Yoga Series for Recovery of Rotator Cuff Injury
YOGA FOR AVOIDING AND HEALING ROTATOR CUFF INJURIES
Ginger Griffis – 02/2017
Rotator cuff injuries are very common and types of treatments vary from just letting it heal, to ice packs and rest, to physical therapy, to painkillers, and surgery in some extreme cases of rotator cuff tears. In conjunction with any of these remedies, yoga can play an important part on the path to recovery. Certain yoga poses can help with strengthening and stretching the rotator cuff muscles and other poses can help strengthen the larger surrounding muscles and train the body to use them for weight bearing. Increased stability for this incredibly mobile joint is the best of what yoga can offer. And at the very least, yoga practice can be adapted so that it does not hinder healing or further aggravate the injury.
The rotator cuff is comprised of four muscles that interlock around the shoulder joint to both stabilize and create movement of the humerus bone in the shoulder joint: supraspinatus, infraspinatus, teres minor, and subscapularis. All four muscles converge at one tendon that connects them to the top of the humerus bone. The supraspinatus originates on the back top part of the scapula and serves to abduct the arm, rotate the arm medially, and to stabilize the joint by holding the humerus bone up toward the socket. Both the infraspinatus and the teres minor perform the function of laterally rotating the shoulders. The infraspinatus originates on a large portion of the lower posterior scapula while the teres minor originates from the lateral and posterior edge of the scapula. The teres minor also serves the stabilizing function of keeping the humerus head down as the arm is abducted and the infraspinatus further stabilizes the joint. Finally, the subscapularis originates from the front of the scapula and rotates the shoulder medially, as well as stabilizing the humerus forward and downward when the arm is raised. The main shoulder joint, which connects scapula to humerus, is the most mobile ball and socket joint in the body, and thus the most prone to injury due to the necessary lesser stability and depth of the joint. Since the shoulder is so free-moving and delicate and the rotator cuff muscles so small, it is important to learn how to stabilize the joint and how to most effectively move the arm around when weight-bearing.
The hardware of the shoulder consists of the scapula, the clavicle, and the humerus bone, which rests in the glenoid cavity of the scapula, forming the glenohumeral, or main shoulder, joint. The only site at which this shoulder structure attaches by joint to the rib cage is at the sternum. Therefore, the muscles that do connect the scapula to the rib cage are very important to aid in stabilization. While the rotator cuff muscles are designed specifically to stabilize the humerus head in the shoulder joint locally, they are not meant to do any heavy weight bearing—like the weight of the body. In essence, the role of the larger, more superficial, muscles that connect to the scapula is to anchor the scapula to the rib cage as a stabilizer during any weight bearing activity on the shoulder, whether stationary or in motion. Three of these larger muscles are the serratus anterior, the rhomboids, and the mid-trapezius.
The serratus anterior muscles originate on the first to ninth ribs on both sides of the front of the body and insert on the medial border of the scapula. The serratus anterior can protract the scapulae as well as raising them when the arms are raised. The superior portion of the serratus anterior also performs the antagonistic action of depressing the scapulae when the arms are lifted, thus stabilizing the shoulder joint.
The rhomboid muscles also insert at the medial border of the scapulae but they originate from the areas of cervical vertebrae seven through thoracic vertebrae five and thus act to retract the scapulae. The antagonistic actions of the serratus anterior and rhomboids can serve to stabilize and hug the scapula into the perfect mid-point on the rib cage between full protraction and full retraction during various weight bearing activities of the shoulders and arms. In contrast, full retraction is required for stabilization during overhead arm movements such as throwing or swimming, in order to put a break on the forward motion of the shoulder (Paine and Voight).
The mid-trapezius muscles originate from cervical vertebrae 7 and thoracic vertebrae one through three and insert in the medial border of the acromion process and the superior spine of the scapula. Along with the rhomboids beneath, they also serve to retract the scapulae. The lower trapezius muscles are used to depress the scapulae.
The larger muscles, together with the more delicate and specialized rotator cuff muscles, can allow for strength and flexibility through the maximum range of motion. The supraspinatus initiates abduction of the arm, up to 15 degrees; then the deltoid should take over up to 90 degrees, followed by the trapezius and serratus anterior for anything above 90 degrees. The pectoralis major, deltoid, and lattisimus dorsi can perform the main medial rotation of the shoulder, taking any weight bearing off of the supraspinatus and subscapularis. More importantly for most people, the infraspinatus and teres minor should be aided by the deltoid and upper trapezius in laterally rotating the shoulder.
