Breathing, Rib Flare, and Winged Scapulae: The Factors That Can Affect Your Shoulder

From breathing mobility, to thoracic positioning, to scapular motion, looking your shoulder health and mobility is even more complex than you think.

Overhead motion isn’t necessary for everyone, but it’s a good idea to keep it if your clients have it, and try to regain it (where possible) if they’ve lost it. What follows is a “brief” overview of a bunch of contributing factors that can affect shoulder and overhead motion in your clients.

Having control over more motion is always better than having no control over motion, or not having that motion at all. That said, I have a lot of clients for whom going overhead isn’t an option due to injury, degenerative changes, or other fun things that get in the way. This is where goal setting and matching the exercise to the client becomes important–because not everyone needs it and forcing it won’t result in good things.

Overhead motion has a ton of moving parts.
There’s rarely only one keystone that holds people back from getting to a specific position or range of motion, especially so with the shoulder complex. There are a lot of moving parts that create shoulder flexion to get the arm overhead: 12 ribs and their vertebral attachments–10 with sternal attachments; scapular motion through three dimensions (frontal plane, sagittal plane, and transverse plane rotations); humeral rotation and alignment within the glenoid fossa; AC and SC joint motions or limitations; vertebral motion of at least the 12 thoracic vertebral segments; and finally, local muscular issues.

The means to simply get your arms in the air (to wave them like you just don’t care) can take motion from 38 joints through three planes of action, and muscular actions from at least 24 muscles that attach through the thoracic spine, scapula, and humerus.

Assuming your client has relatively normal anatomy–we’re talking no congenital structural issues like scoliosis and degenerative changes disturbing motion abilities, or neural dysfunctions like cerebral palsy–many mechanical issues can be grouped together. In many cases these issues, whether they’re foundational or joint-specific, seem to follow a set pattern.

How breathing plays a role in overhead motion
The main function of breathing is obviously gas exchange, though breathing is sort of a hot button topic in the fitness industry these days. Some people say things like, “I’ve been breathing my whole life and I seem to be doing okay.” Others say, “Do this breathing drill to add 340 pounds to your deadlift today!” Focus on breathing mechanics, however, is not for either of these reasons. It should be more on how that motion of breathing occurs.

We’ve all become pretty good at breathing and not suffocating over the years, but breathing requires a lot of motion from a lot of segments, with assistance from a lot of muscles. Your diaphragm plays a big role in breathing, but don’t forget the intercostals, serratus anterior, rhomboids, rectus and oblique abdominals, transverse, pelvic floor, upper traps and scalenes, subclavian, pec minor, sternalis, erector spinae, sternocleidomastoid, and probably another dozen or so I’m forgetting. Altogether they contribute in varying amounts to breathing depending on how you or a client choose to access lung expansion and depression.

Your client’s position–thoracic extension, flexion, rotation, scapular protraction or retraction, or even a forward head posture–determines whether using some muscles will be easier than using others. If your client chronically holds one position for many years, he begins to automatically rely on those muscles that are used all of the time and pretty much shut down the ones that aren’t. The result is, it becomes difficult to make these muscles work with your client’s positional breathing; but it can also be difficult to make them work in other positions.

According to the law of Specific Adaptation to Imposed Demands (SAID), if you’re consistently in a certain position or posture, your body gets good at being in that position or posture. If you never move from that posture, you’ll likely not be great at moving into other postures either. This makes it challenging to breathe via rib expansion at the sternal attachments or through the ribcage and diaphragm depression. The individual, however, will find other ways.

In order to bring your client’s arms overhead, he has to go through some thoracic extension and rib expansion to allow the shoulder blade sufficient rotation to let the arm actually go overhead, without causing the humerus to butt into the acromion. When bone-to-bone contact happens, movement doesn’t get easier. So if a person’s breathing is keeping him from accessing that thoracic extension and rib expansion, it’s going to hinder his shoulder mobility (which is why it’s the starting point in that series mentioned above).

In a study looking at tetraplegics, De Troyer et al (1986) showed that while they had no use of the diaphragm they could still get comfortable inhalations and exhalations by using the clavicular head of the pectoralis muscle and a large rib flare motion. This simply shows that breathing mechanics can occur from a number of different mechanisms in different people. Having worked with a few spinal cord injured clients, I’m always amazed to see what adaptations can occur.

Rib flare? We can help fix that.
With non-plegic individuals, there’s a form of rib flare, where the positioning of the anterior chest wall almost looks concave instead of convex. As the arms raise up, the ribs don’t expand but simply tilt up:


If someone is getting that massive rib flare motion to substitute for thoracic extension, try to use inhalation movements to create some expansion through the rib cage, which would help prime the person have that motion during shoulder movements.

