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How to Assess Thoracic Mobility

The latest Inner Circle webinar recording on How to Assess Thoracic Mobility is now available.

 

How to Assess Thoracic Mobility

how to assess thoracic mobilityThis month’s Inner Circle webinar is on How to Assess Thoracic Mobility.  In this presentation, I’m going to show you how I assess thoracic mobility from multiple perspectives.  Many people have thoracic mobility restrictions and just blindly throwing thoracic mobility drills at them is going to be suboptimal without an accurate assessment.  Some need to focus on extension, some rotation, and others can move well, they just don’t!

This webinar will cover:

  • The key things I look at to assess thoracic mobility
  • How to integrate posture, thoracic movements, and functional movements
  • How to assess for compensation elsewhere when the thoracic spine is limited

 

To access this webinar:

 

Shoulder Impingement – 3 Keys to Assessment and Treatment

Shoulder impingement really is a pretty broad term that most of us likely take for granted.  It has become such a junk term, such as “patellofemoral pain,” especially with physicians.  It seems as if any pain originated from around the shoulder could be labeled as “shoulder impingement” for some reason, as if that diagnosis is helpful to determine the treatment process.

Unfortunately, There is no magical “shoulder impingement protocol” that you can pull out of your notebook and apply to a specific person. [Click to Tweet]

I wish it were the simple.

A thorough examination is still needed.  Each person will likely present differently, which will require a variations on how you approach their rehabilitation.

But the real challenge when working with someone with shoulder impingement isn’t figuring out they have shoulder pain, that’s fairly obviously.  It’s figuring out why they have shoulder pain.

 

 

Shoulder Impingement: 3 Keys to Assessment and Treatment

To make the treatment process a little more simple, there are three things that I typically consider to classify and differentiate shoulder impingement.

  1. Location of impingement
  2. Structures involved
  3. Cause of impingement

Each of these can significantly vary the treatment approach and how successful you are helping each person.

 

Location of Impingement

The first thing to consider when evaluating someone with shoulder impingement is the location of impingement.  This is generally in reference to the side of the rotator cuff that the impingement is located, either the bursal side or articular side.

shoulder impingement assessment and treatment

See the photo of a shoulder MRI above.  The bursal side is the outside of the rotator cuff, shown with the red arrow.  This is probably your “standard” subacromial impingement that everyone refers to when simply stating “shoulder impingement.”  The green arrow shows the inside, or articular surface, of the rotator cuff.  Impingement on this side is termed “internal impingement.”

The two are different in terms of cause, evaluation, and treatment, so this first distinction is important.  More about these later when we get into the evaluation and treatment treatment.

 

Impinging Structures

To me, this is more for the bursal sided, or subacromial, impingement and refers to what structure the rotator cuff is impinging against.  As you can see in the pictures below (both side views), your subacromial space is pretty small without a lot if room for error.  In fact, there really isn’t a “space”, there are many structures running in this area including your rotator cuff and subacromial bursa.

Shoulder impingement

You actually “impinge” every time you move your arm.  Impingement itself is normal and happens in all of us, it is when it becomes excessive or abnormal that pathology occurs.

I try to differentiate between acromial and coracoacromial arch impingement, which can happen in combination or isolation.  There are fairly similar in regard to assessment and treatment, but I would make a couple of mild modifications for coracoacromial impingement, which we will discuss below.

 

Cause of Impingement

The next thing to look at is the actual reason why the person is experiencing shoulder impingement.  There are two main classifications of causes, that I refer to as “primary” or “secondary”shoulder  impingement.

Primary impingement means that the impingement is the main problem with the person.  A good example of this is someone that has impingement due to anatomical considerations, with a hooked tip of the acromion like this in the picture below.  Many acromions are flat or curved, but some have a hook or even a spur attached to the tip (drawn in red):

shoulder impingement

 

Secondary impingement means that something is causing impingement, perhaps their activities, posture, lack of dynamic stability, or muscle imbalances are causing the humeral head to shift in it’s center of rotation and cause impingement.  The most simply example of this is weakness of the rotator cuff.

The rotator cuff and larger muscle groups, like the deltoid, work together to move your arm in space.  The rotator cuff works to steer the ship by keeping the humeral head centered within the glenoid.  The deltoid and larger muscles power the ship and move the arm.

