Find Your Wings: 3 Things You Should Know About Your Shoulder Blades

We all have them, the big broad bones that fold onto the back of your ribcage like wings. But what do we really know about them?

To understand the function of the shoulderblade, or “scapula,” we must first understand their form.

1. The only bone to bone attachment of the scapula to your trunk is a tiny joint where your collarbone meets the top tip of the scapula.

This joint, called the acromioclavicular joint, or AC joint, is about as secure as if you put the tips of your two index fingers together head on, i.e. it’s pretty flimsy.

picture of two hands with the tip of the index finger touching. This represents the AC joint. — *The joint between your shoulderblade and the rest of your body* is about as secure as the joining of two fingertips.

The crazy thing is that the arm bone attaches to the scapula bone via a shallow concavity, and the scapula is attached to the rest of your body via the above mentioned AC joint. Literally the only bony attachment of your arm to your torso is via a tiny, flimsy joint.

Small attachment of scapula to torso via the acromioclavicular joint, aka the AC joint. — The acromio-clavicular joint, or AC joint, is the only connection between the scapula and the rest of your torso.

So, you’re probably wondering at this point, “how is my arm not falling off?” It is pretty amazing that our arms not only stay attached, but that we are able to climb, crawl, draw, reach, swim, etc with such precision and stability.

2. It is mostly muscle that holds our arm onto the rest of our body.

This is an amazing design because it allows for a huge degree of mobility in the shoulder, which is necessary to do all the precise tasks and vast ranges of motion required of our arms.

However, this can also create a lot of problems. Muscles change their function based on their position, and repetitive, habitual movement patterns can place muscles in suboptimal positions. If we always sit at the same desk, with our phone on the same side, or we always sit the same way in the car, or always throw a ball with one hand, we are slowly but surely ingraining one-sided patterns into our bodies.

When this occurs in the shoulder and shoulderblade regions it is especially impactful due to the heavy reliance of the shoulder on muscles for stability. This is why shoulder injuries often have little to do with the shoulder, unless it was due to a direct trauma. Usually it is a muscle imbalance or aberrant positioning around the scapula that is the issue, even if the pain is felt in the shoulder.

3. Our shoulderblades are concave in shape

Even though at first glance it seems that are shoulderblades are flat, they actually have a concave shape. This allows for the shoulderblade to sit on the ribcage, which is egg-shaped.

Shoulder blade (Scapula) shown from the side. It has a concave shape. — Side view of a shoulderblade showing the concave surface that touches the ribcage.

However, many of us tend to change the shape of our ribcage by changing the way we breathe. For example, a common pathological breathing pattern is pushing the front lower ribs up in order to get air in without completely exhaling. This is a common breathing pattern when we are stressed- it is a shallow, more rapid breath. If we are a little stressed most of the time, our breathing will reflect that, and over time the shape of our ribcage will reflect that as well.

What this “stress breathing” pattern does is create a flattened ribcage in the back, so now we have a concave shoulderblade trying to sit on a flat surface. At this point the muscle activity cannot be restored because it is the structure underneath that is the issue, and must be corrected before the shoulder can start to move better and feel better.

The shoulderblade is often overlooked when we think about how we move our bodies, but its position and function is vital to our arms being able to move well and without pain. Keeping the muscles around your shoulderblade strong and in an optimal position, as well as keeping your ribcage well positioned with proper breathing, will preserve the life of your shoulders and make for a much happier and painfree shoulder complex.

December 18, 2019June 24, 2021

The Illusion of Symmetry

From the outside we look symmetrical. Left to right, it seems that if you drew a line down our center we would get two equal parts. Most anatomical drawings present the human body in this way.

When we dig a little deeper, it turns out that right to left we are quite different, and these differences can have a profound effect on our physical functioning.

Often I have patients ask questions like, “why is it that only my right knee hurts with running?”

Good question! Some may say that this is due to handedness, with most of us being right handed. But have we ever stopped to ask why it is that most of us end up being naturally right handed? I don’t intend to get into a debate about handedness, but it certainly hints that there is something else at play, some asymmetry inherently present in all of us. These asymmetries are normal and natural. However, these asymmetries can become problematic when they become unbalanced.

