Pilates for Active Individuals with Shoulder Impingement Syndrome
Jenny Usher 16 February 2014 2013-2014 CTTC – Brisbane, Australia
Jenny Usher
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Abstract This paper examines the effectiveness of a holistic Pilates program – specifically the BASI Block System - to active individuals diagnosed with Primary Shoulder Impingement Syndrome (SIS). Shoulder Impingement Syndrome is not always specific to athletes or active individuals, and can be caused or aggravated by a variety of risk factors including overhead motions, throwing, reaching, swimming or joint and bone abnormalities. If left untreated, SIS may lead to tendonitis (inflammation of the rotator cuff tendons), bursitis or thinning/tearing of the rotator cuff tendons (Osteoarthritis Health Centre, 2005-2014). The focus of the paper is on conservative administered treatment over a four month period, with consideration given to both the client’s fitness and rehabilitation goals, whilst also bearing in mind any limitations and restrictions.
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Table of Contents Pilates for Active Individuals with Shoulder Impingement Syndrome ................................................................... 1 Abstract .............................................................................................................................................................. 2 The Shoulder Girdle ........................................................................................................................................... 4 The healthy shoulder girdle .......................................................................................................................... 4 Shoulder Impingement Syndrome (SIS) ........................................................................................................ 4 Clinical Presentation of Shoulder Impingement Syndrome .......................................................................... 6 Scapulohumeral Rhythm ............................................................................................................................... 6 Treatment for Shoulder Impingement Syndrome......................................................................................... 7 Case Study.......................................................................................................................................................... 7 Overview ....................................................................................................................................................... 7 Background ................................................................................................................................................... 7 Rehabilitation treatments ............................................................................................................................. 7 Exercise plan ................................................................................................................................................. 9 Program....................................................................................................................................................... 11 Conclusion........................................................................................................................................................ 17 Bibliography ..................................................................................................................................................... 18 Websites...................................................................................................................................................... 18 Online Journals ............................................................................................................................................ 19
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The Shoulder Girdle The healthy shoulder girdle Articulation of the humerus, scapula, clavicle and sternum combined with the rotator cuff muscles (subscapularis, supraspinatus, infraspinatus and teres minor as well as their musculotendinous attachments) make up the glenohumeral joint, or the shoulder girdle. When working properly the shoulder girdle is the most mobile joint in the body and produces a pronounced range of motion of the arm. Due to the lack of ligamentous and muscular support, the shoulder is vulnerable to many varying complications.
Source: Morphopedics,2007-2013
Shoulder Impingement Syndrome (SIS) A relatively common condition, Shoulder Impingement Syndrome (SIS), can be described as pain in the shoulder which is aggravated and intensified by overhead actions or movements. The pinching sensation (the impingement) is the result of mechanical compression of the soft tissue under a bony structure which occurs with specific movements – usually overhead actions (Morphopedics, 2007-2013). The impingement is resultant of the compression and/or degeneration of the subsacromial structures on the anterior undersurface of the acromion. The following structures are involved in the impingement: • Jenny Usher
rotator cuff tendons Page 4 of 19
•
long head of the biceps
•
subacromial bursa.
