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This is the third article in a three part series that will familiarize trainers with
the functional anatomy of the major structures of the body and explain the
most common musculoskeletal imbalances for each. Trainers will learn how to
assess a clients imbalances as well as some techniques that can be used
during regular exercise programs to correct problems, eliminate pain and
improve function.
Figure 1a
Figure 1b
The four most common deviations of the thoracic spine and shoulder girdle
are excessive thoracic kyphosis, a protracted shoulder girdle, internally rotated
arms and elevated scapula.
The thoracic spine is naturally curved forward forming what is called a
kyphotic curve. However, when this curvature is excessive, it can become
problematic. When the thoracic spine rounds forward, the shoulder blades
usually move away from the spine and slide forward on the ribcage. This is
known as protracting the shoulder blades. As the shoulder blades protract, the
arms internally rotate in the shoulder joint preventing the arms from moving
correctly. Consequently, the shoulder blades (scapula) tend to elevate. Any or
all of these compensatory patterns can cause pain and dysfunction.
Verbal Assessment
Conduct a verbal assessment first to gain insight from clients into their
interpretation of the pain and function of the body parts you are assessing. Ask
the following questions:
1. Do you ever experience pain in mid to upper back, chest, shoulders,
neck, ribcage or abdominals? Ask them to be specific about the location
of the pain (i.e., is it on the front of the shoulder, the top of the
shoulder, back of the shoulder, under the shoulder blade, under the
armpit, back of the neck, side of the neck, middle of the chest or
sternum). This will help you to identify a probable cause.
2. Have you ever been diagnosed with arthritis in the shoulders or spine?
This will help you understand the condition of the joint structures of the
thoracic spine, shoulder girdle, neck and head.
Figure 2
Rib to Spine Assessment (Part Two)
Look at your client from the front to check for forward shoulder and internally
rotated arms. If this is the case, you will be able to see the back of your
clients hand(s), rather than his thumbs facing forward. Look also from the
side and back to see if his shoulders are rounded or his shoulder blades have
moved away from his spine (e.g., protracted). The shoulders may also be
shrugged slightly, causing muscle tension in the neck and shoulders.
Figure 3
The two most common deviations of the head and neck are a forward position
of the head and excessive cervical lordosis. A forward position of the head is
evident when the head extends forward of the center line of the body. The
further the head moves forward, the more the neck has to arch keep the eyes
parallel to the horizon. This excessive curvature of the neck is referred to as
excessive cervical lordosis.
When assessing the neck and head, it is important to get a very clear picture of
the structures involved. When necessary, ask male clients to remove their
hats/caps and ask females to pull their hair away from their neck.
Verbal Assessment
As with the other parts of the body, you will need to conduct a verbal
assessment of the head and neck. Ask clients about the specific location of any
pain, if they have been diagnosed with arthritis, about their occupation and
level of physical activity and the level of stress they experience during the
day. Always write down any pertinent information you find.
Figure 4
through the center of the eyeball and out into the room. If this imaginary line
is not parallel to the floor, then your client has excessive cervical lordosis (see
Figure 5). In Figure 5, the client shown has excessive cervical lordosis.
Figure 5
Figure 6
Exercise Recommendations
If the thoracic spine, shoulder girdle and head and neck are not functioning
optimally, any movement under load can cause pain and/or injury to any part
of the body. For example, if a client is performing an overhead pressing
movement and he can not achieve the desired thoracic extension to press the
weight over his head, he may over arch his lower back to stop the weight
falling forward. This may lead to a lower back strain, lumbar disc
compression and/or nerve pathologies. Similarly, if the humerus can not
externally rotate and the glenoid can not move posteriorly to get the weight
over his head, then only the elbow will move back to press over his head. This
will place further stress on the shoulder joint.
Here are three exercises to help your clients overcome the structural
deviations discussed herein.
Two Tennis Ball Trigger Point Release (see Figure 7) - Excessive thoracic
kyphosis can cause the muscles of the thoracic erector spinae group to become
sore and inflamed. These muscles need rejuvenating and regenerating before
trying to attempt strengthening exercises that would place further stress on the
tissues.
Instruct your client to lie on the ground on his back with his knees bent and a
tennis ball placed on either side of his thoracic spine. The tennis balls should
be almost touching but far enough apart so as not to be in direct contact with
the spine itself. Ask your client to lie back over the balls, keeping his chin
tucked in to his chest so his line of sight is perpendicular to the ceiling.
Use a pillow to ensure his neck does not arch backwards. (If the pressure on
the balls is too great, simply increase the size of the pillow to lift his spine off
the balls.)
