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STEP 1
SHOULDER THIS
As with the other books in the FrameWork series, the "frame" part of the program comes before the "work" part. The first step toward healthy shoulders is learning about the form and function--the biomechanics--that are responsible for the action in an active life.
Although I'm primarily a "knee guy," the shoulder intrigues me to no end and I keep my finger, if not my scalpel and arthroscope, on a truly unique joint whose balance of mobility versus stability is unmatched anywhere else in the body. Although there is some rotation in the knee, it's more like a hinge: It places a premium on front-to-back movement, and stability is more important than additional rotational capability. Its ligaments lock things down pretty tight, and the patellofemoral joint is designed primarily to go up and down. The hip is a ball and socket, as the shoulder joint is, but it has a much deeper socket that, again, trades off some mobility for stability. Don't get me wrong--stability is really important in the shoulder--but you have to give up some stability for the enhanced mobility-- action--that only the shoulder provides. It goes up and down, side to side, and almost all around.
Perhaps it was an evolutionary thing when we started to come out of the trees; whatever the explanation, what we've got is a humeral head (the ball at the top of the upper arm bone) that sits in the glenoid (a shallow socket at the end of the scapula, or shoulder blade), and the labrum (firm rubbery material akin to menisci in the knee) and articular cartilage (the cushion covering the joint surface) on the ends of bones that prevent bone- on-bone contact through a wide range of motion.
The glenoid is so shallow that only one-third of the humeral head sits in it, so the shoulder is inherently a very mobile joint that, once more, lacks stability. If it's loose, its movement can be like an ice cube on a plate. That's where the capsule--a tricky anatomical construct if ever there was one--and shoulder muscles, tendons, and labrum come into play big- time to keep things in check.
What it all comes down to is that the shoulder relies more on the soft tissue around it than other major joints do. The good news is that muscles are the one part of shoulder anatomy that you can do something about right now. The brief primer on anatomical basics that follows will get you started.
THE BARE BONES
Large joints have large bones as a foundation, and the three in your shoulder play a large role in the variable motion it provides:
Clavicle (collarbone): This gently curved bone serves primarily as a strut to which shoulder muscles attach from the sternum (breastbone) and chest area. It is prone to fracture because it is just under the skin.
Scapula (shoulder blade): A thin, flat bone with several prominences (ridges and extensions). I've heard it referred to as the "conductor" of the shoulder because of its importance in shoulder function. Three prominences merit special mention because they are closest to shoulder action: the acromion ("peak of the shoulder" in Greek), which narrowly extends from the scapula and then fans out to meet the clavicle at the acromioclavicular, or AC, joint; the aforementioned glenoid (shallow cup), just below the acromion; and the coracoid process, a sort of hook that helps stabilize things.
Humerus (upper arm bone): Of primary importance in shoulder biomechanics is the humeral head, which has an articular cartilage surface (discussed below) to minimize friction, plus attachment sites for the four rotator cuff tendons (also discussed below). It also helps power the main muscles of the upper arm, including the deltoid, biceps, and triceps.
JOINT CONCERNS
Allow me to say yet again that motion is what FrameWork is all about. If the bones above touched, there wouldn't be much shoulder movement, and what little there was would likely come with quite a bit of pain.
Not touching is one thing; proper separation another. When any space between bones starts to differ from what Mother Nature gave you, beware. You may not have any pain or visible symptoms right away, but initial breakdowns pretty much always get worse, and you'll know about it soon enough.
There are three locations in the shoulder where space between bones is critical:
Glenohumeral Joint: If you envision a golf ball on an oversize tee, you'll get a good idea of what this joint looks like and why the humeral head (the "ball") and the glenoid (the "tee") are stable but free to move in any direction.
Acromioclavicular (AC) Joint: Where the clavicle meets the acromion. Small and hardly mobile, this joint is subject to injury ("AC separation") and arthritis.
Sternoclavicular (SC) Joint: Connects the clavicle to the sternum (middle of the chest).