This can occur due to external or internal circumstances. For example, your life requires that you do repetitive tasks to one side only, like reaching for the phone on the right, or getting in and out of the driver’s side of your car. It may also be something intrinsic to you, such as an injury. If you had an injury to your left leg, you felt more stable on your right leg as you were healing. That is helpful while you heal, but that patterning of preferring the right leg to stand on can remain long after the tissues have healed.

The Postural Restoration Institute has a deep understanding of these asymmetries and how they affect us. This institute is unique in that it addresses these complexities of being a human when creating a treatment plan, which I have not seen in literally any other course or training for physical therapists, even when I was in my doctorate program this was glossed over at best.

Let’s Talk Asymmetries.

The primary source of these asymmetries is the center of our body, the trunk. It is the generator of motion in our limbs and it is our center of stability. At the center of our trunk (the “core of the core,” if you will) lies the diaphragm, which is dramatically impacted by the asymmetries of our organ and lung placement.

The diaphragm on the right tends to be more domed due to:

lower attachments of the diaphragm onto the right side of the spine compared to the left.
The central tendon (which makes the dome of the diaphragm) is thicker and stronger on the right than the left.
The right diaphragm has the support of the liver underneath.
The presence of three lung lobes on the right and only two on the left to make space for the heart.

Radiograph showing the right diaphragm (left side of picture) being higher than the left. This is normal human patterning.

All these things cause the right rib cage to be in an “exhale” position with the ribs dropping down and into the body, and the ribs on the left to be in an “inhale,” an elevated and expanded position. Think of the left lung as a big balloon pushing on the smaller balloon on the right. This causes an orientation of our ribcage to the left. The attachments of the diaphragm on the spine cause the spine to turn right.

The Postural Restoration Institute has recognized this natural asymmetry and incorporates this anatomical variance into their training of physical therapists and therefore the treatment of our patients. When I first heard that everyone is biased one way, it was news to me. When I was in my doctoral physical therapy program, we learned all the asymmetries of the vital organs, however the influence of this asymmetry was not applied to physical function. Furthermore, the asymmetrical structure and pull of the diaphragm was hardly mentioned, if at all. I find this surprising now as the diaphragm is a muscle that we use all day, every day, and it has profound impacts on how we move and interact with our world.

So what’s the big deal about the diaphragm?

The diaphragm is huge! It attaches to our lower back spine and interfaces with our abdominals, low back muscles, and hip flexors. After I took my first postural restoration course, I was pleasantly surprised at the emphasis on diaphragmatic function and it’s role as a driver of human movement. I was also surprised at how “belly breathing,” which I taught and practiced myself, was actually detrimental to harnessing the power of the diaphragm. The inherent asymmetries within our diaphragm drive the initiation of human movement, specifically walking. Essentially, the stability of the right diaphragm supports right stance phase of gait (standing on your right leg and left leg swinging).

walking still shot in Right stance phase with left swing phase

The problem occurs when we go to stand on our left leg, but we are still in right stance with our supporting muscles. The left diaphragm is not able to support our body in this position, and our right leg does not adequately recruit muscles to swing the right leg. This occurs not just in walking but also during day to day tasks. This can create all kinds of issues, knee pain on one side being just one of them. Fortunately, this asymmetry can be addressed with specific exercise that is asymmetrical, and therefore corrective. These exercises incorporate the breath to achieve diaphragm function.

Once again, I want to reiterate that this asymmetry is not a bad thing inherently. It is in fact a wonderful thing as it initiates the walking cycle and allows us to begin rotating through our trunk and pelvis. Asymmetry becomes a problem when we get stuck on one side, and are not able to get over to the other side. Relearning how to transition from right to left, and then back from left to right, is how we get balanced again.

Are you transitioning well from right to left stance?

