POSTURAL ANALYSIS & PROGRAMME FOR FEMALE WHO PRESENTS WITH SCAPULA DYSRHYTHMIA BY JENNIFER RUTHERFORD NOVEMBER 2018 THE PHYSIO PILATES STUDIO, AUCKLAND, NZ
ABSTRACT As a fairly new comer (3yrs) to pilates, I have become extremely interested in stabilising and strengthening areas of my body that are hypermobile due to a strong advanced yoga background. With two injuries to my shoulders a few years ago, and because of habitual patterns, both my scapulas wing out causing scapula dysrhythmia, with the right side presenting worse than the left. This paper will investigate the specific areas of weakness, which muscles I have to address (not just specifically the scapula stabilisers) and a tailored exercise programme that will be varied, sound and progressive. My aim is control and stability (not just strengthening), to work hard but not cause pain and to see a marked improvement in the positioning of the scapula against the ribcage within 8 weeks with a daily practice of 20mins or more. I will use the BASI comprehensive block system to give an all round practice as well as a more specific fast and more clinical class so I can ensure rehab is completed even on the busy days. 1
TABLE OF CONTENTS ABSTRACT 1 TABLE OF CONTENTS 2 ANATOMY OF THE SCAPULA 3 THE WORKINGS OF THE SERRATUS: 4 CASE STUDY 6 CONDITIONING PLAN 8 CONCLUSION 11 BIBLIOGRAPHY 12 2
ANATOMY OF THE SCAPULA The Anatomy of the Scapula (also known as the shoulder blade) is a complex area of the body, as it articulates with the humerus and the gleno-humeral joint and the clavicle at the acromioclavicular joint. What we often forget, is that this bone is an attachment for 17 muscles. with this in mind we cannot just wholly focus or isolate the stabilisers of the scapula: these being the serratus anterior, rhomboids, levator scapulae and trapezius. True winging however is due to the serratus anterior muscle dysfunction which will be the main focus. It is a fairly common issue in people, and because it is asymptomatic, usually nothing is done to correct the issue unless there is pain or weakness apparent, paralysis or nerve issue. 3
THE WORKINGS OF THE SERRATUS: Where does the serratus anterior muscle attach? Originates on the upper 8 or 9 ribs Inserts on the medial border or edge of the scapula There is a convergence of fibres on the inferior (bottom) angle of the scapula What actions does the serratus anterior muscle do? Protraction of the scapula brings the scapula forward on the rib cage Upward rotation of the scapula Used after the humerus abducts to ninety degrees. Stabilizes the scapula and prevent the inner edge from winging. Movements of the Scapula The scapulae move in 6 different ways, they are: Retraction (adduction): rhomboids and middle trapezius muscles Protraction (abduction): serratus anterior muscle Elevation: upper trapezius and levator scapulae muscles Depression: lower trapezius muscle Upward rotation: Serratus anterior upper and middle trapezius muscle Downward rotation: rhomboids muscles Sometimes the tightness of the chest muscles plays a huge part in the winging as well, not just from posture or habit but also from overly training the chest muscles. 4
As they get tighter it creates dysfunction in functional movement of the shoulder and shoulder blade on the backline. Sitting at a desk and with a rounded back for long hours on a day to day basis can also create pain and issues with the scapula and surrounding muscles. The serratus anterior can also be affected if there has or is an issue from trauma or injury to the thoracic nerve that runs through the serratus. It is important that any client is first assessed by a physio before planning the right programme. 5
CASE STUDY NAME: JEN RUTHERFORD AGE: 41 LIMITATIONS: As long an I can remember I have always had rounded shoulders, even in pictures of myself as a little girl.. I am a yoga teacher who teaches approximately 20 classes per week. Over 18 years, my mobility has increased and instability in my shoulder blades has become more apparent. When I had an accident by falling over and landing on my right elbow, this created an impingement of my C2, and C3 nerves and pain all down my right arm. This took almost 2 years to recover from due to not being able to stop working. During this time my winging scapulae became a part of the rehabilitation with my physio to help recover the whole area from the injury and pain and maintain correct shoulder alignment. I did not continue with the exercises for this when I finished with the physio, and so I still have winging both sides. Since starting intermediate and advanced pilates classes and trying to build strength, I have noticed discomfort at times in my rotator cuff that is due to the underlying issue of scapula dysplasia and poor form through weakness in the serratus anterior. These are the issues from that were picked up from the physio appt: - Tightness in traps - Pec majo tightness, pec minor severe tightness - Shoulders rounded fwd - Scapula protracted 6
- Poor scapula humeral rhythm when lifting arm - Shows no damage of thoracic nerve REHABILITATION TREATMENTS Through the BASI block system I need to work on correcting poor muscle imbalance. 1. Head and neck alignment throughout all exercises to rehabilitate the slight forward head posture I present with. 2. Properly mobilise the scapula region and become familiar with the sensation of good serratus anterior contraction and control for better scapulo-humeral rhythm. 3. Strengthen the upper back, including scapula stabilisers, with the serratus being a major focus, and thus create new neural pathway connections for better control patterns so other overworked and tight muscles can rehabilitate. 4. Correct execution of movement patterns will be crucial in improving alignment of scapula on the ribcage long term. 7
