Check your Neck before you Wreck your Neck

This one resonates close to me. It was the winter of 2013, excited for having cleared my board exam to practice as a physical therapist in the US, I had just landed my first job overseas. However, apart from being my first job this was not just anywhere in the US, I was to begin working in ‘New York City’ (Oh the dream, I recall). Not just anywhere in NYC, this office was in Manhattan, and if you know anything about that awesome city, it was not just anywhere in Manhattan, it was right in the heart of it all in midtown Manhattan. It came with its pressures, servicing a relatively high end clientele in a very busy office. And if there is one thing I could tell you about New Yorkers it is this, they are extremely driven, outcome oriented and unapologetically blatant. There was no ‘see me for 3x/week for 4 weeks to see results’ or ‘physical therapy effects take time to show’. They would have none of that spiel. No pressure right (haha)? Dead wrong.

Within the first week I crumbled under the pressure like a house of cards(though I didn’t show it to anyone). But that’s New York, if you have lived there, you’d know what I mean. Lest I digress more, part of the problem along with me just being a new kid on the block was that doing countless patient charts looking down for hours apart from the non stop physical work that comes with working as a physio, I started developing neck pain with a burning sensation down my left shoulder blade. With the passing weeks, it only got worse. The problem was that a lot of my patients were seeing me for more or less a similar problem spending hours on their workstations. If I couldn’t fix myself, how could I help them? I did what I could for myself and them but it was no walk in the park. A few years and grey hair have imparted some wisdom and learning.  Having seen hundreds of patients since then, I am now at a better position to tackle this issue. Below are some of the most common advice I give to patients/people who are at a risk of neck pain. A general advice though, these exercises and strategies are to prevent this unpleasant occurrence. If you are already in pain, You must seek professional help and not rely on the videos presented below. There could be many reasons why you could have neck pain and everything is not covered here.

We all have been in this position. It could be a busy day at work staring at your monitor for 8+ hours, staring down into your books pulling an all nighter before that big test, driving through endless traffic to get home ending up spending more time behind the wheel than you’d like to, maybe a car accident, a weight training injury at the gym or just sleeping wrong, very few have managed to escape this annoying and often debilitating condition. And just like if you hang around with the wrong company for too long, you’d find trouble, if the neck remains troubled and painful, chances are that the shoulders, upper back, arms and/or the head might feel some of that pain too. That’s right, often pain (or tingling/numbness) running down the arms, shoulder, upper back pain and/or headaches ‘might’ be because of that nagging neck pain. This is important so I’d like you to read that line again. However, like I mentioned before, neck pain is a complicated topic and beyond the scope of just one blog.

So today’s post and my first ever not for physios, but just people in general who might benefit from common advise we give to our patients is going to be preventative in nature. You probably won’t be surprised to know that a big chunk of neck pain clients that I have seen over the years come from just sitting wrong and too long, staring into a screen all day, snap chatting every few minutes etc than from car accidents (this might be different for the USA and Canada, there are a lot of MVA’s here).

So here are some exercises and strategies you could use if you are at a risk to experiencing neck pain or its related symptoms.

  1. Good Posture

2. Chin tucks

3. Chin tucks and extension

(If you feel an increase in pain, tingling, numbness, dizziness etc with every repetetion, stop!!)

4. If you look on one side for extended  periods of time, correction for that-

5.Thoracic extension

6. Neck stretches

7. Sitting posture and recommendations

(If you’re a image conscious New Yorker, I know your struggle. Don’t carry a sheet to work, shell out some $$ and get that lumbar roll, lol).

8. Setting timer/ reminder

9. Finally, don’t forget to MOVE!!

The key is to not think of them as exercises but as habits. Habits that are acquired and need to be incorporated into one’s  routine on a daily note. Foremost remember, if you are in pain, go see a good physio and get it assessed. Some of the above advice might not be right for you depending upon what is going on. If some of the exercises seem to increase your pain, stop immediately. Comment below if you have questions.

Until the next post and always

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

My current thought process on fixing Scapular Winging

Since my blog post on shoulder part 1 and 2 that you could read Here and Here, I have received a lot of questions on scapular diskinesia and recommendations on managing it. As I did not really cover it in my previous blog post, this blog post will be dedicated to just that.

Scapular dyskinesia, which means abnormal movement of the scapula can present itself in different forms but most commonly manifests itself as ‘winging’ of the medial or inner border of the scapula. ‘Winging’ means that the inner border of the scapula lifts off the rib cage. This could happen during a simple overhead arm elevation (open kinetic chain) or during an exercise like a pushup (closed kinetic chain).

In an ideal healthy shoulder complex, the scapula and the ribcage work like new lovers; always close to each other and ‘almost’ inseparable. The important task to kindle this romance is primarily bestowed upon the serratus anterior (SA) along with the rhomboids and lower traps. However, sometimes these muscles misbehaves creating some trouble in paradise in this relationship. The serratus anterior is supplied by the long thoracic nerve and on observation of winging in your patient, its prudent to check for some kind of long thoracic nerve issue by doing a neck screening.

