Overcoming Chronic Neck Pain

Fix the Shoulder Blades

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Fix The Shoulder Blades

How Poor Shoulder Blade Anchoring Causes Neck Pain and Spasm
Exercise Requirements and Prelims
Fix the Shoulder Blades Exercise
Beyond "Fix the Shoulder Blades"
A more detailed look

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

"One of the more commonly observed postural faults is the protracted and downwardly rotated position of the scapula. A correction strategy is to have the patient move the coracoid upward and the acromion backwards " in Jull, G et al. "A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache" in Spine 2002:27:1835–45.

How was I supposed to do the correction that Dr. Jull suggested?  My shoulder blades (scapula) seemed impossible to control. In a lucky break, I remembered the "Fix the Shoulder Blades" exercise a physical therapist had me doing for torn rotator cuffs. Part of the exercise was "pulling" the shoulder blades down, but at the time, I couldn't feel the correct movements; I'd needed his touch on my upper back plus verbal feedback to do the exercise. Now, many months after therapy had ended, I thought that being able to see my shoulder blades might help, so I rearranged the mirrors in my bathroom; and with this visual feedback I was finally able to do the pull-downs on my own. At the same time I realized this was the scapular correction strategy in Dr. Jull's article: my shoulder blades, which had been rotated forward, were now rotated backward into an upright neutral postion on my back, and in the process, had pulled my hunched upper back straight too.

How Poor Shoulder Blade Anchoring Causes Neck Pain and Spasm:
A couple months of working hard at this exercise stopped my neck from spasming every time I used my arms. The reason, I finally figured out, was that the exercise strengthened the muscles that anchor the shoulder blades to the middle and lower thoracic column. The shoulder blades house the shoulder joint and bear the weight of the arms and any forces the arms generate, so if the shoulder blades are not strongly anchored to the thoracic spine, which happens when middle and lower traps are weak from hunched posture, then the shoulder blades are suspended by the upper trapezius and levator scapula from the upper cervical spine. The upper traps and levator are easily over-stressed, and spasm under the unaccustomed load, which causes muscular pain and spasm; their attachment points on the cervical vertebra become irritated and painful too, and nerve roots may be compressed during spasm. [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.] See illustrations and more information on shoulder blade destabilization and pain.

The fix the shoulder blade exercise helped me, but it won't help everyone. If the collar bones are horizontal or slope down and/or the shoulders slope down steeply and the neck is very long, see Depressed Shoulder Syndrome. Do not do part #1, the Pull Down, of Fix the Shoulder Blades exercise because pain and nerve impingement may result. See below: Check Slope of Collarbones.

 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.

pivoting mirror

— The technical term for using mirrors while learning and doing an exercise is "neuromuscular re-education with mirrors" and is done for people, who have some forms of paralysis and need to re-learn 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 input. 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 the physical therapist guiding me through the shoulder blade pull-down exercise 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, though not late CRPS. 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 the slope of collarbones - depressed or horizontal collarbones indicate that the shoulder blades are already set too low in back.

2. 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 together" 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 up" 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, and the lower trapezius is too short and tight. Doing a high shrug with shoulders up as high as they will go, also stretches the lower trapezius and helps the shoulder blades rise higher in back.

3. Check kyphosis of upper back. View yourself in profile. If the upper back is very kyphotic (hunched), then pulling down the shoulder blades may end up pulling down on top of the shoulders. In this case use the alternate Wall Plank Position (see below) or do the exercise lying on your back on a firm surface so as to flatten the kyphosis (if still flexible). Another possibility is to do "Pinch the Shoulder Blades Togethe"r first, if it helps flatten the kyphosis. The best strategy to to observe your back in a mirror while doing the pull-down, hold the position and then turn sideways to check that the kyphosis has flattened and the neck has come back over the shoulders and more in line with the back.


Fix The Shoulder Blades Exercise

Pre-Exercise Chest/Shoulder Stretch: Do Pec Minor Stretch and/or Thumbs-up, Palms up exercise to stretch the pec minor and chest area, so there is less resistance to the pull-down.

