1 THE SHOULDER COMPLEX: REHABILITATION AND STRENGTHENING THE ROTATOR CUFF THROUGH PILATES BY ALISON NELLA COMPREHENSIVE PROGRAM TORONTO, ONTARIO 2017
2 ABSTRACT Pilates is a form of exercise that was founded and developed by Joseph Pilates. When practiced it can increase strength, improve flexibility and body awareness. It emphasizes alignment, a strong trunk, improves coordination and balance. It also utilizes the mind, requires concentration, and builds awareness of the body. In this paper I will focus on the shoulder complex within the body. I will explore the structure of the shoulder as well as functional issues within the shoulder, in particular the rotator cuff and impingement. I will explore how pilates can help with the rehabilitation of this area as well as help to condition the entire body.
3 TABLE OF CONTENTS The Shoulder-anatomical description 4 Issues with the Shoulder 6 Symptoms of Shoulder Impingement and Rotator cuff issues 6 Rehabilitate of shoulder impingement and the rotator cuff 7 Case Study 8 Workout/Program 9 Conclusion 11 Bibliography 12
4 ANATOMICAL DESCRIPTION The shoulder joint is very large and complex. It is made up of bones, muscles, joints, tendons and ligaments. Its range of motion is more varied than any other joint in the body. It is also the most unstable joint, leaving it open to injury, as well as wear and tear. The shoulder girdle is made up of the clavicle, the scapula and attaches to the humerus on either side of the body. The shoulder has 4 joints. 1. Glenohumeral joint-found between the humerus and the glenoid cavity. It is a small ball and socket joint and is the primary joint of the shoulder. This socket is not deep, letting the humerus to fit loosely into the cavity. This allows for a wide range of motion. This mobility allows for lots of movement, however it also leaves the joint susceptibility to wear and tear and well as injury. 2. Acromioclavicular joint-found between the clavicle and the acromium (bony projection of the scapula). It allows the arm to raise above the head, allows cross body movements of the arm as well as transmits forces from the arm to the rest of the body (pushing, pulling, lifting)
5 3. Sternoclaviclular joint-located between the sternum and clavicle. It supports the shoulders and connects the arm to the body. It allows for the movement of the upper limbs and is highly mobile. 4. Scapulthoracic joint-the link between the scapula and thorax. It is not a true join and works with the acromioclavicular joint to allow scapula movement against the rib cage. There are many muscles surrounding the shoulder girdle. The rotator cuff muscles are a group of 4 muscles that help reinforce the shoulder joint, provide mobility of the joint as well as help to hold the arm bone in its socket. 1. Supraspinatus-adbucts the arm/shoulder. It works closely with the deltoid and prevents the humerus from being displaced upwards. 2. Infraspinatus-externally rotates the shoulder and assists with adduction. It helps prevent the humerus from being displaced upwards. 3. Teres Minor-externally rotates the shoulder. It helps prevent the humerus from being pushed forward. 4. Subscapularis-primary muscle of internal rotation. It prevents the head of the humerus from gliding backwards. Surrounding the rotator cuff muscles are many muscles that work together to help provide movements of the shoulder. They also provide coordination of the of the
6 scapula, clavicle and humerus. This is called scapulohumeral rhythm. This rhythm allows for proper overhead movement through flexion and abduction. When things work as they should the shoulder is pain free. Without correct mechanics problems occur. PROBLEMS OF THE SHOULDER Impingement-when the rotator cuff structures are compressed limiting overhead movements, The most commonly impinged are the Supraspinatus and Infraspinatus tendons, the bursa and the long head of the bicep. There structures get in the way of each other causing wear and tear. Postural imbalance-prevent the humerus from moving smoothing in the cavity. This usually begins with swelling which leads to small tears. This increases inflammation and to the degeneration of the rotator cuff muscles, the bicep muscles and may lead to bony changes. Rotator Cuff Tears-can be caused by repetitive movement of the shoulder, traumatic injury or shoulder dislocation. Most tears however are through wear and tear. They frequently appear as we age. With postural changes and muscle imbalances they are commonly found in people over the age of 40. SYMPTOMS OF SHOULDER IMPINGEMENT/ROTATOR CUFF PROBLEMS 1. Pain/weakness in affected shoulder during motion or rest 2. Pain when lifting affected arm, arm abduction 3. Shoulder hike on affected side
7 4. Pain when sleeping on the affected side 5. Loss of range of motion 6. Pain radiating down arm and across clavicle REHABILITATION OF THE IMPINGEMENT AND THE ROTATOR CUFF There are many things that need to be done to help improve shoulder problems. Postural issues need to be addressed. The rotator cuff muscles need to be strengthened as well as the muscles that stabilize the scapula (serratus anterior, rhomboids, the trapezius and levator scapulae). Core strength needs to be increased to help stabilize the spine and scapulohumeral rhythm needs to be restored.
