Corrective Exercise Solutions to Improve Common Hip and Shoulder Dysfunction

Whether your personal training clients want to lose weight, run a marathon, or simply walk around the block with greater ease and less pain, hip and shoulder dysfunction can delay or even prevent them from achieving their functional health and fitness goals. Corrective exercise is one of the most effective ways to improve your clients’ function while empowering them to take charge of their own health.

But what IS corrective exercise? And why is it so important to you as a fitness professional?

Corrective exercise is a progressive training protocol designed to help a client reach their functional goals by taking into consideration their history (injuries, surgeries, current and previous exercise, nutrition, medication, etc.) and their current stabilization and movement strategies. Regardless of their goals, your training program must help your client achieve three primary objectives, which I refer to as the principles of human movement:

1. Develop optimal respiration,
2. Be able to centrate the joints, and
3. Integrate optimal respiration and joint centration while performing the fundamental movement patterns of squatting, lunging, rotating,pushing, pulling, and bending.

Corrective exercise incorporates a series of exercise patterns to “correct” or improve the client’s ability to perform these fundamental patterns. In this article, we will look at two regions that present chronic problems for many personal training clients – the hips and the shoulders. We will briefly discuss three of the primary driving factors behind movement dysfunctions in these regions and outline several corrective exercise patterns you can use to improve their stability with less down-time related to shoulder and hip pain and dysfunction.

3 Common Causes of Shoulder and Hip Dysfunction

As noted above, hip and shoulder problems are common issues in personal training clients. Even if clients don't volunteer the information, they will often express common signs of dysfunction in these regions by rubbing the back of their neck after a set of pull-ups or constantly stretching their “tight” hamstrings after a few sets of leg exercises. While factors such as stiffness and/or stress are potential causes, chronic tightness is merely a sign of a larger underlying issue: chronic instability within the kinetic chain.

What causes instability that leads to compensatory changes through the hip and shoulder regions?

Neurodevelopment

According to Dr. Vaclav Vojta, who developed reflexive locomotion and influenced the work of Pavel Kolar, nearly 1 in 3 infants are born with less than optimal neuromotor skill (Cohen, 2011). This means that these individuals will find it more difficult to establish optimal respiratory, stabilization, and movement patterns. While these individuals may not show outward signs of dysfunction, they are typically the clients who were less athletic and even clumsy during childhood and who have significant problems performing even simple movement patterns such as squatting, lunging, push-ups, or cable rows during training sessions. They typically present with common postural issues such as forward, anterior tilted scapula and hip “gripping” or pelvic misalignments.

Surgery and injury

While any surgery or injury can affect hip and shoulder function, abdominal and trunk surgeries such as C-sections, hysterectomies, gall bladder removals, and GI resections have significant effect on the kinetic chains that connect the hips and shoulders. More problematic is the fact that these surgeries affect the ability of these clients to generate optimal intra-abdominal pressure to stabilize and decompress the trunk and spine (Kolar, 2009). The lack of optimal intra-abdominal pressure and inhibition of the abdominal wall causes these individuals to over-grip or over-contract their hips and shoulders to provide proximal trunk-core stabilization thus affecting the mobility and ultimately the function of the limbs  (Umphred, 2009).

Exercise

Too often, the exercises that clients perform directly contribute to their hip and shoulder problems.

In some cases, the way that the client performs the exercises contributes to the problem. For example, squeezing or over-gripping the gluteals during bridging, squatting, lunging, deadlifting, kettlebell swings and related patterns decentrates the hip by driving the femoral head forward in the acetabulum (Lee, 2008; Lee, 2011). This helps create instability in the hip and pelvis, and contributes to groin, hamstring, and sacroiliac joint problems as well (Lee, 2008; Lee, 2011; Vleeming, 2012).

On other occasions, the exercises themselves contribute to the problem. For example, Ys, Ts, and Ws are classic corrective exercise patterns used to restore function in the shoulders. Unfortunately, these are mobility exercises and don’t improve the stability function of the key scapular stabilizers. Besides that, the biggest challenge clients have with their shoulders is not scapular adduction and depression. The greatest challenge with scapular stabilization is achieving upward rotation and posterior tilting of the scapula – otherwise known as “wrapping” the scapula around the thorax – during functional pushing and pulling patterns. The inability to appropriately position the scapula creates compensatory hypertonicity in the pectoralis minor, levator scapula, and upper rhomboids, which are the regions where most clients develop their chronic trigger points and pain.

In light of these causes of hip and shoulder dysfunction, we need a corrective exercise strategy that addresses the most common cause of dysfunction in these regions – altered patterns of stabilization. Since alterations in respiration and trunk stabilization create significant compensations throughout the shoulder and hips, the way to improve function through corrective exercise always begins with a proximal approach; in other words, it begins with improving the client’s respiratory and core stabilization patterns.

