Corrective Exercise Solutions to Common Hip and Shoulder Dysfunction Excerpt

Excerpted from Corrective Exercise Solutions to Common Hip and Shoulder Dysfunction
Evan Osar
From the Introduction, pages 7-16, edited for space

In his book How the Mighty Fall, author Jim Collins discusses cancer and how it is harder to detect in the early stages but easier to treat, and how it reverses in the advanced stages where it is easier to detect but much harder to treat. A similar analogy can be made about movement patterns—it is much harder to detect the subtleties of compensatory movement in the early stages although easier to correct them, and much easier to detect errors in chronic movement dysfunction when they are much more difficult to change.

What makes movement patterns so challenging to correct in the later stages than in the earlier stages? And what makes our clients’ movement so dysfunctional in the first place? It is important to ask these questions, as they are at the beginning of the journey to understanding the marvels and complexities of the human body, as well as provide a framework for both the correction and education processes that will help a client return to function. Too often clients are told there is nothing that can be done outside of medication or surgery, or worse, that the pain or limitations in movement are all in their heads. Unfortunately, for all the advances in medical technology, there are no fewer incidences of movement dysfunction.

Part of the issue with this disconnect is the fact that there are no medical machines or blood tests to prove movement dysfunction. The best these tests can prove is either there is or there is not pathology within the given region, meaning muscle inhibition cannot be seen in any test based on medical standards.

Poor stabilization in a single-leg stance does not register in any standardized equipment. However, the manifestations of these poor movement and stabilization strategies can be graphically visualized on a radiograph or MRI image. Osteoarthritis, more accurately described as degenerative joint disease, is just one manifestation of poor movement strategies and is not simply a process of getting older. Non-traumatic labral tears within the shoulder or hip are not the result of poor genetics or hereditary weakness, but rather the result of poor stabilization of the humeral and femoral heads within their respective articulations. Disc bulges and herniations are the result of poor stabilization strategies, leading to either overcompression or instability at or around the area of the disc pathology.

The point is not to discount genetics or hereditary causation, but rather suggest that individuals are more responsible for what happens to their musculoskeletal system than the intangible hereditary factors.

Why do we lose function, particularly stability, range of motion and movement efficiency? While there are multiple causes of these issues, they essentially fall into one of three primary categories: poor neurodevelopment, injuries and learned behaviors.

Lack of optimal neurodevelopment
Dr. Vaclav Vojta, a Czechoslovakian neurologist focusing on the challenges of motor rehabilitation in children, suggested that one-third of children never develop optimal central nervous system function. This often manifests in poor patterning and many of the postural or movement dysfunctions we see in adolescent and adult populations.

Trauma including surgeries, injuries (chronic and acute) and emotions
These factors affect how an individual is able to both stabilize and create efficient movement. Surgery will always lead to muscle inhibition and alterations in motor control throughout the system. Trauma generally results in a reflexive stiffening of the injured region and subsequent compensatory alterations in the stabilization and movement systems.

Learned behaviors
These are patterns we adopt, based not necessarily on ingrained neurological patterns, but rather on things we learn throughout life. Everything from lifestyle to adapted postures and movement habits learned in childhood, from mimicking what we see to adopting a gripping pattern to appear slimmer has a dramatic effect on our movement patterns. Unfortunately, the very thing we use to improve our movement dysfunction—exercise—is an often-overlooked contributor to altered movement patterns.

For example, many of the exercises we perform are in direct opposition to the functional patterns ingrained in our nervous system. Consider the crawling child where the spine is moved around the fixed limbs. Many of the exercises we perform in the gym, such as barbell squats, barbell rows, biceps curls and bench presses, utilize the trunk and limbs in the exact opposite way they were intended: the trunk is fixed and the limbs move around the fixed trunk.

