Designing  a  Pilates  Program  

For  A  Client  With  Shoulder  

Impingement  Syndrome  

 

 

 

 

 

 

Kyuyoung  Nicole  Huh-­‐Limousi,  CPT  

Body  Art  and  Science  International  

Comprehensive  Teacher  Training  Program  

July  2013  

Paris,  France  

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Abstract

The many structural problems slouching causes include forward migration of head and rounding of shoulders. The migration of head and rounding of shoulders is then found to cause muscle imbalances between force couples, manifesting through pain and dysfunction of the shoulder. Whether imbalances in other part of the body may have caused the symptom or vice versa, conventional exercise programs and therapies often overlook the importance of conditioning the body as a whole, only focusing on the muscles responsible; rotator cuff muscles. This paper discusses the structure of shoulder girdle and the spine on a functional continuum and how BASI Pilates block system, when applied as a holistic exercise system, can contribute to achieving neck and shoulder girdle stabilization, and improving functional strength for a client diagnosed with functional shoulder impingement.

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Table of contents 1. Abstract 2. Shoulder Anatomy 3. Shoulder pathology 4. Rationale for holistic approach 5. Case study

a. Assessment and goal setting b. Exercise Plan c. The program d. Phase 1 - releasing tension and core stabilization e. Phase 2 - addressing the shoulder mechanism

6. Conclusion

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Anatomy of shoulder Shoulder joint is made up of the clavicle, the scapula, and the humerus (fig.1) and complex layers of muscles and ligaments across the entire upper body. (fig.2) Of the 4 joints of shoulder, Glenohumeral joint, commonly referred to as shoulder joint, has the ball shaped superior head of humerus, the arm bone, loosely fitted into the shallow socket-shaped lateral edge of scapula, the shoulder blade. The glenohumeral joint is held in place by surrounding ligaments and muscles (fig.2). Scapula can slide along the posterior ribcage to further facilitate the arm

Figure  1  Bones  of  shoulder  joint

Figure  2  muscles  of  Upper  

extremity    (source  :  

shoulderdoc.co.uk)

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movement. Among the muscles of shoulder complex, a group of four muscles called rotator cuffs, Supraspinatus, infraspinatus, teres minor, and subscapularis is identified as being responsible for the stability and movement in shoulder (fig.3). Shoulder pathology Shoulder impingement is the irritation or compression of one or more of the rotator cuff muscles in between the socket and the ball, creating inflammation, pain, and decreased function of shoulder. Primary impingement is structural and due to overcrowding of subacromial space due to bony abnormality or thickening of tendon through repeated injuries. Secondary, or functional impingements results from uncoordinated manner of arm bone movement or due to overuse when arm bone slides forward during abduction and external rotation of the shoulder. Rationale for holistic approach While rotator cuff muscles are often singled out as being responsible for shoulder health, shoulder is a complicated structure requiring an advanced sense of proprioceptive capacity due to its multiple joint mechanism and the dependence of its stability on the supporting muscles. These muscles, in turn, have their origins and insertions spanning the

Figure  3  Rotator  cuff  muscles  (source  :  shoulderdoc.co.uk)

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entire torso, front and back. For example, pectoralis minor connects upper ribs of chest to coracoid process, and overactive pectoralis minor draws scapula forward which then pulls the shoulder into forward and rounded position. In a controlled study, Borstad and Ludewig found that « short pectoralis minor demonstrated scapular kinematics similar to the kinematics exhibited in earlier studies by subjects with shoulder impingement, support the theory that an adaptively short pectoralis minor may influence scapular kinematics and is therefore a potential mechanism for subacromial impingement. Similarly, overactive muscles of elevation and flexion such as upper trapezius and levator scapulae may pull the pectoral girdle superiorly, then anteriorly, leaving the antagonist muscles of depression and extension deconditioned. Contrary to popular belief, Latissimus dorsi is another dominant player in multiple shoulder and arm movements, due to its position covering the entire lower vertebrae from T6, as well as the iliac crest of hip bone and the lower three to four ribs, which then has impact or are affected by the mechanisms of lower extremities. When we consider that scapula glides against the ribcage which are attached to thoracic vertebrae, study results showing a significant relationship between thoracic spine and scapula kinematics are not surprising either (figure 4; Kebaetse M, McClure P, Pratt NA, 1999). Holding the pelvis in fatigue posture, as well as excessive foot pronation may all contribute to shoulder health as these maybe cause compensating effect on the entire structure’s integrity. This maybe a reason behind the persisting pathologies even after localized approach to repetitive rehabilitation efforts. As such, conditioning clients with shoulder pathology must take more global approach addressing the whole body posture and muscular imbalances, instead of working locally around the pain.

