Greetings yogis! Did you read last month’s episode, where we explored shoulder impingement and rotator cuff tendonitis, and how yoga can benefit these issues?
In the third instalment of our monthly Samadhi Anatomy with Greg Walsh article we are going to discuss how what we think of as our shoulder joint is actually a conglomeration of joints, we will explore where, how and why shoulder dislocation occurs, and we will look at how to execute some poses which can help to stabilise and strengthen your shoulders through yoga.
Please be aware we always advise that you get the opinion of a medical professional, be it your GP or a physiotherapist, before you embark on any treatment or exercise regime.
Episode 3: Dislocated Shoulder & Shoulder Instability, and how yoga can help
Firstly lets talk shoulder anatomy:
Do you know that you actually have four joints or articulations your shoulders?
What we normally think of as your shoulder joint is actually called your Glenohumeral (GH) Joint 1. It is the most mobile joint in your body. Then there is the Acromioclavicular (AC) Joint 2, which is where the shoulder blade joins with the clavicle or collarbone. Where the clavicle meets the sternum is called Sternoclavicular (SC) Joint 3. The fourth is a floating joint, called the Scapulothoracic (ST) Joint 4, where the scapula floats on the posterior ribcage.
These four joints work as a collective to give the amazing combination of mobility and stability which we have in our shoulders. You have shoulder mobility in almost every direction: you can reach up, down, forward, back, and out. this can cause trouble: we have mobility at the expense of stability. Our shoulders engage in a mobility-stability trade off. To explain that further, mobility is facilitated by the joints, and stability is mostly created by the muscles. So good muscle tone is crucial to shoulder health and function.
Of these four shoulder joints, the joint which most commonly gives us trouble is our glenohumeral joint, where the head of our humerus, our upper arm bone, connects via a very shallow socket (called the glenoid fossa 5), with the scapula. We discussed the glenoid fossa at length in Episode 2, The glenohumeral joint is the one we will focus on in this article.
Dislocated Shoulder & Shoulder Instability
How can a shoulder dislocation occur? Usually through a sharp force or a sudden hit to the shoulder, though it can also occur with extreme rotation. It can happen playing sports when you take a hit, or in a car accident, or even just if you fall over and land on your shoulder. There is a related injury called a shoulder subluxation, this is a partial dislocation. The prognosis and treatment is really the same, so when we refer to dislocation we are also including shoulder subluxation.
Dislocation can bring complications:
- Nerve tissue damage
- Blood vessel damage
- Muscle tears
- Ligament tears
- Tendons tears
- Shoulder instability
If this is the case surgery may be needed to repair the damage.
There are two main types of dislocation:
- Anterior Dislocation
- Posterior Dislocation
Anterior dislocation occurs when the head of the humerus is displaced forward. Over 95% of dislocations are anterior. Most sports or impact dislocations are anterior.
Posterior dislocation occurs when the head of the humerus is displaced backward. Approximately 4% of dislocations are posterior. They are often caused by a seizure or sometimes an electric shock, though sometimes falling on an outstretched arm can can cause a posterior dislocation.
Occasionally shoulder dislocation can occur through normal arm movements, like reaching the arm overhead, or rolling over in bed. This is due to unusually lax shoulder ligaments. Lax ligaments may be inherited, but they are often due to a history of dislocation. It is important to remember that muscles are elastic, and ligaments and tendons are plastic. Stretch a muscle and it will return to its original shape. Stretch a ligament or tendon and it may stay stretched.
- Severe shoulder pain
- Reduced shoulder mobility
- A change in shape of the shoulder
- The head of the humerus may be visible or palpable through the skin
It is always recommended that you see a medical professional if you feel you have any injury or illness. They will have the skills to diagnose you. If you think you have a shoulder dislocation or subluxation, you need to go to a doctor or hospital. It will not go back into the socket, it will not get better on its own.
