Hi, I'd like to introduce you to the way that I teach people how to use their shoulder appropriately. In physical therapy. I work with a lot of patients who have shoulder pain and shoulder dysfunction, but a lot of times people just have poor biomechanical control or they have decreased range of motion or they have a little impingement that can really be helped by some simple things to do in the [inaudible] environment. So I'm going to start by looking at Candace and looking at her, really her structure, her posture, where she sort of holding her shoulder in space on her body and then, uh, help her with understanding how to use her shoulder more effectively and bringing her attention to the shoulder mechanics and how the shoulders it should be working. So Candace, thank you for coming. Um, come on up to standing and then I'd like to have you just face me first and then the right shoulder has been a problem. You said it has a little bit of decrease in range of motion. It's been painful, but it's getting better. You've been doing [inaudible], right? You also play tennis and so you've been having a little bit of elbow pain with that too. And have you ever had neck pain? Not really. Okay.
So no neck pain, nothing radiating, tingling, numbness down the arms cause you always want to kind of see if the person has having a net problems that can be contributing to the shoulder, which can often be the case the case. So we look into, we want to look to see if the shoulder is positioned correctly on the body. And right now we see that the Scapula has a bit of an angle here and she's holding the shoulder forward in the socket. She's quite muscular and she's developed nicely and in the upper body. And sometimes it's harder to see the scapula in that way. And I'm looking at the upper traps and just kind of feeling around the shoulder to see is there a big difference in muscularity or tone, tension in the muscles.
And I'm not seeing a huge difference from right to left. And then, um, I'm going to straighten your top just a little bit. Cause when we look at you from the back, it's going to look, um, off center. So let me just make sure that centered in your body. Okay, now go to the back there and we look at both scapula and it's hard to see where the scapula are. So you have to really put your hands on there. And I think of um, finding the, the points of the Scapula here, the inferior lateral angles of the scapula first. And then I imagine that the scapulary like two continents of Africa.
So the Cape of Good Hope or Cape Town is down here. We're going to go up the borders here, up to the Atlas Mountain Range, which is the spine of the Scapula and out to the acromion. So I'm looking to see if the Scapula is placed evenly on the back, right to left. And I'm also looking to see if there is a difference in the rotational position of the Scapula. Is One scapular more adducted toward midline than the other? All right. Now while we're here, I'm going to palpitate all the way out to the acromion.
And sometimes this is hard to feel with somebody that's more muscular that you'll feel the pointy bits right here at the edge of the acromion. And this a chromium makes a little shelf over top of the humerus. And then there's the acromion right there on both sides. And then I feel the humeral head. And when I feel from the front, let's have you face the front again. And when I feel from the front, I shouldn't feel so much of a protrusion of the humeral head. It should be really well aligned with the, with the clavicle.
So you see the indentions here that um, should be quite flat in better posture of the shoulder. So she might have some tension in the pectoral muscles and some of the muscles that hold that shoulder forward in the socket that will be working on. Okay. All right. So what I want to do is have, um, her also touch the clavicles. And it's funny in teacher training programs, I'm constantly having the students do this palpation technique, but I never did it with clients. And so a few years ago I started doing it with clients and it made a huge difference in their shoulder function. So you're gonna feel across the top here and really feel where the clavicle attaches to the sternum.
The unique thing about the shoulder is that the clavicle only attaches to the axial skeleton right here, and the whole shoulder girdle is held right there by that small ligament that attaches the clavicle to the sternum. And if we didn't have muscles, those 18 muscles that hold the shoulder blade to the body, then it would just be hanging from the the collar bone there. All right. And now rest your arms down, turn around. I'm going to get my bones out, which makes it a lot easier to see what's going on. So this is a a right scapula and if I put the Scapula on her back where her scapula is located, it's actually about right there. So then once I position the Scapula on the back, I'm going to look to see, you know, how far it is from midline. If it's really close to midline, she might be over-correcting or if it's really far away from midline and she's Kyphotic, then that might be an issue as well.
