What causes a dropped shoulder?
Why do shoulders drop? Many of my patients come in complaining of neck and shoulder pain on the side of a shoulder that isn’t raised, but actually dropped. In fact, I’d say it is actually more common to have pain on the side of the lowered shoulder than on the side of the raised shoulder.
When the shoulder drops on one side, these muscles, namely the scalenes, upper trapezius and levator scapulae muscles, are what we would call “locked long”- or, in other words, locked in stretch. They have a hard time shortening. Stretching rarely helps these patients, as the muscles are clearly already under stretch! They feel like they need to stretch it all the time, and feel great for about 5 minutes when they do so, and then the pain returns.
Because of the traction-compression effects of having a dropped shoulder on the long thoracic nerve and dorsal scapular nerve as they pass through the middle scalene, these patients tend to also present with weakness of serratus anterior, levator scapulae and the rhomboid musclces. In other words, they develop a winged scapula: a shoulder blade that protrudes outwards and that sits too far laterally. They hate doing push-ups because they get pinchy wrists and a sore neck and shoulders because they can no longer stabilize their shoulder blades well enough. The effects on levator scapulae further exacerbates the dropped shoulder issue, as levator scapula is one of the main shoulder elevators. They also develop grip strength loss when their arm is lowered because of the traction effects on the nerve roots coming down into the arm. However, their grip strength returns when they lift their arm overhead, as the first and second ribs are elevated and traction is taken off these nerves. For this reason, they love doing chin-ups and overhead presses and find their grip is weak when they do dead lifts or kettle bell swings. They may even develop a clicky shoulder on the downward part of a swing or press.
They often complain of nerve pain or just uncomfortable tension down the back of the arm when they set-up to do things like a bench press and they sometimes present with a non-specific pain around the back of their shoulder blade and into their rib cage on that side (areas innervated by long thoracic and dorsal scapular nerves). They might also develop tingling down their arms and into their fingers if certain nerve roots are affected.
They lose segmental control of their neck and do great, big, sweeping movements of their head instead. They also lose their normal range of motion in the neck: they ‘head dump’ when they side bend, they lose rotation, they create a forward head position, they lose the normal cervical lordosis, they hinge all at C5/6 and C6/7 so these segments become unstable and then eventually degenerate. They chin jut at CO-1 and C1–2 (their upper neck) because they need to keep they eyes on the horizon somehow, which causes overactive suboccipitals and very often eventuates into headaches, jaw pain and even snoring or sleep apnea.
And all these patients’ symptoms are exacerbated in times of stress and anxiety.
Like so many things, it needs to begin with optimizing the breath. My patients get sick of me harping on about breathing, but no one has yet been able to point out to me another musculoskeletal function that takes priority (besides keeping your heart beating, which runs on it’s own circuitry and is still regulated via breathing anyway). When we talk about movement, your ability to get oxygen in is the one thing your body will never sacrifice. It’s really the only thing it cares about when it comes to movement. You can’t thrive if you’re barely surviving, and the same can be said about breathing. You can’t optimize your movement patterns and thus performance if you do not have adequate control over your breathing. If you can’t breathe, your body really doesn’t care how fast you want to run or how far you want to throw something, it will floor you until it feels as though it can get adequate oxygen supply in to the tissues. Ask any asthmatic.
If it doesn’t completely floor you, it will at the very least rob you of your ability to create power by using power-generating muscles for breathing instead, limiting your performance and setting you up for dysfunction and injury. This is exactly how a dropped shoulder is set up.
99% of people with a dropped shoulder will also have a pelvis that is dropped on one side. When you watch them breathe, you’ll see that the breath will expand on only one side of the abdomen, or not into the abdomen at all. In other words, they nearly always have an intrinsic core issue, either on one side or both sides, limiting their ability to move the lower ribs and diaphragm to create good biomechanical breathing. As they inhale, you will also notice excessive expansion into the chest and neck on the side of the dropped shoulder. You may actually even see the 1st and 2nd rib elevate as they inhale. They create a fixed point at the neck so that the other end of the muscles can elevate the ribs with inhalation. They begin to recruit these muscles to move the upper ribs for breathing, rather than being used as prime movers of the neck. And if you are using a muscle to breathe, it can’t do it’s job very well to then create movement for you. If you are using shoulder elevators to breathe, you can’t also ask them to elevate the shoulder for you. Ironically, this actually exacerbates the anxiety as loss of normal neck range of motion results in a state of hyper vigilance.
If you are using your neck instead of your diaphragm, core and oblique muscles to breathe, how are you going to get more air in? You need to increase the range of motion your upper thoracic ribs move through. In other words, you need to start in extreme stretch so that then you can move your ribs through excessive motion. You’re not going to start with an elevated shoulder; otherwise you have nowhere to go when you inhale to get air in. You’re going to drop that shoulder as much as you can, so you can maximize the range of motion you can take those upper ribs through to maximize your ability to breathe.
My patients commonly get disheartened when they find out how often it all just comes back to how they’re breathing. How could we screw up something that is so automatic?! We only do it 20,000–25,000 times every day. I don’t find it distressing though; I find it extraordinary. It’s remarkable how adaptable our bodies are. It’s not a problem; your dysfunction is actually what’s keeping you alive. You should be thanking it. It doesn’t mean it’s optimal though. If we can give our bodies a better, smarter alternative, then we can truly tap into a whole heap of our hidden potential. When you have optimized the breath, then the rest of your movement potential is unlocked.
So if you have noticed you have a dropped shoulder, or if you notice a family or friend with a dropped shoulder, get them assessed by a health professional who includes breathing assessments as part of their examination. In my office, all dropped shoulders are a breathing issue until proven otherwise.
