14. Corrective Strategies for the Thoracic Spine and Shoulder

The anterior surface of the scapula is called the subscapular fossa, and it is where the ____________________ muscle lies

Subscapularis

The postural distortion patterns that determine potential shoulder and thoracic spine dysfunction include Janda's upper crossed and layered crossed syndromes, as well as Kendall's flat back, sway back, and kyphosis-lordosis postures In all of them, the thoracic spine exhibits excessive ________________ (upper back rounding).

Kyphosis

If undiagnosed scoliosis is detected, comanagement with the clients' healthcare provider is necessary, especially in the developing ________________________.

Adolescent

Together with the clavicles, the scapulae form the shoulder girdle and connect with the ____________ to form the glenohumeral joints

Humerus

A spinal disorder in which an excessive outward curve of the spine results in an abnormal rounding of the upper back.

Hyperkyphosis

When the curve is larger than 40 degrees, the individual is considered ______________________.

Hyperkyphotic

An injury to a muscle (tear in tendon) in which the muscle fibers tear as a result of overstretching; usually these are graded from I to III, with I being mild pulls and III being complete tears.

Muscle Strain

The supraspinatus initiates the first ___________ degrees of shoulder abduction followed by deltoid activation for the remainder of the arc of motion.

15

The scapulothoracic joint also plays an important role in providing motion and shoulder girdle stability through the ________ muscles that attach to the scapula

17

Normal anterior to posterior thoracic curvature is called a kyphosis or kyphotic curve and should be ____________________

20-40 degrees

The scapula is a flat bone with _________________angles—the upper (superior), bottom (inferior), and lateral (glenoid) angles—and three borders—the superior, lateral (axillary), and medial (vertebral) borders.

3

The part of the shoulder blade ________ the spine is called the supraspinous fossa and the part below the spine is called the infraspinous fossa.

Above

Dynamic Movement Assessments This is an ____________ technique, so the Corrective Exercise Specialist should make sure their clients have proper push-up and plank form, as well as adequate strength to remain in the high-plank push-up position for prolonged periods of time.

Advanced

A form of arthritis that primarily affects the spine, although other joints can become involved; causes inflammation of the spinal joints (vertebrae) that can lead to severe chronic pain and discomfort.

Ankylosing spondylitis

Hands on Hips Modification If an excessive ________________ pelvic tilt is improved with hands on the hips, this indicates that mobility restrictions above the hip at the shoulder (likely due to an overactive latissimus dorsi) are more responsible for the excessive tilt than below. For these individuals, protocols to correct arms fall forward should help improve their lumbar dynamic posture.

Anterior

The spinal cord and its nerves facilitate ___________________ between the body, the brain, and the outside world. The thoracic spine is unique in relation to other segments of the spine because ribs attach bilaterally to each of the 12 thoracic vertebrae.

Communication

Regardless of the cause, hyperkyphosis in the thoracic spine causes positional changes in the joints and segments above, namely the scapulae, neck, and shoulder. This increased curve places the head into a forward head position and causes ___________ rounding of the shoulders.

Anterior

The scapulothoracic joint is not a true joint but an ________________ and is formed by the convex surface of the posterior thoracic cage and the concave surface of the anterior scapula

Articulation

The coracoid process is slightly below and medial to the acromion process and serves as an _______________________ for certain muscles.

Attachment

Common symptoms associated with scoliosis include the following: One shoulder blade higher than the other One shoulder blade sticks out more than other Uneven hips A rotating spine Problems ___________ because of reduced area in the chest for lungs to expand Back pain

Breathing

The upper lateral side of the shoulder blade is home to the glenoid _____________________, a saucerlike landmark that forms the glenohumeral joint with the humerus. The acromion makes a joint with the clavicle, the acromioclavicular joint

Cavity

Loaded Movement Assessments This provides more _______________ to the musculature and can help draw attention to any remaining imbalance at the joints. While the OHSA does a good job of bringing sagittal plane movement impairments of the shoulder to light, other areas of shoulder dysfunction may be best observed during pushing and pulling tasks, provided the client is able to perform them. A standing cable machine press or pull is a suitable exercise to evaluate a horizontally loaded position.

