Pilates

for Scapular Dyskinesis

Aubrey Lewis

May 25, 2014

Course year: 2014

Denver, Colorado, USA (Pilates Denver Studio)

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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 subjects shoulder, but of the

strength, posture, and spinal alignment of the whole body, utilizing the holistic

approach of the BASI Block System.

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

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

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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 Attach scapula to thorax, Serratus anterior,

stabilize or move scapulae trapezius, rhomboids,

levator scapulae,

pectoralis minor

Scapulohumeral Maintain shoulder Supraspinatus,

muscles stability and contribute to infraspinatus, teres minor,

(Rotator Cuff muscles) subtle movements subscapularis

Axiohumeral muscles power muscles, produce Pectoralis major, lattismus

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 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-

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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.

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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, Stevens 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:

Stevens 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.

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 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:

Stevens 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

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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 With only a medium tension, Steven will

Parallel Toes focus on stability and correct alignment

V Position Toes (specifically of the thoracic and cervical

Open V Heels spine) without emphasizing resistance

Open V Toes and quadriceps strength. A small ball

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Calf Raises was necessary in the beginning beneath

Prances the chin to correct forward head posture.

Prehensile 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- This series builds hip adductor strength

Frog and emphasize pelvic lumbar stability, it

Circles (Up, Down) is fundamental and a integral part of this

Openings holistic Pilates program.

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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 clients 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

clients primary goal of shoulder

mobility and flexibility.

Full Body Integration: Cadillac

Push Through Group- The client will stretch the hamstrings,

Sitting Forward while also stretching the shoulder

Side Reach adductor and oblique. These exercises

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 emphasize spinal mobility, another

crucial part of this holistic program.

Arm Work: Cadillac

Arm Standing Series- Focus on scapular stabilization while

Chest Expansion strengthening and practicing

Hug-A-Tree recruitment of latissmus dorsi, the

Circles (Up, Down) shoulder extensors, pectoralis major, the

Punches triceps, and the biceps. I cue for postural

Biceps alignment and the recognition of each

muscle involved in rehabilitation of

scapular dyskinesis.

Push Through Group- Shoulder adductor control is very

Shoulder Adduction Single Arm important for the clients rehabilitation.

Shoulder Adduction Double Arm This is great for latissmus dorsi

Sitting Side Prep 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.

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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

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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.

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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.

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