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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  subject’s  shoulder,  but  of  the  

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

approach  of  the  BASI  Block  System.  

 

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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  

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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,  

stabilize  or  move  scapulae  

Serratus  anterior,  

trapezius,  rhomboids,  

levator  scapulae,  

pectoralis  minor  

Scapulohumeral  

muscles  

(“Rotator  Cuff”  muscles)  

Maintain  shoulder  

stability  and  contribute  to  

subtle  movements  

Supraspinatus,  

infraspinatus,  teres  minor,  

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,  Steven’s  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:  

Steven’s  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:  

Steven’s  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  

Parallel  Toes  

V  Position  Toes  

Open  V  Heels  

Open  V  Toes  

With  only  a  medium  tension,  Steven  will  

focus   on   stability   and   correct   alignment  

(specifically   of   the   thoracic   and   cervical  

spine)   without   emphasizing   resistance  

and   quadriceps   strength.     A   small   ball  

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Calf  Raises  

Prances  

Prehensile  

was  necessary   in   the  beginning  beneath  

the  chin  to  correct  forward  head  posture.    

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-­‐  

Frog  

Circles  (Up,  Down)  

Openings  

This   series  builds  hip  adductor  strength  

and  emphasize  pelvic  lumbar  stability,  it  

is  fundamental  and  a  integral  part  of  this  

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   client’s   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  

client’s  primary  goal  of  shoulder  

mobility  and  flexibility.  

 

Full  Body  Integration:  Cadillac  

Push  Through  Group-­‐  

Sitting  Forward  

Side  Reach  

The  client  will  stretch  the  hamstrings,  

while  also  stretching  the  shoulder  

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-­‐  

Chest  Expansion  

Hug-­‐A-­‐Tree  

Circles  (Up,  Down)  

Punches  

Biceps  

Focus   on   scapular   stabilization   while  

strengthening   and   practicing  

recruitment   of   latissmus   dorsi,   the  

shoulder  extensors,  pectoralis  major,  the  

triceps,  and  the  biceps.    I  cue  for  postural  

alignment   and   the   recognition   of   each  

muscle   involved   in   rehabilitation   of  

scapular  dyskinesis.  

Push  Through  Group-­‐  

Shoulder  Adduction  Single  Arm  

Shoulder  Adduction  Double  Arm  

Sitting  Side  Prep  

Shoulder   adductor   control   is   very  

important   for   the   client’s   rehabilitation.    

This   is   great   for   latissmus   dorsi  

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.