Both muscles groups need to work together.  If rotator cuff weakness is present, the cuff may lose it’s ability to keep the humeral head centered.  In this scenario, the deltoid will overpower the cuff and cause the humeral head to migrate superiorly, thus impinging the cuff between the humeral head and the acromion:

evaluation and treatment of shoulder impingement

 

Other common reasons for secondary impingement include mobility restrictions of the shoulder, scapula, and even thoracic spine.  We see this a lot at Champion.  In the person below, you can see that they do not have full overhead mobility, yet they are trying to overhead press and other activities in the gym, flaring up their shoulder.

shoulder impingement mobility

If all we did with this person was treat the location of the pain in his anterior shoulder, our success will be limited.  He’ll return to gym and start the process all over if we don’t restore this mobility restriction.

The funny thing about this is that people are almost never aware that they even have this limitation until you show them.

 

 

Differentiating Between the Types of Shoulder Impingement

In my online program on the Evidence Based Evaluation and Treatment of the Shoulder, I talk about different ways to assess shoulder impingement that may impact your rehab or training.  There are specific tests to assess each type of impingement we discussed above.

The two most popular tests for shoulder impingement are the Neer test and the Hawkins test.  In the Neer test (below left), the examiner stabilizes the scapula while passively elevating the shoulder, in effect jamming the humeral head into the acromion.  In the Hawkins test (below right) the examiner elevates the arm to 90 degrees of abduction and forces the shoulder into internal rotation, grinding the cuff under the subacromial arch.

Shoulder impingement tests

You can alter these tests slightly to see if they elicit different symptoms that would be more indicative to the coracoacromial arch type of subacromial impingement.  This would involve the cuff impingement more anteriorly so the tests below attempt to simulate this area of vulnerability.

The Hawkins test (below left) can be modified and performed in a more horizontally adducted position.  Another shoulder impingement test (below right) can be performed by asking the patient to grasp their opposite shoulder and to actively elevate the shoulder.

how to assess shoulder impingement

There is a good chance that many patients with subacromial impingement may be symptomatic with all of the above tests, but you may be able to detect the location of subacromial impingement (acromial versus coracoacromial arch) by watching for subtle changes in symptoms with the above four tests.

Internal impingement is a different beast.

This type of impingement, which is most commonly seen in overhead athletes, is typically the result of some hyperlaxity in the anterior direction.  As the athlete comes into full external rotation, such as the position of baseball pitch, tennis serve, etc., the humeral head slides anterior slightly causing the undersurface of the cuff to impingement on the inside against the posterior-superior glenoid rim and labrum.  This is what you hear of when baseball players have “partial thickness rotator cuff tears” the majority of time.

shoulder internal impingement

 

 

The test for this is simple and is exactly the same as an anterior apprehension test.  The examiner externally rotates the arm at 90 degrees abduction and watches for symptoms.  Unlike the shoulder instability patient, someone with internal impingement will not feel apprehension or anterior symptoms.  Rather, they will have a very specific point of tenderness in the posterosuperior aspect of the shoulder (below left).  Ween the examiner relocates the shoulder by giving a slight posterior glide of the humeral head, the posterosuperior pain diminishes (below right).

how to assess shoulder internal impingement

 

3 Keys to Treating Shoulder Impingement – How Does Treatment Vary?

There are three main keys from the above information that you can use to alter your treatment and training programs based on the type of impingement exhibited:

Subacromial Impingement Treatment

To properly treat, you should differentiate between acromial and coracoacromial impingement.  Treatment is essentially the same between these two types of subacromial impingement, however, with coracoacromial arch impingement, you need to be cautious with horizontal adduction movements and stretching.  This is unfortunate as the posterior soft tissue typically needs to be stretched in these patients, but you can not work through a pinch with impingement!

A “pinch” is impingement of an inflamed structure!

Also, I would avoid elevation in the sagittal plane or horizontal adduction exercises.

 

Primary Versus Secondary Shoulder Impingement

This is an important one and often a source of frustration in young clinicians.  If you are dealing with secondary impingement, you can treat the persons symptoms all you want, but they will come back if you do not address the route of the pathology!

I do treat their symptoms, that is why they have come to see me.  I want to reduce inflammation.  However, this should not be the primary focus if you want longer term success.

This is where a more global look at the patient, their posture, muscle imbalances, and movement dysfunction all come into play.  Break through and see patients in this light and you will see much better outcomes.

