Introduction (00:00.00)
You are listening to From Pain To Possibility with Susi Hately. You’ll hear Susi’s best ideas on how to reduce or even eradicate your pain, and learn how to listen to your body when it whispers so you don’t have to hear it scream. And now here’s your host, Susi Hately.
Susi (00:23.19)
Welcome and welcome back. Today, I wanna dig more into the shoulders, particularly because I am fascinated by the conversation around shoulders—shoulders and menopause and hormones. And there is a bit of a drumbeat these days that all issues around shoulders have to do with hormones. And I wanna get into more of the mechanical part of it because while there’s a biological reality of hormones playing a part—I’m not gonna dispute that at all, there truly is a biological reality—and seeing all of my clients who are in perimenopause and menopause, some of whom are on hormones, some that are not, every single one of them still needs to improve their mechanics. So that’s why I can say that, yes, hormones play a part, and I see what happens, whether someone’s on hormones or not, when we improve their mechanics, so much changes.
My hope here is that there’s, um, a little seed of possibility—especially for folks who cannot or don’t want to take hormone replacement therapy—that there’s still an opportunity for change. And those of you who took HRT for your shoulder issues and it hasn’t fully resolved them, again, I hope that there’s a possibility here of seeing that there’s a little bit more that can be done to support the progress you’re seeking. Because when we improve mechanics, the neuromuscular communication, when we improve movement patterns, we’ve got so much more to work with in terms of supporting shoulder function—and that’s what I wanna get into today.
It’s so easy to not look at the whole of the shoulder complex, especially how the shoulder blade moves and relates to the arm and the ribcage. It’s really easy to be out of touch with the shoulder blade, even to feel the shoulder blade. And then there’s the whole notion of cuing the shoulder blades, which I’m going to offer that maybe should be reconsidered as we continue to retrain and improve not only our foundation, but also to add strength.
So we’re gonna begin this conversation by looking at this triangle-shaped bone that sits on either side of the spine and the ribcage on the posterior side, and take a look at its significant function and how it enables us to move our arm in many directions—including moving the arm forward, raising it overhead, giving someone a hug, bringing the arm behind us, whether doing up a bra or scratching one’s back, or bringing the arm behind us on the other seat when we’re looking at parallel parking and we don’t have a camera to follow.
And what else? Well, let’s take a look at pushing: pushing open a heavy door, or a shopping cart, or ourselves up off the floor. Pulling: pulling open a door, rowing, doing a chin-up. Carrying: holding a child, carrying groceries, moving a laundry basket—perhaps all three at one time. And then there’s supporting weight through the arms, whether we’re on hands and knees, or moving into downward dog, or doing a pushup; reaching across the body to wash the opposite shoulder or reaching for a seatbelt; and placing the hand where we need it, whether it’s washing our hair, getting dressed, or putting dishes away.
So when it’s sticky, we’re stuck. When the muscles that attach to it aren’t working well together, when the neuromechanics between brain and body are not working well together, we can start to see how someone changes in their movement patterns. Maybe when we reach overhead, more of the ribcage is moving or we’re arching through the back. There might be more effort through the neck, less ease through the arm. There might be a sense that’s being felt of just having to work a whole lot more to make up for the movement that’s not available at the shoulder.
But what’s interesting is oftentimes we’re not thinking about the blade and its mechanics; we just notice that it’s effortful or something’s just not working. We might see that the hand’s not getting to where it needs to go. A lot of times when the blade’s not functioning well, we don’t pay attention to it because it’s so outside of our level of awareness. But what can start to get you thinking about maybe the shoulder blade’s involved is when you can see that the hand is not getting as far as we want it to. Maybe it can’t reach your head when you’re washing your hair. Maybe you can’t push the door open quite as well, or the shopping cart, or the vacuum.
I’m not saying all of these are absolutely 100% related to the blade; I just wanna start getting your mind thinking that way. The reason being is because so many people intellectually know where those blades are, but somatically, interoceptively, and proprioceptively, it’s a total wash—they don’t know where they are. And so because of that, because they’re not even on their radar, it’s so easy to go so many other places to consider what’s wrong. And again, I really wanna emphasize, I’m not saying that it’s the blade that’s at fault, but because it’s not in our field of awareness, a lot of times we don’t even go there.
So I wanna go there. I wanna play here because when we get a bit granular, we can start to understand maybe that the blade has some involvement in where some problems are. I say this over and over again: we can’t change what we aren’t aware of. So the more we can feel the blade, the more we can recognize how it’s moving or how we’re holding it, the more we have to work with as we retrain movement and build strength.
So if we dig into the anatomy here, the blade has a series of muscles that connect to the spine—both the thoracic part of the spine and the cervical part of the spine—and the ribcage. I like to call this the primary stabilizing structure. So we can take a peek at the rhomboids, the lower, middle, and upper traps, serratus anterior, and pectoralis minor.