CONDITIONING PLAN I will choose to chart my own progress and work with a BASI certified instructor for best practice. I have been specific in explaining the focus of the work around the shoulder for the exercises below, but have assumed good form for muscle focus and objectives correlating to the exercises in each block. These exercises are to correct muscle imbalances in the shoulder region and reduce ongoing pain around the scapula. *To make this class shorter when time is restricted, pick 2-3 from each block. BLOCK APPARATUS EXERCISE FOCUS/GOAL PRE-WARMUP Gondola Pole Stretches Shoulder Stretch Overhead Stretch Side Stretch Spine Twist stretching WARM-UP Mat Pelvic Curl Chest Lift Chest Lift w rotation Spine Twist Supine Roll Up Beginning with shoulder blade movements and easy rotational and lateral Abdominal connection work and scapula placement - depression and protraction FOOTWORK Wunda Chair All in series Focus on the variation of arm positions and movements during footwork. Good engagement of spinal extensors. ABDOMINAL WORK Wunda Chair OR Standing Pike Reverse Full Pike Cat Stretch Kneeling Ab activation with control over scapula stabilisers and serratus control incl lats Reformer Short Box Series - Round Back - Flat Back - Tilt - Twist - Roundabout These I like due to the scapula placement for each arm position and using overhead pole 8
- Climb a tree emphasis on lat and serratus engagement HIP WORK Reformer Circles Frogs Openings Other than good pelvis stabilisation, ensuring good pressure down through shoulders, and feeling any rolling or lifting (protraction and elevation) of the R shoulder inparticular SPINAL ARTICULATION STRETCHES Mat OR Reformer Cadillac Open Leg Rocker Boomerang Semi Circles Shoulder Stretch Open leg rocker has good overhead arm placement to work on different angle of stabilisation for the shoulder, and the boomerang great arm articulation to give the arms a rest from downward stabiliser engagement Great stretch through the anterior shoulder and into pec muscles giving a good counter exercise for the stability work. FULL BODY INTEGRATION 1 Reformer Cadillac Hamstring Stretch Group Side Split Push Through Group Sitting Forward Side Reach Kneeling Cat Stretch Here I would encourage good placement of scapula while holding the footbar, then moving into the side split with arms in a t-position being mindful to set and not wing the scapula and include hug a tree movement pattern with the leg flow as well to work rhomboids All wonderful exercises for stabilising and mobilizing correctly. 9
Watching closely for winging. ARMS Cadillac Push Through Group Shoulder Adduction Single and Double arm Sitting Side Prep Sitting Side Lat Dorsi work Then moving into abduction and adduction All for scapula humeral rhythm work FULL BODY INTEGRATION 2 OR Reformer Reformer LEG WORK Cadillac Changes Scissors LATERAL FLEXION & ROTATION BACK EXTENSION Reformer Reformer Shoulder Push Dbl and Single Arm Arms Sitting or kneeling Rowing front 1 and 2 Cross Arm Pull Arms Overhead Tendon Stretch Balance Control Front Balance Control Back prep and full Tilt Twist Roundabout Mermaid Side over on box Long Box Group Breaststroke Prep Pulling Straps 1 Pulling Straps 2 Breaststroke These all challenge the entire shoulder incl Rotator cuff and scapula stretch and proper movement control. Watching for good scapula control, I would also scapula set while holding the Balance control front position before starting the exercise. Love these two for the control required through the shoulders with arms in an overhead position, watching for good upward rotation with careful downward rotation with no winging of scapula. All these use great placement and flow of arms so integrating more control while gaining strength in the core and back extensors This whole set not only works the entire back line but also has great movement for flexibility, strength, and control of the entire shoulder region 10
CONCLUSION In summary, this paper is aimed at giving me a thorough plan to address the issues with stabilisation of the scapula and improve shoulder stability. During the short time I have been following the programme, it has created different aches in muscles that are now having to recruit correctly and adjust somewhat as I refine, and correct my movement, including my chest and neck and shoulders and mid back. If I stabilise well through the exercise and work hard on using the serratus anterior, all pain through the shoulder/humeral head disappears in exercises that previously niggled. Stabilisation is still a way off, as it s been over 30yrs of bad posture, this may take some time, but I expect to see my R scapula sitting far better on the ribcage if I can continue this programme for 3-4 months. 11
BIBLIOGRAPHY http://anatomysciences.com/shoulder-blade-muscles/shoulder-blade-musclesmuscles-of-the-shoulder-blade-anatomy-inner-body/ CHA Ambulatory Didactics Kate Lupton, MD Isacowitz, Rael. Pilates Complete Guide. 2007 Isacowitz Rael. Body Arts and Science Intl Study Guide, Comprehensive Course https://www.yoganatomy.com/serratus-anterior-muscle/ 12