Challenge

Behind-the-Neck Exercises For example, many people try to strengthen their latissimus dorsi and deltoids by performing behind-the-neck pulldowns or presses. This forces a person to place their shoulder into the ____________-packed position (shoulder external rotation, abduction, and maximal elevation).

Closed

Shoulder Elevation - Phase 3 - Activate Key activation exercises with isolated strengthening exercises include the ball __________________ and ball scaption to reinforce scapulothoracic rhythm and downward rotation and depression of the scapula.

Cobra

These fossae allow the supraspinatus, infraspinatus, and teres minor muscles to fit tight to the scapula and _____________ to the head of the humerus.

Connect

Because of the extreme degrees of freedom of the shoulder joint, its limited ______________ surface, and its regional interdependence with the lumbo-pelvic-hip complex (LPHC) and cervical spine, key static positions and movement impairments can be used to identify shoulder dysfunction.

Contact

The deltoid and supraspinatus work together in a force-couple to __________ the humeral head in the frontal plane.

Control

Loaded Movement Assessments Another loaded movement pattern that may be utilized to assess the shoulder complex is the standing overhead dumbbell press, provided the client can safely perform the exercise. This primary movement pattern requires at least a foundational level of ___________ stability and strength, as well as upper body mobility, stability, and strength to perform it safely. Any time an individual is pressing a load overhead, observe their shoulder and scapular mechanics for any impairments. Overhead presses also provide an opportunity to assess the corrective progress of the arms fall forward movement impairment.

Core

Scoliosis CES should note muscle imbalances and train appropriately by considering ___________ stability training and unilateral training to attempt balance between the muscle groups.

Core

Dynamic Movement Assessments The use of the _______________ test introduces repetitive plyometric movements for the upper extremity, testing the stabilization and dynamic posture of the shoulder in a more complex situation than the OHSA and loaded primary movement patterns

Davies

These altered postures create range of motion and altered length-tension relationships, thus decreasing performance and placing the individual at at risk of injury Hyperkyphosis will cause increases in multisegmental spinal loads and trunk muscle forces in upright and sitting positions. These factors are likely to accelerate ________________ processes in spinal motion segments and contribute to dysfunction of not only the thoracic spine but to the segments above

Declerative

Some cases of hyperkyphosis are caused by _____________________________, or wear and tear. Over time, the degenerative process can result in collapse of the intervertebral disc, changes in the shape of the vertebrae, and weakening of the ligaments that support the spine. This can result in the gradual development of hyperkyphosis over many years. Once the hyperkyphosis begins to form, it gets worse because the imbalance of the forces continually increases the wear and tear (Singla & Veqar, 2017).

Degeneration

Loaded Movement Assessments During pushing and pulling, the optimal position of the scapulae and shoulders is a _______________ and retracted state while still allowing for normal scapulothoracic rhythm where scapular protraction is not excessive.

Depressed

Hands on Hips Modification Just as elevating the heels increases available ______________________ ROM by taking tension off the calf musculature, placing the hands on the hips reduces tension in the latissimus dorsi and creates more ROM throughout the trunk.

Dorsiflexion

The joint must rely on the static and ___________ stabilizers for its stability as well as for its motion. The static stabilizers include such structures as the glenoid labrum and the glenohumeral joint capsule, consisting of two major ligaments, the middle and inferior glenohumeral ligaments

Dynamic

Ability of the human movement system to control and minimize unwanted joint motions during movement.

