Assessing Overhead Arm Elevation

assessing overhead arm elevationOne of the many things I look at during my comprehensive assessment process is the movement quality of raising your arms overhead.  The information you gather on the person’s ability to perform such a basic task is often invaluable when designing someone’s rehab or training program.

UPDATE: I have posted my follow up of this article breaking down the scapular winging.

I have a video below of a recent assessment I performed.  This is an interesting case and something I wanted to share.  However, I want to try something completely different for this week’s post, let’s try to make this interactive!  I am going to post a video below.  Use the comments section, either on this website or using the Facebook comments section below, to tell me what you see and what you think is going on in this video.

I’ll be upfront, there are no wrong answers, just what you see!  And there are a decent amount of things to see in this one video, so don’t be shy.

I will give you a little history.  Patient is a competitor high school swimmer with insidious onset of bilateral generalized shoulder discomfort and fatigue in the pool after prolonged swimming.  Mostly posterior in nature but not specific.  Exam obviously reveals generalized laxity you would expect with a swimmer, however no significant structural pathology detected.

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Comment below and let me know what you see and what may be going on in the video – remember there are a lot of things to see, so don’t be shy – there are no wrong answers!  I fully expect people to see things that I missed.  I’ll give everyone a couple of days to join in and then on Wednesday I will post and update and discuss more about what I saw, so check back here later in the week as well.

Hopefully this interactive post experiment goes well.  If you like this type of post, please join in and let me know in your comment, and share this with your friends to get more discussion going!

 

UPDATE: I have posted my follow up of this article breaking down the scapular winging.

 

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46 Responses to “Assessing Overhead Arm Elevation”

  1. Nice post Mike. Videos of cases are always fun! First I would like to point out that he should stick with swimming because he clearly sucks at paintball!!! Kidding aside if you look at his static position you can see that the right scapula is more anterior tilted and protracted compared to the left side giving that typically impression that it is depressed. The left side has a worse type I scapular dyskinesis pattern with the inferior angle protruding, although it is slightly observed on the right. There also seems to be hyperextension of his left elbow as you can tell from the minimal distance between his lats and elbow. During dynamic motion the right has slightly more upward rotation. The wiggle is interesting and I think might be caused by a combination of the laxity in his left elbow and the lack of neuromuscular control during forward flexion of his scapular stabilizers and rotator cuff. This is why its very clear during the mid range of motion when the capsule is not engaged. He clearly has inhibition of his lower trap and serratus as you can tell from the eccentric phase as well as how the pattern gets worse with more repetitions. I also agree with the others that he has a tight levator on his left that is most likely in spasm. It seems that this is purely a neuromuscular control issue with some typically structural tightness (pec minor, levator, etc) and the combination of time off from the pool and rehab should alleviate his pain.

  2. It’s challenging to evaluate without seeing a side and front view. I see the movement in left arm and neck, as well as protrusion and elevation of the left shoulder blade. From the rear, he appears to be tipping his chin towards chest – perhaps habit, but not optimal. Again, a side view would be helpful.

    Where will we be able to see your evaluation and suggestions for this young man?

  3. L scapular dyskinesia is greater than R.

    Scapular winging indicative of inhibited serratus anterior.

    It’s difficult to tell, but it doesn’t look like his lower traps are kicking in as much as I would expect after 120 deg of flexion.

    Trunk motion on eccentric phase indicative of poor eccentric control.

    I’ve found great success with focusing on lower traps, serratus anterior, and upper traps. I would definitely start there with treatment. Other findings will likely fix them selves. The ones that don’t should be addressed as needed.

  4. The first thing I saw was the obvious dyskinesis of the left scapula and the winging, as Nick already pointed out. Can’t wait to see your thoughts on this one.

  5. Really cool video and love that you posted this up!I’m excited to see what you have to say about it Mike!

    Shoulder flexion and thoracic extension range of motion look really good. Ability to control left scapula is clearly flawed. It appears to wing when challenged indicating a serratus ant. issue. The neck waggle looks very funky. My first thought would be some kind of levator scap. involvement.

  6. + L scapula inferior angle and superior border instabilty. I would have the patient stop the cupping treatments he is getting…. :)??? Stick with motor control exercises of L scapula. Good video. I ask patients if they would like to see what their scapula is doing and offer them to watch the video – they really enjoy seeing what their shoulder/scapula complex are doing.