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Figure  4  Thoracic  kyphosis  and  scapula  kinematics  

demonstrating  reduced  shoulder  ROM  on  thoracic  

kyphosis      (source  :  dynamicchiropractice.com)

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Case study Dominique, 45 years old, is a corporate marketing professional who has always been tall and slim. He is a long time runner and cyclist, with love for motorcycle and photography. He was diagnosed with shoulder impingement in his 30’s and has followed through shoulder re-education in several occasions. He never changed his life style except during his recurring episodes of shoulder tendinitis, which would force him to limit his activities. In the past 2 years, however, he has completely stopped his running and cycling due to worsening shoulder condition. His short-term goal is to “rectify” his shoulder problem, and long-term goal is to regain strength and improve general health and energy level. Posture assessment and goal setting Static posture assessment reveals forward head position, hyper extended neck, protracted and upwardly rotated scapulae, internally rotated arms with hands facing back, ribs showing exaggerated curvature and thoracic spine in exaggerated posterior curve. The entire body from his chest down simply hangs from his shoulder girdle, in a fatigue or sway back position; the anterior curve of lumbar spine is flattened, pelvis jutted forward with a posterior tilt, hip joints are extended, knee joints hyperextended, and feet turned out. From the assessment, upper trapezius, pectoralis major and minor erector spinae, and hamstrings are identified as shortened or tight but not necessarily strong. These are the muscles that will need stretching before strengthening. The rest of the body was deconditioned in general and needed strengthening. During forward flexion, the client showed exaggerated thoracic spine flexion, limited hip flexion and bent knees early on towards the end of forward bending, suggesting inflexible gluteal, hamstrings and or calf muscles, confirming the result of static posture assessment. Exercise plan

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Although his ultimate goal is to build back overall strength as quickly as possible, we came to agree that ignoring his shoulder issue will in the long run only set him back more than go forward. During the first phase, the attention will be on improving breathing, and cervical and thoracic spine alignment and function. While the focus is working on opening up the rib cage to give more space to the lungs and other internal organs, the exercise program in phase 1 also introduces truck and pelvic stabilization as well as foot and knee awareness. As soon as Dominique can dynamically stabilize and control the lumbo-pelvic complex, or the core, the exercise will gradually add on strengthening the deep mid and lower back muscles and re-activating proper scapula rotation rhythm. Also, more exercises for abdominal strength will be incorporated into the daily program. Phase 1 tension release and corrective stretches Stretch (administered independantly everyday and before each session) Ladder barrel shoulder stretch 1 and 2 Breathing with chest opening on pilates ball • Warm-up - emphasis on pelvic curl to encourage lower abdominals and

gluteal activation, and to introduce the client to spine articulation. Traditional chest lift is modified with the Step barrel in order to encourage opening of the chest muscles and isolation of abdominals, discouraging upper back flexion

o Pelvic curl o Side twist supine o Negative chest lift on step barrel

• Foot work series on reformer- giving closed chain feedback to activate

the posterior trunk proprioceptive receptors to re-adjust the thoracic curvature. Ideally, conscious supine position will provide the mind a chance to work on releasing the neuromuscular hold on neck and shoulder tension, and bringing awareness to TA and Latissimus dorsi, to balance out the natural spine curvature. Having a flat surface on his

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back (closed chain) to refer to facilitates the mind to focus on conveying information regarding alignment to the body.

• Hundred prep on reformer – encourage dynamically controlling shoulder extensors and build up abdominal strength

• Cadillac basic leg spring series – while the leg spring series will increase mobility of hip joint and strengthen the quadriceps and hamstrings, the main focus will be on stabilizing the pelvis while legs are in motion. The client will also work on knee and foot alignment in relation to femur positioning – parallel or external rotation. The client is gently yet consistently encouraged to ‘let go’ of the tension in his neck and shoulder.

