Posture Evaluations, Part 3: The Shoulder and Scapula
By Jeffrey Tucker, DC, DACRB
Let's discuss normal shoulder resting posture so we can determine if there is a link between a postural deviation and pain. Static postural analysis is performed before range-of-motion examinations, orthopedic testing, movement pattern assessments and palpation analysis. When I perform a static posture evaluation, I focus on subtle asymmetries or deviations from normal patterns to aid my diagnostic decisions and treatment transition decisions (passive care to active therapy). I allow myself the time to pause and focus on what I see posturally before beginning other procedures. The changes I see in static posture and functional-movement assessments, visit to visit, help me navigate through the treatment process.
I ask the patient to stand with their shoes off, hands at their sides, in their normal, relaxed position. The evaluation is done with the person in a standing position, which accounts for the normal effect of gravity on the individual. I observe the patient from the front, side and posterior. I look to see the person's chronic holding patterns.
Look for postural deviations, including forward head, forward shoulders (scapular protraction), humeral internal rotation, and increased thoracic kyphosis. All of these deviations have been implicated in the development of shoulder pain.1-4
An abnormal posture or chronic holding pattern may change the muscle system's ability to produce precise movement, and over time or with exposure to repetitive tasks, will cause pain to develop as a response to these imprecise movements.5 Abnormal changes in 1) muscle balance and strength (length-tension relationships), 2) muscle recruitment (force couple relationship) timing issues and 3) articular joint motion dysfunction can cause increased scapular internal rotation, decreased scapular posterior tilting, and decreased scapular upward rotation, leading to subacromial impingement syndrome and other shoulder pathology.6-8
After you have looked at the thoracic curve, look at the humeral head. Normally, the body of the humeral head should be approximately one-third forward of the AC joint. Normally, when the patient's arms are at their side, the humerus should be in neutral rotation and the olecranon process should face posteriorly. The thumbs should be pointing straight ahead (forward) and the palms should be facing each other.
Next, look at the scapula. The scapulae function in three dimensions. The scapulae tilt forward and backward, rotate inward and outward, and rotate upward and downward. Without proper trunk alignment, it is impossible to have proper alignment of the scapulae. Due to the position of the scapula on the rib cage, the scapula is "offset" 30 degrees to the frontal plane.6 This position allows for the necessary "safe" motion of the shoulder. Looking down from the head, a forward or protracted scapula is more than 30 degrees forward, and a retracted scapula is less than 15 degrees forward.
Carefully look at the scapular alignment itself. Normal or "scapular neutral" features the following characteristics:
After visual analysis, use your hands to feel and "listen" to the scapular controlling muscles: serratus anterior, rhomboids, upper trapezius, levator scapulae, middle/lower trapezius, and pectoralis minor.
The practice of being a "muscle whisperer" using posture analysis, guiding manipulation, self-directed soft-tissue release work (foam roll), static stretching, dynamic self-mobilization and strength training can create extraordinary posture changes that improve the function of the scapulothoracic and glenohumeral joints. In an upcoming article, I will discuss identification of the winged scapula and rehab exercises for this condition.
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