(Morphopedics, 2007-2013)
Source: (Guildford Upper Limb Clinic, 2010)
There are three different types of Shoulder Impingements, but for the purpose of this paper we will concentrate on Primary Shoulder Impingement. Primary Shoulder Impingement This type of impingement is the structural narrowing of the sub-acromial space (Miller, Physioworks) and results from the humeral head and anterior acromion process compressing the long head of the biceps tendon, rotator cuff tendons, glenohumeral joint capsule and/or subacromial bursa; and may be caused by any or all of the following factors: Intrinsic factors
Extrinsic factors
Inflammation of subacromial bursa/rotator cuff tendons
Curved or hooked acromion
Weakness of the rotator cuff
Acromial spurs
Rotator cuff degenerative tendinopathy
Postural deviations
Tightness in the posterior capsule which leads to irregular anterior/superior translation of the head of the humerus
(Morphopedics, 2007-2013)
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Secondary Impingement This type of impingement commonly occurs with athletes or individuals regularly involved in overhead activities (eg. Tennis, painting, throwing, building etc) and is resultant from dynamic instability or excessive joint movement, ligament laxity and muscular weakness around the shoulder joint (Miller, Physioworks). The instability of the glenohumeral joint or irregular scapulothoracic kinematics causes the decrease in subacromial space (Morphopedics, 2007-2013). During repetitive overhead motions the supporting musculature becomes fatigued and is incapable of counteracting the humeral head from drifting out of the scapular plane and up into the sub-acromial space, resulting in the compression of the bursa or tendons. Coracoid Impingement Syndrome Coracoid Impingement Syndrome or Anterior Shoulder Pain is a far less common reason for shoulder pain and occurs when the coracoid and lesser tuberosity of the humerus compresses upon the subscapularis tendon (Okoro, 2009). This type of impingement can lead to pain and teninosis and is present with repetitive activity-
related anterior shoulder pain. Exacerbated adduction, internal rotation and forward flexion can contribute to Coracoid Impingement Syndrome (Morphopedics, 2007-2013). Clinical Presentation of Shoulder Impingement Impingement Syndrome A client suffering from SIS is likely to present the following symptoms or postural deviations: •
protracted or tilted scapulae
•
limited range of motion (ROM) in internal rotation
•
forward head
•
increased pain during external rotation and abduction of the shoulder
•
rounded shoulders
•
The humerus head may appear to sit more anterior and superior in the glenoid fossa compared to the uninvolved side
(Morphopedics, 2007-2013)
Scapulo Scapulohumeral Rhythm To reach optimal functional movement of the shoulder relies on coordinated movement of the scapula and humerus (Kibler, 1998). The kinematic interaction between the scapula and humerus when placing the hand in space was introduced in the 1930s and is known as scapulohumeral rhythm (Codman, EA). This normal motion of the scapula and humerus creates a powerful function of the shoulder and should be pain-free. The scapulothoracic motion dynamically controls the humerus, clavicle and scapula articulating around the ribcage. During elevation of the shoulder approximately one-third of movement occurs at scapulothoracic joint and two-thirds at the glenohumeral joint. The specific timing and coordination of the muscles and how they control the scapulohumeral rhythm is the most important factor in correct shoulder mechanics (Miller, Physioworks).
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Treatment for Shoulder Impingement Syndrome For those suffering Primary Shoulder Impingement, it is unlikely the patient would be considering surgical treatments at this stage and therefore conservative treatment is sufficient. Rest is the primary advice given, followed by a specific program to strengthen the surrounding musculature of the shoulder in order to facilitate correct glenohumeral and scapulohumeral rhythm.
Case Study Overview A case study was undertaken over four months between the dates of October 2013 when the impingement was reported, to February 2014. Name:
Anna Nicholson
Age:
30
Profession:
Full-time Office Worker, dancer, yoga/pilates and general fitness enthusiast
Limitations:
Primary Shoulder Impingement Syndrome resulting from poor scapular stability and control. Nil other concerns – fit, healthy, strong and flexible.
Background In September 2013, Anna started to feel a slight pinching sensation in her left shoulder, which seemed to be exacerbated by daily tasks such as reaching for coffee cups from an overhead cupboard, shampooing her hair, lifting her handbag off the passenger seat; and fitness related activities such as attending ballet class and using weights in an overhead motion at the gym. As her condition worsened over the month of September her range of motion (ROM) decreased due to sharp, stabbing pain during specific activities as well as pain when sleeping on her left side. Although she was already practising regular Pilates, Anna decided to seek advice on devising a specific program which may help with her injury. Rehabilitation treatments Anna was receiving sporadic physiotherapy which enabled the tightened latissimus dorsi, serratus anterior, posterior deltoid and pectorals to release. Once the tension had been released Anna was given the all-clear to undertake a Pilates program. Having worked with similar clients to Anna, whilst only working within the scope of my training I was able to devise a BASI Pilates program to facilitate correct glenohumeral and scapulothoracic motion in order to correct her shoulder mechanics. Goals Although Anna is a full-time office worker it was apparent that dancing and fitness was of utmost importance to her, and giving up on physical activity was not an option. On this basis we sat down and devised a
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progressive Pilates program designed to assist her in managing her shoulder impingement. One of Anna’s main concerns was variety and not ‘getting bored’ with her program. Short-term goal Resolve current shoulder pain in order to perform daily activities with no pain (such as lifting her handbag of the passenger seat and sleeping on her left side). Long-term goal Build and maintain shoulder strength and full range of movement in order to return to her normal fitness activities of dance, yoga, pilates and general cardio. It is noted that Anna is a highly physical person and what is considered ‘normal levels of physical activity’ for her, could be considered extreme for others. Assessment After a general postural assessment, it was identified that Anna has relatively good posture, however hyperextended knees with an anterior tilt of the pelvis were present. She also displayed a slight tendency to slouch the shoulders, with some cervical extension observed. When observed from the front, her left shoulder sits slightly higher than the right side. During adduction and abduction she experienced pain and pinching when passing through the T position, combined with clicking and catching of the left scapula during articulation with the rib cage. Pain was also felt during flexion beyond 90 degrees, but to a lesser degree. She explained that she is unable to weight bear within these painful arcs.