A good discussion of the activities that are causing their symptoms may also shed some light on why they are having shoulder pain.  Again, using the example above, if you don’t have full mobility and try to force the shoulder through this tightness you are going to likely cause some issues.  This is especially true if you add speed, loading, and repetition to elevation, such as during many exercises.

 

Internal Impingement

One thing to realize with internal impingement is that this is pretty much a secondary issue.  It is going to occur with any cuff weakness, fatigue, or loss of the ability to dynamically stabilize.   The athlete will show some hyperlaxity in this athletic “lay back” shoulder position.  Treat the cuff weakness and it’s ability to dynamically stabilize to relieve the impingement.  How to treat internal impingement is a huge topic that I cover in a webinar for my Inner Circle members.

 

Learn Exactly How I Evaluate and Treat the Shoulder

If you are interested in mastering your understanding of the shoulder, I have my acclaiming online program teaching you exactly how I evaluate and treat the shoulder at ShoulderSeminar.com!

The online program at takes you through an online 8-week program with new content added every week.  You can learn at your own pace in the comfort of your own home.  You’ll learn exactly how I approach:

  • shoulder seminarThe evaluation of the shoulder
  • Selecting exercises for the shoulder
  • Manual resistance and dynamic stabilization drills for the shoulder
  • Nonoperative and postoperative rehabilitation
  • Rotator cuff injuries
  • Shoulder instability
  • SLAP lesions
  • The stiff shoulder
  • Manual therapy for the shoulder

The program offers 21 CEU hours for the NATA and APTA of MA and 20 CEU hours through the NSCA.

Click below to learn more!

large-learn-more

 

An Easy Drill to Enhance Thoracic Extension

Thoracic mobility drills are commonly given to people to enhance mobility.  I have shown some common thoracic mobility drills in the past, and recently showed a newer muscle energy technique I have been using.  If you haven’t seen these yet, you should check them out:

 

One of my big principles of rehabilitation and corrective exercises is that you follow up mobility drills with some sort of activation or strengthening drill.  You want to use the body in this newly gained mobility.

For some reason, I feel like this is often ignored with thoracic mobility.

I would actually argue that a very common reason for having limited thoracic mobility is poor endurance into thoracic extension.  The muscles can’t maintain an extended posture and resort to the path of least resistance, a slouched posture.

If you are going to spend time working on thoracic extension mobility, you should follow that up by working on thoracic extension endurance.

In the video below I show an extremely easy way to start working on thoracic extension endurance.  Certainly not groundbreaking, but an important drill that is often overlooked.

 

An Easy Drill to Enhance Thoracic Extension

 

Learn How I Enhance Thoracic Mobility

If you want to learn more about how I enhance thoracic mobility, I have a presentation on Enhancing Thoracic Mobility.  I review some of the self mobility and manual therapy techniques I use to enhance thoracic mobility. This webinar will cover:

  • The importance of thoracic mobility
  • Manual therapy techniques to improve thoracic mobility
  • My favorite self mobility drills to improve thoracic mobility on your own
  • Correct exercises to enhance movement after gaining thoracic mobility
  • How to put it all together to maximize outcomes

To access this presentation:

 

 

Enhancing Thoracic Mobility

enhancing thoracic mobilityLimited mobility of the thoracic spine is a common finding and something that tends to get worse over time.  To me, it’s one of those “use it or lose it” types of mobility in the body.  Several issues can occur from limited thoracic mobility, such as shoulder, neck, and even low back pain.

Thoracic mobility drills are common, but only part of the puzzle.  I have a new presentation where I’ll be reviewing some of the self mobility, manual therapy techniques, and corrective exercises I use to enhance thoracic mobility.

 

Enhancing Thoracic Mobility

This presentation will cover:

  • The importance of thoracic mobility
  • Manual therapy techniques to improve thoracic mobility
  • My favorite self mobility drills to improve thoracic mobility on your own
  • Correct exercises to enhance movement after gaining thoracic mobility
  • How to put it all together to maximize outcomes

 

Access the Presentation

You can purchase access to this presentation for only $10, or join my online Inner Circle Mentorship program for only $10/month and gain access to this and ALL my past presentations, product discounts, exclusive content, member only forum, and more!

 

 

Thoracic Mobility Muscle Energy Technique

Have you ever worked with someone that never seemed to improve their thoracic mobility, especially thoracic rotation?