Consider these breathing drills as mobility exercises, specifically looking at thoracic and sternal motion. If a rib cage is locked down, it’s going to be tough to get enough thoracic extension to allow for sufficient scapular motion. This doesn’t mean pain, just movement that isn’t sufficient for what you want and may lead to mechanical issues downstream.

Breathing drills that reposition your client can help restore some lost motion and set up more successful movements from distal joints. It’s tough for the scapulae to retract and depress if the rib cage is stuck in flexion, and these two movements are effective for getting enough upward rotation to get your client’s arms overhead.

The role of scapular motion in the overhead motion: Is a winged scapula a bad thing?
In terms of scapular motion, the shoulder blades have the ability to move through three planes due to their floating attachment to the body. Most of the posterior attachments are through muscular and fascial networks, whereas the only true bony attachment is via the AC joint in the front and the sternoclavicular joint in the center of the chest.

For rotation, the scapulae rely on triangulation force application from three different muscle groups to create upward rotation and produce downward rotation:


During upward rotation movements, sufficient scapulohumeral rhythm (relation of how much rotation occurs at the shoulder blade versus at the humerus) should be 2:1, where the humerus moves two degrees for every degree that the scapula rotates. For reference, in an ideal world when the arm is overhead at 180 degrees of flexion, the scapula should be rotated to 60 degrees (180-60 = 120, which maintains the 2:1 ratio).

People get into trouble when that scapular rotation doesn’t happen and they wind up shrugging the shoulder to get it into place, essentially substituting side bending at the torso for scapular motion. There could also be adhesive changes in the shoulder joint itself, a condition commonly known as frozen shoulder. In this instance, the rhythm goes from 2:1 down to 1:1, where pretty much all of the movement comes from the shoulder blade and none comes from the humerus itself.

Aside from upward and downward rotation, there’s also forward and backward tilting. Forward tilt is also commonly called winging scapula.

By itself, a winged scapula isn’t a problem, but it is a graphic example of a shoulder that may not have positional strength or stability to get the blade flat to the spine. In order to find stability, the shoulder blade winds up peeling off the torso and angling forward, making it difficult to adequately retract or rotate. Everyone wings in some position or another, it’s a matter of how much and whether it’s a problem or a solution.

Typically, improving “winging” involves directly training the serratus anterior to help promote protraction, but in my experience the serratus isn’t weak, just constantly on. As a result, you can barely palpate the lower traps and rhomboids because they’re fairly atrophied. In many ways, a winging scapula isn’t a single muscular problem, but a systemic compensation. Pretty much all of the muscles that are attached to the scapula need to be strengthened to help regain that torso-hugging position again.

If the goal is to improve strength and stability through the shoulders, a winged scapula might have to be identified and addressed to see significant gains. This just illustrates the rotational capability of the shoulder blade outside of upward or downward rotation. This type of tilting works through the transverse plane in relation to the torso, but there’s also sagittal tilting where the shoulder blade sort of leans over the top of the shoulders, like a weird, creepy Yoda backpack.

This is common with people who have significant thoracic rounding into kyphosis, as well as a forward head posture. It’s challenging to do anything with the shoulder blades other than elevate and protract in this position without addressing thoracic motion first. Hence breathing mechanics work to try to pull them away from the flexion bias and push them towards more extension positional aptitude.

Getting the shoulder blade to move better
A lot of these motions can be helped or hindered through common muscle training and posture work, but some is affected through degenerative or injurious tendencies through the AC joint and SC joint. Having worked with a number of hockey players who all seem to have bilateral AC separations, I’ve observed that their upward rotation is significantly impaired and often not something that can be restored, or even needs to be restored. Not too many hockey players put their arms over their head, except when they score a goal. (I live in Oilers country, so…)

Many people with degenerative issues like arthritis tend to also develop some significant reductions in movement capability via the SC joint. When healthy, it should be able to rotate, elevate, and protract relatively easily. If it’s stuck, the shoulder blade won’t move. Most people won’t have to worry about this unless they’re over 50 and have been stuck in a cubicle for the past 30 years with no other physical activity; or they played a sport with a significant amount of stress on the SC joint.

There are many different ways to get the shoulder to move again. Make it move through the basic patterns of protraction, retraction, elevation, depression, and upward and downward rotation, and you’ll have your bases covered. Just make sure the movement is in the direction you want for your client and not some other Frankenstein direction to simply get the job done.

Written by Dean Somerset for The PTDC


Looking to bring awareness to many different potential shoulder issues,

Dr. Phil Kotzan, DC

How do SLAP Tears Occur: Mechanisms of Injury to the Superior Labrum

Traumatic SLAP Injuries

Traumatic events, such as falling on an outstretched arm or bracing oneself during a motor vehicle accident, may result in a SLAP lesion due to compression of the superior joint surfaces superimposed with subluxation of the humeral head. Snyder referred to this as a pinching mechanism of injury. Other traumatic injury mechanisms include direct blows, falling onto the point of the shoulder, and forceful traction injuries of the upper extremity.