So she's got a good distance of the shoulder away from midline there. Then I take the humeral head and put it in the socket right there. And I like to tell people that the humeral head's like a socket, like a golf ball on a tee and the socket is really tiny and look at that. So the job of the rotator cuff is to hold that Scapula and the in the humeral head within one centimeter of the center of that socket. So you can face me now while I'm talking about this. Um, so there's that tiny little center of the, the Glenoid Fossa and again, the, the job of the rotator cuff is to hold that humeral head within one centimeter of that midpoint of the socket. So it has a big job.
I think of it like a sandwich. And we have it like this and it's rotating back and forth. So there is muscle under the scapula that holds onto the front of the shoulder joint and there's muscle on top of the scapula that holds onto it. So if you don't have really good biomechanical control of the Scapula and humerus, you're going to have, you're going to end up having shoulder problems. You don't have them when you're 20 you end up having them.
When you're like 40 45 you're like, oh my shoulder kinda hurts, you know, or it hurts when I lift my arm up and then it starts to get a little more irritated a little more often. It gets a little achy in the morning when you wake up, hard to sleep on it. Does this sound familiar? Has its own pillow? Yeah, it has it's own pillar. Wonderful. And then, and then eventually you start to lose a little bit of range of motion and then we don't want to end up with frozen shoulder so that that's a painful situation that you don't want to end up with. So we're going to see if we can prevent that. All right, now I want to see how, how you move. Um, let's have you face the windows and when we move the arms to about 90 degrees, let's go ahead and bring the arms straight up and forward.
We shouldn't see much motion in the Scapula. So I'm going to be looking for that now come back down and then I'm going to hold onto the Scapula here and let's just see if it moves and lift up. So hers moves a little bit and it actually shouldn't and it actually moves more on the right than the left. So what that means is that she may have either a mechanical patterning problem with the muscles, or she might have tension or stiffness in the glenohumeral joint. So that kind of drags the scapula forward.
She also noticed when she was talking to me earlier, that she has weakness in shoulder flection. When she tries to do like the serving exercise on the reformer, it's hard for her to push that, that right shoulder forward. All right, now let's look from 90 degrees. Let's also look at what these muscles are doing. So if you could do that one more time. So I don't think she's overusing her upper traps. She holds a lot of tension here to start with, but I don't think that she's over recruiting the upper traps and I don't think that the Scapula is pulling in.
So a lot of times you'll see people when they lift their arms, they do it with their neck and with our upper traps. Okay, coming back down. Now bring your arms out to the side like this. Okay. And let's see what happens there. Come back down again
Now bring the arms forward again. All right. Now what I want to see is where does the scapula end up when she raises the arm overhead. So go ahead and go overhead. Yeah, and she's starting to, she has a little stiffness and a little bit of pain and then the right Scapula is really far forward to the left. I'm going to have you turn to the side. Come back down first though. Good. Now come back to the side. That's right. Now do that same thing again. We're going to look at that from all directions and then come back down.
Great. Let me get behind you one more time. I stick my hand in the armpit and I feel when that edge of that scapula comes forward and to see where does it end up. So hers ends up just a little in front of the greater trow canter and the left side is actually in alignment. Come back down. All right, now facing the front. Now lift the arms straight forward so they can see that from the front. And now let's go up overhead.
Do you see the difference in the the left Scapula and the right Scapula? The right shoulder is a little bit forward of the left and then what's happening up here is that there's a, a lot of decreased space between the shoulder and the neck. So we need to work on that. Okay, coming back down. Excellent. All right. So then we get out our trusty little PyLadies tools. But um, one thing I want to see first before we start is um, the external rotation. Cause you mentioned that that was a little stiff too.
So we look at external rotation by palms up and then take the arms out as far as you can. Look at the difference between the rotation on the right and the rotation on the left. She's limited here. So that means there is a little bit of limitation in that glenohumeral joint. All right, face the back and let's do that again facing the back and let's see what happens there. And notice the difference in the left and right. So this scapula's almost winging a little bit.
So the left is not not quite right on this one either. But then the right is definitely more limited than the left. Now take your right hand and reach it up as far as you can on your back. So this would be more internal rotation so you, she can go to about right here. And what you can do is count the number of vertebrae that she can reach up to and then come back down and then, uh, reached with the left and see how far you can go up. So yeah, she can go up to almost like t five or so. He or she's like a t nine or t 10.
