Don’t shrug off shoulder work

Shoulder injuries are more common in women than you might think. Did you know that 65 per cent of clients presenting with a frozen shoulder are women? As women age shoulder injuries become increasingly common so it’s important that we understand how we might support our female clients to take care of their shoulders.

As we all know women are great at multitasking. That might mean holding the shopping while carrying a child or maybe just a heavy gym bag; it also makes us prone to shoulder injuries. It might sound obvious to highlight that we don’t have the same musculature as men, so with that in mind, it’s even all the more important that we take care of the shoulders at any age. In this article, we look at ways we can restore movement to this complex yet increasingly important area of the body.

Let's take a rotator cuff injury as an example. An injury that is often caused by repetitive movements like throwing, lifting and overhead activities such as painting and cleaning. Clients with a rotator cuff tendon tear complain of weakness, loss of shoulder function, or symptoms typical of rotator cuff tendonitis. The pain can be aggravated by reaching, pushing, pulling, lifting, or positioning the arm above shoulder level. Most clients with tears of the rotator cuff complain of difficulty sleeping on the shoulder at night.

If your client has been diagnosed with a rotator cuff injury, it’s quite common for them to work with a physio before returning to you for further work. Movement should be encouraged as soon as possible, and the entire limb and affected side of the torso should be returned to strength post-rehabilitation.

So what exactly is the Rotator Cuff?

The Rotator Cuff is a common name for the group of four distinct muscles and their tendons, which provide strength and stability during motion to the shoulder complex. They are also referred to as the SITS muscle, with reference to the first letter of their names (Supraspinatus, Infraspinatus, Teres minor, and Subscapularis). The muscles arise from the scapula and connect to the head of the humerus, forming a cuff around the glenohumeral joint.

Sprain to the Rotator Cuff

Often we see sprains of the rotator cuff which also need to be taken seriously. A sprain is an injury to a ligament when the joint is carried through a range of motion greater than its normal range without dislocation or fracture. A shoulder sprain is stretching or partial tearing of the ligaments and capsule that support the shoulder. Significant damage to one or more of the connective tissues of the shoulder can result in joint instability and chronic dislocations.  Ligaments, due to a low blood supply, are slow healing and ongoing instability may be an issue in the joint.

So what can cause a shoulder sprain?  

A shoulder sprain could be a result of playing sports, from poor coordination and or poor balance, inadequate flexibility and strength in muscles and ligaments or loose joints. They could have fallen on an outstretched arm, forced the twisting of the arm or had a blow to the shoulder.

The symptoms of shoulder pain for your client may include:

• Pain, tenderness and swelling around the shoulder joint as opposed to in a muscle

• Redness, warmth or bruising around the shoulder

• Limited ability to move the shoulder and increased pain with movement

• Unstable sensation in the affected joint

General treatment

Treatment of grade three or moderate-to-severe grade two sprains generally includes some external support (sling or taping) and restricted activities. Once the ligaments have undergone sufficient early repair, controlled passive motion can help to prevent the formation of adhesions (scarring in areas of movement). Resistance exercises are introduced to stimulate a stronger repair and to assist in movement re-education.  It’s also important to note that a complete tear can sometimes be less painful than a partial tear.

Isometric is progressed to isotonic forms of resistance, based on the client’s tolerance for joint motion. For athletes, regaining full stability may require advanced forms of exercise in the functional phase of rehabilitation, such as proprioceptive training and plyometrics. These manoeuvres help to re-coordinate the sensory receptors and motor controls at the spinal cord (non-thinking) levels.

Strains and Tears of the Rotator Cuff

Having a strain or tear of the rotator cuff is another level entirely. And while common once again it’s the type of injury that requires careful consideration.

Shoulder strains and tears may be caused by:

• an acute injury, which may include bone breaks,

• degeneration, causes include bone spurs, decreased blood flow and overuse,

• improper use of a muscle or the

• overuse of a muscle.

In simple terms, a strain is when a muscle becomes overstretched and tears. This painful injury also called a "pulled muscle".

While a tear is a tendon becoming partially or completely detached from the head of the humerus.  In most rotator cuff tears; the tendon is torn away from the bone.

Most tears occur in the supraspinatus tendon, but other parts of the rotator cuff may also be involved.  In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.  The subacromial bursa can become inflamed and painful in association with rotator cuff tendon injuries.