THE SOFTER SIDE
Now that we've gone through the "hard" stuff, let's explore some other frame parts in your shoulders that have their counterparts in the knee and are just as critical for healthy joint function:
Articular Cartilage
Our old friend that we visited in the knee book--the opaque white stuff that we see on the ends of chicken bones--is back, this time as the head of the humerus and the crater rim of the glenoid. Articular cartilage is smooth material that absorbs shock, and it's slippery, so it keeps friction between touching, moving parts to an absolute minimum. In other words, it allows for smooth and pain-free articulation, or motion. It is pretty remarkable stuff; when healthy, it has a coefficient of friction 10 times greater than ice on ice! That's a pretty smooth ride.
Labrum
Akin to the meniscus, this wedge-shaped fibrocartilage ring sits atop the glenoid articular cartilage. The labrum helps to anchor the biceps tendon, cushions the humeral head, and deepens the joint socket, which adds static, or relatively stationary, stability to the shoulder.
Capsule
This frame part, which also provides static stability, is a watertight sac between the gle-noid and the humerus that is designed to prevent shoulder instability, such as subluxation and dislocation.
Ligaments
These fibrous bands connect bone to bone:
. Glenohumeral Ligaments: They limit excessive sliding and rotation of the humeral head on the glenoid during arm movement--the last leg of the triad that provides static stability to the shoulder. . Coracoclavicular Ligaments: The acromion (the scapula peak) is held in correct relation to the clavicle primarily by these ligaments. . Coracoacromial Ligament: Connects the acromion to the coracoid process (the scapula's "hook"), forming a vault that protects the humeral head, and plays a supporting role to the coracoclavicular ligaments. . Acromioclavicular Ligament: Connects the acromion to the clavicle.
Tendons
These softer tissues are much like ligaments, but they connect bone to muscle instead of bone to bone:
. Biceps Tendon: Connects the biceps muscle to the top of the glenoid, and also melds with the labrum. . Rotator Cuff Tendons: Each of the four muscles that make up the rotator cuff (discussed below) has a corresponding tendon that attaches its deepest layers to the humeral head.
Muscles
Muscles provide dynamic, or mobile, stability in the shoulder. Muscle strength has been a cornerstone of the FrameWork philosophy and programs from the start, but muscle balance, especially around the shoulder girdle, is just as important. This is perhaps why shoulder problems rank number one in weight lifters and gym rats, especially men. In their effort to achieve maximum strength and muscular growth, they all too often overwork certain shoulder muscles, do not allow for adequate recovery between workouts, and in the process create fatigue and imbalances, especially in the smaller muscle groups. Muscles are designed to move. These are the ones that get your shoulder going, and the ones that will all need your attention:
. Trapezius: A large, superficial muscle that extends from the occipital bone (back of the head) down to the midback vertebrae and over to the scapula spine (protruding ridge of the backbone). Its primary function is to retract the scapula. . Rhomboids: Smaller muscles in the upper back that originate on the spinal column and attach to the midregion of the scapula. They also function as scapula retractors and are extremely important not only for posture but for optimal shoulder health and function. . Serratus Anterior: Originates on the upper eight or nine ribs at the side of the chest and attaches to the long edge of the scapula below the glenoid. . Deltoid: Powers glenohumeral joint abduction, flexion, and extension. It takes over lifting the arm once it's away from the side. . Pectoralis Major: A thick, fan-shaped muscle that covers much of the upper chest. Its broad side originates in the upper part of the sternum and extends to attach to the clavicle; its tapering side terminates in the upper humerus. The pectorals are powerful abductors and internal rotators of the gleno-humeral joint. In layman's terms, they move the arms across the body. Bodybuilders often work their "pecs" with the bench press. . Latissimus Dorsi: The widest and most powerful back muscle. It originates on the lower half of the back at the iliac crest (hip bone) and then tapers to attach to the front of the upper part of the humerus. It also provides abduction and internal rotation, moving the arm downward and backward. . Rotator Cuff: Last, but certainly not least, is this somewhat infamous frame part that helps to raise the arm from the side and rotates the shoulder in myriad directions. As important as those biomechanical functions are, however, the cuff sprimary purpose is to stabilize the humeral head against the glenoid. Unlike the deltoid, it's a very tiny group of four strap muscles that can easily become overworked, imbalanced, and fatigued. (The reason it tears, especially after long-term high- spirited sports and recreation, is that we demand performance that exceeds design specifications. We'll have plenty to say about this affliction in the next step.) While the deltoid is the power mover, the cuff provides fine-tuned movement.