Notice how the developing child moves his spine around stable extremities—right hip and left shoulder. This develops simultaneous limb stability and spinal mobility. The majority of the exercises we perform with our clients do the exact opposite; they move the extremities around a fixed spine. Often these patterns are performed in a bilateral fashion, which fixates and locks the thorax, creating compensatory hypermobility in the extremities. This is not to suggest that these exercises are bad, but rather point out the long-term effects these exercises have on the mobility of the thorax and stability of the shoulder and hip complexes.

What about exercise cues we often use when instructing our clients? Generally, we cue our clients to ‘tighten the core’ or ‘squeeze the glutes’ or ‘pull the shoulder blades down and back.’ These cues often get the intended response of increased activation of the abdominal wall, glutes and scapular retractors. However, the biggest problem clients have is not in activating prime movers, but in activating the stabilizers, as well as coordinating the timing and efficiency of using these muscles. The result of our exercise cues is increased problems, such as compression syndromes at the spine and hips, as well as stabilization issues of the scapulothoracic region.

Additionally, whether we like to admit it or not, most of us have been influenced by learned behavior. As young children we watch and adopt the postures, mannerisms and movement patterns of our parents, peers and social influences. Models who are taught to hang off their hips and overly extend through the thoracolumbar junction influence many young girls. Moreover, we are influenced by fashion, including things such as wearing high-heeled shoes, overly supportive athletic shoes, use of orthotics, each of which affects an individual’s stabilization and movement patterns.

Ultimately, these learned behaviors can lead to stiffness and rigidity of the spine and thorax, which in turn leads to common movement impairments including—

• compensatory hypermobility patterns at the scapulothoracic, thoracolumbar and lumbopelvic regions;
• reflexive tightness of the glenohumeral and femoroacetabular joints;
• altered respiratory mechanics necessitating the increased utilization of the accessory respiratory muscles and further perpetuation of these patterns.

While the medical field is quick to blame genetics and old age, the resultant poor stabilization and movement patterns that result from improper neurological development, trauma and learned behaviors are the most common reasons for the majority of our client’s degenerative conditions, chronic pain and decreases in overall performance.

Our job, as well as our challenge as fitness and health care professionals, is to help clients and patients recognize the intimate relationship between how they move and what happens to their body as a direct result of how they move. Regardless of genetics, trauma, disease, past experiences, thoughts, beliefs and previous learned patterns, we can help our patients and clients create positive changes. This is not to suggest that someone with multiple sclerosis or just having suffered a stroke will ever return to a high level function they had prior to the disease. But it is not up to us to place restrictions or limitations upon them. Our job is to teach and empower them to regain their strength, stability, movement awareness and confidence so they can achieve the highest level of function they are able to given the current state. Empower them to challenge the current level with the faith that the nervous system is capable of so much more than it is often given credit for.

Because so many patients and clients present to medical doctors, chiropractic physicians, physical therapists and fitness professionals with movement dysfunction of the extremities, this book will focus on the hip and shoulder. The focus will be on the functional anatomy and kinesiology, as well as the common movement dysfunctions and corrective strategies for improving function. However, it is difficult, if not impossible, to discuss the hip and shoulder without giving attention to the thoracopelvic core. The thoracopelvic core will be discussed briefly throughout the book, as this region is an overlooked cause of, as well as a solution to, many common hip and shoulder conditions.

This book is designed in three parts to help you make the most of the information presented within. The first part is an introduction to movement and the components of the movement paradigm, including muscles, joints, proprioceptors and fundamental movement patterns. It also addresses some of the underlying problems that are recognized as keys to the development and prevalence of movement dysfunctions.

The second part discusses functional anatomy and kinesiology of the shoulder and hip complexes, including some of the common dysfunctions as well as several concepts that are necessary for improving function of these regions. An assessment of the trunk, hip and shoulders is also included in this section.

The third part will demonstrate the corrective exercise and movement progression based on the principles that were set up in the first two sections of the book. Included in this book are tables that contain both descriptions of the exercises, including setup, alignment, activation strategies and what your client should be feeling. Additional tables supply you with clinical keys. All these are designed to provide you with clinically applicable techniques, strategies and ‘aha’ moments to help make the information connect and add even more relevance for you and your patient or client.

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