• Arm series supine on reformer - continue giving the support for back chain while working to stabilize the shoulder girdle, focus on lengthening of the movement to work on ‘crowded’ articulation and to engage intrinsic muscles of shoulder girdle including serratus anterior

• Standing lunge stretch – while still getting an effective stretch on his hip flexors and hamstring, by placing hands on the foot bar and actively pressing down with the entire arm, an upright closed chain position is created. Dominique is encouraged to imagine his shoulder girdle expanding 3 dimensionally and upper trapezius melting away, and to experiment with his body in relation to the space. Lateral Flexion and rotation - Side over – leaning on to the Step barrel gives support to pelvis for stabilization and keeping the spine neutral while oblique muscles go through full ROM

• Leg work – Gluteals Kneeling series and Adductor Lift are chosen to

activate and strengthen the hip extensors and adductors which are weakened from holding the sway position for too long. Kneeling with elbows on the box also reduces the intensity of gravity on upper girdle, allowing us to work on weakened neck flexors by keeping the head lifted

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• Back extension – by focusing on keeping the abdominals engaged and reaching the arms and the legs towards the back of the room, Dominique is strengthening his entire posterior chain while eccentrically working the shoulder depressors including serratus anterior  and teres major. The adductor muscles are encouraged to stay active in order to aid in pelvic floor muscle activation

The client is also given as homework pectorals stretches and a simple fundamental Mat routine with emphasis on back extension and shoulder girdle stabilization. Phase 2 - addressing the shoulder mechanism After a month of training with 2 private sessions per week and keeping up 20minutes routine everyday, Spine articulation and Full body Integration blocks are added to previous exercise blocks. Avalon is introduced to add more strength training. More abdominal work is added with careful emphasis on avoiding excessive flexion. Strict priority is given to movement quality over the amount of resistance or flexibility.

• Progress from Supine arm work to Sitting arm work on Avalon - Arms sitting side series are introduced with focus on rotator cuff muscles while stabilizing the trunk

• Sitting side on Cadillac – scapula protraction and retraction is explored before combining the recruiting of shoulder depressor muscles

• Shrug on chair – Dominique is encouraged to take as much time resisting the way up as well as the way down, thus to be in control of the movement the complete repetition.

• Arm work - Triceps Press sitting, Side Kneeling Arm press, Side Kneeling stretch on Wunda chair: more movements to combine stabilization of the trunk, and the activation and strengthening of shoulder depressor muscles. The movements balances out tight antagonist muscles, namely the upper trapezius.

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• Full body Integration on reformer – Up stretches with emphasis on

scapula stabilization. Down stretch with emphasis on mid back strength and scapula stabilization

• Hip extension and back extension on Avalon – in addition to providing challenges to mind by putting the body in a unfamiliar position, the back chain exercises on Avalon challenges the client by freeing up the ROM, allowing supine movements to go from negative to neutral to positive.

Conclusion A carefully thought out Pilates exercise program can safely and successfully improve general fitness of clients with shoulder issues because its approach is global. Incorporating well-executed Pilates movements can reverse the faulty movement pattern that causes pain and deconditioning in other parts of body. While each movement has different muscle focus and objectives, the underlying principle of holistic care is constantly present to reinforce the motor learning and adaptation, and reinforcement of healthy and efficient use of our body be it static or dynamic. The client should be reminded that good habits form the same way bad habits form. Even after the pain is gone, tight muscles relieved and weak muscles strengthened, and the general balance is brought back to the body, in order to maintained the balance and the “good” posture, the client should be encouraged to continue Pilates or include some form of mindful and holistic exercise in her life.

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Bibliography Borstad J. D., Ludewig P. M. (2005 April). The effect of long versus short pectoralis minor resting length on scapular kinematics in healthy individuals. Retrieved 23 July, from http://www.ncbi.nlm.nih.gov/pubmed/15901124. Clark, M. A., Lucett, S. C., & Sutton, B. G. (2012). NASM Essentials of personal Fitness Training. Fourth edition. Piladelphia, PA:Lippincott Williams & Wilkins Feil, C. & Morgan, W. E. (2010 May 6). The Importance of the Thoracic Spine in Shoulder Mechanics. Retrieved 20 July 2013, from http://www.dynamicchiropractic.com/mpacms//dc/article.php?id=54622 Franklin, E. (2012). Dynamic alignement through imagery. Champaign, IL:Human Kinetics. From FDA reports: Depression and Kyphosis n.d. Retrieved 20 July 2013, from http://www.ehealthme.com/cs/depression/kyphosis Isacowitz, R. & Klippinger, K (2011). Pilates Anatomy. Champaign, IL:Human Kinetics. Isacowitz, R. (2013). Study Guide. Comprehensive Course. Costa Mesa CA: Body Arts and Science International Kebaetse M. & McClure, P. & Pratt N. A. (1999 August) Thoracic position effect on shoulder range of motion, strength, and three-dimensional scapular kinematics. Retrieved 20 July 2013, from http://www.ncbi.nlm.nih.gov/pubmed/10453773 Paterson, J. (2009). Teaching Pilates for Postural faults, Illness & Injury. A practical guide. Kidlington, Oxford:Butterworth-Heinemann Elsevier

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