To be honest with you, I don’t know if this is actually the underlying cause of the SLAP lesion. I have questioned this theory in the past and don’t know the answer, but part of me at least wonders if these patients already had a certain degree of pathology to their superior labrum and the acute injury led to a MRI and diagnosis of a SLAP tear.

Essentially the MRI may have found an old SLAP tear.


Repetitive Overhead Activities
Repetitive overhead activity, such as throwing a baseball and other overhead sports, is another common mechanism of injury frequently responsible for producing SLAP injuries.

This is the type of SLAP lesion that we most often see in our athletes. In 1985, Dr. Andrews first hypothesized that SLAP pathology in overhead throwing athletes was the result of the high eccentric activity of the biceps brachii during the arm deceleration and follow-through phases of the overhead throw. To determine this, they applied electrical stimulation to the biceps during arthroscopic evaluation and noted that the biceps contraction raised the labrum off of the glenoid rim.

Another study from ASMI simulated each of these mechanisms using cadaveric models. Nine pairs of cadaveric shoulders were loaded to biceps anchor complex failure in either a position of simulated in-line loading (similar to the deceleration phase of throwing) or simulated peel back mechanism (similar to the cocking phase of overhead throwing). Results showed that 7 of 8 of the in-line loading group failed in the midsubstance of the biceps tendon with 1 of 8 fracturing at the supraglenoid tubercle. However, all 8 of the simulated peel back group failures resulted in a type II SLAP lesion. The ultimate strength of the biceps anchor was significantly different when the 2 loading techniques were compared. The biceps anchor demonstrated significantly higher ultimate strength with the in-line loading (508 N) as opposed to the ultimate strength seen during the peel back loading mechanism (202 N).

You can see photos of the study below. The first photo is a normal glenoid with the labrum and attaching long head of the biceps. The second photo is the simulation of the traction and eccentric biceps contraction. The final photo is simulation of the peel-back lesion.


In theory, SLAP lesions most likely occur in overhead athletes from a combination of these 2 previously described forces. The eccentric biceps activity during deceleration may serve to weaken the biceps-labrum complex, while the torsional peel back force may result in the posterosuperior detachment of the labral anchor.

Written and published by Mike Reinold, PT


Looking to bring attention to labral tears,

Dr. Phil Kotzan, DC

What Exactly Is a SLAP Tear? Top 5 Things You Need to Know About a Superior Labral Lesion

A very common diagnosis for shoulder injuries is a superior labral tear, or SLAP tear. SLAP stands for Superior Labral tear Anterior to Posterior. There many different variations of SLAP tears, which have different levels of severity and treatment strategies. Back in the day, surgeons would want to operate on all SLAP tears but we learned that some do well without surgery. In fact, some SLAP tears aren’t even worrisome .

Understanding how a SLAP lesion occurs and what exactly is happening pathologically is extremely important to diagnose and treat these shoulder injuries appropriately.


Classification of SLAP Lesions
As you can see in the figure, the long head of the biceps tendon inserts directly into the superior labrum. There are several variations of injuries that can occur to the superior labrum where the biceps anchor attaches.

Following a retrospective review of 700 shoulder arthroscopies, Snyder et al: Arthroscopy 1990, identified 4 types of superior labrum lesions involving the biceps anchor. Collectively they termed these SLAP lesions, in reference to their anatomic location: Superior Labrum extending from Anterior to Posterior. This was the original definition but as we continue to learn more about SLAP tears, they certainly do not always extend from anterior to posterior. But, the most important concept to know is that a SLAP lesion is an injury to the superior labrum near the attachment of the biceps anchor.


Type I SLAP Lesions
Type I SLAP lesions were described as being indicative of isolated fraying of the superior labrum with a firm attachment of the labrum to the glenoid. These lesions are typically degenerative in nature. At this time, it is currently believed that the majority of the active population may have a Type I SLAP lesion and this is often not even considered pathological by many surgeons.

Type II SLAP Lesions
Type II SLAP lesions are characterized by a detachment of the superior labrum and the origin of the tendon of the long head of the biceps brachii from the glenoid resulting in instability of the biceps-labral anchor. These is the most common type of SLAP tear. When we receive a script from a surgeon to treat a “SLAP repair” he or she is more than likely talking about a Type II SLAP and surgery to re-attach the labrum and biceps anchor.

Three distinct sub-categories of type II SLAP lesions have been further identified by Morgan et al: Arthroscopy ’90. They reported that in a series of 102 patients undergoing arthroscopic evaluation 37% presented with an anterosuperior lesion, 31% with a posterosuperior lesion, and 31% exhibited a combined anterior and superior lesion.

