Fix The Shoulder Blades — The Exercise

 

"fix" — to attach to, to stabilize, to correct, to restore to normal function.

"One of the more commonly observed postural faults is the protracted [wide apart] and downwardly rotated position of the scapula [top of shoulder blade/scapula tilts down toward front of the body instead of vertical, neutral position on the back]. A correction strategy is to have the patient move the coracoid upward and the acromion backwards [which simply means to rotate or tilt the shoulder blade upward so it's more vertical and lies flat on the back. The coracoid and acromion are little processes or bony knobs on the top part of the shoulder blade, but knowing that didn't help me visualize how to accomplish the movement.]" in Jull, G et al. "A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache" in Spine 2002:27:1835–45.

This quote was a first clue, but I couldn't understand it at the time, and even if I had, my shoulder blades seemed impossible to control, like wiggling one's ears. In a lucky break I remembered the "Fix the Shoulder Blades" exercise a physical therapist had shown me for torn rotator cuffs, and while observing my back in a mirror, I realized I was accomplishing the task of tilting the shoulder blades back up to vertical, and that I didn't have to think in terms of "acromions" and "coracoids".

It was later that I realized why a couple months of working hard at this exercise had stopped my neck from spasming every time I used my arms. It strengthened the muscles that anchor the shoulder blades to the thoracic spine, thus insuring that the weight of the arms and the forces generated by the arms in weight-bearing exercise would be transferred to the sturdier spinal column of the back, rather than hanging off the more delicate cervical spine of the neck. The weight of the arms transfers entirely to the shoulder blades, which house the shoulder joint. At the shoulder joint, the upper arm bone (the humerus) inserts into the glenoid cavity of the shoulder blade. The shoulder blades have three ways of transferring the arm's weight and forces generated to the spinal column:
1. through a series of joints in the anterior shoulder girdle: acromion process of shoulder blade —> collar bone —> rib cage (consisting of sternum —> costal cartilages —> ribs —> thoracic spine).
2. through two groups of muscles – the Rhomboids, and Middle and Lower Trapezius – which attach the shoulder blades to the thoracic spine; and
3. through two muscles – the Upper Trapezius and Levator Scapula – that suspend the shoulder blades from cervical/neck vertebra.
If the shoulder blades are not strongly anchored to the thoracic spine, which happens if the rhomboids, and middle and lower traps are weak, it's the upper traps and levator scapula that must support the shoulder blades, which over-stresses/spasms these smaller muscles and pulls on the cervical vertebra, causing irritation at attachment points and sometimes to nerve roots.

[There were times that my arms, as thin and light as they were, weighed so heavy on my neck that I didn't dare lift the slightest thing because of instant spasms.]

 If the collar bones are horizontal or slope down to ends of shoulders and/or shoulders slope down steeply and the neck is very long, see Depressed/Droopy Shoulder Syndrome. Do not do part one, the pull down, of Fix the Shoulder Blades exercise because pain and nerve impingement may result. Also do not do part one if the shoulder blades are already low-set on the back. Check #2 below: Check height of shoulder blades.

Exercise Requirements:

Two mirrors set up to see one's back and profile without difficulty. For example: a swing out, pivoting mirror on one wall, and a large mirror (wardrobe mirror) on the opposite wall.

 

"Pivot-N-View Mirror"
Height 22", Width 14"

— The technical name for using mirrors while learning and doing an exercise is "neuromuscular re-education with mirrors" and is done for people, who have had some forms of paralysis and need to relearn how to use their muscles. Similarly, those of us with poor shoulder blade position and function need to be able to see our backs to figure out how to correct the problem. Most of us, in our whole lives, have rarely see our backs and have no mind map of what the structures look like or how they move. It doesn't help that some of those back muscles lack sensory inputs. There are people who may be able to learn this exercise without mirrors but for those of us with poor body awareness, mirrors are necessary. I absolutely needed them. The touch of another person was not enough, neither was someone telling me what my shoulder blades were doing. I needed to see for myself.
— Of interest: Seeing It Helps: Movement-related Back Pain is Reduced by Visualization of the Back During Movement by Lorimer Moseley et al-2012. "Patients with chronic nonspecific low back pain reported less increase in pain and faster resolution of pain when moving in an environment that enabled them to visualize their back. This is consistent with emerging research on the use of mirror visual feedback in other long-standing pain problems and suggests that similar lines of inquiry may be worth pursuing in the chronic nonspecific low back pain population."
— Improving vision-based motor rehabilitation interactive systems for users with disabilities using mirror feedback.
— And mirror visual feedback seems to improve early Complex Regional Pain Syndrome, not late.  A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1).

