Why is my shoulder such a pain in the neck?
Raise your hand if you suffer from neck or shoulder pain? Just kidding, please don’t do that, especially since that’s usually an aggravating factor for those working through discomfort in one or both of these areas.
Neck and shoulder pain are two of the most common reasons why people seek out medical care. For the vast majority, poor posture and overuse injuries are the primary drivers for developing pain and mobility deficits in theses areas. Think about how many hours a day we spend sitting in front of a computer screen, commuting to and from work, and staring at our phones. Now how much of that time would you say is done while maintaining good posture? Probably not very much if we’re being honest. We’re all guilty, myself included, of spending too many hours hunched over. With this forward head posture being where most people spend the majority of their day, it’s no wonder this poor alignment carries over into seated and standing postures as well. Then we add further insult to injury by loading this misaligned system with repetitive stressors like reaching, lifting and throwing activities albeit for sport-specific or day-to-day tasks. Thus, it’s only a matter of time before overuse injuries of the neck and shoulder develop as a result.
Try this simple test right now: allow yourself to hunch forward in your chair and then raise your non-painful arm as high as you can. Take note of how high you can reach, then lower your arm back down. Now sit tall with your very best posture and raise that same arm again being sure that you aren’t cheating by overextending through your back or letting your ribcage pop forward. Notice anything different? In the better posture scenario, it should have been easier to raise your arm and you should have noticed a significant increase in the amount of overhead range available. You’ll find the same is true with neck mobility. The amount that you can move your head side-to-side or up and down should be greater when sitting with good posture versus hunched over. I hate to admit it, but our mother’s were right to nag us about the importance of good posture even if they didn’t know about its impact our neck and shoulder health.
So why is posture so influential on neck and shoulder mechanics? The neck and shoulder share a number of myofascial connections. This is why most people don’t have just a neck problem or a shoulder problem, but typically have a combination of both. Forward head posture (FHP) is a term we use in physical therapy to describe the hyperextended position of the neck and rounded upper back, which then causes what is known as upper crossed syndrome (UCS).
UCS describes the muscular relationship that develops as a result of FHP. You’ll notice a red line that divides the photo to the right. When our body is in the correct alignment, the earlobe intersects this line and continues straight down through the acromioclavicular joint (where the collarbone and shoulder blade meet). However, in the case of someone with FHP, the head translates too far forward past the shoulders and ribcage disrupting the length-tension relationship of the corresponding musculature. The neck flexors, rhomboids and lower trapezius muscles become weak and over lengthened, while the pectorals, upper trapezius, levator, and suboccipital muscles become tight and shortened. People with this condition often complain of constant tension in their neck and upper shoulders, which can also be accompanied by headache symptoms, in addition to pain in and around their shoulder blade. These ‘tight’ muscles are trying to compensate for their ‘weak’ dysfunctional teammates but eventually become exhausted from the extra workload they’re unable to overcome.
So why does this system fail? Why are the ‘tight’ muscles unable to support this FHP? Over lengthened muscles don’t have the capacity to generate the force they’re capable of since they’re being asked to contract contraction beyond their optimal range. Thus, they either generate a suboptimal force or none at all. Similarly, a tight muscle won’t be able to generate the force they’re capable of since they’re being forced to start their contraction from an already shortened position resulting in decreased force generation. Tight and overactive doesn’t mean strong! Both muscular teams in this case are underperforming for different reasons. This unbalanced system eventually reaches a breaking point since the ‘tight’ team is doing the work for the ‘over lengthened’ team. They weren’t designed to work under such conditions. That’s when neck and shoulder pain begin to show their true colors.
The seated test I had you preform earlier put you into an upper crossed syndrome position. That position compresses the neck and shoulder girdle due to the over lengthened and shorted muscular relationships mentioned above. The other important piece we haven’t talked about yet is how the majority of these same muscles involved with UCS also attach to your shoulder blade (scapula). So when those muscles aren’t able to do their job correctly, your scapula won’t be able to move correctly either, further perpetuating pain and movement dysfunction throughout the neck and shoulder regions.
So why is movement at the scapula so important? First, take a look at the pictures above and identify the following muscles: pectoralis minor, levator, rhomboids, and trapezius (which is divided into three regions the upper, middle and lower trap). Notice where those muscles attach and remember what I mentioned above about those muscles being too tight or over lengthened. We’ll come back to that idea soon…The other important piece I want to touch on here is the fact that there are 17 muscles alone that attach to the scapula; and remember they attach to the scapula and also connect somewhere else – base of the skull, spine, ribs, or humerus. Now, imagine putting 17 people in a room and asking them to work together as a team. It can happen with the right environment (think posture), right instructions (think movement education and proper strengthening), and the right preparation (think motor control and sequencing of movement), but it requires work and practice. With this many people on a team, it’s also highly likely that there will be some dysfunction within the group at some point…this is one of the many reasons why the shoulder is so complex and often susceptible to injury.
Now, the good news is you don’t need to know all 17 muscles that attach to the scapula to fully understand and appreciate what I’m sharing in this post. However, I do want you to pay attention to the muscles that we talked about with regards to UCS. The upper/mid/lower trapezius, levator, rhomboids, and pectoralis minor all attach to the scapula. When these muscles become unbalanced, the scapula cannot move correctly. This usually becomes most apparent as we try to raise our arm to shoulder height and above. That’s because the scapula is supposed to rotate and move out to the side with overhead activities to make room for the humerus to glide inferiorly downward within the glenoid fossa (where the scapular and humeral head meet). This highly coordinated movement is referred to as scapulohumeral rhythm. With UCS, this coordination becomes disrupted, resulting in abnormal movement at the shoulder girdle called scapular dyskinesia. The upper trap, levator and pec minor elevate and anteriorly tip the scapula out of alignment. Over time these muscles all become tight and shortened, preventing the scapula from moving properly and locking down the the shoulder girdle into a rounded forward position. When this movement pattern is left uncorrected and then loaded with repetitive activities, cervical spine dysfunction, impingement pathologies, and injuries to the rotator cuff and labrum eventually occur. It’s a messy domino effect.
So what can you do to address these imbalances? There are a number of things that need to be done to correct these aches and pains, which is why I will be presenting this material over a series of posts. Posture needs to be your starting point. That’s your foundation and how you set your body up to be successful (or unsuccessful in the case of FHP) for your activities.
Stay tuned for the second installment of this series (coming soon!) which will provide examples of how to assess and adjust your posture for common activities like sitting, working at your computer, driving, reading, and standing. Finally, the third installment will include myofascial release, mobility, and strengthening exercises you can incorporate into your daily routine to address the dysfunctional movement patterns discussed in this post. Get your foam rollers, tennis ball/lacrosse ball, and resistance bands ready!