Dynamic Stabilization

Primary care reports an annual incidence rate of at least 14.7 per 1,000 patients per year experiencing shoulder ___________________ The athletic population experiences rates of injury of about 2.27 shoulder injuries per 10,000 athletic exposures at the high school level. Overall, shoulder injuries accounted for 8% of all injuries sustained at the high school level Olympic weightlifters and powerlifters can experience up to a 50% shoulder injury rate depending on experience level and age CrossFit® athletes experience injury rates to the shoulder that are comparable to Olympic weightlifting, rugby, football, gymnastics, or ice hockey In weightlifting, Olympic lifting, and CrossFit, risk factors for shoulder injuries include poor mobility and strength, lifting heavy loads overhead, quick and explosive movements like the snatch and jerk, and kipping pull-ups

Dysfunction

If proper motion is not available at the thoracic spine, the surrounding areas may be compromised with _____________ (ROM) or altered force-coupling ability. For example, decreased thoracic spine mobility can lead to excessive cervical ROM to compensate for the limitation in the thoracic spine. Excessive motion in a compensating area of the spine can cause dysfunction and/or pain.

Dysfunctional

Bending Elbows During the OHSA Once again highlighting the Regional Interdependence (RI) model at work, the movement impairment of _________ flexion (i.e., the inability to fully straighten the arms overhead) may frequently be seen in clients whose arms also fall forward during the OHSA. A rounded shoulder posture is sometimes also associated with overactivity or shortening of the biceps brachii muscle. Corrective strategies for the elbow and wrist should be followed when this movement impairment is observed.

Elbow

For every 2 degrees of glenohumeral elevation, there is 1 degree of scapulothoracic __________________

Elevation

The scapulothoracic articulation allows shoulder movement beyond the 120 degrees of _________________ provided by the glenohumeral joint.

Elevation

Hands on Hips Modification If placing the hands on the hips does not correct the _____________ tilt, then the corrective program should focus on the LPHC. Remember that programming decisions should be made with a full set of assessment results.

Excessive

If the thoracic spine is not rotating well, the body will allow the lumbar spine to make up the difference in movement. Most lumbar spine injuries occur at L5/S1 and L4/L5. These lower lumbar vertebrae will move excessively to compensate for a lack of movement in the thoracic spine directly above. _______________ movement at these joints can cause early wear and tear, dysfunction, and pain

Excessive

Arms Fall Forward - Phase 2 - Lengthen Key lengthening exercises with static stretches include the latissimus dorsi, pectorals, and thoracic ______________ over a foam roller.

Extension

Loaded Movement Assessments This posture extends the thoracic spine and allows for maximal protection and alignment of the torso from which the most efficient force can be generated. When there is a lack of thoracic ________________ ROM, upper trapezius and levator scapulae muscles can become dominant and cause the shoulder structures to migrate upward when they should otherwise be held down in place

Extension

The integrated assessment process will reveal movement compensation patterns that may warrant the implementation of corrective programming for the thoracic spine and shoulder complex with the most common one being arms ______________ forward.

Fall

The scapula is a __________ bone with the gliding surfaces formed by the subscapularis and the serratus anterior

Flat

Mobility Assessments _______________ of the shoulder extensor group, including the latissimus dorsi and pectorals, has a considerable influence on the positioning of the glenohumeral joint, as is demonstrated with the arms fall forward movement impairment. For most, internal rotation of the shoulders will not be limited due to the already-forward shoulder position many will present with; however, individuals with rounded shoulders will tend to have limited external rotation ROM.

Flexibility

The acromioclavicular joint and the sternoclavicular joint are at each end of the collarbone, connecting the shoulder girdle to the rest of the body. The scapula "_______________" on top of the rib cage and is held in place by muscles and two small joints

Floats

Arms Fall Forward - Phase 4 - Integrate An integration progression should be implemented first to emphasize scapular retraction and depression, such as a squat to row. Note that the sagittal plane row is largely dominated by the latissimus dorsi and that the latissimus dorsi are often overactive. Thus, the Corrective Exercise Specialist should place importance on _______________ and scapular mechanics

Form

Overhead Squat Assessment: A squat with the arms overhead requires optimal _________ mobility, thoracic extension, and shoulder girdle stability. Due to these factors, many common movement impairments associated with a lack of thoracic extension, glenohumeral flexion, and scapular muscle weakness can be observed in the OHSA.

Glenohumeral

The shoulder joint (glenohumeral joint) is formed where the humerus fits into the ____________ cavity of the scapula, like a ball and socket.