Source: (South Mountain Sports Medicine and Rehabilitation, 2012) Jenny Usher
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Exercise plan The symptoms displayed by Anna indicates the need for the following, although not listed in any particular priority: •
Improve cervical and thoracic alignment
•
Create awareness of and facilitate correct recruitment of scapula stabilisation muscles (lattissimus dorsi, rhomboids, lower trapezius, serratus anterior) and bring focus out of upper trapezius
•
Stretch pectorals and release tension which may be contributing to ‘slouch’ position of shoulders
•
Strengthen upper back to counteract undesired action of tight pectorals
•
Strengthen hamstrings and facilitate vastus medialis oblique (VMO) to control hyperextension of the knees which may be contributing to the anterior pelvic tilt
•
Strengthen deep stabilisation muscles through effective TA and abdominal strength building exercises
•
Strengthen muscles which will correct anterior pelvic tilt - gluteus maximus, hamstrings and abdominals
•
Stretch hip flexors and quads to counteract anterior pelvic tilt
•
Maintain current flexibility in order to facilitate an optimal return to dancing and fitness
The exercise plan was broken down into three progressive phases. It is noted that Anna was already strong enough to complete all/most of the exercises listed, and progression was steady through increasing/decreasing resistance in order to facilitate challenge and build strength. Quality was not compromised for quantity, as it is of paramount importance that correct mechanics and strength was achieved before progressing to the next stage. Phase 1: Create awareness and deeper understanding of core strength and stability •
Facilitate absolutely correct muscle mechanics and technique when focusing on both thoracic and pelvic-lumbar region. Focus was initially greater on the musculature supporting the shoulder girdle as Anna already had a strong core and was relatively stable through the pelvic-lumbar region
•
Stretching of the shoulders and pectorals to open up the chest with a particular focus on breathing
•
Independent stretching program for home use including simple quads and hip flexor stretches. Pole stretch series were also completed at home in order to stretch pectorals and facilitate correct shoulder mechanics
Phase 2: Address scapular strength and stabilisation through dynamic movement •
Once the shoulder girdle had regained strength and correct muscle mechanics, more challenging exercises such as Upstretch 2 and 3 were introduced, which when performed correctly was a valuable tool for re-educating the neuromuscular system and correcting bad habits
•
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Introduce Full body 2 integration exercises
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Phase 3: Maintain Pilates program and integrate into lifestyle to ensure adequate management of strength and avoid relapse of injury •
By the time Anna reached phase three she was relatively pain-free with no limitations as far as continuing her Pilates practice.
•
In future, care will be taken to ensure adequate focus is continued to be placed on maintaining shoulder stability and strength, while shifting focus to other areas of the body for added challenges.
