Relieving Upper Back Pain by Strengthening the Major Muscle Groups that Act on the Shoulder Joint

Jacqueline Christy February 25, 2015 Balanced Bodies, Herndon, VA (2014) 1

Abstract Take a breath and relax your shoulders down away from your ears. Now pull them slightly back and broaden your chest. Don’t you feel better? Upper back and shoulder pain is a significant condition for many individuals. Our society incorporates many rounded shoulder activities, such as, sitting at computers, driving, texting, etc., and it will continue to be an issue that must be addressed. This paper begins with an overview of the major muscle groups that act on the shoulder joint-- the muscles of scapular stabilization, rotator cuff and the movers of the shoulder joint. With the knowledge of their importance, I outline a case study of an individual who seeks to combat her upper back and shoulder pain through a Pilates conditioning program. Through Pilates exercises and increased body awareness in her daily life, she is able to see success and less pain.

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Table of Contents

Title Page ....................................................................................................................................................1 Abstract ......................................................................................................................................................2 Table of Contents........................................................................................................................................3 Anatomical Descriptions.......................................................................................................................4–6 Introduction and Case Study.................................................................................................................7–9 Sample Program .......................................................................................................................9–14 Conclusion ................................................................................................................................................15 Bibliography .............................................................................................................................................16

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Anatomical Descriptions The shoulder girdle is comprised of paired clavicles (collarbones) and scapulae (shoulder blades). The structure of the shoulder joint is a ball-and-socket joint, which allows the possibility of a wide range of movements. However, this great mobility is accompanied by a lack of stability. Therefore it is vital to develop correct mechanics and balanced muscular support. The major muscle groups that act on the shoulder joint include the muscles of scapular stabilization, the rotator cuff and the movers of the shoulder joint.

Major Muscles of Scapular Stabilization: Trapezius: Moves, rotates, stabilizes the scapula and extends the head at the neck. It is a wide, flat, superficial muscle that covers most of the upper back and the posterior of the neck. Rhomboid Major, Minor: Connect the scapula with the vertebrae of the spinal column; work together to keep the scapula pressed against the thoracic wall and retract the scapula toward the vertebral column. Levator Scapulae: Resides at that back and side of the neck; its goal is to lift the scapula. Serratus Anterior: A broad, curved muscle located on the side of the chest. It functions to pull the scapula down and to the front, and is used to thrust the shoulder forward as when pushing something. Pectoralis Minor: Thin triangular muscle on upper part of chest, located beneath pectoralis major; assists in protraction of the scapula, depression of the shoulder and downward rotation of the scapula.

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Rotator Cuff Muscles (connect the scapulae to the proximal humerus): Supraspinatus: Located in the depression above the spine of the scapula on the back surface. Connects the scapula to the greater tubercle of the humerus. Infraspinatus: Thick triangular muscle; main function is to produce external rotation of the humerus and stabilize the shoulder joint. Teres Minor: Smaller/thinner than Teres Major; produces shoulder external rotation and horizontal abduction. Subscapularis: Large triangular muscle; produces internal rotation.

Movers of the Shoulder Joint: Deltoid: Muscle forming the rounded contour of shoulder; powerful mover of the humerus in flexion, extension and abduction. Pectoralis Major: Thick fan shaped muscle on the chest that flexes the shoulder joint. Latissimus Dorsi: The broadest muscle of the back (often referred to as the “lats”); a very thin triangular muscle. The functions involve arm adduction, extension and medial rotation of the arm (see image on prior page). Teres Major: A fairly thick, flat muscle on the posterior shoulder; a major internal rotator of the shoulder joint (see image on prior page). Coracobrachialis: Small muscle that attaches to coracoid process of the scapula. Not a significant mover. 5

Biceps Brachii: Two-headed muscle that lies on the upper arm between the shoulder and elbow; main function is to flex the forearm at the elbow and supinate the forearm. Triceps Brachii (Long Head): Muscle of back arm that originates from the scapula and shoulder to insert at the elbow. This Long Head portion has a role in stabilizing the shoulder joint (see image on prior page).

