Shoulder Pain & The Winging Scapula
Meet the Scapulothoracic Joint
A common postural deficit and root cause of much shoulder dysfunction is the winging scapula. The scapula, “wings,” when its medial border lifts off of the ribcage and sticks out. In this position, the scapula is no longer sitting properly on the ribcage, is out of position, and has now upset the length-tension relationship of all of the 17 muscles that attach to it. At best, this posture weakens the shoulder. At worst, this posture predisposes the shoulder for rotator cuff tears and dislocations.
The scapula (shoulder blade) and clavicle (collar bone) have only one small boney attachment to the axial skeleton at the sternum, otherwise this bone finds itself floating on the ribcage, with only muscular attachments. The primary function of the scapula is to provide the foundation for movement of the upper arm. The force producing muscles of the shoulder and arm use the scapula as a stable platform from which to move the humerus (upper arm) through space. The rotator cuff muscle help keep the humerus and the scapula in proper position relative to each other. The remaining muscles dynamically angle the scapula to allow the shoulder joint the largest range of motion in human body.
The Scapulothoracic joint is the articulation of the underside or anterior side of the scapula and the ribcage. The scapula is supposed to sit tight against the ribcage wall, gliding over the ribs as it is positioned for movement of the humerus. In many cases the scapula wings away from the rib wall, not due to muscular weakness or nerve injury, but due to the rib cage pulling away from the scapula. This ribcage posture is call, “flat back syndrome.” This is easily identified by looking at the thoracic spine between the shoulder blades.
The thoracic spine should slightly bow out between the shoulder blades in a kyphotic curve. To accommodate this curve, the anterior side of the scapula is concave, resting appropriately on the ribs. An individual with, “flat back syndrome,” will have a thoracic spine that is flat between the scapula, pulling the ribs anteriorly away from the scapula. Often times the individual will looked hunched over as the upper thoracic and cervical spine flex forward to accommodate the flatness of the spine below.
The main cause of, “flat back,” posture can be found at the the ribcage. Ribs are supposed to move with each breath. Upon inhaling, the anterior ribs elevate, rotating up, while the posterior ribs depress, rotating down. This rib motion causes the thoracic spine to straighten, losing its kyphotic curve. Upon exhaling, the anterior ribs depress, rotating down while the posterior ribs elevate, rotating up. This rib motion causes the thoracic spine to flex, regaining its kyphotic curve. “Flat back syndrome,” happens when the ribs get, “stuck,” in inhalation, with the posterior ribs flat and the thoracic spine extended.
The ribs don’t, “stick,” in an inhaled position spontaneously, this posture develops from movement patterns that take years to develop. Ultimately the muscles between the ribs and the sternum adjust to this new posture, creating rigid rib cage that is, “stuck,” in an inhalation posture. To fix this posture and ultimately a winging scapula, the ribcage must be compelled to expand in all directions, but especially posteriorly, closing the gap between the scapula and the rib wall. This is done with a progression of ribcage mobility exercises combined with breathing techniques.
Foam Roll Rib Cage
The first exercise focuses on loosening up our the ribcage so that it can expand in all directions. Lay on your right side over a foam roller that should hit your ribs approximately 3-4 inches below your arm pit. Take a slow inhale lasting 5 seconds. Then slowly exhale for 5 seconds, reaching with the left arm up and overhead, pulling and expanding the left side of the ribcage. As you continue to exhale, you should allow your right side to sink and bend over the foam roller. On subsequent inhales/exhales, focus on feeling your ribcage expand front, back and out to the left, as you block the right side of the ribcage. Repeat this for a total of 10 breath cycles on each side, 2 times daily, for 2 to 3 weeks. Spend some time with this exercise before progressing to the next.
Goblet Squat
The goblet squat directly targets the mid-back back, compelling the thoracic spine to flex and round, gradually filling the gap between your ribs and scapula. The reason this exercise works is that as we hold the weigh out in front of our body, our mid-back will automatically flex to balance out the weight distribution. Begin by rolling up and standing on a towel to elevate your heels. Take a manageable weight, 10-20lbs, in your hands and raise it up to chin height, resting your elbows on your ribs for support. Now squat down to a 45 degree angle at your knees, about halfway down. Hold this position for about a minute, slowly inhaling for 5 seconds and exhaling for 5 seconds. Repeat this for a total of 5 repetitions, 2 times daily, for 2 to 3 weeks.
The Scapulothoracic joint is often overlooked when trying to tease out the root-cause of shoulder pain and persistent shoulder dysfunction. These two exercises are a great additional to any shoulder strengthening and/or rehab protocol.