These findings are consistent with my clinical observations of patients. Different types of patients and mechanisms of injuries will result in slightly different Type II lesions. For example, the majority of overhead athletes present with posterosuperior lesions while individuals who have traumatic SLAP lesions typically present with anterosuperior lesions. These variations are important when selecting which special tests to perform based on the patient’s history and mechanism of injury.

Type III SLAP Lesions
Type III SLAP lesions are characterized by a bucket-handle tear of the labrum with an intact biceps insertion. The labrum tears and flips into the joint similar to a meniscus. The important concept here is that the biceps anchor is attached, unlike a Type II.

Type IV SLAP Lesions
Type IV SLAP lesions have a bucket-handle tear of the labrum that extends into the biceps tendon. In this lesion, instability of the biceps-labrum anchor is also present, similar to that seen in the type II SLAP lesion. This is basically a combination of a Type II and III lesion.

What is complicated about this classification system is the fact that the Type I-IV scale is not progressively more severe. For example a Type III SLAP lesion is not bigger, or more severe, or indicative to more pathology than a Type II SLAP lesion.
To further complicate things, Maffet et al: AJSM ’95 noted that 38% of the SLAP lesions identified in their retrospective review of 712 arthroscopies were not classifiable using the I-IV terminology previously defined by Snyder. They suggested expanding the classification scale for SLAP lesions to a total of 7 categories, adding descriptions for types V-VII.
Type V SLAP lesions are characterized by the presence of a Bankart lesion of the anterior capsule that extends into the anterior superior labrum.
Type VI SLAP lesion involve a disruption of the biceps tendon anchor with an anterior or posterior superior labral flap tear.
Type VII SLAP lesions are described as the extension of a SLAP lesion anteriorly to involve the area inferior to the middle glenohumeral ligament.
These 3 types typically involve a concomitant pathology in conjunction with a SLAP lesion. Although they provided further classification, this terminology has not caught on and is not frequently used. For example, most people will refer to a Type V SLAP as a Type II SLAP with a concomitant Bankart lesion.

Since then there have been even more classification types described in the literature, up to at least 10 that I know of, but don’t worry, nobody really uses them.

Top 5 things you need to know about classifying SLAP lesions
Here’s all you need to know about classifying SLAP tears:

Just worry about Type I-IV SLAP lesions and realize that any classification system above Type IV just means that there was a concomitant injury in addition to the SLAP tear.
You can break down and group Type I and Type III lesions together. Both involved degeneration of the labrum but the biceps anchor is attached. Thus, these are not unstable SLAP lesions and are not surgically repaired. This makes surgery (just a simple debridement) and physical therapy easier.
You can also break down and group Type II and Type IV lesions together. Both involve a detached biceps anchor and require surgery to stabilize the biceps anchor. Type IV SLAP tears are much more uncommon and will involve the repair and a debridement of the bucket handle tear.
Type II lesions are by far the most common that you will see in the clinic and are almost always what a surgeon is referring to when speaking of a “SLAP repair.” That being said, we are seeing trends towards NOT repairing SLAP II lesions, as they may be more common than once expected. This is especially true in overhead athletes.
We all may have a Type I lesion, it is basically just fraying and degeneration of the labrum.


Written and published by Mike Reinhold, PT


Looking to assist in describing SLAP tear shoulder injuries,

Dr. Phil Kotzan, DC

Shoulder Impingement: 3 Keys to Assessment and Treatment

To make the treatment process a little more simple, there are three things that I typically consider to classify and differentiate shoulder impingement.

Location of impingement
Structures involved
Cause of impingement
Each of these can significantly vary the treatment approach and how successful you are helping each person.

Location of Impingement
The first thing to consider when evaluating someone with shoulder impingement is the location of impingement. This is generally in reference to the side of the rotator cuff that the impingement is located, either the bursal side or articular side.


See the photo of a shoulder MRI above. The bursal side is the outside of the rotator cuff, shown with the red arrow. This is probably your “standard” subacromial impingement that everyone refers to when simply stating “shoulder impingement.” The green arrow shows the inside, or articular surface, of the rotator cuff. Impingement on this side is termed “internal impingement.”

The two are different in terms of cause, evaluation, and treatment, so this first distinction is important. More about these later when we get into the evaluation and treatment treatment.

Impinging Structures
To me, this is more for the bursal sided, or subacromial, impingement and refers to what structure the rotator cuff is impinging against. As you can see in the pictures below (both side views), your subacromial space is pretty small without a lot if room for error. In fact, there really isn’t a “space”, there are many structures running in this area including your rotator cuff and subacromial bursa.


You actually “impinge” every time you move your arm. Impingement itself is normal and happens in all of us, it is when it becomes excessive or abnormal that pathology occurs.

