Improving Shoulder Function - Part 3

In Part 1 of this series, we discussed normal shoulder biomechanics and several causes of shoulder dysfunction while in Part 2 we outlined the specific progression to pushing patterns. In this, the final installment of the series, we'll cover pulling patterns as they relate to improving scapular mechanics.

In Part 2, we discussed the myofascial linking of the upper extremity to both trunk and the contralateral lower extremity as seen in the anterior oblique chain. Recall that the anterior oblique chain is important in controlling and producing rotary motions of the trunk and upper extremity. The posterior oblique chain, consisting of the latissimus dorsi, the thoracolumbar fascia and the contralateral gluteus maximus, is a direct agonist and antagonist to the anterior oblique chain. Similar to the anterior oblique chain, the posterior oblique chain is critical to ensuring proper stability and mobility of the shoulder complex. Synergistically, it functions with the anterior oblique chain to control and produce rotary movements, especially during the gait cycle when the opposite arm and leg are flexing (see Figure 1). The pre-stretching of the posterior oblique chain during the flexion allows for an efficient and powerful extension movement that aids in propelling the body forward. Antagonistically, the posterior oblique chain controls forward rotation of the trunk.

Mechanices During Pulling Patterns 

The key to any pulling patterns lies in utilizing proper scapular mechanics. As was seen with pushing patterns, scapular control is paramount, regardless of the pattern performed. The key points are listed below.

• The thorax should be neutral during pulling patterns. Clients should be cued appropriately given their postural presentation. If they are in a hyper-kyphotic (increased thoracic curvature) thorax position, they are cued to lift the sternum as they perform the pulling pattern. If they are in a hypo-kyphotic (decreased thoracic curvature) position, they are cued to drop the sternum slightly while lengthening the thorax as they perform the pulling pattern.
• The core should be activated, and diaphragmatic breathing maintained during any pattern. Heavier loads may necessitate more of a "bracing" stabilization strategy while diaphragmatic breathing patterns should be encouraged during lighter loads.
• When performing vertical pulling such as in pull ups or pull downs, the scapula should be allowed to go into upward rotation during the eccentric phase of the exercise and should be pulled back to a neutral position during the concentric phase. The scapulae should not be pulled into downward rotation or “squeezed” together as this favors the downward rotators (primarily the pectoralis minor and rhomboids).
• During horizontal pulling as in rowing, the scapulae will protract or abduct mildly during the eccentric phase and retract or adduct mildly during the concentric phase of the exercise.
• The elbows should not be pulled beyond the mid-line of the torso in individuals who have a propensity toward the forward shoulder position as this encourages downward rotation of the scapula.

You may be wondering why “squeezing” the shoulder blades is being discouraged when the forward shoulder position is so prominent? That is a valid question considering the propensity of the forward shoulder position. The basis of this series of articles has been the correction of the most common shoulder dysfunction: downward rotation. Virtually all individuals who demonstrate the forward shoulder position have accompanying downward rotation of the scapula. To prove this to yourself, stand in front of a mirror and roll your shoulder forward. What happened? The scapula abducts and rotates anteriorly. This position inhibits the serratus anterior and lower trapezius, the two muscles most responsible for upwardly rotating and posteriorly tilting the scapula. When the scapula is in downward rotation, any attempt to adduct or retract the scapulae will result in further downward rotation. Therefore, neutral scapular position must be maintained to favor optimal mechanics and strengthening of the scapular stabilizers, particularly the lower trapezius and serratus anterior.

Functional Patterns 

Although there are innumerous permutations, vertical and horizontal pulling patterns are the two essential movements that will be performed. Horizontal patterns include all rowing type patterns that can be performed with dumbbells, bands or a cable column. Vertical patterns include any patterns that involve either pulling a weight down towards the body as in cable pull-downs or any pull up type movement.

Horizontal Pulling

The dumbbell row is one of the fundamental movement patterns targeting the scapular stabilizers as well as the shoulder and back extensors. Historically, this pattern has been performed with one knee and arm stabilized on a bench. This position limits the training effect of the spine extensors, making the trunk stabilizers essentially “lazy.” Therefore, a modified stabilization position will be utilized. The specifics of the pattern are listed below.

• Supported dumbbell rows should be performed with the feet parallel or in a split stance. One hand is lightly stabilized in front of the body. The key, however, is light stabilization. The bodyweight should not be "hanging" off the stabilized arm. The spine and scapula should remain neutral.
• The scapulae should remain fairly neutral. Note the position of the scapula is stabilized in both the eccentric and concentric phases of the movement (black arrow in Figure 2). Do not pull the elbows past the midline of the trunk in individuals with shoulder instabilities or scapular control issues (black arrow in Figure 4).
• Once the basic version is mastered, progress to the unsupported version to further challenge the trunk stabilizers (see Figures 3-4). Ensure neutral position of the scapula and trunk. Alternating patterns can be performed once the bilateral version is mastered (see Figures 5-6).
• Add in further challenges by incorporating rotation patterns (see Figures 7-8). Ensure neutral spine (vertical arrow) and proper pulling mechanics through the scapula (diagonal arrow).

Vertical Pulls

All mechanics during the horizontal pull will apply to vertical pulling patterns. The scapula and spine must be controlled during any version. The cable pulldown can be performed in a seated, standing or kneeling position utilizing unilateral (see Figures 9-10), bilateral or alternating patterns. Do not allow the individual to pull the scapula into downward rotation or the trunk to move into lateral (side) flexion during the concentric phase of the exercise. 

Incorporating the Posterior Oblique Chain

Functional progressions of pulling patterns include loading of the entire posterior oblique chain. The single leg cable row (see Figures 11-12) is one of the most functional patterns as it challenges the entire posterior oblique chain. Ensure the individual can stabilize on one leg, maintain solid scapular mechanics and is able to maintain a neutral spine position throughout the pattern. 

Conclusion

Improving shoulder function relies on the ability to properly assess and evaluate an individual’s ability to move his or her shoulder complex under neuro-motor control. Restoring optimal function includes first, achieving a neutral scapular position; second, developing optimal stabilization patterns in the neutral position, and third, optimal motor control during functional progressions. By following the guidelines and principles of motor control and functional training, shoulder function can be established, even in those individuals with chronic shoulder instabilities.

References

1. Liebenson, Craig. Rehabilitation of the Spine- 2nd Edition. Lippincott Williams and Wilkins, Baltimore MD, 2007.
2. Osar, Evan. Complete Core Conditioning- DVD. Fitness Education Seminars, Chicago, IL 2007.
3. Osar, Evan. Complete Rotary Conditioning, Fitness Education Seminars, Course Handouts, Chicago IL, 2007.
4. Osar, Evan. Complete Shoulder and Upper Extremity Conditioning, Fitness Education Seminars, Chicago IL, 2005.
5. Roskopf, G. Muscle Activation Techniques- Upper Body Function, Course Handouts, Muscle Activation Techniques, Greenwood Village CO, 1999.