Pilates and Shoulder Impingement

Transcription

1 Pilates and Shoulder Impingement Rebecca Bonnel March 15., 2016 Course Date: March-July 2015 Berkeley

2 Abstract Most people who live with shoulder impingement experience immense frustration as their ability to perform every day functions diminishes. Shoulder Impingement is when the space between the acromion and the rotator cuff narrows causing discomfort and/or pain when doing everyday activities, especially with activities that involve lifting your arm above shoulder height and doing weight bearing activities. Most people who experience shoulder impingement experience pain and weakness as well as a loss of their range of motion and the pain and discomfort increases the longer the problem is untreated. The purpose of this paper is to examine how Pilates can effectively help an individual who has been struggling with shoulder Impingement by helping them gain back their range of motion, as well as recruiting the correct muscle patterns and helping them regain their strength. (BASI Study guide, pg. 89). In some cases, it may be to find a range that works for their body structure and be successful in their Pilates workout within their newfound range of motion. 2

3 Table of Contents Abstract 2 Anatomical Description 4 Case Study 7 Conditioning Program 9 Conclusion 11 Bibliography 12 3

4 Anatomical Description The shoulder joint, often referred to as the glenohumeral joint, is a ball a socket joint that allows a wide range of motion but the joint itself does not have a lot of stability. Every joint in the body has a bursa, which is a fluid-filled lubricating sac that facilitates smooth movement between joints; in the shoulder, it is located between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm (American Academy of Orthopedic Sugeons, online). When this sac becomes inflamed or irritated it decreases the amount of space in the joint where movement takes places and this is just one factor that can contribute to impingement. Normal anatomy of the shoulder. Graphics from: Because the shoulder joint is not a stable joint, it is extremely important to develop correct mechanics and balanced muscular support, especially when dealing with a shoulder impingement. The shoulder is made up of three bones: the upper arm bone (humerus), the shoulder blade (scapula), and your collarbone (clavicle). The arm is kept in your shoulder socket by your rotator cuff, and the muscles and tendons form a covering around the head of the upper arm bone and attach it to your shoulder 4

5 blade. The rotator cuff is the dynamic stabilizer of the glenohumeral joint; therefore, it is very important to make sure that the rotator cuff is strong enough in order to help assist the shoulder move properly throughout its movement (American Family Physician). There are three muscles groups that help support stabilization of the shoulder joint and they are the muscles of scapular stabilization, the rotator cuff, and the large shoulder muscles. The first group, the muscles of scapular stabilization, are the trapezius, rhomboids, levator scapulae, pectoralis minor and serratus anterior. The second group, the rotator cuff, is a small group of muscles that connect the scapulae to the proximal humerus. The rotator cuff is essential for providing shoulder stability and facilitating subtle desired mechanics of the shoulder. The muscles that make up the rotator cuff are the supraspinatus, infraspinatus, teres minor and subscapularis. The third group, the large shoulder muscles, assist in producing great movement of the arms. The key muscles in this group are the pectoralis major, deltoids, latissimus dorsi, and teres major. (Basi Study Guide, pg. 87). It is very important to strengthen the rotator cuff muscles as well as the scapulae stabilization muscles in order to promote correct mechanics allowing proper execution of exercises, especially when dealing with an impingement since one is already limited on space in that region. Graphic from: Trail Guide to the Body by Andrew Biel 5

6 Graphic from: Trail Guide to the Body by Andrew Biel As discussed earlier, an inflamed bursa can be a contributing factor to shoulder impingement as the inflammation decreases the space you have to move around the joint. Another contributing factor to shoulder impingement can be the structure of your acromion. As you can see from the image below, there are 3 different types of acromion s: Type 1 is a normal looking acromion, Type II is a slightly curved and downward dipping, and Type III is a hooked and downward facing acromion which obstructs the outlet for the supraspinatus tendon. Cadaveric studies have shown an increased incidence of rotator cuff tears in persons with Type II and Type III acromion structure (American Family Physicians). The Type III image is the acromion structure that my client presents. Lateral view of scapula, showing the three types of acromion. Graphics from American Family Physician, online 6