Exercise Preliminaries:
1. Check slope of collarbones - if they are depressed or horizontal, this is an indicator that the shoulder blades are already set too low in back. Do the next test, #2.2. Check height of shoulder blades (see next illustration:  Finding T-2 and T-3) – if shoulder blades are set too low, the upper trapezius is over-stretched and weak, while the lower trapezius is too strong and short, which pulls the shoulder blades too low in back. Skip part #1 of the exercise, "Pulling Down the Shoulder Blades." It is definitely not needed because the shoulder blades are already set too low.

3. Check distance between shoulder blades - if less than 4 or 5 inches apart do not do part 2- "Pinching the shoulder blades." The muscles between shoulder blades are already strong.
— For those with depressed shoulder blades, "Pinching the shoulder blades" should still be okay if the shoulder blades at rest are more than 4 or 5 inches apart in back. But make sure at the same time to also "shrug" or lift the tops of the shoulders, an inch or so, toward the ears. The pinching together of shoulder blades helps strengthen the rhomboids, while lifting the shoulders activates and shortens the upper trapezius. Both the rhomboids and upper trapezius are over-stretched when shoulder blades are depressed.

Fix the Shoulder Blades Exercise

Pre-Exercise Chest/Shoulder Stretch: With arms down at sides take a few deep, slow breaths; and with each breath: 1) lift the chest, 2) widen the ribcage and 3) let the arms rotate clockwise so that palms turn to face front and thumbs point out to the side.

The Exercise: While observing one's back in the mirror, follow these steps: 

#1– Pull Down the Shoulder Blades by slightly lifting tops of shoulders, then rotate them back and down in a smooth motion that continues by pulling down the shoulder blades (scapulas). The effort should be felt in the mid to lower back, where muscles from below — the lower trapezius and perhaps lower fibers of serratus anterior (see last illustration below) contract and pull down on the shoulder blades. (The shoulder blades don't actually move much, and they shouldn't, but their tops tilt up vertically allowing the shoulder blade to lie flat against the posterior ribcage/upper to mid-back; margins of the blades closest to the spine should be parallel with each other and the spine. The results should be that the kephotic curve of the thoracic spine flattens (if flexible), and the neck and head come back into line with the spinal column.) Very importantly, the movement takes place in back and not directly on top of the shoulders. Done correctly there is minimal depression at tops of shoulders.

[Self Check #1: Face the mirror, repeat the pull down, and check that the tops of the shoulders do not depress]

**Alternate Arm Position for Pulling Down the Shoulder Blades: Dr. Evan Oser recommends the following: Stand in front of a door or wall, place forearms against the surface (a wall plank position) thereby stabilizing scapula in a slight upwardly rotated position (more vertical). And then pull down the shoulder blades. This modification helps avoid pulling down on top of shoulders.

See the video: Best Exercises for Shoulder Impingement.

                                                                                      to continue... 

#2– Hold step #1 (Pull Down the Shoulder Blades) and add "Pinch the Shoulder Blades Together" without letting shoulders shrug up. Effort should come from between the shoulder blades, not from moving or twisting arms or hands. (#2 is not needed if shoulder blades are generally held less than five inches apart*at rest; which indicates that intrascapular muscles are already strong, and rhomboid antagonist —the serratus anterior— may be elongated and weak. Healthy scapular movement depends on balance.
*this measurement may be closer to 4.5 inches or to 6 inches depending on the width of an individual's ribcage; if uncertain, aim for maximizing shoulder width at rest; shoulder width narrows when shoulders are rounded forward (when shoulder blades are too far apart) or pulled back too far (when shoulder blades are too close together).

#2 for Depressed Shoulder Blades - Let the shoulder blades shrug up while pinching them together. See action of Rhomboids and Middle Trapezius in the following Illustration:

#3 – Hold all positions and tense back muscles, getting them to "pop out" for an isometric strengthening exercise. (5 seconds to start)

[Self Check #2: Adjust mirrors to see upper body in profile. Hold all positions of the exercise and note the results on posture. Hopefully flattening of thoracic kephosis and elimination of forward head is seen.]

At first aim to get the movements right. Then hold for longer and do more repetitions. If there is a feeling of strain and arching of the mid and lower back, adjust the effort accordingly (the lower trapezius augments the back extensors in increasing the lumbar lordotic curve), and/or tighten the abdominal muscles; activation of the rectus abdominis, the vertical "6-pack muscle" down the center of the abdomen, works to tip the pelvis up and back, which counteracts the action of the back extensors in increasing lumbar curve.

How many sets and reps? When I first started, I'd do one set of 5 or 6 repetitions in the morning and one set at night both times in front of the mirror; I'd hold each rep about 5 seconds. During the day, I'd do the exercise without mirrors, and whenever correcting whole body posture. In time, I'd hold each rep 8 to 10 seconds. Currently, with my neck pain resolved, I may do one rep a day in the course of correcting my posture, especially when sitting. (I have to always pay attention to my sitting posture especially when using the computer.)

