Pilates for the treatment of Rounded Shoulders

Pilates for the treatment of Rounded Shoulders Nicola Heweston September 2015 Wimbledon UK, January 2014

Abstract Rounded shoulders is a description of a common posture abnormality whereby the shoulders appear further forward, often accompanied by a hunching or bending forward of the upper spine and head (kyphosis). The rounded shoulder posture is often associated with and contributes to non-optimal function of the shoulder complex. This paper outlines the BASI Pilates conditioning program used, to help correct rounded shoulders, in a 33-year old and otherwise healthy individual. It concludes that with regular Pilates sessions, improved body awareness and accompanied lifestyle changes, the muscular imbalances and holding patterns that cause rounded shoulders can be addressed, and the posture of the individual improved.

Table of Contents Title 1 Abstract 2 Table of Contents 3 Anatomy of the Shoulder 4 Introduction 7 Case Study 7 Conditioning Program 8 Conclusion 12 Bibliography 13

Anatomy of the Shoulder The bones of the shoulder complex consist of the humerus (the upper arm bone), the scapula (the shoulder blade), and the clavicle (the collar bone). The clavicle is the only bony attachment between the trunk and the upper limb (sternoclavicular joint). It forms the front portion of the shoulder complex and runs the entire length with a gentle S-shaped contour. The clavicle articulates at one end with the sternum (chest bone) and at the other end, with the acromion of the scapula (bony structure on top of the scapula). This articulation between the acromial end of the clavicle and the acromion of the scapula forms the roof of the shoulder (acromioclavicular joint). The scapula is a large, flat triangular bone that forms the back portion of the shoulder complex. The flat blade of the scapula glides along the thoracic wall (back of rib cage) allowing for extended movement of the arm, encased by 17 muscles that provide control and stabilisation (sometimes referred to as the scapulothoracic joint however there is no bone connection). The scapula also has a shallow cavity (glenoid cavity) where the head of the humerus connects to the shoulder joint (also known as the glenohumeral joint). This ball and socket joint of the shoulder allows arm movement in every direction. The lack of bony and ligamentous support in the shoulder complex means that the shoulder is muscle dependent, relying heavily on the muscular for good shoulder function and shoulder stability. These muscles can be divided into three groups:

Fig 1 Joints of the shoulder girdle Global stabiliser muscles that connect the scapula to the surrounding bones (head, spine, ribcage) but with no direct connection to the humerus (upper arm). The primary function of this group is to stabilize or move the scapula in accordance to needs of the arm: trapezius, rhomboids, levator scapula, serratus anterior and pectoralis minor. Local stabilisers the rotator cuff is a group of small muscles that connect the scapula to the proximal humerus, essential for providing shoulder stability and facilitating correct shoulder mechanics: supraspinatus, infraspinatus, teres minor and subscapularis (Fig 2). Global mobilisers large muscles that function to produce gross movement of the arms: pectoralis major, latissimus dorsi, deltoid and teres major.

Fig 2 Rotator cuff muscles Good alignment of the trunk, as close to the plumb line as possible, is key to achieving correct shoulder mechanics. Conversely, without good body alignment, good shoulders mechanics are not achievable and faulty shoulder mechanics can lead to shoulder problems. Rounded shoulders can lead to impingement (when the bony structures of your shoulder begin to compress the bursa and the underlying rotator cuff tendons), impingement can lead to rotator cuff inflammation, inflammation to tearing and potential incapacitation. Correct shoulder mechanics also involves a co-ordinated, linked movement of the scapula and humerus termed scapulohumeral rhythm. To this there are two key components, the first is abduction of the glenohumeral joint (primarily produced by the supraspinatus and deltoid muscles) and the second is upward rotation of the scapula (serratus anterior, upper, middle and lower trapezius includes scapular depressors to prevent excessive elevation). If this linked movement is properly co-ordinated, there will be a 2:1 ratio of movement in the glenohumeral joint to that of the scapulothoracic articulation. Conditioning programs that focus on achieving good shoulder mechanics must start with attaining good alignment of trunk, followed by the inclusion of strengthening exercises for the rotator cuff and muscles involved in scapular stabilisation.

Introduction Rounded shoulders is a description of a common posture abnormality whereby the shoulders appear further forward, often accompanied by a hunching or bending forward of the upper spine and head (kyphosis). There are many lifestyle factors in modern day society that contribute to this posture; sitting at a desk working on computers, bending over whilst using a mobile phone and sitting for hours to eat, drive or watch TV. All these activities involve forward flexion and typically lead to weak back extensors and shoulder external rotators; tight pectorals, hip flexors, hamstrings, and shoulder internal rotators; and an overactive levator scapula and upper trapezius. Fig 3 Head and shoulder muscle imbalance pattern upper crossed syndrome, often found in individuals with rounded shoulders and desk-workers Case Study Name: Claire Age: 33 Lifestyle: Desk-worker who has practiced Pilates regularly for last 2 years. Goals: To achieve correction of forward head, rounded shoulders posture and improvement in shoulder stability and range of motion (current restriction observed when raising arms overhead).

