oftentimes, if we don’t fix this foundation FIRST, it’s almost impossible to have success in the following next components..
Key Component #2: CORE
The next key player in fixing your shoulder dysfunction is the CORE. The core which is the major player foundation has two primary functions. One is to maintain overall alignment and joint posture of pretty much everything in your body (including your skeleton, which includes the spine and even all the organs) and the other is to stabilize the center of your body while your head/neck, arms, and legs move in order to generate force and torque.
IF the CORE doesn’t perform its job, then guess what? The neighboring muscles will try to take on its job. This is called compensation. Like we tell our patients, these compensatory neighboring muscles will be nice and lend a helping hand, but when they have to keep doing those jobs for you, boy oh boy will those neighbors become quite pissed off!
In fact, if these neighboring muscles lend a hand with core stability work, then they are absolutely already pre-occupied performing those duties and in turn can’t properly perform their own jobs anymore, and then they’ll be overworked. Hence those tight annoying trigger points in the neck and traps, tendonitis in the rotator cuff and bicep muscles just to name a few. So now your shoulder muscles are too busy being a “core” to hold the shoulder joints in the right position and on top of that, try to move your shoulder around as well.
Unfortunately, once you pretty much live in this modern day world, people often are subjected to the rigors and stresses of being stooped over a sedentary desk job, and being on phones, and screens for hours at a time. This leads not only the Core to get weak, and lazy, but easily we get stuck in bad joint alignments and positions, AKA Poor Posture! What does poor posture lead to?! That’s right, poor joint centration that we spoke just a little bit about above in KEY COMPONENT # 1.
“So this a question that gets asked all the time in the clinic, does poor posture lead to breathing dysfunctions, or does poor breathing lead to bad posture?”
And of course, the answer is never a simple one or the other, but perhaps we can sum it up into ONE simple truth and that is that if you don’t use something, then you will lose it! That includes having to breathe in bigger excursions, that includes all ROMs, strengths, cardiac demand, the list goes on, you get the point!
For this very reason, it is imperative to move and activate your core, that starts at the diaphragm and pretty much your whole body everyday! WHY?! In fact, it’s just the laws of nature in play. Our genetic make-up has pretty much substantially stayed the same over the course of the last two million years. It was engineered for SURVIVAL. That means to hunt and gather to find food, shelter, and to fight and flee from our environmental dangers.
As you may imagine, this entailed being able to get on the ground, crawl, crouch, climb, jump, run, look behind your back for any potential dangers. If we continued to do these very things just to live, then guess what, we would never have to even think about exercising these systems that would have automatically been the case in our previous natural life forms, unfortunately not so much our current day situation.
To properly activate the core, you first need to focus on ideal joint position and posture (centration). And if it has been years that most of us have fallen out of tune, please seek out a qualified practitioner who truly understands these concepts. A quick self check-point motto that we like to use for your rehab and performance clients concentrates on 3 key regions.
- Chin Tucked, Neck Tall
- Shoulders Wide (they are not shrugged, have fallen forwards, or retracted too far back)
- Ribs Down (without arching your back and pelvis)
And when these 3 regions are in check, then you are set to concentrate on dialing into your training and quickly getting on your way to properly training and progressing towards healthy and functional shoulders!
If you happen to not know how to go about it, then all the specially trained SJPT clinicians and trainers will show you exactly all the ideal proper alignments in set-ups for progressing and addressing strengthening the core, allowing for optimal whole body alignment for optimal shoulder function. That is of course, if all else is balanced to even be able to ACCESS the core!
In fact, I would wager that the majority of shoulder problems stem from a lack of proper breathing mechanics and poor core activation!!!
But there are still a few players left to talk about.
Key Component #3: The Spine
Specifically what we are talking about is the upper/middle Thoracic Spine and the Cervical Spine.
Once again, stiffness in these areas are going to have a snowball effect on the surrounding structures–so if your thoracic spine and neck are stiff, they are going to pull the shoulder out of its proper alignment (joint centration). This is going to cause havoc on your shoulder function. Not only are a mobile thoracic spine and neck are REQUIRED for your scapula (shoulder blade) to be adequately mobile and stable.
To address these areas, a simple combination of coupled multi-planar mobility drills are usually necessary in order to put them in the most leveled foundations for which everything else attached to these structures to function optimally. Yes, which involves ALL of the associated shoulder structures.
Just a few examples from what is covered in the SJPT’s Optimal Bulletproof Shoulders Manual:
Be careful though, attention must be taken here to perform these correctly because most people resort to overstretching their Lumbar Spine (low back) instead of the thoracic spine, which can actually cause more low back problems AND NOT help with your shoulder function at all.
