Shoulder Impingement: Part 4 – The Thoracic Spine and Ribcage’s Role in Impingement

So far we’ve gotten pretty deep on the concept of shoulder impingement but it’s time to delve a little deeper.  Next in the line-up we’ll talk about the thoracic...

source: eorthopod.com

source: eorthopod.com

So far we’ve gotten pretty deep on the concept of shoulder impingement but it’s time to delve a little deeper.  Next in the line-up we’ll talk about the thoracic spine and ribcage.  If you missed the previous parts you can find them here:

Part 1  Part 2  Part 3  

If we take a closer look at the shoulder joint and scapula we’ll notice that we only have 1 true joint that connects the shoulder to our trunk.  The scapula attaches to the clavicle at the acromioclavicular joint and the clavical attaches to our thorax via the sternum at the sternoclavicular joint. These two relatively small joints are the only real joints that connect our arm to our trunk.

source: conornordengren.com

source: conornordengren.com

There is also a connection between the scapulae and the posterior element of our ribcage as seen to the right.  Although this is not a true joint we refer to this connection as the scapulothoracic joint.  The scapula lies directly on top of our rib cage and slides smoothly across the surface of the ribs during shoulder movement.  Because of this, efficient and healthy movement at the scapulothoracic joint has everything to do with the orientation of the ribcage that the scapula slides along.  If the position of our ribcage is off, it will change the position of our shoulder blades and as described later, can lend itself to impingement.

Our spine consists of a series of vertebrae stacked on top of each other that extend from the base of our skull down to our sacrum (and a bit lower to our coccyx).  The vertebrae that make up our neck are known as cervical vertebrae. The vertebrae in our trunk that attach to our ribs are known as thoracic vertebrae and the vertebrae that make up our lower back are known as lumbar vertebrae.  As mentioned previously, the vertebrae in our thoracic spine attach to the ribs.   Because of this, the orientation of our ribcage is directly related to the mobility of our thoracic spine.

Food for thought: The thoracic spine’s attachment to the ribs creates stability.  This can make it difficult to gain mobility in the thoracic spine when we need to.

When we press a barbell overhead we need full mobility of our gleno-humeral joint (shoulder joint), full mobility of the scapulothoracic joint (scapular motion) and full extension range of motion of our thoracic spine in order to get the weight overhead efficiently.  If we don’t have this mobility we run into issues. (Use this simple test to see if you’ve got enough mobility)

Now here is where things get interesting.  When compared to patients with healthy shoulders, patients with subacromial impingement syndrome have on average less thoracic spine extension mobility (1).

Food for thought:  Research from McClure et al. 2006 showed that there was no difference in thoracic spine posture at rest between healthy individuals and those with subacromial impingement.  This suggests thoracic spine mobility may be more important that static posture (3).

As we learned previously patients with impingement also present with increased anterior tilting of the scapula (2).  As we learned previously, anterior tilting of the shoulder blade decreases room in the subacromial space.  This impinges on the tissues that lie within the subacromial space and over time can lead to rotator cuff tears.

Food for thought: More recent research has shown that individuals with subacromial impingement syndrome may have increased posterior tilt when lifting their arms overhead. This may be a compensation pattern to help increase subacromial space and decrease pain and impingement. (3)  If this makes no sense don’t worry, I found this interesting!

source: www.dynamicchiropractic.com

source: www.dynamicchiropractic.com

Thoracic spine mobility and posterior tilting of the scapula are synonymous.   Understanding this concept can be difficult.  Think of it this way.  As we raise our arms overhead the scapula is supposed to ride flat along the thoracic spine.   In healthy overhead motion the scapula will upwardly rotate, elevate and posteriorly tilt.  In order to posteriorly tilt properly, the ribcage must create an optimal surface to allow this motion.  Adequate thoracic extension creates a more optimal ribcage surface to allow the scapula to do it’s job and get our arms overhead safely and efficiently.  If we have a large kyphosis and decreased ability to extend at the thoracic spine, the surface of the ribcage will make overhead motion much more difficult.

Now here’s a little experiment to help explain the above details.  Stand with poor posture with your shoulders and head forward with a big round in your upper back.  Keep this posture and try to raise your arms overhead as much as you can.  Not too good huh?

Now fix your posture.  Pull back your shoulders and tuck your chin.  Straighten up your upper back.  Now reach overhead again.  Better?  If we’re lacking thoracic spine extension range of motion it’s going to make healthy efficient overhead motion impossible.

source: www.ericcressey.com

source: www.ericcressey.com

On top of that, normal overhead elevation of the shoulder is only 165-170 degrees(4).