And if we begin with the rhomboids, we can see that there are two: the rhomboid minor and the rhomboid major, and they connect to the lower part of the neck, upper thoracic spine, and the inner border of the shoulder blade—that’s the edge closest to your spine, the medial border. And the minor attaches higher up along that edge, and the major attaches below it.
We also have the trapezius: upper, middle, and lower. Now, these are different regions of one broad muscle that extends from the back of the skull through the back of the neck, down the thoracic spine, with attachments onto the collarbone and the shoulder blade. The upper fibers attach to the outer third of the collarbone. The middle fibers attach around the acromion—the bony part of the top of the shoulder, like right near that tip—and also along the spine of the shoulder blade. And the lower fibers come up from farther down the thoracic spine and attach near the inner end of that ridge. So we can see that we have connections coming from above, middle, and then below with the rhomboids and with the trapezius.
When we bring in the serratus anterior, we can see how it attaches to the upper eight or nine ribs and wraps around the ribcage and connects to the inner border of the shoulder blade on the underside of that shoulder blade. So now let’s take this in a picture format: the rhomboids approach the inner border from the spine; serratus anterior comes from the ribcage and meets that border underneath. And there’s a connection here that we don’t tend to look at when we’re looking at someone’s back.
Now let’s go to the pectoralis minor, and it sits underneath the pectoralis major in the front of the chest, and it usually attaches to ribs three, four, and five, and travels toward the coracoid process where it attaches. And that coracoid process is a little hook-like projection of the shoulder blade that comes forward below the collarbone. So even though we tend to picture the shoulder blade as being on our back, part of that bone reaches toward the front, and a muscle from the front of the ribcage attaches to it—and that’s the pec minor.
Now if you look at that pec minor and the orientation of those fibers, and you look on the backside, you’ll see a mirror image almost to the lower trapezius fibers. So a moment ago, I talked about the rhomboids and the serratus anterior. Well, even though there’s not a direct connection between the pec minor and the lower traps, there is a mirroring between the fiber orientation, and there’s a relationship between those two.
So you can begin to see that when you have these opposites, when you have them working together, that this can be the primary stabilizing structure, as I’ve mentioned. Think of them like ropes that are attaching a boat—like a boat has come into port, and there’s docks on either side, and we attach ropes to either side of the dock and forward, and they’re kind of pulling and moving the boat in different directions. While I know this is not the greatest metaphor, keep working with me on it: these muscles are pulling and connecting the blade in the various different directions. And so when things aren’t working well, it becomes interesting to see the relationship between these muscles—not just pec minor to lower traps or rhomboids to serratus, but really the whole of it.
So we can go granular and look specifically at a muscle. We can pull back, zoom out a bit, and see relationships. We can keep zooming out. And from this place, we can even go a bit further to another group of muscles that play into the blade, and that’s the rotator cuff. And these four muscles attach from the blade onto the upper arm bone. So in this case, the blade becomes the base from which the rotator cuff works. So as we explore the blade’s support and movement through this primary stabilizing structure, we’re also exploring part of the foundation for how the rotator cuff does its job.
So with these connections in mind, let’s come back to this word stabilization, and what does it mean to have a stable shoulder blade? And when we’re trying to create that stability, are we supporting its ability to move, or are we putting effort into keeping it still? A definition I really like about stability is control and coordination over a range of motion—and not “control” like a capital C, “I’ve got to control you.” I mean, as a small c. I’m referring to motor control and motor coordination over a range.
And by motor control, I mean how the nervous system directs and regulates neuromuscular activity for what we intend to do, using sensory information to make adjustments. And motor coordination is how that activity works together: the timing, amount of effort, and relationship among muscles and body parts as we carry out the movement.
So then how does this relate to stability in real life? Motor control and coordination allow us to manage a movement as it unfolds, including responding to changes in direction or load. Compensation, then, is how we accomplish a task when the control and coordination that we’re looking for is not available. So the hand still gets to where we want it to go, but other movement or effort is making up for what’s missing.
So with the shoulder blade, when something’s sticky or not moving well, when there’s not great connection neuromuscularly, that might mean bracing the rib cage, or lifting the rib cage, or holding the breath, or arching the back to make up for the limited shoulder movement in order to get the arm overhead. The endpoint is achieved, but reaching that endpoint doesn’t demonstrate the foundational control and coordination of a blade through the range. So in improving function and the foundation for good shoulder mechanics in and out of menopause, these fundamentals of control and coordination really need to be developed.
