Purpose of this case study

This case study had 3 major aims:

1. To help someone live pain free and feel empowered about their body.

2. To examine the effectiveness of the ONI system to approaching shoulder pain related to winged scapula.

3. To provide a learning experience for the ONI team. Lead by myself, this was designed to be a chance for everyone to use what they've been learning all year in real time practically and a chance to work with a real person with real issues. In a group environment, the team had opportunities to contribute to assessment and analysis, treatment planning, as well as manual therapy and exercise prescription.

What is Winged Scapula

A winged scapula is when the medial border of the scapula protrudes (or sticks out), like wings as pictured below. Most commonly, it's a result of the muscles of the scapula being too weak or paralysed, resulting in a limited ability to stabilise the shoulder. There are a many classifications of severity, the biggest being a neurological condition where the long thoracic nerve isn't stimulating the serratus anterior muscle. In some rare cases where the muscles can’t contract and symptoms continue to be severe for more than 3–6 months, surgery may be necessary.

Who is the case study

Guy Hilliard, aged 24 is currently employed as an electrician which involves a moderate to high amount of work with his arms, often overhead. Aside from work, he leads a very active lifestyle, pursuing swimming and cycling sports. He presented with a winged scapula on his right side along with pain on the same side. The pain has been described as "achy" along the front of the shoulder deltoid area, "generally uncomfortable", and "crunchy", especially when doing shoulder exercises in the gym.

Pictured above is our case study presenting with a minor case of winged scapula (right shoulder). 

Assessment & Analysis

Our assessments consisted of standing posture analysis, range of motion, and muscle strength and function tests.

Initial posture analysis in standing showed:

• Protraction of the left shoulder.

• Mild scapula winging on the right.

• Head tilted to the right.

• Mild deviation in the spine.
  When cued verbally, Guy could retract both of his shoulder blades, although this came with some elevation on both sides.

Shoulder flexion (overhead) range of motion:

• Passive: Shoulder flexion was tested passively in supine to see how much movement Guy was capable of when muscle activation is not at play or minimal. A full 180° overhead was observed on both sides with mild ache presenting on the right side.

• Active: Guy was capable of reaching both of his arms to the table, appearing to have a full 180° of motion, but much of this was coming from compensatory movements like the spine extending and the shoulders elevating - particularly on the right side.

Serratus anterior muscle strength and function:

(Winged scapula is linked with weakness in the serratus anterior, which is a key muscle that keeps the shoulder blade flush (or more flush) against the ribs, rather than it protuding)

• The serratus anterior muscle was tested for strength and function, particularly it's lower fibres in protracting and upwardly rotating the scapula. Activation was minimal and could not be felt by either Guy or myself (or the team) through palpation, until cued "armpits up". Once cued verbally along with touch feedback provided by my fingers on his serratus muscle, the serratus was felt engaging and Guy could feel it activating from this point onwards as well.

• Once Guy was comfortable activating both sides in a supine position, he was moved into an upright seated position (which more reflects his daily activities, like working as an electrician) and asked to perform the same motion (shoulder flexion). Again, once cued, he could engage but not as effectively as he did in supine. Still, some activation is all we need, as we can build on it and challenge it in creative ways to make it stronger and instinctive.

Serratus Anterior

This muscle not only stabilises the medial border of the scapula so that it doesn't wing out, but it's also essential to create the necessary scapula movement to be able to achieve an overhead position. In technical terms, the scapula must upwardly rotate, depress, and protract for optimal stability.

It is generally accepted that the scapula moving in this way provides the last 60° of shoulder flexion (overhead) as depicted on the right. This can explain why the pain is aggravated for Guy when the shoulder is flexed past 90°, as the soft tissues in the sub-acromial space become impinged due to improper shoulder mechanics and instability.

The Treatment Plan

The goal was for Guy to be able to move with proper shoulder mechanics and efficiency without having to think about it. Over 6 weeks (6 x 30–45 minute sessions), we used a combination of massage and exercise for Guy to gain awareness of his shoulder stabilisers (the serratus anterior in particular) and then challenged the activation of those muscles through a range of functional needs: stability, strength, speed, and coordination. This progression of incrementally increasing stress causes the cells involved to adapt to higher demand in theory, as well as training Guy's movement patterns to adjust so that the use of these stabilisers becomes instinctual.