Important: make sure neck and shoulders are relaxed during the pull-down. If back of neck/upper traps are tense and shoulders are "up around the ears" the pulldown may cause upper trap spasm.

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 rotating them back and down in a smooth motion that continues by pulling down the shoulder blades. The effort should be felt in the mid to lower back, where muscles from below, especially the lower trapezius and possibly the 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. The result should be that the kyphotic 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.

See illustration: cross section of shoulder blades on ribs, tilted forward and upright.

[Self Check A: Face the mirror, repeat the pull down, and check that the tops of the shoulders do not depress, but the triangle of muscle between neck and shoulder - the upper trapezius does depress as it elongates.]

**Alternate Arm Positions for Pulling Down the Shoulder Blades:
1.) Dr. Evan Osar 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.

2. If the thoracic spine is very hunched, it's difficult not to pull down on the shoulders at first. Try flattening the thoracic curve by lying on the back on a firm surface and then doing the pull-downs.

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 (and shoulder blades are too far apart) or pulled back too far (when shoulder blades are too close together).

Part #2 for Depressed Shoulder Blades — Let the shoulder blades shrug up while pinching them together. See line of action of Rhomboids and Middle Trapezius in the Illustration to the left:

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

[Self Check #B: Adjust mirrors to see upper body in profile. Hold all positions of the exercise and note the results on posture. Hopefully flattening of thoracic kyphosis 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 a couple reps 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 kyphosis 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. If Pulling Down of the Shoulder Blades causes pain, please stop. There might be another disorder causing pain, not what one may have self-diagnosed. An example is osteoporosis, which can mimic a postural pain issue.

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.

Pectoralis Minor and Shoulder Blades

If very tight and short, the pectoralis minor may need to be stretched first 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. For those willing to take the risk, I have added instructions and illustrations plus precautions on doing the pec minor stretch. 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. Be gentle but persistent.

(One reader 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) by a therapist. 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." Caveat: for those with very inflamed muscles, any kind of needling, message, and other hand-on treatments may worsen symptoms.)

At first, maintaining good posture is difficult because muscles that have been weakened by years of poor posture will fatigue easily, especially when antagonistic muscles are too tight. Posture correction, in itself, is legitimate exercise that pays off by toning** and strengthening postural stabilizing muscles, and in time, posture correction will feel more natural and becomes progressively easier. See Fix the Posture.

**Muscle tone is muscle contraction/tension that we are not aware of. Without muscle tone, our bodies would not be stiff enough to stand upright. The goal of postural correction is to increase muscle tone in the muscles needed to maintain the needed correction and to decrease muscle tone in muscles that oppose correction; and ultimately to develop balanced posture that we don't have to continually think about maintaining, but becomes a tough-to-break habit.
An exception to use of part #1 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 collarbones (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 (see illustration to the left) help with strengthening the upper trapezius. High shoulder shrugs also stretch the tight lower 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" by L. Clein, and "The Droopy Shoulder Syndrome" by Swift and Nichols. Rick Olderman has devoted a book to neck pain involving Droopy/Depressed Shoulders called Fixing You: Neck Pain and Headaches. However, if you have the common problem of Upper Trapezius Dominant with weak lower trapezius, upward sloping collar bones, and shoulder blades that ride too high on the back and tilt forward 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 neck/upper back pain is gone, see the exercises at www.fitnesseducationseminars.com. First watch Front/Lateral Raises, where Dr. Oser begins by showing what shoulder blade instability looks like. Then while observing your back in the above mirror set-up, begin lateral and front raises without weights; Take care that the shoulder blades move in a controlled manner. When that's easy, 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, use 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 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 (tensing the gluteal/butt muscles helps) 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 and pulling chair close to the desk. Keep the chest high.

 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 kyphosis, if still flexible, with a deep breath, which will bring the head back, or do the Fixing the Shoulder Blades Exercise. Wall Angels help too.)
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 (collarbone) 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 kyphotic 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 the Lower Trapezius. (Kendall) 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. (Kendall)

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.




© 2017 Rochelle Cocco