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Program It should be noted that the below is an example program and was not performed exactly the same each time – but the essence and objectives set out earlier were observed each session. Also note not all exercises are necessarily performed in this exact order, depending on the flow of the session. Phase 1: Create awareness and deeper understanding of core strength and stability
Phase 2: Start to address scapular strength and stabilisation through dynamic movement
Block
Apparatus
Exercise & Rationale
Apparatus
Exercise & Rationale
Warm up
Mat
Pelvic curl
Mat
Roll up
Although Anna is an intermediate client as far as Pilates practice goes, I decided to go with the fundamental warm up series in order to bring focus back into the breath and correct recruitment of the TA. This exercise is also excellent for engaging the glutes and hamstrings which is an objective of this holistic program. Spine Twist Supine The gentle action of rocking the pelvis from side to side will gently warm up the spine. The focus will be on taking tension out of the neck and shoulders and utilising the deep abdominal connection to control the action of the pelvis. Jenny Usher
Having built up abdominal strength and facilitated correct technique the intermediate warm up is a good progression from the fundamental warm up. Particular emphasis will be placed on breath, maintaining the C curve with deep abdominal connection and shoulder position whilst in the C curve. Spine Twist Supine The gentle action of rocking the pelvis from side to side will gently warm up the spine. The focus will be on taking tension out of the neck and shoulders and utilising the deep abdominal connection to control the action of the pelvis. Double Leg Stretch/Single Leg Stretch/Criss Cross This combination of abdominal exercises will challenge Anna to maintain TA activation whilst also concentrating on breathing patterns and Page 11 of 19
Phase 3: Maintain Pilates program and integrate into lifestyle to ensure adequate management of strength and avoid relapse of injury
By the time Anna reaches phase three, her injury should be mostly resolved and ideally there are no restrictions placed on her program. Care should be taken to continue to strength and stability exercises for the scapula, but additional challenges and other focus areas can be introduced to keep Anna interested in the repertoire.
pelvic lumbar stabilisation. Due to the overhead motion of the arms in double leg stretch, this will be a good test for ROM. It is also a good prep for flowing into footwork on the Wunda Chair where an effective co-contraction of the abdominals and back extensors is required.
Chest lift
Step barrel
This exercise is excellent for warming up the abdominals and when performed slowly and with complete control will facilitate activation of the TA. The strengthening of the abdominals will assist with correcting the anterior tilt of the pelvis. Performed on the step barrel means a greater stretch across the chest can be achieved and will provide a variation to the regular chest lift. Chest lift with rotation With oblique emphasis, this exercise will assist in maintaining pelvic lumbar stability while giving the body an added challenge. Again, on the step barrel this will keep Anna interested and motivated and provides an alternative to her usual Pilates sessions.
Footwork
Reformer
Footwork series Lying supine on a flat surface provides excellent proprioceptive feedback and will aid in correcting alignment of the thoracic and cervical vertebrae. Initially, we may use the headrest to avoid excess tension in the neck. Focus will be on maintaining neutral spine, breathing and opening up the chest.
Wunda Chair
Footwork series Footwork on the Wunda Chair is a perfect progression from the reformer due to the absolute necessity for solid core strength and trunk stability. The varied positions of the arms during the series will maintain awareness and control of the affected scapula.
Performed on a medium weight, this allows the client to focus on perfect alignment and stability rather than quad strength. Cues will be given to Jenny Usher
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move through the full ROM of the knees whilst avoiding hyperextension. Abdominals
Reformer
Hundreds prep Again, the flat surface provides excellent feedback for correct recruitment of the latissimus dorsi, serratus anterior and lower trapezius when extending the arms to avoid shoulder elevation.
Wunda Chair
Cues will be given for TA activation to avoid the undesired motion of bulging abdominals.
An excellent exercise to further the deep abdominal connection, pike sitting also offers the benefits of building strength in the latissimus dorsi and shoulder extensors.
To keep the program challenging and to fulfil Anna’s goals of maintaining strength and stability, this is a fantastic exercise for muscle endurance and strength, as well as a challenge for the mind. There will be a focus on breathing, choreography as well as TA activation. Reformer
Circles / Extended frog / Extended frog reverse
Cadillac
Jenny Usher
Reformer
Bottom lift / Bottom lift with extension As building hamstring strength is an objective, this exercise facilitates this while also building glute strength in
Basic leg springs series Comprising of Frog, Circles, Walking, Bicycle and Bicycle reverse this series focuses on (amongst others) pelvic lumbar stabilisation, hamstring stretch and strength, breath and coordination, thereby keeping Anna interested and involved in the work.