  7. Some of my thoughts while watching:

    Initial alignment- depressed scap bilat, L>R downward rotation, adducted scap bilat, C/S rot R, L>R GH adduction, L>R elbow hyperextension

    Conc mvmt- relatively greater GH movement vs. scap (GH hyper), L GH IR, decreased/late scapular upward rotation bilat, R scap does not posteriorly tilt and/or ER at end-range, and excessive anterior humeral head glide at end-range likely due to stiff pec minor (note creases).

    Eccentric phase- his R RTC mm are clearly stiffer than the scapular mm (literally “pushing” the scap into the winging) and there is a motor control issue since his rhomboid fired near the end of motion (improperly), and the RTC was unable to properly lengthen giving him that “hitch” at the end. The serratus anterior is long on the L (unable to generate enough force to maintain proper scapular alignment against the ribs).

  8. Long thoracic nerve paralysis causing serratous on left to be weak. forward head posture. T-L area very hypertonic looking. Would like ot see his movement at 90 degrees.

  9. Primary issues I see are:
    1. Left sided serratus weakness/rhomb major weakness (he was able to stabilize for only one rep.)
    2. Left: levator/rhomboid minor tightness: likely elevating the scap, and causing left lateral cervical flexion when returning to neutral.
    3. Other compensatory issues noted at ribs difficult to asses with the info curious about SC joint, SCM may also be part of the problem.
    Nice video I am looking forward to your assessment.

  10. Firt a question: Did he receive a cupping treatment, acupuncture? Left side significant weakness in serratus and rhomboid weakness. Definite levator scap involvement and lat tightness some thoracic extension compensation. Right sided involvement as well scap dyskinesis. I would like to see some different views.

  11. I agree with the comments above & would like to add there appears to be a lack of mobility/stability, week core with abs/glutes not firing in the right sequence, need to breath deep into the diaphragm to help engage the mid & low traps first. If this swimmer which appears to be breathing shallow would activate the mid & upper traps & neck muscles first as a compensation for muscle imbalances.

  12. Great discussion here and thanks for posting this interesting video Mike.

    My initial thoughts:

    If you took a representative sample of 100 swimmers matched for age, gender, and ability level and perhaps predominant swimming stroke, would you be able to tell who had pain versus no pain by watching a video of them performing bilateral shoulder flexion? In other words can we say that the movement patterns we see on this video, and the theorized impairments that are attributed tothem, are causally related to his pain?

    I just attended a one day seminar with L. Moseley. So given my acknowledged recency bias I suggest that this is a cortical issue:) Perhaps this swimmer’s neurotag for shoulder extension and cervical rotation are now inextricably linked given the repetitive nature of these actions occurring together during a sport that is notorious for a high volume of training?

    Bill

    • This is the best response yet.

    • Bill is onto something critical IMO.

      You’ve taken a fish out of water and asked him to move on dry land, with no environmentally relevant feedback and using a movement pattern that he would not normally use (in training).

      Your focus is the shoulder and that’s fine for assessment but what enters the water first?

      Look at how he postures the hand during arm elevation in this video- this is abnormal and not functional for a swimming stroke. This type of movement pattern that moves from the shoulder IMO is probably not meaningful to this athlete nor functional.

      Skilled hand use/feedback/drills in an elevated position would IMO be a better assessment/treatment direction test.

      Great post.

  13. I see tight lats bilateral that are trying to compensate for lack of stability. With the left he has resting posture of downward rotation which could indicate tight rhomboid and levator. He also has anterior tilt of left greater than right, which would make me test pec minor length. In elevation on the left he shows more signs of scapular instability therefore increasing the distal movement of hand and elbow. He also has obvious poor eccentric strength of mid and low trap as well as serratus which leads to the winging and control faults in the eccentric phase. I feel that he tries to over compensate with upper trap on left for stability and gets the resultant ipsilateral cervical side bend. I would therefor like to see both strength and endurance tests of Low trap, mid trap and serratus. As for the right resting he has downward rotation, scapular internal rotation. His right scapulae does not achieve enough upward rotation in full flexion and he deviates to scapular plane to try to achieve full elevation. His eccentric faults are not as marked on the right. I would also be interested in core strength and stability since swimming consists of a lot of open chain motions. I think he could become much more efficient with his stroke if his deficiencies are addressed. I also feel he would be a perfect candidate for red cord due to the nature of full suspension like he functions in the pool. Interested to hear how he progresses and possibly some of the other results of tests and measures that you did.