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Introduction It is common for individuals to complain of upper back and shoulder pain but not be able to pinpoint where or why they have developed this issue and why it persists. In the body of this paper, I discuss a case study on my sister. To begin, I identify some of the possible causes of this pain and the need for developing a balanced program to address her discomfort. The Pilates conditioning program is outlined and highlights certain exercises pertaining to scapular stabilizers and scapular mover muscles to achieve her goals. The conclusion summarizes the overall findings and outlines suggestions for others to achieve success as well.

Case Study Name

Meredith Lucas

Age, Sex

28 years old, Female

Limitations

● ● ● ●

Rehabilitation Treatments

● Visit to orthopedist to validate there were no musculoskeletal issues associated with the pain ● Physical Therapy and Massage Therapy ● Pilates Conditioning Program

Dominant/ tight upper trapezius muscles Weak lower trapezius and serratus anterior muscles Slight forward head posture Shoulder blade imbalance: Right shoulder blade sits farther from the spine than the Left shoulder blade ● Pronated foot alignment

Meredith’s upper back pain began approximately two years ago while working a full-time, sedentary marketing job in Washington DC. It started gradually while juggling work and personal life, but got to a point where she was thinking about her pain approximately 80% of the day and as she went to sleep every evening. She had always been an active person with primary activities including running/walking, Pilates, barre and yoga classes. She participated in approximately 3 group classes per week while trying to live a healthy lifestyle.

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There came a point when she realized stress and years in a sedentary job were probably contributing to an increase in pain. After a bit too much “self diagnosis,” she decided it was time to figure out the reason for this chronic pain. First she went to an orthopedist because she wanted to rule out that her condition was anything related to bones, joints, etc. Since she had a dull pain for so long, there was never a specific incident to note as an injury. However, at the time of the doctor appointments, she was feeling more pain on the right side and it traveled to the back of her arm during certain upper body exercises. The doctor did some initial tests to make sure she could perform all forms of movement around the shoulder joint. There was nothing that alarmed him, so he referred her to a physical therapist to address the pain and give a more detailed diagnosis. In her initial visit to the physical therapist, he measured that the right scapula was sitting further from the spine than the left and that she had slight forward head posture. There was also some hyperlordosis posture elements present, such as, hyperextension of knees, forward head and slight anterior tilt of pelvis. The physical therapist validated that the upper trapezius muscle fibers were tight and acting as a dominant force in exercise and daily activities, and identified tightness in the pectoral muscles. It was further explained that she had developed improper movement patterns of the shoulder muscles and over time these muscle imbalances resulted in the significant pain. Additionally contributing to her discomfort was overuse of certain muscles in her group exercise classes (most likely because the instructor did not have time to ensure that every client was using the correct muscle for the desired movement). For example, in a barre class, she was using too much weight in the arm series, which can cause the upper traps to tighten and work harder, so the desired muscles aren’t working. And in yoga class, she wasn’t 8

engaging the proper back muscles --rhomboids, trapezius, serratus anterior-- in a chaturanga pose (similar to a front support or tricep push-up). It was clear that in order to be free of this upper back and shoulder pain, she needed to dedicate significant time to strengthening the surrounding muscle groups that act on the shoulder joint. Since she was no longer seeing a physical therapist, it was also necessary to relieve the muscle tension through massage and stretches so that the Pilates strengthening program would be as effective as possible. I developed a Pilates conditioning program utilizing the BASI Block System while keeping in mind the importance of the body as a whole. While she had been practicing some Pilates on the mat, she didn’t have as much experience with the various apparatuses. Below is an example of our conditioning program. Throughout our sessions, it was important to keep in mind that the muscles she needed to strengthen might affect other areas that focused on advanced scapular stabilization.

