This is the third article in a three part series that will familiarize trainers with the functional anatomy of the major structures of the body and explain the most common musculoskeletal imbalances for each. Trainers will learn how to assess a client’s imbalances as well as some techniques that can be used during regular exercise programs to correct problems, eliminate pain and improve function.
About the Thoracic Spine and Shoulder Girdle
The thoracic spine is the area on the torso where the ribcage attaches to the spine. The shoulder girdle (comprised of the structures described below) articulates with this part of the spine via muscles, tendons, ligaments and bones.
The sternum is a T-shaped bone where your ribcage meets at the front of your chest. The clavicle attaches to and extends outwards from the sternum to help form the shoulder girdle. The scapula (shoulder blade) sits on the back of the ribs. The acromium is part of the scapula that extends forward to also help form the shoulder joint above the humerus (see Figures 1a and 1b). The head of the humerus helps form the shoulder joint via the labrum which gives the end of the humerus a nice cup-shaped piece of cartilage to sit in. All the movements of the shoulder are highly complex and depend on perfect articulation of all the bones, tendons, ligaments and fascia.
The four most common deviations of the thoracic spine and shoulder girdle are excessive thoracic kyphosis, a protracted shoulder girdle, internally rotated arms and elevated scapula.
The thoracic spine is naturally curved forward forming what is called a kyphotic curve. However, when this curvature is excessive, it can become problematic. When the thoracic spine rounds forward, the shoulder blades usually move away from the spine and slide forward on the ribcage. This is known as protracting the shoulder blades. As the shoulder blades protract, the arms internally rotate in the shoulder joint preventing the arms from moving correctly. Consequently, the shoulder blades (scapula) tend to elevate. Any or all of these compensatory patterns can cause pain and dysfunction.
Assessing the Thoracic Spine and the Shoulder Girdle
In order to assess the lumbo-pelvic hip girdle, you must be able to see the area clearly. Inform clients prior to their visit that they should wear a form fitting t-shirt or sports bra (females). The assessment process includes a verbal, visual and hands-on evaluation. Always write down or make note of your assessment findings.
Conduct a verbal assessment first to gain insight from clients into their interpretation of the pain and function of the body parts you are assessing. Ask the following questions:
- Do you ever experience pain in mid to upper back, chest, shoulders, neck, ribcage or abdominals? Ask them to be specific about the location of the pain (i.e., is it on the front of the shoulder, the top of the shoulder, back of the shoulder, under the shoulder blade, under the armpit, back of the neck, side of the neck, middle of the chest or sternum). This will help you to identify a probable cause.
- Have you ever been diagnosed with arthritis in the shoulders or spine? This will help you understand the condition of the joint structures of the thoracic spine, shoulder girdle, neck and head.
- Do you ever experience numbing, tingling or loss of strength in the arms or hands? This may indicate that nerves are being compressed in the spine or by soft tissues such as muscles or fascia.
- What is your occupation or job and level of physical activity? This will help you understand any additional stress on the joints.
- What aggravates the condition and what makes it feel better? Does the pain coincide with any other pains or symptoms in the body? Does the pain increase with stress (i.e., while in heavy traffic, after a long week or after an argument)? This will help you and your client understand the cause of the pain.
Visual and Hands-On Assessment
Rib to Spine Assessment (Part One)
Look at your client’s head and shoulders from the side while he is standing. The place where the first rib meets the sternum should be parallel with the first thoracic vertebrae. Draw an imaginary line from the breastbone to the spine to evaluate whether your client’s sternum and ribcage have dropped (see Figure 2). If the shoulders are rounded in an excessively kyphotic posture, the ribcage will drop. In Figure 2, the client shown has excessive thoracic kyphosis.
Rib to Spine Assessment (Part Two)
Look at your client from the front to check for forward shoulder and internally rotated arms. If this is the case, you will be able to see the back of your client’s hand(s), rather than his thumbs facing forward. Look also from the side and back to see if his shoulders are rounded or his shoulder blades have moved away from his spine (e.g., protracted). The shoulders may also be shrugged slightly, causing muscle tension in the neck and shoulders.
