Pilates for Scapular Dyskinesis Aubrey Lewis May 25, 2014 Course year: 2014 Denver, Colorado, USA (Pilates Denver Studio) 1
Abstract: The purpose of this paper is to implement a rehabilitation program designed for an active individual with a painful scapular deviation called Scapular Dyskinesis. He attributes this condition to a high school wrestling injury, made worse by rigorous, daily yoga practice. The goal of shoulder rehabilitation is to establish normal function rather than to alleviate specific symptoms. The program must involve the restoration of normal anatomy, physiology, biomechanics, and the correction of any adaptations that have occurred, in order to re- establish the normal kinetic chain of action. Therefore, the focus of this paper is the rehabilitation of not only the subject s shoulder, but of the strength, posture, and spinal alignment of the whole body, utilizing the holistic approach of the BASI Block System. 2
Table of Contents 1. Title Page 2 Abstract 3 Table of Contents 4 The Shoulder Girdle 5 Scapula in Shoulder Function 6 Scapular Dyskinesis 7. Case Study, Background 8.. Rehabilitation, Goals, Assessment 10.. Exercise Plan, Exercise Program 15 Conclusion 16. Resources 3
The Shoulder Girdle The shoulder is one of the largest and most complex joints in the body. It is formed where the humerus fits into the glenoid fossa of the scapula, much like a ball and socket. Other bones of the shoulder include the clavicle, the acromion, and the coracoid process. Other shoulder structures include the rotator cuff, the bursa, and a cuff of cartilage. Anatomically, the scapula is part of both the glenohumeral (GH) joint and the acromioclavicular (AC) joint. It is the bony linkage between the humerus and the clavical and the axial skeleton. Physiologically, the scapula is the stable base of origin for muscles contributing to GH stability and arm motion. The coordination 4
between the scapula and the humerus (scapulohumeral rhythm) is needed for both arm movement and GH alignment. In a healthy shoulder, the humerus fits loosely in the shoulder joint and is freely moveable. Because of the wide range of motion of the shoulder joint, it is highly unstable. The shoulder functions as a kinetic chain, which is defined as a series of links and segments activated sequentially in a coordinated fashion to generate and transmit forces to accomplish a specific function. The Scapula in Shoulder Function: The scapula is the large triangular bone commonly referred to as the shoulder blade. Its only attachment to the skeleton is at the clavicle (acromioclavicular joint). Therefore, the scapula is held in place primarily by muscle groups which allow the wide range of motion of the shoulder. Axioscapular muscles Scapulohumeral muscles ( Rotator Cuff muscles) Attach scapula to thorax, stabilize or move scapulae Maintain shoulder stability and contribute to subtle movements Serratus anterior, trapezius, rhomboids, levator scapulae, pectoralis minor Supraspinatus, infraspinatus, teres minor, subscapularis Axiohumeral muscles power muscles, produce Pectoralis major, lattismus 5
gross movements dorsi, deltoids, teres major Scapular Dyskinesis: Scapular Dyskinesis can be described as altered scapular motion and position. Dys meaning alteration of and kinesis meaning motion is a general term used to describe the loss of normal control of scapular motion. Another term used to describe this condition is SICK scapula, an acronym for: scapular malposition, inferior medial border prominence, coracoid pain, and malposition, and dyskinesis of scapular movement. All of these conditions refer to an injury resulting from overuse and fatigue of the muscles that stabilize the scapula. A SICK scapular will become a case of Scapular Dyskinesis when the normal position and movement of the scapula is altered during scapulohumeral movements. This usually happens when injuries inhibit activation patterns in the muscles involved with the scapula, and is generally the result of loss of muscular coordination. Risk Factors: Repetitive overhead activity, Overuse, Direct trauma, Muscle strain, Tense pectoralis major (unbalanced weight training), Injury to other shoulder structures Signs/ Symptoms: Shoulder appears dropped in comparison to the unaffected shoulder, Medial scapular protrusion, Pain at scapula, front, back, or top of the shoulder, Pain on outside of upper arm Treatment: Physical therapy focused on kinetic chain- based rehabilitation- 6