I try to differentiate between acromial and coracoacromial arch impingement, which can happen in combination or isolation. There are fairly similar in regard to assessment and treatment, but I would make a couple of mild modifications for coracoacromial impingement, which we will discuss below.

Cause of Impingement
The next thing to look at is the actual reason why the person is experiencing shoulder impingement. There are two main classifications of causes, that I refer to as “primary” or “secondary”shoulder impingement.

Primary impingement means that the impingement is the main problem with the person. A good example of this is someone that has impingement due to anatomical considerations, with a hooked tip of the acromion like this in the picture below. Many acromions are flat or curved, but some have a hook or even a spur attached to the tip (drawn in red):


Secondary impingement means that something is causing impingement, perhaps their activities, posture, lack of dynamic stability, or muscle imbalances are causing the humeral head to shift in it’s center of rotation and cause impingement. The most simply example of this is weakness of the rotator cuff.

The rotator cuff and larger muscle groups, like the deltoid, work together to move your arm in space. The rotator cuff works to steer the ship by keeping the humeral head centered within the glenoid. The deltoid and larger muscles power the ship and move the arm.

Both muscles groups need to work together. If rotator cuff weakness is present, the cuff may lose it’s ability to keep the humeral head centered. In this scenario, the deltoid will overpower the cuff and cause the humeral head to migrate superiorly, thus impinging the cuff between the humeral head and the acromion:


Other common reasons for secondary impingement include mobility restrictions of the shoulder, scapula, and even thoracic spine. We see this a lot at Champion. In the person below, you can see that they do not have full overhead mobility, yet they are trying to overhead press and other activities in the gym, flaring up their shoulder.


Differentiating Between the Types of Shoulder Impingement
In my online program on the Evidence Based Evaluation and Treatment of the Shoulder, I talk about different ways to assess shoulder impingement that may impact your rehab or training. There are specific tests to assess each type of impingement we discussed above.

The two most popular tests for shoulder impingement are the Neer test and the Hawkins test. In the Neer test (below left), the examiner stabilizes the scapula while passively elevating the shoulder, in effect jamming the humeral head into the acromion. In the Hawkins test (below right) the examiner elevates the arm to 90 degrees of abduction and forces the shoulder into internal rotation, grinding the cuff under the subacromial arch.


You can alter these tests slightly to see if they elicit different symptoms that would be more indicative to the coracoacromial arch type of subacromial impingement. This would involve the cuff impingement more anteriorly so the tests below attempt to simulate this area of vulnerability.

The Hawkins test (below left) can be modified and performed in a more horizontally adducted position. Another shoulder impingement test (below right) can be performed by asking the patient to grasp their opposite shoulder and to actively elevate the shoulder.


There is a good chance that many patients with subacromial impingement may be symptomatic with all of the above tests, but you may be able to detect the location of subacromial impingement (acromial versus coracoacromial arch) by watching for subtle changes in symptoms with the above four tests.

Internal impingement is a different beast.

This type of impingement, which is most commonly seen in overhead athletes, is typically the result of some hyperlaxity in the anterior direction. As the athlete comes into full external rotation, such as the position of baseball pitch, tennis serve, etc., the humeral head slides anterior slightly causing the undersurface of the cuff to impingement on the inside against the posterior-superior glenoid rim and labrum. This is what you hear of when baseball players have “partial thickness rotator cuff tears” the majority of time.


The test for this is simple and is exactly the same as an anterior apprehension test. The examiner externally rotates the arm at 90 degrees abduction and watches for symptoms. Unlike the shoulder instability patient, someone with internal impingement will not feel apprehension or anterior symptoms. Rather, they will have a very specific point of tenderness in the posterosuperior aspect of the shoulder (below left). Ween the examiner relocates the shoulder by giving a slight posterior glide of the humeral head, the posterosuperior pain diminishes (below right).


3 Keys to Treating Shoulder Impingement – How Does Treatment Vary?
There are three main keys from the above information that you can use to alter your treatment and training programs based on the type of impingement exhibited:

Subacromial Impingement Treatment
To properly treat, you should differentiate between acromial and coracoacromial impingement. Treatment is essentially the same between these two types of subacromial impingement, however, with coracoacromial arch impingement, you need to be cautious with horizontal adduction movements and stretching. This is unfortunate as the posterior soft tissue typically needs to be stretched in these patients, but you can not work through a pinch with impingement!

A “pinch” is impingement of an inflamed structure!

Also, I would avoid elevation in the sagittal plane or horizontal adduction exercises.

Primary Versus Secondary Shoulder Impingement
This is an important one and often a source of frustration in young clinicians. If you are dealing with secondary impingement, you can treat the persons symptoms all you want, but they will come back if you do not address the route of the pathology!

