THE ROTATOR CUFF AND SHOULDER STABILITY

Caroline Freeman

1st September 2017

The Pilates Clinic, Wimbledon

2016/2017

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ABSTRACT

The shoulder joint is a highly flexible but also fundamentally unstable joint and

consequently shoulder injuries are amongst the more common injuries that

pilates instructors will encounter. This paper addresses the structure and

anatomy of the shoulder, a more specific rotator cuff injury and a conditioning

program designed to be practiced without pain and with the intention to

rehabilitate from the original injury, strengthen the relevant muscles of the

shoulder and regain a significant range of movement. The program

incorporates the principles of pilates and addresses the mind and body as a

whole, in accordance with the teachings of Joseph Pilates.

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TABLE OF CONTENTS

Page

Title Page ………………………………………………. 1

Abstract ………………………………………………. 2

Table of Contents ………………………………………………. 3

Anatomy of the Shoulder ………………………………………………. 4

Case Study ………………………………………………. 7

Conditioning Program ………………………………………………. 9

Conclusion ………………………………………………. 11

Bibliography ………………………………………………. 12

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ANATOMY OF THE SHOULDER

The shoulder area is where the arm is joined to the thorax. The primary joint

of the shoulder is the glenohumeral joint, between the head of the humerus

and the glenoid cavity of the scapula. It is a ball-and-socket joint and so, by

its very nature, allows a wide range of movement but is inherently unstable.

There is no bony attachment of the shoulder girdle to the axial skeleton. The

only true bony connection is of the scapula to the sternum at the

sternoclavicular joint therefore the muscles and ligaments of the glenohumeral

joint are key to the correct mechanics and stability of the shoulder.

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The muscles that act on the shoulder joint can be categorized into three

groups:

(1) Muscles for scapular stabilization: this group of muscles is responsible

for stabilizing or moving the scapulae in line with the movements of the

arm but are not actually attached to the humerus (trapezius,

rhomboids, levator scapulae, pectoralis minor and serratus anterior

muscles)

(2) Rotator cuff: these are small muscles connecting the scapulae to the

proximal humerus and assist with shoulder stability and correct

mechanics (supraspinatus, infraspinatus, teres minor and

subscapularis)

(3) Large shoulder muscles: this group produces the gross movements of

the arms (pectoralis major, deltoids, latissimus dorsi and teres major)

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In many exercise programs the emphasis is placed on this last group, the

larger shoulder muscles. They can be given more attention for both aesthetic

and athletic reasons, but strengthening of the scapulae stabilizing muscles

and the rotator cuff are key to correct mechanics and the ability to execute a

full repertoire of exercises. In this paper we give particular focus to the rotator

cuff because the correct recruitment and the coordinated use of these

muscles is so important when lifting the arm, to prevent impingement

(excessive movement of the head of the humerus into the overlying

structures). This is relevant to the following case study.

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CASE STUDY

Jane is a 37-year-old female with a history of right shoulder stiffness and

discomfort. This stemmed from a minor injury around four years ago when

she fell into a door, forcing her shoulder back and beyond its normal range of

motion. Jane has seen various physiotherapists in the intervening time, who

all confirmed that there was likely only soft tissue damage, however the issue

has persisted and Jane experiences discomfort on an intermittent basis.

Some movements, such as raising her arm above shoulder height, gives rise

to pain in the glenohumeral joint and she can also be adversely affected in

weight bearing exercises such as push ups and planks.

This condition has been a source of annoyance and frustration for Jane. She

is very active and enjoys a range of sports including trail running, stand-up-

paddling and netball. It can also cause her discomfort after sleeping.

Therefore, on the advice of her general practitioner, Jane recently underwent

an MRI scan, which revealed a very small tear in one of her bicep tendons in

addition to more noticeable swelling and thickening of the supraspinatus

muscle. The specialist reviewed her scan and advised that with rest and

rehabilitation Jane could recover much of her original range of movement but

that he would not dismiss the possibility of cortisone injections or surgery

should the pain persist. Jane is understandably very reluctant to opt for

surgery, as she has three young children and the rehabilitation from such a

surgery would cause significant disruption to both herself and her family.

Therefore she would like to undertake a pilates program with specific

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monitoring and focus in this area in the hope that sufficient progress can be

made to allow her to recover a level of functionality enabling her to continue

with the various sports and activities she enjoys.

