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Always seek medical advice first when dealing with neck, back, hip or shoulder pain or functional limitations. Pain or muscle weakness may have any number of causes, one of which is severe nerve root or spinal cord impingement, and needs more than exercise or any of the passive therapies.

Posture and Pain

1. Pain in Neck, Shoulder and Upper Back Muscles
2. How Forward Head Causes Pain:
2. Benefits of Improving Forward Head:
4. Destabilized Shoulder Blades—postural causes and indicators
5. How Destabilized Shoulder Blades Cause Neck and Upper Back Pain
6. Benefits of Improving Shoulder Blade Stability
7. How Poor Posture Causes Worsening of Radicular/Nerve Root Pain
8. Cervicogenic Headaches
9. Shoulder Pain: Rotator Cuff Tears and Frozen Shoulder
10. Thoracic Outlet Syndrome – Numb Fingers, Hands and More
11. Aggravation of Big Toe Arthritic Pain and Arthritis
12. Chronic Pain Worsens Posture

1. Pain in Neck, Shoulder and Upper Back Muscles:
Slouched posture causes Forward Head and Destabilization of Shoulder Blades, both of which, predispose to spasm, pain and inflammation of the neck, upper back and shoulders. These are chronic muscle strain symptoms (not generally nerve compression symptoms) and even though attributed to a previous neck injury and/or existing degenerative disc disease and spinal osteoarthritis, slouched posture may likely be the root cause even though these other disorders are present.

2. How Forward Head Causes Pain: When posture is hunched, the chest "caves in," the shoulders round forward, the upper back hunches over (increased kyphotic curve) and the shoulder blades (scapulas) rotate/tilt down to the front. The increased kyphotic curve causes the neck to extend forward, causing the bowling-ball-sized head to be held in front of the center of gravity. For each inch forward, the force needed to support the head's weight increases by ten pounds per inch. At 3 inches forward, the average 10 pound head feels like 30 pounds (Cailliet). It's the back neck extensors that must bear the increased weight by contracting more forcefully to keep the out–of–balance head from falling further forward, while the front neck flexors, especially the deep neck flexors, which are supposed to help in balancing the head by pulling it forward aren't needed at all. Over time, habitual Forward Head causes the back neck extensors to weaken and atrophy from chronic tightness and spasm, which squeezes out oxygen and nutrient–rich blood, thus starving the muscle. At the same time neck flexors weaken and atrophy because they are hardly used at all (disuse atrophy). (Jull)  And of course all this spasm and tightness causes pain, especially at the back of the neck. 

slouched and improved posture

3. Benefits of Improving Forward Head: Lasting benefits from improved posture takes consistent practice over time. Though simply taking a deep breath and lifting the sternum/chest goes a long way to reducing thoracic kyphosis (if flexible), straightening the mid-back, and helping with the realization of what improved posture feels like. But maintaining improved posture, after years of poor posture, is difficult because important postural muscles have become elongated and weak, while muscles that maintain poor posture have become short and strong. For exercises that helped me, see Fix the Posture.
  Once posture is improved and the head is held more in line with its base of support, the back neck muscles (Neck Extensors) and front neck muscles (Neck Flexors) are able to work together to keep the head steady, balanced, and eyes level with the least amount of effort.   A byproduct of improving Forward Head is the re-balancing and strengthening of neck muscles. Flexors that weakened and atrophied from disuse (My neck flexors were so weak I couldn't lift my head from the pillow.) now do more of the work of keeping the head upright and balanced on top of the spine; and neck extensors that were spasmed and atrophied from working too hard to keep the head from falling further forward are less stressed. Direct neck exercises are not needed to regain neck strength. (Surprisingly, I recovered the ability to lift my head from the pillow without additional neck exercises.) However, when spasm and inflammation have subsided, neck exercises can be done for extra strengthening. See Professor Jull's Whiplash Injury Recovery: A Self-Management Guide—a free download! Also see the following YouTube video: Deep Neck Flexor Training. (Jull's key instruction for the neck flexor exercise is that a patient lying on the back, can feel the back of his/her head slide up the bed as they nod or tuck their chin, which stops substitution movement of more superficial neck muscles in place of the deep neck flexors—the important muscles in need of strengthening.)


