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Unravel Those Hip Flexors

Hip Flexor Tightness

What are the Hip Flexors?

As the summer starts to close many people will be noticing the after effects of increased running mileage. I hear a lot of people mention tight, aching, or painful sensations over the front of the hips which may also be accompanied by a painful lower back. This is partially down to a tightness of the hip flexors which is a collective name for a group of muscles known as the rectus femoris, psoas, and illiacus.

The hip flexors primary function is to flex the hip, this basically means that they lift the thigh forwards and up towards the torso. If you think about the cyclic pattern of running we are repeatedly lifting the thigh in our swing phase. Not only this but the majority of jobs and lifestyles nowadays involve a lot of sitting; at a desk, in the car, or in meetings. The seated position puts the hip flexors in a shortened state. If we hold this position for prolonged periods these muscles will become very tight.

Psoas Muscle

Psoas Muscle

Rectus Femoris Muscle

Rectus Femoris Muscle

Iliacus Muscle

Iliacus Muscle

What does this mean for my body?

If the hip flexors are tight when the thigh is pulled backwards during walking, running, or standing it will stretch these tight muscles and cause some discomfort. The other issue is that the prolonged sitting position and the tightening of the hip flexors causes their counterparts (the gluteals or buttocks) to become lengthened and weaker. This results in a stronger pull on the pelvis in the forward or anterior direction which causes our pelvis to tilt forwards. This has a knock on effect on the lower back causing it to arch inwards hence the common lower back aches and pains.

What can I do?

The fix seems very straight forward, if the hip flexors are tight and short we need to lengthen and loosen them. As well as this to create muscular balance we need to retrain and strengthen the gluteals. By restoring balance in these muscles the postural imbalances will be rectified and hopefully relieve any aches and pains as well as regain a normal range of movement.

Exercise Ideas:

Perform the following 1-2 times per day (or every other day depending on time) or it can be added to your warm ups for any activity you currently do.

1. Hip Flexor Kneeling Stretch

Kneel on one knee, so your leg trails behind you, lunge the other foot out in front of you. keep your torso upright and thrust the pelvis forwards until you feel a stretch up your thigh and over the hip. Hold this position for 30secs and repeat 2 times on each leg. Once you can balance effectively introduce raising the arms straight up over the head, remaining upright through the torso. (See Image 1)

Image 1. Hip Flexor Stretch

Image 1. Hip Flexor Stretch

2. Pigeon Pose

Place one leg and knee flat on the floor in front of you, then trail the other leg flat behind you. Use your arms to control your weight and lower your weight down so your hips drop towards the floor. you will feel this stretch around the buttock and hip area. Hold this for 30 secs and do 2 sets each side. (See Image 2)

Image 2. Pigeon Pose

Image 2. Pigeon Pose

3. Fire Hydrants

This gets its name from the pattern of movement mimicking that of a dog and fire hydrant. Kneel on all fours so your hands are under the shoulders and the knees under the hips. Then keeping your back flat and straight raise one knee off the floor and take the leg out to the side, as though cocking the leg (hence the name). return the leg back in and repeat. Do 2 sets of 15 each leg. (See Image 3)

Image 2. Fire Hydrants

Image 3. Fire Hydrants

4. Gluteal Bridges

Lie on your back and bend your knees so you feet become flat on the floor. Then, keeping your shoulders and upper back flat on the floor, raise your hips up off the ground as high as you can, squeezing the buttocks. Once at the top hold it for 1-2 seconds then slowly return to the floor and repeat. Do 2 sets of 15. Once you can do this with great control you can try the same movement but using one leg only (make sure you work both legs thought). See Images 4 & 5.

Image 3. Double Glute Bridge

Image 4. Double Glute Bridge

 

Image 4. Single Leg Glute Bridge

Image 5. Single Leg Glute Bridge

 

It’s All In The Hips!

Trapped in Squat Pain? Release Yourself!!

The squat involves a whole complex of joints and problems can occur at any and sometimes all of these joints. For this article I will look at pain within the hip joint complex during squatting. This is something I have experienced and had a lot people ask me about.

There are an infinite number of things that could cause pain in the hip and without delving deep into everything I want to focus on an impingement like, nipping pain that often occurs during deep flexion of the hip such as in the bottom of the squat. This deep flexion of the hip occurs during everyday activities too however such as stair climbing or sitting into a chair. Therefore it could be very debilitative for some if this pain is persistent and not addressed.