Figure 7
Once he is in position, coach him to tilt his pelvis to try to flatten his lower
back. This will increase the pressure on the balls. Instruct him to stay on one
spot for about 30 seconds and then move the balls to another sore spot along
the thoracic spine and repeat. Be sure to only place the balls near, not on, the
thoracic spine. This exercise can be done once a day where there are any sore
spots.
Supine Wave Goodbye (see Figure 8) - Excessive thoracic kyphosis can lead
to a weakness in the muscles that retract and depress the shoulder blade,
externally rotate the arm and flex the head and neck as well as to tightness in
the anterior shoulder and chest. All of these areas need addressing to help
create a balanced shoulder girdle and head and neck.
Instruct your client to lie on his back on the ground with his knees bent. Ask
him to raise his arms to shoulder height with elbows bent and the back of his
palms on the ground. Have him pull his shoulders back to the floor and down
towards his hips. (Clients with rounded shoulders may be tight in the anterior
shoulder. If you place a towel under their elbows, they will be able to pull
their shoulders down more effectively.)
Figure 8
When your client is in the correct position, place a foam roller under the back
of his palm and instruct him to apply isometric resistance into the roller.
Coach him and observe to ensure that he keeps his shoulder back and down as
he applies resistance with the back of his hand into the roller. This exercise
will help strengthen the posterior shoulder muscles to help stabilize the
glenoid. During the exercise, also coach your client to keep his chin tucked in
with his line of sight perpendicular to the ceiling. This will strengthen the
anterior neck and head flexors and decrease an excessive cervical lordotic
curve. Do six to 10 isometric contractions every day for a hold of five to 10
seconds per contraction.
Thoracic Extension with Hip Extension (see Figure 9) - When your clients
soft tissue structures have been addressed, he may be ready to begin
strengthening the muscles that help put the thoracic spine into better extension
and flex the shoulder.
Instruct your client to interlock his fingers and raise his arms over his head
with the palms up. Be sure he doesnt excessively shrug his shoulders during
the movement. As he raises his arms, ask him to simultaneously step back
with one leg, tilting the pelvis posteriorly to reduce the amount of extension
occurring in the lumbar spine.
When your clients soft tissue structures have been addressed, he may be
ready to begin strengthening the muscles that help put the thoracic spine into
better extension and flex the shoulder. Instruct your client to interlock his
fingers and raise his arms over his head with the palms up. Be sure he doesnt
excessively shrug his shoulders during the movement. As he raises his arms,
ask him to simultaneously step back with one leg, tilting the pelvis posteriorly
to reduce the amount of extension occurring in the lumbar spine.
Figure 9
Evaluate the mechanics of the shoulder girdle as the client raises their arms. If
they bend one or both arms excessively, they may have shoulder discomfort,
and you will have to progress to this exercise more gradually. Do five to 10
repetitions daily.
Conclusion
This series of three articles has helped to explain how to perform a basic
structural assessment of your clients. In my next series of articles, you will
learn about functional anatomy, look at how to assess and address the soft
tissue structures of the body and explore functionally based exercises that will
correct even the most problematic imbalances.
References:
1. Abelson, Dr. Brain and Abelson, Kamali. Release Your Pain. Calgary:
Rowan Tree Books, 2003.
2. Golding, Lawrence A. and Golding, Scott M. Fitness Professionals
Guide to Musculoskeletal Anatomy and Human Movement. Monterey,
CA: Healthy Learning, 2003.
3. Gray, Henry. Grays Anatomy. New York: Barnes & Noble Books,
1995.
4. Petty, Nicola and Moore, Ann, P. Neuromusculoskeletal Examination
and Assessment: A Handbook for Therapists. Edinburgh: Churchill
Livingstone, 2002.
5. Price, Justin. A Step-by Step Guide to the Fundamentals of Structural
Assessment. Lenny McGill Productions, 2006.
6. Price, Justin. A Step-by Step Guide to the Fundamentals of Corrective
Exercise. Lenny McGill Productions, 2006.
7. Schamberger, Wolf. The Malalignment Syndrome: Implications for
Medicine and Sport. Edinburgh: Churchill Livingstone, 2002.
8. Shafarman, Steven. Awareness Heals: The Feldenkrais Method for
Dynamic Health. Massachusetts: Perseus Books, 1997.
9. Taylor, Paul M. and Taylor, Diane K. (Eds.). Conquering Athletic
Injuries. Champaign, IL: Leisure Press, 1988.
10.Whiting, William C. and Zernicke, Ronald F. Biomechanics of
Musculoskeletal Injury. Champaign, IL: Human Kinetics, 1998.