About 2 million people in the U.S. visit the doctor annually for rotator cuff problems (AAOS 2008), and at least 3% of adults will experience adhesive capsulitis, or frozen shoulder (Manske & Prohaska 2008). Multiple exercises can help prevent or postpone surgery, but what if they don’t seem to work? When regular shoulder exercises don’t help your client improve, or if they hurt too much, it’s time to start looking beyond the shoulder girdle.
Because the scapula articulates with the rib cage (protracting with flexion, retracting with extension, etc.), if the ribs and spine have developed a postural tendency such as kyphosis, lateral flexion or a rotation, this may affect the resting position and movement of the scapula. So, how do you get the ribs in the right spot? You program moves that increase mobility in the thoracic spine.
What’s So Special About the Thoracic Spine?
Decreased thoracic spine mobility has been linked to a variety of shoulder difficulties, according to Laurie Devaney, MSc, a personal trainer and a clinical instructor in the department of kinesiology’s physical therapy program at the University of Connecticut. “Any time you lift your arm, you are involving the thoracic spine, so limited movement in the thoracic [vertebrae] and ribs will impinge the shoulder and put more mechanical strain on the shoulder itself.” Devaney suggests that if you do not address the thoracic spine when working with a shoulder impingement, any results you see could be negligible. To avoid pain, she recommends targeting a remote area before dealing with the immediate source of pain.
That’s where Cate Vallone, STOTT PILATES® instructor trainer and owner of Evolution Pilates in Hartford, Connecticut, began with her client, Sandy (name changed). Sandy’s profile may sound familiar: a sporadic runner in her early 50s whose body, like that of many runners, was tight and tense. Her legs were built; her upper body was tight but not strong. She muscled through exercises and didn’t like corrections.
Sandy came for a workout, not to get involved with the Pilates method. But then life happened, forcing her to pay a little more attention to her body. She rescued a dog that was difficult to walk. Over time, the dog’s pulling on the leash injured her shoulder. After ignoring it and trying cortisone shots, she asked Vallone for help with the injured area.
It’s important to remember that Pilates teachers are not physical therapists. As a rehabilitative team member, Vallone saw her job as “restoring proper functional movement to the injured area.” It’s a physical therapist’s job to include massage and provide ways to reduce inflammation, two tasks that remain outside the Pilates purview.
The Value of Mobilizing the Rib Cage
At the start of their rehabilitation sessions, Sandy’s shoulder was in such pain that Vallone couldn’t incorporate the arm. She began working on a remote location—the thoracic spine—to mobilize the rib cage. She introduced flexion and extension and progressed to lateral flexion and rotation, making spinal mobility the exclusive goal of Sandy’s workout.
Before a client like Sandy can learn better movement skills, she needs a basic understanding of how parts connect and interact. There must be a dialogue about movement so the client understands how the work on the remote area will support the affected area, ultimately leading to more strength and less pain.
As instructors we can explain a basic ball-and-socket joint to our clients. Stephenie Liebler, PhD, a biomedical engineer in Naples, Florida, who works as a research associate, suggests we give clients a visual of a mortar and pestle surrounded by muscles that act as the strings of a marionette puppet—pull one string in one direction and another needs to give. We can then incorporate the scapula as a counterweight.
Think of your arm as an old drawbridge—it is long and reaches across the water. To be lifted for a boat to pass, a block has to move on the other end to balance and off-load the weight; otherwise, the bridge won’t rise. The scapula serves that purpose for the arm—it’s the counterweight. Once a client understands the scapula’s role in shoulder joint and arm movement, it’s easy to visualize the scapula resting on the ribs. The spine moves the ribs; we must move the spine.
Ask your clients to feel this in their own bodies. Have them round into kyphosis and then (using the good arm) lift the arm up in front of them. How far does it go? Does it produce pain? Next have them sit in as neutral posture as possible and lift the good arm. How high does it go? Does it produce pain? The answer will be considerably higher and with less discomfort. The more mobility the spine has, the more mobility the scapula has. The more mobility the scapula has, the more mobility the shoulder and arm will have. Each piece links to the next piece.
Change Does Not Come Quickly
The process between Vallone and Sandy took time. Retraining someone’s neuromuscular control doesn’t happen overnight. Younger clients who are fit, healthy and athletic with an acute shoulder injury should be able to pick up on these changes and be rehabilitated faster, since generally they still have good thoracic flexibility. Older clients have practiced poor posture and bad habits for much longer, as in Sandy’s case. So while the dog walking was the straw that broke the camel’s back, a lifetime of tension and tight kyphosis was causing impingement in Sandy’s arm and shoulder muscles every time she moved. It’s the chronic postural and lifestyle issues we need to work on with clients to improve shoulder injuries.
This was a hard lesson for Sandy, someone who was really fit and active for 50 years old. Vallone had to build trust and keep encouraging Sandy to understand that learning something new takes time and patience—an empowering recognition. The dog walking wasn’t going away. Even if a cortisone shot worked, she would just get injured again. Learning another way to function in her body became a valuable tool.
As we help clients regain thoracic mobility, we need to make sure the movement comes from the correct place. Devaney recommends using the cue “Lift the sternum” to retrain bad habits many of us were taught: jutting our ribs forward and pulling our shoulders back and down. It’s not just about strengthening the posterior muscles but also about lengthening the anterior muscles, including the pecs, abdominals and hip flexors—the “marionette strings” that enable a person to lift the sternum. Without lengthening the front, clients are forced to work through a lot of passive resistance.
Once Vallone reincorporated arm movement, she never programmed in isolation because she didn’t want Sandy to move her arm as a “separate entity.” Instead, she wanted her to think, “I start from my foundation. I create support and move from the center of my body.” Vallone aimed for minimal load on the arm. “If you fight the pull of a dog with your arm, you are only as strong as your arm. If you fight the pull of a dog with your whole body—your back, your legs—you gain skills that make you stronger,” says Vallone.
The goal for each client, no matter the circumstance, is to learn to regain strength and mobility from the center out. For the shoulder, that center is the ribs. Rib cage mobility is vital for proper shoulder movement and impingement reduction.
AAOS (American Academy of Orthopaedic Surgeons). 2008. Rotator cuff tears. www.orthoinfo.org; accessed April 1, 2014.
Manske, R., & Prohaska, D. 2008. Diagnosis and management of adhesive capsulitis. Current Reviews in Musculoskeletal Medicine, 1 (3-4), 180-89.