So coming back down. So again, you could count to see how far she can reach behind the bat. We call it HBH, hand behind, head and behind. Back. Yeah. So now take your hands behind your head. Let's see how you do with that. Does that feel okay? Yeah, that looks okay. That's not too bad. So it's really around the 90 degree angle and then lower than that that she has some limitation. So come back down all the way and then reach the arms up and forward and then bend the elbows to a goalpost position if you could like that.
So that's the first thing we want to do is get that straight first and then start to do other things. So you're going to hold this like a serving tray palm up [inaudible] yeah, and when I showed this to Ron Fletcher, he always called this the Sherri shoulder setting exercise. And um, it's what I like to do before I start any towel work and to get the shoulder in the position that I want it to be in before we work it. Um, and then again, this is the, the Fletcher towel and developed by Ron Fletcher in the 1970s. All right, now separate your hands a little bit farther. That's it. And then re grip with your fingers and keep your families. That's it. And then pull the towel.
I just want to see what happens when she pulls and then release it. Interesting. Okay. Yeah. She's feeling something there. So I want you to, to zone in on this at home and to see what is happening to that. This humorous is not doing a whole lot, but this right one is really moving back in the socket quite a bit. That looks really good. That's exactly what I want to happen.
And I didn't pay you to make you do that, right? That's exactly what I want to happen. Yeah, that looks good. And then separate your hands a little bit more. So what I'm doing instead of passively getting my hands in there and being a physical therapist and stretching your shoulder, what I'm asking her to do is use the back of her rotator cuff for what it's intended to do. So again, that's that infraspinatus and Terese minor are supposed to pull that humeral head back in the socket and rotated externally and get it in a better position so that it's holding onto that humeral head and a better biomechanical position so you don't damage your shoulder. Uh, the, the head of the humerus as you work. All right. So what I'm also going to look for turn around and face the back please. Is, is she cheating? Because if she just adducts the Scapula, then that's not actually what I want.
So let's see if she keeps the scapula pretty much in place. Yeah. So you want to keep your scapula wide, that's it. And then do the action. Exactly. So the calculus should be stable on the back and then the humeral head rotate back just a little bit. That looks great. Now see if you can go out a little bit wider.
Now of course I would also be teaching her about her spine posture, making sure that her spine posture is aligned from the feet all the way to the head before I ever start doing anything with the shoulder. That's a different tutorial. So, so her spine posture looks pretty good though. She might be a little bit flat in the Thoracic and um, she might be a little bit shifted forward in the rib cage that we can work on as well. Okay. So now do again the arms out, elbows down by your side. That's it. And then keep the scapulas slightly wide on your back. And then you want to think of connecting the back to open the front. Perfect.
That looks really good. So she's not using her neck, she's not using her scapular adductors. She's using the humeral head in the right way. Good. So that's the preparation. And so that would be your homework exercise to start with. Now you're going to face the front again and then put the towel so that it's folded in half and take it across the shoulder girdle like that. Yup. And you're going to hold it at the ends.
So it's double the width of your shoulder girdle. Yep. Hold it. Yeah, right there. Both sides. [inaudible] that's how you know how, how, where to hold it. Does that make sense? So you fold it in half. [inaudible] I know this is the hardest part of the telework is that you fold it across the shoulder girdle and then you hold it at the open end. So then it's double the distance of your shoulder girdle. Okay. So there's a lot going on with this movement. So if she takes the towel out in front of her, I kind of like to start at collarbone height so they can kind of see their hands, see the towel. And I want you to flex your wrist down.
And so you're gripping the towel with your fingers, not so much your thumb. So flexing down and then back up again and then flex down and back up. I want her to know that she has control of her wrist position. So then I also want to see that she has a straight line between the inside of the elbow and thumb. Exactly. And then hold here. Now the idea is that you connect your pinky to the armpit, right?
