Teaching someone to move their shoulder with authentic and ideal movement can be a rollercoaster ride at times; sometimes it’s the most powerful reset and other times the most frustrating event of your day. That’s because the shoulder in many ways can be the most complicated joint on the body because its very large freedom of motion. When a joint has abundant motion like the shoulder, then it can be easy for the stability and support to be compromised. Therefore, often times we need to get the pendulum back to neutral by findings ways to build motor control and stability.
What’s most often involved with building motor control is the concept of a “packed” shoulder (i.e. engaging the rotator cuff and scapular stabilizers to ensure proper humeral head position on the glenoid of the scapula during any shoulder movement pattern).
There are several techniques that can properly cue the shoulder to be “packed”, and help regain needed stability. Here are a few techniques that may work well for you and your patients:
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| what a finely packed shoulder you have... |
- Isolate the scapula then integrate with the humerus.
It may be beneficial to isolate the scapula to improve the proprioceptive awareness, proper kinematics, and muscle recruitment needed for overhead motions. The scapula is the driver for proper scapulohumeral rhythm. Or another way to point it, proximal facilitation provides distal control. What I have found to be a very effective technique is side lying PNF diagonals on the scapula. (PNF D1 replication or combination of isotonics[google it])
- Ensure proper body position and let your hips move the scapula. You need to be “dancing” with the scapula. Therefore be in the same line of the movement.
- Tactile cueing the inferior angle and infraspinatus gives the best kinesthetic feedback for the posterior depression (what the scapula usually needs more of to lock in the humerus). Try not to be too “handsy” and give conflicting proprioceptive information.
- “90% down, 10% back”. Stay close to 1 (or 11) oclock. Not 2-3 oclock. This is the biggest mistake most of my interns will make
- Once the patient gets a good idea of scapular motion then start moving lifting the arm into different angles (45, 90, 110, etc). Watch and palpate the acromion. You and the patient should see and feel the humerus “drop” and gap right down. That ensures that the rotator cuff inferiorly glided the humeral head down (like a boss)
- Don't let the arm compensate by shurging, or elbow bending (long head biceps compensating) for the rotator cuff. Even when the humeral head drops the wrist shouldn't!
- Use Analogies.
Patients need to understand why we are working to pack the shoulder. Otherwise, they will not be reinforcing and applying it outside of the clinic. For a patient to understand Sharmann's concept of PICR, or simply the correct force couple and ideal alignment of the shoulder on the shoulder blade should be broken into more simple ideas.
Two simple analogies are the golf ball on the tee (with this analogy they can understand the lack of structural stability that the small scapular glenoid provides for the large humeral head and the importance of the humeral head to be in the proper position so it doesn’t “roll off”).
Another useful analogy is the seal balancing the ball on its nose (here you can educate on the importance of dynamic stability that the rotator cuff provides when the ball moves).
- Start static but don’t forget to move dynamic
Lets face it, most of our patients aren’t performing for cirque du soleil so they may not have the best motor control in the world. Therefore, its probably best to start somewhere simple, with a unloaded and static technique.
Begin with the patient in supine with your fingers and palm flat in a cupped position having your hypothenars contacting near the inferior angle of the scapula. With the other arm begin to perform perturbations and rhythmic stabilization then progress to pulling on the arm with the cue “do not let me unpack your shoulder, even if I pull you off the table”. Progress the intensity by pulling harder or letting them not know when you are pulling so they react quickly (this would be considered RNT).
- Teach packing on a 0-100 scale (and progress static to dynamic!)
Similar to slouch over correct technique, we may teach the shoulder being packed from very poor 0 position (superiorly shrugged, anterior tilted, and forward shoulders) and to a perfect 100 position (chest open, post scap chain engaged, humeral head posterior and inferior). It’s important for the patient to understand the shoulder doesn’t need to be a perfect 100 with all movements and in fact this may be a little overkill, but a 90ish is ideal and >50 will suffice. However anything 50 and below is clearly too inefficient and not preferred.
A good exercise for this is the tennis ball drop-catch
Have the patient work in different planes of motions and diagonals, ensuring a packed shoulder with the movement . I love doing this in quadruped! Progress them from static packed to staying packed with movement. If they drop below 50, they are awarded no points and may God have mercy on their soul.
- Incorporate open chain and “closed chain” exercises
Llearn how to move the arm around a fixed core (wall slides) as well as learning to move the body around a fixed arm (roll bar, Turkish Get Up)
- Put in a position that will easily engage packing
This can be accomplished by having the patient maximally rotate or “ twist and look over your shoulders”. This puts the shoulder in a great starting position and engages the posterior shoulder chain. It s a nice cheat and super simple to let the patient feel a properly packed position (say that 5 times fast!).
This is way longer than I wanted (take it from someone who is ADD). If you made it this far, consider yourself to be a scap packing ninja (with 6 ninja stars). Oh, I never get a lot of comments, so let me know if some of this works, if you agree/disagree, or if you have other strategies that work well/better. Thanks!