I have read around this subject and also analysed my own and others squat. Many of the people who experience this have some or all of the following symptoms.

Common Symptoms. . .
• Pain that occurs in the front of the thigh and hip, feels like a nipping or catching
• Pain in the front or outside of the knee
• A feeling of tightness and congestion in this front thigh/hip area
• Pain in the lower back

On analysing the squat I then found some common dysfunctions or compromises evident on both my own and others squat technique. Things I found were as follows:

Signs of Dysfunction and Compromise. . .
• Knees may bow or collapse in with an inability to keep them pulled out
• There is an excessive forward lean of the upper body
• Arching and overextension of the lower back
• Shift of weight on to one leg
• Shift of weight onto the toes

What Could Be Happening? . . .
There is no one factor that will be responsible for a dysfunction, or pain. You should not rule out any pathology or condition so if the problem doesn’t subside with an attempt to self-treat then visit a medical professional. I have found both in myself, and others that there are some common factors present in individuals with squatting pain or activity related pain in the LPH complex. These factors are:

• Joint Dysfunctions
• Shortened, Overactive Muscles
• Lengthened, Underactive Muscles

Joint Dysfunctions. . .
Dysfunctions can occur at any point in the “chain” during the squat. However, for this article we will focus on the hip and pelvic area. If this joint is altered in terms of positioning this will have a knock on effect on the movement occurring at these joints and thus overall movement compensation. Another effect of an alteration in joint position is the ‘nagging’ or impingement like pain in the hip. Areas I have found to be dysfunctional in those (and myself) with this hip discomfort are as follows:

• Head of the Femur (Thigh Bone) sits more forward in its socket
Shirley Sahrmann proposed some familiar muscle imbalances to be contributors to this anterior translation. One of these is a tightness in the posterior capsule in combination with weak gutes prevents the femoral head from gliding backwards when the hip flexes, therefore the femur is forced forward. Along with this there is a proposal that one of the hip flexors (psoas major) is actually weak and unable to stabilise the hip into its socket. This allows this forward translation and creates the ‘nipping’ during a squat as the head of the femur can’t glide backwards as we flex the hip, instead it remains forward catching the soft tissues in the front of the hip.

• Anterior rotation of the sacroiliac joint (SIJ). . .
This is a very common alteration in the athletic and active population. A lot of people tend to be front dominant in their activities and therefore these front muscles become overworked and tight. A lot of people mention tight hip flexors when it comes to forward tilting of the SIJ and the pelvis. However, Sahrmann mentioned that the psoas may be actually be weak if the head of the femur is translating forwards. The psoas is a hip flexor but I believe the rectus femoris (one of the quadriceps, and hip flexors) is hugely responsible for anterior pelvic tilt. This muscle attaches to the inferior spine of the ilium and therefore if it is tight it will pull this and thus the pelvis forward. The psoas could still be weak and actually part of the reason the rectus femoris is tight as it may be working overtime to make up for the psoas weakness. If the glutes are also weak, as mentioned above, they will be unable to rectify any anterior tilt of the pelvis.

If the femoral head translates forwards as well as an anterior tilt of the SIJ and pelvis. This will close the space within the hip joint itself and therefore increase the likelihood of impingement and discomfort when moving through ranges of motion at the hip. During a squat you already close the angle between femur and pelvis so if there is an excessive amount of forward tilt even before we start squatting this will cause obvious problems.

Shortened, Overactive Tissues. . .
There are many muscles that could be involved in problems at the hip but for the purpose of this article I will discuss the major muscles I have found to be major contributors to hip pain during squatting.

• Rectus Femoris (part of the Quadriceps)
• Adductors (or groin muscles)
• TFL (outside of the hip, causing tightness in the Iliotibial band or ITB)
• Erector Spinae (lower back muscles)
• Piriformis (deep muscle in the buttock region)
• Hip Capsule

So when experiencing some form of hip pain assess these areas, if shortened they may feel tender to touch. One step to attempting to rectify your hip position and ultimately your pain would be to release these tight tissues. There are many ways to approach this, stretching, foam rolling and self-release, or deep tissue massage. These will be covered in the treatment section of this article.