When the humerus becomes dislocated from the glenohumeral joint, it will still be connected to the surrounding bones by the shoulder, arm, back and chest muscles. Due to the trauma and shock these muscles often go into spasm. Muscular spasm needs to be managed before the humerus can be manoeuvred back into its socket, as the spasm will create too much resistance. A doctor may give you muscle relaxants, and when they take effect they will carefully but firmly pull the arm, to realign the humerus head with the socket of the glenoid fossa, and let it slide (or snap) back in. This is called Closed Reduction.
After Closed Reduction
When the dislocation has been reset, pain will recede almost immediately. However the shoulder will be bruised and very tender, and vulnerable to slipping back into dislocation. The shoulder needs to be immobilised for a few days, with a sling. An icepack is really useful to reduce swelling. Once swelling recedes, you can use a heat pack to relax tight muscles. It may take 12 – 16 weeks to fully recover from a shoulder dislocation.
If surrounding tissues are damaged due to the shoulder dislocation, surgery may be recommended immediately. Oftentimes closed reduction is enough, the patient has no further recurrence of dislocation, and no surgery is needed. However sometimes as previously discussed, dislocation leads to lax ligaments and muscles, and longer term shoulder instability. In this instance surgery is also recommended.
With an anterior dislocation, a Bankart lesion may occur. This is when the labrum, a ring of cartilage which deepens the glenoid fossa, is torn or damaged. Bankart repair surgery, which may be performed as an open surgery or an arthroscopy (keyhole surgery) aims to repair and reattach the labrum.
When shoulder dislocation leads to shoulder instability due to multiple occurrences, the shoulder ligaments can become lax. Capsular shift surgery tightens the ligaments by removing the slack tissue.
Latarjet procedure / Bone grafting
Sometimes the boney base of the shoulder socket can be damaged during a bad dislocation. The Latarjet procedure involves grafting bone from elsewhere into the socket. As with Bankart repair surgery, Latarjet may be performed as an open surgery or an arthroscopy.
In extreme cases, often when age is a factor, a shoulder replacement is necessary.
How yoga can help with shoulder dislocation and instability:
Yoga is a really useful tool in helping to recover or heal shoulder pain of many types. It is a safe and controlled method of rehabilitation, and the mindful approach of yoga lets us carefully work to but not beyond our safe limit. With shoulder instability strength training is highly recommended, as we want to create firmness and stability in and around the shoulders, as well as supple flexibility. As we mentioned at the start of the article, muscles give our shoulder joint its stability.
While we would never wish an injury on anyone, having an injury really sharpens your awareness of the injured area. Injuries often give warning signs, but we often choose not to heed them.As you recover from a shoulder injury it is really useful to apply a heightened awareness to the action and movement of your shoulders as you practice yoga, as you work out, as you work, as you relax.
Sometimes in a yoga class you will hear conflicting instructions, like “reach the arms up as you take the shoulder blades down”. These kind of instructions have a poetic symmetry, but are not physiologically sound. Instructions like this are really not helpful, especially when recovering from shoulder dislocation or managing shoulder instability. What your shoulders need is stability as has been said already. You should aim to draw the head of the humerus into your shoulder as you practice yoga (or do anything) to keep that stability. But what if you are reaching out, or stretching up? If you cannot draw the head of your humerus into the shoulder socket, then you should draw the shoulder socket into the head of the humerus! Lets put that into simple yogi terms: Virabhadrasana 1, Warrior 1, you extend your arms up over your head. People often say “take your shoulder blades down as you reach your arms up”. That is going to add to your shoulder instability. You need to lift your scapulae to your arms. In simple terms, lift your armpits. Try it right now: reach your arms straight up, and lift your armpits with them. Keep a spread in the back of the neck to reduce cervical tension, but lift the arms and armpits. Do you feel the stability in the shoulders? Something else you will feel is you can take your arms further back with less strain!
A few key points to bring onto your mat to benefit your shoulders:
- Create external rotation in the shoulders
- Stretch out the chest, as a tight chest puts heavier demands on the shoulders
- Create stable strong shoulders
- Allow shoulders to rise if the arms come up over the head
1. Virabhadrasana 2
Virabhadrasana 2 or Warrior 2 is primarily a leg and pelvic pose, but it also has great potential as a gentle shoulder strengthening pose. Try holding the arms out at shoulder height in it for a few minutes and you will know what I mean. It does not put the shoulders under any strain, only healthy strengthening stress. It opens the chest, develops Deltoid muscle 6 strength and shoulder stability.
