What Does a Good Shoulder Treatment Look Like?

There is strong evidence to support suspension based physical therapy for shoulder rehabilitation and performance. So it’s perplexing why it has taken so long to become the gold standard of care. This type of treatment intervention is common in Norway, where it originated. But here in the United States it barely exists. I guess one reason for this is that the profession of physical therapy began in this Nordic region of the world in the early 1800s. Therefore they have about a hundred more years of clinical experience than us.

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Since starting my Redcord journey in 2007, I have been studying how these Norwegian physiotherapists use the suspension system to test and treat their patients. I also find myself often looking through the latest research on pain science, joint stability, neuromuscular control and other topics that I didn't learn much about in PT school. Instead of keeping all of this great knowledge to myself, I thought I would share some of what I have learned and thus applied into my everyday clinical practice here at Activcore.

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So let’s discuss the shoulder. It is the most mobile joint in the body and often the hardest to treat (i.e., hardest to stabilize).

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Shoulder pain can come from some obvious contributing factors that require surgical intervention, like a full thickness tear of a rotator cuff tendon.

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Shoulder pain can also stem from factors that are not so obvious and might seem totally unrelated, such as stiffness in your thoracic spine, weakness in your opposite hip, and/or excessive pressure in your core and pelvic floor. As a physical therapist, it is my job to find and fix all of these hidden imbalances as part of a comprehensive rehab program. (FYI if your PT isn't looking beyond your shoulder, you should find someone else who thinks more holistically.)

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According to the research, there’s one other primary contributing factor to consider when treating shoulder pain: scapular dyskinesis.

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WHAT IS SCAPULAR DYSKINESIS?

The scapula is your shoulder blade. “Dys” means alteration and “kinesis” means movement. So scapular dyskinesis is a fancy term for altered shoulder blade movement.

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Now that you know what it means, the big question is: What causes the shoulder blade to move poorly in the first place?

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When Dr. Ben Kibler and Dr. Aaron Sciascia from the University of Kentucky came up with the idea to study scapular dyskinesis, they must have been inspired by watching a Redcord video or something similar. Over the next 25 years, these two shoulder experts published numerous research studies on this topic. One study in particular, Current Concepts: Scapular Dyskinesis, had a profound effect on how I view shoulder injuries.

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In this 2010 study, they concluded that poor shoulder blade movement is from a non-specific response to a painful condition in the shoulder rather than from a specific injury to the shoulder. Now what the heck does that mean? Basically it's saying that no matter what type of injury you have in the shoulder, the blade moves poorly based on the presence of pain and not because of the injury itself.

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So when your doctor tags you with a shoulder diagnosis (rotator cuff tendonitis, shoulder impingement, frozen shoulder, etc.), it matters less about the label you’ve been given, and more about the underlying stabilizer muscles that aren't working properly. Due to the presence of pain, these inner muscles turn off (deactivate) and the outer muscles take over as a protective mechanism. It's a common process known as neuromuscular de-activation.

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HOW DO WE TREAT SCAPULAR DYSKINESIS?

There are countless ways to approach the shoulder. But the following 3 treatment concepts stand out in the literature:

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1. Motor Control versus Strength

In 2022, these same authors published a follow-up “Clinical Viewpoint” called Current Views of Scapular Dyskinesis and its Possible Clinical Relevance. When it comes to treatment intervention, they concluded, “Finally, rehabilitation approaches should be reconsidered where enhancing motor control becomes the primary focus rather than increasing strength.” Essentially this means that, instead of working on the outer muscles which make us look good in the mirror, we should focus on the inner muscles which stabilize our joints to provide pain-free functional mobility.

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But how do we prioritize motor control over strength? Furthermore, how do we exercise in a pain-free manner so that the scapular dyskinesis doesn’t get any worse?

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This is where the Redcord suspension system comes in. By using slings and bungee cords, we create a "zero-gravity" environment that makes you feel like you are floating on water. Then we apply suspension exercises to wake up the dormant joint stabilizer muscles and reverse the pain cycle. Our approach is called NEURAC (NEURomuscular ACtivation). It's a method of rebooting your body's deep core stabilizing system. It's like turning on a light switch to muscles that went dim from chronic pain.

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2. Closed Chain versus Open Chain

When it comes to optimizing motor control, the research supports the application of closed-kinetic-chain (CKC) exercises over open-kinetic-chain (OKC) exercises. A classic example is a push-up versus a bench press. Leveraging your own body weight on a fixed surface (floor, table, etc.) versus pushing an external weight (barbell, etc.) helps you get the most out of your neuromuscular system.

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CKC exercises inherently foster greater co-contraction of muscles around the joint to provide better stability. They also enhance proprioception, which is the body’s awareness of where the joint is in space. For example, whether you do a push-up or a bench press, the pectoralis major muscle might be doing a similar amount of work. However, during the push-up exercise, the inner core stabilizers (rotator cuff, transverse abdominis, pelvic floor, etc.) are far more active.

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Performing CKC exercises in suspension ropes will take your motor control to new heights. In fact, a 2008 study at the University of Virginia showed that doing CKC exercises performed on the Redcord significantly improved throwing velocity compared to traditional strength training. The program was conducted during the off-season and was carried out 3 times per week for 12 weeks. All of the softball players did the same sport-specific training, but during their workouts, half of the players did OKC exercises while the other half performed CKC exercises using the Redcord. So what did they find? Turns out the group who used the Redcord improved their throwing velocity by 2.0 MPH compared to the OKC group which only improved by 0.3 MPH. This may not sound like much, but that could be the difference between the runner being safe or out.

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Even though throwing is an open-chain movement, the closed-chain exercises actually had a bigger impact on throwing performance.

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Despite the overwhelming research that supports CKC exercises for improving motor control and joint stability, most physical therapists in the United States are still prescribing the same old OKC theraband exercises for shoulder rehabilitation and performance. It's no wonder why so many people say that physical therapy doesn't work.

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3. Proximal versus Distal

The research also highlights a proximal before distal approach. This means you should focus on your core (hips, pelvis and spine) before working on your shoulder and arm. If there are stability, mobility and pressure abnormalities in the core, you need to prioritize those before touching the shoulder. In fact, I find that treating those first will sometimes naturally resolve the shoulder pain. Then the shoulder becomes far easier to stabilize.

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Unfortunately, no matter what the research reveals, physical therapists will never prioritize the core over the shoulder. After all, researchers have been publishing articles about scapular dyskinesis for more than 25 years, and yet most physical therapists in the United States are still providing “vanilla” treatments on 1980s equipment.

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You should expect more from your physical therapy. To learn more about how I find and fix hidden muscle imbalances, check out the Redcord suspension system.

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REFERENCES:

Kibler WB, Sciascia AD. Current concepts: Scapular dyskinesis. Br J Sports Med. 2010;44(5):300-305.

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Sciascia A, Kibler WB, Current Views of Scapular Dyskinesis and its Possible Clinical Relevance. International Journal of Sports Physical Therapy 2022;17(2):117–130.

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Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg. 2003;11:142-151.

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Kibler WB. The role of the scapula in athletic function. Am J Sports Med. 1998;26:325-337.

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Prokopy, MP, Ingersoll, CD, Nordenschild, E, Katch, FI, Gaesser GA, Weltman A. Closed-kinetic chain upper-body training improves throwing performance of NCAA Division I Softball players. Journal of Strength and Conditioning. 2008;22(6):1790-8

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Disclaimer: The views expressed in this article are based on the opinion of the author, unless otherwise noted, and should not be taken as personal medical advice. The information provided is intended to help readers make their own informed health and wellness decisions.

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