T Nation

Long Term Depressed Scapula


#1

So Ive been lurking around here a while reading articles and it seems there are some users with good knowledge / experience that Im hoping may be able to help me.

I have been trying to rehab this issue (and get a correct diagnosis) for almost 5 years, I think I may be finally on the right track but I've been down this road before... Ive had a lot of ups and downs and this is severely affecting my quality of life. The last 6 months or so I have taken this upon myself to learn as much as I can and not just rely on the professionals, I have also finally found a good Physio who listened to me about the issue with the hip.

Ive made some progress recently and I am now able to get my arms properly overhead and actually do some overhead work pain free. I have also just been diagnosed with a Labral tear and FAI in my right hip.

Im looking for 1) an opinion on the diagnosis e.g. likely-hood and 2) whether my rehab for my current diagnosis is on the right track.

Any help or even pointers would be VERY, VERY much appreciated!

Symptoms:
Aching pain in the neck. Levator Scap and Upper Traps. Also pain tightness in the whole right side of the body starting of from the right hip / lower back region and travelling up to the right Levator Scap.

Current diagnosis and contributing factors:

Depressed (more on the right) and slightly downward rotating scapulae are stretching and overworking the Levator Scapula and Upper Traps causing pain and muscle spasms in and around these muscles. There are several factors contributing to this:

Main factors
1) Overly tight Lats / lower back muscles / thoracolumbar fascia pulling down on Scapula and further depressing them.

2) Increased tightness in the right lower back and hip area pulling down the right shoulder blade further. Muscles around the right hip area are constantly tight (psoas, TFL, QL etc) there is FAI and a labral tear in the right hip which is thought to be the cause of the tension in this area. Cortisone injection recently relieved this slightly.

3) Strong/tight Scapula downward rotators (Pec minor, Rhomboids, Lev Scap) + weak upward rotators (SA, Upper trap, lower trap). This places the Scapula in a position which further lengthens the Levator Scap.

Secondary factors:
4) Poor posture with head forward (upper crossed syndrome) adds increased tension in the Upper Traps and Levator Scap in order to support the extra weight.

5) Due to the increased length / tension in the Levator Scap / Upper Traps any activity which creates added strain to these muscles will increase pain levels. Activity which causes more Scapular depression or downwards rotation will cause pain.
Examples of this would be downwards traction on the arm from carrying something (depression), pulling the Scapula back and down (downwards rotation) or turning the head which requires one Levator Scap to lengthen as the other contracts.

6) Other contributing issues:
-Laxity of the Glenol-Humeral joint on both shoulders. (Rotator cuff exercises)
-Slight Anterior tilt of both scapula

Current treatment plan:
1) Thoracic Mobility exercises to reduce mobilise Thoracic spine and create a flat base for the scapula.
2) Release and then stretch tight muscles opposing. Mainly Lats and Pecs.
3) Downward Scapula Rotators (Levator Scap, Rhomboids, Pec Minor, Lats) are overly tight/strong while the Upward Scapula Rotators (Upper, Lower Traps, Serratus Anterior) are weak/long. This is causing downward rotation and depression of the scapulae. Avoid exercises using downward rotators and concentrate on exercises using the upward rotators to correct downward rotation.
4) Strengthening the Upper Traps will reduce depression.
5) Stretching and releasing (lacrosse ball) Lower right back and area around hip will reduce pull on right rib cage and scapula and further reduce depression.
6) Retraining right hip to not hitch will reduce the QL becoming tight on the right.
7) Rotator cuff work to reduce laxity in the Glenol-Humeral joint.

Current exercises:
Basically upward scapula rotators and glute work are the main focus.
*I have just recently removed cable rows and reverse db flys as I realised I was downwardly rotating the scap with these.

Overhead DB Press, Lateral raises on scapular plane, Face pulls, Wall push ups
Lower / Core
Leg Press, Hamstring Leg Curl, Glute Bridges, Single Leg Glute Squat, Dead bugs, Plank
Daily Exercises
Rotator Cuff with DB, Deep Glute Contractions, Wall pushups


#2

when I get some free time I will look more in-depth at your situation, I am assuming that downwardly rotating scapula means SICK scap. Scap malposition, inferior angle prominence, coracoid pain, and scap dyskinesis. Taking a brief look at things, slow down, simplify things first. Focus on end points, aka increased ability to perform painfree overhead activities. It seems like your suffering from a little paralysis by analysis. Some ways to simplify this for would be first correct the faulty posture, with a forward head and thoracic kyphosis your scapula will automatically be malpositioned causing point tenderness of the levator scap at its insertion on the superior angle. Focus on correct scapular positioning and worry less about this muscle strengthening and avoiding that muscle, although sounding very intelligent and knowledgeable, the final endpoint is proper scapular positioning and the means to get there is regardless. Therefore perform postural and scapular exercises with this being the number one goal in mind. Learning to place your shoulder blades in the proper place with automatically take care of a . b. c. d. etc


#3

Cheers BHOLL, Thanks for the quick response.
Yeah SICK Scap seems to cover it.
Except I'm not really experiencing shoulder pain rather Lev Scap and Trap and pain mostly on carrying any kind of weight e.g. dbs, groceries.

I know I've hit almost every angle I could think of here, I think my lack of results and the number of practitioners I have seen has caused me to just keep looking for answers.
Apologies for the over analysis!

I've spent a look of time working on posture (still am). Have read Neanderthal no more and computer guy on here.
I think you are right though that ultimately it just boils down to Scap position.
Also the new Physio I am seeing is the first one to actually try and restore overhead movement rather than avoid it.


#4

I agree with BHOLL regarding correcting posture first. I've had similar issues recently (being 6'5) and addressing my posture has been the most consistent area for improvement. Focus on chest / ribcage up for everything. Secondly - always being skeptical about therapy, this site convinced me to seek ART - and it made an immediate improvement.

Also, exercises that promote posture and upward mobility (shoulder disconnects with bands or broom stick, band pull aparts, wall slides, etc..). Foam rolling the back, shoulders, and lats has helped a lot also. After not being able to do over-head work forever, I am finally able to do so after a few months of focusing on the above. Started using snatch grip behind the neck presses with light weight to groove the feel again and has been fun getting back to overhead. Good luck.