Glenoid

A common anatomical analogy refers to the shoulder joint as a ___________ ball resting on a tee The unique architecture of the shoulder joint relies less on bony structures for stability (such as the ball and socket of the hip joint) and more on the ligaments and muscles surrounding the joint

Golf

Standing in this position minimizes the forces of _______________________ and allows a person to stand with the best posture. Normal thoracic kyphosis ranges from 20 to 40 degrees when viewed from the side. A curvature that exceeds that range means hyperkyphosis is present

Gravity

The thoracic spine and shoulder are regions that are significantly affected by other regions of the kinetic chain. However, the thoracic spine and shoulder may also influence other aspects of the ____________

HMS

Shoulder Elevation If a body is correctly aligned, the shoulders will be at the same ____________ and neutral (facing forward and slightly retracted). Uneven shoulders occur when one shoulder is higher than the other. This can be a slight or significant difference and may be due to several causes.

Height

Muscle ________________ along the sides of the spine have been noted to have strength differences from side to side

Imbalances

Mobility Assessments If the client demonstrates ______________________ related to the thoracic spine or shoulder in the static posture assessment, movement assessments, or both, mobility assessments for the thoracic spine or shoulder should be performed to better pinpoint the muscle imbalances requiring correction via the Corrective Exercise Continuum. Mobility of the shoulders and thoracic spine can be evaluated using tests for shoulder flexion (latissimus dorsi length) and extension, shoulder retraction (pectoralis minor length), shoulder internal and external rotation, thoracic extension, and thoracic rotation.

Impairments

Behind-the-Neck Exercises In this position, most of the ligaments and a capsule surrounding the joint are taut. Performing exercises in this position increases a compressive and shear force applied to the joint and ___________ the risk for injury.

Increases

The scapulothoracic joint _______________ "attaches" to the axial skeleton through the acromioclavicular joint and the sternoclavicular joint

Indirectly

The ______________ ligament is divided into three sections: the anterior-inferior, axillary pouch, and posterior-inferior glenohumeral ligaments.

Inferior

Rounded shoulders can be a result of poor posture, increased thoracic kyphosis, muscle weakness, muscle tightness, or any combination and can be classified as Janda upper crossed syndrome. With this static observation, back muscles of the neck and shoulders (upper trapezius and levator scapula) become overactive and strained The muscles in the front of the chest (e.g., pectoralis minor) become shortened and overactive, as does the latissimus dorsi, which causes _______________ rotation of the humerus. As a result of these overactive muscles, the surrounding countermuscles become underactive and lengthened, contributing to poor length-tension relationships

Internal

The infraspinatus and teres minor prevent _______________ rotation of the shoulder. In addition, they decelerate the humerus during internal rotation, such as slowing the arm down during the pitching follow through.

Internal

Instead of one large bone protecting the important structures (like a turtle shell), there is space between each vertebra. space contains an ____________________ made of cushioning material that connects the vertebrae, pads the joints, and allows movement between each segment.

Intervertebral disc (IVD)

Dynamic Malalignments Dynamic movements such as throwing, hitting, and serving occur as the result of integrated, multisegmented, sequential joint motion and muscle activation. This system is referred to as the ____________________________

Kinetic Chain

Scapular Winging - Phase 1 - Inhibit Key regions to inhibit with foam rolling include the pectoralis minor, _______________ dorsi, upper trapezius, and thoracic spine.

Latissimus

That rounding of the upper back is typically caused by a combination of overactivity of the ________________ dorsi and pectoralis minor muscles paired with underactivity of shoulder and scapular retractor muscles. This leads to forward-positioned shoulders that create the visual appearance of rounding of the upper back as the thoracic spine responds The muscle imbalances responsible for this static posture are also the same ones that cause arms to fall forward during an overhead squat assessment (OHSA).

Latissimus

Thoracic spine pain and dysfunction is _______________________ common than in other regions of the spine. One study of a Norwegian population found a 1-year estimate of thoracic spine pain prevalence of 13% compared with 43% and 44% for low-back and neck pain, respectively (Leboeuf-Yde et al., 2009). A different study found lifetime prevalence data for thoracic spine pain ranged from 3.7% to 77% (Briggs et al., 2009) with a higher incidence found in teenagers and women.