Very Important: Do not overdo "Pulling Down of Shoulder Blades." Some people pull down so vigorously and so often, that the upper trapezius becomes over-stretched and weakened, which damages its task of holding up the shoulders in a healthy position. An over-stretched upper trapezius causes depressed shoulders, which is a potential source of neck pain. Strive for balance between upper and lower trapezius. Monitor progress in a mirror. If sufficient reduction in forward head and thoracic kephosis has been achieved, stop pulling down further. Only do isometric tightening in the balanced position to "stiffen" the muscles so they resist returning to a slouch.

What if the chest muscles are so tight that shoulder blades cannot be pulled down in back? One of the chest muscles—the pectoralis minor—arises from the front of ribs 3, 4 and 5 and inserts on the coracoid process of the shoulder blade. It is responsible for pulling on and tilting the top of the shoulder blade down, toward the front of the body.
If very tight and short, the pectoralis minor may need to be stretched to allow the shoulder blades to tilt back up. It is best if a therapist helps with this. The Unilateral Corner Stretch is reported to yield the best pec minor stretch, but there is a risk that the anterior shoulder capsule will be over-stretched. Mike Reinold has a good home pec minor stretch. Here is a variation for those without a therapy table: Lie on your back on a mat or carpeted floor, with head and upper back supported by a large pillow. Do a "snow angel"—raise arms along the sides until in a wide "V" position, with palms up. Let the shoulders relax and drop back. Feel the stretch in the area of the pec minor (upper chest) that's shown in the illustration, and not the front of the shoulder joint. There should not be any tingling or pain down the arm. Remain in this position for 30 seconds. In time, extend the hold for a minute or more.

Patience is the key. It takes weeks or months to add sarcomere units to lengthen a short, tight muscle that's been that way for years. Be gentle but persistent.

(One reader commented that he takes a hot shower to help loosen tight chest muscles before doing the 'fix the shoulder blade' exercise. Another reader found a marked reduction in muscle tightness with dry needling of trigger points in the chest, upper traps, levator, deltoids, and back (including rhomboids). But a note of caution: "She can needle all these areas, however some spots she can't, due to the risk of hitting arteries and lungs.")

Maintaining good posture is difficult, but in time it feels more natural and in itself is a legitimate exercise that pays off by toning and strengthening postural stabilizing muscles (the Core) so that good posture becomes progressively easier. See Fix the Posture. 

*Muscle tone is muscle contraction/tension that we are not consciously aware of. Without muscle tone, our bodies would fall in a heap. Ultimately the goal in postural correction is to increase muscle tone in the muscles needed to maintain that correction and decrease muscle tone in muscles that oppose it. And by doing so, develop balanced posture that we don't have to continually think about to maintain. That means balanced posture must turn into a habit.

An exception to use of part one of Fix the Shoulder Blades Exercise is a condition called Depressed or Droopy Shoulders Syndrome that is often present in women with low set, steeply sloping shoulders and long necks. Their collar bones (clavicles) slope down toward the shoulder joint rather than the usual slope up. In lateral neck x–rays, all of the 7th cervical vertebra, the 1st thoracic and sometimes part of the 2nd thoracic vertebra are easily seen, when usually the shoulders would prevent visualization. Pain in neck, shoulder, arms and hands is aggravated by downward traction on shoulders and relieved by propping up the arms. Thoracic outlet syndrome may be involved. In Depressed/Droopy Shoulders the shoulder blades are already held too low on the back and don't need to be lower. Maintaining a slight lift of the shoulders helps. Exercises such as shoulder shrugs help with strengthening the upper trapezius. Part 2, Pinch the Shoulder Blades is still useful for depressed shoulders if the shoulder blades with arms at sides are held more than 5 inches apart. Consult a physician or physical therapist. See "The Droopy Shoulder Syndrome" L. Clein, and "The Droopy Shoulder Syndrome" by Swift and Nichols. Rick Olderman has devoted a book to neck pain from Droopy/Depressed Shoulder, Fixing You: Neck Pain and Headaches. However, if you have what I believe is the more common problem: *Upper Trapezius Dominant with weak lower trapezius, an upward slope to collar bones, and shoulder blades riding too high on the back and tilting forward to to the front of body, Olderman's book won't help as much.
*Greater activity in Upper Trapezius vs. Lower Trapezius. 