The intermediate hip work series was chosen as Anna had already achieved pelvic lumbar stability. Particular focus was on breathing patterns and ROM while working through neutral. Spinal Articulation
This exercise focuses on deep abdominal connection – which will assist in correcting the anterior pelvic tilt. It also focuses on scapulae stabilisation and therefore fulfilling two objectives of the program and is a good warm up for a slightly more advanced exercise on the Wunda Chair, pike sitting. Pike sitting
Coordination
Hip work
Standing Pike
Cadillac
Monkey Original In order to fulfil the objectives of stretching the hamstrings, monkey original is a great exercise whilst also concentrating on controlled spinal Page 13 of 19
controlling the articulation of the spine. Particular focus was on pelvic stability and drawing attention to articulating each vertebrae to create awareness of pelvic alignment. Stretches
Reformer
Kneeling lunge
articulation and shoulder stability. The abdominals will control the dynamics of the movement and the hamstrings will decide whether the legs will stretch to full extension. Careful attention can also be placed on the shoulder girdle to avoid shoulder elevation and increase scapula control. Cadillac
This exercise is excellent for both stretching the hip flexors, quads and hamstrings – all objectives in correcting Anna’s anterior pelvic tilt. Although the primary focus of the hamstrings is strength, it is also important to focus on flexibility to ensure good balance and to maintain her current levels of flexibility. Full Body 1
Reformer
Down stretch It should be noted that this movement may aggravate Anna’s impingement, and so care should be taken to keep the ROM small and within pain-free range. Down stretch is excellent for building serratus anterior recruitment, which will assist in drawing the scapula down – therefore creating a stable base for arm movement. Elephant/Upstretch 1 As this exercise focuses on the pendulum motion of the legs, particular focus is also on the stability of the shoulder girdle. Regular cues to avoid shoulder elevation and to find the connection with the lower traps, SA and lats were given.
Jenny Usher
Shoulder stretch If performed while the shoulder is inflamed or irritated this stretch can feel uncomfortable or intense, so introducing it at a later stage is advised. Focus on correct humerus placement and breath will avoid tension and steadily increase ROM.
Cadillac
Sitting back Great for both abdominal control and shoulder stretch, this exercise will help to open up Anna’s chest and steadily increase ROM. Careful care should be taken when cueing and to ensure the weight of the springs are appropriate. The specific choreography in this exercise will ensure she is involved and present within the movement. Thigh stretch Whilst fulfilling the objective of stretching the quads, thigh stretch will assist in correcting the anterior tilt of the pelvis. This exercise also contains a degree of shoulder stability in keeping tension on the RUB.
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Arm work
Reformer or Ped-a-pull
Full Body 2
Arms supine / Arms series
Cadillac
Again, the flat surface provides great feedback for articulation of the scapulae around the rib cage. The arms never go above shoulder height and is perfect for building stability.
-
Shoulder adduction single arm/double arm/sitting side prep/sitting side This group of exercises would not necessarily be performed altogether each session, but rather alternating. All fulfil the objective of scapular stabilisation with different variations, and all facilitate correct recruitment of lats, SA and lower trapezius, as well as facilitating correct glenohumeral rhythm.
Reformer
Upstretch 2 and 3 Once Anna has mastered Upstretch 1, progression to 2 and 3 will challenge her scapula stability. Care must be taken (especially in Upstretch 3) to ensure excessive pressure is not placed on the shoulder girdle. These exercises are also excellent in targeting the lower abdominals.
Leg work
Lateral flexion & rotation
Jenny Usher
Wunda Chair
Wunda Chair
Forward Lunge/Backward step downs
Reformer
As Anna is an intermediate client, this exercise is excellent for not only providing a challenge, but great in fulfilling our objectives of gluteal strength. Initially, only a few reps with heavier springs with progression to lighter springs and greater repetitions. Focus will be on absolute pelvic alignment, as well as scapula position in order to maintain the position of the arms. Side Stretch Not only is this a beautiful stretch for any fit body, it is particularly useful for Anna in stretching the tight lats and serratus anterior. Particular focus in will
Single leg skate Specifically focusing on the gluteals, this exercise effectively builds strength while at the same time focus can be placed on upper body posture and alignment. Side split This flows beautifully from single leg skate and after targeting the glutes, provides a nice break by focusing on the hip adductors. Again, posture and core strength is also a focal aspect.
