THE ROTATOR CUFF AND SHOULDER STABILITY

Transcription

1 THE ROTATOR CUFF AND SHOULDER STABILITY Caroline Freeman 1 st September 2017 The Pilates Clinic, Wimbledon 2016/2017

2 ABSTRACT The shoulder joint is a highly flexible but also fundamentally unstable joint and consequently shoulder injuries are amongst the more common injuries that pilates instructors will encounter. This paper addresses the structure and anatomy of the shoulder, a more specific rotator cuff injury and a conditioning program designed to be practiced without pain and with the intention to rehabilitate from the original injury, strengthen the relevant muscles of the shoulder and regain a significant range of movement. The program incorporates the principles of pilates and addresses the mind and body as a whole, in accordance with the teachings of Joseph Pilates. 2

3 TABLE OF CONTENTS Title Page. 1 Page Abstract. 2 Table of Contents. 3 Anatomy of the Shoulder. 4 Case Study. 7 Conditioning Program. 9 Conclusion. 11 Bibliography. 12 3

4 ANATOMY OF THE SHOULDER The shoulder area is where the arm is joined to the thorax. The primary joint of the shoulder is the glenohumeral joint, between the head of the humerus and the glenoid cavity of the scapula. It is a ball-and-socket joint and so, by its very nature, allows a wide range of movement but is inherently unstable. There is no bony attachment of the shoulder girdle to the axial skeleton. The only true bony connection is of the scapula to the sternum at the sternoclavicular joint therefore the muscles and ligaments of the glenohumeral joint are key to the correct mechanics and stability of the shoulder. 4

5 The muscles that act on the shoulder joint can be categorized into three groups: (1) Muscles for scapular stabilization: this group of muscles is responsible for stabilizing or moving the scapulae in line with the movements of the arm but are not actually attached to the humerus (trapezius, rhomboids, levator scapulae, pectoralis minor and serratus anterior muscles) (2) Rotator cuff: these are small muscles connecting the scapulae to the proximal humerus and assist with shoulder stability and correct mechanics (supraspinatus, infraspinatus, teres minor and subscapularis) (3) Large shoulder muscles: this group produces the gross movements of the arms (pectoralis major, deltoids, latissimus dorsi and teres major) 5

6 In many exercise programs the emphasis is placed on this last group, the larger shoulder muscles. They can be given more attention for both aesthetic and athletic reasons, but strengthening of the scapulae stabilizing muscles and the rotator cuff are key to correct mechanics and the ability to execute a full repertoire of exercises. In this paper we give particular focus to the rotator cuff because the correct recruitment and the coordinated use of these muscles is so important when lifting the arm, to prevent impingement (excessive movement of the head of the humerus into the overlying structures). This is relevant to the following case study. 6

7 CASE STUDY Jane is a 37-year-old female with a history of right shoulder stiffness and discomfort. This stemmed from a minor injury around four years ago when she fell into a door, forcing her shoulder back and beyond its normal range of motion. Jane has seen various physiotherapists in the intervening time, who all confirmed that there was likely only soft tissue damage, however the issue has persisted and Jane experiences discomfort on an intermittent basis. Some movements, such as raising her arm above shoulder height, gives rise to pain in the glenohumeral joint and she can also be adversely affected in weight bearing exercises such as push ups and planks. This condition has been a source of annoyance and frustration for Jane. She is very active and enjoys a range of sports including trail running, stand-uppaddling and netball. It can also cause her discomfort after sleeping. Therefore, on the advice of her general practitioner, Jane recently underwent an MRI scan, which revealed a very small tear in one of her bicep tendons in addition to more noticeable swelling and thickening of the supraspinatus muscle. The specialist reviewed her scan and advised that with rest and rehabilitation Jane could recover much of her original range of movement but that he would not dismiss the possibility of cortisone injections or surgery should the pain persist. Jane is understandably very reluctant to opt for surgery, as she has three young children and the rehabilitation from such a surgery would cause significant disruption to both herself and her family. Therefore she would like to undertake a pilates program with specific 7