Lengthened, Underactive Tissue. . .
• Gluteus Maximus (big glute muscle)
• Gluteus Medius (smaller glute muscle)
• Rectus Abdominis (“Abs” or “6-pack”)
• Transversus Abdominis (internal core muscle)
• External Obliques (muscles around the side of the core)

If these muscles are weak they are unable to aid the stability and proper control, and movement of the hip and therefore these compensatory patterns of movement and altered joint positioning occur. To attend to this issue, we do what we would normally do with a weak muscle, we train it to strengthen it and activate it. How we do this will be covered in the treatment section of this article.

Just for a second we will go back to the common dysfunctions and look at these in relation to the above contributing factors.

• Knees may bow or collapse in with an inability to keep them pulled out
This could be attributed to the tight adductors pulling the knee and thigh inwards, as well as having the weak glutes being unable to externally rotate the hip and pull the knee outwards. Therefore if you experience this bowing in of the knees then maybe try stretching and releasing the adductors and also strengthening the glute muscles in particular the glute maximus and medius.

• There is an excessive forward lean of the upper body
This could be due to the tight rectus femoris pulling the body forward from the pelvis with a weakness of the core and glutes being unable to stabilise and pull the trunk respectively during the movement. It may also be the hip capsule tightness restricts the hip movement and therefore the upper body needs to lean excessively to achieve squat range of movement. Therefore if you notice a forward lean then try strengthening the whole core (abs and deep core) as well as loosening the hip capsule, and rectus femoris.

• Arching and overextension of the lower back
This one will more than likely be due to the tightness of the erector spinae muscles pulling the lower back into the arched position. But also the weakness and inability of the rectus abdominis to pull the spine forward, and the glute inability to pull the pelvis backwards and thus the lower back out of an excessive arch. Therefore when feeling this arch occur work on loosening those lower spinal muscles, and strengthen the glutes and rectus abdominis (abs).

• Shift of weight on to one leg
Now this could occur due to a simple imbalance of strength from one leg to another, a leg length discrepancy or previous injury. However, looking at the structures that are usually tight it could also be the tightness of the TFL because if the foot is fixed the hip cant abduct so contraction of this tight muscle will tilt the upper body from the hip causing some sideways lean and potential for a shift of weight to one foot. A weakness of the obliques will also mean that the core cannot stabilise itself in this sideways plane as well as it should. Therefore this tightness and weakness could be addressed if this occurs.

• Shift of weight onto the toes
This is usually due to ankle mobility restrictions due to tight calves and not directly related to the hip, however it could have a knock on effect because if this starts to occur it will cause compensations further up the chain. Therefore if this is noticed then it needs addressing.

Treating Yourself. . .

Addressing Joint Dysfunctions. . .
When it comes to adjusting this alteration in joint position and mechanics we need to physically manipulate this joint. This is usually done manually by a therapist however, there are many ways in which you can apply similar mobilisations yourself using resistance bands.

1. Addressing Anterior Translation of the Femoral Head
The issue is that the head of the femur is stuck in a forward position and doesn’t glide as it should in the socket which causes the discomfort we feel during movements of the hip. Good ways of addressing this situation are as follows:

• Kneeling Banded Mobilisation – attach a band at kneeling hip height behind you. Place your affected leg through the band and place it high up into the groin region so it covers the hip joint. Kneel on all fours. You should adjust you distance from the band to alter the tension, you want to feel the band pulling the hip joint back. Once you have a good tension you can rock back and forth sitting onto your heels and back. You can also rotate you hip in and out from this position by twisting your leg so you lower leg moves side to side. The direction of pull can be altered in order to pull the head in different directions and mobilise the hip in various directions. You can perform 30 or so reps with band at one angle and then change angle and do another 30. Do a couple of sets at each angle of pull and also the rotations.

• Standing Split Squat Banded Mobilisation – stand through a band attached behind you at hip height wrap around the affected leg. Then perform a split squat, leading with your good leg. Adjust your position to alter the tension on the band, tension should be enough to pull the hip joint back as you dip into the split squat. Do 15-20 for 3 sets.

• Banded Step Ups – attach the band behind you again and place your leg through it wrap up into the groin around the head of the femur. You then want to step up with the banded leg and perform your step up. Choose the tension wisely as you don’t want it pulling you off the step/bench, but you want enough to pull back on the hip joint. Ensure you get full extension on the step up and if you want to engage the core too try not to touch down with the trailing leg and raise it up so thigh is parallel to the floor before stepping back down. Do 10-15 step ups.

