Chapter 1:
Anatomy and Movement of The Shoulder

This article is an excellent place to start if you want a better understanding of shoulder anatomy and movement. It will explain the assembly and mechanics in simple terms, but also provide a solid explanation for how the shoulder works.

It's like the cliff notes for a Shoulder 101 course that will prepare you for future articles aimed to fix your shoulder hang-ups.

Shoulder Anatomy– “The Framework”

First, get to know the bones of your shoulder.  They are the scaffolding that supports the entire structure, similar to a wood frame for a house.

Starting at the ground floor with the rib cage. 

This is the bony structure designed to protect your internal organs and also provides a good place to attach your arms. rib cage

Although, as you will learn shortly, the shoulder is not tightly fixed to the rib cage. There’s only a single bony attachment that allows freedom for the shoulder to glide around the contours of the rib cage.

The rib cage is usually not included in the shoulder discussion, but it dramatically impacts shoulder function. Feel how bending and rotating the spine orients the rib cage differently and changes your shoulder position.

The big take-home is that often the shoulder relies on the body's posture to put it in a position to work most effectively.

But for the classic shoulder bones, it comes down to three that make up the joint.

1. The Clavicle

The first piece is the clavicle, often referred to as the collarbone.  It’s a support beam of sorts, forming the one bony attachment of the shoulder to the frame of the body.


2. The Scapula

Next is the scapula, also called the shoulder blade, or as slag, it's referred to as the scap.  The scapula hangs off the end of the clavicle and against the rib cage, held in place by 17 different muscles.

The scap muscles act as guide wires, pulling the shoulder blade into different positions.  On the outer corner of the triangle is the shoulder socket (you’ll see later, it isn’t much of a socket.)



Before moving onward, move your shoulder blade around a bit.  Notice how the arm moves along with it.  The term used to describe how the scapula and arm move together is scapulo-humeral rhythm. The key word rhythm describes the movement of two things in synchrony.

This is all too important for the shoulder.  The scapula and arm must work together as a team, otherwise, it’s just a half working shoulder. What I’m getting at, is your fix for shoulder pain, or building arm strength, must include the muscles that move the scapula as well.

3. The Humerus


Then there is the arm bone. In medical terms, it's the humerus. It has a ball on the end which attaches to the shoulder socket. The benefit of a ball and socket is lots of movement....but it's not a socket. 

Instead, the head of the arm bone is much larger and often described as a golf ball sitting on a tee.  Again, the advantage of this is freedom of movement!

Holding it Together

Shoulder anatomy is that simple— only three bones!

All held together by “tape and rubber bands.”The tape describes the static stabilizers. Things that don’t move and aren’t all that stretchy. They do a good job of holding things in place, kind of like tape. The most talked-about static stabilizers are the shoulder ligaments and the labrum.

The rubber bands describe muscles and their tendon attachment (technical folks refer to the rubber bands as the dynamic stabilizers.) They hold things together but also lengthen and shorten, which makes the arm move. 

The Shoulder Trade-Off

To summarize everything to this point, the shoulder is made for movement. It can work in many different directions. Along with that, it can go fast, for things like throwing, or it can be strong to lift weights and carry bags of dog food, or it can be exact to catch something tossed your way.

Compared to the hip, it’s much less clunky. Free to wave around like those tube dancers that jive in front of car lots. However, as with anything, there is a trade-off.

All that movement freedom can bring about problems. First of all, it’s prone to become unstable when the things holding it together aren’t working right (remember…tape and rubber bands.) Secondly, just like any complex machine, there are many ways things go wrong.

We’ll get to the breakdowns in other articles, but for now, let’s cover how it works when things go right.

Movement of the Shoulder

There are lots of shoulder muscles. Each one has a specific action and combines with other muscles for additional movements.

But you don’t need to know any of those things! More important are the principles behind shoulder movement. So let’s break those down into small movements and big movements.

Small Movements

Small movements are performed close to your body with loads that aren’t too heavy—everyday tasks like picking up a coffee cup or working at a desk.

The minor moves happen mainly by the ball of the arm moving in the socket. These actions rely on the four smaller shoulder muscles around the joint called the  rotator cuff. They connect in a circular pattern around the ball of the shoulder joint to move it around.

Big Movements

Now things get a bit more complex. As movements progress away from the body or overhead, it requires more moving pieces.  For things like washing your hair, reaching into the backseat of the car, or opening the overhead bin on an airplane, only so much can happen with the ball moving around the socket. To achieve the extra range of motion, the scapula needs to move to free up additional ranges of motion.

For example, reach as far forward as you can, and you should feel the scapula wrap around the body; or pull your elbows back and notice how the scaps squeeze together. There is significant scapula movement to bring your arm overhead. Several muscles pull from opposing sides to pivot the scap for this action to happen. Moving the scap aligns the shoulder blade with the elevating arm bone and creates a stable support structure for the arm.

And do you feel like you’re tight? Are you stuck in your range of motion, even without much weight? That’s often because the scapula isn’t moving enough to allow that range of motion.

Even Bigger Movements

What about moving heavy weight, pull-ups, and throwing fastballs?

