Practical Shoulder Health


I don’t usually write about specific exercises or movements in these newsletters. It’s tough to get the details across. It’s like trying to present a physics thesis via interpretive dance. It can be fun, sure, but something always gets lost in the translation. So, while I have some very practical stuff at the bottom that YOU can use, we’ve first got to travel through some surprisingly philosophical territory. You can skip down if you like but, as any number of fridge magnets will tell you, the journey is just as important as the destination.

As a quick disclaimer, I’m going to talk about pain to provide greater context on all of this stuff but my bailiwick ends where pain begins—and that’s where we send you to someone with clinical chops. So, if you are feeling pain, get yourself a great manual therapist. And if you don’t know one, let me know and I’ll do my best to give you great recommendations.

The cardinal boo-boo

The most intuitive—and frequently wrong—approach to dealing with pain or diminished function is to over-emphasize geography. This is where strategies focus exclusively on the specific location of symptoms. “You’re feeling it here, so we’re treating it here.” There is a long list of issues with this. On one end, we have simple anatomy—nerves can refer pain from other locations. On the other, we have the complexity of systems—the function of every joint and muscle can be impacted by a host of factors elsewhere in the body.

Knowing that we can’t just focus on symptoms gets us to ask about the broad picture. Sometimes, though, we get so broad that we try to predict the future.

Shoulder Psychics

In the worlds of rehab and physical training, there’s a big, bony line with rightness and wrongness of movements on one side. As an aside, moralizing human health is always a major red flag. Here, for example, someone might say that if the shoulder blade moves outside of a certain range (too big or too little), it will create pain and dysfunction. This is not an outrageous-sounding conclusion. But non-outrageous is not the same as correct.

It’s easy for an expert to say something that sounds predictive. E.g. “No wonder your shoulder hurts; your scapula has insufficient downward rotation.” It sounds reasonable and sciency. Except that it might just be confirmation bias. The symptoms are already present, so it’s easy for the expert to blame whatever their go-to bugaboos are. Anything from an insufficient range of motion to global elites stealing our precious synovial fluid. The chance for confirmation bias is high. And, unfortunately, pretty common.

The other direction to take would be to assess asymptomatic (healthy, pain-free people) and predict issues based on the same framework. Here, someone has to look at how you’re moving now and tell you whether you’ll be injured in the future. Many of these approaches are hooey. The best practitioners can only offer probabilities; not predictions. Meanwhile, the worst ones make people feel unnecessarily fragile or movement-averse.

To be clear, sometimes there will be an easy link to track. If you’re hitting yourself repeatedly in the shoulder with a hammer, we can probably guess what’s going on. But this kind of clarity between cause and effect is by no means guaranteed.

The behaviour of a crowd can be more easily predicted than the behaviour of one person can.” —Isaac Asimov

Curiosity and insufficiency

There’s a trait that I see highly represented by leaders in the worlds of rehab and training: curiosity. Rather than come in with an agenda, they just want to understand what’s going on. This takes them on the hunt for clues and patterns. This is where knowledge and intuition can work together.

Some things, like strength or total range of motion, can be quantified. So they are. These details then get collected, systemized, and taught formally. But if curiosity is left out of that learning process, a different kind of trouble emerges. It’s a pedagogical broken telephone. People are taught a list of standards, which is fine. But the temptation then becomes to look for wherever standards are not met. Let’s call this insufficiency. And when something is deemed insufficient, what do we instinctively do? We try to restore it.

So, let’s say we have someone with an inadequate range of motion in external rotation (as below).

Image credit: Mike Reinold

The fellow in this diagram has plenty of external rotation (the bottom half of his movement). Given his jaunty cap, I’ll assume he plays basketball. I don’t know; I don’t really watch sports. In any case, let’s say that he can only drop his hand as far as the uncoloured space—as in the second diagram. Here, we’d naturally want to restore his range of motion. But here’s where we risk falling into the trap of trying to fix the issue at its source. Stretching, for example, is wildly over-prescribed.

How we think about this stuff at Bang

You’ve probably heard a wise person or two emphasize abundance over scarcity. At Bang, we start with the idea of over-utilization. In the above example, there are a number of things that might limit shoulder external rotation (ER). So, we want to ask where is this fellow spending most of his time positionally? And before we get to “why”, we have to ask “what” the impact of that will be.

So, let’s say that a sports ball enthusiast is only spending time in the middle 60º (of what should theoretically be in the ball court of 180º). We can assume that his shoulder is getting plenty of use and insufficient rest. This can create changes in healing, tissue quality, movement choices, and perception of pain. And any one of these things may create compensations further down the chain—like hiking up his shoulder when he’s fatigued. So, the cascade of changes might have different intensities and lifespans. Lots going on.

So, our goal isn’t necessarily to chase range of motion or a specific type of mechanics. Rather, we need to start by asking how we can give the most affected tissues a break. And not just in the moment either but in the person’s day-to-day life. This creates a practical framework. Instead of trying to find the best exercise, we are asking what someone can and will implement multiple times per day, every day. And if we can’t do that, then, at least, what they can implement multiple times per training session with us.

“Watching. Always watching.”

As part of the larger total package, we also step away from ideas of causation—or trying to predict the future—and instead strive to develop a foundational level of every single quality that we’d see in a healthy, highly-skilled person. So, rather than go an inch deep on a singular detail, we go broad—focusing on high standards for a range of basic skills. The more options you have for movement, the more control you have over what you do—and how you do it. Ultimately, you need to take over this process and do what works best for your body. We simply help you build the options.

On that note, here’s a list of shoulder-related skills and drills and an accompanying video with demonstrations and explanations:

Drills and skills video

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