#1. Beyond "Fix the Shoulder Blades": For further strengthening of the upper back when shoulder blades are better stabilized and there's no longer neck or upper back pain with daily activities, see the exercises at www.fitnesseducationseminars.com. First watch Front/Lateral Raises, where Dr. Oser begins by showing what shoulder blade instability looks like. Using the above mirror set-up to observe, start without weights and then progress to light weights. The important points: 1) chest is up and shoulders back, 2) in the Lateral Raise (start arms down at side, straight raise to the side until 90 degree angle with body): when arms come back down, keep shoulder blades strong/stabilized, if unable to and shoulder blades drop quickly, that shows weakness in scapular stabilizers, 3) in Front Raise (raise straight arms to the front until 90 degree angle): shoulder blades should come around to the side and not wing out from the ribs, and 4) muscle tension in neck and upper trapezius should be minimal. With any instability/weakness do not use weights, weight of arms only until stability improves. Also see  Lat Pull-Down in front of the body (never the Lat Pull-Down behind the head! Doing resistance exercises at the end of the shoulder's range of motion (ROM) risks injury. A Thera–band anchored at the top of a closed door with a knot so both ends hang down can substitute for a machine. (Try to balance work outs to avoid shoulder/anterior rotator cuff problems. If lots of pushing exercises are done like push-ups or bench presses, or lifting up exercises like the front/lateral raises, also do pulling down exercises like lat pull downs or try pull ups/chin ups.) 

#2. Beyond "Fix the Shoulder Blades": Once the excessive kyphotic curve of the upper back (if it was still flexible) is reduced and upper back extensors are strengthened, (Through activation of the middle and lower parts of the trapezius, which "reinforce the upper back extensors" Kendall) there is still the effects that long term slouched posture have on lower body posture. Sustained correction of slumped posture also depends on reminding oneself to straighten the mid-back and lift the chest during all activities throughout the day. And especially in sitting, when slouching is almost automatic, try to sit straight on the butt, not on the lower back, and maintain the lumbar curve by sitting back in a chair with a lumbar support. Keep the chest high. See the following video for proper sitting posture For a neat reminder see the "4-Finger Posture Correction in Sitting" Video. Learning to stand straight is a challenge too. I finally understood that I had always been leaning forward when I found it felt unnatural to stand straight against a wall—with butt, shoulders/upper back, head# touching and knees slightly bent. (#if the head doesn't touch, do not force and do not tilt it back; but straighten excessive thoracic kephosis, if still flexible, with a deep breath, which will bring the head back, or do the Fixing the Shoulder Blades Exercise) 

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A more detailed look at Fix the Shoulder Blades Exercise: It helps to think of the shoulder blades as two rigid, triangular, curved plates lying on and fitting the contour of the posterior rib cage.

    The outer top corner of each shoulder blade is connected to the outer end of each clavicle (collar-
bone) and just below forms a joint/pivot point with the arm at the shoulder joint (see "Correction #1" below).
    In slouched posture the shoulder blades ride up the upper back's exaggerated kephotic curve like it was a hill; the tops of the shoulder blades tilt downhill toward the front of the body, while the bottoms tilt up. And as well, the shoulder blades have drifted apart and down the sides of the hill/ribcage, toward the underarms.

 
    What is needed for improved posture is: #1—to rotate the shoulder blades upward, back and down, to a more vertical position. This requires they be pulled* down the "hill" by muscles such as the lowest fibers of the Serratus Anterior and theLower Trapezius. (Kendle) And at the same time the kyphotic curve of the thoracic spine straightens.
     Pulling down the shoulder blades is opposed by the pectoralis minor, which attaches the coracoid to the 3rd through 5th ribs in front. Tightness of the pectoralis minor can be seen when lying on one's back on a firm surface with arms at sides. The shoulders don't relax on the surface but are held above it. Stretching of the pectoralis minor can be done. See the following Youtube video—Pectoralis Minor stretches. (Tight pectoralis minor muscles can cause Coracoid Pressure Syndrome—tingling, numbness or weakness down the arm from compression of the brachial plexus (nerves to arm and hand) and can mimic Carpal Tunnel (see following video—False Carpal Tunnel from Pectoralis Minor). Also can cause pain in the upper trapezius, which spasms trying to lift the shoulder girdle from the nerve cords. Pain worsens when wearing a heavy coat, backpack or shoulder bag, or carrying a heavy weight.) 
    In pulling down the shoulder blades, the lordotic curve of the lower back may increase. If uncomfortable, tighten the abdominals to counteract. 

And #2—to pull the shoulder blades closer together (only needed if they are usually held more than 4 inches apart in one's usual posture). The muscles used are the Middle and Lower Trapezius and the Major Rhomboids. (Kendle)
But it seems nothing about the body is ever simple. The serratus anterior that helps pull the shoulder blades down, also tries to pull the shoulder blades apart, which there's already too much of. And the rhomboids (major and minor) that can pull the shoulder blades together also cause them to elevate (shrug up) or ride up the back—also not wanted. So a great deal of coordinated action is needed for the shoulder blades to move in the desired direction. However, the details of which muscles control which movement aren't really important; what is important is the knowledge that it's possible to do the exercise and to keep trying while observing the action until it looks and feels right.