The BASI Block System is an ideal rehabilitation program for those suffering from Scapular Dyskinesis. Pilates rehabilitation will focus on regaining normal muscular activation patterns and range of motion, strengthening affected muscles, and muscle coordination. Case Study: This case study took place over the course of four months from March 2014 through June 2014. Name: Steven Williams Age: 29 Profession: Massage Therapist, Rolfing student, Avid yoga practitioner Limitations: Medial right scapular pain with a burning, dull, and constant quality and decreased range of motion of right shoulder with sharp, stabbing pain beneath the clavicle with forward rotation, adduction, and raising the arm. Background: Steven attributes his inclination to shoulder pain to old high school wrestling injuries, which he is unable to define. However, he did not have a noticeable problem with his shoulder until 2012, when he began a vigorous Ashtanga yoga practice. At first, Steven only experienced shoulder pain during yoga class, but by March of 2014, it was a constant 4/10 on the pain scale, and an 8/10 during class. As a body worker, this pain is a significant disadvantage. Steven has decided to try a BASI Pilates rehabilitation program in order to correct his imbalances, with the goal of alleviating pain and restoring full range of motion. 7
Rehabilitation Treatments: I met Steven in the acupuncture clinic I work in. Acupuncture is the only modality of treatment he has sought to correct his shoulder imbalance. Acupuncture has been effective in the short- term alleviation of pain and during a treatment, can improve his range of motion significantly. However, these treatments never last in his body for more than two days and he refuses to take a break from Ashtanga yoga. I suggested that he try BASI Pilates in order to correct his imbalance in a holistic way. He was very open to taking responsibility for his healing. Goals: In the short- term, Steven s goal is to alleviate the constant pain felt on the medial scapula and beneath the clavicle. His first priority is being able to work as a massage therapist without pain. In the long- term, his goal is to restore full range of motion in the right shoulder, eliminate all pain, and be able to practice yoga on a daily basis without it interfering with his massage practice and Rolfing classes. Assessment: Steven s initial postural assessment identified many deviations in his posture. From the sagittal plane, an anterior tilt of the pelvis, forward head posture, lumbar hyperlordosis, and thoracic kyphosis were noted. From behind, the right scapula appears winged, as it is visibly lower than the left scapula, and rotated out. He holds his left shoulder higher than the right. Steven also appears to stand with his ribs flared out, lifting through the sternum and pulled up in the knees, with very little grounding or awareness of his feet. 8
He feels pain in his right shoulder, especially beneath the clavicle, during adduction, forward rotation, and when raising the arm. The most painful positions involve yoga stances in which his body weight is over his arms. Exercise Plan: Steven s symptoms indicate the need for the following: Strengthen abdominals and stretch the hip flexors and low back extensors in order to correct the anterior tilt of the pelvis and lumbar hyperlordosis Strengthen thoracic extensors and stretch the anterior shoulder muscles Correction of forward head posture Improvement of cervical, thoracic, and lumbar alignment Re- education of where the head of the humerus fits in relationship to the glenoid fossa Encourage awareness of muscle recruitment to improve scapular deviation (trapezius muscles, serratus anterior, levator scapulae, and rhomboids) Strengthen upper back Bring awareness to feet and grounding Discourage lifting through the sternum by engaging the TA Habituate the body to utilize correct muscle recruitment 9
Exercise Program: Warm Up: Mat Roll Down Begin each session with a roll down to assess subtle changes in posture, growing body awareness, specifically an awareness of the feet in this stance. Pelvic Curl Because the client is new to Pilates, this will help him learn to activate the pelvic floor and TA. The pelvic curl is an excellent measure of progress. Chest Lift Slowly warm up the abdominals with control, focusing on C curve and intercostal breathing. Chest Lift with Rotation Oblique focus with C curve, continue to focus on intercostal breathing Foot Work: Reformer Parallel Heels Parallel Toes V Position Toes Open V Heels Open V Toes With only a medium tension, Steven will focus on stability and correct alignment (specifically of the thoracic and cervical spine) without emphasizing resistance and quadriceps strength. A small ball 10