Using the correct combination of muscles and stabilizing positions of the scapulae is important for healthy shoulder usage and maintenance. Achieving symmetrical strength and range of motion of all muscles surrounding the shoulder will aid in this endeavor. This usually involves working more on muscles that achieve lateral rotation of the shoulder joint and retraction of the scapulae since most people spend more time in medially rotated positions in everyday life.
Before delving into rotator cuff injuries, it is important to discuss, in the context of yoga practice, how to avoid these types of injuries in the first place. Chaduranga, in particular, practiced without knowledge of proper form, greatly increases one’s risk of rotator cuff injury. That is why it is important to utilize the large muscle groups listed above (rhomboids, trapezius, and serratus anterior) to support one’s weight when lowering in chaduranga. One can achieve this goal by following these guidelines: when starting in plank pose, press down through hands strongly, thus lifting the space between the shoulder blades upwards; rotate elbows inward; and most importantly, draw low belly up and in. When one starts to lower, simply bend the elbows straight backwards and only go as low as possible while maintaining the same exact form as plank pose, just like an elevator lowering. If the chest starts to dip down, which often happens, that is an indication that one’s strength in the large muscle groups has been exceeded and the weight bearing has started to shift into the rotator cuff muscles, making one prone to injury, especially over repeated practice of exceeding one’s strength and collapsing into chaduranga. Do not let shoulder blades come together when you lower in chduranga—rather keep this area lifted up toward the ceiling.
If the larger musculature and skeletal apparatus do not support the shoulder, wear and tear over time or acute injury to the rotator cuff can occur. The following are some of the more common injuries. Dislocation occurs when the head of the humerus bone slips partially or fully out of the glenoid socket, usually in a forward direction. Rotator cuff tears occur most often in the supraspinatus muscle and tendon, and more often through wear and tear than through acute injury. Impingement is caused by the top of the humerus bone and the acromion moving too closely together, pinching the tendons and bursa in between and causing inflammation and irritation therein. This crowding can be caused by improper posture, injury (acute or overuse), or bone spurs that can result from arthritis. Impingement most frequently affects the area around the supraspinatus. Tears, dislocations, and impingement occur most often in people who engage regularly in activities that involve raising the arms over the head for working or throwing. Rotator cuff tears can sometimes also lead to a form of arthritis. Regular arthritis will affect use of the shoulder and rotator cuff apparatus as well.
In frozen shoulder, the shoulder capsule thickens and becomes tight. Stiff bands of tissue — called adhesions — develop. Often, there is also less synovial fluid in the joint. According to George S. Athwal, MD, on the American Academy of Orthopaedic Surgeons website, Frozen shoulder develops primarily between ages 40 and 60 and mostly in women, usually without any acute injury. Causes are not exactly known but it occurs with much greater frequency in people with diabetes.
If a student asks about or sustains a shoulder injury, or any other type injury, during class, she should be referred to a doctor or specialist to diagnose her injury or problem. In particular, according to one physical therapist, Stacy Hyden, a student should be immediately referred to a medical professional if she experiences shoulder pain that is sharp or is the result of a fall or causes sudden weakness in the shoulder. An immediate trip to an emergency clinic is also called for if the symptoms include radiating pain or numbness in the arm or shortness of breath, which could indicate a heart problem. Once the condition is diagnosed and any emergency attention is rendered, there are a number of types of therapies that can help with recovery, depending on the injury.
From a physical therapy perspective, the following are some things to consider, according to Hyden, for the most common of rotator cuff injuries. For shoulder dislocations, the student “[s]hould avoid end ranges of motion, especially with weight bearing, if the dislocation was recent or the student reports a chronic instability” (Hyden). Impingement syndrome falls generally into three categories: postural, injury, and arthritis. For postural causes, “[t]he muscles that rotate the shoulder inward become tighter or stronger than the muscles that rotate the shoulder outward.” This decreases the space for the supraspinatus muscle to operate, which in turn pinches the muscle, causing inflammation and thus pain. Improvements to posture and shoulder usage can help improve the condition. Injury through strain or overuse can cause the supraspinatus to swell, which also causes friction within the rotator cuff space. Injury can be treated with “rest, ice, anti-inflammatories, [and] gradual strengthening” (Hyden). Rotator cuff tears can result from ongoing impingement. According to Hyden, who regularly presents at yoga teacher training courses in Norman, Oklahoma, yoga can be helpful at various stages of recovery from these shoulder injuries, especially during the “thawing” phase of frozen shoulder syndrome. In general, poses that encourage improved posture, chest opening, and external rotation of shoulders are indicated.