Step Barrel
Side lift Focusing primarily on abdominal oblique strength and stretch, this exercise also focuses on correct trunk alignment and shoulder position. It requires Page 15 of 19
also be correct shoulder placement. The weight will be light to extra-light, and careful tactile cueing techniques and verbal cues will ensure shoulder elevation is minimised Back extension
Wunda Chair
Swan on floor This exercise will assist in strengthening the upper back extensors – a primary objective in assisting to open up the chest and minimise slouching. In order to keep the movement out of the lower back, careful tactile cueing in the thoracic spine will be used as well as cues for abdominal engagement. Careful attention will also be placed on ensuring the shoulders are in perfect alignment with SA and lat engagement.
abdominal connection to stabilise the core before using obliques to lift the body.
Step Barrel
Swan prep/swan Utilising the step barrel for back extension allows particular focus to be placed on the thoracic or upper back extensors. Care should be taken with positioning of the scapulae and shoulders to avoid elevation or abnormal tracking. Rest
Mat
A lovely stretch for the entire back after back extension is a perfect way to finish the class. Focus will be placed on breath to conclude.
Rest A lovely stretch for the entire back after back extension is a perfect way to finish the class. Focus will be placed on breath to conclude.
Mat
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Conclusion After four months of a holistic, varied and carefully administered program, the BASI Block System proved an easy to follow, thorough, interesting and balanced approach to conservative rehabilitation. Anna displayed almost completely pain-free movements with a greater range of motion than observed at the beginning of the program. The most startling improvement was her scapula control and awareness of correct mechanics and control. Pelvic-lumbar stability and general improvement in posture seemed almost a by-product, and this reiterates the basis for a holistic and balanced approach to rehabilitation. When Anna performs the daily tasks which once gave her pain, she is now more aware of correct mechanics and core stability – which in turn dramatically reduces the risk of injury during normal, everyday activities. Anna was encouraged to continue with her Pilates training in addition to her other passions for dance, yoga and cardio training, but she now continues with a greater understanding of the need for core stability, correct muscle mechanics and a balanced workout not only for the body, but also for the mind.
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Bibliography Websites Owner/
Title of Page
Year Published
Title of Website
Date viewed
URL
Morphopedics
Shoulder Impingement Syndrome
2007-2013
Morphopedics - Where technology and Orthopaedics Collides
16/2/14
http://morphopedics.wikidot.com/shoulderimpingement-syndrome
American Academy of Orthopaedic Surgeons (AAOS)
Shoulder Impingement/Rotator Cuff Tendonitis
1994-2014
OrthoInfo
16/2/14
http://orthoinfo.aaos.org/topic.cfm?topic=a0003 2
Guildford Upper Limb Clinic
Shoulder Impingement
2010
Guildford Upper Limb Specialist Hand, Shoulder and Elbow Clinic
16/2/14
http://www.guildfordupperlimb.co.uk/shoulder/ shoulder-impingement
John Miller
Shoulder Impingement
Physio Works
16/2/14
http://physioworks.com.au/injuries-conditions1/rotator-cuff-impingement
Writer of Site
Scapulohumeral Rhythm Exercises
http://physioworks.com.au/treatments1/scapulohumeral-rhythm-exercises
T. Okoro, V. R. M. Reddy & Ashvin Pimpelnarkar
Coracoid Impingement Syndrome: a literature review
2009
US National Library of Medicine National Institutes of Health
16/2/14
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2 684954/
South Mountain Sports Medicine and Rehabilitation
About Shoulder Impingement Syndrome
2012
South Mountain Sports Medicine and Rehabilitation
17/2/14
http://www.southmountainrehab.com/extra/ne ws/shoulder_impingement_syndrome.php
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Osteoarthritis Health Centre
Shoulder Impingement Syndrome
2005-2014
WebMD
17/2/14
http://www.webmd.com/osteoarthritis/guide/im pingement-syndrome
Online Journals Author
Title of Article
Publication
Year of publication
Kibler, WB
The role of the scapula in athletic shoulder function
Am J Sports Med
1998
Codman, EA
The Shoulder
G.Miller Company
1934
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