Are We Becoming Over-Health Conscious?
In the news over the last few weeks there has been mention of a change in pattern of alcohol and drinking habits between the younger and older generation. This got me thinking and with me being in this “young” bracket I asked myself what has been changing in this younger population to bring about this change? I am writing this short article to share with you my proposed suggestion for a contributor to this change in alcohol behaviour, and what may have taken its place.
Change in Statistics…
The average weekly consumption of alcohol in 16-24 year olds dropped from 16.9 to 11.1 between 2005 and 2010. Interestingly, one surveyed showed that the number of men aged 16-24 claiming to have drank during the week, also showed a drop of 12 people (from 64 to 52) dropped between 2005 and 2011. The drop for women was much less. Also, the number of men claiming to drink 5 out of 7 days in the week dropped by half between 2005 and 2011 . Men, aged 16-24, claiming to drink over the daily limit also showed a pattern of decline, dropping from 46 to 32 for those drinking more than 4 units on at least one day. A drop in those drinking over 8 units also dropped from 32-22.
These are very brief statistics but it does show a trend that these figures for the young male population are dropping. So what has changed in these young men?
I have a huge interest in and passion for male body image so I always take note of the behaviours of males in the gym (where I work). I have noticed a huge desire for the big, lean, and muscular physique within this population. The commitment to the gym, lifting weights, and meticulous attention to dietary habits is unbelievable. Even in school age boys, this desire is on the rise. This population is under huge pressure from media and peers to “look good”, this portrayal of looking good is plastered all over the TV, magazines, movies, and within sport. This portrayal is in the form of a big, “ripped”, muscular man who gives off the impression of increased female attention, success, and beauty. Is this focus on “looking good” contributing to these drops in the alcohol behaviour figures?
I overhear a lot of conversations in the gym and they all breed the same topics such as eating habits, progress updates, and restricting certain behaviours etc. There is always a young man talking about how he is reducing or restricting his carbohydrate intake in order to reduce his body fat and get “ripped” or someone talking about his “gains” and how he is tailoring everything to achieve these “gains”. This made me think maybe these lads are reducing behaviours such as alcohol intake as it is deemed an intake “empty” calories and bad for their “gains”.
Then it hit me in the face (or ears), over hearing a group of lads talking about a night out. One responded with “I will come out, but will drive, I am not drinking. I am making gains, can’t have booze reducing my test (testosterone) levels”. I have also been more aware of my friends adopting the same outlook, turning down nights out or meeting up for drinks because they are “in training”. Bearing in mind a lot of them don’t play sport or train for any reason other than aesthetics. So here it is, one possible reason for young lads reducing their drinking habits, they are focused on “looking good” and making “gains”.
This is Great Right?
At face value, this is brilliant, the younger population no longer living up to this binging stigma, and improving their health by reducing these toxins in their bodies. Yes, but if you then delve into what else these young lads engage in are they just swapping one potentially unhealthy behaviour for others?
The media portrayal of males in today society has a lot to answer for. Young impressionable men are buying into this ideal physique and going to great lengths to achieve it. Yes they may be adopting healthy behaviours in that they tidy up their diet, engage in regular exercise, and reduce their unhealthy behaviours such as alcohol intake. But what happens when they a) don’t quite get to that ideal, b) realise they want more than that ideal, or c) the ideal changes and becomes even bigger, leaner and more muscular?
They then modify their diet to extreme levels, exercise more (maybe to extreme levels), and introduce other “aids” and potentially harmful behaviours. So realistically, they have simply swapped one unhealthy behaviour (alcohol) for another (or more than one) such as steroid use, disordered eating, or excessive exercise. Now exercise and a clean diet is healthy, but is this latter progression of exercise and dietary behaviour a sign of us being “over-healthy”? By being “over-healthy” are we actually making what we do unhealthy both physically and mentally?
Don’t get me wrong the drop in alcohol related incidents and health related problems in this population is a great thing and deserves this exposure. However, despite me being biased in that my passion is in the area, I do believe we need to see this and ask why? Then look into men’s health with a focus on their exercise psychology. If we can tap into this and provide education regarding male body image, their drive for muscularity, and safe exercise and nutritional behaviour we may be able to help also reduce the prevalence of other unhealthy extreme behaviours.
Now this is a very short article designed to introduce the topic and express my view and passion. I have completed an MSc research project in this area of male body image concerns, in particular Muscle Dysmorphia. If anyone is further interested please do not hesitate to contact me. I am also in the process of applying for a PhD in this area, with the hope of contributing to tackling the issue of Men’s Health and their image issues.
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 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.
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.
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.
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.
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
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.
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.
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
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.
The shoulder complex is a highly mobile joint expressing a large range of movements. To achieve this large range of motion (ROM) there is limited stability provided by the inert structures within the complex. This meaning that there is a high responsibility on the muscles of the shoulder to provide stability to support the large ROM. This large responsibility on the muscles means that any imbalance in muscle function and strength may cause problems with overall stability, and function.
This article will look specifically at the imbalances, alterations and factors that may lead to impingement syndromes in the shoulder. This stems from the large amount of cases of impingement I have seen over recent months. It will be split over 3 parts, describing the functional anatomy of the shoulder complex, the common contributors and causes of impingement, and finally some possible treatment considerations.
As most people will know the shoulder joint is described as a ball and socket joint. This being true the shoulder as a functional unit doesn’t stop there. It is best to view the shoulder as a complex unit. This unit comprising of the “ball and socket joint” or glenohumeral (GH) joint and the shoulder girdle. The shoulder girdle is comprised of the shoulder blade (scapula) and the collar bone (clavicle).
