The Shoulder Girdle

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There is perhaps no joint in the human body as complex, fascinating, or baffling as the shoulder. It can leave clinicians scratching their heads, wondering why a problem they have solved many times before is this time so stubborn. And shoulder problems can certainly be difficult That’s why, in every case, prevention is so much better than cure.

A golfer’s shoulder would not be normal if it did not have niggling pain, while many have a history of a significant shoulder problem.

Shoulder injury management, and some DIY home injury prevention and performance enhancement techniques. will help all players.

Preliminary precautions

If you have a shoulder injury and would like to try to treat yourself, please remember:

  • It would be wise to rule out structural damage first, via X-rays, CT-Scan, US Scan or MRI, particularly if your shoulder joint experiences sharp catching pains, locking sensations, clunks, pins and needles or numbness, looseness or laxity, or the history of the injury was in any way traumatic, involving body contact or a fall.
  • The length of time it took to develop your problem will give you some indicator of how long you will need to persist with correcting the faults before the results will be felt. Don’t forget, as I’ve said, that the pain is often only the tip of the iceberg, directing you to the real issue.
  • However intelligent and self-aware you are, you will probably need the help of professionals – for treatment, guidance, feedback and motivation.
  • Some treatment ‘pain’ is allowed, but only really what is associated with muscle fatigue as opposed to soft-tissue strain (therapeutic massage is an exception: no pain no gain!).
  • If you are already training and competing at a high level and have no difficulties with your shoulder, then be extremely careful how many new exercises you take on during the competitive season. It’s better to wait until the off-season to make sure you don’t overload your shoulder or throw it off balance by adding new demands.

Treatment, prevention and performance enhancement

The advice that follows relates to the prevention and treatment of overuse injuries of the shoulder, not the management of acute or traumatic injuries such as glenohumeral dislocation, clavicular fractures, or tears of the labrum (‘cartilage’). However, the broader principles of rehabilitating a shoulder that has been surgically repaired, or been stuck in a sling for four weeks, are no different, although there may be restrictions and time constraints imposed by orthopaedic surgeons.

The most important principle of shoulder management is: start working on it now. Don’t wait until your shoulder starts to hurt! But, in addition, the preventative measures outlined below are guaranteed to improve your performance – they will genuinely improve the way your shoulder works, and thus it will be stronger, more coordinated, reach further and last longer before fatigue sets in. All the experts say it: injury prevention equals performance enhancement.

Some simple anatomy of the shoulder complex

The shoulder joint actually comprises four joints – see if you can feel them on your own body:

  • Sternoclavicular (SC) joint (between the sternum and the collar bone) – this is actually the only bony connection that the shoulder has with the main skeleton;
  • Acromioclavicular (AC) joint (between the collar bone and the point of the shoulder called the acromion, which is part of the scapula or shoulder blade);
  • Glenohumeral (GH) joint between the glenoid part of the scapula – the socket – and the head of the humerus (HOH) – the ball; and the
  • Scapulothoracic (ST) joint (the ‘false joint’ between the scapula and the rib cage that it rides over).

The GH joint is the most susceptible to injury as it is entirely dependent on non-bony connections for integrity. Whereas the hip joint (also a ‘ball and socket joint’) has a deep socket formed by the bone of the pelvis, the GH joint relies on the balance, strength and control of muscles, ligaments/capsule and labrum (cartilage) to function properly. The labrum acts like the edges of a skateboarding rink in preventing the HOH from spinning/sliding too far from the centre as it acts to deepen the socket. In an attempt to describe the delicate balance of the HOH sitting on the scapula, the GH joint has been likened to a seal balancing a ball on its nose.

The rotator cuff muscles

Without learned muscle control, any overhead activity, let alone just lifting the arm, would be impossible – the GH joint would dislocate or the HOH would jam under the arch of the acromion. The muscle group we rely on for this control is the rotator cuff (RC) muscles – the infraspinatus, supraspinatus, teres minor, and subscapularis muscles (an anatomy book will show where they lie). They all originate from the scapula and are coordinated together to keep the HOH spinning/rotating as close to the centre of the glenoid as possible with movement. The long head of biceps tendon running over the front of the GH joint also has a stability role to play in conjunction with the RC, especially with the throwing action.

The muscles primarily designed to position the scapula for overhead movement are the trapezius (especially lower trapezius), and serratus anterior – called therefore the ‘scapular stabilisers’ – with counterforces being produced by levator scapulae, rhomboids and pec minor muscles.

The larger and more powerful muscles that generate movements of the arm are the deltoids, latissimus dorsi, and pectoralis major. So while the RC muscles coordinate the proper positioning of the HOH by acting close to the centre of the joint (the ‘inner core’), the larger muscles with long lever arms move the arm with speed and force (the ‘outer core’).

The five ingredients: balance through control

Let us now unpack what could be considered the five most essential ingredients for an athlete whose main weapon is the shoulder:

  1. Sports-specific technique
  2. Flexibility
  3. Core stability
  4. Rotator cuff control
  5. General strength

The primary goal of these five areas of intervention is, in a word, balance. And the way to achieve it? Control. The higher your levels of performance, the greater the control required to maintain balance – just as a Formula 1 car needs much higher levels of balance and control than does a standard road car. A deficit in any one area will ultimately cause muscle imbalances to develop, which lead to soft-tissue breakdown and later even joint degenerative change. Picture a bike wheel where one spoke in the wheel is bent out of shape: a gradual warping takes place with use which creates an imbalance that further damages other spokes until the whole system comes to a grinding halt.

The more elite the athlete, the more committed he/she needs to be to getting professional help in fulfilling and maintaining these principles. You will also save yourself much time and anguish if you seek experienced help as a preventative measure, rather than only asking for treatment once the problem has surfaced. Having a regular tune up/ service can be done in the form of screening, where a sports-experienced physiotherapist will run you through a series of tests to find out if any of the areas below are not being adequately dealt with.

1. Golf-specific technique

Poor performance and shoulder pain very commonly originate in bad habits of technique. Often they are only clearly seen when muscle fatigue sets in. However, a good coach will be able to pick up when this is happening and realise it’s time for rest and recovery.

As a general rule, technique work should be done after a thorough warm-up (or even as part of a warm-up), while the muscles and the brain-connections are still fresh and strong. On the other hand, when fatigue sets in can occasionally be a good time to do specific drills that do not load the shoulder, yet will reinforce good movement patterns. The only proviso is that one must be extra diligent to see when compensation strategies are setting in, and call a halt immediately.

Without wanting to state the obvious, practice is the key! Once you have mastered a new aspect of technique it must be repeated around 10,000 times before it becomes engraved on your brain, in other words, the point at which the movement pattern becomes subconscious and feels ‘natural’.

There are many ways to find out if your technique is faulty, but one of the best is video recording in order to slow down the action and break it into smaller components. The better the technology, the better the result, but for real value it comes down to the experience of the person evaluating the picture. Using a mirror is rarely effective since the position of the head focusing on the mirror can greatly affect the shoulder position. The two most important sources of feedback in this regard are your coach and a biomechanist, and often a sports physiotherapist who has had a lot of experience in your sport.