The Hunchback of Shoulder Pain

The shoulder is a particularly interesting joint. It is one of the most mobile, dynamic, useful,… and, unfortunately, most vulnerable to injury.[1] As we learned in this month's Deep Dive, the shoulder is complex and there are numerous joints and muscles involved with simple motions like lifting your arm overhead. If you are experiencing shoulder pain, massaging and stretching often help, but not always. Why is this? The truth is that another very important body region plays a pivotal role in the normal use of our shoulder: our upper back (Thoracic Spine).

The shoulder and the upper back have a regional interdependence – meaning, they rely on each other for normal movement.

How To Throw A Ball

The cause of shoulder pain isn’t always obvious. We can develop pain from lifting incorrectly, reaching repetitively, or even from just sleeping in awkward positions.[2] The shoulder and the upper back have a regional interdependence – meaning, they rely on each other for normal movement.[3] When you reach above your head, about 2/3 of the motion comes from your shoulder joint, and the last 1/3 comes from the shoulder blade, other joints, and extension of your thoracic spine.[1] In those with stiff and “slouched” spines, the motion from the shoulder blade cannot be fully accessed.[1] This is important – if the shoulder blade and upper back aren’t helping during arm movements, the shoulder joint takes on extra strain.[4] Try this: throw a balled-up piece of paper with your upper body slouched, generating all the force from just your arm. Now try throwing the ball with an upright posture, naturally turning your body during the motion. Which felt better? When analyzing baseball pitchers, it has been shown that not only the shoulder joint (glenohumeral) is required for a smooth throw, but also contributions from the shoulder blade (scapula) and upper back (thoracic spine).[5] Maintaining an upright and neutral spine reduces the mechanical demand in the shoulder joint while throwing, which, in turn, reduces the risk of a shoulder injury.[6]

As previously mentioned, those with more rounded upper spines and shoulders have an increased likelihood of pain around the shoulder blade.[7] Those who develop “pinching” issues in their shoulder have reduced mobility in their thoracic spine and very often live with forward flexed postures.[4] Thankfully, many studies have shown that spine extension (upright) helps improve shoulder function and range of motion along with reduce the risk of impingement.[3] In fact, mobilizing our spine not only helps our joints move more smoothly, but also alters sensory information from the spine muscles which, in turn, improves our pain processing within the central nervous system.

Avoiding postural challenges (i.e., avoiding changing postures) can result in poor postural fitness, meaning they have issues adapting to new positions.

The "Bad" Posture

There is no true “bad" posture. The idea of a bad posture was originally described by a Czech physician in the mid-20th century.[8] His definition of “slouched postures” was useful for quickly understanding how muscles and joints are affected by our posture, but lacks a clear connection to pain. High-quality studies since then have shown that even “good” postures can lead to pain.[9] Any single posture is not inherently bad, but any posture can produce pain depending on how long we remain in that posture. Avoiding postural challenges (I.e., avoiding changing postures) can result in poor postural fitness (i.e., issues adapting to new positions).[10] Poor postural fitness may lead to issues such as pain and difficulty coping with new postures when they are needed. It is for these reasons that we recommend simple exercises to counteract any single posture throughout your day. Specifically, the ability to move out of a slouched posture during the day helps reduce the chance or recurrence of shoulder pain.

The Hunchback of Less Pain

The HALO exercise combines mobility and stability into one smooth motion that will loosen your upper back and improve the mobility and stability of your shoulder.[11] The exercise is simple - grab a weight and move it around your head!

For a quick way to improve upper back mobility and reduce shoulder stress, try leaning over a chair or edge of a table - you can do this at work or home! Place your arms either as shown in the picture, or crossed on your chest.

REFERENCES

1. Culham E, Peat M. Functional anatomy of the shoulder complex. J Orthop Sports Phys Ther. 1993;18(1):342-350. doi:10.2519/jospt.1993.18.1.342

2. Holdaway LA, Hegmann KT, Thiese MS, Kapellusch J. Is sleep position associated with glenohumeral shoulder pain and rotator cuff tendinopathy: a cross-sectional study. BMC Musculoskelet Disord. 2018;19(1):408. doi:10.1186/s12891-018-2319-9

3. Haik MN, Alburquerque-Sendín F, Silva CZ, Siqueira-Junior AL, Ribeiro IL, Camargo PR. Scapular kinematics pre- and post-thoracic thrust manipulation in individuals with and without shoulder impingement symptoms: a randomized controlled study. J Orthop Sports Phys Ther. 2014;44(7):475-487. doi:10.2519/jospt.2014.4760

4. Hunter DJ, Rivett DA, McKeirnan S, Smith L, Snodgrass SJ. Relationship Between Shoulder Impingement Syndrome and Thoracic Posture. Phys Ther. 2020;100(4):677-686. doi:10.1093/ptj/pzz182

5. Miyashita K, Kobayashi H, Koshida S, Urabe Y. Glenohumeral, scapular, and thoracic angles at maximum shoulder external rotation in throwing. Am J Sports Med. 2010;38(2):363-368. doi:10.1177/0363546509347542

6. Suzuki Y, Muraki T, Sekiguchi Y, et al. Influence of thoracic posture on scapulothoracic and glenohumeral motions during eccentric shoulder external rotation. Gait Posture. 2019;67:207-212. doi:10.1016/j.gaitpost.2018.10.022

7. Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis CA. Incidence of Common Postural Abnormalities in the Cervical, Shoulder, and Thoracic Regions and Their Association with Pain in Two Age Groups of Healthy Subjects. Physical Therapy. 1992;72(6):425-431. doi:10.1093/ptj/72.6.425

8. Page P, Frank CC, Lardner R. Assessment and Treatment of Muscle Imbalance: The Janda Approach. Human Kinetics; 2010.

9. Richards KV, Beales DJ, Smith AL, O’Sullivan PB, Straker LM. Is Neck Posture Subgroup in Late Adolescence a Risk Factor for Persistent Neck Pain in Young Adults? A Prospective Study. Physical Therapy. 2021;101(3):pzab007. doi:10.1093/ptj/pzab007

10. Ingraham P. Does Posture Matter? A detailed guide to posture and postural correction strategies (especially why none of it matters very much). PainScience.com. https://www.painscience.com/articles/posture.php

11. Chang AU, Liebenson C. The Halo exercise for shoulder and thoracic spine mobility. Journal of Bodywork and Movement Therapies. 2014;18(1):145-147. doi:10.1016/j.jbmt.2013.11.014

Healthy Is Wellness, LLC (“Healthy Is Wellness”) is not a health care provider, and does not provide professional medical advice, diagnosis, and/or treatment. THE INFORMATION PROVIDED BY HEALTHY IS WELLNESS IS FOR INFORMATIONAL PURPOSES ONLY.