  14. It’s a motor control problem on the left side. Because there’s insufficient upward rotation of the scapula he makes use of his GH laxity and this leads to GH instability. The mediorotation of the scapula when lowering the arm is a just a way to center the caput in the cavitas glenoidalis. It has nothing to do with weak traps or rhomboids. He needs to learn how to upward rotate and stabilize his scapula by motor control training.
    @Mike: I think the marks on his back are from cupping, is that right? Why do you make use of that? He won’t learn to move his shourdle girdle with that kind of therapies.

    • I would tend to disagree with the patient not having weakness surrounding his left scap. If he did not have weakness, he would have a 5/5 Midtrap, low trap and serratus anterior MMT. I would bet the farm this is not the case based on his function. I think he has a neuromuscular component to his lack of function or poor mechanics and he can be taught to function in an improved fashion but at this point it would have to be considered a strength deficit. I also think you are going to

      • I do not think this problem has anything to do with strenght of certain muscles. If you don’t know how to move / stabilize there’s no indication of strentght training. Btw the rhomboid is a retractor. The patient needs to upward rotate not retract. Rhomboid training (retraction excerices) will increase the GH instability!

        • Ruben,

          If you read my post again I state that I believe the rhomboids are TIGHT and are possibly a cause of him not achieving full scapular upward rotation. I did not say to strengthen rhomboids as this would tend to increase downward rotation and retraction. I also believe that, as I said, there are two components of strength. One is neuromuscular activation and recruitment of muscle fibers, the second is muscle cross sectional area. That is why you will see two types of strength gains in patients. First six weeks is neuromuscular strength gains where a patient learns to recruit a muscle better. Second which is after six weeks of consistent strength training you can see increased cross section area. In both cases a MMT or dynamometer will show an objective increase in strength. So with this in mind I would guess that he has less than 5/5 strength in Low Trap, serratus, mid trap and possibly rhomboids. I would choose to strengthen mainly low trap and serratus, and mid trap due to the fact that they are scapular stabilizers but also upward rotators. During the strengthening process he will hopefully improve both neuromuscular activation as well as cross sectional area.

  15. I agree with all the comments about the left scapular but think that there is something going on with the right that is forcing the movement pattern to occur. There is a left lateral shift in the upper thoracic region through the movement.
    The work mentioned to solve the left scapular issues are required but the right side looks tight at the top of the movement, and as someone has mentioned, does not go through to full scapular elevation.
    The neck wiggle, the hyperextension of the left elbow all look like compensations for this movement fault.
    I look forward to hearing more about the case and how it develops, plus some other movement angles and tests.

  16. Hi Mike,

    Thanks for posting such an unique video. I feel his L shoulder has RC muscle deficit especially supraspinatus. He is using two joint muscles(triceps , Biceps) to bring about the elevation and his depression is controlled by Trapezius and Levator. All those red patches also indicates some thing which you would have obtained through history..

  17. What’s up with those red patches?? I see obvious weakness in the serratus anterior with obvious scapula winging. Also poor recruitment of the lower trapezius.Since he is a swimmer he might be tight in his lattisimus as well. I would start treatment in those areas.

  18. I wonder what the heck his long thoracic nerve is doing these days.

  19. 1. Poor eccentric control: scapular winging on return from flexion
    2. Overactive levator scap (L>R). And on L side shldr flexion is initiated by scap elevation (levator) not GH motion
    3. C-spine lateral flexion L on return for flexion (most likely upper trap/levator compensating for weak eccentric control of GH muscles)
    4. R shoulder more ER and R forearm more supinated than L (weak biceps and rot cuff on L)

  20. Looks like significant inferior angle dysfunction (Type II scapula dyskinesis) with eccentric shoulder elevation most likely due to serratus anterior weakness. With the amount of anterior scapula tipping and assumed serratus weakness, I would wonder about a long thoracic nerve palsy. Would be interesting to see what patient would look like with wall push-ups. I would also be interested in checking patient’s symptoms with scapular retraction test as well as ability to stabilize in closed-chain.

    Patrick Davin MSPT, ATC, CSCS

  21. Hi everybody from Australia.
    To my mind this video would suggest winging scapula Left with other compensatory movements just that. I think our swimmer friend needs to be cleared of neurological injury. A likely prolonged conservative management seems likely.
    Thanks MIke.

  22. scapula alata, weakness of serratus anterior.

  23. Left GH joint lesion, labral tear, instability, begins just before 90º of concentric flexion. The various dysfunction muscle firing patterns are compensatory for primary joint dysfunction.

  24. Obvious scapula stability issues as mentioned in detail above, in addition to loss of thoracic flexion in neutral. At the limits of glenohumeral flexion, there is a distinct over accentuating of thoracic extension. General loss of thoracic extensor bulk and over development of lumbar extensors. Piece it all together for us MIKE!!!