As you hold the pose, feel the shoulder blades spread, so that the glenohumeral sockets move into the humerus heads. I recommend playing with the shoulders in the pose. Explore how the shoulders feel as you externally rotate the upper arms. Try turning the palms upward. Compare how the shoulders feel when you broaden the shoulder blades vs. the collarbones. Get to know your safe range of motion in the pose!
You can also explore the range of comfortable motion in your shoulders in other standing poses, as they bear no shoulder weight.
Tadasana is an effective pose for playing with the shoulders, collarbones, sternum and spine, in a neutral standing posture.
Uttitha Trikonasana has a similar spacious shoulder opening feel to Virabhadrasana 2, except that the arms are vertical. Again explore spreading the shoulder blades, allowing the glenohumeral sockets to move into the humerus heads.
Uttitha Hasta Padangusthasana is a strong leg strengthener and hamstring stretch, but it also has a shoulder aspect. Use the Latissimus Dorsi 7 rather than the shoulder muscles to lift the leg. The Latissimus Dorsi muscles are the largest muscles on the back, and by strengthening them you can take pressure off the shoulders.
2. Forearm Plank with Props
Once you feel you are able to start bringing some weight bearing back into your shoulders you could try this. The belt and brick stabilise the shoulder joints, allowing you to develop strength. Feel the humerus heads draw firmly into the joints, and draw the scapulae down toward your lower back ribs. If you do it carelessly you will feel the shoulder blades push toward each other, creating a furrow in the upper back. Keep the scapulae spreading away from the spine as you draw them down. Hit out into the belt to create resistance.
3. Chaturanga Dandasana with Knees on Floor
Chaturanga Dandasana. The pose we love to hate. It is a challenging pose, and applies a heavy load into the shoulders. The classic pose is probably too strong when recovering from a shoulder injury, so I recommend putting the knees on the floor. Now if you have been to my classes you will know that I usually do not encourage this, as the abdominal muscles switch off when the knees rest down. However it takes some of the load out of the shoulders, and makes it accessible. If you find that it is manageable then you can explore doing it with the knees on a bolster instead of the floor, which brings more weight back into the shoulders and upper body.
In Chaturanga Dandasana with knees down be mindful of the shoulder blades and collarbones. Like Forearm Plank with props draw the scapulae down toward the lower back ribs, keeping space between them. Grip the back of the armpits, and broaden the collarbones.
4. Setubandha Sarvangasana
If you have healthy and injury free shoulders and spine this is a very pleasant pose. However if you are recovering from an injury you will feel the effort in the pose, and appreciate more fully the effort it involves and benefits it brings. It opens the chest and strengthens the rear shoulders, the rhomboids and the lower fibres of the trapezius.
Grip the elbows in using the upper back muscles, and have the forearms vertical. Keep the hands off the hips, and see if you can widen the hands by gripping in the rear armpits and drawing the scapulae down and in.
Hold as long as is comfortable.
5. Purvottanasana Arm Action
Like Chaturanga Dandasana, full Purvottanasana applies a heavy load into the shoulders. But if the bodyweight is reduced, it becomes a useful strengthening, stabilising pose, with some great built in chest stretch and external shoulder rotation.
Do this asana variation either sitting crosslegged, or with the legs straight out in Dandasana.
I recommend the classical hand position, facing forward, unless there is a wrist injury. People often ask can they turn their hands out or even back, as this “feels nicer”. I agree that it feels nicer, but it is less stable in the shoulders.
In the pose the focus should be on drawing the shoulder blades down and in, and once again closing the rear armpits. Feel the skin on the rear upper arms descending, to help to lift and broaden the chest.
Bhujangasana is a back arch, but has built in shoulder and chest benefits. It opens across the collarbones and front ribs, creates a larger breath space, externally rotates the arms and creates firm shoulders.
