Are Shoulder Stabilization Exercises Useful?

Your physiotherapist or trainer may have taught you the following exercise(s) to help with shoulder pain. You may have been asked to bring your elbows back while squeezing your shoulder blades together behind you. You were told that you should feel the muscles between your shoulder blades activate and your chest stretching or opening up. This is also to help position your scapula(e) for an improved posture.

R shoulder

I must confess that I, too, have been guilty of teaching this in the past. Fortunately, that's a long time ago! I used to to instruct patients to do scapula (or shoulder blade) stabilization exercises when they come in to our clinic complaining of shoulder impingement. This is also known as subacromial pain syndrome. Sub acromial means all structures below the acromion that can cause problems. Please see picture above and below.

What are some common scapular stabilization exercises? Anything that emphasizes retraction (drawing back)  and depression (bringing lower) of the scapular. Like what I described in the first paragraph of the article.

Well, not all cases of subacromial pain patients will benefit from doing the above exercise. Not according to a recently published randomized controlled study (Hotta et al, 2020).

The objective of that study was to determine if adding scapular stabilization exercises especially retraction and depression of the scapular will help patients with subacromial pain. 60 subjects were randomly divided into two groups. One group did strengthening exercises for muscles around the scapular while the other did the strengthening as well as stabilization exercises for 8 weeks (3x daily).

Results at the end of their study after 8 weeks and even 8 weeks after showed no differences between the 2 groups. The researchers concluded that adding scapular stabilization exercises that emphasized scapular retraction and depression to a general strengthening exercise for muscles around the scapular did not add any benefits to pain, muscle strength or range of motion.

Now after 21 years of treating patients with shoulder pain, my approach has changed dramatically. I now look at a person's shoulder together with the ribcage, neck, spine, hips, feet. I look at how a patient's body is sitting in space and how it moves through space. All while assessing the balance of the structures around their joints. I see which structures need to be worked on by me and which the patient would need to tone and strengthen on their own with specific instructions.  

Reference 

Hotta GH, De Asiss Couto AG et al (2020). Effects Of Adding Scapular Stabilization Exercises To A Periscapular Strengthening Exercise Program In Patients With Subacromial Pain Syndrome: A Randomized Controlled Trial. Muscu Sci Pract 49: 102171. DOI: 10.1016/j.msksp.2020.102171.

Patient With "Shoulder Tendinitis" Not Better After Medication

Can you guess what's wrong with my patient's shoulder?

Just by looking at the picture above, can you guess which shoulder was giving my patient problems? I also showed the picture to some of my staff and asked them "what can you see from this picture?"

Alright, for those who can't tell, here are some more clues. My patient came in with some neck pain and a very uncomfortable shoulder. He had seen his family doctor who told him he had tendinitis in his shoulder and gave him some NSAIDS (non steroidal anti inflammatory drugs).

However he did not get much better with the medication. He still had some neck discomfort and couldn't raise his arm above shoulder height. Lying on his affected side made his shoulder worse and he could only sleep supine.

At first I too thought the shoulder pain was referred from his neck. He mentioned that there was slight tingling sensation in his fingers occasionally too (which was why I thought the problem was coming from his neck). However I changed my mind after seeing he had trouble even lifting his arm sideways above shoulder height.

I told him that he probably had a tear in his L Supraspinatus muscle. If you look at the picture above carefully, you will see a hollowing above his left shoulder blade. There is also wasting in the muscle (or muscle atrophy) around the part where his neck on the left connects to his shoulder.

I was told later after an ultrasound scan that he had a full thickness tear in his left Supraspinatus muscle with retraction of the tendon! The doctor referred him for an MRI and said he may need surgery to repair the retracted tendon.

By the way, scientists have assessed biopsies from both people and animals with supposed tendinitis and found very few signs of inflammation in the tendons.

NSAIDs are commonly prescribed to reduce pain and inflammation of tendinitis. So if there is no inflammation, the medication is not going to help.

So the word tendinitis with the suffix "itis" means inflammation is misnamed since the condition has little or no inflammation. Researchers prefer the term "tendinopathy" meaning damaged or degenerating tendon.


Reference

Warden SJ (2009). Prophylactic Misuse And Recommended Use Of Non-steroidal Anti-inflammatory Drugs By Athletes. BJSM. 43(8): 548-549. DOI: 10.1136/bjsm.2008.056697.