Wednesday, June 7, 2017

Shoulder pre-habilitation for injury prevention

The next time you are in an acro workshop, look around and see how many people are rubbing the fronts of their shoulders, or sporting the oh-so-colorful kinesiotape.  Per my observation shoulder pain in acrobats is common, but with a bit of intelligent training it can often be prevented.  This blog will review basic anatomy and common causes for anterior shoulder pain, as well as a few exercises to stabilize your shoulder and prevent injury.

Shoulder Anatomy 101

The shoulder is a complex of four joints:
  1. Sternoclavicular (breast bone to collar bone)
  2. Acromioclavicular (collar bone to tip of shoulder blade)
  3. Glenohumeral (glenoid fossa - or socket - to head of humerus, aka upper arm bone)
  4. Scapulothoracic (shoulder blade to rib cage)

Instability in any of these four joints can cause pain.  Instability can be due to ligamentous laxity or weakness in surrounding musculature, which can be traumatic or cumulative in nature, or as a result of an injury to the neck or upper back. 

In addition to the joints note these structures:  

The glenoid labrum is a rim of cartilage that deepens the socket of the glenohumeral joint.  When the labrum is damaged - either from traumatic injury, or by gradual degeneration over the course of time - the head of the humerus moves around more than normal, which puts the biceps and rotator cuff tendons at higher risk for injury.  The primary work around to this is strengthening the muscles that stabilize the scapula to help provide an anchor for the arm, and strengthening the rotator cuff to create a suction-like force to improve joint stability when the labrum is compromised.   

The biceps tendon (for the long head) attaches within the glenohumeral joint, including fibers into the above mentioned labrum.  When the labrum is torn, the biceps tendon can get irritated by either being over used, or simply by having lost its anchor point.  When the biceps tendon is over used by poor mechanics, it can put undue stress on the labrum and cause a problem... creating a classic chicken-or-egg scenario.

The rotator cuff is a group of four muscles that surround the shoulder blade and help keep the arm in its socket.  The tendon for the supraspinatus travels sunder the acromion process of the scaupula to the upper part of the humerus, and can easily become impinged and irritated if the position of the scapula is faulty.  One common cause for faulty scapular position is tightness in the pec minor, which - because of its attachment to the scapula - creates anterior tipping of the shoulder blade (aka  "forward shoulders").  One relatively easy thing you can do to protect the health of your rotator cuff is to mobilize your pec minors with a lacrosse ball.

Pec minor release using ball
Note the attachment point

Without going too far down the anatomical rabbit hole, let's review:

The shoulder is a complex joint that involves 4 joints and multiple structures that are at risk for injury when the biomechanics are off.  Because the socket for the arm is relatively shallow, we need to stabilize the arm and scapula so we don't injure the labrum, biceps tendon or rotator cuff tendons with excessive shearing forces.  

Creating shoulder stability:

Please note:  if you have shoulder pain that persists for more than several days after a training session, do yourself a favor and get it checked out as soon as possible to determine what structures are involved so you can treat it appropriately.  If you have pain while doing any of the exercises listed below - stop, reposition, and try again.  If pain persists - get help!  

Plank:  if your wrists tolerate long arm plank, do that!  If your wrists are not comfortable in long arm plank, you can use blocks, or try forearm plank.  Note:  you need fairly decent lat extensibility (stretchiness) to tolerate forearm plank without impinging your rotator cuff or biceps tendon.   

Plank Variation: place a band around your hands then weight shift to one side and externally rotate your opposite arm; replace that hand on ground in external rotation and weight shift back to center; weight shift away from that side to unweight then rotate back to neutral before weight shifting back to center; repeat on opposite side.  This exercise strengthens your arm in the direction of external rotation which helps stabilize your arm in an overhead position.

Photo credit:  Jen Crane, aka Cirque Physio

Overhead carries with kettle bell (bell up for increased demand on your wrist):  make sure to externally rotate the arm (turn palm or pinky towards side of head) and keep elbow straight.  Note:  if you cannot raise your arm overhead without arching your back you may not have sufficient flexibility yet.  20-60 second intervals, 2-3x; work to fatigue but not failure.

Bell up for increased stability
Overhead carry; walking

Triangle pose to standing with weight overhead, with external rotation:  start without weight and progressively add weight to tolerance (I use 8-10 pounds; Ariel uses 15; many of my clients use 3-5).  Start in the forward fold/side bend position with palm facing forward in neutral or slight internal rotation; as you come to standing EXTERNALLY rotate the shoulder so that your palm is pointing towards your head as you complete the motion.  2 sets, 5-10 reps; Work to fatigue but not failure.