There are additional pieces for high-performance.

First off, these moves usually need full ranges of motion. (Yet again! Moving the scap is important.)

Then with the shoulder in the right position, the rest relies on the prime movers. Those are the workhorses responsible for strength and power.  These are the muscles we hit in the gym—things like the pecs, deltoids, and lats.

But the rotator cuff still has an important job to do here too.  The muscles of the rotator cuff keep the arm bone centered inside the shoulder socket.

Summing it Up

Working the remote or eating cheeseburgers doesn’t require too much from the shoulder. If this is your only goal, there probably isn’t much reason to worry. But to have an active life, as you can see, there are lots of working pieces that need to be strong and coordinated.

So when pain pops up, it’s usually because one of the parts isn’t meeting the demands. The future articles in this series will apply this understanding of shoulder anatomy and movement to explain the many shoulder breakdowns and how pain flares ups. And of course, we’ll show you some ways to fix it.

Chapter 2:
The Reason Your Shoulder Most Likely Hurts: The Infamous Shoulder Impingement Syndrome.

There is a common cause of shoulder pain—and there’s a good chance it’s the reason your shoulder hurts.

A condition called shoulder impingement syndrome.

It can also go by names like:

  • subacromial impingement,
  • painful arc syndrome,
  • supraspinatus syndrome,
  • swimmer’s shoulder, or
  • thrower’s shoulder

And in the medical world shoulder impingement will sometimes get defined by the pathology of what’s actually hurt.  Things like rotator cuff tendonitis, biceps tendonitis, bursitis, or other medical ‘itis’ words.

It’s one reason why people get so mixed up about their shoulder pain.  There are a lot of words, all describing the same thing!

What is Shoulder Impingement?

Take a quick review of your shoulder anatomy (which you can dig into this a bit more HERE), for an important structure to point out.

There is a small gap in the shoulder called the subacromial space.  And Inside this space are muscles, tendons, and sacs of lubricating fluid.

For a long time, we considered the acromion to be the primary culprit of shoulder pain.  It was observed as a nasty hook that would grab onto and rough up tissue in the shoulder, to the extent that shaving or cutting the acromion became a common procedure.  But we’re now cluing in that “shoulder impingement” is actually supposed to happen, and with all shoulder movement, the tissues naturally glide between the bones of the shoulder.

But if it’s normal, then why does it hurt?

First of all, there’s not much room for error beyond the normal shoulder biomechanics. If shoulder function is thrown off, even just slightly, it will add extra compression to the tissues in the space.

Things like stiff and inflexible shoulders are likely to decrease the subacromial space…

Or if the scapula isn’t moving with the arm correctly, it can position the bony prominence too low…

Or if the rotator cuff isn’t doing its job to keep the arm stable in the shoulder socket…

All of these things will lead to a greater degree of shoulder impingement. 

If this extra compression happens while sipping a cup of coffee, it’s not likely to flare anything up (unless it’s already irritated).  But consider playing tennis, or throwing a ball, weightlifting, or painting a ceiling. 

It’s usually through a cocktail of shoulder mechanics, loads, speed, and volume that our shoulder ends up in pain.

Additionally, if something is irritated, it’s likely to hurt if you poke it.

For example, if you twisted your knee playing soccer, it’s likely to hurt for a few weeks if you bend it.  In this example, bending your knee causes pain, but it’s not the cause of your injury.

Likewise, even if impingement is normal, if you’ve irritated something in your shoulder, it’s likely to be bothered when it’s compressed.

So the impingement pain may be in response to other shoulder issues, like rotator cuff or labrum tears, that not only increase the degree of impingement but also make the shoulder cranky when it gets pinched.  

Thus, it’s too simple to say that impingement syndrome is caused by the compression of the tissues inside the shoulder.  Because by itself, that’s what’s supposed to happen.

Although the diagnosis…

Desk-job-stiffness-with-mild-rotatorcuff-fraying-and-lot-o-push-ups-itis

is a hard one to say, so we’ll stick with shoulder impingement.

Tests for Shoulder Impingement

There are lots of assessments used to determine if someone has impingement syndrome.

A very simple one for someone to do on their own is to reach across the body and put the hand on the opposite shoulder.  Then lift the elbow towards the face and check for pain.

 

 

There is another assessment called a painful arc test.

For this assessment, lift the arm up away from the body, into an overhead position.  If there is pain between 60 and 120 degrees this is a positive test.

 

Shoulder pain during either of these tests would be an indicator that you’ve got some irritation that’s getting further irritated with impingement. Even if you check out on these tests, if you have shoulder pain, there is a very good chance that shoulder impingement is involved somehow.

 

And regardless, the corrective plan for shoulder impingement will help your shoulder, no matter the cause.

Which leads us to the next question…what to do about it?

Fixing Shoulder Impingement

If you want to fix your shoulder impingement, there are two big steps in order to get you there, which both involve lessening the degree of impingement.

The first is to lighten the stress on your shoulder,  By reducing the loads and volume on your shoulder, the shoulder impinges less and allows for some healing.  The best guide for this is to simply eliminate any painful movements.  This should make sense, but many continue to push through pain, which only makes matters worse.  As a general guideline, give it 2 good weeks of good shoulder rest.

