Welcome back yoga fans and anatomy nerds! Did you enjoy last month’s episode, where we discussed rotator cuff injuries, and how yoga can help?
In the second instalment of our monthly Samadhi Anatomy with Greg Walsh article we are going to dive a little deeper into the anatomy and physiology of your shoulder, discuss where how and why pain occurs, and we will look at how to execute poses which can ease your pain and discomfort through yoga.
Episode 2: Shoulder Impingement & Rotator Cuff Tendinitis, and how yoga can help
Your shoulder joint, also known as your glenohumeral joint1, is a ball & socket articulation. In this joint the head of your humerus2 bone connects to the glenoid fossa3 of your scapula4 or shoulder blade. A fossa is a socket or cavity, and the glenoid fossa is a very shallow bowl shape. The head of the humerus (the ball) is larger than the glenoid fossa (the socket), so the socket is deepened by the glenoid labrum5, a roughly circular fibrocartilaginous structure. Both the head of the humerus and the inside of the glenoid fossa have a coating of hyaline cartilage, to give a smooth, gliding surface to the bones.
All of this is enclosed in a sheath of fibrous connective tissue, which creates the joint capsule. The inside of this capsule is lined with synovial membrane, which produces synovial fluid6. Synovial fluid is one of the slipperiest fluids known to science. In his novel Moby Dick, Herman Melville mentions harvesting synovial oil from the jaw of a dolphin, which was prized for lubricating watch mechanisms.
The shoulder joint has several synovial bursae7, to prevent friction. A synovial bursa is a sac of synovial fluid, which acts as a cushion or barrier, between two bones, tendons or muscles. If a bursa becomes inflamed, infected or irritated, bursitis occurs8.
Shoulder Impingement & Rotator Cuff Tendinitis
To impinge means to press upon, to infringe or encroach. Shoulder impingement is where one bone in the shoulder is pushing either into another bone, into a tendon or into a bursa. If the bone is pushing into a bursa you have shoulder bursitis, if it is pushing into a tendon you have rotator cuff tendonitis. Both of these may have shoulder impingement at their root, and it is the outer tip of the scapula or shoulder blade which is the troublemaker. Let’s drill into the anatomy of this a little.
The outer tip of the scapula is called the Acromion9. A shoulder rotator cuff tendon runs under the acromium, and there is also a bursa situated under the acromium10.Some of us have a short flat acromion in each shoulder, whereas some of us have longer and more hooked acromions. If you have shorter acromions you may have a greater natural range of motion in your shoulders.
Lets look at some examples of different acromions to the right.
There are three classifications of acromions: type 1, type 2 and type 3, and they are shown in this illustration, from left to right. You can see how the”normal acromion” is shorter and flatter. This is a type 1 acromion, and will not intrude into the space above head of the humerus bone, which is filled by the supraspinatus tendon and a bursa. However look at the “hook shaped acromion”. this is a type 3 acromion, and it intrudes into the humerus space, potentially putting pressure on the bursa, tendon, and potentially at certain angles, even the head of the humerus. Type 2 or type 3 acromions usually pose no issue when the humerus is down and the arm is by the side, but may begin to impinge on movement as the arm is raised. Here is where yoga can help, by creating space in the joint. but more on the ins and outs of that later.
How do you know that you may have shoulder impingement or rotator cuff tendonitis:
Firstly, 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.
Shoulder impingement may manifest as tenderness in the front of the shoulder, especially when you try to raise your arm. In fact you may feel a sudden sharp pain on lifting your arm. This is because as you lift your arm your humerus bone raises closer to the acromium, and squeezes the supraspinatus tendon or the shoulder bursa.
How to treat shoulder impingement or rotator cuff tendonitis:
Ignoring shoulder impingement or tendonitis can lead to a tear or fray of the tendon. The first line of treatment is short term rest and anti-inflammatories. This will ease the pain and bring down inflammation which is complicating the injury. Ice packs for 20 minutes three times a day will also help with pain and swelling. Immobilisation or a sling should not be used, as this can result in adhesive capsulitis11, or frozen shoulder.
If it worth looking into your habitual movements, to see if there are any offending movements which have caused or are irritating the impingement. If these are found and eradicated, rest, ice, anti-inflammatory medication, some physical therapy and stretching should be enough to lead to a full recovery.
If the pain does not resolve, your doctor or medical professional may advise you to have a steroid injection. This was covered in our Samadhi Anatomy Episode 1 article here.
Failing that, surgery may be recommended. An arthroscopy, or keyhole surgery, can be performed, This is called subacromial decompression12. A little of the acromion bone may be shaved off, and any tendon damage can be repaired.
How yoga can help with shoulder impingement and rotator cuff tendonitis:
,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.
