Postural assessment should be a staple in every therapist’s initial evaluation, no matter the diagnosis. How else are you supposed to know the relationship between the spine and the rest of the body? And yes, this means for guys, asking them to take their shirts off, and for females too (as long as they have a tank top or sports bra underneath). A lot times the client does not wear the proper clothing to their first visit, and you may have to make do with what you have, but at some time during their POC, it is important to visually see their posture.
The scapula sits on the posterior aspect of the rib cage; therefore their relationship is vital in the assessment of an athlete’s shoulder. What should we look for when assessing posture? First, I look at the spinal curvature, or lack thereof. I want to make sure that there is a normal cervical and lumbar lordosis and thoracic kyphosis. A lot of times, the overhead athlete will have a decreased thoracic kyphosis – a flattened T spine. This can cause a lot of problems because the athlete is now “stuck” in spinal extension; the first being that spinal extension is important to shoulder flexion, and the second being that this now puts the scapula in relative anterior tilt when compared to the rest of the thoracic spine and rib cage (with extension the rib cage will be posteriorly rotated). The second problem listed can also lead to RTC tendinitis and impingement, with the worst-case scenario being a tear later in the athlete’s career.
Once I’ve looked at the spinal curvature, I then look at scapular positioning on the rib cage. Normally, the medial border of the scapula should be about 2-3 inches away from the vertebral column (I tend to eyeball about 2-3 finger widths). Many times I will look to see if both of the scapula are positioned equidistant to the vertebral column instead, as well as if they are excessively abducted. Other dysfunctions that can be detected in scapular positioning include anterior tipping, upwardly or downwardly rotated, and winging. An abducted scapula could be due to lengthened (and weak) lower trapezius or rhomboids, both of which can be caused due to a shortened serratus anterior.
An anteriorly tipped scapula can be assessed best in supine; looking from the head down in the axial direction, assess if both shoulders rise off of the treatment table or if one is higher than the other. Due to the scapula being an attachment for multiple muscles, scapular dysfunction can lead to many shoulder problems. The pectoralis minor muscle attaches from the ribs (2-5) to the coracoid process off of the scapula, and when shortened, can lead to an anteriorly tipped scapula. In standing posture, this can also be seen as rounded shoulders. With rounded shoulders, the therapist will typically want to look at the cervical spine due to the risk of the client being in upper crossed syndrome – would be picked up on the spinal assessment. Subscapularis and serratus anterior can be the culprit to an upwardly rotated scapula (assessed by measuring the posture of the inferior angle) and a shortened levator scapulae or rhomboid major/minor can lead to a downwardly rotated scapula.
As you can see, a lot can happen with scapular dysfunction to lead to shoulder pain. Seventeen muscles insert or attach on the scapula, and if any of them are lengthened or shortened, the scapula will be positioned poorly. If you are overwhelmed with performing a thorough postural assessment, a good place to start treatment would be on the scapula.
Following a scapular assessment, I will look at cervical spine and humeral head position. Cervical spine is important because forward head posture plagues a majority of Americans and consists of hyperflexion of the lower cervical spine and hyperextension of the upper cervical spine and lead to upper crossed syndrome. Humeral head positioning can tell you if the clients humerus is internally rotated – in standing posture, the therapist should not be able to see the backs of the clients hands in the frontal plane, and the olecranon process should be pointed in the sagittal plane more than the frontal plane.
Now, what does this all mean for the athlete? There are huge implications on how posture will affect how the athlete throws or hits. If the athlete’s thoracic spine is “stuck” in extension and the athlete does not have full GH flexion, during their acceleration phase, the athlete may bring their arm into more horizontal abduction to complete the throwing or hitting motion due to inability to throw or hit form above their head, leading to increased stress on the ulnohumeral joint, increased activation of the pectoralis muscle group for stability, and probably a lengthened lower trapezius muscle (typically seen as unintentional “side arming” a pitch in baseball).
If the lower trapezius muscle fibers are weak due to an overactive serratus anterior or subscapularis, this will lead to scapular dyskinesia – where the athlete will be unable to control his or her shoulder mobility in the scapular plane. This can be seen with shaking during the lowering phase of “scaption”. Due to the complexity of the upper quarter, a thorough assessment is needed to find the source of the client’s pain/dysfunction. The lower extremity postural assessment is just as important due to it’s involvement in power generation and will be discussed in Part 3.