I have a client who broke his right clavicle while performing dips about three months ago. He just recently started training with me, and I was wondering if there is anything I shouldn't be doing. I don't have him perform dips because of his fear of it happening again, but when we do a chest workout, he gets very discouraged because he doesn't have the strength he once had. What can I do to help him strengthen his shoulder and chest area? And about how long will it take for him to regain his strength?
This is a serious injury, and it would be wise to gain medical clearance from qualified medical professional (preferably an orthopedic doctor), prior to beginning any exercise regimen. If your client has done any physical therapy, it would also be a good idea to be in contact with his therapist in order to find out the exact details of his injury and rehabilitative progress - or lack there of.
Rome wasn't built in a day, explain this to your client - it is going to take time, and more importantly, it's going to take a paradigm shift on your part as the exercise professional. Your client's steady regimen of isolated exercise (along with other contributing factors including: poor work ergonomics, poor functional flexibility, etc.), has manifested itself in the worst manner possible - INJURY and PAIN. It will be important for you to be aware that pain reprograms the CNS (central nervous system) faster and more efficiently than any training stimulus one could use. This means compensation by way of poor static and dynamic segmental and gross posture(s) is soon to follow. However, with diligence on you and your client's part, this can be overcome. Your new approach, in order to prevent this from happening again as well restoring your client's health and function to levels higher than they were prior to the injury, should be an integrated approach, including corrective flexibility/exercise, integrated training, and nutrition and lifestyle analysis/awareness.
This is a roundabout way of saying - stop the "chest workouts."
Dips are a concern altogether. Please see the diagrams below. Diagram 1 shows the available active ROM of shoulder extension WITHOUT any compensation at the shoulder girdle (the average individual is usually between 0-45 degrees). Diagram 2 shows a dramatic increase in excessive/passive/FORCED ROM of shoulder extension that the shoulder is forced into UNDER LOAD during a dip exercise. This excessive ROM is coming from the passive structures (i.e. ligaments, capsule, etc.), around the four joints of the shoulder (i.e. SC - Sternoclavicular, AC - Acromioclavicular, GH - Glenohumeral, ST - Scapulothoracic). This creates wear and tear - it's that simple. When performed with chronic regularity in the presence of muscular imbalances the chances of injury increase exponentially. In your client's case, injury was obviously inevitable!
Muscles can be generally divided into two functional groups:
- TONIC muscles: prone to facilitation/hyperactivity, predominantly postural muscles, fatigue late, and react to poor posture/function/loading by shortening/facilitating/tightening.
- Tonic muscles located at the shoulder girdle are: Pectoralis Major, Pectoralis Minor, Levator Scapulae, Upper Trapezius, Biceps Brachii (long head), Scalenes, Subscapularis, Sternocleidomastoids, and Masticatory.
- Due to their tonic nature, with regard to corrective techniques, these muscles generally require flexibility and increase ranges of motion.
- PHASIC muscles: prone to inhibition, predominantly movement muscles, fatigue early, and react to poor posture/function/loading by lengthening/inhibiting.
- Phasic muscles located around the shoulder girdle are: Rhomboids, Middle & Lower Trapezius, Triceps Brachii (long head), Deep Neck Flexors, Supraspinatus, Infraspinatus, Serratus, and Deltoid.
- Due to their phasic nature, with regard to corrective techniques, these muscles generally require facilitation via corrective exercise.
Your musculoskeletal assessment should begin with a thorough evaluation of the muscles above (as well as the rest of the body) in order to identify the length/tension deficiencies that most likely lead to the injury in the first place, and are now becoming more pronounced, hence, delaying his full recovery. This assessment should include static and dynamic features in order to see the body from multiple perspectives. If you feel uncomfortable with this responsibility, or lack the appropriate experience/education, I would highly recommend referring your client out. A skilled PT (and I emphasize "skilled"), or a C.H.E.K Practitioner (preferably Level 2 or 3), should be up to the task. Again, I would highly recommend this if you've no experience in the technicalities of corrective exercise and evaluation.
For more on vital nutrition and lifestyle factors that will play important roles in his recovery, please read my Research Corner article on Rheumatoid Arthritis (see "related articles" at bottom and right).
Your client's recovery time will be greatly dependent upon his diligence regarding the above information as well as the diligence of his trainer/therapist. Many of these suggestions may be unfamiliar to you, so here are several recommended readings under "related articles." Please take the time to read them all. Up education is the key to success.
- Wolcott, W.; Fahey, T. (2000). The Metabolic Typing Diet.
- Chek, P. (2004). How to Eat, Move & Be Healthy!
- Chek, P. (2001). The Golf Biomechanic's Manual.
- Chek, P. (2001). Movement That Matters.
- Clark, M. (2001). Integrated Training for the New Millennium. (NASM)