Less

Shoulder Elevation - Phase 1 - Inhibit Key regions to inhibit with foam rolling and apparatus-assisted modalities include the pectoralis minor, thoracic spine, upper trapezius, and __________ scapulae.

Levator

Toward the end-ranges of glenohumeral motion, these ligaments tighten to _____________ motion and provide functional stability. These ligaments attach to the glenoid labrum and blend into the humeral head.

Limit

Arms Fall Forward Progress by moving to alternating arms or using a transverse plane row (i.e., wide-grip row) rather than by increasing ________________. Additional progressions may include one-arm and eventually base-of-support changes.

Load

Dynamic Malalignments When the body segments do not have the required flexibility or strength along the kinetic chain, increased __________ and stress may occur on the shoulder, elbow, and wrist joints, which can lead to dysfunction in other areas away from the dysfunctional segments.

Load

Loaded Movement Assessments Clients who demonstrate proper static and dynamic posture under body weight alone can be progressed to using ________________ variants of primary movement patterns.

Loaded

Behind-the-Neck Exercises To decrease stress on the joint and decrease the risk of injury, the joint should be placed in the ______________________-packed position. This is the position where the joint has the most extensibility in the capsule and ligaments

Loose

The ___________ spine has about 10 to 12 degrees cumulatively of rotation The thoracic spine should contribute between 45 to 60 degrees of rotation

Lumbar

Scapular Winging Scapular winging is an impairment that affects the shoulder blades. The scapulae usually rest flat against the back of the rib cage. Winging occurs when a shoulder blade "sticks out" or appears as if the ____________ portion of the scapula is coming off of the rib cage. The dysfunction can disrupt scapulohumeral rhythm, resulting in a loss of power and limited flexion and abduction of the upper extremity; it can also be a source of considerable pain

Medial

The sternoclavicular joint is where the clavicle and sternum ______________. It is the only bony connection of the scapula to the entire axial skeleton by way of the clavicle.

Meet

The shoulder is the most _____________ joint in the body This mobility provides the upper extremity with tremendous movement capabilities. The large amount of mobility allows for specialized actions like the baseball pitch or volleyball serve.

Mobile

Dysfunction of the thoracic spine can cause issues to joints and regions both above and below the area. These areas may include the scapulae, neck, shoulder, elbow, wrist, and lumbar spine, respectively. Increasing thoracic spine _________ has been shown to reduce discomfort and ROM in patients with neck and/or shoulder dysfunction

Mobility

The glenohumeral joint is a synovial, ball-and-socket articulation The joint affords a vast range of motion and great _______________________

Mobility

The thoracic spine and shoulder provide the upper body with a high level of _________________. Although the thoracic spine is not inherently mobile, optimal thoracic spine mobility combines with the scapula and shoulder to provide significant degrees of freedom.

Mobility

Numerous studies have focused on the use of thoracic spine __________ versus specific cervical spine therapy for treating individuals with neck dysfunction All of the studies utilizing multiple interventions combined with thoracic mobilization (multimodal approach) found improved function and decreased dysfunction Five of the studies also found improved cervical spine range of motion after intervention. These findings would suggest that having good mobility of the thoracic spine is imperative to improving injury resistance and ROM to the regions above the thoracic spine.

Mobilization

Additional effects on the shoulder girdle after thoracic mobilization include increased middle trapezius activity in individuals with rotator cuff tendinopathy and increased lower trapezius strength in asymptomatic individuals This improved muscle function after mobilization may provide support for _____________ the thoracic spine using a foam roller (or other modality) prior to horizontal or vertical push/pull exercises.

Mobilizing

Transitional Movement Assessment: Occasionally, clients might have relatively impairment-free static posture; however, when in ______________________, active muscle imbalances may come to light. With essentially all movement having some influence on the thoracic spine and shoulder, the transitional movement assessments provide objective information from which to design effective corrective exercise programs.