Jane has excellent overall fitness and good general health. She is body

aware and has practiced pilates for close to five years. She has a good

overall control of her body and is capable of some of the more advanced

pilates repertoire. Observing her posture and initial movement indicated that

she has some rounding in the upper back (kyphosis) and has to take

particular care to keep openness across her chest and control over her

scapular. When she raises her arm to the side or the front there is a tendency

for excessive elevation of the scapular, of which she is aware. She also

carries a lot of tension in her neck and upper back, it is not clear if this

postural adaptation is an adopted anomaly as a result of her injury or has

come about over time due to her daily activities.

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CONDITIONING PROGRAM

Given Jane’s medical and exercise history in addition to her initial assessment

I determined that she required a program based on three key ideas:

• Increasing the range of movement of the shoulder joint without pain

• Improving scapular strength and stabilization

• Continuing to challenge her within her pilates practice

Utilizing the BASI block system, the following program was designed ensure

that we have the flexibility to address the body as a whole yet consider the

shoulder issues that Jane has been experiencing. This will build strength and

maintain flexibility throughout her body and prevent negative compensatory

patterns. The exercises outlined below allow Jane to challenge herself, utilize

her pilates repertoire and continue to garner the positive associations she has

from her regular pilates practice.

BASI BLOCK EXERCISES GOAL

Warm Up Mat - Roll Down, Pelvic Curl, Spine Twist Supine, Chest Lift, Chest Lift with Rotation

Warm up of the whole body giving particular consideration to alignment

Footwork W/Chair - parallel heels/toes, V position toes, open V heels/toes, calf raises, single leg heel/toes

Trunk stabilization, foot and ankle control, knee extensor strength, hip extensor control

Abdominal Work W/chair - standing pike Reformer – short box series (round back, flat back, tilt, twist, round about, climb a tree)

Abdominal strength and control, scapular stabilization, trunk stabilization

Hip Work Reformer – frog, circles down/up, openings, extended frog, extended frog reverse

Hip adductor strength, knee and hip extensor control whilst maintaining pelvic stability

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Spinal Articulation

Reformer – short spine, long spine

Spinal articulation, hamstring stretch, hip extensor control

Stretches Ladder Barrel – shoulder stretch 1, shoulder stretch 2

To stretch the shoulder extensors and to safely increase flexibility and ROM

Full Body Integration (F/I)

Cadillac – kneeling cat stretch

Working the abdominals and back extensors whilst providing a shoulder stretch and truck stabilization

Arm Work Cadillac – push through series (shoulder adduction single arm/double arm, sitting side prep, sitting side)

Deliberate exercises to encourage careful control of the scapula and shoulder muscles

Full Body Integration (A/M)

Reformer – tendon stretch

To strengthen the abdominals and the serratus anterior while maintaining scapular control

Leg Work Reformer – single leg skating

Hip abductor and knee extensor strength, stability of the lumbar pelvis

Lateral Flexion/Extension

Reformer – mermaid Maintaining scapular stability throughout lateral flexion and rotation

Back Extension Reformer – pulling straps 1, pulling straps 2

Focus on shoulder extensor and adductor strength

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CONCLUSION

The shoulder complex includes the flexible but ultimately unstable

glenohumeral joint. It is also integral to much of our daily activity and so pain

in this region can cause significant disruption and inconvenience. It therefore

requires careful management to avoid injury. In the case of shoulder pain, it

is estimated that around 70% of reported cases in the UK involve the rotator

cuff (BMJ, 2017) and so the issues affecting Jane and aspects of her

recommended conditioning program may have relevance for a number of our

pilates clients. Jane has been following this program, or a variation of it, at

least once a week for approximately six months now, alongside her regular

pilates classes. She now presents with much less frequent pain and a greater

range of motion. She also reports an increased awareness of the exercises

that are beneficial to the strength and stability of the shoulder joints and also

those that may require modification in her case. The ten pilates principles and

the BASI Block System have enabled Jane to achieve balance in both mind

and body whilst she continues her rehabilitation.

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BIBLIOGRAPHY

Books

Isacowitz, Rael Study Guide: Comprehensive Course. 2000-2014 Body Arts and Science International

Calais-Germain, Blandine Anatomy of Movement. English language edition,

Seattle, USA, 1993 Isacowitz, Real Pilates Anatomy, USA, 2011 Clippinger, Karen Websites BMJ Best Practice www.bestpractice.bmj.com, BMJ Publishing

Group Limited 2017 Physio Works http://physioworks.com.au, Australia, 2017 New Health Advisor www.ehealthstar.com, USA, 2017