Pilates Conditioning Program (sample of Fundamental+/Intermediate Level) BLOCK: WARM UP Apparatus Mat

Exercises ● ● ● ● ●

Roll Down Pelvic Curls Spine Twist Supine Chest Lift Chest Lift with Rotation

We begin with a standing Roll Down to assess posture and try to relax the shoulders. The fundamental BASI warm-up is a comprehensive way to warm up the spine and abdominals for greater movements. Specifically, I look for the shoulders to relax during the pelvic curls and spine twist supine. Often times, in chest lifts, I give her a magic circle to support the head and let go of neck tension to focus on the abdominals. 9

BLOCK: FOOT WORK Apparatus Cadillac

Exercises ● ● ● ● ● ● ● ● ●

Parallel Heels Parallel Toes V Position Toes Open V Heels Open V Toes Calf Raises Prances Single Leg Heel Single Leg Toes

A benefit of the footwork on the cadillac is the stretch you receive in the hamstrings, as well as the feedback you can observe with the positions of the feet. She often elevates the shoulders to the pads of the reformer, so when lying down on the cadillac I mention cues to remind her to relax the shoulders, maintain a neutral spine position and pelvic stability.

BLOCK: ABDOMINAL WORK Apparatus

Exercises

Cadillac

Breathing with the PT Bar Bottom Lift with the RU Bar

Breathing with the PT Bar was selected because it incorporates a brief stretch of the shoulders overhead while using stabilizers to keep the shoulders from elevating. It then utilizes abdominals as a main muscle focus while incorporating the hamstrings for the pelvic curl and back extensors for the teaser portion. The back extensors play a key part in achieving proper spinal alignment, which is part of our goal. The Bottom Lift with the RU Bar focuses on the abdominals and the latissimus dorsi, so as you reach the bar to the thighs, we are strengthening the broadest back muscle and working towards our goal of strengthening a major shoulder muscle.

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BLOCK: HIP WORK Apparatus

Exercises

Cadillac

Supine Leg Series ● Frog ● Down Circles ● Up Circles ● Walking ● Bicycles

Hip work focuses primarily on pelvic lumbar stability, hip adductor and hamstring strength. Doing hip work on the cadillac requires additional pelvic stability and relieves tension through the hip joints that comes from sitting for long periods of time.

BLOCK: SPINAL ARTICULATION Apparatus Cadillac

Exercises ● Monkey Original ● Tower Prep

Monkey Original provides a nice stretch for the hamstrings after the intense work on those muscles while engaging the abdominals. Tower Prep focuses on the abdominals and hip extensors while gaining much needed articulation to stretch and strengthen the spine.

BLOCK: STRETCHES Apparatus

Exercises

Cadillac

● Shoulder Stretch Prone

Step Barrel

● Shoulder Stretch Lying Side (when time permits or at start/end of session)

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Shoulder Stretch Prone is a deep stretch that works the shoulder rotators and provides a stretch for the pectorals. It is during this stretch that I can notice a deeper tightness in her right side. It is important to move through the stretch very slowly through full range of motion (visualizing a screwdriver type motion). Note: If a client has a shoulder injury, tear, etc. they should not do this exercise/take caution.

BLOCK: FULL BODY INTEGRATION F/I Apparatus

Exercises

Cadillac

● Side Reach (Push Through Group)

Reformer

● Up Stretch 1 ● Long Stretch

Side Reach on the Cadillac is another great stretch in the pectorals as you reach back. While the main muscle focus is the abdominals with an emphasis on the oblique, it is important to stretch the muscles we are focused on throughout the session so these muscles are trained to relax. On the Reformer, I chose Up Stretch 1 to focus in on the basic Up Stretch position for when we add on to it. This position is key for training proper shoulder stabilization and achieves a good shoulder stretch. Long Stretch continues the emphasis on trunk and scapular stabilization, as well as shoulder flexor strength. The serratus anterior is a significant muscle aiding in scapular stabilization in the Long Stretch and its activation should be carried on throughout other planking exercises.

BLOCK: ARM WORK Apparatus

Exercises

Reformer

Arms Sitting Series ● Chest Expansion ● Biceps ● Rhomboids ● Hug-A-Tree 12

● Salute Wunda Chair

● Shrugs ● Triceps Press Sit

The Arms Sitting Series on the Reformer works many of the muscles we are focused on to strengthen the major muscles of the shoulder joint such as, the latissimus dorsi, biceps, posterior deltoid, pectoralis major and triceps. It is important to do these exercises with proper form. At times, I would reduce the resistance and ensure the correct muscles were working in the specific exercise. On the Wunda Chair, Shrugs is a fundamental exercise that focuses on the trapezius muscle and is designed to achieve scapulae depressor strength. Triceps Press Sit flows nicely after Shrugs and enforces scapular stabilization once again.

