Winging It! · Abstract Scapular winging is a rare and usually painful condition where the shoulder blade, which ... injuries such as washing the car and digging, to non-traumatic

Winging It!

Name: Louise Carey

Date: 20 January 2018

Course year: 2016

Location: Live & Breathe Pilates, Dublin, Ireland

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Abstract

Scapular winging is a rare and usually painful condition where the shoulder blade, which

should rest flush against the posterior ribs, protrudes.

As Pilates instructors, the most common cases we see are less severe, where a client

struggles with stabilising their shoulder blades during Leg Pull Front for example.

There are many reasons for this difficulty in stabilising, ranging from repetitive motion

injuries such as washing the car and digging, to non-traumatic injuries such as viral illnesses

and medical conditions.

This paper will focus on the former type – repetitive motion injuries – and in particular an

office worker who sits at a desk all day, hunched over a computer/laptop, repeatedly using a

mouse on one side.

The purpose of this research paper is to look at how to overcome this type of ‘office worker

posture’ with exercises outside of, and indeed within, the working environment.

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Table of Contents Abstract ................................................................................................................................................... 2

The Science – Shoulder Anatomy ........................................................................................................... 4

Introduction ............................................................................................................................................ 7

Case Study Details ................................................................................................................................... 8

BASI Programme ..................................................................................................................................... 8

Conclusion ............................................................................................................................................. 12

Bibliography .......................................................................................................................................... 13

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The Science – Shoulder Anatomy

The shoulder complex is just that- complex! The shoulder girdle is composed of one clavicle

and one scapula, and the shoulder complex includes the humerus (as illustrated in Figure 1

below).

Figure 1: Source - www.townsvillemassage.com

The scapula has no direct attachment to the spine or skeletal arrangement but rather, slides

along the ribcage with only muscles connecting it to the spine. In fact, the only bony

attachment of the arm to the axial skeleton is at the sternoclavicular joint (see Figure 1

above).

Because of this, shoulder mechanics and movement are very dependent on the surrounding

muscles (thus the complexity), resulting in imbalances in this area having a large impact on

the efficiency of shoulder movements. For example, the arm (humerus) should be able to

move independently of the scapula but this commonly is not the case.

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At it’s most serious, scapular ‘winging’ is often associated with a weak serratus anterior

muscle and trapezius muscle (see Figure 2 below), stemming from damage to the long

thoracic nerve and spinal accessory nerve respectively.

Figure 2: Source – US National Library of Medicine, National Institutes of Health

(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684151/)

The serratus anterior assists in 3 movements:

1. allowing the scapula to rotate when the arm is lifted overhead

2. protracting the scapula (moving shoulder blades away from each other)

3. rotating the inferior angle (bottom tip of the scapula) upward and laterally (to the

side, either toward the spinal column or away from it)

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At its simplest, the trapezius muscle works to:

1. elevate the scapula (shoulders to ears)

2. retract the scapula (draw the shoulder blades together)

3. rotate the scapula (scapula movement when lowering arm by side or lifting

overhead)

Figure 3: Source - https://www.acefitness.org/fitness-certifications/resource-center/exam-

preparation-blog/3516/muscles-that-move-the-scapulae

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Introduction

This research paper focuses on the struggle with scapular stabilisation, and in particular

medial winging of the scapular – of someone ‘winging it’ too much (extreme case

photographed in Figure 4 below). It seeks to address how this may occur in the office

environment and what can be done to mitigate these causes.

Figure 4: Source - https://www.physio-pedia.com/Winged_scapula

The case study is based on a 34 year old female. Although on a daily basis she sits at an

office desk for a minimum of 9 hours a day, she is also active. However she struggles with

scapula stabilisation in all her training, particularly (being a right-handed person) on the

right hand side. This does not cause her any pain or discomfort, but rather is something

that her personal trainer and Pilates instructor have observed in her movement.

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During the course of the research, the focus was placed on strengthening and isolating the

serratus anterior and trapezius muscles.