Motion

Oftentimes, ____________ movement impairments across the kinetic chain occur together (such as excessive kyphosis during static assessment and arms fall forward during the OHSA) and may benefit from exercises that address both, based on the integrated assessment process. For example, inhibition and lengthening of the pectorals may improve both impairments. As such, the Corrective Exercise Specialist may create a program that efficiently addresses multiple movement impairments.

Multiple

A study by Crosbie et al. (2008) described the relationship between thoracic spine mobility and arm elevation. The study described how thoracic spine hypomobility may lead to impairment of shoulder mechanics. Ensuring good thoracic spine mobility may help improve shoulder performance via improved force-coupling and ___________ activity.

Muscle

Therefore, a significant relationship may exist between the thoracic spine and surrounding regions. Although many of the studies included thrust manipulation by a licensed healthcare provider (physical therapist or chiropractor), improvements have also been seen by nonthrust mobilization and self-mobilization CES can teach their clients _____________ rolling using foam rollers (and other mobility tools) to apply these studies' outcomes.

Myofascial

To demonstrate how shoulder position affects the posture of the spine, stand with ________ posture perpendicular to a mirror and round your shoulders and head forward. When doing so, you will notice the middle of the upper back comes into view, highlighting the tight-knit regional interdependence of the upper torso. Next, retract the shoulders and stand up straight. Now you should see the thoracic region move back into a neutral position and be blocked from view by the shoulders now that they are back in line with the ears and hips.

Neutral

Hands on Hips Modification If an individual exhibits arms fall forward on the OHSA, limited thoracic extension above the lumbar spine may be a primary contributor. To help confirm this assumption, the hands-on-hips modification to the ___________ should be used.

OHSA

Another bone that is vital to shoulder function is the clavicle (collarbone). The clavicle offers the ___________ bony attachment to the axial skeleton, as it makes up the sternoclavicular and acromioclavicular joints

Only

The most common form of arthritis, affecting millions of people worldwide; occurs when the protective cartilage that cushions the ends of the bones wears down over time.

Osteoarthritis

Literally "porous bone"; a disease in which the density and quality of bone is reduced.

Osteoporosis

Overhead Squat Assessment: The movement impairment of arms fall forward is often observed when a client lacks optimal shoulder mobility. The lack of full shoulder flexion may be due to overactive ____________ major/minor and latissimus dorsi muscles, which pull the shoulders forward and contribute to excessive thoracic kyphosis

Pectoralis

Shoulder Elevation - Phase 2 - Lengthen Key lengthening exercises with static stretches include the __________ minor, upper trapezius, and levator scapulae. Reinforcing thoracic extensibility over a foam roller is also effective for shoulder elevation.

Pectoralis

Arms Fall Forward - Phase 1 - Inhibit Key regions to inhibit with foam rolling include the latissimus dorsi and ___________________. A small massage ball or medicine ball placed between the client and a wall are often more effective than using a roller on the pectorals. Self-myofascial rolling the thoracic spine is primarily done to reduce tension, reinforce scapular retraction, and improve thoracic extension.

Pectorals

Many times, this posture will be evident with an increased lumbar lordosis, as in Janda's layered syndrome or Kendall's kyphosis-lordosis posture. Recall that in this posture the head is held forward, the neck is hyperextended, the thoracic spine is flexed more than usual (and, usually, the scapulae are protracted or rounded forward), the lumbar spine is hyperextended, the pelvis is tilted anteriorly, and the hip joints are somewhat flexed. Typically, the knees are slightly hyperextended and the ankles are slightly ___________________ flexed.

Plantar

Postural kyphosis, or round back, is usually the result of poor ___________________. Previously, this condition was most common in adolescents and young adults, because they often slouch when standing and sitting, causing the spine to curve forward. Whether as a result of age-related changes or the increase of cell phone and computer use, people of all ages can experience this condition

Posture

Shoulder Elevation - Phase 4 - Integrate One additional integration exercise that can be implemented is a standing lat ____________________. During this exercise, it is vital to ensure the client is focusing on scapular retraction and depression first, and then humeral adduction. This movement may be progressed by reducing the base of support or performing with a single arm.

