Is your shoulder a real pain in the neck?

The shoulder joint is inherently unstable by its design. It is classified as a ball-and-socket joint but it more closely resembles a golf ball sitting on a tee.

It is amazing that everyone doesn’t have shoulder pain.

It is amazing that everyone doesn’t have shoulder pain.

An important idea that you should take from this image is how much the shoulder joint requires optimal positioning (relative joint positions) and the muscles around it for support and proper function. More on this in a minute.

I would be remiss if I did not point out that there are, technically, four shoulder joints. Most people call this joint (the glenohumeral joint) the shoulder joint, but it is just one of four. Good. Now you are ready for the shoulder category on Jeopardy.

These ideas work best for chronic shoulder pain. If you recently hurt your shoulder, I would not start messing with these strategies unless you have been evaluated and they are indicated for your rehab.

All of the strategies will have multiple videos to help guide you through the process. These are strategies I have used with both clients and patients to not just manage but ultimately resolve their shoulder pain.

I am going to go over each in more detail, but the 5 strategies are:

  1. Thoracic mobility - if the t-spine lacks mobility the shoulder and neck try to compensate.

  2. Assisted range of motion (ROM) - if your ROM is limited, use something to help assess and improve your ability to move the shoulder and arm.

  3. Supine exercises - this position helps utilize improved thoracic mobility, supports the body and makes controlling shoulder movements easier.

  4. Rows - rows are shoulder-friendly and most people do not do enough of them - especially those who have shoulder pain.

  5. Isometrics - learning how you can engage the muscles around the shoulder is key to managing pain. These are way harder than they look.

Although it is not listed as one of the five strategies, posture needs to be looked at and modified (in most cases). This idea ties into many of the strategies and will be talked about often.

While I cannot guarantee these will resolve your shoulder pain, I have had great success using these strategies to resolve shoulder pain with my clients and patients.

The one commonality to those that did well? They did their homework!

If you do not follow the plan, it can’t work. This is true of any rehab plan, training program or nutrition strategy. You have to be willing to put the time in and change HOW YOU DO THINGS.

1. Thoracic mobility

Quick anatomy lesson. The thoracic spine is the part of the spine between your neck and your low back. It curves forward naturally but rounds forward more when you slouch.

As the thoracic spine rounds more, the neck compensates to try to keep the eyes level. This is less-than-ideal.

As the thoracic spine rounds more, the neck compensates to try to keep the eyes level. This is less-than-ideal.

Due to the t-spine's curve, and our tendency to sit in front of computers, phones, tablets and in our cars in a slouched position, the spine can lose its mobility. We start to lose the ability to stand up tall (extend our thoracic spine).

Why does thoracic mobility matter?

Here is why it matters.

1️⃣ Your thoracic spine rounds forward.

2️⃣ Your ribs attach to the thoracic spine and their position changes.

3️⃣ Your shoulder blades sit on top of the ribs, so their position changes.

4️⃣ At the end of your shoulder blade is the socket where your humerus meets with the socket to form what most people call the shoulder joint. This relationship between the ball and socket is changed.

5️⃣ This change with the ball and socket creates abnormal stress in the shoulder when moving the arm above shoulder height, not just with exercise, but even daily activities.

Yikes. None of that is good. But just working on the shoulder joint won't fix the problem. We must deal with the thoracic spine first.

Trying to perform a bunch of shoulder exercises in the compensated position will not improve your symptoms. It will make them worse!

The Thoracic Mobility Tutorial video below expands on this idea and shows you how rounding the back impacts the shoulder and why just working on shoulder exercises will not fix the problem. The whole video is great but starting around 1:05 goes into the cascading of events that happen.

There are many ways to improve thoracic mobility. It is something that most people need. Once you start working on it, you should keep it in your routine not just start it and stop it when the pain is better. Here are two options to work on:

The tutorial highlights the MOST common mistake people make when performing this mobilization.

Hold mobilization for 5-6s. Repeat 10 times. Try to perform 3x/day to start.

Stand in front of a bar (or another surface that is stable and will not move - kitchen counters also work great for this). Walk the feet back, perform a hip hinge and pivot forward until you feel so resistance to the movement in the thoracic spine. Hold this position for 5-6 seconds.

2. Active-assisted range of motion (AAROM)

If you have limited ROM due to pain or have full (or near full) ROM but the pain is still present, the AAROM is a great solution.

This type of ROM can also be used as an assessment to help determine if your pain is coming from the muscles or the joint.

What am I talking about?

If you can lift your arm up and there is pain, the pain could be coming from muscle issues or joint issues. When you just base it on movement, it is hard to tell which is causing the pain.

When you use AAROM, the demand on the muscles is significantly reduced as the band or pulley is providing assistance throughout the movement. If the pain is decreased, or eliminated completely, then your pain is more-than-likely muscular in nature.

If the pain persists when using AAROM, the pain is most likely joint-related. This scenario is trickier and requires more evaluation as the pain could still be from a muscular origin.

you done messed up AAROM.png

Instead of setting up to use pulleys or bands to create resistance, you can position yourself to allow the pulley or band to assist you through the painful portion of the motion.

