It’s time to think differently about shoulder stability!
Subacromial pain syndrome is a blanket diagnosis typically characterized by pain when performing movement overhead, and is often coupled with an apparent “weakness” of the rotator cuff muscles. This “weakness” of the rotator cuff muscles is something that we feel is overstated. When you appreciate the anatomical dynamics of the rotator cuff, they’re not tissues that would typically express a lot of force producing behavior. What we mean by this, is that testing the strength of the rotator cuff via classical muscle testing is most likely not going to give you a great insight into their natural behavior to dynamically stabilize the glenohumeral joint in a low threshold manner. What if the rotator cuff appears to be “weak” because the upper limb as a whole is not sharing and distributing load well, and the rotator cuff tissues are expressing a higher threshold strategy to compress the glenohumeral joint? What if they’re just fatiguing too quickly because they’re already working at a higher threshold? These are questions that we feel are very important to consider, before blindly throwing scapular stabilization exercises at every client with this diagnosis.
The study attached attempted to determine the clinical value of the classic scapular retraction exercises, which we’ve probably all used/seen before. It’s commonly taught by cueing a client to pull their shoulder blades down and back as if they were sliding them into their back pockets. Well, this study showed that exercises involving scapular repositioning or strengthening yielded no difference in symptom reduction when compared to participants who engaged in general periscapular loading exercises.
While this study gives us a great insight into the importance of not being too hyper-focused on the position of the scapula, there’s obviously much more that needs to be considered when working with clients experiencing the symptoms mentioned above. I’m sure we’ve all been aware that even general periscapular strengthening exercises are many times, not enough. The role of the associated tissues of the shoulder need to be considered within the context of the entire limb.
The past injuries of the client are features that need to be considered and are very important to guide us. For example, imagine we have two clients with identical symptoms that fit under this blanket diagnosis of subacromial pain syndrome. Both experienced a gradual onset, yet both share a completely different past injury history. Client #1 has a history of wrist and elbow problems before they experienced shoulder pain. Client #2 has a history of whiplash/neck injuries on two occasions, and still experiences intermittent pain in their neck. Do you think the assessment of both these clients will look the same?
For us, certainly not. Do you think the starting point of treatment/rehab will look the same for these two clients? For us, certainly not. Each client, because of their unique injury history, most likely express unique limiting factors that need to be considered during the assessment and treatment process.
If you have time, check out the study! Hopefully, this information will help you ask different questions when approaching these clinical scenarios. Thanks for reading!