• Lying Wall Squat With Rotation – Lie on your back with your feet flat against the wall and hips and knees bent as though in the bottom squat position. From here you can allow your knees to fall out stretching the inside of the hip and the adductors (groin). Extra pressure can be applied by the hands for more stretch on this. You can also then cross one foot over the other knee, as though cross the leg. Once crossed you can press down on the crossed-leg knee pushing it towards the wall. This can be pressed and held or can be oscillated in and out stretching the capsule.

To make the banded exercises effective you should have enough tension so you can feel the band pulling the head of the femur feeling it glide slightly as you move.

2. Addressing Anterior Pelvic Tilt
This is a common problem and is a fairly simple fix if you put in the time and work. It comes down to primarily two things. Tight anterior (front) musculature pulling the top of the pelvis forwards, and under-active posterior (back) musculature not pulling the top of the pelvis backwards. This imbalance then has the overall forward tilt of the pelvis. This in turn then alters the position of the hip joint as discussed above. So based on this the way to approach this is simple. Lengthen the tight tissues, and activate the under-active tissues.

• Foot Up Hip Flexor Stretch – This is similar to the Bulgarian Split Squat. Place the laces of your shoe on a bench and lunge the opposite foot forward. Then drop your hips towards the floor, keeping the foot in contact with the bench. You are wanting to feel a stretch right up the quad and into the hip flexor, this can be further stretched by raising the arms straight above the head and keeping the torso upright as you drop down. You eventually are aiming to be able to get the trailing knee to the ground, getting the raised foot against the buttocks, whilst keeping the torso upright so knee, hips and shoulders are all inline. This should be held for 30secs once a stretch is found or can be gently oscillated in and out of stretch 20-30 times.

• Lying Quad Stretch – lie face down with legs straight out. Then grasp one foot behind you by bending the knee, pull the foot into your buttocks. Aim to keep the pelvis, hips and core flat on the ground. If you struggle to grab your foot without raising the hips or arching the back you can use a band or towel and use this to pull your foot close to your buttocks without compromising position of the hips etc. Hold this stretch for 30 secs and repeat 3 times.

• Single Alternate Leg Wall Push – lie on your back next to a door frame. Bring the foot closest to the door frame up so it is flat against the frame, you want to have the knee as bent as you almost like this side is a deep squat position. Have the other leg out straight. Then you want to push hard down on the frame with the foot flat so the glutes are firing. Hold this for 20 secs or so, relax then repeat 5-10 times. Then you can swap sides so other foot is pushing down. This causes the glutes to maximally fire aiming to pull the pelvis back and into a better position, rectifying any anterior tilt.

• Single Leg Bridges – lie on your back with the feet flat and knees bent. Then raise one foot off the floor completely straightening and outstretching the leg. Then push through the flat foot, firing the glutes, and raise the hips off the floor until your knee, hip and shoulder is flat and in a diagonal line. Hold at the top for a second or two, keeping the core engaged, then lower under control then repeat. Do 3 sets of 15-20 reps.

You should also learn to adjust your own posture to help rectify any stuck hips or tilted pelvis.

• Stand up tall
• Squeeze and contract the glutes hard
• Flex the abs and engage the core and transversus abdominis so you stomach is pulled in and ribs pulled towards the pelvis slightly.
• Once all contracted you can ease off slightly as walking around in a fully flexed state is not comfortable, so ease off to about 50%.

3. Other Areas to Strengthen. . .
The following areas will help maintain good hip and pelvis as well as help stabilise the complex of joints and tissues.

• Superman – kneel on all fours and level your spine so it is flat, then attempt to pull your navel towards your spine without moving your spine or over-contracting your abdominals. To do this you should pretend you are trying to cut off your flow of urine mid-flow or clenching your rear passage. This is the best way to cue the Transversu Abdominis (deep core muscle) to activate. Once you can master contracting this muscle and keep core flat, then raise one arm straight out in front of you. As you do this raise the opposite leg straight out behind you, then lower them both and repeat with the other arm and leg. If you feel any movement in your spine or abs, or you feel your Transversus Abdominis turn off then stop reset and start again. Do 15-20 reps each side for 2-3 sets.

