The most common source of shoulder pain presenting to clinical practice is called SubAcromial Pain Syndrome (SAPS.) SAPS is shoulder pain that does not come from trauma. It is felt right at the point of the shoulder, at the part of the shoulder blade called the acromian process, and the pain gets worse with lifting your arms above your head. Clinical tests aren’t very good at identifying the pain, so SAPS has been adopted to be used when there is some sort of subacromial impingement, bursitis, or rotator cuff tendinopathy.
The pain that you might feel from having SAPS can really affect your quality of life, and can really lead to pain-avoidance behavior. If your shoulder hurts every time you raise your arm over your head, you would quickly learn to no longer do that. You adapt to your own innate human movements if you have SAPS, hence the pain avoidance behavior. SAPS can really affect your quality of life.
A review article published in 2016 in Manual Therapy (Barrett et al.) looked at the role that thoracic spine posture plays in shoulder pain, range of motion, and of function. In other words, if your mid back is too round, is too hunch backed, or is too flexed forward, will it make your shoulder hurt? Will it lead to SAPS? Will it affect your quality of life–the way you move through the world with your body? I always say that the musculoskeletal system if the most important system for your quality of life, and the shoulders play an enormous role in this, and shoulder pain is the easiest to hide and compensate.
When you raise both of your arms over your head, you should be able to elevate them straight up with out pain, and without popping or clicking. One of the things that allows us to bring our arms overhead is our ability to extend our upper backs 15º when we do this. If we only raise one arm, we only need to extend our thoracics 9º. This goes for any age. Young and old. Thoracic kyphosis is when your upper back is angled more than 40º, and it has been shown to affect shoulder pain and function.
Yamamoto in 2015 evaluated 525 volunteers to look at how common rotator cuff tears are in certain populations according to their postures. They looked at ideal alignment, kyphotic-lordotic posture, flat back posture, and sway back posture. The prevalence of rotator cuff tears in the ideal posture was only 2.9%, but in the people with rounded backs and low backs (kyphosis-lordosis group) was 65.8%! People who follow pain science may claim that posture doesn’t matter, but if the posture is affecting rotator cuff function, and thus your ability to elevate and use your shoulders, this is very detrimental to your quality of life.
They say that when your mid back is too rounded, then your shoulder blade become too elevated up your rib cage. This tilts your shoulder forward, and it creates unnatural angles at the muscles and structures in your shoulder. It narrows the space between your acromion and your shoulder joint, rubbing your rotator cuff muscles against the space above, creating irritation to soft tissues, and causing SAPS. SubAcromial Pain Syndrome.
This is controversial, of course. Some researchers don’t think the shoulder blade alignment creates impingement. Some don’t think there is evidence showing shoulder blade angles affect the subacromial space, nor does it affect the angulation of the muscles. And this question is why Barrett conducted this review study. In my clinical experience, you can have a flat back and also suffer from shoulder girdle pain, just as much as if you have too much kyphosis. Barrett ended up reviewing 10 studies involving a total of 2794 people.
Some studies show that when you slouch, your shoulder range of motion is reduced. If you slouch with a hunched back, you cannot lift your arm all the way overhead. If you sit up straight, you can again. I see this in practice all the time. It’s a great teaching opportunity when you see that slouching can affect your range of motion so much. however, when you slouch, you can internally rotate your shoulders easier, which might be a little bit less useful compared to other shoulder movements.
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