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  • Kris Krotiris

Shoulder Pain and Posture: Is There a Connection?

A man doing a weighted pull up with chains around his back

Many people spend their workdays seated at desks or handling tools. Similarly, leisure activities often involve computers, television, or the use of smartphones and tablets. It's a widespread belief that poor shoulder posture leads to shoulder pain, an ailment likely contributed to by the above mentioned activities. But is the belief of shoulder posture as a cause of pain justified?

The picture below is a common example of a rounded shoulder, a postural deviation where the shoulder rolls forward, often indicative of a muscle imbalance. This position typically involves a protracted scapula, where the shoulder blade sits excessively away from the spine, and an anterior tilt, where the scapula tilts forward excessively. Historically, this rounded posture, as well as numerous other variations in shoulder posture (e.g. the downwardly rotated or elevated scapula) have been thought to result in a less efficient biomechanical position of the shoulder joint which in turn influences the strain on specific structures in and around the shoulder.

A picture of an anteriorly titled and abducted shoulder posture

Does it really matter?

Historically, therapists with a biomechanical focus have argued that there should be a direct correlation between this increase in strain and injury risk, therefore details such as scapula/shoulder alignment are of critical importance. More recent research however presents a murkier picture. The ongoing debate now considers whether the focus should shift to enhancing the resilience of the primary load-bearing muscles around the shoulder through more generalised resisted exercises instead of attempting to alter shoulder posture itself through specific targeted exercise of postural muscles. Two conflicting points to consider within this debate are:

  • Cueing of the muscles around shoulder to move the scapula into a more neutral posture changes muscle activity and favourably influences the distribution of load around the shoulder joint and;

  • Interventions which focus on exercises to improve scapula posture in patients with shoulder pain may not offer any additional benefit interventions that focus on general shoulder loading exercises

What does this mean?

Both points hold significance, highlighting that the factors contributing to shoulder pain and its solutions are diverse and individualised. When considering the impact of posture on pain, it's essential to take into account:

  • The influence of physiological stress on tissues and the body's capacity for adaptation;

  • The role of psychosocial factors in pain perception, including how stress and social contexts affect pain experiences.

Illustrating a common scenario for the onset of shoulder pain can provide a clearer understanding. In situations where the shoulder is subjected to heavy or repetitive strain, the imposed load may surpass the body's capacity for adaptation, potentially resulting in discomfort or injury over time. Contributing factors include:

  • The physical demand placed on tissues by the task itself, such as the weight and repetition of the activity;

  • The biomechanical efficiency of the shoulder joint and its impact on tissue strain, such as how rounded shoulders might alter the distribution of load, leading to increased strain on specific structures under the same external load.

  • The body's recovery capabilities from such stress. Factors like insufficient sleep, suboptimal nutrition, and health conditions like diabetes can impede the tissue's recovery process.

So with all this in mind, the question of whether there is a link between shoulder posture and pain cannot be answered with a simple 'yes' or 'no'. It is essential to appreciate the multifaceted nature of shoulder pain and injury. Yes, posture may influence the strain the tissues are placed under, however if this happens over time and the body is able to adequately adapt, this may not be of concern. In this sense, the intricacies of biomechanics do play a role; however, they represent just one piece of a larger puzzle. The cumulative effect of lifestyle factors, such as inadequate rest or nutrition, can compromise the shoulder's recovery capacity, potentially exacerbating the risk posed by any postural imbalances. Therefore, an integrated approach that considers not only mechanical corrections but also the enhancement of overall tissue resilience and health may provide the most comprehensive strategy for managing any potential injury risk associated with postures like rounded shoulders.

'Improving' Shoulder Posture

The importance of improving shoulder posture should remain a consideration, although not in isolation. Since certain shoulder postures may increase the strain on specific anatomical structures, in the presence of an injury or pain, modifying shoulder posture may reduce tissue strain on these areas which can have a significant and often immediate impact. So, what steps can we take to move towards more optimal shoulder postures?

  • Re-educate Muscles: In the case of a rounded shoulder posture, training the muscles around the shoulder to achieve a degree of posterior tilt and/or adduction while performing any strenuous or repetitive tasks should be considered, especially if such a posture results in immediate symptom relief. An example of this postural correction can be seen in the picture below.

  • Strengthen Key Muscles: Focus on strengthening the muscles that facilitate this neutral posture. A skilled sports physiotherapist assessment can help in identifying areas of tightness or weakness. Commonly, the lower and middle trapezius and serratus anterior are underdeveloped- an effective exercise for engaging these muscles is shown below with the Y-Hold exercise.

A mans shoulder posture

Building postural strength/endurance

The Y-Hold exercise is very effective at activating and strengthening the lower trapezius, an important muscle involved in achieving and maintaining a neutral shoulder posture as discussed above. See the pictures and steps below on how to perform this exercise correctly. The arms should only be lifted to a point where control is maintained, muscle activation is felt between the shoulder-blades and not at the front of the shoulder.

A man demonstrating a Y-Raise exercise

Take Home Message

Addressing shoulder pain requires a multifaceted approach that goes beyond correcting posture alone. The most important consideration should remain load management and the body's ability to tolerate and recover from strain. Secondary to this, re-educating and strengthening postural muscles play an important role within a rehabilitation program and should not be overlooked. Together, these elements form a comprehensive plan aimed at not just mitigating pain but also at preventing future injuries, supporting a healthier, more resilient musculoskeletal system.

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