The four muscles that make up the cuff and work in concert to activate and protect are:
. Supraspinatus: Lies above the scapula spine and attaches along with the infra-spinatus muscle on the outer tuberosity (protuberance) of the humeral head. It is active in any motion involving elevation of the humerus, working to stabilize the glenohumeral joint. The supraspinatus is the cuff muscle that tends to get into the most trouble. . Infraspinatus: Also stabilizes the humeral head, and it accounts for 60 percent of external rotation strength at the shoulder. . Teres Minor: Just below the infraspinatus, it provides the remaining 40 percent of external rotation strength at the shoulder. . Subscapularis: The only muscle attaching to the lesser tuberosity of the humeral head; serves as an internal rotator.
Nerves, Blood Vessels, and Bursae
With one exception, all of the important nerves that power the shoulder and transmit messages back to the brain are branches of the brachial plexus, which begins in the spine and also controls elbow, wrist, and hand function. That exception, the cranial nerve that is also known as the spinal accessory nerve, is connected to the trapezius muscle. Blunt force trauma and/or swelling in the shoulder can lead to tingling, numbness, or paralysis--usually temporary--in the shoulder, elbow, or hand. Compression of the suprascapular nerve may result in a motor palsy (also known as muscle weakness) that can mimic a rotator cuff tear. The long thoracic innervates the serratus anterior muscle, which can be prone to stretch injury.
The shoulder is often the source of "referred pain" when nerves are malfunctioning, stretched, or irritated. This is especially true when there is a pinched nerve in the neck: Many patients call the office complaining that they have a shoulder problem or injury. This is why a proper shoulder evaluation always includes the neck or cervical spine area as well as a check of the other nerves mentioned above.
Traveling along with the nerves are the large vessels that supply the arm with blood. Six branches extend from the axillary artery, all of which provide rich collateral circulation to much of the shoulder. (If you place your hand in your armpit, you may be able to feel the pulsing of this large vessel.) Unfortunately, as we learned about the articular cartilage in the knee, the humeral head does not have extensive collateral circulation, and this complicates how fast and how well its injuries heal.
Sandwiched between the rotator cuff muscles and the outer layer of large, bulky shoulder muscles are sacs with small amounts of lubricating fluid that are known as bursae. They are everywhere in the body, including the knee, as we learned, and you'll find them wherever two body parts move against one another and there is no joint to reduce the friction. The shoulder joint, like all synovial joints, also contains a lubricating, nourishing fluid called synovial fluid.
WEAK LINKS
Every health-management or improvement program, especially an exercise one that places additional stresses on the frame, should consider one's predisposition to breakdown. If your family has a history of cardiovascular disease, it's prudent to get on a diet and supplement regimen at an early age to keep cholesterol in check. If breast cancer is the issue, closer monitoring of that tissue is called for. When it comes to working out, one must consider those "setups" for the breakdowns I'm always talking about, which everyone has in one way or another, to one degree or another.
Weak links are one of the common threads in this series because they play a role in every aspect of frame health. Many of them can be corrected by you yourself, and those that are beyond your control can usually be well managed.
Age
First up is something that no one can control forever: the wear and tear on body parts and the changes in tissue composition as time marches on. Friction takes its toll and collagen loses elasticity, so most adults over the age of 40 have rotator cuffs that have already started fraying. We have learned much of this from MRI technology that shows the internal architecture of the cuff and associated tendons--sometimes more than we want to see. Few adults have significant discomfort at first, but the fraying goes on and degenerative scar-type tissue forms within the cuff. Compromised strength and mobility in your shoulder may be slight, even imperceptible at first, but the process can be relentless and unstoppable. (It can be minimized, however, hence this program.)
