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October 14 2019

A Must For Shoulder Assessment

Shoulder problems are by far the most common issue I see with clients, whether it’s the average lifter, the elite lifter, the CrossFitter or even the overhead athlete.

Some come in with shoulder pain. Many others come in because they can’t get into a specific position, most often the overhead position. That limitation hurts their performance and can lead to intermittent or recurrent shoulder pain.

 

MAKE SURE TO WATCH THE FULL VIDEO TO LEARN HOW TO PERFORM THE TEST

 

The challenge is figuring out where the problem is actually coming from. Most of these clients assume (or have been told) that they lack shoulder mobility. So they stretch, do banded distractions, yank on their shoulders and get plenty of soft tissue work and manual therapy, yet see little improvement.

I know you’ve heard it before, but it bears repeating: the shoulder is often not where the problem started, only where the pain or dysfunction shows up. That’s why the first thing I look at is the bilateral standing shoulder flexion screen. In my opinion, it is one of the most valuable functional tests in a shoulder assessment.

 

A screen, not a diagnosis

The bilateral standing shoulder flexion screen is a first-step look at fundamental overhead movement. It won’t tell you which structure is irritated. It tells you how a person gets into the overhead position and where to look next.

That makes it equally useful for two jobs: deciding whether someone is ready for overhead loading, and pointing your assessment toward mobility, stability and motor control, or a combination. I use it with almost every shoulder client, and it’s one of the core screens in the Movement Optimization course.

 

The cascade of overhead movement

Getting into a stable overhead position isn’t a shoulder-only event. It’s a cascade of coupled movement between segments, where each region moves with the other:

Shoulder flexion → thoracic spine extension → scapula anterior tilt 

If one link is missing, the others may be affected. That is the whole reason to screen the full position rather than only measure the shoulder in isolation.

 

Why bilateral? What the research says about the thoracic spine

Research suggests that roughly 15° of thoracic extension is needed for full bilateral shoulder flexion, compared with about 9° for one arm. Raising both arms takes away the option of side-bending or rotating the trunk to “find” range, so a thoracic limitation has nowhere to hide.  (Of course, that doesn’t stop you from subsequently testing both sides individually as part of your assessment.)

The thoracic spine also shows up in people with shoulder pain. A 2024 study found that people with rotator cuff-related shoulder pain had reduced cervical and thoracic mobility compared with matched pain-free individuals, and the authors recommend assessing both regions in these patients. Earlier work in subacromial pain found limited end-range thoracic extension alongside a more protracted, anteriorly tilted scapula.  (NOTE: While these deficits may not be the cause of shoulder pain, restoring them should be part of the rehab plan in the context of providing the best possible movement resources for the client/patient. This is what we call tertiary prevention.)

Here is the interesting part. Resting posture, meaning how rounded the upper back looks while standing, does not appear to differ much between people with and without shoulder pain. A systematic review found moderate evidence of no association between increased kyphosis and shoulder pain.

In other words, it’s how the thoracic spine moves, not how it looks standing still, that seems to matter. That’s precisely what a movement screen captures and a posture photo doesn’t.

 

When the screen isn’t enough

The screen tells you where to look, not what’s wrong. If the movement provokes pain, if range is limited in a way that looks capsular or blocked, or if there’s a history of trauma, instability or recent surgery, the screen is the start of the assessment rather than the end of it. Refer or complete a full clinical evaluation before moving on to corrective work.

 

The bottom line

Before you reach for the band or start working on the shoulder itself, watch how your client gets overhead. The bilateral standing shoulder flexion screen takes less than a minute, and it tells you whether to look at the shoulder, the thoracic spine, the scapula, or all three. The research supports this approach: it’s how the thoracic spine moves, not how it looks, that seems to matter in shoulder pain. Even when a movement deficit isn’t the cause of the pain, restoring it gives your client the best possible movement resources moving forward.

Screen first, then treat what you find.

Want to know more about this test and the valuable information it can provide?  Head to this article for more tips and full video explanation.

 

References

Barrett, E., O’Keeffe, M., O’Sullivan, K., Lewis, J., & McCreesh, K. (2016). Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Manual Therapy, 26, 38–46. https://doi.org/10.1016/j.math.2016.07.008

Crosbie, J., Kilbreath, S. L., Hollmann, L., & York, S. (2008). Scapulohumeral rhythm and associated spinal motion. Clinical Biomechanics, 23(2), 184–192.

Hunter, D. J., Rivett, D. A., McKeirnan, S., Smith, L., & Snodgrass, S. J. (2020). Relationship between shoulder impingement syndrome and thoracic posture. Physical Therapy, 100(4), 677–686. https://doi.org/10.1093/ptj/pzz182

Manoso-Hernando, D., Bailón-Cerezo, J., Elizagaray-García, I., Achútegui-García-Matres, P., Suárez-Díez, G., & Gil-Martínez, A. (2024). Cervical and thoracic spine mobility in rotator cuff related shoulder pain: A comparative analysis with asymptomatic controls. Journal of Functional Morphology and Kinesiology, 9(3), 128. https://doi.org/10.3390/jfmk9030128

 

 


Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U

 

 

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