Although the first step is for nothing without the second one—it’s critical and often missed or ignored.

The second step involves building shoulder strength and mobility.  This not only improves shoulder mechanics for less impingement but progressing through pain-free movement is an important part of getting past your brain’s perception of pain.  You can read more into this in our article End Your Pain by Retraining Your Brain.

These are the underlying principles of our 30 Day Shoulder Fix.

In this program, we walk you through a 30-day rehab program, designed to fix your pain and improve your shoulder strength and mobility, so that it never returns.  But it’s not always the right fit for everyone.  

Take our Red Flag Screen to determine if shoulder impingement is likely the cause of your pain and if our self rehab program is right for you.

Chapter 3:
The Rehab Approach to Rotator Cuff Tears & Why It’s Usually the Best First Approach.

Chapter 4:
How to Keep Kicking Butt Despite a Torn Labrum

Before we layout a plan for your labrum tear using Crossover Symmetry, take a second and observe the shoulder.

The ball is 3x the size of the socket. It’s more like a ball on a tee than an actual “ball and socket” like the hip.

 

 

It’s not the most stable build, but it makes up for it with a ton of mobility.

Sandwiched between the arm bone and shoulder socket is a key structure called the labrum. 

(Please note that it says LABRUM. Many times I’ve heard it confused as the LABIA.  This is a different part of the body that I’m confident we’ll never write an article about.)

The labrum is a rubbery ring that surrounds the shoulder socket, and does things like:

  1. Deepen the socket to support stability.
  2. Provide an attachment to anchor ligaments and tendons.
  3. Create a negative pressure to further stability—think of it as a suction cup.

In summary, the labrum provides stability, for a joint that very much needs the help. It also finds itself in the conversation around shoulder pain very often.

In this article, we’ll explore the labrum further, especially related to pain and injury, and shine some light on the best way to fix issues related to a torn labrum. 

But spoiler alert…the labrum doesn’t fix itself.

Labrum Injury 101

Henry Gray (1918) Anatomy of the Human Body

Labrum tears generally occur when stability fails.

Sometimes that failure is due to an accident—like taking a fall on an outstretched arm or a lift that went wrong. This forces the arm bone into the labrum ring causing it to tear. Sometimes the forces are so great that the shoulder dislocates. In these cases a labrum tear is almost guaranteed, resulting in what’s called a Bankart lesion.

The labrum can also be injured by pulling on it. Notice in the picture how the bicep tendon attaches to the upper ring of the labrum. Stress that pulls on this attachment can peel away the upper part of the labrum ring, causing what’s called a SLAP tear.

The SLAP tear is extremely common in baseball players due to the extreme layback that occurs as part of the throwing motion. Or it can also occur from dropping down hard while hanging onto something (I’m looking at you butterfly pull-ups.) Or a SLAP tear can occur due to a blow to the shoulder as well.

Either way, when the labrum tears, it leaves behind an issue of both pain and lost stability that must be dealt with. This type of injury doesn’t have the ability to regrow either, so just taking some time off will not help the issue.

Next, we’ll cover the follow-up to a labrum injury.

Diagnose a Labrum Tear

If you dislocated your arm while hucking off jumps at the terrain park—or maybe something slightly less awesome—bet on a labrum issue. This may follow up with a feeling that the shoulder will dislocate again and deserves a medical evaluation.

But sometimes it’s not so obvious, especially in the case of SLAP tears. Here are the signs and symptoms that you may have damaged your labrum:

  • Pain. Often deep and hard to pinpoint, with the feeling that it’s too deep to touch.
  • Catching/clicking
  • Pain with overhead activity
  • Decreased force production on that side
  • Sometimes a loss in shoulder range of motion, especially with internal rotation.

In the clinic, a PT or sports med doc has lots of special tests to diagnose a labrum issue. You could search for them, but there is no one test that will check yes or no. It’s a system of ruling out other pathology, manual assessment, paired with patient information to create a full impression.

Basically, if you need assurance, you should get an evaluation with a specialist to feel more confident moving forward. Although, it’s not ridiculous nor harmful to initially work on a home fix for a suspected torn labrum with a program like Crossover Symmetry.

Next, we’ll show you how…

The Labrum Fix

As we mentioned earlier, the labrum doesn’t repair itself. So what kind of hocus pocus might we recommend?

The answer is a conservative plan of strengthening and some rest.

Which isn’t actually a cure, because the labrum remains torn, yet have no fear! You can still be healed.

First of all, labrum tears rarely happen in isolation. Due to instability caused by the torn labrum, or potentially the underlying issue that caused the labrum tear to happen, things such as bicep tendinosis, rotator cuff impingement, and bursitis can pop up as well. These are pain generators that will usually go away if you stop poking them.

Secondly, strengthening the muscles can make up for the loss in stability, restoring function as before. To support this, a 2016 study showed that 72% of people over the age of 40 had a SLAP tear that was pain-free.

If you’re unconvinced, it’s been estimated that close to 80% of major league baseball players have some degree of labrum tearing. Showing that it’s possible to buffer a labrum issue well enough to sustain the forces required to play a pro sport.