4. Destabilized Shoulder Blades: In hunched upper body posture, the thoracic spinal column (upper and/or mid back) bends (flexes) forward, stretching spinal extensor muscles and vertebral ligaments, while the spinal curve bulges rearward (hyper-kyphosis). In front, the chest "caves in" as pectorals (pectoralis major), intercostals (muscles between the ribs) and anterior shoulder muscles, contract and shorten also, which rounds the shoulders and arms forward. The rib cage sinks lower (toward the pelvis) and drags down the pectoralis minors and attached shoulder blades, causing the tops of the shoulder blades to tilt forward.

Shoulder blade destabilization occurs when two muscles groups—
1.) the muscles between the shoulder blades (middle trapezius and to a lesser extent: rhomboids) that stabilize the shoulder blades to the mid-thoracic spine stretch, and
2.) the muscles (lower trapezius) that attach the shoulder blades to the lower thoracic spine
—are chronically stretched by a hunched forward body posture. Muscles when stretched, undergo stretch weakness—"...causing muscle spindle inhibition and creation of additional sarcomeres" that change the length-tension curve. Additionally, as muscles weaken, the off-balance weight of the forward-bending upper body is supported less by muscle tension and more by the posterior vertebral ligaments (which become over-stretched) and intervertebral discs (subjected to uneven anterior force). Assessment and Treatment of Muscle Imbalance: The Janda Approach By Phillip Page et al (2009).

So when the shoulder blades are held wider apart in back, and have shifted too high and tilted forward, stabilization to the thoracic spine is compromised. Only one avenue of stabilzation is left—the two muscles (upper trapezius and levator scapula) that suspend the shoulder blades from the cervical spine. Thus, the reason neck tension is so common with hunched posture is that the shoulder blades and arms are literally hanging from the more delicate cervical spine by two relatively small, weak muscles, rather than being anchored securely by larger, stronger muscles to the more robust mid and lower thoracic spine. Thus with hunched posture, the shoulder blades, which house the "socket" for the "ball" of the upper arm bone (humerus) of the shoulder joint, no longer serve as stable platforms for arm use.


Shoulder blade stabilizing muscles also control shoulder blade movements, which are needed to accommodate a wide range of arm movements without dislocating the shallow shoulder joint. As the arm raises, the shoulder blade glides laterally under the arm. (See illustration of normal shoulder blade movement)


Faulty shoulder blade stabilization changes movement patterns and muscle activation:

A. Shoulder blades rise too high, and muscles of posterior neck and top of back – location of upper trapezius – contract too strongly when arms are raised. This is mostly due to imbalance of lower and upper trapezius. When the lower trapezius is elongated and weaker, it is unable to keep the shoulder blades from rising because the upper trapezius, having "taken up the slack," has become shorter and relatively stronger (upper trap dominant), and pulls the shoulder blades up toward the neck. However, the upper trapezius, being a smaller muscle and not adapted to the heavier load, becomes over-worked, especially when the arms are lifting, pulling or pushing against resistance. A single instance of muscle strain (acute damage) eventually becomes chronic muscle strain, because the upper traps take longer to recover each time there's damage, until they spasm no matter how light the load. Janda called this "tightness weakness" and says it is the "most severe form of muscle tightness...." The shortened upper trap's length-tension curve has changed, which makes it more readily activated and weaker over time." See illustration below. Also Evan Osar's video "Shoulder: Front/Lateral Raises". Assessment and Treatment of Muscle Imbalance: The Janda Approach By Phillip Page et al (2009).

B. Lagging or feeble gliding movements of the shoulder blades when arms are raised. See image below. Also, when lowering the arms, if the shoulder blade "crashes down" faster than the arm moves lower (lack of control due to weak stabilizing muscles). See Evan Osar's video "Shoulder: Front/Lateral Raises"

C. "Winging" or poking up of shoulder blade edges rather than hugging the back ribs. This is often due to weakness of serratus anterior. See photo on right, above. Also Evan Osar's video "Shoulder: Front/Lateral Raises".

D. Difficulty raising one arm and shoulder blade on same side rises higher and does not swing to the side under the arm; scapular winging is present along with shoulder pain. May be caused by weakness or paralysis of serratus anterior muscle, especially after traumatic injury to upper shoulder and lower neck area (e.g. sports injury or fall from bicycle or motorcycle that injures the long thoracic nerve). refs. Isolated Paralysis of the Serratus Anterior, Foo and Swann, 1983 and Physical Therapy Management of Isolated Serratus Anterior Muscle Paralysis, Watson and Shenkman, 2014]