The only direct attachment from the shoulder to the axial skeleton is via the clavicle attaching to the breast bone (sternum). This joint is known as the sternoclavicular joint (SC).
The GH joint is where the head of the upper arm bone (humerus) or the “ball” meets the scapula and specifically the “socket” known as the glenoid fossa. This joint is very shallow so to allow for the great ROM.
There are many bony landmarks on the scapula but so not to complicate this article we will discuss the main aspects. There is a joint where a prominence of the scapula (acromion) meets the clavicle, this is known as the acromioclavicular joint (AC).
As mentioned the bones do not provide significant stability to the shoulder due to the shallow joint surface of the GH joint. Therefore the support for the shoulder has to come from elsewhere.
When the shoulder complex is static there is support provided by the capsule surrounding the shoulder joint, the ligaments, and the cartilage lining around the rim of the glenoid fossa (glenoid labrum).
There are 3 main ligaments of the GH joints; the top (superior), middle, and bottom (inferior) glenohumeral ligaments. Surrounding these ligaments there is then the capsular ligament or capsule. Inside the joint itself, under all these ligaments, is the labrum. This increase the congruence of the joint creating a deeper “socket” for the humeral head. See figure 2 and figure 3 showing the ligament structures of the shoulder. These structures do provide some element of stability, primarily when the shoulder is static. In order to maintain the large ROM of the shoulder these structures must be relatively lax to allow this movement of the shoulder.
The low contribution of the skeletal and ligamentous structures means that the majority of the stability of the shoulder complex comes from the active structures i.e. the muscles.
The muscles of the shoulder complex provide the majority of the stability for the shoulder especially during dynamic movements. The muscles of the shoulder all serve their own function during specific movements of the shoulder but all work as unit to provide stability and control proper mechanics during these movements.
Rather than rattle on explaining the ins and outs of every movement of the shoulder and muscles they have been put into table 1 below.
|Deltoid||Raising arm out to the side (Abduction)
Raising arm out to the front (Flexion)
Raising arm backwards (Extension)
|Pectoralis Major||Bringing arm across the body (Horizontal Flexion)
Contributes to flexion
Turns arm and shoulder inwards (Internal Rotation)
|Latissimus Dorsi||Raising arm backwards (Extension)
Bringing arm in to the side (Adduction)
Draw arm horizontally backwards (Horizontal Extension)
|Trapezius||Pulls shoulder blades back (Retraction)
Lower part pulls shoulder blades down (Depression)
Upper part lifts Shoulder blades up (Elevation)
Rotation of the scapula
|Teres Major||Turns arm and shoulder inwards (Internal Rotation)
Bringing arm in to the side (Adduction)
Stabilises humeral head
|Rhomboids||Pull shoulder blades back (Retraction)
Generally hold the shoulder blades onto the rib cage
|Rotator Cuff Muscles||Actions|
|Supraspinatus||Raising arm to the side for first 15 degrees (Abduction)
Stabilises and pulls the humeral head into the socket.
|Infraspinatus||Turns arm and shoulder outwards (External Rotation)
Stabilises and pulls humeral head down in the socket (Depression of Humeral Head)
|Teres Minor||Turns arm and shoulder outwards (External Rotation)
Stabilises and pulls humeral head down in the socket (Depression of Humeral Head)
|Subscapularis||Turns arm and shoulder inwards (Internal Rotation)
Stabilises and pulls humeral head down and forward when arm is raised
|Serratus Anterior||Pulls scapula forwards around the ribcage (Protraction)
Helps with scapula rotation
Helps keeps scapula pulled into the rib cage
|Pectoralis Minor||Pulls scapula forward around the ribcage (Protraction)
Pulls scapula downwards (Depresses Scapula)
Rotates Scapula Downwards
|Levator Scapulae||Lifts the scapula (Elevates Scapula)|
The extensive list of muscles above may look overwhelming. These muscles all work as a unit to ensure efficient movement of the shoulder. Various movements are possible around the GH joint, and the scapula as described below, you can use Table 1 for reference to muscle involvement.
Movements of the Shoulder Complex
The GH joint movements include flexion-extension (raising arm up in front and pull arm back), abduction-adduction (raising arm out to the side and back in), internal-external rotation (turn shoulder inwards and outwards), and horizontal flexion-extension (taking arm horizontally across the body and pulling it back).
The scapula movements include, protraction-retraction (forward and backward tilt around the ribcage), elevation-depression (uplift and downward pull), and upward-downward rotation.
The co-ordination of both GH and scapula movements needs to be precise to allow unrestricted and efficient movement of the shoulder complex. For example as the arm is abducted the scapula rotates upwards in a 2:1 fashion after the first 30° of abduction. The same applies for flexion of the shoulder after the first 60° of flexion. If the scapula is restricted then the whole shoulder movement will be restricted. This shows the importance of examining the shoulder as a whole unit or complex rather than narrowing on the GH joint itself.
This has been a very brief and simplified description of the shoulder complex anatomy. This will be followed up by discussing and explaining the common dysfunctions that occur and lead to problems in the shoulder, in particular a chronic condition known as impingement syndrome. Although this term is very common it is not a diagnosis it a term given to the symptoms and experiences of the patient. The cause of this is often down to other irregularities such as a dysfunction in movement or weakness in certain muscle groups.
Part 2: Common Dysfunctions will soon follow.