So you feel this connection. Now I want you to keep your eyeballs locked for a moment and then pull the towel and notice where you feel. Usually you feel something in the elbow, the triceps, that's not where we're targeting. We want to target your back, right? So now bend your elbow just slightly and you're going to make a little parenthesis out of your arm. And then pull. That's it. So you're stabilizing the wrist. You keep the elbow slightly bent in the parenthesis arm shape, and then you pull. All right.
Next thing is to make sure that you're staying in that position. Yeah, Nick, making sure that you're pressing the humeral head back in the socket a little bit. So pull back into my fingers here. So I'm touching the back of the humeral head and having her pull. So that gives her width across the front. So we're, we're connecting the back to open the front. Good. That looks great. Now coming back down, and a lot of people get tired of holding the towel up. They get their deltoids, their neck is getting involved.
It's building endurance a little bit. So turn around and face the other way so we can show from the back. All right, so take the towel to collar bone height, flex the wrist down and then back up. And then find the middle. And then think of pulling the, I always say, pull the ears of the towel towards your armpit and then soften the elbows so that you have a little bit of a parenthesis shape. And my cue as a is to go in here and pull down on the armpit. So, and, and touch what I want her to work.
So I want you to push that down into my fingers. Yeah. And then almost got it. Go up and then down. Rise up with the shoulders toward the ears for a moment. That's it. And I'll pull them down. Sometimes you have to go up to end up to, to go down and then down and out. That's it. Up and down and out.
So I want this to be wide and I want her to activate the back of that arm pit to work the towel. Okay, so take the towel up and again, I want a little more work here in the armpit. Push down into my fingers. It's very strange. I know. And keep pushing down into my fingers. Good. And stay there. Push down and stay there. And now pull the towel taut. And then release it. Now breathe into, pull the towel, God expanding across the back and in Hell to release. Exhale to pull and inhale to release. All right, now that she's got the muscles that I want active, then we can go overhead.
Okay, so now take the towel to the front and then again, pulling the armpits down and you're going to think of driving the scapula forward and around your back. So let's get this left. Scapula forward a little bit more, right? Exactly. So think about driving the movement from here and take the towel overhead. Wonderful, right there. And then I want you to think of aiming the outside of your armpit forward and pull the ears of the towel forward a little bit so you can soften here, right?
So this should be more push as she's holding the towel up because she's activating here. Now go up with the shoulders and then back down. [inaudible] inhale to take it up. Exhale down, push into my hands. And that's it. That's it. Beautiful. That last one you just did was great. Yeah. One more. And then pull down and then forward like, yes.
And you're wrapping the scapula around your back. Perfect. That's exactly what I want. So let's go again, taking the towel forward and then armpit down on that right side. Great. Think of the armpits down and then take it up. Yeah. And then I'm going to have you push into here. Right here. Yeah. And then wrapped the ears of the towel forward, wrapping the scapular round, right. It's like you're trying to show off your armpits.
You've got a really cool tattoo. You want it to show. Exactly. Good. And then coming all the way back down now, how does that feel in your shoulder? Are you okay? You tired? It's a lot. Yeah. So there's some weakness. That weakness to me indicates that there's either some pain inhibition or there could be some contribution from your neck.
If you have a little bit of compression on the nerves that innovate the arm in your neck, that could be an issue. So if, if I were going to refer her to physical therapy and, and look at that more closely, I would do reflex testing. I would do neural tension testing and really clear the neck to make sure that there's nothing going on with the neck that's contributing to the shoulder problem. Okay. But for right now in the Pilati studio, there's no reason why she can't continue on with trying to get a little stronger, trying to activate better, trying to decompress this shoulder joint as she uses it so that you guys can can work with her and not have her go to physical therapy. I'm always trying to put myself out of a job, you know, so I want my plots teachers to be doing the work to reeducate my patients or clients so that they don't need physical therapy. Right. You don't want to run to the doctor or the PT every two minutes. Right. Okay. So I'm going to do one more exercise that you would do in the studio.
So say that she had a lot of pain with lifting the arms overhead and you had a lot of difficulty with that. I would take you to supine and then go ahead and lay on your back. Yeah. And I'm going to do the exact exercises that we just did. So I'm going to hold, have you hold the towel, Pama. And what's nice about this is that she has the connection of the scapula onto the table and she can lengthen the neck. And if I need a pillow then I can, I can use one.