Labrum Fix Using Crossover Symmetry

There is a good chance you can too, with a simple prescription:

  1. Avoid things that are painful for at least 30 days. If you keep provoking your pain, it’s not going to get better.
  2. The “protocol” for a labrum tear would follow the same principles for approaching other shoulder issues. Work on restoring range of motion and improving the function of the scapula and rotator cuff muscles in all planes of motion.

Even if you don’t have a labrum tear, you’re still taking the steps in the right direction for fixing whatever shoulder ailment that pains you. Most important to the process is that the program needs to be consistent with daily compliance.

I would say this is the biggest reason the Crossover Symmetry program is so effective.  Athletes use it much more regularly compared to other home rehab programs that are often prescribed.

More Advanced Treatments

Give it 30 days and if the pain is still limiting your progress, high dose NSAIDs or corticosteroid injections are an appropriate option. 

You’ll feel good after an injection, but don’t sit around and assume everything is fixed. Instead, it’s important to use the relief to address strength deficits.

As an athlete progresses past the basic rehab template, more advanced movements may be necessary to take on the specific stressors that will show up as part of their sport. In the end, nearly 70% of athletes have good outcomes with pain relief and return to sport through conservative management (ref).

If after 4 to 6 months, there has been no improvement despite a consistent effort with a conservative approach, it’s time to consider more advanced medical procedures.

Imaging may be ordered, but an MRI is not great at picking up all SLAP tears, so an MRA may be ordered for a more accurate assessment. 

The final approach is arthroscopic surgery, which follows up with a 6 to 9-month recovery.  The bicep tendon is often relocated from the superior labrum to lower on the arm during the procedure as well.  This is called a bicep tenodesis and tends to have less pain and reduced risk of the repair failing.

Conclusion

Whether you are a weekend warrior, throwing a baseball in the Majors or working to get to the CrossFit Games, a torn labrum is not a career-ending injury. It may disrupt training and competition for a few months, but the majority of labral tears can be addressed successfully with non-operative care.

Take this as a reminder to continue your active participation in your shoulder health. This includes a plan for warming up the shoulder, accessory work, and sport-specific training. 

Click Here to learn more about Crossover Symmetry and how it can maximize your shoulder health.

Chapter 5:
Self Treatment Guide for Shoulder Separation

If you’ve got lingering shoulder pain following a nasty fall or direct blow to the shoulder, made worse by reaching across your body, you may have suffered a shoulder separation.

This is caused by the stretching or tearing of the ligaments of the AC joint.  It’s a common injury among hard-hitting sports like football, rugby, and hockey. Or it also shows up in everyday life due to an unfortunate accident.

While they can be painful injuries, that cause swelling and an odd looking shoulder, most will progress with time and guided therapy.  In this article, we’ll take a look at the types and plan of attack to help you get past your shoulder separation.

Know Your Grades and Recovery Timeline

Before going any further, let’s identify what’s going on.

Start by locating your collar bone and then trace it to where it meets your shoulder. You’ve found your acromioclavicular joint, or better known as the AC joint.

Notice the collection of ligaments that hold it all together.  It’s the tearing or stretching of these ligaments that cause a shoulder separation.

 

 

There are six categories of shoulder separation based on the size, structures involved, and type of displacement,

 

Grades I and II

 

These are the most common tears and caused by either a partial or complete tear of the acromioclavicular ligament.

 

While they are painful and may present with swelling and a bump over the shoulder, they most likely don’t need surgery.  They will return to normal within a few weeks to a couple of months with rest and exercise.

What to expect:

  • Grade I tears will need 1-2 weeks out of activity
  • Grade II tears anywhere from 3-6 weeks.

Grade III

Grade III separations involve the tearing of the coracoclavicular ligaments as well.  This causes a complete separation of the clavicle and shoulder. These are easy to spot by a stair step that is formed over the shoulder.

(Image Credit: Stack.com)

It’s a more complicated issue because there isn’t consensus within the medical community on the best way to manage a Grade III tear. Even with new surgical procedures, the outcomes are nearly identical with and without surgery.

So it’s logical to approach a grade III tear conservatively to avoid the expense and potential complications of surgery. But individual factors such as goals, competitive level, and sports activities need to be weighed as well.

This makes a consult with an orthopedic specialist worthwhile to determine the best course of action.

What to expect:

As mentioned, there isn’t a consensus on the best treatment for a Grade III separation. The standard procedure is 3-weeks of rest and rehab and then consider surgery if there is little improvement.

The rehab process is like the grade I and II separations, yet may demand up to 3 months before a return to activities.  It may also need more intensive strengthening to make up for the loss in stability. Again, another reason to get medical help for these injuries.

Grades IV, V, VI

The later grades (IV-VI) are less common and much more severe and usually caused by major impacts like car accidents. They are more advanced medical cases or even sometimes medical emergencies.  These will need surgery and don’t fall into the scope of this article.

Shoulder Separation Treatment Guide

If you want a general understanding of the treatment approach to a shoulder problem then read The Approach to Shoulder Pain.  It’s a nice overview of the plan of attack.