5. How Destabilized Shoulder Blades Cause Neck and Upper Back Pain: When the Middle and Lower Trapezius muscles are stretched and weak, the work of anchoring the shoulder blades to the spinal column passes to the Levator Scapula and Upper Trapezius, which suspend the shoulder blades from the neck/cervical spine. But the levator scapula and upper trapezius are not adequate for the extra load** and in response they become hyperactive and tight, and seem to always be pulling the shoulders up toward the ears. Use of the arms in weight bearing activity such as in lifting or pulling adds to the load, and may cause the upper traps and levator scapula to spasm. Focal points of hyperactivity are felt as tender knots at the levator scapulas' points of attachment to the shoulder blade (red X in illustration above and at left). Unfortunately in slouched posture, the levator scapula and the upper trapezius are also stretched—their points of attachment on the shoulder blade having moved further away. Being simultaneously stretched and "shouldering" more of the work of stabilizing the shoulder blades, the upper traps and levator are in a bind—not able to strengthen adequately because they're stretched and yet also overworked. Even small muscle strains have difficulty healing and occur more often, becoming chronic. And chronic muscle damage becomes chronic inflammation and chronic pain. Inflammation at origin points of the levator scapula and upper trapezius on the cervical spine and back of the head cause side and back neck soreness/pain, and headaches (Cervicogenic/occipital headaches). Chronic soreness/pain of the upper back and fleshy triangle between the neck and shoulder (body of the upper trapezius) is common. (Cailliet).

Pain due to inflammation of the levator and upper trap. may flare with neck massage or neck exercise.

**the weight of the arms hangs off the upper outside edge of the shoulder blades (shoulder joint). Half of that weight is transmitted to the spinal column in back via the Rhomboids and Trapezius. If Rhomboids and Trapezius are weak the weight is borne by Levator Scapula and Upper Trapezius (Darn Uncomfortable!). The rest of arm weight is transmitted via the anterior (front) shoulder girdle joints and rib cage to the spinal column (acromion process of shoulder blade—›collar bone—›sternum—›costal cartilages—›ribs—›thoracic vertebra).


6. Benefits of Improving Shoulder Blade Stabilization:
Posterior neck muscles are more relaxed. The shoulders assume a more neutral position as they are pulled back by the shoulder blades that now lie closer to the spine, pulled there by stronger middle and lower trapezii. The chest is less depressed as the anterior chest muscles—pectoralis major underlying the breast area and intercostal muscles between the ribs—return to their longer, more normal length, allowing the chest to expand more easily with each breath.


7. How Poor Posture Causes Worsening of Radicular Pain: Radicular Pain is pain that radiates down the arm (or leg in the case of sciatica) in a specific pattern (see sensory dermatome). Radicular pain often results from irritation of spinal nerve roots by narrowing of the tunnels called foramina formed by the vertebral facet joints.
The narrowing of the foramina may have at least 4 causes: 1.) Herniation of gel from a torn intervertebral disc, caused by an acute injury, 2.) Bone spurs that form from flattened, desiccated discs (degenerative joint disease/spinal arthritis, see image to left),  3.) Combination of pre-existing narrowing of foramina and muscle spasm around the spine clamping vertebral facet joints closer together further narrowing the foramina, or 4.) Increased lordosis# of the cervical spine, which also forces vertebral facet joints closer together in back.

Are we stuck with painful radicular pain once we have it? I have found that as long as posture has improved and muscle spasm is absent, radicular nerve pain can improve as long as the compression is not too severe. In my case, in spite of moderate to severe narrowing in several nerve root foramina in my neck, I no longer have radicular pain (see my MRI report). I believe that my radicular pain was from inflammation, perhaps even swelling, brought on by severe compression from chronic muscle tightness and spasm as well as the narrowing due to the bone spurs of degenerative disc disease. But with improved posture the muscle tightness decreased and inflammation subsided over time.

But very importantly, if there is numbness and/or weakness of arms or legs, see a doctor. "Persistent pressure upon a nerve root of three-months duration may not recover when the pressure is relieved."(Cailliet) This means surgical decompression must be done before damage is permanent.

#In hunched posture, the excessive kyphotic curve of the upper back is balanced by an excessive lordotic curve of the neck/cervical spine (unless the cervical lordotic curve is lost) in an effort to balance the weight of the head without overworking the back neck muscles (neck extensors). Improved posture takes some of the pressure off nerve roots by straightening the neck and easing muscle spasms.

Spinal nerve roots become the nerve bundles that contain both sensory nerves (carry signals for hot, cold, touch, pain, etc. back to the central nervous system-CNS) and motor nerves (signals from CNS to muscle to control voluntary movement). Specific nerve roots connect to specific parts of the body: nerve roots from the lower neck service the arms and hands, and nerve roots from the lower back service the legs, and aide in bowel and bladder function.