Another modality of treatment for rotator cuff injuries is craniosacral treatment. Heather Islander, Seattle craniosacral therapist, suggested that craniosacral therapy could be effectively used in concert with physical therapy and yoga for rotator cuff injuries. If chiropractic treatment were also indicated, Islander recommended the treatments be started in this order: 1) chiropractic, 2) craniosacral, 3) physical therapy, 4) yoga. Once initiated, though, these therapies can coincide. One of the reasons to start craniosacral therapy early on in the sequence, according to Islander, is its gentle non-invasive nature, which can help loosen up the tissues surrounding the injury, increasing range of motion without increasing inflammation or causing pain. The body tends to want to press tightly around an injured area, which can be helpful at first, but craniosacral therapy can gently encourage the fascia to loosen up, allowing for more space and movement, when the body is ready (Islander). This allows the entire shoulder structure—fascia, muscles, tendons, and bones—to return to a neutral position. Then the muscles can help to support the new, correct positioning of the rotator cuff muscles and scapulae. And that’s where yoga can come in to strengthen, stretch, and train the muscles appropriately. Regarding frozen shoulder, Islander, who has worked successfully with many clients suffering from this condition, noted that the shoulders can represent, emotionally speaking, how one “carries one’s weight” in the world, how one takes in and pushes away, and in essence one’s attitude about her career. She also shared an observation regarding the prevalence of women between ages 40 and 60 experiencing frozen shoulder—that often that is the time that children leave home and, at least in the past, this could be a stage of transition of a woman’s career, and perhaps a sense of uncertainty as to what to do next. Grief also, according to Islander, is often stored in joints in general, which could further add to the potential for shoulder issues at this stage in life as the sense of loss of children in the home sinks in.
Informed by sound medical advice and physical therapy, craniosacral therapy can gently start someone with rotator cuff injuries on the path to healing, loosening and realigning the shoulder structure. This helps pave the way for the strengthening, stretching, and awareness that yoga can provide.
During the recovery from a rotator cuff injury, after the proper medical advice and treatment has been initiated, one should generally stick to these principles when attempting any strengthening or stretching exercises. First and foremost, avoid any movement or position that is painful. More specifically, one should avoid or reduce weight bearing on the shoulder until it can be done comfortably and is recommended by a health care professional. When ready, one should gradually add weight-bearing activities—certainly not starting with the full body weight. In addition, most people will want to avoid too much medial rotation or hunching of the shoulders, since many rotator cuff injuries start from overly tight and/or strong medial rotating muscles or overly stretched and/or weak lateral rotating muscles. Lastly, one may want to avoid the fullest stretch in any direction—shoulder rotation, shoulder abduction, or shoulder extension or flexion.
In a yoga context, this would mean avoiding any poses with a large portion of the body weight on the hands and any poses that require any extremes of flexion, extension, or medial rotation of the shoulder joint. Some common poses that would be contraindicated are full downward dog, upward dog, hands and knees poses with too much weight on the hands, arm balances, any of the full inversions, plank or side planks, bridge pose, wheel pose, warrior I pose with arms fully extended overhead, or any pose with arms extended fully overhead, in full flexion behind the back, or arms wrapped forward, like the arm position for eagle.
While in the recovery stage of a rotator cuff injury, it is important for a patient/student to be trained to properly place and use the scapulae as a stabilizing force for the shoulder socket as it is used for movement and/or weight bearing activities. As Paine and Voight assert in the article, “The Role of the Scapula”, “most of the abnormal biomechanics and overuse injuries that occur about the shoulder girdle can be traced to alterations in the function of the scapular stabilizing muscles.” It is also important to establish an understanding and habit of proper posture.
If the shoulders tend to be rounded forward, the first step should be gentle stretching of the pectoralis minor over time in order to allow space for the shoulder to operate properly. Once normal flexibility has been achieved, Paine and Voight recommend a three-step approach to strengthening: first, exercises to “normalize the scapular resting posture”; second, exercises to restore balanced muscle control through movement; third, scapular muscle strengthening through specific sports related movements, which won’t be covered here.