165 degrees does not get our arms completely overhead.  We’ll need full range of motion for all exercises that requires us to press weight overhead (Military Press, Push Press, Push Jerk etc).  Our body achieves those last degrees of full 180 degrees of overhead motion with thoracic spine extension.  As we learned previously a lack of thoracic spine extension opens ourselves up to shoulder injuries and leads to a pretty weak press.   To add insult to injury, a lack of overhead flexibility can cause a compensation somewhere down the chain in order to get our arms completely overhead.  Often times we try to achieve extra motion by extending our lumbar spine.  (Anyone else smell lower back pain?)

Well, there’s the details on the thoracic spine.  I think I’ve strained my brain enough writing about this topic.  Give me some time to ice my brain and I’ll get back to you next week as we talk about have breathing can effect the shoulder.  Until then…

Part 5 HERE

Rotary cups of steel,

Dan Pope

P.S. If you enjoyed this article then sign up for the newsletter to receive the FREE guide – 10 Idiot Proof Principles to Crossfit Performance and Injury Prevention as well as to keep up to date with new information as it comes out via weekly emails.

Resources:

1. Meurer, A., Betz, U., Decking, J., & Rompe, J. (2004). [bws-mobility in patients with an impingement syndrome compared to healthy subjects–an inclinometric study]. Z Orthop Ihre Grenzgeb,144(4), 415-420. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15346302

2. Lukasiewicz AC, McClure P, Michener L, et al. Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther. 1999;29:574–583.

3. McClure, P., Michener, L., & Karduna, A. (2006). Shoulder function and 3-dimensional scapular kinematics in people with and without shoulder impingement syndrome. Physical Therapy86(8), 1075-1090. Retrieved from http://ptjournal.apta.org/content/86/8/1075.full

4. Gulick, D. (2009). Ortho notes. (2nd ed., p. 189). Philadelphia, PA: F.A. Davis Company.

 

Categories
Injury PreventionRibcageShoulderThoracic SpineUncategorized
24 Comments on this post.
  • Darren
    21 April 2013 at 10:26
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    hey dan, im 17 …iv had a kyphotic posture sense i was about 15 due to bad habits…as u know that causes an assortment of problems…iv been stretching and mobilizing alot and iv mostly narrowed it down to the pec minor and thoracic spine…iv read that with a excessively kyphotic thoracic spine will inhibit ur scapula retractors/depressers big time…iv been using 2 lacrosse balls tape together to mobilize the thoracic spine for about a week now…i lay on it for at least 5mins at a time starting from the point of my upper abs to close to the top of my shoulder blades …iv noticed some improvement but my mid/lower traps are still inhibited and im still experiencing some popping and grinding(no pain)while moving my scap around..im guessing the popping and grinding is from the kyphotic posture..does getting the t-spine mobilized take some time? am i missing something?

    • djpope
      22 April 2013 at 10:26
      Leave a Reply

      Hey Darren, thanks for the reply! I just wanted to say that poor posture does not always lead to shoulder problems. If you have poor posture at rest but can correct it and press a weight overhead without an issue then I really think you’re good to go. I’d definitely improve your posture to avoid future issues though. Do you have shoulder pain with it?

      • Darren
        23 April 2013 at 10:26
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        Appreciate the reply Dan…i have no pain at all when performing any overhead movements or any movements for that matter…the issue for me is the fact that my mid/lower traps are asleep and upper traps take over anytime i try to perform any activation exercises for lower traps…iv been stretching scalenes muscles and levator scapulae for some time now so iv pretty much ruled those out…for me it seems like my pec minor is VERY tight…and almost seems unstretchable..any time i try to stretch them i sit in the stretch for over 2 mins at a time and see almost no improvement after…also is popping/grinding when moving the shoulder blade around not uncommon for someone with a excessively kyphotic posture? thx

        • djpope
          26 April 2013 at 10:26
          Leave a Reply

          Darren my man, I’m doing a podcast tomorrow and we’ll discuss the problem a little more in depth. Look for it to be up on itunes soon. I’d check to see if your posture can be corrected if asked. If it can be then you probably don’t have a mobility problem. It’s probably going to be an issue of consciously holding good posture throughout the day.

  • Daniel Beaulieu
    4 August 2013 at 10:26
    Leave a Reply

    I value the actual post.Really thank you! Keep writing.

  • Lin
    18 August 2013 at 10:26
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    Hi Dan. I broke T6 and was told nothing was wrong for almost a year. Well my shoulder blade in line with T6 ached along with so many other types of pain, tingling, burning, twitching, etc… Anyway by the time I had an MRI and X RAY My spine looked like as they put it the leaning tower of Pizza and I’ve sense then broke T5. I have lost about two inches in height. I ask repeatedly ask my doctor about my shoulder blade pain and I never get an answer? I really can’t use my right arm. I definitely can’t reach upward or push or pull? What can you tell me about this? Oh and I just had my C Spine MRI and I have very bad arthritis in three more vertebraes.