8. Cervicogenic Headaches: Tight back neck muscles due to Forward Head and Neck can irritate the occipital nerve, which runs through the upper trapezius and another neck extensor, the semispinalis capitis. The nerve may be compressed and irritated by spasms of those muscles high at the back of the neck near the base of the skull (see occipital neuralgia). (Kendall)
Tight and spasming neck muscles, especially at the side of the neck, can cause pain just underneath the ear at the jaw/tmj joint, and tingling, pulling sensations up the side of the face that may extend across the forehead and down the other side. I've never seen this mentioned in textbooks or online, but I've experienced these uncomfortable sensations.

9. Shoulder Pain: Rotator Cuff Tears and Frozen Shoulder: Slouched posture causes weakening of the muscles supporting the shoulder joint, which predisposes to shoulder problems like torn rotator cuffs and frozen shoulder (adhesive capsulitis). In particular the downwardly tilted scapula can't create enough space for the topmost tendon of the rotator cuff (which is already slack from lateral drift of scapula) when the arm is lifted overhead, causing it to be pinched and damaged by the bony process of the shoulder blade called the acromion. (Fitzgerald) (see illustration)

10. Thoracic Outlet Syndrome – Numb Fingers, Hands and More: Several nights a week, I would be awakened from sleep with numb fingers and hands. I would sit up in bed and shake my hands until the feeling came back. This was one of the seemingly unrelated symptoms along with headaches and big toe pain that disappeared when my posture improved. Night–time numbness and tingling in hands and arms are symptoms of Thoracic Outlet Compression Syndrome. See this webpage for illustrations and more detail. For a detailed Medscape article: Thoracic Outlet Compression Syndrome.

11. Aggravation of Big Toe Arthritic Pain and Arthritis:
For over 25 years I've had an enlarged, arthritic first big toe joint on my right foot. This is called Hallux rigidus or rigid big toe, which has caused limited movement of my right big toe and pain while walking. (Try walking without bending your big toe. It's difficult.) Fifteen years ago I had surgery to remove the bone spurs, but within 6 months much of the excessive bone had grown back, though the worst of the bone spurs didn't return. But I still had chronic pain and inflammation and used an insert to stiffen the sole of my right shoe to limit bending of the painful big toe.

...But then I improved my posture and my toe pain began to improve. Apparently I had always been leaning forward from flat back posture and had been putting too much pressure on my arthritic big toe. With improved posture and awareness that my weight should be distributed evenly between heel and forefoot, my big toe pain improved greatly...even to the point that I don't need the sole stiffener and can go barefoot.

12. Chronic Pain Worsens Posture: It's not only poor posture that begets worse posture. But any chronic pain, especially in the core areas of spine, shoulders, chest, and abdomen, seems to protectively tense up the front of the body, and curling it into flexion (fetal position). When we're in any kind of pain or feeling sick in other ways, don't most of us just want to curl up on the couch or in bed? So the observation by Professor Jull that neck pain patients when rising to a standing position can't "shape" their lower back/pelvic area into a normal (lordotic) curve, (which requires contraction of back extensors and stretching of abdominals), and don't use their deep stability muscles well (such as the spinal multifidus), may be a general effect of all kinds of chronic pain, and not only spinal-related neck or lower back pain. 

Prior to the worst of my neck pain, I had developed a chronic stomach condition called post-viral gastroparesis (partially paralyzed stomach), which is like bad stomach flu but lasts for 6 months to forever. Soon I looked skeletal and had profound fatigue from the medication as well. I remember how carefully I moved as rounds of nausea, heartburn and stomach cramps knocked me down day after day; how stiff and out of balance I felt, how all I wanted to do was huddle on the couch and watch of all things, reruns of CSI (Crime Scene Investigations). No wonder my posture suffered, and my neck pain, spasm and weakness ramped up worse than ever. A total nightmare. Eventually I wasn't able to do household chores or drive. How did I let myself get so weak? Avoidance of pain and my depressed mood (whether cause or effect?) limited more and more my everyday activities until I could barely do anything. And I didn't even notice how slouched I'd become, and no one said anything because I was so ill.

An important lesson: When chronic illness and pain limit physical activity, making the effort to use good posture helps keep postural muscles strong and reduces the risk for increased neck, shoulder and back pain.

 

 

 

 

 

© 2017 Rochelle Cocco