Key Component #4: SCAPULA
The Scapula (shoulder blade) is a very tricky little structure that is considered a false joint, because it’s really not a joint at all. It can be hard to tell exactly what it needs without a proper evaluation.
In my experience most folks have ZERO ability to move their shoulder blade without compensations from the elbow or neck. This is especially true when observed in the hanging position. In fact, most individuals can not hang onto a limb or bar for more than even 5 seconds without them feeling pain in their hands.
Questions during assessment that we ask are:
- Can you draw a circle with your shoulder blade?
- Can you shrug them to your ear, can you pull them down away from your ear?
- How about, can you squeeze them towards your spine to pinch them together?
- Do you have the ability to fold/protract them forwards?
- How about, can you perform all of these now with your arms completely straight? (key piece in early gymnastics scapular strength)
How about from a push-up position?
Or how about hanging from a bar?
These movements are rarely done, but are necessary for strong, healthy, and flexible shoulders. This is especially true for the scapular muscles, which are NOT adequately strengthened with traditional weight training and gym exercises.
Fun Fact! Did you know that our human genome is 98.8% identical to the chimpanzee?!
That’s right, like the chimpanzees, just like we need to ambulate (ability to walk) to move and get around for survival, we are also built to brachiate (hang from limbs and go from one monkey bar to another).
If the shoulder blades don’t work properly, they do not provide a solid foundation for the GH joint to move from–and you know how that story ends…
Key Component #5: GLENOHUMERAL JOINT
The last key player is that pesky glenohumeral joint. The most mobile joint in the body and that in turn just naturally makes it the most vulnerable joint as well. The biggest pain in the ass for Olympic lifters, athletes and desk-bound individuals alike. It’s also where most people FEEL the pain.
However, the SITE of the pain is RARELY the SOURCE of the pain.
IF the proper steps have been taken in addressing the prerequisites (breathing, core, spine, scapula) it is important that you give that GH joint the right love as well which are the traditional rehab exercises that even the brand new graduated Dr. Ken coming out of PT school even knew! The system has just taught us the sequence backwards and it took this relentless life journey of figuring out this issue for myself over the last decade, was I able to adapt it to being able to help all of my clients that my associates and I see now in our rehab clinics!
Usually, though, addressing the prerequisites takes care of most, if not all the problems. The culprit is almost never the GH joint itself–and yet people just crank away on that poor joint.
The ideal exercises for this are going to be a hybrid of exercises. Exercises that require and train BOTH mobility and strength that we lay out clearly in our programs with the clients that we work with. Or lucky for you, we have laid that out in our SJPT’s Optimal Bulletproof Shoulders Manual.
With that said, like a house would be built, once we lay out all the work to fortify the foundation, now we can start building that robust, sturdy, beautiful house!
This is where the Fun Starts! The RE-INTEGRATION training like the Chimpanzees and how our earlier human counterparts used to live!
By properly dialing in all of the key players and placing your shoulder in the ideal joint position (centration)–you can have strong and healthy shoulders EVEN if you have a mechanical injury.
In fact, as the mechanical stressors come off the injured structures, and start to dissipate into the shared efforts of the body, nutrients and chemical signaling factors come to help fortify and repair once abused and overused tissues and start the healing process. The more healthy blood that brings the nutrient rich blood to the affected tissues, the more chance that healing actually happens.
Not only that, but repairing the damaged tissue might not be the best choice either. Studies have shown that exercise and surgery provide equivalent relief–BUT those who exercised were stronger and less likely of re-injury.
I know (intimately) how an injury can make you feel powerless– whether you want to smash weights in the gym, or reach for the top shelf without fear of a sharp pain, or just want to be able to blow dry your hair. I’ve been there myself, and I’ve worked with thousands of people to solve these problems.
Correct mechanics on even the simple “Core” Push-Ups, or how to properly perform a row, possibly even perform Handstands, L-sits, Skin the Cats, and other advanced strength movements really separate our program from most traditional “shoulder rehab” programs that can only get you so far. These “Multi-Vector” exercises are essential to healthy shoulder function. Just staying in the normal planes of movement (Like bench press and overhead press) simply does not train the entire shoulder, leaving you with some cracks in your foundation.
I want to take you ALL THE WAY from aches and pains into athletic beasts with shoulders like cannonballs. By smartly progressing into advanced strength and mobility movements, you significantly lower your risk of re-injuring your shoulder and really just setting yourself that much further away from even the remote likelihood of a shoulder injury.
It’s probably my own OCD mindset, but I believe that “good enough” just isn’t good enough if you want the best out of life. And truly to fare well in this life, you better be able to pull your own weight, or push your own weight if you want to THRIVE in this game called life!