Pulldown

Loaded Movement Assessments Scapular winging will be best seen during _________________ tasks and is typically due to underactivity of the serratus anterior and scapular stabilizers. The location of these muscles is sandwiched between the scapula and the posterior rib cage. When they are not properly recruited, the scapulae are not held as tightly against the rib cage as they should be and can externally rotate slightly in the transverse plane, causing them to look like small "wings" on the individual's back.

Pushing

The shoulder girdle has the greatest _________ of any joint in the body and refers specifically to the articulations between the humerus, scapula, clavicle, rib cage (thorax), and sternum that make up the glenohumeral (GH), acromioclavicular (AC), sternoclavicular (SC), and scapulothoracic joints

ROM

Dynamic Movement Assessments When clients are ___________ for this assessment, they have already demonstrated relatively efficient form in all previous assessments, so compensations in the Davies test are typically due to deficits in muscular stability and strength rather than ROM deficits.

Ready

The concept of ______________ is seen in the upper body as movement impairment in the hips and lumbar spine region that may directly affect the thoracic spine and shoulder

Regional Interdependence

On the concave side, the ____________ appear to be weaker compared to the convex side Scoliosis can occur for a number of reasons

Rhomboids

The thoracic spine runs from the base of the neck down to the abdomen and articulates with the _________________

Rib Cage

Due to the articulation with the rib cage, the thoracic spine is more _________ than the lumbar and cervical spines and provides protection for the thoracic viscera, such as the heart and lungs

Rigid

Many muscles are associated with the shoulder joint The dynamic stability of the glenohumeral joint is dependent on the musculature that surrounds the joint, including the rotator cuff and the scapular stabilizers. The __________ cuff is the primary steering mechanism of the glenohumeral joint.

Rotator

As mentioned previously, the human spine has natural curves forming an ________-shape. Abnormalities of the spine, like scoliosis can affect the body's ability to provide a sufficient articulating surface for the scapulae and alter normal muscle activity of the shoulder, upper extremity, neck, and lower back

S

Behind-the-Neck Exercises However, a simple modification is to pull or press the load in front of the shoulder (front lat pulldowns or front shoulder presses), which avoids the closed-packed position and provides a ________ alternative to avoid injuries in the future.

Safer

A developmental dis-order of the spine that causes abnormal growth of usually the thoracic (upper back) vertebrae, but it can also be found in the lumbar vertebrae.

Scheuermann's disease

Sideways curvature of the spine that occurs most often during the growth spurt just before puberty.

Scoliosis

Scapular Winging - Phase 3 - Activate Key activation exercises with isolated strengthening include the _________________ anterior (e.g., push-up plus) and middle and lower trapezius (e.g., ball combo 1).

Serratus

The four most common causes of __________ pain described in the literature include rotator cuff disorders, glenohumeral disorders, acromioclavicular joint disease, and referred neck pain

Shoulder

There appears to be a relationship between _______________ dysfunction and reduced upper thoracic spine mobility Numerous studies have reported individuals complaining of shoulder dysfunction where more than 40% had associated mobility problems of the cervicothoracic spine and adjacent ribs and determined that the dysfunction in these adjacent areas may be a primary cause of some patients' shoulder dysfunction

Shoulder

On the posterior side of the shoulder blade, at about two-thirds of its height, a bony ridge called the ________ of the scapula runs diagonally upward toward the lateral angle and ends as a bony hook, the acromion process, which protrudes anteriorly and makes a bony roof of the shoulder joint.