8 monitoring and focus in this area in the hope that sufficient progress can be made to allow her to recover a level of functionality enabling her to continue with the various sports and activities she enjoys. Jane has excellent overall fitness and good general health. She is body aware and has practiced pilates for close to five years. She has a good overall control of her body and is capable of some of the more advanced pilates repertoire. Observing her posture and initial movement indicated that she has some rounding in the upper back (kyphosis) and has to take particular care to keep openness across her chest and control over her scapular. When she raises her arm to the side or the front there is a tendency for excessive elevation of the scapular, of which she is aware. She also carries a lot of tension in her neck and upper back, it is not clear if this postural adaptation is an adopted anomaly as a result of her injury or has come about over time due to her daily activities. 8

9 CONDITIONING PROGRAM Given Jane s medical and exercise history in addition to her initial assessment I determined that she required a program based on three key ideas: Increasing the range of movement of the shoulder joint without pain Improving scapular strength and stabilization Continuing to challenge her within her pilates practice Utilizing the BASI block system, the following program was designed ensure that we have the flexibility to address the body as a whole yet consider the shoulder issues that Jane has been experiencing. This will build strength and maintain flexibility throughout her body and prevent negative compensatory patterns. The exercises outlined below allow Jane to challenge herself, utilize her pilates repertoire and continue to garner the positive associations she has from her regular pilates practice. BASI BLOCK EXERCISES GOAL Warm Up Footwork Abdominal Work Hip Work Mat - Roll Down, Pelvic Curl, Spine Twist Supine, Chest Lift, Chest Lift with Rotation W/Chair - parallel heels/toes, V position toes, open V heels/toes, calf raises, single leg heel/toes W/chair - standing pike Reformer short box series (round back, flat back, tilt, twist, round about, climb a tree) Reformer frog, circles down/up, openings, extended frog, extended frog reverse Warm up of the whole body giving particular consideration to alignment Trunk stabilization, foot and ankle control, knee extensor strength, hip extensor control Abdominal strength and control, scapular stabilization, trunk stabilization Hip adductor strength, knee and hip extensor control whilst maintaining pelvic stability 9

10 Spinal Articulation Reformer short spine, long spine Stretches Ladder Barrel shoulder stretch 1, shoulder stretch 2 Full Body Integration (F/I) Arm Work Full Body Integration (A/M) Leg Work Lateral Flexion/Extension Back Extension Cadillac kneeling cat stretch Cadillac push through series (shoulder adduction single arm/double arm, sitting side prep, sitting side) Reformer tendon stretch Reformer single leg skating Reformer mermaid Reformer pulling straps 1, pulling straps 2 Spinal articulation, hamstring stretch, hip extensor control To stretch the shoulder extensors and to safely increase flexibility and ROM Working the abdominals and back extensors whilst providing a shoulder stretch and truck stabilization Deliberate exercises to encourage careful control of the scapula and shoulder muscles To strengthen the abdominals and the serratus anterior while maintaining scapular control Hip abductor and knee extensor strength, stability of the lumbar pelvis Maintaining scapular stability throughout lateral flexion and rotation Focus on shoulder extensor and adductor strength 10

11 CONCLUSION The shoulder complex includes the flexible but ultimately unstable glenohumeral joint. It is also integral to much of our daily activity and so pain in this region can cause significant disruption and inconvenience. It therefore requires careful management to avoid injury. In the case of shoulder pain, it is estimated that around 70% of reported cases in the UK involve the rotator cuff (BMJ, 2017) and so the issues affecting Jane and aspects of her recommended conditioning program may have relevance for a number of our pilates clients. Jane has been following this program, or a variation of it, at least once a week for approximately six months now, alongside her regular pilates classes. She now presents with much less frequent pain and a greater range of motion. She also reports an increased awareness of the exercises that are beneficial to the strength and stability of the shoulder joints and also those that may require modification in her case. The ten pilates principles and the BASI Block System have enabled Jane to achieve balance in both mind and body whilst she continues her rehabilitation. 11

12 BIBLIOGRAPHY Books Isacowitz, Rael Study Guide: Comprehensive Course Body Arts and Science International Calais-Germain, Blandine Anatomy of Movement. English language edition, Seattle, USA, 1993 Isacowitz, Real Pilates Anatomy, USA, 2011 Clippinger, Karen Websites BMJ Best Practice BMJ Publishing Group Limited 2017 Physio Works Australia, 2017 New Health Advisor USA,