More specific to shoulder separation rehab uses the following treatment guide as a tool. This is directed at Grade I and II tears, anything more severe get it checked out.  

1. Screen

If you suspect an AC separation start with a screen for more advanced issues.  A quick run through our Red Flag Screen is a good start to pick these things out.

This is designed to identify things that need further medical evaluation.  Click here to take the screen: Red Flag Screen.

 

 

If nothing turns up there’s a good chance you can manage this on your own.  But if you’re ever in doubt, rest easy by seeing a doctor about your issue.

2. Address Pain

Start by addressing the pain. Because you don’t want to live in misery, but it will also get you moving quicker, which is important to the recovery process.

In the first few days, if you’re uncomfortable, try wearing a sling to ease some stress on the joint. Most people don’t require the use of a sling, but if you are really struggling with pain, this may help in the initial few days.  But you want to ditch the sling as soon as tolerated.

Ice is another good analgesic that will help with the swelling.  If you visited a doctor, pain medications would probably be recommended, but for this self-treatment guide, that’s under your own discretion.  

3. Movement

It’s important to start working on restoring movement as soon as possible following an AC joint injury. This will help speed up the return to activity and avoid other shoulder complications.

Initially, if you’re in significant pain or too afraid to move your shoulder, start with the basic pendulum exercise to help restore range of motion.

Otherwise, you’re good to go with basic rotator cuff work and scapula stability exercises below shoulder height. 

When dealing with an AC tear, reaching across the body and overhead are the most aggravating motions, but basic pulling movements are usually ok. For this reason, the Crossover Symmetry program would not be appropriate at first, but you can still use the equipment to do go through your recovery work.

Use the following recovery program 2-3 times per day to help maintain rotator cuff function and scapular movement.  It’s also important during this time to maintain thoracic mobility with foam roller mobilizations and side lying thoracic rotations.

Week 1 –

  • Start with the pendulum exercise if needed
  • 2 Sets of 10-15
    • Prone Scap Retraction
    • Prone Single Arm Y in a pain-free range
    • Banded rows at the side from a single attachment
    • Banded ER and IR in a pain-free range

Week 2-

  • You should have ditched the sling and pendulum exercises at this point.
  • 2 sets of 10-15
    • Banded rows at the side from a single attachment
    • Banded reverse fly from a single attachment
    • Banded ER and IR in a pain-free range
    • CS Scaption exercise to shoulder height
    • 5lb Shoulder Press

As pain decreases and range of motion improves start returning to your normal activities and use pain as your guide. Pain should be less than a 3 on a 10 point pain scale and should return to baseline within 2 hours following exercise or your activity.

As functional range improves, you will progress into the full Crossover Symmetry activation program to prepare the body to return to normal activities.  

Week 3-

  • Progress to the full Crossover Symmetry Activation program.  Start with a lighter resistance if needed.
  • Start integrating sport specific training but stay away from contact.

Week 4-

  • Continue with Crossover Symmetry Activation.
  • Return to contact sports if pain-free, but go through 2 full practices before returning to competition.

Long Term Recovery

Most shoulder separations return to full activity without any long term complications.

Although there are some cases of ongoing nagging discomfort.  For example, a study at the US Naval Academy shows 9% of Grade I tears and 23% of grade II tears continued to have pain that limited activity three and a half years later (ref).

A concerning statistic for anyone with an AC separation, but it highlights the need for ongoing care.

Continuing to promote scap movement and rotator cuff strength will help support and lessen loads placed on the AC joint.  For that reason, don’t give up on the Crossover Symmetry program once you are “healed.”

Using CS Activation daily will support the long term care for a number of shoulder issues for whatever your sport or activity might be.

References

1. Deans CF, Gentile JM, Tao MA. Acromioclavicular joint injuries in overhead athletes: a concise review of injury mechanisms, treatment options, and outcomes. Curr Rev Musculoskelet Med. 2019 Feb 26

2. Virk MS, Apostolakos J, Cote MP, Baker B, Beitzel K, Mazzocca AD. Operative and Nonoperative Treatment of Acromioclavicular Dislocation: A Critical Analysis Review. JBJS Rev. 2015 Oct 27;3(10).

Chapter 6:
How to Use Crossover Symmetry to Fight Frozen Shoulder

The worst part of Frozen Shoulder is the recovery timeline can drag out for many years with little way of knowing the prognosis.  But with an exercise plan like Crossover Symmetry, you’ve got a tool for a crucial part of the recovery process.  Although, the full scope of the issue is a bit more complex. 

We have had the opportunity to help address many shoulder issues over the years and frequently have people reach out to us hopeful that the Crossover Symmetry System can help with frozen shoulder.  Continue reading for insights into what is Frozen Shoulder and how best to manage it.

What is Frozen Shoulder?

Frozen shoulder, also known as adhesive capsulitis, is caused by inflammation and thickening of the connective tissue that surrounds the shoulder joint.  The underlying causes remain uncertain and even sometimes just appear out of the blue.

Although there is a higher incidence in people with diabetes, shoulders that have been immobilized for a period of time (often following injury or surgery) and women; (specifically, women who are pre-menopausal or menopausal.)  There is also mounting evidence that the condition is driven by low levels of systemic inflammation (ref).