Case Study Details

The case study is Emma Browne – a 34 year old intermediate Pilates student who cycles to

and from the office each day (30 minutes each way) and then sits at her desk for a minimum

of 7 hours. She described her computer as being slightly to the right of her desk so her

sitting position is slightly rotated to the right.

Emma has a good level of fitness, regularly doing weight and spin classes. Outside of

difficulty with stabilising the right shoulder blade, Emma struggles with tight hip flexors

particularly when her legs are in table top for any length of time, and also during exercises

such as teaser. She has never seen a physiotherapist or received any treatment for any of

her issues and advises that she does not suffer any pain in these areas.

BASI Programme

Being an intermediate student, the BASI programme selected for Emma over 10 sessions

included foundation and intermediate exercises, adding advanced exercises in later sessions

to add challenge. The exercises, reason for selecting these particular exercises and the

desired results are listed below (note, not all exercises where used at every session):

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BLOCK Exercise(s) Apparatus Focus of Exercise Reason for selecting and Desired Result

Warm up Roll down’s X3 Roll Up Supine Spine Twist Double Leg Stretch Single Leg Stretch Criss Cross

Mat (actually performed on reformer with platform extender for fluidity of class)

Focus of these exercises are mainly abdominals and obliques.

Warming up body in preparation for the class. Want to include spinal articulation and rotation as well as warming up the core. Particular focus was put on keeping serratus anterior activated by ‘reaching through the little finger’ during roll up.

Footwork Parallel heels/toes V position toes Open V heels/toes Calf raises Prances Prehensile Single leg heel/toes

Reformer (3 red springs)

Muscle focus - abdominals for

pelvic stability - hamstrings - quadriceps - foot plantar

flexors

Emma did footwork lying supine in order to help her feel the ‘heaviness’ and ‘breadth’ of the shoulder blades on the carriage.

Abdominal Work

Breathing with the push through bar Full Pike

Cadillac (medium spring) Wunda Chair (medium to heavy springs)

This exercise works on the abdominal muscles while improving coordination, balance and breathing. While this exercise takes much abdominal strength, Emma also focussed heavily on getting the serratus anterior working.

One of Emma’s favourite exercises so it was included regularly throughout the sessions for her enjoyment! Emma worked on the cue of ‘ballooning’ her thoracic area to keep the shoulder blades broad and stable, as well as pushing the Wunda Chair into the ground throughout. This helped with the serratus anterior engagement

Hip Work Single Leg Supine Series Frog Down/up Circles

Cadillac (leg spring – medium to heavy)

Hamstrings and adductors are the main focus of these exercises.

Good exercises to help Emma focus on engaging the back of her thigh (rather than the dominant

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BLOCK Exercise(s) Apparatus Focus of Exercise Reason for selecting and Desired Result

Hip extension Bicycle

quadriceps) while keeping the pelvis stable

Spinal Articulation

Tower Prep Cadillac (medium springs)

This exercise is for abdominals and hip extensors

This is a good exercise for Emma, not only to get her hip extensors activated, but also for the scapula stabilisation that is required throughout. Broad shoulder blades were always cued

Stretches Shoulder Stretch lying side

Step barrel

This exercise focuses on stretching the latissimus dorsi and pectoral muscles

Another exercise that Emma specifically requests – she enjoys the open sensation this gives across the front of her chest and shoulders after a long day at work.

Full Body Integration (Fund/Inter)

Cat Stretch Kneeling

Cadillac (medium springs)

Working abdominals and back extensors while putting particular focus on scapula stabilisation during the shoulder stretch phase

Emma has to pay particular attention to reaching down and forward into the push through bar during this exercise to keep her right shoulder blade stabilised.

Arm Work Pole Series - Shoulder Stretch, overhead stretch, side stretch, spine twist Shrugs Triceps Press Sit

Box and Pole Wunda Chair (medium springs)

The shoulder stretch in particular focuses on the trapezius muscle The muscle focus of shrugs is the trapezius so Emma returned to this exercise regularly.