Some exercises to improve the scapular resting position include first isometrics (static muscle engagement) and then isotonics (muscle engagement with movement). The suggested isometric exercises involve squeezing and holding the shoulder blades back and together, while sitting or lying on the floor or an exercise ball with arms bent in “robbery position”. Another isometric strengthening exercise is to stand with your back flat against the wall, arms out to a ‘T’ position, and press the palms into the wall (Paine and Voight).
According to Paine and Voight, one can continue to isotonic exercises when painful movement symptoms are substantially diminished and movement within a reasonable range is possible. They recommend various exercises utilizing resistance bands while performing movements that require retraction and protraction of the scapula, such as rows, hugs, punches, and stretching arms in front of body in various directions.
Once most of the pain of lifting the arm(s) above the head has subsided, it is suggested to progress to exercises that restore “dynamic control in order to restore muscle balance with various arm movements” (Paine and Voight). These exercises include some from the previous isotonics stage but using heavier weights or machines instead of bands and covering broader ranges of motion. Some examples include: rows at different levels, retracting scapulae as arms bend and pull, then extending arms with scapulae still retracted, then allowing them to fully protract before pulling in again; lattisimus pull downs; lawn mower starting style pulls; “robbery position” on floor or exercise ball with weights; and manually resisted (by a therapist) movements of the scapula.
Yoga can support the course of exercises outlined above, either alongside physical therapy, or independent of it if the student so chooses. During the stretching phase of treatment, yoga poses that passively open the chest can be utilized to loosen up the pectoralis minor and other chest muscles.
During the phase of normalizing the scapular resting posture, poses that hold the scapulae statically in retraction can support the isometric stage. As suggested by Paine and Voight, these will help strengthen the muscles that retract the scapula—rhomboids and mid-trapezius—and the muscles that laterally rotate the shoulders—infraspinatus and teres minor. This will also increase blood flow to the area. In addition to strengthening, yoga can help the student become more aware of how the scapulae can be optimally positioned and used and of the posture in general.
As the pain of moving the arm and shoulder subsides, yoga exercises within a pain-free range of motion can be employed during the first isotonic phase. Movements in and out of retraction/protraction with breath can help to strengthen and bring more blood flow and awareness to the area. This is also a good phase to start strengthening the supporting muscles of the serratus anterior. The range of motion and weight bearing can slowly increase as the pain of movement subsides over time—moving into the second stage of isotonic therapy.
In working with a close friend (who we will call Jose) who sustained a shoulder injury over the summer which was then exacerbated by a follow-up injury this winter after it was almost healed, I have gathered some second hand experience with the type of pain and movement restriction involved in at least one type of rotator cuff injury. In Jose’s case, he never went in to a medical professional to get a diagnosis. We utilized several physical therapy information websites to get a best guess as to what type of injury he was dealing with, which seems to be a possible impingement of some sort, combined with a small labrum tear or strain. The labrum is a piece of fibrocartilage on the rim of the shoulder socket. He experiences pain during certain movements with the arm behind the back or in laterally rotating the arm when lifted overhead, as well as sometimes when lying on the side on the good arm with the bad arm extended forward. We have worked with several of the exercises and stretches suggested by Paine and Voight and he seems to be feeling some slow improvement, though I have suggested that he see a medical professional to get a diagnosis and possible treatment plan. In the meantime, I have put together three 10-15 minute yoga sequences for him to start practicing daily, which incorporate the suggested three-phase approach outlined above. A student should work through each sequence over a period of time until the symptoms indicate moving on to the next sequence.
The first sequence focuses on passive, non-weight-bearing, stretches, mainly for the pectoralis minor and other chest muscles, within a limited range of motion that do not raise the arms above the head. Some of the poses include: lying supine with the sacrum on the floor and the rest of the back on the length of a bolster with the arms draped on the floor as far out to shoulder height as is comfortable; supine twist with arms as far out to shoulder height as comfortable and bent knees as high up as comfortable; stretch with shoulder and arm flat against the wall, only as high as comfortable, turning away from shoulder; if medial stretching is needed, back of hand on lower back, and gently pressing elbow forward with the other hand or by pressing elbow gently against the wall. The sequence also includes some standing leg strength poses with arms open (and only as high as comfortable) to get the blood flowing to the muscles before stretching, such as warrior II.