I do treat their symptoms, that is why they have come to see me. I want to reduce inflammation. However, this should not be the primary focus if you want longer term success.

This is where a more global look at the patient, their posture, muscle imbalances, and movement dysfunction all come into play. Break through and see patients in this light and you will see much better outcomes.

A good discussion of the activities that are causing their symptoms may also shed some light on why they are having shoulder pain. Again, using the example above, if you don’t have full mobility and try to force the shoulder through this tightness you are going to likely cause some issues. This is especially true if you add speed, loading, and repetition to elevation, such as during many exercises.

Internal Impingement
One thing to realize with internal impingement is that this is pretty much a secondary issue. It is going to occur with any cuff weakness, fatigue, or loss of the ability to dynamically stabilize. The athlete will show some hyperlaxity in this athletic “lay back” shoulder position. Treat the cuff weakness and it’s ability to dynamically stabilize to relieve the impingement.


All material written and published by Mike Reinold, PT


Looking to help those with shoulder impingement,

Dr. Phil Kotzan, DC

Effectiveness of Global Postural Re-education in Patients With Chronic Nonspecific Neck Pain: Randomized Controlled Trial

Global postural re-education (GPR) has shown positive results for patients with musculoskeletal disorders, but no previous randomized controlled trial (RCT) has investigated its effectiveness as the sole procedure for adult patients with chronic nonspecific neck pain (NP). The purpose of this study was to evaluate the effectiveness of applying GPR compared with a manual therapy (MT) intervention to patients with chronic nonspecific NP. Ninety-four patients with chronic nonspecific NP (72 women and 22 men; average age=47.5 years, SD=11.3) were randomly assigned to receive either a GPR intervention or an MT intervention. Pain intensity (visual analog scale), disability (Neck Disability Index), cervical range of motion, and kinesiophobia (Tampa Scale of Kinesiophobia) were assessed. The experimental group received GPR, and the reference group received MT. Both groups received nine 60-minute-long sessions with one-to-one supervision from physical therapists as the care providers. All participants were asked to follow ergonomic advice and to perform home exercises. Measures were assessed before treatment, following treatment, and at a 6-month follow-up. No important baseline differences were found between groups. The experimental group exhibited a statistically significant reduction in pain following treatment and in disability 6 months after the intervention compared with the reference group.
The results suggest that GPR was more effective than MT for reducing pain after treatment and for reducing disability at 6-month follow-up in patients with chronic nonspecific NP.


Pillastrini P, et al. Phys Ther. 2016 Sep;96(9):1408-16. Epub 2016 Mar 24.

Written by Scott Buxton of Physiospot


Proof posture matters,

Dr. Phil Kotzan, DC

Cervical And Scapulothoracic Stabilization Exercises With And Without Connective Tissue Massage For Chronic Mechanical Neck Pain: A Prospective, Randomised Controlled Trial

This study was planned to assess and compare the effectiveness of cervical and scapulothoracic stabilization exercise treatment with and without connective tissue massage (CTM) on pain, anxiety, and the quality of life in patients with chronic mechanical neck pain (MNP). Sixty patients with chronic MNP (18-65 years) were recruited and randomly allocated into stabilization exercise with (Group 1, n = 30) and without the CTM (Group 2, n = 30). The program was carried out for 12 sessions, 3 days/week in 4 weeks. Pain intensity with Visual Analog Scale, pressure pain threshold with digital algometer (JTech Medical Industries, ZEVEX Company), level of anxiety with Spielberger State Trait Anxiety Inventory, and quality of life with Short Form-36 were evaluated before and after the treatment. After the program, pain intensity and the level of anxiety decrease, physical health increase in Group 1 and 2 were found (p < 0.05). Pressure pain threshold and mental health increase were detected in only Group 1 (p < 0.05). The intergroup comparison showed that significant difference in pain intensity at night, pressure pain threshold, state anxiety and mental health were seen in favor of Group 1 (p < 0.05).
The study suggested that stabilization exercises with and without the CTM might be a useful treatment for patients with chronic MNP. However, stabilization exercises with CTM might be superior in improving pain intensity at night, pressure pain threshold, state anxiety and mental health compared to stabilization exercise alone.


McMahon S, Cusack T, O’Donoghue G. Barriers and facilitators to providing undergraduate physiotherapy clinical education in the primary care setting: a three-round Delphi study. Physiotherapy. 2014;100(1):14-19.


Written by Scott Buxton of Physiospot


Looking to bring awareness to neck/scapulo-thoracic stabilization,

Dr. Phil Kotzan, DC

An Easy Rehab Exercise Progression For Neck Pain (Mostly Equipment-Free)

There’s a plethora of research showing that training the neck and scapular musculature is beneficial for people with neck pain. Protocols that involve motor control training, strength and endurance for the deep neck flexors and musculature like the serratus anterior, rhomboids and low / mid trapezius are generally helpful.

