On this episode of the #AskMikeReinold show we talk about the shoulder shrug sign and the many possibilities why this occurs. Once you learn these, you’ll have no problem figuring out how to best deal with these when they occur. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 230: Why Do People Have a Shoulder Shrug Sign?
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Show Notes
- Correcting the Shrug Sign After Shoulder Surgery
- Assessing the Shoulder Shrug Sign
- Special Tests for Rotator Cuff Tears
Transcript
Student:
All right. So Anthony from California asks, “Why after post-op shoulder surgery do my patients have issues with glenohumeral separation or early scapular upward rotation?”
Mike Reinold:
Oh, I like that Anthony. And I like how you actually put those two things in there. That was kind of interesting.
Mike Reinold:
So after shoulder surgery, and we can probably talk about this post-op and not post-op too, although post-op tends to differ a little bit. But why do people have issues with glenohumeral separation? So what I’m getting from that is separation in the humerus from the scapula. Maybe they’re elevating together and it sure looks like maybe there’s some excessive early scapular upward rotation. I like this. This is a good question. And there’s more than one reason, right? So who wants to start? Dave? Would you like to start this one off?
Dave Tilley:
Only because I literally had a case yesterday where it was applicable. Yeah. So I had a young gymnast who is doing something and she essentially got her arm caught behind her when she was landing and hyper extended her shoulder and she had a pretty gnarly brachial plexus injury. And she’d been through a lot of PT and stuff like that. But I think just the basic soft tissue flexibility was overlooked unfortunately. They were working a lot on her clavicle and her neck was hurt, But she had a significant amount of soft tissue stiffness under her arm because her arm was in a sling for awhile because it was propped up to decompress the area. But also she just hadn’t used her arm in a really long time and so she had an enormous amount of teres major and lapsed manisca that I think kind of went under looked and she had great caps on mobility, super lax, but she just hadn’t used her arm overhead in a long time.
Dave Tilley:
So as we know, the teres major attaches right to the scap and I think some research shows that the lat can have a pretty good attachment as well on some people. So if you lack basic soft tissue motion and you try to raise your arm overhead and you can’t get the separation, it’s going to tug the scap along for the ride. And that was giving her a lot of occlusion pain. So just basic soft tissue mobility, I think is sometimes easy, but you know, missed.
Mike Reinold:
I like it. Are we going with occlusion pain now? Is that a thing?
Dave Tilley:
Is that a thing? I just made it up.
Mike Reinold:
Did we get rid of impingement because we can’t say impingement anymore? You get-
Dave Tilley:
Well it was thoracic compression. She had tingles not pain.
Mike Reinold:
All right. I’ll give you that. So now is there any chance she had some nerve stuff going? Was that part of it?
Dave Tilley:
Yeah, well, she definitely did. So we tested that active range of motion. You know, I was worried about some serratus or neural damage, but passively, she had really good motion up to a certain point. So there could just be a straight up weakness, but she was nine months out of the injury. So sensitivity was there.
Mike Reinold:
Oh.
Dave Tilley:
She had some allodynia if you’re into that world, but it wasn’t like she had an overt muscle wasting.
Mike Reinold:
All right. So that’s a great way to differentiate too with the nerve type thing too. Is that it was very chronic. So it’s not like she had just a quick traction injury of the plexus. I liked that one. And she didn’t have some wasting atrophy, so that’s a good one. So, all right. So that’s a good example. That’s somebody that’s super loose, right? We have a lax patient, somebody that has a lot of mobility and for some reason she was vulnerable to this. So she just had some soft tissue stuff, maybe some guarding, some self restriction, some mobility concerns just for prolonged positioning in there. And man, that teres major. Like Dave says the thing gets gnarly, right. That thing gets really dense and contracted. It seems like it’s one of those muscles that really tends to contract in my mind.
Dave Tilley:
It was one of those cases. But I got lucky where I worked on it and she got 10 degrees of elevation better. It’s not going to stay. But she was like, whoa. Right.
Mike Reinold:
And you know, it’s hard to say this, but I think I’m close to feeling this way, but I feel like non-operatively, that might be one of the bigger reasons that I see this is that somebody has soft tissue restrictions that is maybe limiting humeral elevation. So that way then the scapula just goes up because remember your brain and your body is just trying to get your arm over your head. It doesn’t really care how it does that. Right. So if it needs to move the scapula more because the humerus isn’t moving. Fine. Right. And that’s kind of what’s thinking. So that’s a good one. We’ve got some soft tissue tightness who wants to throw one into the ring? Leonard?
Lenny Macrina:
I will. I will. And it kind of goes off of Dave, the girl he had recently, because I happened to get the MRI results emailed. And she had also a rotator cuff issue. Which goes into what I will say is another option to look at, especially in a post-op shoulder, is the status of the rotator cuff.
