Shoulder problems are by far the most common issue I see with clients whether it be the average lifter, elite lifter, Crossfitter or baseball player.
While some clients come to me experiencing shoulder pain, I also see many clients whose shoulder problems manifest in the form of an inability to get into specific positions, namely the overhead position. This impacts their performance and may result in intermittent or recurrent shoulder pain.
One of the challenges in addressing shoulder problems is figuring out where the problem is coming from.
Most of the clients I see assume (or have been told) that their shoulder problems stem from a lack of mobility, so they stretch and do band tractions and yank on their shoulders, and they get loads of soft tissue work and manual therapy, but still see little improvement.
I know this sounds like something you have already heard, but the shoulder is usually not where the problem started, only where pain and/or dysfunction has manifested itself.
So, if shoulder problems don’t always come from shoulder problems, where should you start?
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There is a cascade of functional movement along the kinetic chain to get into a stable overhead position:
The Standing Shoulder Flexion Screen is a great tool to get a global view of how an individual gets into an overhead position. There is another video on the blog all about this test.
This screen provides valuable information on the quality of movement of the shoulder complex. It is my go-to way of assessing the fundamental movement of the shoulder complex and pointing me in the direction of what I need to work on to restore this fundamental movement capacity.
Let me say that again.
The ability to get into this position unrestricted and uncompensated is fundamental
The individual is instructed to raise both arms overhead as high as possible.
As you can see from the image above, the last few degrees of range of motion require active thoracic extension. Because this creates an extension moment, the anterior core needs to create a counterbalancing flexion moment.
If you look at this too quickly you might still mistake shoulder problems for shoulder problems.
If you don’t quite grasp the fact that this is a cascade of movement where movement in one region impacts movement in the next region, you will likely miss something.
SHOULDER OR T-SPINE?
Most often, people jump to the conclusion that an excessive rib flare or extension through the lumbar spine is a way to compensate for lack of shoulder flexion range of motion.
This certainly COULD be the case. But again,
if you don’t look at and understand the entire cascade of movement, you might be chasing the wrong suspect
The fundamental movements you should observe with the standing shoulder flexion screen are:
-Full external rotation and flexion range of motion of the glenohumeral joint: Can they get their biceps by their ears?
-Upward rotation and posterior tilt of scapula: Does the inferior angle of the scapula move into the midline of the axilla?
– Thoracic spine extension: Does the thoracic spine flatten out if it is naturally kyphotic?
-Anterior core stability: Is there excessive rib flare of lumbar spine extension?
Here is a client who came to me because he thought it was his lack of shoulder mobility that was impacting his performance on front squats and cleans:
Here is his front squat:
If you didn’t spot it in the standing shoulder flexion video, you can see more clearly in his front squat video that it’s actually his T-spine mobility and not his shoulder mobility that is an issue.
His inability to extend the t-spine prevents him from driving the chest, shoulders and elbows up, which is crucial in the front squat. As such, his hips rise to generate hip drive but he loses the bar forward, as you can see quite clearly in the video on the left.
We got amazing improvements with him in just 4 weeks by leaving his shoulders alone and focusing on thoracic spine mobility and extension strength (video on the right).
By the way, if you have not seen my FREE 60-minute Mobility Webinar, I actually explain his case entirely. I go through the details of how to optimize the nervous, articular and myofascial components of mobility to build a 12-week mobility program addressing his issue.
SHOULDER OR ANTERIOR CORE STABILITY?
Another no-no with the Standing Shoulder Flexion Screen is assuming that excessive rib flare and/or lumbar spine extension is a compensation for lack of shoulder mobility and that as such, we should yank on the shoulders.
It CAN be. But I will repeat it again, if you don’t look at and understand the entire cascade of movement, you might be chasing the wrong suspect.
Here is another client who came to me thinking his lack of shoulder mobility was impacting his performance on overhead squats and snatches:
I hope you can see from the video that his shoulder mobility is not too bad, but there is no way he can hold a weight overhead in that position.
His issue stems from a deficit in his anterior core stabilization (FYI, we also worked on the feet and improving the positioning his center of mass over the tripod).
Speaking of the feet, in my must-read article Foot Stability is the Foundation for All Your Lifts, I explain why working on the feet is so important.
ASSOCIATION AND DISSOCIATION
Addressing T-spine mobility is probably something you’re pretty familiar with already. It is an issue you probably come across fairly regularly.
On the other hand, establishing anterior core awareness and stability can sometimes be more challenging.
When I say the capacity to get into an un-restricted and un-compensated overhead position is fundamental and is a cascade of movement, what you need to understand is that there is an association of movement:
SHOULDER FLEXION – T-SPINE EXTENSION – ANTERIOR CORE REACTIVE FLEXION
If one of these is lacking, it will affect the other. As you know more intuitively, if the T-spine doesn’t extend, the individual may “give up” that anterior core flexion to make up for the lack of extension.
You may also have an individual who has the shoulder flexion and T-spine extension range of motion, just not the anterior core control.
Either way, at some point you’re going to have to find ways to bring awareness to that reactive anterior core stabilization.
How do you create a dissociation of movement?
It really does not need to be complex. What you want to do is challenge the anterior core to resist extension, so classic anti-extension exercises work pretty well. Biasing the dead bug exercise towards the upper extremity is one simple and effective way:
While you work on improving this capacity, you can keep loading your client using exercise variations that prevent them from getting into too much extension and/or create an anterior core flexion moment.
A kneeling landmine press is one great way to do just that:
WATCH THE MAIN VIDEO OF THIS ARTICLE TO SEE MORE EXERCISES
DON’T GET TUNNEL VISION
“Things are not always as they seem; the first appearance deceives many.” – Phaedrus
While many people do have shoulder problems that have a direct link to the shoulder itself, it is rarely the case that the shoulder alone is the culprit.
Understanding that there is a cascade of movement for overhead positioning and that the capacity to get into this position is fundamental will help you solve a lot of shoulder problems that are not really, well, shoulder problems. You get my drift now!
Cook, G., Burton, L., Hoogenboom, B. J., & Voight, M. (2014). Functional movement screening: the use of fundamental movements as an assessment of function-part 2. International journal of sports physical therapy, 9(4), 549–563.
Magee, D. J. (2008). Orthopedic physical assessment. St. Louis, Mo: Saunders Elsevier.