Breathing and trunk stabilization was previously addressed in Corrective Exercise Solutions to Weight Training Injuries http://www.ptonthenet.com/articles/corrective-exercise-solutions-to-weight-training-injuries-3611, so the remainder of this article will focus on restoring the stability function of the hips and the shoulders. The corrective exercise patterns demonstrated here were chosen because they effectively target the primary stabilizers that are needed to address the most common hip and shoulder dysfunctions.

Corrective Shoulder Patterns

Side-Lying Isometric Pattern (Level 1 - 4)

The side-lying isometric pattern is the most effective pattern to restore stabilization of the scapula along the thoracic cage. In particular, it improves the upward rotation and posterior tilting function of the scapular stabilizers including the serratus anterior and lower trapezius. The pattern is broken down into four progressive levels, with each level designed to improve the components necessary to reach the next. Since levels 1 and 2 focus primarily on scapular stabilization, they are included in the corrective shoulder patterns. Levels 3 and 4 are included below, however, since they incorporate unilateral lower extremity support and functionally integrate the hip with the shoulder.

Please note: It is common for clients to be progressed too quickly through the pattern without developing the prerequisite stability in the glenohumeral, trunk, and pelvofemoral regions to efficiently perform the higher-level patterns. Stability in these regions is necessary prior to progressing to the level 4 pattern since the advanced demands of this pattern will cause the client to break down and develop additional compensatory patterns if efficient hip and shoulder stability is not developed first.

• Level 1: Modified Side-Lying Bridge
  The client lies on his side with the ipsilateral shoulder and hip flexed to 90 degrees and 75 degrees, respectively. His shoulder and hips are stacked and his spine is in neutral alignment. He isometrically contracts to push his left elbow and knee (the support side) into the floor. This contraction activates the latissimus dorsi, lower trapezius, and serratus anterior of his support shoulder and the gluteal complex and hip external rotators of his support hip. It also helps connect the shoulder and hip with the trunk and spine. He holds this contraction for 5 seconds and repeats for up to 10 repetitions. Throughout each progression, the core should be activated and the spine should remain neutral.

• Level 2: Modified Side-Lying Bridge
  The client assumes the position and activation from level 1. He activates his shoulder stabilizers to push himself into an elbow-supported position (Images 2a-b). He holds this position for 2 seconds and then returns to the starting position. He repeats the pattern for 5 to 10 repetitions. This is a great pattern for improving rotator cuff function since it combines glenohumeral rotation with scapulothoracic stability.

• Levels 3 and 4: Side-Lying Bridge Pattern
  The level 3 and 4 progression of the modified side-lying bridge is a great pattern to integrate function of the shoulder, trunk, hip stabilizers, and essentially the entire lateral stabilization chain. Compared to the traditional side bridge, the progressions in level 3 and 4 of the modified side-lying bridge enable the client to support himself on his knee rather than on his ankle and foot. This activates the hip complex, unlike the traditional side bridge patterns.
  The client assumes the position and activation from level 2. He then lifts himself up so that he is supported on both his elbow and knee with his back leg on the floor (Images 3a-b). He holds for 2 seconds and returns to the starting position. This should be repeated 5-10 times for 2 sets. Once he can perform this pattern for 2 sets of 10 reps with no loss of shoulder, trunk, or hip stability, he can progress to level 4 (images 4a-b). The client can perform up to 2 sets of 5-10 repetitions as long as there is no loss of spinal control or shoulder/hip stability throughout the pattern.

Prone Thoracic Extension Pattern (Level 1-2)

The prone thoracic extension is one of the best overall patterns for improving stabilization of the trunk, shoulders, and neck. By improving the “wrapping” function of the scapular stabilizers, this pattern is also an excellent way to activate the deep spinal stabilizers and increase thoracic length in clients that are either hyperkyphotic (collapsed) or over-extended (compressed) in the upper thoracic region.

• Level 1: Prone Thoracic Extensions
  The client places their palms down flat on the table or floor level slightly higher than shoulder height depending on their degree of shoulder flexibility. Her chin is lightly tucked to activate her deep neck flexors and she is cued to keep the back of the neck long.The forehead can be placed on a small towel if the client has trouble maintaining this position. She is cued to push the palms into the table and to &wrap the scapula (curved arrows)and then pull as if she is pulling herself forward as she breathes into her abdomen (vertical arrow) (Image 5a). She holds this position for 3 to 5 breath cycles and relaxes before repeating.

• Level 2: Prone Thoracic Extensions
  Once the client can optimally produce this motion while maintaining diaphragmatic breathing, she is cued to lift her head off the towel as if she were still pulling herself forward (horizontal arrow). This forward motion is important as we are trying to create thoracic elongation rather than extension of the spine (Image 5b). It is the scapular stabilizers that provide the anchor required to stabilize the shoulders and enable thoracic elongation. This provides the client the dual benefit of scapular stabilization and spinal elongation during the pattern. Either of these patterns can be repeated 3 to 5 times with 3 to 5 deep breaths per isometric hold. As with any of these patterns, quality of the motion always supersedes quantity.