Here are the easy ways to stabilize/strengthen your neck (mostly no equipment needed!) PROTOCOLS


Written by Dr. Dan Pope, DPT


Looking to bring light to neck stabilization ideas,

Dr. Phil Kotzan, DC

Yes, Neck Stabilization With Manual Therapy Is Best. Neck Stabilization Ideas With Therabands

Lately, I have been getting so many cases of neck and upper back symptoms that would benefit from strengthening and stabilization.  While we know of the many benefits of stabilization exercises to strengthen the neck and to relieve pain, why stop there? Recently, clinicians have been looking into additional treatments to complement cervical and scapulothoracic stabilization exercises to boost patient outcomes and relieve pain quicker. Because manual therapy has historically been a great method of pain relief, researchers decided to put it to the test to better understand if manual therapy combined with stabilization exercises was better than exercise alone (or as other research has shown, manual therapy alone).

Read the methods (with photo descriptions) and results of the article here: RESULTS

Read the protocols for neck and upper back stabilization here: PROTOCOLS


Looking to offer further stabilization ideas,

Dr. Phil Kotzan, DC

4 Strategies To Help Conquer Sugar Addiction

In May 2016, the FDA announced changes to the nutrition facts food label that appears on all packaged foods and drinks. Starting in 2018, the new label must clearly state how much sugar the manufacturer added to the product and what percentage of the recommended daily maximum that represents. This is a huge improvement over the current label, which lists only the total amount of sugar in the product, without distinguishing between natural sugar in the food and added sugars. The new label brings the sugar information into better alignment with the updated Dietary Guidelines for Americans and will help to eliminate confusion and conflicting recommendations. Most importantly, the new label will help consumers realize just how much sugar is added to processed foods.

The added sugar problem
In 1977, the average American consumed about 228 calories a day from added sugars. As the 1980s began and inexpensive high-fructose corn syrup entered the food supply, that amount started to creep up—and so did the rates of overweight and obesity. Over three decades, from 1977 to 2010, U.S. adult consumption of added sugars increased by more than 30%. Today, the average adult eats about 300 calories a day in added sugar, working out to about 142 pounds of sugar a year, more than their body weight for many.

Ultraprocessed food such as soft drinks, packaged snacks, and candy now make up more than half of all calories in the U.S. diet. Not surprisingly, because 1 in every 5 calories from these foods is sugar, they contribute about 90% of all added dietary sugar intake.

Today, almost all the added sugars in the American diet come from high-calorie, low nutrient, ultra-processed foods. The foods are carefully engineered to be hyperpalatable. Cutting back on these foods would be the best possible way to cut back on excessive sugar consumption and the health problems this brings.

How added sugar harms
Excess calories from added sugars in the diet contribute to obesity and associated conditions, such as type 2 diabetes, hypertension, dyslipidemias, and cardiovascular disease. Added sugars are also implicated in tooth decay.

Today, 1 in 3 Americans are overweight or obese; by 2050, this number is projected to rise to 1 in 2. Since 1960, we’ve seen a 10-fold increase in type 2 diabetes. In 1980, type 2 diabetes in children was very rare; in 2008, one out of every four teenagers had it. The direct medical costs to treat type 2 diabetes each year are now in excess of $176 billion. Type 2 diabetes is the seventh leading cause of death in the U.S.

Sugar kills slowly in the case of type 2 diabetes, but much faster in the case of cardiovascular disease. A strong link between sugar consumption and death from cardiovascular disease was shown in a 2014 cohort study using National Health and Nutrition Examination Surveys (NHANES) data. The study showed that the risk of death from cardiovascular disease increased exponentially as the usual percentage of calories from added sugar increased. The more added sugars the participants regularly ate, the greater their risk of death from heart disease—no matter what their age, sex, race, weight, smoking status, fitness, and family history of heart disease. Those who consumed 25% or more of their daily calories from added sugar simply had triple the risk of dying of heart disease.

The current epidemics of obesity and type 2 diabetes and the clear link between sugar consumption and death from heart disease show that sugar plays far too large a role in the American diet. Some 65% of adults currently exceed the recommended daily limit for added sugar as outlined in the 2015 Dietary Guidelines for Americans. The current guidelines have finally firmly stated that Americans should consume less than 10% of calories per day from added sugars. (The original 1980 guidelines simple said “Avoid too much sugar.” The 2010 guidelines were more explicit and allowed up to 15% of daily calories from added sugars.) On a diet that includes 2,000 calories a day, getting 25% of those calories from sugar means eating 500 calories from sugar, or 31 teaspoons. Based on the current recommendations, that amount should be cut by two-thirds, to about 160 calories a day, or 10 teaspoons.