The assistance provided allows the muscles to do less. This should decrease your pain, allowing you to move the arm further with less pain. This preserves joint mobility, improves overall ROM (if it is lacking) and let's you improve scapular mechanics.

The hard part with these movements is to relax and let the weight help you. Most people engage the muscles too much, causing pain. The goal is to have these motions be as close to 0/10 pain as you can.

Assisted shoulder flexion starts st 2:01

Assisted shoulder abduction starts at 3:48

Lift the affected side as far as you can. When the shoulder gets sore or tight, use the other arm to push the affected side up a little higher.

Use these as part of a warm-up before exercise or at any time during the day to keep the shoulder moving.

DO NOT force the overall ROM and go slow. The shoulder may just need some time to get warm so don't be a jerk.

3. Supine exercises.

The exercises you choose when dealing with shoulder pain matter immensely. One of the other considerations when choosing exercises is your body's position. Some positions can put more or less stress on the shoulder joint and associated muscles.

Performing exercises in a supine position (laying on your back) work well for a number of reasons:

1️⃣ Your body, especially the head and neck, are supported by the floor.

2️⃣ Gravity is pressing down on you and, in this position, helps to facilitate a more neutral posture.

3️⃣ The support by the floor allows muscle that we are not working to stay quiet as they are not needed to stabilize posture.

4️⃣ You get real-time, tactile feedback from the floor or mat while you are performing your exercise.

Basically, you can “feel” your shoulder blades moving on the floor and if your head comes off the floor during the movement.

Chances are, you have some issues with thoracic mobility and have some pain in the shoulder when moving it, with or without loss of ROM. This position helps to manage both of those situations.

When you are sitting or standing, lifting the arm up is done against gravity. I know, I know. That is not breaking news.

When you are in a supine position and the arm moves past about 90 degrees, you now have gravity assisting the motion as it moves over your head. This is similar to the AAROM you already learned about.

mind blown.jpg

The supine position is beneficial as it also allows you to train while reducing the irritation to the shoulder(s). Remember, one of the first goals of dealing with any injury is to reduce or eliminate the irritating factors.
While this is not an exhaustive list, these are some of the exercises I used to treat shoulder pain in my patients, clients, and my own shoulders:

Lay down with the knees bent and the feet flat on the ground. Press the low back towards the floor and keep the abs tight throughout the exercise. GENTLY press the head and neck into the mat/floor to help engage some of the deep neck stabilizers. This needs to be done easily.
Hold the weight by overlapping your hands allowing you to cradle the weight. This works better than holding the handle of the dumbbell, especially as the weight gets heavier. Press the low back towards the floor and brace the abs throughout the entire motion. Keep your elbows almost straight.
Even though this is an upper body movement, make sure there is no movement of the knees or hips (moving side to side). Keep the glutes and abs tight and the opposite shoulder on the ground. It should not lift up when the dumbbell is in the bottom position.

Lay on your back. Set a neutral low back position and brace the abs. Bring your arms up to the start position. Squeeze the shoulder blades, press the forearms against the mast and slide the arms up. Focus on these three movements together works shoulder the rhomboids, posterior deltoids, rotator cuff and middle deltoids all at the same time.

NOTE: for some, just rotating back to get the forearms on the floor will be the exercise at first.

The AAROM with the dowel (from above) can also be done in a supine position. Sometimes, you may find it more comfortable when done in the supine position.

The key with these, or any exercise you choose, is that the movement CANNOT INCREASE YOUR PAIN! This would be counterproductive and it is probably why you are in pain in the first place.

That being said, there is a fairly large area of grey we have to discuss when it comes to pain.

Pain is a tricky beast to tame. If you have low-level pain (2-3/10) and the pain stays at that level during the movement, it is generally safe to perform. If the pain starts low but climbs, STOP IMMEDIATELY!

Some pain is to be expected early in the rehab process. It MUST be managed properly to get you out of pain. Keep reps low and work on managing fatigue and improving technique.

4. Lots of rows

If you are too young to get the reference, watch Back to the Future when you have some free time. It’s a classic.

If you are too young to get the reference, watch Back to the Future when you have some free time. It’s a classic.

Doc Brown is wrong on this one. Rows are going to be a big part of your rehab. You need rows and lots of them.

Rows work well because they allow you to keep the shoulder moving but also keeps the arms at or below the level of the shoulder. When you do transition from supine movements and start to look at seated or standing movements, always start with rows.

Even if your posture is jacked up and your thoracic mobility is garbage and you have pain when lifting the arm over shoulder-height, rows, done properly, are usually safe to perform.

That being said, here are some things to focus on during your rows:

1️⃣ Initiate the movement with the shoulder blade, not the arm. Sounds weird, I know. If you are unsure what I am talking about, check out this video:

Most people struggle to perform pulling exercises correctly. Throw in some fatigue and a shit ton of volume and proper pulling technique is a distant memory. This video shows you a simple way to check if you are pulling correctly at any point during your set or your workout.