• Half Plank Progressing to Full Planks – the plank is often done wrong to reduce the difficulty of the exercise. The shoulders, hips and knees should be all in line with no sag of the stomach or arch in the lower back. If you struggle to do this without lower back arch, or a sag in the hips or stomach start with a half plank with the knees on the floor. Hold the plank for 30-40 secs for 3 sets.

• Straight Leg Reverse Crunch – Lie on your back and grasp some stable object behind your so your shoulders and arms are fixed still. Then squeeze your abs pulling your legs towards your chest, keep legs as straight as possible to avoid excessive firing of the hip flexors, you are only aiming to lift the hips off the floor so don’t need to fully bring legs into the chest. Also avoid any excessive folding of the pelvis. Perform 3 sets of 15-20 reps.

• Glute Medius Clams – lie on your side and bend the knees to 45° with one foot on top of the other. Then open the knees apart as far as you can without twisting your body or separating the feet. There may not be a huge movement you are looking to feel the outside of the glutes activating here. Do 20-30 reps on each side.

• Active Oblique Activation – lie on one side keeping the bottom leg straight and in line with the shoulders and neck. Bend the top leg to 90° out in front of you. Grasp the underside of your this thigh with your bottom hand. Place your top hand on the back of your head, with the elbow pointing to the ceiling. Then try touch your top elbow to the floor by rotating the core inwards, hold briefly at this point then rotate the core outwards, opening the body out and try get your back and arm flat on the floor, keeping you hand on your head. Again hold at this end point. Perform this for 15 or so reps. Check this link for a demo. https://www.youtube.com/watch?v=vxocwecYjqE

4. Foam Rolling and Self-Release
I could write a whole article on this area alone with the vast range of exercises available. However, I thought I would share a little gem of simplicity that can be used when trying foam rolling or self-release exercises. If you find an area that is tight or shortened you can pick up your foam roller, barbell or hockey ball etc. (something solid to apply pressure to the muscle tissue) and do the generic sit on it and roll. This may give you some relief but there is so much more you can do.

• Contract-relax – place the body area on the roller, hunt around until you find a sore, painful, tight spot. Once you find this spot hold as much weight over it as you can, holding it still on the roller. Then contract the muscle, in a static contraction and hold it for 5-10 secs, when you relax try put more weight onto the area via the roller. Do this until you notice an improvement in pain.

• “Lock and Load” – this is a concept I decided to term lock and load. If you find a muscle that is short or tight, you can place a “lock” on the muscle near the tight area. This can be done by placing the roller or cricket ball etc. across the muscle belly or near the tendon (depending where the tightness is felt in the muscle). Once the lock is in place you can “load” and move the muscle into stretch through full range as far as you can. As you do this keep pressure on the muscle locking it in. then you can release the lock and return to start. You can then repeat on same area until improvement occurs or find another tight area.

There isn’t any really right or wrong way to do this. Simply find an area that is tight and go at it using these methods as well as your generic sitting and rolling on a foam roller. For example if my quad feels tight just above the knee I will lie face down and place this thigh on a roller. The roller will sit at the end of the muscle at the top of the knee near where it starts to meet the tendon. Once there I will lock it in putting my weight through it. I will then move my heel towards my buttocks so my quad stretches. This pulls the fibres from the “lock” stretching the tight area.

Take Home Message. . .
If you are suffering with a nagging hip pain during your squats, or even just a noticeable anterior pelvic tilt (which could lead to hip pain) try addressing the above issues using the exercises above.

Basically all you need to consider is to lengthen and stretch the shortened tissues (listed above), and strengthen the weaker, lengthened tissues (listed above). By addressing these common characteristics you may help alter any alteration in joint and pelvis position, as well as create more space for the hip joint to glide during your squats.

You should always gain medical advice for any long lasting hip complaint that is not relieved with exercise or with time. The above is not an alternative for seeking advice from a medical professional it is merely what I have found to be successful for myself and some of my clients.