Calf Raises Prances Prehensile was necessary in the beginning beneath the chin to correct forward head posture. Prehensile drew awareness to the feet. Abdominals: Reformer Hundred Prep The recruitment of latissmus dorsi, serratus anterior, and the lower trapezius is crucial to the rehabilitation of the scapula. This exercise also emphasizes TA engagement and shoulder extensor control. Hundred With minimal carriage movement, this exercise requires the client to stabilize the shoulders and trunk, while maintaining pelvic lumbar stabilization and building abdominal strength. Hip Work: Reformer Supine Leg Series- Frog Circles (Up, Down) Openings This series builds hip adductor strength and emphasize pelvic lumbar stability, it is fundamental and a integral part of this holistic Pilates program. 11
Extended Frog Extended Frog Reverse Spinal Articulation: Cadillac Monkey Original Emphasize abdominal control while bringing awareness to all three sections of the spine through controlled articulation. Tower Prep The deep hamstring stretch is good for the client s overall posture. He must focus on his posture with straight arms and scapular stability. Stretches: Cadillac Shoulder Stretch Prone This is a great stretch to address the client s primary goal of shoulder mobility and flexibility. Full Body Integration: Cadillac Push Through Group- Sitting Forward Side Reach The client will stretch the hamstrings, while also stretching the shoulder adductor and oblique. These exercises 12
emphasize spinal mobility, another crucial part of this holistic program. Arm Work: Cadillac Arm Standing Series- Chest Expansion Hug- A- Tree Circles (Up, Down) Punches Biceps Focus on scapular stabilization while strengthening and practicing recruitment of latissmus dorsi, the shoulder extensors, pectoralis major, the triceps, and the biceps. I cue for postural alignment and the recognition of each muscle involved in rehabilitation of scapular dyskinesis. Push Through Group- Shoulder Adduction Single Arm Shoulder Adduction Double Arm Sitting Side Prep Shoulder adductor control is very important for the client s rehabilitation. This is great for latissmus dorsi recruitment and scapular adductor and abductor control. Leg Work: Wunda Chair Leg Press Standing Focus on balance and hip extensor control, while checking in on the breath pattern. 13
Hamstring Curl Emphasize pelvic/lumbar stabilization, while checking in with neutral pelvis. Hip Opener Move deep into external rotation. Lateral Flexion/ Rotation: Wunda Chair Side Stretch Cue abdominal control, continue to work on pelvic stabilization through the lateral flexor stretch. Side Kneeling Stretch Focus on maintaining scapular stabilization. Back Extension: Wunda Chair Swan Basic Addresses the goal of strengthening the back extensors while maintaining scapular stabilization. Cue to check in with the spinal alignment and sequential extension of spine. Back Extension Single Arm Continue to strengthen the back extensors, focusing on extending each vertebrae sequentially from head down. Final Roll Down 14
Conclusion: After four months of consistent practice of the BASI Block System, Steven has experienced increased range of motion in his right shoulder and significantly reduced pain. He is more aware of muscle recruitment when exercising and also when performing normal tasks such as washing the dishes or performing a massage at work. The holistic BASI Pilates approach has proven effective in creating a foundation for Steven to increase his flexibility and maintain proper alignment, consequentially rehabilitating his shoulder and overall postural deviations. 15
Resources: Isacowitz, Rael, and Karen S. Clippinger. Pilates Anatomy. Champaign, IL: Human Kinetics, 2011. Print. Kibler, Ben, Paula Ludewig, Phil McClure, Lori Michener, Klaus Bak, and Aaron Sciascia. "Medscape Log In." Medscape Log In. British Journal of Sports Medicine, 2013. Web. 21 May 2014. Magee, David J. Orthopedic Physical Assessment. St. Louis, MO: Saunders Elsevier, 2008. Print. Rubin, Benjamin, MD. "Practical Orthopaedic Sports Medicine & Arthroscopy1st Edition." Principles of Shoulder Rehabilitation. Lippencott Williams and Wilkins, 2007. Web. 24 May 2014. "Scapular Dyskinesis/ SICK Scapula." Shoulder Injury,. Sports and Orthopedic Specialists, 2013. Web. 21 May 2014. 16