Here is a rough timeline of frozen shoulder which is broken into 3 phases: freezing, frozen, and thawing. 

  • Freezing (2-7 months)  – During this stage, the shoulder is typically painful at end ranges of shoulder movement in all directions and often very painful at night. 
  • Frozen (4-12 months) – At this time stiffness primarily limits the shoulder.  There may still be some pain but it’s less than experienced during the freezing stage. 
  • Thawing (5-24 months) – The thawing stage is the light at the end of the tunnel, albeit it may be a long tunnel.  There’s typically minimal pain and a progressive improvement in range of motion. 

Depending on where you’re at in the process you’ll have different directives for treatment.

Getting Past Frozen Shoulder

The good news is that 90% of people with frozen shoulder will recover with conservative management strategies like exercise and stretching (ref).  However, it can be a long and frustrating road, especially for the active individual.

Here we’ll highlight the current best practices in dealing with frozen shoulder and help identify the best strategies for getting past it, and more specifically how Crossover Symmetry can support this plan.

During the Freezing Stage

In the early stage of frozen shoulder, the primary issue is pain.

NSAIDs and other oral steroids can be somewhat useful during this initial “freezing” stage.  They don’t provide a significant change in the overall recovery or duration of symptoms but do offer moderate pain relief.  It’s worth noting that long term use of NSAIDs and oral steroids are linked to stomach ulcers, weight gain, and have adverse effects on the liver and kidneys.

Another option shown to be more effective during the early parts of the freezing stage is Corticosteroid injections.  During this early stage, a cocktail of corticosteroids alongside a high volume dose of saline and localized anesthetics offer promising results.  Despite the risk of infection, the side effects are few, and it has better long term pain reduction.

During this time, aggressive stretching is counterproductive but gentle and light exercise in your pain-free range is a good thing.  An exercise program like Crossover Symmetry is recommended.  Although, stick with exercises that you can perform with little pain, and without having to compensate too much to achieve an adequate range of motion.

The best Crossover Symmetry options are usually:

  • Row
  • Pull-down
  • Reverse fly (with a modified range)
  • Scaption (just to shoulder height or pain limitation)

During the Frozen and Thawing Stages

Unfortunately, despite one’s best efforts during the freezing phase, most will spend some amount of time in the “frozen stage”.  During this time there is usually less pain but the shoulder remains stiff and range of motion is limited. Because pain becomes less of an issue, injections and other pain relief agents are not as effective.  Instead the focus transitions to more aggressive stretching and physical therapy.

Eventually, the stiffness will decrease and individuals will note an improvement in ranges of motion and little pain.  These changes mark a progression to the “thawing” phase.  Strategies encouraged during this stage include more aggressive stretching, physical therapy, aerobic exercise, and basic strength training.

So keep up with Crossover Symmetry as your range of motions allows, even trying the Strength program as mobility improves. This will help to limit the limitations caused by frozen shoulder and improve strength as you work through the issue.

Bringing Out the Big Guns

Despite injections, physical therapy, and pain medications, some will need more advanced treatment. If pain and limited range of motion persist for more than 6-9 months more advanced medical procedures may be indicated.

These are invasive protocols that aggressively attack the contracted shoulder tissue. Methods such as using anesthesia to put the patient out and then cranking on the shoulder, or more popular these days is arthroscopically cutting the capsule.

Of these more advanced methods, they do show good results but create lasting changes to the shoulder structure. Therefore, these options are a last-ditch approach in treating the condition, especially for one who hopes to return to more strenuous activity.

Crossover Symmetry for Frozen Shoulder

Unfortunately, there’s no slam dunk for frozen shoulder.

There is a lot that remains unknown, paired with the fact that each episode is unique, so what works for one may not help the other.  Although what we do know is that movement is an important part of the recovery process for any ailment.  Read here why people in pain need movement.

Specifically for frozen shoulder here is a quick take-home summary of a plan to help you get past the issue using your Crossover Symmetry System.

Frozen shoulder has 3 stages:

  • Freezing – The primary issue is pain with some restrictions in range of motion.  Corticosteroid injections and high volume injections may be useful during this stage.  This is not the time for aggressive stretching or strength training, but some light use of Crossover Symmetry exercises is beneficial for reducing the pain and limitations.
  • Frozen –  Some pain may still be present but a loss in a range of motion is the primary limiter.  More aggressive stretching and a shoulder strength program like Crossover Symmetry (but with modifications for the limited range of motion) are important during this stage.
  • Thawing – In the final stage, the shoulder range of motion progressively improves and pain is usually minimal.  Keep up with aggressive stretching and you can progress your resistance training within your available range of motion.

I hope this is helpful in getting past your issue of frozen shoulder.  Please send any questions my way at matt@crossoversymmetry.com. I would be more than happy to support you in the recovery process.

Chapter 9:
Stress, Pain, and Stiffness

We get comments like this all the time…

"There are always knots in my traps"

or…

"My traps are super tight, and I cannot stretch them enough"

Along with these complaints, there's also stacks of research implicating the upper traps as the driving force behind shoulder pain.