Teaching Neutral Thoracic Spine and Shoulder Girdle
Ask the client to stand with his heels back to the wall, his head back with his chin in. The back of the head should come within about a third of an inch of the wall without the head tilting back and the eyes looking up. Coach the client to tilt his pelvis so that the lower back is only “two knuckles” distance away from the wall (see “Lumbo-Pelvic Hip Assessment” in part two of this article series for clarification). Now ask the client to pull his shoulders back to the wall without changing the position of his head, lower back or feet. This will be difficult for the majority of your clients. However, it helps them to understand what muscles need addressing to help them achieve this desired position.
About the Head and Neck
The head is made up of several bones. It sits on top of the atlas bone, which is the first vertebrae of the neck. The neck is comprised of the first seven vertebrae of the spine. The jaw is another bone in the head that articulates with the head via the temporomandibular joint (see Figure 3). As the head moves forward, backwards and side to side, the neck moves accordingly, communicating with the head via a complex system of nerves, muscles, tendons, ligaments and fascia.
The two most common deviations of the head and neck are a forward position of the head and excessive cervical lordosis. A forward position of the head is evident when the head extends forward of the center line of the body. The further the head moves forward, the more the neck has to arch keep the eyes parallel to the horizon. This excessive curvature of the neck is referred to as excessive cervical lordosis.
Assessing the Head And Neck
When assessing the neck and head, it is important to get a very clear picture of the structures involved. When necessary, ask male clients to remove their hats/caps and ask females to pull their hair away from their neck.
As with the other parts of the body, you will need to conduct a verbal assessment of the head and neck. Ask clients about the specific location of any pain, if they have been diagnosed with arthritis, about their occupation and level of physical activity and the level of stress they experience during the day. Always write down any pertinent information you find.
Visual and Hands-On Assessment
Forward Head Position
Ask the client to sit on a gym ball with her feet facing forward. Look at your client’s cheek bone just below the eye. Place one forefinger on the client’s cheek and the other on her collarbone. Imagine a piece of string is hanging down from her cheek with a small weight attached to the end, like a plumb line. Determine where the plumb line would fall on your client’s upper chest. Ideally, it should fall on top of her collarbone. If it falls forward of this point, then your client’s head is too far forward of optimal alignment (see Figure 4). In Figure 4, the client shown has a forward head.
Excessive Cervical Lordosis
Ask your client to stand with her back to the wall with her heels touching the wall. Instruct her to flatten her lower back to the wall so that there is “two knuckles” space between her lower back and the wall. Ask her to maintain this position in the lower back as she tries to bring the back of her head back to touch the wall. As she brings her head back, watch the lower back to see if the space between the wall and the lower back increases. Tell your client she can relax slightly so that her head is just a third of an inch away from the wall. With her head in this position and her lower back in the correct position, assess her line of sight. Draw an imaginary line from the corner of her eye through the center of the eyeball and out into the room. If this imaginary line is not parallel to the floor, then your client has excessive cervical lordosis (see Figure 5). In Figure 5, the client shown has excessive cervical lordosis.
Teaching Neutral Head and Neck Position
Ask your client to stand with his heels and back to the wall. Instruct him to tilt his pelvis so that only two of your knuckles will fit between his lower back and the wall. Ask him to pull his head and shoulders back to the wall without arching the lower back or tilting his head back (looking up). The head and neck is neutral when the back of the head is approximately a third of an inch away from the wall, the line of sight is parallel to the ground, the shoulders are aligned under the front of the ear and there is approximately a two knuckle space under the lower back (see Figure 6).
Relationship Between the Thoracic Spine and Shoulder Girdle, the Head and Neck and the Rest of the Body
As previously discussed, when the thoracic spine rounds forward (kyphotic curve), the head will also move forward and the neck will arch to align the line of sight. This will eventually place undue chronic stress on the neck. As the upper body shifts forward, the pelvis will most likely anteriorly rotate to accommodate the tipping forward of the upper body. This shift in the pelvis will also lead to an increase in the lumbar curvature. These imbalances in the spine and pelvis will most likely cause a resultant shift in the femur to internally rotate, a medial (or valgus) displacement at the knee, an internal rotation of the tibia and the resultant pronation of the foot and ankle complex.
Each and every time you work with your clients, be sure to utilize visual, verbal and hands on assessments as you continually evaluate their entire body to help improve your client’s function.