Corrective Hip Patterns

Bridge Pattern (Level 1-2)

The bridge pattern is one of the best patterns to improve the stability function of the gluteal complex. What makes this pattern so effective is that it targets the two most important functions of the gluteal complex: stabilization of the pelvis over the femur in single leg stance, and centration of the femur within the acetabulum and sacroiliac joint stability. Unfortunately, because there is a relatively low learning curve to this pattern, it is frequently one of the most poorly performed patterns by clients, which will actually perpetuate dysfunctional gluteal function. The most common dysfunction during this pattern is that trainers and therapists cue their clients to “squeeze” their gluteals hard, which most clients have no problem doing. This results in the superficial fibers of the gluteus maximus driving the femoral head forward in the acetabulum. As we mentioned above, this results in common back and lower extremity issues such as anterior groin pain, adductor and hamstring strains, and even dysfunction in the SIJ and low back.

While the bridge is a popular pattern to improve hip extension, it is important to note that the bridge is not a good pattern to use with most clients to improve this function of the gluteus maximus because, as noted above, very few individuals can perform this pattern without driving the femoral head forward within the acetabulum and decentrating the femoral head. Walking lunges and sled pushes are much more effective patterns for improving the hip extension function of the gluteus maximus once the individual is able to centrate their hips.

• Level 1: Fundamental Bridge
  Performed properly, the fundamental bridge pattern can be quite challenging. Not because it is hard but rather because it is hard to perform without over-activation of the gluteals which drives de-centration of the femoral head within the acetabulum. The client must be able to activate their gluteal complex without over-gripping the gluteals or the deep hip rotators. There should not be any significant hollowing or deep grooves in the lateral hip region during this pattern. If you note significant hollowing or deep grooves as in Image 6, your client is over-gripping or as Diane Lee and Linda-Joy Lee suggest, they are a “butt-gripper” (Lee, 2008; Lee, 2011).

Images 7a-b: Fundamental bridge. Note the optimal alignment of the trunk and pelvis with an ideal centrated position of the femoral head within the acetabulum (blue dot in Image 7a). With over-gripping of the superficial gluteals, there is loss of the thoracopelvic canister, the hip is decentrated, and the femoral head is driven forward within the acetabulum with subsequent hyper-extension of the low back and over-compression of the sacroiliac joints (Image 7b).

• Level 2: Marching Bridge
  Once the client can utilize their gluteals appropriately in the level 1 fundamental bridge, they are progressed to level 2 marching bridge. This pattern is key to developing the unilateral stability function of the gluteal complex and is the prerequisite pattern to determine whether or not your client can return to running. If they cannot show adequate pelvic stability for a minimum of 10 repetitions per side, there is no way they have the stability required to support the 3 to 5 times bodyweight that is required while running. It is important that the pattern is performed slowly so you can pick up instability especially as the client transitions their weight from leg-to-leg. Again, they must be able to lift their leg with no change in pelvic position and without over-gripping their gluteal complex. Any shifting of the pelvis or over-gripping of the gluteal complex or spinal erectors are signs of instability.
  Images 8a-b: Marching bridge. Note the un-levelling of the pelvis during the marching bridge (a) and correction of the pelvic alignment as the client is cued to activate and connect her core without over-gripping her gluteals (b).

Image 8a. Level 2 Marching bridge	Image 8b. Level 2 Marching bridge

The video below demonstrates examples of these patterns.

Conclusion

Many personal training clients will have hip and shoulder dysfunction created by compensatory movement patterns that are secondary to neurodevelopmental issues, previous surgeries, injuries, and/or learned/adopted compensatory patterns. Corrective exercise is the most effective way to restore optimal movement patterns, since it focuses on developing and integrating the fundamental principles of respiration, centration, and functional integration to improve stabilization and, therefore, movement.

As fitness professionals, we must understand the fundamentals of human movement and how to incorporate a corrective exercise strategy to restore optimal function in our clients. If we continually empower our clients to improve their breathing, stabilization, and performance of the fundamental movement patterns, then we are providing the corrective movement-based solution that our clients need, want, and will pay for.

References

1. Cohen, Richard. (2011). Introduction to Reflex Locomotion According to Vojta. Course Hand outs. Chicago, IL.
2. Kolar, Pavel. (2009). Dynamic Neuromuscular Stabilization: A Developmental Kinesiology Approach. Course Hand outs. Chicago, IL.
3. Lee, Diane. (2011). The Pelvic Girdle (4th ed.). New York, NY: Churchill Livingston.
4. Linda-Joy Lee (2008). Discover the Sports Pelvis: The Role of the Pelvis in Groin, Knee, and Hamstring Pain and Injury. Course Hand outs. Fairfax VA.
5. Umphred, Darcey. (2007). Neurological Rehabilitation (5th ed.). St. Louis, MO: Mosby Elsevier.
6. Vleeming, Andry. (2012). Understanding the Diagnostics and Treatment of the Lumbopelvic Spine. Course Hand outs. Chicago, IL.

Additional Reading by this Author

1. Osar, Evan. (2012). Corrective Exercise Solutions to Common Movement Dysfunction of the Hip and Shoulder. Chinchester, UK: Lotus Publishing.