7 Case Study Linda is a 26 year old office manager who sits approximately 8 hours a day and while she sits the majority of her day she says her job is very stressful and she carries a lot of her stress in her neck and shoulders. She is very active and lifts weights twice a week with a personal trainer, walks on a treadmill three times a week, and hikes every weekend. About 4 years ago Linda had some discomfort in her shoulder and went to see an orthopedist who sent her to see a physical therapist after an x-ray showed an impingement in her left shoulder. Linda saw the physical therapist 3 times a week for 6 weeks and her shoulder responded well to physical therapy enabling her to go back to her regular workout routine with very limited restrictions. About a year ago Linda was taking a yoga class and was in the downward dog position. The instructor came over and attempted to adjust Linda in this position and she immediately felt something in her shoulder. She described it as an immediate burn and extreme discomfort, as if something or someone had pulled her muscle or stretched it in a way it should not go. She iced it and took antiinflammatories for about 6 weeks but was in so much discomfort that even removing a shirt overhead was unbearable and sleeping on it was very uncomfortable. Linda went back to her orthopedist and he did another x-ray and an MRI. The MRI revealed that in addition to the impingement, Linda now had moderate tendonitis as well as a labral tear and bicep tendon tear. The doctor sent her back to physical therapy and the PT gave her home exercises, in addition to having physical therapy 3 times a week for 3 months. All exercises kept aggravating the shoulder and causing flare-ups. With this new regimen of physical therapy and 3 cortisone shots later there was still no improvement so her doctor suggested surgery. Linda spoke with the PT and he thought that surgery was too drastic a solution and suggested letting the shoulder rest for a few more months and then revisit PT again. Seven months after PT and seeing the orthopedist for the second time, Linda came to me as she had gone for a second opinion and this doctor felt that surgery was not the right choice. This new 7

8 doctor suggested trying Pilates as a way to stabilize and strengthen the surrounding muscles and to work on getting Linda s range of motion back. Linda s goal was to be able to do everyday living activities as well as getting back into her weekly routine of lifting light weights. Her short term goal was to be able to perform daily activities with no pain (getting dressed every day, sleeping through the night, and showering without discomfort). Linda s long term goals was to build and maintain her shoulder strength and attempt to get full range of motion or as close to full range as possible. A postural assessment of Linda showed that she had relatively good posture; however, she has a slight anterior tilt of her pelvis. Her shoulders were slightly rounded but her left shoulder appears to be more rounded and forward than the right, probably due to the type of impingement she has and sitting for 8 hours a day at a desk. I asked Linda to demonstrate how she sits at her desk the majority of her day and based on what she said and showed me, I believe tight pecs are factoring into some of her shoulder issues as well. When observing from behind it appears that Linda s left scapula is slightly elevated and winged. When I asked Linda to raise her arms to a T-position she did so very carefully. She could not hold her arms in this position very long as she felt some discomfort. If she stayed slightly lower than the T-position she was fine but anything approaching the T-position above brought immediate discomfort. 8

