The Pilates Shoulder
I have been lucky over the years and treated many pilates instructors, mainly due to previous dancing related issues, however, there has been a reoccurring theme – The Pilates Shoulder!
I have not coined the phrase yet, but I have seen this problem in many people not just pilates instructors, but trainers and general public who have previously been told to hold their shoulder blades back and down!. This problem relates to ‘engaging’ the lower traps and ‘setting’ the scapulae to maintain a neutral posture. This is all done with the best intention of helping with or preventing shoulder dysfunction, but in my experience this often has the opposite effect.
My treatment strategy for most of these clients has been the same “relax your shoulder, stop engaging” and miraculously their RoM and pain has resolved. So why is this occurring?
What does the research say?
Many studies (Kelly et al 2005, Ludewig 2000, Reinold 2009) , have looked at sub-acromial impingement, scapula dyskinesis, upper crossed syndrome all relating to muscle imbalances around the shoulder girdle (over active pectorals and upper traps and decreased lower trap and serratus) and have been linked to different shoulder pathologies.
Many of the rehabilitation exercises for these conditions consist of ‘engaging/setting’ under-active muscles, resisted band exercises, and mobility stretches. A lot of these principles and exercises are used as ‘prehab’ for prevention of injuries and improving strength/posture.
Correct scapulae motion
During active abduction of the gleno-humeral joint the scapula will move at a ration of 1:2 through abduction, coupled with the movements of retraction and elevation which is produced by the upper trapezius. This action clears the acromium and allows the humeral head to rotate producing full RoM.
If someone is focused on keeping the shoulders ‘back and down’ to engage the lower trapezius this will in turn inhibit the ability of the upper fibres to produce the correct scapula motion and actually create an impingement in the GHJ.
Also, these exercises are largely isometric, which is an action that does not occur very often in normal activity. The body prefers an eccentric to concentric action or ‘load to explode’. How can we change these common exercises to create an eccentric lengthening to concentric shortening?
Treat the body as a whole
With most shoulder pains/dysfunction there will be a movement or stability issue at the scapulae and probably the thoracic and cervical spine. This means assessing in all 3 planes of motion and coupling motions of the spine (type 1&2).
But this should not be as far as we look!
We need to look at the core musculature, in particular its ability to lengthen in all planes, as well as the motion at the hips and feet in an upright position.
When we throw a ball or perform a dynamic movement we use the whole body to help the shoulder, this creates a summation of force from the ground up. In my opinion most shoulder problems occur because we are isolating the shoulder too much and the rest of the body is not helping enough. This problem is then compounded when we give more isolative exercises to the area and further decrease the link to the rest of body.
A simple way to assess the link between the shoulder and the rest of the body is with gait, this shows the action and reaction that the lower body can have on the scapulae motion. Another simple test is to assess the shoulder motion in a single leg stance. If we flex the GHJ in a standing position we also create extension at the spine and hips along with a transfer of weight towards the forefoot. What happens if we have restricted hip extension and decreased balance in a sagittal plane direction?
If we just look at the scapula and GHJ in this scenario we are missing a large chunk of the problem.
There is a large body evidence to show scapula dyskinesis is linked to shoulder pain and dysfunction, however this is an isolated view and does not really look for the cause of symptoms. Why has it occurred?
Look for the mostability (mobility and stability) throughout the body to see what is causing the shoulder to become dysfunctional and isolated.
Mark Leyland MCSP FAFS
For further information on this approach and our upcoming courses see:
www.momentum-physio.co.uk, weybridge, surrey, kT15 2SD
Cools AM, Dewitte V, Lanszweert F, et al. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med. 2007;35:1744-1751.
Decker MJ, Hintermeister RA, Faber KJ, Hawkins RJ. Serratus anterior muscle activity during selected rehabilitation exercises. Am J Sports Med. 1999;27:784-791.
Gray, G. Scapula, Peltrunkula. FVDS. www.grayinstitute.com
Kelly BT, Williams RJ, Cordasco FA, et al. Differential patterns of muscle activation in patients with symptomatic and asymptomatic rotator cuff tears. J Shoulder Elbow Surg. 2005;14:165–171.
Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther 2000;80:276–91.
Reinold MM, Escamilla R, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther 2009; 39(2):105-117.