    On a social media note, this format of post is obviously a WINNER, look at the levels of engagement? A social media managers JOY. Congratulations.

  25. Thanks for posting Mike.
    I can only say that if their is a perception in the patient of a problem and pain in the shoulders, we are probably looking at “defense” patterns versus “defecty”.
    IOW, analyzing his present moevement patterns is interesting, but does not provide us with anything solid to focus on for treatment, does it?

  26. Question about nerve palsy. wouldn’t the scapula wing with significant downward rotation and up trap facilitation from the onset of shoulder flexion if the long thoracic nerve conduction/SA was impaired? I see pretty good concentric SA activation, not so good eccentric. The SA is working. To me the muscle impairment is due to joint dysfunction and inhibition

  27. Apologies for the terrible typos!

  28. I’m guessing long thoracic nerve palsy (as mentioned by Patrick) probably due to compression from hypertrophy of muscle or traction from swimming, & then medial & upward migration of scapula compresses it more or other way round migration of scapula from muscle imbalance causing compression of nerve.
    Thanks for this mike, I enjoy your posts & this time I felt compelled to interact!

  29. Aside from the obvious poor eccentric control of the left scapula, look at his left elbow on the way down…it does a weird wiggle/hyperextension type thing. Could this be related to him avoiding a painful position at the shoulder or generalized laxity at the ulnohumeral joint?
    Also, he looks as though his scapula bilaiterally sit in a downwardly rotated position at rest..this could be a function of tight lev scap/rhomboids, weak lower traps or a combination of the above. I also noted a mid cervical spine right side bend on the way down..hard to know what that means without a few other tests.

    Looking forward to your thoughts mike!
    Jessephysio

  30. Oh, and I see he tried some form ogf cupping…how did that workout for him? Did you treat him with cupping?

  31. Severe scap instability L. Serratus ant not stabilizing at all but lots of other muscles compensating. Early upward rot L scap significant during GH flexion, scap slips into stabilized position near EROM L sh flex as shoulder flexors torque on scap lightens up once a overhead. During return to neutral from L sh flexion , scap goes way past normal downward rotation and with no stabilization slips upward and adducts also. This lack of stability at scap causes the cervical stabilizers (lev, UT etc.) not to be able to assist as much at cervical spine causing significant R lateral Side bend/shift at mid cervical. Excessive c spine motion likely leading to diffuse ache B upper back, sh, neck etc? Am I close? Likely all coming from Long thoracic nerve damage L. Is there a history of trauma here. Could the swimming mechanics of certain strokes have caused an over stretch injury to L long thoracic Nerve?

  32. Since someone mentioned tightness in scalenes, how about compression of the long thoracic nerve?

  33. Mike,
    Great format to present something like this. Would like to discuss with you more on this style.

    Given the brief onset history and watching the video would want to look at C5-T1 to for anything that could be causing nerve irritation that would affect the muscles that are being affected in the shoulder.

  34. Primary complaint:
    “bilateral generalized shoulder discomfort”

    1. Cannot rule out that motor function on the L is pre-existing, who knows why

    2. any rationals for primary complaint (see above) solely based on variable movement patterns of L scapula or other bodyparts are more likely based on speculations (confirmation bias) and less likely based on what is established in the literature.

    3. If 1 and 2 are true and the goal is helping eliminate symptoms, then attempting to correct what has been mostly suggested so far as “dysfunction” does not make much sense.

    • You won’t find knowledge of normal and abnormal kinematica of the shoulder girlde in static images and text from literature. Try x ray cinematografic examination and you’ll learn to see the problem.

  35. Ruben, if the problem is the experience of B shoulder pain, you cannot really see that with xray’s or any imaging studies. You can make a lot of assumptions thought from studying mechanics (see above).

  36. I think that head tilt is to improved the mechanical advantage of lavator scap which does a lot more work than it should stabilizing.

  37. Great post Mike. Like others, I would appreciate a different view or 2! What are his CS movement like….I agree with Darryl Elliott…I would want to check out his mid CS and upper TS.

  38. Definite scapular dyskinesia, left elbow hyperextension, also seems to be some poor patterning or rhythm. Would be nice to see side or front view to see what the ribs are doing. Also are those paint ball marks or some cupping therapy?

  39. Thanks for posting Mike. Looking forward to knowing your thoughts.

  40. Thanks so much everyone, love the thoughts, comments, and discussion! I am just finishing up my summary of the video and will post it up tomorrow as a new post for everyone to see.