    • djpope
      18 August 2013 at 10:26
      Leave a Reply

      Hey Lin, thanks for responding. Have you sought out a second opinion from another doctor or attempted physical therapy. I think those are two solid things to try first. Let me know if you’re having trouble finding a good doc or therapist and I’ll try and help out.

    • Cassie
      9 June 2015 at 10:26
      Leave a Reply

      I’m glad I listened to this this monrnig. I have one client who’s been in and out with various injuries and another who just won a NYS wrestling title after 3 major surgeries since he was in 7th grade who was constantly working with me to train around them so he could continually improve in other areas. The champion continually progressed while the one with injuries always seems to be starting from square one. I’m definitely going to pass this on to him to see if it sheds some light on the issue; thanks!

  • Lin
    19 August 2013 at 10:26
    Leave a Reply

    Well after the hospital and my doctor told me nothing was wrong for a year my doctor finally ordered an MRI because the hospital had only done a chest Xray when I was brought in by ambulance having a seizure. See when I came to I just could not breathe and severe pain around my whole chest, yhey said I was having panic and didn’t take me to an Xray room, brought a machine to the room I was in and didn’t even prop me up for the Xray said nothing is wrong and sent me home. By the time I got the MRI I’m sure I had done a lot more damage trying to do thing I couldn’t anyway I was immediately sent to a spine specialist who took a new Xray and sent me to a spine surgeon and I went to a new doctor right away. The surgeon was going to grind a rib for bone and take the broken vertebrae and herniated disc out screw the new bone in but we found my boned are soft so they put me on Forteo shots for more than a year and a recent MRI showed a new break in T5. Now I’ve had a C Spine MRI and I haven’t broke any more but I have severe arthritis there. The thin is my shoulder blade that hurts the worst, I think my doctor said in the original T6 break I fractured my shoulder blade in line with the vertebrae.

  • Ryan Booyens
    11 February 2014 at 10:26
    Leave a Reply

    Hi, I am currently doing my Masters in Chiropractic and my research topic is the “short term efficacy of thoracic spine manipulation on shoulder impingement syndrome.” I am wondering if you could point me in the right direction regarding literature that helps link the thoracic spine/rib cage to the shoulder?
    Thanks

    • djpope
      22 February 2014 at 10:26
      Leave a Reply

      Hey Ryan, To borrow a response from my friend Chris Johnson: I think the best approach would be to scour your resources for what the literature says. This way you’ll have the best idea of what the literature really says and you’ll have some respect for how complex the issue can be. As a sidenote I do T-spine manips on most of my patients with neck or shoulder pain.

  • dennis
    16 September 2014 at 10:26
    Leave a Reply

    What have you to say about genohumeral joint disease and/or impingement and subsequent management…….?

    • djpope
      7 December 2014 at 10:26
      Leave a Reply

      Hey Dennis, it really depends on the individual. All of the discussed aspects can affect impingement and should be addressed accordingly. It also greatly depends on what you want to get back to.

  • JP
    27 February 2015 at 10:26
    Leave a Reply

    Hi Dan,

    I did weight lifting a few years ago and had significant problems with chest / overhead stuff. My “winged” side always seemed very weak and limiting in bench/pull-ups. I could never keep my winged side parallel on barbell overhead press.

    I stopped and went to a doctor/physical therapist. I was diagnosed with scapular dyskinis and they basically they had me doing lat pulldown, rows, a few shoulder exercises, and chest stretch. I pretty much have only done this and other various pull/leg exercises at the gym over the last year and haven’t seen any improvement on my shoulder.

    My winging is very noticeable during overhead activities. Basically if I keep my elbow tucked in towards my body/side and attempt to lift my hand towards the ceiling it’s impossible without my elbow flaring out.

    Any suggestions beyond what I’m currently doing?

    • djpope
      14 June 2015 at 10:26
      Leave a Reply

      Any chance you have a video of it? It’s ok to let your elbow stray from your side.

      • nawaz
        8 August 2016 at 10:26
        Leave a Reply

        I have a prolem in shoulder while throwing and smashing from last two yes still diagnose is unknown mri and usg is completely safe …….

        • djpope
          21 October 2016 at 10:26
          Leave a Reply

          ? Can you explain better?

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  • Shawn
    7 August 2016 at 10:26
    Leave a Reply

    Great post. I’m curious if you have insight for dealing with this problem in the opposite population. I have a flat thoracic spine with similar symptoms on my scapular and gleno-humeral joints.

    • djpope
      21 October 2016 at 10:26
      Leave a Reply

      I’d try to work the opposite! Some people need a bit more thoracic flexion. Google rabbit’s pose. that’s one of my favorites for improving thoracic flexion. Just make sure you actually have decreased thoracic flexion and that your pain is resulting from it.

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