You may have difficulty transitioning from side to side if you:

Tend to always have tightness in one hip more than the other
Always cross one leg over the other (usually the left one over the right)
One leg feels longer than the other
You notice different wear patterns on your shoes or bike saddle

Try this simple exercise to test your asymmetry:

Stand with toes pointed straight forward (feet not turned in or out). Keep this foot alignment as you transition to standing on one leg. You can touch a counter in front for support. Now, turn your pelvis so that the zipper of your pants comes over your right big toe. Try the same thing standing on the left leg, toes pointed forward, knee slightly bent. This time, try to turn the zipper over your left big toe. Notice if you can do this on one side, but not the other.

If you find one side to be challenging, but not the other, that indicates you may have trouble shifting to one side. Because of our natural human pattern, it is usually harder to do this standing on the left leg. That doesn’t mean you can’t stand on that leg at all, but it means that when you are standing you aren’t using the correct chains of muscles, which results in pain and dysfunction. To address this issue, come see me or a PRI trained therapist near you to get properly screened and the tools to find better ease and balance in your body.

November 6, 2019August 29, 2021

The Posture Myth: Why Straighter is not Better

Most of us remember being told to “sit up straight!” or “shoulders back, chin up!” as a child or maybe more so as a teen. While this advice was given with the best intentions, it may not have been that helpful. Don’t get me wrong, I’m not advocating the slumped computer posture with shoulders rounded and head poking forward.

This is certainly not a biomechanically sound posture and can lead to all sorts of dysfunction and pain. In an effort to avoid this unsightly slump, we may find ourselves in a position I call “reverse slumping.” This is the tendency to pull the front lower ribs up and push the chest forward. While this may look more upright, it is an overcorrection, and can be more problematic than helpful.

The Problem

So what’s wrong with a lifted chest and elevated front lower ribs? The problems that arise are largely due to how we breathe, and the important relationship between the ribcage and the pelvis. The Postural Restoration Institute has defined the relationship between the breath and function. Below is my meager take on their extensive understanding of the topic. For more information check out https://www.posturalrestoration.com/.

1. Poor oxygenation. If our front lower ribs are “flared” up and out, the mid-upper back is essentially closed off and becomes flat. This causes many problems, one of which is poor oxygenation. The human body is designed to breathe into the back mid and lower ribs, not just the front. These back middle and lower regions of the lungs have the largest area of lung tissue, and the highest blood flow to lung tissue ratio. This means that this area is very important for getting oxygen from your lungs to the rest of your body. When this is closed off (by pushing front ribs up) we are forced to breathe shallowly into our front upper chest, which may recruit neck muscles to help inhale and result in increased neck tension (among other issues). Further, it is harder to get air out because the chest is in a hyper-inflated state. This means less new, oxygen-full air in. Theoretically, if you improve the expansion of your mid back, you will use oxygen more efficiently and fatigue less quickly with sport and daily living.

2. Altered neck and shoulder mechanics. The spine is not meant to be straight, rather it has natural curves that allow a springy quality for shock absorption. When the front ribs are pushed up, the upper back spine becomes flat. This destabilizes the shoulders, as the shoulderblades are designed to function on an egg-shaped surface, not a flat one. As a result, the muscles that manage the shoulderblade cannot function optimally, thereby changing the mechanics of the shoulder in an adverse way. Many of the muscles that attach to the shoulderblades also attach to the neck spine and can create increased tension in the neck area if they are not functioning well.

The muscles that attach to your shoulderblades, back, and neck can become strained and painful with poor posture.

A flat upper back also burdens the point where the upper back spine meets the neck spine. The neck spine is naturally curved and is designed to follow the curve of the upper back. However, if the upper back is now flat, the spring-like shock absorbing factor is lost. Furthermore, the juncture from upper back spine to neck spine becomes vulnerable due to a sharp corner instead of a nice smooth curve between the vertebrae. This can create pain and sensations of tension in this area.