Which brings me to a common, common cue in yoga, Pilates, fitness, and so many other movement realms, which is: “Keep the shoulder blades down” or “Draw them into your back pockets as you raise the arms overhead.” And I get where that cue comes from. A teacher sees the shoulders rising as someone brings their arms overhead and wants to help. The shoulders are not meant to rise as the arms are rising, but doing the opposite is also not what we want to have happen. We need to consider mechanically what is the blade doing or supposed to be doing during that movement.
So if we’re taking the arms overhead, one thing that needs to happen with the blade is upward rotation. Picture the bottom tip of the shoulder blade rotating outward and upward as the socket turns more upward. The blade’s changing its orientation in order to support the arm going up overhead. So when a teacher uses the cue to pull the blade down while the student’s arm is going up, the teacher is likely asking them to hold against the very movement they need. And this brings us back to control and coordination: is the cue helping them develop that coordination, or is it adding to more holding and bracing?
So what do we do instead? Well, there’s not an opposite or a “do this instead of that,” because the reality is the reason why the teacher is offering that cue is because of what they see—which is the shoulders scritching up towards the ears. And a reason why that’s happening is because of what the person’s unaware of. So just slapping on another cue to not make that happen—that’s not the solution, because the person’s doing it because likely they’re unaware of what they’re doing. So to try and cue something that someone’s not aware of is sort of a lost cause.
Instead, what I would do is I wouldn’t bring the arms overhead right away, right? As I mentioned way at the beginning, people will get the hand where it needs to go, but at what cost? But rather, I’d begin with something like shoulder rolls—raising the shoulder blades up, pulling the shoulder blades back, and then bringing them down—and starting with that simple movement. And notice: do their arms really get into tutu train, or can they really drive the movement from their blades and not drive it from their arms? Their arms are involved, but it’s not leading the movement. Do they overuse their lower back? Does their chin poke forward when they do it? So it starts the awareness process.
And then you can bring them into goalpost or cactus arms, where the arms are coming out to the side, elbows are bent at about 90 degrees. And depending on the person’s, um, available mobility and stability, they might bring the elbows in line with the shoulders, or it might be a little bit lower, more like a W-type position. Then maybe from there, if they’re there for a few breaths, maybe bringing the arms up overhead after that.
I’d also bring in some twisting that includes retraction and protraction of the shoulder blades. So when we’re in a twisting position, initially leading into the twist, keeping the neck quiet so we’re not driving the movement from the neck and the head. And then once they’re in a comfortable position, uh, with the twist, pelvis quiet, retract the back shoulder blade, protract the front shoulder blade, and have someone feel and recognize the blades moving on the ribcage and the relationship between the blades moving and their overall twisting. Because lots of times when people add a little bit of that retraction back shoulder blade, protraction front shoulder blade, they’ll start to see their twist deepen a little bit—not huge, but there’s also this connection that they start to feel myofascially down to the pelvis and into the rotation.
When we start there, that’s when we begin to develop the awareness. And we don’t have to go super granular with our students and make this really boring, but we can be very intentional and deliberate in, we could call it a warmup section of the class, where we’re moving someone towards a position where the arms are overhead—maybe high lunge or warrior one with arms up, or maybe downward dog with arms up and now bearing load. And if we can get those blades sort of moving or simply a person becoming aware of those blades, then when they come into those movements, they’re moving a little more freely or just with a little bit more embodied connection.
And that’s really what this is about in yoga and in yoga therapy: we’re building asana—sitting comfortably and still—and nowhere in that definition is the word tension or strain. And that comfort and still nurtures the awareness, and that awareness nurtures our retraining process and our strengthening process. It’s where ease is built, right? And ease, sitting comfortably and still—it’s all kind of in the same realm.
So as you’re going into your next class, whether you’re a student or a teacher, or whether you’re going into your next movement process and your arms are coming up overhead, take a moment and just pause and notice what you can feel on the backside. Notice if you intellectually know where the shoulder blades are, but somatically or interoceptively or proprioceptively, you really don’t have a clue. And then start to just maybe roll those shoulder blades. Notice the ribcage and if it’s filling with your breath or not. Sometimes just being in front of a computer for multiple hours in a day, it can shut us down to feeling that area. And if you go and suddenly start to load with handstands or arm stands or weights or whatever, we just add more load on a part of our body that we’re just not connected to, and it makes it more difficult to create the retraining we want—especially when we’re in a cycle of our life where the raw material, hormones, is a little bit lower.
When we can honor and grow that level of awareness, we can make so much change with the raw material we do have and help facilitate so much better strength, so much better stability, so much better mobility, and better function overall. So here’s to reduced pain, eliminated pain, and super strong and healthy shoulders all the way through our life.
If this is resonating with you and you wanna dive deeper into this with me, November 23rd and 24th, I am running Power Up Your Movement: Perimenopausal and Menopausal Shoulder Love, and I would love, love, love for you to join me. You can read more over at functionalsynergy.com/shoulderlove.
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