Spine

Behind-the-Neck Exercises The close-packed position is when the joint surfaces are maximally aligned, which creates the greatest amount of mechanical ___________________. This position is achieved at 90 degrees of glenohumeral abduction and full external rotation

Stability

However, in the midranges of shoulder motion these ligaments are relatively lax and the joint must rely heavily on the musculature that surrounds the joint for dynamic ____________________

Stability

Shoulder Elevation - Phase 4 - Integrate An integration progression should be implemented first to emphasize scapular depression and cervical spine ____________________. An integration exercise that may be implemented includes a single-leg Romanian deadlift with PNF (proprioceptive neuromuscular facilitation) pattern

Stability

Shoulder Instability It is important to consider that the connections of the sacrum, pelvis, and spine to the arms, legs, and head are functionally interrelated through muscular, fascial, and ligamentous structures. Efficient body movement does not provide a solution for individual joints but orchestrates efficient reaction forces to integrate and stabilize the segments of the body. For example, focusing on singular anatomical structures to comprehend lumbopelvic pain, rather than considering the spine and pelvis as an integrated, interdependent, and dynamic biological structure might blind the observer to the larger picture (Vora et al., 2010). Because of this interconnectivity, the health and ___________ of the shoulder girdle are directly related to the ability of other segments to accept, distribute, and stabilize forces.

Stability

The tradeoff for enhanced mobility is reduced ________________ of the glenohumeral joint structure.

Stability

The main action of the subscapularis is ___________________ of the humeral head from external rotation. Secondary actions are internal rotation and depression of the humeral head.

Stabilization

The complex inferior glenohumeral ligament is the primary _____________ against anterior translation of the humeral head.

Stabilizer

Scapular Winging - Phase 4 - Integrate An integration exercise that could also be implemented for this compensation might be a _____________ one-arm cable chest press (see Table 14-6).

Standing

Transitional Movement Assessment: Based on the collective information obtained from the _____________ postural assessment, CES will have a high-level estimation of which muscles might be overactive/shortened and which ones might be underactive/lengthened.

Static

Dynamic Malalignments Proper utilization of the kinetic chain allows maximal force to develop at the legs and hips through the core, which can then be efficiently transferred to the arm. For the tasks to be effective and efficient, the different body segments must have optimal amounts of joint flexibility and ___________________.

Strength

The rotator cuff is made up of the __________________ and subscapularis anteriorly, with the infraspinatus and teres minor posteriorly

Supraspinatus

The anterior and posterior portions of this ligament help stabilize the joint by becoming ___________ in extreme ranges of internal and external rotation and often are injured with repetitive use in these positions.

Taut

When these muscles function properly, they provide a stable base for the humerus to glide on and allow for an efficient ______________ of force from the lower extremities and trunk.

Transfer

Arms Fall Forward - Phase 3 - Activate Key activation exercises with isolated strengthening exercises include the middle and lower ___________________, rhomboids, and rotator cuff (ball combo 2 with dowel rod is an effective exercise to engage rotator cuff external rotation). The ball combo 2 exercise can also be performed with dumbbells, as needed.

Trapezius

Overhead Squat Assessment: Sometimes, to compensate for a lack of glenohumeral flexion and thoracic extension, individuals may recruit upper ______________ and levator scapulae muscles to accomplish the arms overhead position, producing shoulder elevation as a means of relative flexibility. If this is difficult to observe during the OHSA, it may also be evaluated during a loaded pushing/pulling assessment.

Trapezius

Scapular Winging - Phase 2 - Lengthen Key lengthening exercises with static stretches include the pectoralis minor, latissimus dorsi, and upper ___________________.

Trapezius

This is accomplished through force-couples of the upper, middle, and lower ____________ as well as the serratus anterior

Trapezius

For example, the hips are like the speed limiter of a golf cart. The cart can have all the horsepower in the world, but if the limiter only allows a top speed of 25 miles per hour, it will never make use of its full capabilities. The same thing applies for a baseball pitcher. A person can have a lot of power in the legs, but if they have no range of motion in the hips, it makes transferring energy created from the lower body to the upper body impossible. The restricted mobility of the hip becomes the limiting factor of ground reaction force transfer to the upper extremities. Robb et al. (2010) found that poor hip range of motion adversely affected pitching biomechanics and ball velocity. Two of the key components to pitching velocity are hip range of motion and trunk rotation. This study demonstrated that by improving hip range of motion, trunk rotation also improves, allowing more opportunity for hip to shoulder separation, and therefore greater ______________. This study also showed good hip mobility increased stride length, which is an indication of more power from the lower body and perceived velocity to the hitter.

Velocity