1. Tadasana Variations
Tadasana is such a simple pose that it is often overlooked. Because in shoulder terms it is not weight bearing, and because the spine is in a neutral position, it allows us to play with shoulder mobility, and explore where pain begins in various arm positions.
a. Arms Back, External Rotation
Take the hands behind the back, with the palms facing forward. Explore rotation in the shoulders, especially external rotation, where you feel you are turning the thumbs out and back. What is important is not the angle of the thumbs or palms, it is the rotation in the shoulder socket, so make sure it is shoulder rotation and not wrist or forearm rotation masquerading as shoulder rotation. Draw the shoulder blades downward and inward, without puffing the chest forward. Hold as long as is comfortable.
b. Arms in front at Shoulder Height
From Tadasana, take the arms out directly in front of the shoulders, with the hands shoulder width apart. Start with the palms facing down. Hold it with the fingers together rather than stretching apart, as this brings extra muscular engagement to the forearms. Explore external rotation by turning the palms in to face each other, and then try turning the palms to face upward. As with Tadasana a. what is important is not the angle of the thumbs or palms, it is the rotation in the shoulder socket, so make sure it is shoulder rotation and not wrist or forearm rotation masquerading as shoulder rotation.Hold as long as is comfortable.
c. Arms in front at Shoulder Height with stretchy Band
From Tadasana, take the arms out directly in front of the shoulders, with the hands shoulder width apart, holding a stretchy band. Start with the palms facing down. Keeping the hands and arms at shoulder width, externally rotate the hands by turning the palms in to face each other, and then try turning the palms to face upward.
As with Tadasana a. & b. what is important is not the angle of the thumbs or palms, it is the rotation in the shoulder socket, so make sure it is shoulder rotation and not wrist or forearm rotation masquerading as shoulder rotation. Watch the elbows, the inner elbows should externally rotate as the hands rotate.
Hold as long as is comfortable. Take a rest, and then cycle through slow external and internal rotations.
Take the palms together into prayer pose in front of the chest. Explore the effect of firmly pushing the palms together, rather than just making the shape.
Are there any noticeable differences when you push the finger-bases together, compared to the heels of the hands? Explore differences in sensation when you take the fingers higher, and when you take the elbows higher or lower.
A really useful variation is to to lift the hands, and take the elbows closer together, perhaps even take the forearms right in to touch if possible. As you draw the elbows allow the shoulder blades to spread. As the forearms touch, raise the arms and hands, and feel how, as you push the arms together, you strongly engage the chest muscles, the pectoralis major.
Hold as long as is comfortable
2. Creeping Urdhva Hastasana
Face a wall, and take your hands onto the wall. Your distance from really depends on how much movement you have in your shoulder(s). Begin creeping your fingers up the wall. The elbows will be bent as the arms rise. Watch the width of the elbows, try to keep them at shoulder width. As your fingers walk up the wall, you will need to step closer to the wall. Walk the fingers as high as you can, and then hold at that height. If you want to add more weight and work into the shoulders, you can stand further from the wall, to ease weight and lighten the work stand closer to the wall.
3. Garudasana Arms
Garudasana arms is a wonderful way to open across the upper back and shoulders. When you pick up a shoulder injury, the greater area tightens up, not just the injured area. So it is worth opening around the whole area, not just focusing on the exact area of the injury. When you take one elbow under the other and ant attempt to wrap the forearms around each other and bring the hands together, you will feel a strong spreading of the shoulder blades.
If getting the hands together is too challenging, you can use a strap to hold the hands in place. I find it more useful to hold a strap rather than just have the hands floating, as the strap give stability and creates resistance.
Once you are in the pose, work on lifting the elbows and hands, and take the wrists forward away from the face.
Hold as long as is comfortable, and then repeat on the second side.
4. Gomukhasana Arms
What a wonderful stretch this has in store for you! Gomukhasana externally rotates one arm and strongly internally rotates the other arm. It stretches the tricep and latissimus Dorsi on one side, and the trapezius and rhomboids on the other side. However with an injury the full version of the pose will probably not be possible, so we will use a strap to give some space and make it accessible. With that in mind please do not force yourself into the full version of the pose. Enjoy the space that the strap gives you, and over time you will slowly and safely progress into the prop-less version of the pose.
Hold a strap in your right hand, take the right arm up over your head, bend the elbow, and let the right hand and belt drop back behind your head.Take your left arm up your back behind you, and take hold of the strap. You can explore straightening your right elbow, which will pull your left arm up your back. Proceed with caution, try to explore the feeling of stretch without moving into pain.
Hold as long as is comfortable, and then repeat on the second side.
5. Ardha Adhomukha Svanasana
If you are a regular in my classes you will know that Adhomukha Svanasana is one of my favourite poses. I think it has so much to give! However, it is also a weight bearing pose. So if you are rehabilitating a rotator cuff tear of shoulder injury, 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 shoulder blades.
Once you can do all of these stretches and poses without pain, it could be time to begin applying weight into your yoga practice once again. 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 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 in that all important frontal shoulder area.
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.
Dislocated Shoulder/Shoulder Instability