The Shoulder Complex Part 2: Common Dysfunctions

The Shoulder Complex Part 2: Common Dysfunctions in Impingement

The focus for this article is impingement syndrome in particular and what common dysfunctions and factors contribute to the development of impingement within the shoulder complex. The reason for this focus is because over recent months I have assessed and treated several clients who all present with symptoms of impingement and appears to be a common complaint within the sporting and recreational fitness world.
As mentioned briefly in part 1 impingement syndrome is not a diagnosis in itself it is more a result of some alteration in function, strength or stability of the shoulder complex or in many cases a combination of these factors. This may be through an acute injury or usually a more chronic occurrence.

What is Impingement Syndrome?
This complaint involves the area under the acromion process of the scapula, known as the sub-acromial space, see image below. This space is where the tendon of the supraspinatus muscle passes and also where a fluid filled sac, known as the sub-acromial bursa, sits and acts as a sort of shock absorber or lubricator. In brief impingement syndrome is when this space is reduced and encroached upon and the tissues within that space are compressed. Impingement has been categorised into primary and secondary impingement.

Primary Impingement
Primary impingement is a direct encroachment on the sub-acromial space, and this is usually a result of a structural deformity of the acromion itself, it may be genetically more hooked or can grow bone spurs which directly compress the structures underneath. These spurs can be a result of conditions such as osteoarthritis. Detection of primary impingement requires scans of the affected area and often requires surgical intervention to reduce the bone spurs and free up the space under the acromion. This type of impingement is usually observed in the older athlete or client, although not exclusive to this population.

Secondary Impingement
This is the type of impingement that you are more likely to see in your athletes. It stems from postural and movement related causes. In many cases, much like the ones I have seen, there is a whole combination of factors related to the cause of impingement. These factors include an instability in the shoulder due to ligament laxity, or muscular weakness. An alteration in movement patterns can also result in impingement, which again can be down to muscular weakness or imbalance. This can be treated by targeting the weakness/imbalance and rectifying any compensatory movements.

Common Symptoms of Impingement
• A “painful arc” – pain within the middle portion of the movement when moving the arm out to the side or up in front.
• Nipping sensation that can send pain from top of the shoulder to the elbow.
• Dull ache in the shoulder, and point tenderness around the front and/or side of the acromion process.
• Pain exacerbated by overhead movements, weakness in overhead lifting movements.
• Pain on side lying on affected side.

Below I discuss the common factors I have encountered in the cases of impingement that I have experienced. This is not an exclusive list, only the common factors associated with impingement that I have seen.

Muscle Weaknesses

Rotator Cuff
One of these factors is a weakness in the rotator cuff, i.e. the supraspinatus, infraspinatus, teres minor and subscapularis. These muscles, as described in part 1, have the primary role of rotating the humerus externally and internally respectively. However, they also play a big role in the stabilisation of the humeral head, they pull it down and depress it into the socket. Therefore if these muscles are weak this ability is diminished and therefore during arm movements the humeral head rides up and compresses the supraspinatus tendon against the arch between the acromion and coracoid process (coracoacromial arch). The symptoms of this compression tend to be replicated with overhead movements. During these arm movements of the shoulder complex there is a force couple between the deltoid and the rotator cuff. As the arm moves the deltoids pulls vertically upwards on the humerus, and the rotator cuff muscles pull horizontally towards the midline of the body. If the rotator cuff is weak and this horizontal pull doesn’t keep the humeral head pulled in then the upward rise occurs and the compression and pain occurs.

Serratus Anterior
As described in part 1, this muscle aids protraction and rotation of the scapula. It also plays an important role in holding the scapula in against the ribcage. If this muscle is weak or not functioning correctly then the scapula position will be altered and thus its movements will be hindered. The scapula and GH joint work together to allow full range of motion. If the scapula is not able to rotate effectively and is not pulled in to the ribs it is likely to tilt away from them, this is likely to cause the whole shoulder unit to move forward or rise to compensate for the lack of scapula rotation. This may then contribute to the reduction in the sub-acromial space and result in the compression and impingement of the structures within it.

Rhomboids
A weakness in the rhomboids have a similar effect as above. This muscle is responsible for pulling the scapula back (retraction) and holding the scapula onto the rib cage. If these are weak the scapula will translate forwards and tilt away from the ribs as above, and again the shoulder unit will translate forwards. This will result in compression of the sub-acromial structures for the same reason as discussed above.