2️⃣ Focus on squeezing the shoulder blade and pulling the elbow back. Your hand may not make it to your chest and that is ok. If the shoulder blade stops moving back (toward the spine) and you keep pulling, the shoulder blade will start to move up and forward and the wrist will tend to roll in.

3️⃣ Brace the abs hard. Many people arch their low back when trying to squeeze the shoulder blades. This is not desirable.

4️⃣ Keep your wrist neutral. Rolling the wrist does not help the movement and can be a catalyst for some issues with the forearm and elbow.

Here are good rowing options to get started with:

Set the pulleys so they are around chest-height. Grab both handles and take a couple of steps back so the weight stack does not bottom out in between each rep. Squeeze the shoulder blades to initiate the movement. Do not over row. When the shoulder blades stop moving, stop pulling.
Set up on an incline bench so your hands are just above the ground. Rest your chin just over the top of the bench. This will allow you to maintain a more neutral neck position. Try to brace the legs, glutes, and abs prior to, and throughout, the rowing motion.
Set the pulleys so they are around chest-height. Grab a handle and take a couple of steps back so the weight stack does not bottom out in between each rep. Try to keep the hips and shoulders lined up. Do not rotate to start the motion or at the end of the motion.
This version of the bent-over row gives you some added stability due to the fact that the other weight stays on the step. This can help to take some stress off the low back. Find a step height that allows you to get into a position where the trunk is close to parallel to the ground.
The closer the straps get to vertical (or your body gets to parallel), the more challenging this exercise becomes. Focus on squeezing the shoulder blades down and back. Once the shoulder blades stop moving, the movement stops. DO NOT over row, which causes the chin to drop and the wrist to roll in towards your chest.
Many people struggle with performing a rowing motion properly and using the prone position can help improve overall mechanics. In the video, I have a special treatment table that is narrow and high off the ground which makes it ideal for exercises like this. A ball or bench will also work.

5. Isometrics

After major shoulder surgery, having a patient just hold their arm in a certain position (without moving it) proves to be incredibly challenging for the patient. It is a great, and safe way to start strengthening.

The isometrics we are going to discuss here will be a little different as you are not post-op. If you are, this is not for you. That being said, the principles are the same. Muscles are contracting but no movement is occurring. Unless you are doing it wrong. Then a lot of movement occurs.

Focus on creating total body tension in these movements. Do not just focus on the shoulder. In regards to the shoulders, try to squeeze the shoulder blades back (toward the spine) and down (into your back pockets).

Burning in the muscles due to fatigue is ok. Pain is not ok. Stop if you have increasing pain or if the pain is more than ~3/10.

Most of these movements will be done from a pushup position, which is more of a prone position (on your belly vs on your back with the supine position).

This position will challenge your ability to hold your posture, low back position and will demand more from the shoulder muscles as well.

Get into a pushup position. Create total body tension and hold this position. The beauty is in the simplicity.
Start in a pushup position with the hands under the shoulders and the feet a little wider than the hips. Brace the abs hard. Squeeze the shoulder blade and pull the arm alongside the body. Focus on squeezing the shoulder, not swinging the arm. Return to the start position and move the other arm.
Start in a pushup position with the hands under the shoulders and the feet a little wider than the hips. Brace the abs hard and move one hand towards the opposite shoulder. Return to the start position and move the other arm. Keep the abs tight and minimize rocking or shifting side-to-side when lifting the arm.
Set up in a pushup position, with the hands under the shoulders. Keep the feet a little wider than hip-width. If you struggle with maintaining your position during the exercise, try moving your feet wider apart. Pick one hand up off the ground. Do not let the body shift or rock.
Setup in a pushup position on top of a ball. Set a neutral spine position and brace the abs. Focus on maintaining total body tension. Hold. For awhile. Then rest.
If possible, stand against a wall or beam to get some feedback about your overall posture during the movement. Keep the head and shoulders back against the wall. Pull one arm out to the side while holding the other arm straight out in front.

Now, I understand that pullaparts are not a true isometric movement. But it does have an isometric component. The arm that stays out in front has to stabilize (isometrically contract) when the other arms moves.

If you follow these five steps and listen to the body, you can calm the shoulders down and get back to having pain-free shoulders. Trust me. I have done this both as a clinician and a patient.

However, if you have shoulder pain this all seems overwhelming, let’s chat so I can help you design the right program for you to manage and, ultimately, resolve your shoulder pain. Click below to get started.

All of the videos shared in this post, plus a bunch of others, can be found on EBM’s YouTube channel. It’s a safe place on the internet that won’t require you to clear your history after you leave.

If your posture is really kinda messed up, a more thorough guide to help get you back on track. The Complete Neck and Shoulder Rehab Guide is a step-by-step guide to dealing posture-related issues like shoulder pain, neck pain and even headaches. Click the link to download your FREE copy.

Until next time,

Dr. Tom

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