Conditioning Program 8 week programme, 2-3 sessions per week Objectives: Strengthen the abdominals, back extensors and neck flexors to achieve improved head and trunk alignment. Strengthen the rotator cuff muscles and muscles involved in scapular stabilisation (rhomboids, serratus anterior, lower and mid trapezius), stretch the pectoralis minor and major to lengthen and open out the chest. Encourage awareness of unhelpful movement patterns (e.g. over-activation of the levator scapulae and upper trapezius), as well as holding patterns (e.g. habitually holding shoulders / arms in a hunched position). WARM UP Roll Down Mat: Pelvic Curl, Spine Twist Supine, Chest Lift, Chest Lift with Rotation Cue client to slightly tuck chin when required, to correct the habitual forward head and train the head to retract to plumb line position. Chest Lift and Chest Lift with Rotation performed on a Step Barrel to increase the range of motion from spinal hyperextension to spinal flexion. Added benefit of significant stretch for the chest (thoracic region). FOOTWORK Reformer: Parallel Heels, Parallel Toes, V Position Toes, Open V Heels, Open V Toes, Calf Raises, Prances, Single Leg Heels, Single Leg Toes Footwork performed lying on a half foam roller, taking arms out to sides with the palms facing up, allowing the pectoral muscles to open and stretch. Chair: Parallel Heels, Parallel Toes, V Position Toes, Open V Heels, Open V Toes, Calf Raises, Single Leg Heels, Single Leg Toes

Progressed to Chair to further develop trunk and pelvic stabilization. Hand positions selected to stretch chest, varying between a) hands near rear of seat resting on fingertips, with elbows bent and reaching back and b) arms outstretched into a T. ABDOMINAL WORK Step Barrel: Overhead Stretch, Teaser Prep Chair: Standing Pike Reverse, Full Pike, Torso Press Sit Progressing to Chair to further develop abdominal control and scapular stabilization. Full Pike to further strengthen the shoulder girdle. Torso Press Sit to strengthen the back extensors and abdominals, stretch the chest and shoulders, and develop hip flexor control. HIP WORK Cadillac: Basic Leg Springs Series - Frog, Circles Down, Circles Up, Walking, Bicycle Avalon Chair: Frog, Circles Down, Circles Up, Openings, Helicopter Progressed to Avalon to leverage the hand position to open out the chest further (hands holding levers, elbows reaching out to sides). Plus Helicopter is a good for a functional hamstring stretch. SPINAL ARTICULATION Chair: Pelvic Curl Reformer: Semi-Circle Semi-Circle selected as has the added benefit of arms overhead for a chest/shoulder stretch and in comparison to other repertoire, an increased range of motion to take lower back from flexion to extension.

STRETCHES Reformer: Hamstring Stretch Group - Kneeling Lunge Step Barrel: Shoulder Stretch Lying Side Week 3-5: Ladder Barrel: Shoulder Stretch 1, Shoulder Stretch 2 Cadillac: Shoulder Stretch Week 6-8: Pole: Pole Series Shoulder Stretch, Overhead Stretch, Side Stretch, Spine Twist FULL BODY INTEGRATION F/I Selected 1-2: Reformer: Up Stretch Group Long Stretch, Up Stretch 2, Down Stretch Group Down Stretch Cadillac: Push Through Group Cat Stretch Kneeling, Sitting Forward, Side Reach ARM WORK Selected 2-3: Chair: Shrugs, Triceps Press Sit Cadillac: Push Through Group Shoulder Adduction Single Arm, Shoulder Adduction Double Arm, Sitting Side Prep Avalon Chair: Arms Sitting Series Chest Expansion, Biceps, Rhomboids, Hug-A- Tree, Circles Up, Circles Down, Salute Selected Arms Sitting Series on Avalon Chair oppose to Reformer for 3 reasons a) removes constraint of tight hamstrings, b) has the addition of Circles Up and Circles Down that have a wider range of motion, and c) addition of back support to help client keep a broad back and scapulae stabilised throughout (oppose to Reformer Arm Kneeling Series).

FULL BODY INTEGRATION A/M Week 7-8: Reformer: Balance Control Front To develop trunk and scapular stabilization and to strengthen the shoulder extensors. LEG WORK Reformer: Long Box Group Hamstring Curl Selected over other leg work repertoire as the position of lying prone, hugging the front of the box with the upper back extended is advantageous to opening out the chest. LATERAL FLEXION / ROTATION Selected 1: Cadillac: Butterfly Reformer: Mermaid Reformer: Short Box Group Side Overs BACK EXTENTION Step Barrel: Swan Prep Cadillac: Prone 1, Prone 2 COOL DOWN Rest Position, Roll Down

Conclusion Claire is pleased with her progress to date from her BASI Pilates program. Her shoulders look visibly less rounded and internally rotated, and her chest feels more open with a greater depth of breath. Claire has gained more awareness of faulty movement patterns, such as bending over to reach for an object by folding at the chest (oppose to bending at hip joint). Claire has also made lifestyle changes such as sleeping on her back with one pillow (previously slept on two pillows) and using a backpack when possible (oppose to holding a handbag over one shoulder). Lifestyle changes alongside increased strength in her abdominals, back extensors and neck flexors have resulted in Claire s head retracting and spine aligning closer to the plumb line, key in achieving good shoulder mechanics. Her shoulder stabilisation has also improved and the abduction / adduction range of motion of her scapulae increased. Claire plans to continue with the BASI Pilates program to work on fine tuning her shoulder mechanics, increasing her overhead range and incorporating the principles of Pilates into her everyday life.

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