What I'm noticing is that the, the right Scapula is a lot farther from the table than the left. So that she's got that, that holding pattern but don't, don't force it. It's okay. I'm just noticing and you don't need to do anything about it right now. Cause we could do some foam roller work. We could do some, you know, release work to this area here to get that.
Yeah. And she's already feeling a little bit of a pulling. So there may be some mild factual, you know, restriction there, but we're going to try to deal with it with exercise instead of doing manual therapy. Okay. So bring that hands up to a bent elbow position. Keep the elbows on the table. Now sometimes I have to put little props under the elbows so that it gets the shoulder in alignment. So that might be good for her. I'm going to do that with this other towel just to, to get her in a better biomechanical position.
So in a prop that elbow up a little bit. Good. Okay. Now pull on the towel and did you see that humeral head moved back a half an inch or so and then release? Excellent. So again I'm connecting the back to open. The front I'm using isn't that great. I'm using the rotator cuff posteriorly, the infraspinatus and the Terry's miner, which is right here to pull that humeral head back. And neurologically what happens is that you activate the back of the rotator cuff and you inhibit the front.
So it's a neurological called inhibition. So it sort of stretches that muscle and releases the muscle that's holding too much in the front. So that's what you want to do is activate that opposite muscles that you don't normally use. Right? So doing a few poles here and then open the hands a little bit more. And then sometimes I even take little balls and put them under the shoulders and have our press into the balls. Yep.
And then release and press and release. So there's just this tiny little movement, but again, you're only looking at that small joint, trying to get it more oriented in the socket. So it seems really tiny but very important. Good. So just she's got this really great awareness now of that, that area of the shoulder that she needs working. Okay. Then your next homework piece is to take the towel and your hands like this.
And again, folding the towel and getting me in the right position so you can practice that. So you can do it at home. You take the folded in, bring it across the shoulder girdle, and then hold it right there. And then if you have your own towel at home, you'll, you'll be able to count the number of knots and figure out which where to hold it. So take the towel overhead, that's it. Flex the knuckles and then straighten them out. That's it. And then pull the ears of the towel outward. That's it.
So you want a straight line here, which is what I love because you can see it very easily if you're doing it correctly, slightly bent elbows, that makes a big difference in what happens to the shoulder. So you want to open up through the front of that shoulder and then pull. Yeah. And you should feel a pull and a downward pull of the humeral head. Yup. And then release and pull and release. Good. And do a very gentle pole. And then take the towel overhead.
And of course you wouldn't have the, the tower bar in a way. And then come back up and then let's have you come down a little bit further. So let's get rid of this and then you can just bend your knees and um, you should be able to reach overhead now and then take the towel overhead. Okay, so now come back. You've got to get your biomechanics right. So you're going to do a gentle towel pole was slightly bent, elbows and straight wrist outward like that. And then taking the towel overhead, holding that scapula down and wide.
So slide back and your head will be all the way at the end of the table. Good. Okay. And then you're going to hold onto the tower bar. Now I chose two blue springs for her, which is a bit heavy, but um, but a good moderate amount of weight cause she's strong. But if she was very painful or very weak, I would choose two yellow or maybe one blue and then I would progress up to a red. All right. So making sure that the spine is in alignment. You're going to take a breath in and then reach the uh, bar up to the ceiling, letting the scapular wrap around your back and then pull the bar down.
Now when I know that she's got control of this bar, then you're not going to let go of it. Right. Okay. Then I'll go around to the back and one of my favorite things to do is to see if she's using her neck to do this work. So I want her to, to keep her neck relaxed. So I've got my fingers on the suboccipital area and I'm just placing my hands there just to monitor the tension and see if she's got tension in the neck as she's doing it. And she actually doesn't, most people do. I see. So we work on that, trying to do this motion without the neck being involved. And then my cue again would be to get in that outside of the arm pit here and pull down towards your waist. Good. And drive it from there.