Mid and Lower Trapezius
A weakness of this portion of the trapezius is quite common. This muscle holds the shoulder blades back and down, this stabilises the scapula and controls rotation. If this portion is weak then this control of rotation and stabilisation is lacking and therefore any over-activity of the upper trapezius, discussed next, will lift and elevate the scapula excessively affecting its rotation and thus overall shoulder motion. This dysfunctional movement may cause translation of the humeral head as previously mentioned and thus contributing to any impingement.

Overactive Shortened Muscles

Upper Trapezius
It is common for the upper trapezius to become overactive and become shortened. As this portion of the muscle acts to, rotate, lift and elevate the scapula it will cause the scapula to rise into excessive elevation and affect the ability of the scapula to rotate. This again affects the motion and position of the scapula so when the arm is raised the sub-acromial space is further reduced due to this elevation. Also the GH joint position and movement may be altered to achieve its ROM with the limited/altered scapula movement, i.e. the humeral head may rise to help achieve overhead ranges. This occurrence of over-activation of the upper trapezius tends to occur in combination with a weakness of the other scapula rotator muscles such as the serratus anterior.

Levator Scapulae
Similarly to the above, the levator scapulae becomes overactive as it has to work harder in compensation for a weakness of other scapula stabilising muscles. When this muscle becomes shortened it excessively lifts the scapula, and has the same effect as above in the upper trapezius.

Pectorals
Many of my clients with impingement symptoms present with very over-active, tight pectorals (both major and minor). A tightness and shortened state of the pectoralis major pulls the head of the humerus forwards in its socket. If the pectoralis minor is also tight, which it usually is, this will pull the scapula forwards into protraction which again moves the whole shoulder unit forwards. This forward translation of the humerus and shoulder complex reduces that sub-acromial space and the head will compress the structures within this space.

Altered Kinematics (Movement) and Posture

Scapula Dyskinesis
This term scapula dyskinesis sometimes gets thrown at people almost in a diagnostic sense, much like impingement. However it is not a diagnosis in itself. Scapula dyskinesis basically means a dysfunction in the movement of the scapula. This could take many forms, anything that strays from normal scapula movement could be termed scapula dyskinesis.

Common characteristics that I have seen with my clients have been excessive protraction and tilt of the scapula, this results in the scapula “sticking out” or “winging” and reduces the movement of the scapula around the ribcage. This could arise through some of the above factors such as weak rhomboids, serratus anterior, and mid-lower trapezius.

I have also seen excessive elevation which reduces the ability of the scapula to rotate optimally, this could arise from a combination of weak scapula stabilisers and an overactivation of the upper trapezius, and levator scapulae.
The movement of the scapula in some cases is judders and lacks control which stems from a combination of imbalances and fatigues of the mentioned muscles. Scapula dyskinesis often comes down to alterations in muscular control, strength or endurance. These altered movements of the scapula then alter the movement of the whole shoulder complex as previously mentioned. There are compensations, both muscular and mechanical, that occur to achieve different ranges of motion. For example the position of the humeral head in the GH joint may alter with poor scapula mechanics in order to achieve full abduction or flexion.

Upper Cross Syndrome
This concerns a common position that someone with shoulder problems may adopt. It often consists of a forward head position, rounding of the neck and upper back and also the altered position of the scapula that have been included above. These positions including anterior tilt (winging), elevation and protraction.

The altered mechanics and posture in the shoulder complex such as scapula dyskinesis and upper crossed syndrome alters the axis of shoulder movement in the GH joint this can then cause the humeral head to encroach on the sub-acromial space and compress the structures within leading to impingement.

Take Home Message as a Therapist

As a therapist we should not use impingement as scape goat. We should dig deeper and assess the whole shoulder complex. Be that therapist that is annoyingly pedantic and looks at areas that people wouldn’t think to look at. Don’t leave any stone unturned when it comes to impingement. In the long run it will help your client with a truly successful rehabilitation. Look for those weaknesses, altered mechanics, lack of control, and over-active structures and design your rehabilitation to alter these factors. These are the real diagnoses not simply “you are experiencing impingement” and prescribe the generic shoulder rotation exercises.

Do ensure that serious pathologies are cleared as a priority, such as a long thoracic nerve pathology which affects the control and position of the scapula. Clear all neurological symptoms by testing athletes’ sensations and looking for any significant motor weakness, numbness, tingling, or complete loss of muscle tone.

Part 3 of this article will discuss potential approaches to treating shoulder impingement.