Not only does the Pole Series work the trapezius and shoulder muscles, it is also a great posture exercise, the learnings of which, Emma can take to the workplace. Helps to isolate and strengthen the lower trapezius muscle to depress the scapula.

Full Body Integration (Advanced/ Master)

Balance Control Front

Reformer (1 red spring)

Specifically working on abdominals and deltoids.

Wanted Emma to get the sensation of always pushing the shoulder blocks to the floor to keep shoulder blades broad across the back

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BLOCK Exercise(s) Apparatus Focus of Exercise Reason for selecting and Desired Result

Tendon Stretch

Wunda Chair (medium to heavy springs)

Abdominals and the serratus anterior are the muscle focus for this exercise

Similarly to the full pike, looking for abduction and depression of the scapula during this exercise so Emma had to focus on pushing into the Wunda Chair and ‘ballooning’ the thoracic area.

Leg Work Hip Opener Wunda Chair (light to medium springs)

The focus of this exercise is the hip external rotators

From sitting and cycling, Emma is very dominant in her quadriceps and hip flexors. This brings focus into the hamstrings and hip external rotators.

Lateral Flexion/ Rotation

Mermaid Reformer (1 red spring)

The main focus of this exercise is obliques, however scapula stabilisation is also of utmost importance

Challenging Emma to stabilise the scapula in rotation, and keeping it depressed while bringing the carriage back to the stopper. Also nice open hip sensation for her.

Back Extension

Swan on floor Finished with Roll downs

Wunda Chair (light spring)

The trapezius is the muscle focus for this exercise to depress the scapula as the back extends.

Not only does this exercise focus on the trapezius (one of the muscles this case study wanted to focus on), it also is great upper back work which is always important for office workers who can become tight and rounded in the front of the upper body.

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Conclusion

After 10 sessions, Emma had an increased awareness of the movement of her shoulder

blades, particularly on the right side. She started to recognise the difference between using

and not using her serratus anterior in exercises such as the full pike.

Following an ergonomic assessment of her workstation, Emma adjusted her desk and

computer so that she was facing straight on, at the right head (eyeline in line with the top of

her screen). She alternates using the mouse on the right and left side when using her

computer in work and has found that, along with her Pilates return, this has significantly

improved the ‘winging’ scapula on the right side.

Emma is conscientious about correcting her posture at her desk during the day using the

cues and alignment learned during her sessions, as well as performing small range thoracic

extensions at the desk at regular intervals. All of these factors have culminated into Emma

feeling less restricted in her pectoral muscles and with greater control of her shoulder

blades.

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Bibliography

1. Calais-Germain, B. (2014). Anatomy of movement. Seattle: Eastland Press.

2. Innovations in Pilates, Matwork for Health and Wellbeing. (2018). 1st ed.

Hurstbridge: Rebus Press.

3. Isacowitz, R. and Clippinger, K. (2011). Pilates anatomy. Champaign: Human Kinetics.

4. Pilates, J., Miller, W., Robbins, J. and Van Heuit-Robbins, L. (2012). Pilates' return to

life through contrology. [Place of publication not identified]: Presentation Dynamics.

5. Shoulderdoc.co.uk. (2018). Winging Scapula | ShoulderDoc. [online] Available at:

https://www.shoulderdoc.co.uk/section/492 [Accessed 20 Jan. 2018].

6. Physiopedia. (2018). Winged scapula. [online] Available at: https://www.physio-

pedia.com/Winged_scapula [Accessed 23 Jan. 2018]

7. Martin, Ryan M., and David E. Fish. “Scapular Winging: Anatomical Review,

Diagnosis, and Treatments.” Current Reviews in Musculoskeletal Medicine, Humana

Press Inc, Mar. 2008, [online] Available at:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684151/

8. Author Mollie Martin Contributor Mollie is a Study Assistance Consultant at the

American Council on Exercise who holds a BS in Psychology. She is an ACE Certified

Personal Trainer. “Muscles That Move the Scapulae.” ACE,

www.acefitness.org/fitness-certifications/resource-center/exam-preparation-

blog/3516/muscles-that-move-the-scapulae