BLOCK: LEG WORK Apparatus Wunda Chair

Exercises ● Backward Step Down

The main objective is hip extensor strength, which is imperative for a well-balanced body. Specifically, the muscle focuses of the gluteals, quadriceps and hamstrings do a great deal is supporting other fitness activities and daily activities that she partakes in as well.

BLOCK: LATERAL FLEXION/ROTATION Apparatus

Exercises

Wunda Chair

Side Pike

This is a challenging exercise that needs a lot of attention to detail to be done correctly. The objectives include scapular stabilization and shoulder flexor strength, which are key in our program. Initially, I wanted her to obtain the correct position (even if she didn’t move the pedal much). I spotted this by 13

holding her shoulders directly over the hands while using the abdominals and deltoids to go into the pike position.

BLOCK: BACK EXTENSION Apparatus

Exercises

Wunda Chair

Swan on the Floor Roll Down (to conclude the session)

Back extension is one of the focuses of this program to recruit the proper muscles. Swan on the Floor teaches scapular stabilization, back extensor strength and shoulder extensor control. Cuing to pull the abdominals in is imperative throughout the exercise. We complete the session with Rest Position to release the back muscles and a standing Roll Down to gain further postural awareness.

Results Through a steady Pilates program of two to three times per week for four months, she was able to see significant results and decrease the pain in the upper back by strengthening the surrounding muscles. This helped relieve the muscle imbalances of the upper and lower trapezius and her shoulder scapulae are now evenly spaced from the spine. Specifically, the focus on scapular stabilization and correct use of the rotator cuff muscles in the chosen exercises (and so much of the Pilates repertoire) taught the proper mechanics in accordance with the needs of proper arm movements and more advanced exercises. Additionally, the correct activation of the large shoulder muscles (the latissimus dorsi, deltoid, pectoralis major and teres major) resulted in increased strength. In conjunction with this program, I instructed her to do stretches on the foam roller and use a small ball to relieve muscle tightness on a regular basis. During stressful situations or not being conscious of her alignment, she can start to see old habits recur, so it is imperative to reiterate this muscle awareness in daily activities and posture. 14

Conclusion The time and dedication to research this topic is so important because various shoulder dysfunctions are widely prevalent in today’s world of increased use of technology and sedentary lifestyles. This can contribute to round shoulder syndrome, neck pain, headaches and many faulty postures. There is also an ongoing trend towards a wide range of group fitness classes and it is important to know which muscles you should be activating in order to avoid muscle imbalances and to progress at your current level in a healthy manner. Ideally, individuals would obtain private instruction to ensure proper form in combination with group classes, but that is not always the case. Unfortunately, I do foresee upper back pain continuing to be a common issue in the future, but through regular Pilates programs we can help prevent and relieve those issues with great success.

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Bibliography 1. Body Arts and Sciences International, BASI Study Guide Comprehensive Study Guide. Costa Mesa: BASI Pilates, 2000 - 2013. 2. Clippinger, Karen and Rael Isacowitz. Pilates Anatomy. Champaign: Human Kinetics Publishing, 2011. 3. Elson, Lawrence M. and Wynn Kapit. The Anatomy Coloring Book. San Francisco: Benjamin Cummings, 2oo2. 4. http://www.innerbody.com/ 5. Graphics: a. http://droualb.faculty.mjc.edu/Lecture%20Notes/Unit%203/Pectoral_Muscles.jpg b. http://droualb.faculty.mjc.edu/Course%20Materials/Elementary%20Anatomy%20and %20Physiology%2050/Lecture%20outlines/06_16Figurea-L.jpg c. http://www.drjonhyman.com/rotatorcuffpage.html d. http://fce-study.netdna-ssl.com/images/upload-flashcards/back/8/4/54848603_m.jpg

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