If the thoracic spine, shoulder girdle and head and neck are not functioning optimally, any movement under load can cause pain and/or injury to any part of the body. For example, if a client is performing an overhead pressing movement and he can not achieve the desired thoracic extension to press the weight over his head, he may over arch his lower back to stop the weight falling forward. This may lead to a lower back strain, lumbar disc compression and/or nerve pathologies. Similarly, if the humerus can not externally rotate and the glenoid can not move posteriorly to get the weight over his head, then only the elbow will move back to press over his head. This will place further stress on the shoulder joint.
Here are three exercises to help your clients overcome the structural deviations discussed herein.
Two Tennis Ball Trigger Point Release (see Figure 7) - Excessive thoracic kyphosis can cause the muscles of the thoracic erector spinae group to become sore and inflamed. These muscles need rejuvenating and regenerating before trying to attempt strengthening exercises that would place further stress on the tissues.
Instruct your client to lie on the ground on his back with his knees bent and a tennis ball placed on either side of his thoracic spine. The tennis balls should be almost touching but far enough apart so as not to be in direct contact with the spine itself. Ask your client to lie back over the balls, keeping his chin tucked in to his chest so his line of sight is perpendicular to the ceiling. Use a pillow to ensure his neck does not arch backwards. (If the pressure on the balls is too great, simply increase the size of the pillow to lift his spine off the balls.)
Once he is in position, coach him to tilt his pelvis to try to flatten his lower back. This will increase the pressure on the balls. Instruct him to stay on one spot for about 30 seconds and then move the balls to another sore spot along the thoracic spine and repeat. Be sure to only place the balls near, not on, the thoracic spine. This exercise can be done once a day where there are any sore spots.
Supine Wave Goodbye (see Figure 8) - Excessive thoracic kyphosis can lead to a weakness in the muscles that retract and depress the shoulder blade, externally rotate the arm and flex the head and neck as well as to tightness in the anterior shoulder and chest. All of these areas need addressing to help create a balanced shoulder girdle and head and neck.
Instruct your client to lie on his back on the ground with his knees bent. Ask him to raise his arms to shoulder height with elbows bent and the back of his palms on the ground. Have him pull his shoulders back to the floor and down towards his hips. (Clients with rounded shoulders may be tight in the anterior shoulder. If you place a towel under their elbows, they will be able to pull their shoulders down more effectively.)
When your client is in the correct position, place a foam roller under the back of his palm and instruct him to apply isometric resistance into the roller. Coach him and observe to ensure that he keeps his shoulder back and down as he applies resistance with the back of his hand into the roller. This exercise will help strengthen the posterior shoulder muscles to help stabilize the glenoid. During the exercise, also coach your client to keep his chin tucked in with his line of sight perpendicular to the ceiling. This will strengthen the anterior neck and head flexors and decrease an excessive cervical lordotic curve. Do six to 10 isometric contractions every day for a hold of five to 10 seconds per contraction.
Thoracic Extension with Hip Extension (see Figure 9) - When your client’s soft tissue structures have been addressed, he may be ready to begin strengthening the muscles that help put the thoracic spine into better extension and flex the shoulder.
Instruct your client to interlock his fingers and raise his arms over his head with the palms up. Be sure he doesn’t excessively shrug his shoulders during the movement. As he raises his arms, ask him to simultaneously step back with one leg, tilting the pelvis posteriorly to reduce the amount of extension occurring in the lumbar spine.
When your client’s soft tissue structures have been addressed, he may be ready to begin strengthening the muscles that help put the thoracic spine into better extension and flex the shoulder. Instruct your client to interlock his fingers and raise his arms over his head with the palms up. Be sure he doesn’t excessively shrug his shoulders during the movement. As he raises his arms, ask him to simultaneously step back with one leg, tilting the pelvis posteriorly to reduce the amount of extension occurring in the lumbar spine.
Evaluate the mechanics of the shoulder girdle as the client raises their arms. If they bend one or both arms excessively, they may have shoulder discomfort, and you will have to progress to this exercise more gradually. Do five to 10 repetitions daily.
This series of three articles has helped to explain how to perform a basic structural assessment of your clients. In my next series of articles, you will learn about functional anatomy, look at how to assess and address the soft tissue structures of the body and explore functionally based exercises that will correct even the most problematic imbalances.
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