Defining the Muscle Movements:

— Teres Minor is the lateral rotation of the humerus, adduction of the arm

— Infraspinatus is the lateral rotation of the humerus, abducts the arm (brushing hair)

— Supraspinatus initiates abduction of the humerus to 15 degrees (holding shopping bag away from the body)

— Subscapularis is the edial rotation of the humerus.

Once again it could be caused by playing sports, poor coordination, poor balance and posture, inadequate flexibility and strength in muscles and ligaments, repetitive job or movement patterns and or age.

Most clients with a strain or a tear will present with:

• Pain, tenderness and swelling in a muscle rather than in a joint

• Redness, warmth or bruising around the shoulder

• Limited strength to move the shoulder and increased pain with movement

• Pain that worsens overnight or after resting

It’s important to note upfront, that the aim of any rehabilitation work is to have the scapula move in synchronicity with the humeral head in order to maintain a supportive surface and stabilise the glenohumeral rhythm. Failure to do so, through weak or tight shoulder stabilising muscles will increase the chance of injury. Strengthening of the scapular stabilisers (Serratus Anterior, Pectoralis Minor and Major, Trapezius, Rhomboids Major and Minor, Levator Scapulae) is paramount to strengthening the rotator cuff in order to maintain a stable platform and favourable posture for rotator cuff biomechanics.

Part 1 - Start with Postural Treatment

Our first next step at Tensegrity would be to undergo a first-stage general postural treatment, starting with stretches. We’ll stretch the

• Upper Trapezius

• Side Stretch (with arms down by sides or across chest)

• Levator Scapula

• Pectoralis Minor

It’s important for each exercise that we check that humerus is deep in the glenohumeral socket. It is useful to develop some good imagery tools to assist your clients to sense good alignment. For example:

• Shoulders broad as if they have sharp pencils on the tip of each shoulder reaching towards opposite walls

• Scapula moving down the back and sternum rising

You might also see the postural issues like a forward head, a kyphotic spine and multiplane stability as some examples. You can view the full story on our website to see what sort of exercises they would use to support the client here. Once they master this, we move into the second phase, utilising a small ROM.

Part 2 – Introduce a small range of movement

Ultimately, rehabilitation exercises and stretches should:

§  aim to strengthen the rotator cuff muscles and re-pattern movements involving these muscles (to prevent reoccurrence).

§  Involves exercises and stretches that work on internal (medial) or external (lateral) rotation are helpful, particularly with Stretch Band.

§  Ensure shoulder blade stabilisation is also crucial for a comprehensive shoulder rehabilitation program.

It is crucial to listen to the client who will direct you in regards to their pain threshold and range of motion.

On the reformer this will mean arms down, chicken wings, arms side, curl ups and obliques and chicken wing coordination, kneeling chest stretch, reverse abdominals, chariots, hug a tree, side pull across, chest expansion, tiara, side press out and pulling straps I and II while being excellent shoulder exercises, should be introduced with caution and only introduced in a pain-free stage.

Indications/Symptoms at Initial Assessment

According to research, physical examination accuracy is low. However, a thorough understanding of the four muscles of the rotator cuff and their specific roles will improve the likelihood of successful diagnosis by a registered medical practitioner.

There are a number of things we need to consider as Pilates Professionals:

·      Stage one and two clients should be in private or small group sessions

·      Work with the clients Health Professional

·      Constantly check in with the clients’ progress and evaluate home activities to gain a complete picture

·      Atrophy in the surrounding hard (bone) and soft (ligaments, tendons, muscle) tissue

·      Mental state of the client

·      Support the joint with blocks, cushions, Pilates balls, etc. (remembering that instability is contraindicated)

·      Maladaptive movement patterns – this may change over the rehabilitation phase and is a good reminder to take a full body approach to every session

·      Take note if the Upper Trapezius, Pectoralis Major and Minor, Latissimus Dorsi and Quadratus Lumborum are tight, overworked or restricted?  Dysfunction in these muscles will affect optimal rotator cuff activation and arm movement.

Tracey Nicholson is the Director of Tensegrity Training an RTO that offers several different levels of training to help you at any stage of your career in Pilates. Offering accredited training, short courses and somatic and movement therapy, Tracey and her team are dedicated to their clients and comprehensive in approach. You can find out more at tensegritytraining.com.au