3. Increased stress levels. When we are stressed, that really means our body is entering a “fight or flight” state, which means that there is some imminent threat, and we need to either fight or get away. Blood is shunted away from the core and immune function and digestion are halted as the body prepares to fight or flee. This threat could be anything from being chased by a mountain lion to a steady drip of small daily stressors, like traffic, aches and pains, worrying about money, etc. Our body simply does not distinguish what the cause of the stress is, the same pathways and neurotransmitters are stimulated in the case of a lion attack or spilled coffee. The “fight or flight state” has its purpose, however it is not healthy to remain in this state for prolonged periods of time.

The part of our nervous system that promotes our “rest and digest” state is governed by the vagus nerve which passes from the brain to the abdomen through the ribcage. This state allows the body to be calm and relaxed, allowing for sleep, healing, and digestion. When we are in this state, our breathing is full and deep, with the diaphragm moving through its full range of motion.(1) This is the state that we should be in most of the time.

So what does this have to do with posture? Well, if we push the front ribs up and close off the back of the ribcage, the sympathetic ganglia (the nerves that promote a “fight or flight” state and live along the upper back spine) become overly stimulated due to compression. Furthermore, with the front ribs elevated, the body is in a constant state of shallow inhales and exhales, which is correlated with higher stress levels and promotes release of stress hormones in the body.(2) What’s really amazing about our bodies is that this system works both ways. That is, just as the state of our nervous system causes our breathing patterns to change, we can similarly alter our nervous system by modifying the way we breathe.

4. Poor recruitment of deep abdominals, especially upon inhale. Even if you have six pack abs, that doesn’t necessarily mean you are using the abdominals in the way they are meant to be used. Deep to the well known “six pack” of the abdominals are deeper muscles that create a cylinder around the center of the body. These are breathing muscles. They attach to the lower rim of the ribcage and the upper rim of the pelvis. They create stability and order within the body as well as reduce pressure on the lower back spine and associated nerves. They allow us to be both stable and mobile when they function correctly.

When the front ribs are excessively elevated, the front of the pelvis is often tipped forward as a counterbalance. This places the deep abdominal muscles in the front of your body in a state of excessive length. Our muscles do not function very well (or hardly at all) from their most lengthened state. It’s like trying to pick up a heavy bag of groceries with your arm totally straight instead of slightly bent. It just doesn’t work as well.

A deep stabilizing muscle, called the transversus abdominus, helps us maintain neutral posture.

So then what is good posture?

Essentially, your rib cage should be egg shaped, and sit atop your level pelvis. The spine should be lengthened while maintaining its natural curves. In sitting, you can achieve this by:

Sit in a firm chair with your feet flat, knees and hips at 90 degrees.
Feel your sit bones (the boney protrusions at the base of your pelvis). You may need to lean forward and back a few times to find where you feel them most. When you are most aware of your sit bones pressing into the seat, this indicates that your pelvis is level. It may feel like your pelvis is slightly “rolled under.”
With a long, relaxed exhale breath through your mouth, allow your front lower ribs to drop down slightly. Pause a few seconds at the bottom of the exhale. There should be a sense of your front lower ribs coming down to the front top rim of your pelvis.
Maintain this position as you imagine your lower back ribs expanding with each inhale, and your lower front ribs moving down and back towards your spine with each exhale. Hint: pausing after your exhales for 3 seconds will make it easier to feel back ribs expanding.
Below is a video on finding a neutral sitting posture.

And there you are! If you are used to pushing your chest up, it probably feels like you are slouching when you come into a correct posture. To assure yourself that you are still sitting straight, you can use a mirror to see that you are indeed not slouching. If you can see yourself from the side in the mirror you may also notice that now you have a little more expansion in your lower back ribs. Good job!

References:

1. Russo MA, Santarelli DM, O’Rourke D. The physiological effects of slow breathing in the healthy human. Breathe (Sheff). 2017;13(4):298-309.
2. Hirotsu C, Tufik S, Andersen ML. Interactions between sleep, stress, and metabolism: From physiological to pathological conditions. Sleep Sci. 2015;8(3):143-52.
3. Tenney, R., KL Boyle, A DeBord. Influence of Hamstring and Abdominal Muscle Activation on a Positive Ober’s Test in People with Lumbopelvic Pain H. Posturalrestoration.com. Accessed January 26, 2019.