9 Conditioning The minimal range of motion and discomfort level Linda experienced at the T-position and above showed me that we needed to take things slowly in order to avoid flare-ups and discomfort. The exercise plan was broken down into three steps: teaching the 10 principles of Pilates and the importance that each principle plays in her movement; addressing scapular strength and stabilization; and maintaining a program that Linda can integrate into her everyday living so she can avoid having another relapse or flare-ups. Session 1-10 Session Session 21+ Preparation for Session Roll Down, Foam Roller-Pecs stretch Roll Down, Foam Roller-Pecs stretch Roll Down, Foam Roller-Pecs stretch Warm Up Mat: Pelvic curl, spine twist supine, chest lift, chest lift w/rotation Mat: Roll up, spine twist supine, double leg stretch, single leg stretch, criss-cross Mat: Roll up, spine twist supine, double leg stretch, single leg stretch, criss-cross Foot Work Reformer: Footwork Reformer: Footwork Cadillac: Footwork Abdominal Work Hip Work Spinal Articulation Stretches Full Body Integration Mat: Hundred prep, roll up (modified slightly as arms could not go overhead to begin) Reformer: Frog, Circles (Down, Up), Openings Mat: Rolling (Roll-Likea-ball), Spine stretch Ladder Barrel: Gluteals, Hamstrings, Hip Flexors Mat: Hundred, single leg stretch Cadillac: walking, bicycles, frog (single leg supine), hip extension (single leg supine) Wunda Chair: Pelvic Curl Reformer: Standing Lunge, Side Split Reformer: Stomach massage round back Reformer: Hundred, Coordination, double leg stretch (modified slightly as arms could not go completely overhead) Reformer: Frog, Circles (Down, Up), Extended Frog, Extended Frog Reverse Reformer: Bottom Lift, Bottom Lift w/extension Ladder Barrel: Shoulder Stretch 1. Step Barrel: shoulder stretch lying side (modified slightly as elbow had to bend as approaching T position) Cadillac: Sitting Forward, Side Reach 9

10 Arm Work Leg Work Lateral Flexion/Rotation Reformer: Arm Supine Series (no springs, modified to work w/shoulder discomfort). I also incorporated some exercises that her PT gave us for her rotator cuff (without weights) Mat: Gluteals Side Lying Series (modified w/pillow under head and arm under side with elbow bent at 90 degrees), Adductor Squeeze Mat: Side Lifts Reformer: Arm Sitting Series or supine series (no springs, 2lb weights for some, modified to work with shoulder discomfort). I also incorporated exercises that her PT gave her for her rotator (2lb weights) Reformer: Jumping series Mat: Saw Ladder Barrel: Side Over Prep Back Extension Mat: Back Extension Wunda Chair: Swan Basic, Mat: Cat Stretch Cadillac: Arm Standing Series (slightly modified to work with shoulder discomfort). I also incorporated exercises from her PT for rotator cuff. Wunda Chair: Leg Press Standing, Hip Opener Wunda Chair: Side Stretch Reformer: Breaststroke Prep The goals for this conditioning program, using the BASI Block System, was to help Linda work through her shoulder pain and discomfort by teaching her proper body mechanics to avoid reinjuring her shoulder and to give her the tools she needed to strengthen her shoulders so she can continue to work out at the level she was doing prior to her injury. With Linda s shoulder injury, regaining full range of motion or as close as you can get to full range of motion is what she desired. I broke exercises down into what I hoped to accomplish in the first 10 sessions, followed by the next 10 sessions and so forth. My goal was to make it through each of the exercises during each session and to modify according to what worked or didn t work for her body. Most of the exercises I chose for Linda were fundamental and intermediate exercises and they were chosen because I thought these would work best for what she needed and what she was able to do based on the history provided to me. All exercises were geared toward gaining range of motion back as well as strengthening the surrounding muscles around the shoulder joint. 10

11 Conclusion Shoulder impingement can be a very painful issue and in some cases, can be extremely debilitating for many individuals. Through my observations and the exercises used in my Pilates conditioning program, shoulder impingement is something you can work through and have a positive outcome. While it is not an easy issue to deal with and can be extremely frustrating, if you truly take the time and energy needed to work on the healing of the impingement, it can be done in a non-surgical manner. As previously discussed, it is critical to strengthen the muscles of scapular stabilization, rotator cuff muscles and your large shoulder muscles in order to have a strong/healthy shoulder. By strengthening these muscles you are allowing these muscles to help you throughout your daily activities in a pain free manner. 11

12 Bibliography American Academy of Orthopedic Surgeon American Family Physician ( Biel, Andrew, Trail Guide to the Body Isacowitz, Rael, The BASI Study Guide 12