Cutting back on sugar
Unfortunately, cutting back on sugar is difficult—and lack of understanding can actually make things worse. Concerns over sugar have led many school systems to replace the sugary sodas in vending machines with supposedly healthier alternatives, such as flavored milk drinks and juice. These drinks may not have bubbles, but they’re no better than soda when it comes to sugar. The “juice” drinks are made largely from juice concentrates, which are basically nothing but fruit-flavored sugar. An 8-ounce serving of chocolate milk has 22 grams of added sugar; 8 ounces of cola has 26 grams; 8 ounces of Snapple apple juice has 24 grams of added sugar. Most containers of these drinks contain far more than 8 ounces; a standard Snapple bottle is 16 ounces while a standard soda can contains 12 ounces. Until these machines are removed entirely from every school, kids will continue to consume supposedly healthy drinks and the added sugars they contain.

Another way to cut back on sugar is to replace it with artificial sweeteners. This too can make things worse. A number of studies have shown that consumption of artificially sweetened sodas can have deleterious metabolic effects and actually can significantly raise the risk of the metabolic syndrome and type 2 diabetes. The only artificial sweetener that doesn’t seem to have health risks is stevia.

It’s up to doctors and other healthcare professionals to help their patients reduce their sugar intake in an intelligent way. Simply discussing the risks of excess sugar isn’t enough, however. Sugar is everywhere in the American diet, even in salad dressings, bread, and soup. Patients need education on just how widespread added sugars are, and they need help in finding ways to cut back. This is a difficult challenge because obvious ideas, such as switching to diet soda, can actually be harmful.

My recommendations:
The best way to help your patients cut back on sugar is with solid dietary advice that will help them crave sugar less. I recommend four basic steps:

Eat small meals regularly, making sure to include protein and fat each time. Particularly for patients already showing signs of glucose intolerance, this will help prevent the blood sugar lows that cause cravings for sugary snacks.
Eat breakfast and make sure the meal contains both protein and fat. Again, especially for patients with glucose intolerance, this will help keep the blood sugar on an even keel and avoid sugar cravings.
Choose whole foods over processed foods. By definition, whole foods don’t contain added sugar. For example, suggest old-fashioned or quick oatmeal with fresh fruit instead of flavored instant oats.
Because clients with high sugar consumption may not have a balanced diet, I also recommend taking four supplements every day: A good-quality multivitamin with minerals and phytonutrients, omega-3 fatty acid, vitamin D, and a probiotic.

Written by Dr. Robert Silverman, DC for DCAligned by MeyerDC

Looking to reduce sugar consumption–myself included!

Dr. Phil Kotzan, DC

JAMA Study Provides Further Support for Spinal Manipulation for Acute Low Back Pain

A new study published in the Journal of the American Medical Association (JAMA) adds to a growing body of recent research supporting the use of spinal manipulative therapy (SMT) as a first line treatment for acute low back pain, according to the American Chiropractic Association (ACA).

The review examined randomized controlled trials, systematic reviews and other published research since 2011 to determine the effectiveness and safety of SMT for low back pain patients. Researchers found that spinal manipulation was associated with statistically significant improvements in pain and function for up to six weeks with no serious adverse side effects. The JAMA study, published April 11, comes on the heels of new low back pain treatment guidelines by the American College of Physicians (ACP) that recommend first using non-invasive, non-drug treatments, including spinal manipulation, before resorting to drug therapies.

“As the nation struggles to overcome the opioid crisis, research supporting non-drug treatments for pain should give patients and health care providers confidence that there are options that help avoid the risks and dependency associated with prescription medications,” said ACA President David Herd, DC.

Just last month, ACA’s House of Delegates formally approved a resolution to adopt ACP’s low back pain treatment guidelines, in conjunction with chiropractic-specific guidelines from the Clinical Compass. The Clinical Compass guidelines focus on the management or co-management of low-back pain patients within a chiropractic office.

“By identifying and adopting guidelines that ACA believes reflect best practices based on the best available scientific evidence on low back pain, we hope not only to enhance outcomes but also to create greater consensus regarding patient care among chiropractors, other health care providers, payers and policy makers,” added Dr. Herd.

According to a 2016 Gallup survey, more than 35 million people visit a chiropractor annually. Widely known for their expertise in spinal manipulation, chiropractors practice a hands-on, drug-free approach to health care focused on disorders of the musculoskeletal system. Chiropractors are trained to diagnose and manage cases of back pain and refer patients to appropriate medical specialists when necessary.

The American Chiropractic Association is the largest professional association in the United States representing doctors of chiropractic. ACA promotes the highest standards of ethics and patient care, contributing to the health and well-being of millions of chiropractic patients.

Written by the American Chiropractic Association

Great to see this news,

Dr. Phil Kotzan, DC