Okay. And now come down to the table and then breathe in to come up. Breathe out to pull down. Good and breathe in and breathe out. Nice. And she has less range of motion posteriorly than the right. So she is going farther down with the left side and not so much with the right, but that still looks good. She's done a good job. All right, now you're going to bend the bar towards your head, bringing your elbows slightly towards your waist. So, so not pulled in too far, but just having the idea that you're active here and here. Go ahead. Okay, now take the bar out towards your forehead. Keep the elbows aimed in. So pretend like you have two panes of glass on the outside of your mat and you don't want to touch them. Okay?
So you're going to keep your elbows at about a 45 degree angle. Perfect. That's it. And then push the bar overhead. Okay. And then coming back up. So you're not going to go all the way overhead, right? So you're just going to pull the bar towards you. And I want to see if she's pulling it here from here. So pull it from there.
Yes. Make that do the work and keep the elbows in a little bit. [inaudible] cause she's going into that impingement position if she goes out wide. So I want to keep her a little bit more narrow. That's it. Nice. And then back up one more time. Elbows in [inaudible] and then back up. Okay. I've got the bar. You can release it. Exactly.
Great. And then of course I could take the tower bar. I usually take the springs off when someone does overhead work and then turn your head to the side just so you don't feel like you're going to need it by the bar. And then I want you to hold onto the bar overhead. That's it. And again, I'm going to just see how does she extend the arms? Yeah, that's actually really good. And then shrug the shoulders up toward me and pull down towards your waist.
Good. And then up toward me and down towards your waist. And again, I don't have any springs so I'm not in danger. I can just have her go up and down and again, queuing here, constantly trying to get her more aware of this muscle group so that she can use that to control the shoulder. One more time. Great. And then pull the bar all the way through. Bring the elbows in a little bit. So interesting. You've got this elbow here and this one way out here, right? So I want them to same and I want you to imagine those, those two pieces of glass on the outside of your mat. So let's do it again.
Take the bar overhead. Can you see your elbows in your peripheral vision? And I want you to make sure that that right elbow is down and forward. Make them the same. Okay. Can you see them now and pull this elbow forward. That's it. Uh Huh.
And then arms up toward the ceiling and pulled down toward the mat and then elbows in and pushed the bar overhead.
All right, now taking that armpit down toward my fingers. There you go. Okay, now keep that action and go overhead. Yeah, that's it. That's it. That's it. Much better. There you go. She's hanging onto this muscle, using it to asymmetrically control the shoulder, little shaky, right? And then coming down, she's just not used to using that muscle.
Feeling the sense of activation of that armpit, and then take the arms overhead. Let's see what that looks like. Still a little bit of work in this, this side versus this side. Do you see the pack? How it tends to want to work. So we still need to work on the towel work and then really getting that pattern to change and then coming back down. All right. And let me, let me touch here and do it again. Take it up. That's better.
So what you might want to do is look in the mirror and try looking at both sides of the arms and then come down. So if we were in the [inaudible] studio where I had a mirror that I could have you in front of, I would have you watched these two muscles here and make sure they stayed the same. Right? Because one of them is popping out on the right. Yeah. So you would keep that sense of that muscle length and as you go overhead and using the towel is going to help to activate that to great. Yeah, little shaky because there is a strength issue and it's again, muscles have been turned off for a while, it looks like, and we're trying to turn them back on. Great. Yeah. Any questions for me? Um, if I were to do this at home, how many repetitions would I do? Good question. Um, you do maybe four or five repetitions of the setting exercise in different range of motion and trying to get equal to the left and then do four or five like this and then start to reach the arms overhead four or five times.
So it's not a lot of repetitions. It's just trying to, trying to, um, really stimulate your brain and the biomechanics in the right patterning as often as you can. So it'd be better to do five repetitions, two or three times a day. Okay. You know, then to do 25, right? Yeah. I'm just really focusing in on your body and looking at in the mirror and kind of trying to figure out, wow, what looks different one side as opposed to the other. And again, I would put you in front of a mirror and have you and point those things out so that you can remind yourself that. And then of course, working with the teacher that can reinforce those patterns will be good. Yeah. Once or twice a week and then you practice at home. All right. All right. You're welcome. Thank you for being my subject.