Once the student’s shoulders, specifically the medial rotator muscles such as the pectoralis minor, have achieved a more comfortable level of flexibility and the shoulders are not overly rounded forward, he can move on to the second sequence, which focuses on isometric strengthening without weight-bearing. Yoga offers many poses suited for the purpose of strengthening the muscles that retract and protract the scapulae. A good place to start, according to yoga teacher Neil Keleher, from his website, is with scapular awareness exercises. To begin with, the student can sit in a comfortable seat and simply breathe in and out and become aware of his scapulae. After a few breaths, he can start protracting and retracting his shoulder blades, noticing the various muscles involved, with information provided by the teacher. Then the student can start working on some strengthening exercises with that awareness. Cobra pose with hands off the floor is a perfect pose for strengthening the muscles that retract the scapulae and laterally rotate the shoulder, as is locust pose.
When pain is diminished through a larger range of motion, the student can move on to the third yoga sequence, which will involve more strengthening through movement and stretches in a broader range of motion and with gradual addition of weight. Regarding strengthening, according to Keleher, “[t]he idea is to learn how to activate the muscles that control the scapulae so that they [sic] you can use the same muscles to resist movements of the shoulder blades relative to the rib cage and thus create shoulder stability.” This sequence begins with the same breathing awareness exercises and retracting and protracting the scapulae, but this time with the arms out in front of the body, or as high as is comfortable, noticing the different placement of the shoulder blades as the arms move forward and backward. The teacher can help the student understand the antagonist actions of the serratus anterior and rhomboids and mid-trapezius. After this sequence, various poses can be practiced using the new awareness and trying different shoulder blade positions to find the most stable, balanced position—intentionally using the push and pull actions of the serratus anterior and rhomboids and mid-trapezius to stabilize the shoulder and transfer weight-bearing to the larger muscles and away from the small rotator cuff muscles. Cat/Cow pose is a great place to start. The student can ease into weight bearing by bending the knees further to take more weight in the legs and over a few sessions bringing the knee joint to 90 degrees. The student will go through the same scapular retraction and protraction, in concert with the breath, noticing the rib cage rising and falling and intentionally activating the serratus anterior and rhomboids and mid-trapezius. Then the student can find a neutral position and notice the push/pull of the antagonistic muscles finding a perfect, stabilizing, balanced position. This can also be practiced in a modified downward dog against the wall, moving the feet away from the wall to increase weight bearing over time. With the breath, the student can do a modified “push-up” caduranga, back and forth towards the wall, noticing the retraction and protraction of the scapulae as they stabilize the shoulder joint. Several poses of this nature, with movement, breath, and scapular retraction/protraction, are included in this sequence. More active chest openers are also included, such as clasping hands behind the back and/or arms outstretched to the sides in locust pose and seated wide-legged side bend with lower arm lying along floor toward groin and upper arm opening straight out and wide into a back bend from the shoulder.
If the student can take his time working through these sequences, only moving on when appropriate, and hopefully working in tandem with a physical therapist, he should begin experiencing continued reduction in pain and improvement in range of motion, strength, and function of his shoulder.
For those who find themselves with one of these common rotator cuff injuries, either through wear over time or acute accident, it is recommended to first seek medical attention and find out what has been injured and what are the options for treatment. Then, once treatment and healing are underway, yoga can play an important role in supporting the healing. First step is to understand, if one already has a yoga practice, how to modify it to protect the injury. Second step, work on strength and flexibility through a pain-free range of motion, slowly working towards a fuller range of motion over time as the healing process allows. Learning about and practicing proper scapular placement is key to this stabilization process. A yoga series specifically aimed at aiding in healing the shoulder may be prescribed. Regular practitioners may even want to take a break from their regular practice for a while and just focus on the prescribed series. Coupled with other medical or alternative treatments such as craniosacral or physical therapy, yoga helps bring strength, awareness, breath, blood flow, stability, and flexibility to the entire shoulder girdle, helping to heal and to prevent future injuries.
BIBLIOGRAPHY
Hyden, Stacy, PT. "Considerations for Yoga Teachers for Students with Rotator Cuff Injuries." E-mail interview. 15 Jan. 2017.