But we should stop thinking of the upper ‘Trap' as a four letter word.

It's not the bad guy in the relationship… It's just misunderstood!

This article will shine some light on this common complaint, and give you a better plan to fix the issue.

First…What is the Trapezius?

The trapezius has 3 distinct groups of muscle fibers that align in different directions. This divides it into upper, middle, and lower sections.

Based on their origin, insertion, and fiber orientation, when working alone (no muscle ever works in isolation, but muscles do play more dominant roles) each section plays a different responsibility in stabilizing and moving the scapula.  Considering individual muscle actions:

  • The Upper Trapezius elevates the scapula, which creates a shrugging motion.
  • The Middle Trapezius retracts the scapula, or squeezes the shoulders blades together.
  • The Lower Trapezius depresses the scapula, which pulls is the scapula down.

But often left unrecognized, is how trapezius works synergistically with other muscles to produce more complex movement patterns.  For the trapezius, it's got an important role in rotating the scapula upwards.  Essential to any action that requires lifting the arm.

See below how the upper trap, lower trap, and serratus anterior work together to pivot the scapula. This is important to maintain space within the shoulder joint (i.e.-avoid impingement), but also create a stable position for the arm.

Related to this balance, the upper trap is often blamed for overpowering the balance of the other shoulder stabilizers (ref, ref), which leads to shoulder pain and faulty movement of the scapula—a condition called scap dyskinesis.

Dealing with Pain and Stiffness

Pain and stiffness of the upper trap is a common complaint, often paired with high stress and long work hours.

Notice that any mall or airport these days has a booth staffed with massage therapists ready to work on those tight trap pain points.

The underlying issues behind this pain and stiffness is diverse, not to mention complex and controversial, which we will almost certainly tackle in future articles.  But for now understand that the unpleasant sensations are perceptions.

They're formed by messages traveling to the brain from the body, which the brain then translates into feelings of discomfort, tightness, or pain.

Techniques such as massage, foam rolling, and stretching can effectively alter those perceptions.  Which is a good thing, because it often means relief from nagging discomfort.

However, these are usually temporary changes, that don't necessarily address the stimulus—leaving pain to return once again later on.  

The point being, if you've had a long and stressful work week, find some relaxation with a massage.  Or if you're feeling tight after a long flight, a massage ball may be useful.

But if these are regularly scheduled things to deal with chronic pain and tightness, you're barking up the wrong tree.  

It's time to look at the underlying causes to the recurrent problem.

Carrying the Load

The usual suspect for the faulty upper trap is the everyday desk posture, which can mean that can be either shortened or lengthened for hours at a time. Or heavy workouts can make the traps knotted and sore, especially if they include an overload of heavy pulling exercises.

While correcting posture and workloads can lessen the symptoms, there are bigger and often unaddressed things underlying the issue….

That is the the upper trap has a weak supporting cast.

As discussed earlier, the action of the upper trap combines with the serratus anterior and lower trapezius to create upward rotation of the scapula.

The serratus anterior and lower trapezius are notoriously weak and lack proper neuromuscular control.  With these muscle groups underperforming, something has to step in to carry the load. That is the upper trapezius, which must overwork to makeup for the inability to create upward rotation.

So rather than continuing to hammering the upper trap with mobility, try working on building a better movement system.  A system where muscles effectively move together, contracting and lengthening in coordination with each other.  Specifically for the upper trap, this means improving the balance for upward rotation of the scapula.

How to Create Better Balance

When working with people on Crossover Symmetry, there's often the tendency to shrug with many of the exercises.  That's because the upper trapezius is doing what it's been told to do… carry the load.

The first step is recognizing that it's happening.  Pause at the end of the movements, check into your position, and relax the shoulders down.  At first it feels awkward or even impossible, but overtime the need to reposition will lessen. And with work, strength and motor control will improve and shrugging will be easier to recognize and correct.

In this Crossover Tip we show some some easy correctives for the shrug when using Crossover Symmetry: [LINK]

But if you continue to struggle with the shrug, or find yourself in discomfort without your Crossover System on hand to fix it, here are some additional correctives to try out…

(Notes: For the Thoracic Flexion & Extension exercise work on the movement of the scapula around the rib cage).

(Notes: For the Prone Sphinx, when reaching the scapula should rotate around the body, moving under the armpit.)

(Notes:  For the L-Sit, keep the sets short, but the intensity high.  Drive the shoulder blades down and around the body.  Rest when you feel shoulders lifting up into the ears.)

The Upper Trap Fix

So next time you feel like your upper traps are tight, skip the stretching and give them a dose of movement.  

Doing things like Crossover Symmetry will work the muscles that both oppose and complement the the upper trap, which will create feedback to the whole shoulder complex to be more active where it's needed, and to relax where it's not.

And over time this new found strength and balance will lend itself to better shoulder function and the elimination of tight traps and painful shoulders.

But stop trying to stretch the problem away!  Instead use exercise to strengthen and create a different motor program for your shoulders.  