When practicing this pose there are a few points which I recommend:
- Do not fix the shoulders at the expense of the spine. Draw the navel in, and root your legs into the floor. This will keep your lumbar spine stable.
- Grip in the elbows, and draw the rear upper arm skin down.
- Keep the shoulders down and back.
- Broaden the collarbones.
- Use each inhale to create lift in the chest and front body. Use each exhale to help draw down the scapulae.
Hold as long as is comfortable.
Dhanurasana is a backbend which stretches out the chest with little shoulder work. The arms and hands have to just hold on, and the legs are the lifters. Try it and you will see. People try to lift from the arms, and forget the legs. Hit the feet up and back and you will feel the pose come to life. you can use the pose to open the front chest and firm the rear shoulders, working as hard or as soft as you feel best benefits your shoulders.
Hold as long as is comfortable.
Camel pose, or Ustrasana agin creates firmness in the shoulders and upper back, while creating space and openness in the upper chest. It is more challenging than Bhujangasana or Dhanurasana in the shoulders, because it also strongly externally rotates the humerus head in the glenohumeral joint. Couple that with the back-bending aspect of the pose, and it makes for a lot of work! With that in mind I recommend using two bricks to give some space and make the pose accessible. Do not force yourself into the full back-bending version of the pose. Enjoy the space that the bricks give you, and over time you will slowly and safely progress into the prop-less version of the pose.
Ustrasana Action with Reduced Backbend
The shoulder and chest opening aspect of the pose can be explored without arching fully into the backbend. You can take the arms out and back, turn the palms out to create spacious external arm rotation, and draw the scapulae onward and downward.
Hold as long as is comfortable.
9. Ardha Adhomukha Svanasana
If you can do all of the above poses without pain, you could think of bringing Dog back into your yoga practice. Adhomukha Svanasana is a weight bearing pose, so if you are rehabilitating a dislocated shoulder or working to stabilise shoulder instability, I recommend doing Adhomukha Svanasana with your hands on a height. It can be the seat of a chair, or the wall. If you know Samadhi yoga studios, the upstairs window ledges are perfect for this. Having the hands on a height takes much of the weight out of the shoulders, allowing you to control the amount of effort and stretch, and to focus more directly on spreading and drawing down the scapulae, and drawing the humeral heads into the glenohumeral sockets.
10. Triangular Forearm Support featured in our first episode. It is proscribed for rotator cuff injuries, but it really helps to build stability with a healthy level of functional flexibility.
Interlink fingers, and place the elbows (shoulder width apart) on a wall. Step the legs back, keeping one closer to the wall for steadiness, and ground the forearms into the wall. Extend the head away from the wall, opening your armpits toward the floor. Hold for 30 seconds.
Once you can do all of these which incorporate both strength and stretch poses without pain, it could be time to begin applying weight into your yoga practice once again. At this point it might be useful to work with a personal trainer who can advise you on how to build stable strength using resistance. On the yoga mat, Adhomukha Svanasana (Downward Dog) is the pose I would begin with to reintroduce weight bearing. If it feels too strong, you can do your Adhomukha Svanasana with your hands on bricks, a bench, or some other low support, as discussed above.
As you progress you could explore Uttitha Chaturanga Dandasana (high plank, with straight arms) and perhaps try bending the arms even a little. If you feel you can bend your arms, bend the elbows toward the sides of the body rather than out to the sides, as this keeps space across the chest and collarbones. In time with patience I would hope to see you doing more shoulder focused poses such as full Purvottanasana and even Adhomukha Vrksasana (hand balance)! My experience is that a static yoga practice is more conducive to healing shoulder injury. It can be hard to maintain a full awareness of “shoulder best practice” in a flowing practice. However I am open to my mind being changed on that one!
As I say each month:
Recovery takes time, and requires patience. Always practice with care and carefully observe each movement. That way you can feel any unhealthy movement as it occurs, and you can pull back from it, which will aid your recovery and reduce the risk of re-injury.
Frozen Shoulder (Adhesive Capsulitis)