Lenny Macrina:
So this girl who was very young not to give away too much detail, she had a rotator cuff, what they’re calling a rotator cuff tear in her shoulder. So if this rotator cuff is not functioning well or if there’s some kind of issue to the rotator cuff, you’re not going to be able to raise your shoulder up as easily as if the rotator cuff is attached well. Right? So in a post-op shoulder, the rotator cuff is repaired or there’s some kind of issue to the cuff it was irreparable. You’re not going to get the normal arthrokinematics going on in the shoulder. And you’re going to get that superior migration of the humeral head, which looks like this when somebody tries to raise their shoulder up. So what’s the status of the rotator cuff in that person that had shoulder surgery? And I would say, it’s probably healing, needs to get strong or it’s not doing well. It needs more work.
Mike Reinold:
Right. And you know, oftentimes, you could have a full thickness cuff tear of your superspinatus. If you’re anterior and your posterior cuff are strong enough to stabilize, you can still somehow elevate that arm without a shrug sometimes.
Lenny Macrina:
Yeah.
Mike Reinold:
But not always, right.
Lenny Macrina:
Right.
Mike Reinold:
So it could be weakness could be a cuff tear like her. By the way, Dave totally left out a big piece of that puzzle in your story.
Dave Tilley:
I didn’t want to steal too much thunder.
Mike Reinold:
All right. Good, good. That’s a good point. You actually had someone that has every reason.
Dave Tilley:
I didn’t want to in to the capsular things.
Lenny Macrina:
That MRI showed up at the very end of the session, I was like, hey, by the way, you get an MRI right here. Oops.
Mike Reinold:
And that changes everything going forward. So that’s a good one. So, we got some soft tissue tightness. We have rotator cuff dysfunction and/or tearing. And you can have either of those that could potentially limit that. So again, maybe your rotator cuff isn’t stabilizing, you’re either superior migrating or maybe the humerus isn’t going up and your brain just says, I got to get my arm up. What does it do? It upwardly rotates your scapula more. It gets it up there more. I like that.
Mike Reinold:
Who else? I think Dan had maybe another one did or did Lenny steal your thunder?
Dan Pope:
No, I mean, I can talk about this one too. So I guess Dave’s talking a little bit more about stiffness of the lats and teres major. Of course it could be the capsule as well. Right? So if you don’t have good motion coming from the shoulder joint itself, you’re going to try to make up that motion. That’s coming from shoulder blade instead. And the last one, and I think it’s mostly obvious post-op, is pain. Pain’s a big one. You know, if one third of your motion is supposed to be coming from your shoulder blade and two thirds is supposed to come from the shoulder joint and the shoulder joint just hurts like heck, you’re probably going to move more through the shoulder blade. So we think, okay, the upper trap is too active, but maybe the upper trap is trying to help you out because your shoulders too weak, too painful, too stiff, whatever reason it is.
Mike Reinold:
Right. That’s excellent. That’s actually a really good point too, that sometimes we don’t give enough credit to if it just hurts to move your humerus. You might even have osteoarthritis of the shoulder joint. Right. Or you may have something going on that causes some discomfort. And then they, again, just want to get their arm up overhead. I like that. And then obviously the capsular stuff. And you said it quick probably because in your head it’s pretty obvious, but maybe not for everybody, is if you have capsular tightness. An adhesive capsulitis, frozen shoulder type thing that obviously you’re not going to be able to get the normal motion of the glenohumeral joint and you’re going to be stiff and your scaps going to go even more.
Mike Reinold:
Now postoperatively what I would add too, is that if you’re having a stabilization procedure. So if somebody that has a capsule repair, labral repair or something like that, a capsular shift, anything where we’re actually working on decreasing the capsular mobility. So we’re trying to treat instability then oftentimes that can be over-tightened right?. And that can be excessively tightened. And then what happens is you don’t have the normal arthrokinematics of the glenohumeral joint.
Mike Reinold:
So to go back to the original question from Anthony, I think pain’s a good one that Dan said. I think rotator cuff dysfunction is a good one that Lenny said. And then I would add just the specific capsular tightness from the surgical procedure maybe limiting it. And remember the brain just wants to do what’s easiest. It wants to take the path of least resistance.
Mike Reinold:
So sometimes if you’re seeing this, it’s not necessarily a bad sign. Sometimes you may just have to do just a few simple things to just teach them or work on something and get them on a little bit of pain. And then all of a sudden it’ll get a little bit better. They’re just taking the path of least resistance. Make sense? So I think it was good. I think we nailed it. I think we covered the vast majority of reasons. I mean, there may be some other ones out there, but I think those are going to probably cover 99% of your people that have a shoulder shrug. So, great question.
Mike Reinold:
If you have anything like that, career advice, PT, fitness, strength, condition, sports, sports, anything you guys want to talk about head to mikereinold.com, click on that podcast link. And as always, please, please, please keep spreading the word. Share this with your friends. Share it on Facebook and Instagram so we can get the word out. That would be awesome. And we’ll see you on the next episode.
Mike Reinold:
Thank you.