8 CASE STUDY Jim is a 53 year old male. He has been experiencing shoulder pain for the past year. Jim went to his doctor with pain in his left shoulder. He was experiencing weakness and pain. He had trouble sleeping at night. He was unable to lift his arm overhead without pain and his range of motion became limited. The doctor examined Jim. He performed several range of motion tests and sent him for and MRI. Jim was diagnosed with a Supraspinatus tear as well as impingement at the Acromioclavicular Joint. Jim owns his own business and is very busy. He was extremely motivated to heal as quickly as possible. The doctor suggested plasma injections to quickly heal the tear and physiotherapy. At the encouragement of his physiotherapist Jim is encouraged to try Pilates to reinforce his physiotherapy work and help him with his core stability and mobility as well as reinforce proper movement patterns in his body, especially the shoulder. Jim has never done Pilates before. He is in good physical condition as he as exercised for all of his life. Jim presents with forward head posture and limited mobility in the shoulder. His left shoulder is also higher than his right. When doing the roll down he has extremely tight hamstrings. Our program will include: 1. Strengthening the core muscles to support the truck 2. Increase scapular mobility and stability 3. Improve posture 4. Strengthen the rotator cuff muscles and surrounding trunk muscles
9 THE PROGRAM WARM UP: Start with the roll down Pelvic curl Spine twist supine Chest lift Chest lift with rotation A small pillow was used to accommodate Jims forward head posture. Working on spinal articulation, pelvic lumbar stabilization and abdominal strength. Lying on foam roller with head and back on the roller, legs bent Scapular protraction/retractions Scapular abduction/adduction Working scapula mobility and the foam roller allows Jim a tactile feedback with the scapular movement Foot Work: Parallel heels Parallel toes V position toes Open V heels Open V toes Calf raises Prances Single leg Heel Single leg toes The head rest was raised. Warming up the body Abdominals: Hundred prep Coordination Hip Work: Frog Circles Down Circles up Openings Increase abdominal strength and shoulder extensor control Progression to the 100, Working on Pelvic lumbar stabilization Progression to include extended frog and extended frog reverse.
10 Spinal Articulation: Bottom Lift Bottom Lift with Extensions Stretches: Standing Lunge Working on spinal articulation and abdominal strength Progression to short spine Hip flexor and hamstring stretch Progress to Kneeling lunge Full Body Integration: Omitted for beginning appts Elephant Down stretch Long stretch Arm Work: Arms Supine Series Extensions Adduction Up circles Down Circles Triceps Leg Work: Squat Working on trunk and shoulder stabilization as well as abdominal Strength. Working on shoulder adductor and extensor strength as well as shoulder mobility and stability Alternate arm workout Standing arm series on Cadillac (chest expansion, circles up and down, punches, biceps) Progression to arms sitting series then side arm kneeling series using very Light springs On Cadillac. We started with the roll up bar to provide a little more stability for Jim and progressed to using arm handles. Lateral Flexion/Rotation- side bend (on elbows)
11 Back Extension: Back extension Cat stretch Swimming Working on back extensor strength, trunk stabilization and shoulder Flexor strength
12 CONCLUSION The shoulder is such a complex part of the body. It s high mobility allows for a vast range of motion. The shoulder has many joints, muscles, tendons and ligaments involved in the mobility of the joint. For this reason a comprehensive workout routine is needed to address all the muscles involved. Stability and mobility need to be worked as well strengthening the muscles. In this case study we were able to build a program to do just this. Within a few weeks, the awareness of the scapula grew. Mobility and stability increased. Strength gains also occurred throughout the sessions and awareness of posture was greatly improved. Through Pilates we were able to increase range of motion and show that Pilates can improve shoulder problems such as rotator cuff injuries and impingement. Pilates is a great way to condition the entire body, including the shoulder girdle, and a great compliment to physiotherapy of the shoulder.
13 BIBLIOGRAPHY 1. Isacowitz, Rael. Study Guide: Comprehensive Course. Costa Mesa, California: Body Arts and Science International, 2013. 2. Staugaard-Jones, Jo Ann. The Anatomy of Exercise And Movement for the Study of Dance, Pilates, Sports, and Yoga. Berkeley, California: North Atlantic Books, 2011. 3. Wood, Samantha. Pilates for Rehabilitation. Champaign, Il: Human Kinetics, 2018. 4. Calais-Germain, Blandine: Anatomy of Movement. Seattle, Washington: Eastland Press Inc, 2014. 5. Physiowork.com.au/injuries-conditions/regions/shoulder_pain 6. Rotator Cuff Workshop-Body Harmonics, Toronto, Ontario, Canada, 2018, run by KatKajary, Registered Physiotherapist, Pilates and Movement Teacher, Teacher Trainer Images 1. https://wwwlfitforlifewelnessclinic.com/health-concerns/pain-muscle-joint-injuries/knee /frozenshoulder/ 2. https://shoulderdoc.co.uk/images/uploaded/joint3.jpg 3. https://luriechildrens.or/en/specialties-conditions/rotator-cuff-tendinitis/ 4. https://www.p2sportscare.com/product/shoulder-3psposter/