I work with the occasional person that doesn’t respond to many of the common thoracic mobility drills.  Sometimes their daily posture, especially if working a desk job for years, needs more than the simple drills.  Sometimes I feel that thoracic mobility limitations can be true mobility restrictions, but other times I also feel there may be some tone or guarding involved.

A common technique that can be used to enhance mobility drills, especially when tone is involved, is muscle energy technique, or MET.  Muscle energy is commonly used to enhance mobility in other areas of the body, like the shoulder or hamstring, but less frequently used for thoracic mobility for some reason.

In the video below I show a very easy muscle energy technique that you can use to enhance thoracic mobility into rotation.  This is very easy to perform on your own too.

Give it a try and let me know what you think, I’ve been pretty amazed at how much more mobility I can achieve in a short amount of time using this muscle energy technique, especially for those stubborn thoracic mobility limitations.

 

Thoracic Mobility Muscle Energy Technique

 

Learn How I Enhance Thoracic Mobility

If you want to learn more about how I enhance thoracic mobility, I have a presentation on Enhancing Thoracic Mobility.  I review some of the self mobility and manual therapy techniques I use to enhance thoracic mobility. This webinar will cover:

  • The importance of thoracic mobility
  • Manual therapy techniques to improve thoracic mobility
  • My favorite self mobility drills to improve thoracic mobility on your own
  • Correct exercises to enhance movement after gaining thoracic mobility
  • How to put it all together to maximize outcomes

To access this presentation:

 

How to Improve Overhead Shoulder Mobility

The latest Inner Circle webinar recording on my How to Improve Overhead Shoulder Mobility is now available.

 

How to Improve Overhead Shoulder Mobility

Improving Overhead Shoulder MobilityThis month’s Inner Circle webinar is on how to improve overhead shoulder mobility.  In this webinar I’ll discuss:

  • We we are losing overhead shoulder mobility
  • Why it matters
  • The 4 main reasons why we lose overhead mobility
  • How the body compensates when we lose overhead mobility
  • How to assess for a loss of overhead shoulder mobility
  • What you MUST stop doing immediately with people that have lost overhead mobility – you are making them worse!
  • Corrective exercises to enhance overhead position
  • Manual therapy techniques to improve mobility

 

To access this webinar:

4 Ways to Improve Overhead Shoulder Mobility

4 Ways to Improve Overhead Shoulder MobilityOne of the most common areas we attempt to improve in clients at Champion PT and Performance is overhead shoulder mobility.  If you really think about it, we don’t need full overhead shoulder mobility much during our daily lives.  So our bodies adapt and this seems to be an movement that is lost in many people over time if not nourished.

I’m often amazed at how many people have a significant loss of overhead mobility and really had no idea!

That’s not really the issue.  The problem occurs when we start to use overhead mobility again, especially when doing it during our workouts and training.  Exercises like a press, thruster, snatch, overhead squat, kipping pull up, toes to bar, handstand push up, wall ball, and many more all use the shoulder at end range of movement.  But here are the real issues:

  • Add using the shoulder to max end range of overhead mobility and we can run into trouble
  • Add loading during a resisted exercise and we can run into trouble
  • Add repetitions of this at end range and we can run into trouble
  • Add speed (and thus force) to the exercise and we can run into trouble

 

4 Ways to Improve Overhead Shoulder Mobility

In this video I explain the 4 most common reasons why you lose overhead shoulder mobility and can work on to improve this movement:

  1. The shoulder
  2. The scapula
  3. The thoracic spine
  4. The lumbopelvic area

The first three are commonly address, but not so for the lumbopelvic area, which is often neglected.  I’m going to expand on this even more in this month’s Inner Circle webinar.  More info is below the video:

 

Assessing and Improving Overhead Shoulder Mobility

For those interested in learning more, I have a few Inner Circle webinars on how to assess and improve overhead shoulder mobility:

 

 

 

Enhancing the Balance Between Upper and Lower Trapezius

Enhancing the Balance between Upper and Lower Trapezius

The latest webinar recording for Inner Circle members is now available below.

Enhancing the Balance Between Upper and Lower Trapezius

This month’s Inner Circle webinars discussed strategies to enhance the balance between the upper and lower trap, a common dysfunction I see.  We’ll cover:

  • The impact on posture and trapezius balance
  • The relationship between imbalances of the trapezius and shoulder and cervical pathology
  • The relationship between imbalances of the trapezius and performance
  • Strategies for exercise selection
  • Coaching cues and programming considerations

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

 

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