Chapter 10:
The Approach to Shoulder Pain

"Improvise, adapt, and overcome…"

The unofficial mantra of the United States Marine Corps and an important mindset for anyone looking to overcome an obstacle….and certainly applicable to getting past pain and injury.

Let's dive into an understanding of what's needed to overcome a shoulder problem, specifically when surgery is not an option, or the last resort.

The Initial Step to Healing

It shouldn't be a surprise that continuing to hammer the same painful movements is not an effective solution for pain.

Therefore, the fundamental first step is to deload the painful tissue…best known as rest!

Although rest by itself actually a poor solution to pain!

That's because it doesn't support the most difficult part of the healing process— fighting the urge to return to max effort as soon as possible.

There's not an athlete in the world who wants to sit back while their injury heals!  Watching their hard work and effort go to waste! Any effective shoulder fix must address this and get away from the mindset of rest.

Instead create compensations to maintain activity levels.

These things keep performance moving forward, while lessening the engagement of painful tissues.  This facilitates both physical and psychological success to get past the shoulder pain.

Examples of compensations are:

  • Movement modifications,
  • Taping techniques,
  • Avoiding specific painful stimuli and positions,
  • and workload modifications

For more information on this, take a look at our shoulder scaling guide.  It provides many effective ways to train the shoulder despite injury limitations.

Creating a Cure

As much we would like to profess to the magical band powers of Crossover Symmetry, healing is largely a natural process.

Demonstrated in a 2004 study in the Journal of Shoulder & Elbow Surgery (ref), which showed wearing a brace with activity modification was as effective as many weekly physical therapy sessions for treating shoulder impingement syndrome.

Despite this evidence, sitting back with a brace is far from the most effective healing plan. It does not address the strength, mobility, and coordination problems that may have led to the original injury.

Another look at the previous research reveals a short term study only considering pain levels, and not return to function, recurrence rates, or life satisfaction.

Thus, the next consideration for healing is remediation— derived from the latin word remediare, meaning to heal or cure.

Remediation first addresses impairments underlying shoulder issues. Correcting things like poor cuff strength, scapula control, and thoracic mobility creates a better environment for healing to happen and is essential to preventing pain from returning.

Remediation also involves gradually introducing load to painful tissue in a controlled manner. This builds the capacity to withstand the previous activity demands, beneficial to both meeting performance goals and avoiding shoulder pain recurrence.

Even structures that do not heal (e.g.-labrum, some rotator cuff tears, ligament tears) can return to full capacity through remediation. By improving strength and dynamic control of the shoulder, it removes loads and stress on the damaged area.

Many athletes can cover up their issues and continue to perform at high level despite permanent structural changes. For example, research shows up to 80% of major league baseball players continue to compete with a torn labrum (ref).

To further support this, we've seen many Crossover Symmetry users cancel their surgery and remain pain-free, despite things like rotator cuff and labrum tears.

Showing that a comprehensive plan of both compensation and remediation, known as relative rest, can alleviate most pain and keep a person moving towards their goals long term.

Healing Without A Cure

Unfortunately, some issues are beyond remediation and compensation.

A clear example would be a spinal cord injury, resulting in paralysis.

No amount of training can overcome this injury, yet adapting to the disability can restore life activities that bring joy and satisfaction.  

Thus, despite a cure, adaptation is a form of healing.

Not all adaptive situations are this limiting or permanent either. For example, there are plenty of workarounds for dealing with an arthritic shoulder, or severe tendinosis which can take up to 9 months to completely resolve.

Ultimately it requires being smart with training and activities to continue pursuing goals.  Whether it be adaptations around permanent limitations, or short term adaptations to stay invigorated while long term healing runs its course.

For example, it's very possible to be strong, athletic, and look great naked without doing squat snatches or muscle ups.  You can go out and enjoy 18 holes of golf (and for most shoot the same score), without full swings off the tee box. And even for something as shoulder intensive as swimming, a great swimmer can be made by drilling mechanics, body position, and carefully prescribing volume.

If adapting or avoiding these movements is not an option for life enjoyment, it may be time for a surgical consult.  No doubt there are situations when surgery is the best solution. It often has remarkable results that completely resolve pain and limitation.

Although surgery does have many drawbacks, it's not the solution for everyone, and should ultimately be the final approach.  We get more in-depth on the decision making for surgery here: Important Considerations Before Going Under the Knife.

How to Approach Shoulder Pain

In dealing with shoulder pain, use the healing strategies outlined above.

Compensation- Find a Work Around

Remediation- Find a Cure

Adaptation- Find an Alternative

Start by creating a plan of relative rest, using a combination of compensation and remediation.

If you are following the Crossover Symmetry Shoulder Program, we help guide this in our training and education on the Training Zone.

And you can learn more about our plan here: 30 Day Shoulder Fix.

Then after 30 days reevaluate how things have improved.  If pain is gone or continuing to improve keep moving forward!

If things are not getting better, this will require some self analysis to understand what's most important to you. It may be time for more advanced medical procedures, or to create adaptations to satisfy activity cravings, without wrecking your shoulders in the process.

All the best on your road to recovery, however long that may be!  And if you ever need help along the way, please reach out to us at
support@crossoversymmetry.com.