However, in my experience if there is no H/O traumatic injury, systemic illness etc that might effect the long thoracic nerve; we might be dealing with an inhibited SA. In the past I would quickly get to work by strengthening SA with some of these classic exercises for strengthening.

  1. Theraband SA punches
  2. Theraband and pulley Rows
  3. PNF for lower traps
  4. ‘Y’, ‘T’ exercise.

This strategy could be a hit or a miss. It could work for some deconditioned/older patients who have general muscular weakness and strengthening the SA, rhomboids and lower traps  could fix the problems. Makes sense right. However, very often its a miss. Picture a client who is fit, could perform pushups until the cows come home, and is nowhere close to having muscular weakness but still shows signs of winging with arm elevation or with other CKC exercises. What do we make of this??

What this means to me is that the SA is unable to reflexively hold that medial border and inferior angle down on the rib cage during certain movements. In other words, its unable to provide the stability through the full ROM. It could be either an inhibited muscle unable to generate enough force to hold that shoulder blade down due to bad ribcage-scapula position or maybe a timing issue where its not firing well at certain periods through the ROM or more likely a combination of both. Hard to be exactly sure here.

But the key here is stability. In Human kinetics, I believe this means the ability of the body to hold the correct form through full ROM. And here lies the problem. Almost all the above exercises work on a single plane at about a 90-120 degree of arm in flexion. Hate to state the obvious but are they functional? Will they train the muscles to hold that scapula in a good fixed position on the rib cage in a overhead position in OKC exercises? My experience is mostly negative. How about you?

So where do we go from here? Below are some of the strategies that I have incorporated recently that I find extremely useful and better than the traditional exercises stated above. I demonstrate this in videos below on (1) myself  as I have some left scapular winging with arm elevation and (2) on my colleague and fellow Physio who is involved in competitive dragon boat racing.

In the video below, I do a Dumbell press of 40lbs with a plus (protraction) to demonstrate how my left SA struggles to hold the load compared to my right.

 

 

Below is a video of me doing an arm elevation test which demonstrates winging and how I correct it.

 

 

By pushing on the wall and protracting my shoulders, I am getting into a ‘locked ribcage’ position and reflexively activating my SA to hold that medial border down by creating a good congruent ribcage shoulder blade position. No theraband exercises to strengthen the muscle might be needed in my case. Just a favorable position for my SA to work reflexively.

Need another example? Sure. My colleague is a perfect example of a candidate who is not weak, in fact she is very strong and trains hard to compete in dragon boat racing. You think she’d have a weak serratus? Or that you could fix her winging with a theraband? I’m sure you know the answer.

 

 

Here I must report, she does not have any pain, just C/O weakness. Her winging does not seem to be excessively abnormal, it could be well within a certain normal range of winging which most of us might have but asymmetrical to the other side.

 

Now, I like to be a little more specific depending upon the clients needs when prescribing exercises to tackle scapular instability. To give a few examples, I’d prefer more OKC exercises for swimmers, volleyball players, rowers, cricket bowlers etc and CKC for gymnastics. Often, both as the situation demands. Here are some examples of my preferred exercises-

Closed kinematic chain-

  1. Cat Cow

 

 

 

 

2.  Quadripod knee lift

 

 

 

 

3. Plank plus-

 

 

 

 

4. Pushup plus

 

 

Open Kinematic Chain exercises-

  1. Kettlebell press supine

 

 

 

 

2. Kettlebell Overhead press- Now for some of my favorites, the press. Another excellent way to fix a winging problem if noted in a OKC movement is to load that pattern and let the shoulder fix the abnormal pattern by itself. Sound a little like RNT? I think so true. (While I don’t demonstrate winging with a press but more with arm elevation, I’m sure you have seen clients that show instability with pressing. If there is no pain, the best way to fix the instability is by… thats right, pressing but with a load. Try it out

 

 

 

Not convinced that pressing heavy load will fix shoulder winging/ instability during flexion? Watch the next video and reassess your thought process. Hopefully I can convince you to give it a shot.

Kettlebell press with opposite arm-

 

 

So, What do you think?

 

3. Arm bar-

 

 

 

Watch those muscle trying hard to reflexively stabilize. Its oddly satisfying.

 

Time to wrap this up guys, but before I leave you here’s something to ponder about. For long we have thought of scapular instability to be closely related to sub acromial impingement. Not trying to be the devil’s advocate here but recent research has shown that scapular instability might not have a major role in impingement or pain in the shoulder (https://www.ncbi.nlm.nih.gov/m/pubmed/24174615/?i=2&from=/16015238/related). However, I take this with a grain of salt and always keep in mind that there are fallacies and shortcomings with research and this does not mean that it cannot be a cause of the above. Alas, such is research. I will still work on fixing this problem with my patients as I am looking for symmetry on both sides of the body not just for injury prevention but also for better performance.

Hope this blog helps.

 

Until next time-

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

 

 

Reference-

1. Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. Ratcliffe E, et al. Br J Sports Med. 2014.