External rotation exercises for rotator cuff with weight or band:  using a weight will likely allow for better isolation of your rotator cuff; using a band intelligently will allow for working the rotator cuff at varying degrees of abduction and shoulder elevation.  See previous blog for additional images and descriptions.  When warming up for acro, try 5-7 reps in each position so as not to fatigue your rotator cuff to failure.

Can do at varying degrees of abduction
Use a small weight:  2-5 pounds will suffice

Forward facing scapular exercises:  classic T's and W's for a great warm up exercise: lie on your stomach and practice your handstand shape (engage your belly muscles and create a lift of your abdomen from the floor, squeeze your legs together).  Hold for 7 seconds, repeat 10x in each position; more or less depending on your strength/tolerance.

Focus on squeezing scapulae together

Focus on squeezing scapulae together

Childs pose with lift for lower trap endurance:  sit in child's pose with arms reaching forward, hands resting on ground or foam roller (more advanced) and thumbs rotated towards the sky:  without rotating your chest towards the ceiling  lift your arm up and hold for 10 seconds.  Repeat 5-10x on each arm.  This will likely be hard; enjoy the struggle.  Photo credit:  Jen Crane, aka Cirque Physio

Band exercises for scapular stability:  these can be combined with external rotation if you have stall bars or an anchor point.  Please reference previous blog for more info.  

Creating necessary soft tissue extensibility:  

You need sufficient lat extensibility to elevate your arms over your head.  Most of us have tightness in our lats, posterior rotator cuff and pec minors.  My best advice:  get a lacrosse ball and use it.  Get a foam roller and use it.  Reference previous blog  for more info on how to do this.
Foam roller to lats and teres
Stretch lats with elbows bent and thoracic spine rounded
Wrapping up:  

Your shoulders are capable of pretty amazing feats.  Take good care of them by strengthening the rotator cuff and scapular stabilizing muscles and mobilizing your lats and pecs.  If your shoulders hurt, see someone who can help you determine what the involved structures are and what you should do about it.  

I am of the belief that you must learn about your body in order to utilize it to its full potential.  I have included a few case studies below to demonstrate variability in the cause of shoulder pain and why it is helpful to have someone help you tease out the root cause of your symptoms so you can fully recover and get back to doing what you love.  I hope this helps you find peace in your body.  Keep training, keep it safe, and come play with us in SF!

 Case studies from injury through recovery:

1.   Bike crash >> instability of sternoclavicular joint >> excessive use of anterior neck muscles to stabilize clavicle and biceps tendon to stabilize glenoumeral joint >> biceps tendinitis >> resolved with aggressive acupuncture to treat trigger points in neck and stabilize SC joint, and physical therapy for scapular stabilizing program including rotator cuff strengthening to off-load biceps tendon

2.   Injury to disc in neck from acro >> weakness in rhomboid and middle trap >> instability in shoulder >> mild labral tear >> treated with chiropractic to adjust neck, physical therapy to traction neck and re-train scapular stabilizing muscles and rotator cuff

3.   Over-training handstands with stiffness in thoracic spine and short/stiff pec minors >> irritation of rotator cuff and biceps tendon >> treated with physical therapy to mobilize thoracic spine and pec minor and strengthen scapular stabilizing and rotator cuff muscles, acupuncture for trigger point work and AC/SC joint stability work

Upcoming events with Precision Acrobatics:
Semi-private coaching:  June 6th, San Francisco
Master's Handstand Workshop with Ariel:  June 20th, San Francisco
AcroLove Festival: June 30th-July 2nd, San Diego
Standing Acrobatics Series:  July 5th, 12th, 19th, Zaccho Dance Theater, SF
Intermediate Daylong Intensive: Jiggidy July:  July 23rd, Zaccho Dance Theater, SF
Refining Acro Series with Liz:  August 2nd, 9th, Zaccho Dance Theater, SF
Handstand Workshop with Ariel:  August 16th, Zaccho Dance Theater, SF
Strength Training for Acrobats with Ariel:  August 23rd, 5 Stones, SF
Hand to Hand Series:  September 6th, 13th, 20th, Zaccho Dance Theater, SF
Intermediate Daylong Intensive:  Sassy September:  September 10th, Zaccho Dance Theater, SF
Handstand Workshop with Ariel:  October 4th, Zaccho Dance Theater, SF
Divine Play Festival:  October 7th-9th, Portland, OR
Dance Acro Series:  November 8th, 15th, 29th, Zaccho Dance Theater, SF
Intermediate Daylong Intensive:  Noteworthy November:  November 12th, Zaccho Dance Theater, SF

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