CASE STUDY NOTES:

Week 1

Initial assessments and analysis as described above.

Prescribed exercises:

• Serratus anterior overhead activations (from supine): 10 repetitions each side, twice a day.

• Scapula push ups: 10 repetitions, twice a day

Week 2

Guy has reported that he is still feeling shoulder ache, but feels he has more control over his serratus anterior muscle. This was confirmed through our testing and we were so impressed that we progressed Guy straight to overhead squats and arm bars without any issues. Manual therapy was performed on his serratus anteriors on both sides to aid in proprioception. 

The rationale for overhead squats was to challenge his overhead position in a stabilisation context in order to train his shoulder stabilisers appropriately (lower trapezius and serratus anterior work together in an overhead position during normal function). Adding a squat to this shoulder stability, provides added coordination and stability demands as his weight shifts. The arm bar offers a similar concept, just in a different position.

Prescribed exercises:

• Armbar with 8kg: 4 sets of 5 repetitions each side, twice a day.

• Overhead Squat with a barbell: 2 sets of 5 repetitions 1-2 times a week at the gym with a partial range of motion (approximately 1/3).

Week 3

Guy had done 4 swimming sessions in the last week (freestyle) with no shoulder ache. Overhead squat is looking more stable in the shoulders, although the rest of the body could do with some correcting (thoracic spine overextending). Something we will address at a later date. Arm bars are looking good, although there is a slight elevation in the shoulders on both sides, but once cued is corrected with ease. 

Week 4

Swimming again with no issues with shoulder. Overhead squat continues to improve with less shaking through the shoulder. Arm bar has been progressed by added a press in between each repetition. 

Week 5

Shoulders are now feeling stable during biking. Noticeable during 1-2 hour time trial while cycling. Used this opportunity to work on the squat itself, in the overhead squat. Cued in to engage hip flexors and to stay active with the core. Looking like an olympic lifter now with major improvements in shoulder stability and overall body awareness.

Week 6

Now that Guy's shoulders are more stable, stronger, and more coordinated with the rest of his body, another challenge to pit it all against is fatigue. How well can he maintain this level of activation and function while his heart is beating and his muscles are being exhausted. The circuit consisted of:

• Overhead Squat (40kg) x3

• One arm chest press with an upside down kettlebell (8kg): x8/side

• Shoulder Taps x5/side
  Repeat 3-5 times with minimal rest time in between circuits and exercises

Guy performed fantastically. There was minimal deviation in form even while exerting at moderate-high levels. This suggests that throughout the case study, we had progressed the motor patterns effectively through stress levels that were appropriately increased week to week. 

Results

"Laurent and his team at ONI were awesome to work with in their case study. Coming into it I had been dealing with shoulder pain and had not been training as to avoid injuring it again. Very quickly the guys at ONI were able to isolate the cause of the problem and begin to explain how they were going to set up the rehabilitation through setting up a foundation of correct movement patterns engaging and feeling the right muscle groups working.

Within a couple of weeks I had stopped feeling pain in my shoulder and we had progressed to now loading the movements with weight. The improvement that these exercises brought quickly helped not only with the relief of pain, but also allowed me to start swimming again without problems and helped at work with overhead movements. By the end of the six weeks they had started to coach me through putting my shoulder movement and strength through as much as they could handle by coaching me through an overhead squat.

They took their time to discuss and trial with me why they were choosing to prescribe particular movements and what I should expect to gain out of each exercise in order to rehabilitate properly throughout the process and would make sure to always help in cuing helpful tips or give insights as to how I could remember to do the exercise correctly by myself. They were very thorough and helpful throughout case study and I highly recommend their services."

Case Study Subject: Guy Hilliard

Case Study Lead: Laurent Pang

Team involved: Sam High, Abby McCarthy, Michael Lahood, Ben Means, Liam Haberfield

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