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

Protect your wrists!

As an acrobat, cyclist, and bodyworker I am no stranger to wrist pain.  That being said, over the years I have come up with several self care routines to help mitigate this experience and would like to share with you what I have learned along the way.  This blog will focus on strength, flexibility, tolerance, and self-care to help keep your wrists in top form so you can do what you love with minimal pain.

Strength:   Gotta have it!  A few of our favorite exercises include:

• Flashlights to strengthen finger flexors (strength in these muscles will help decompress your carpal bones and support your wrist).  Open fingers wide, then close.  Repeat quickly 30x in various shoulder/arm positions.  You should feel the Bern (or at least the burn).

Close into a tight fist

Open fingers wide

• Isometrics to strengthen all sides of the wrist:  my two preferred methods are wrapping a theraband around the knuckles of my fingers during my shoulder warm up, or holding a kettle bell with the bell up during get-ups or shoulder exercises.

• Table top knuckle "push ups" (changing how close your knees are to your hands changes intensity; can do in plank)

Flexibility:  You need sufficient wrist extension to tolerate standing on your hands.  See below for a simple test for functional wrist extension.  If you don't pass this test - use the exercises listed below in the "tolerance" section to help get the range you need.


From table top:  keep the palm flat on the ground and lean forward so that your shoulders pass your your wrists.  You should be able to get the shoulders just past your finger tips with base of palm flat on the ground.

Please note:  if you have pain during this test, stop, gently shake out your hands and arms, and try again.  If you still have pain, you may be injured -  get help ASAP as wrist pain can exacerbate quickly.

Tolerance:  Weight-bearing through the hands is often uncomfortable at first, but with practice and patience eventually you will build your tolerance.  The most important thing to remember is to progress slowly and back off if you experience pain.  Below are a few positions we utilize as a warm up before starting our hand balancing practice.  

Working wrist extension with turnout

When working on building your tolerance for wrist extension - find the edge of what is comfortable for you, back off a bit, then stay in that position for 10-15 slow relaxed breaths.  Over time your tolerance to these positions should improve.

Self care:  As I get on in my years, I am less drawn to ice, and more drawn to heat.  That being said, during the middle of my work week when I am waking up in the morning with "pumped" forearms, I will draw myself an ice bath in the kitchen sink by doing the following: Fill the sink with water, empty 2 trays of ice cubes, add several ice blocks and let it sit for 5 minutes to get nice and cold.   Submerge forearms, wrists and hands - making sure the water is deep enough to cover elbows - soak for 1-2 minutes.  This usually coincides with obnoxiously loud deep breathing and a few guttural noises because sound healing is the best.   We've also been known to dunk our forearms into cold streams as shown below. Stanley icing his forearms somewhere in CA Other helpful strategies include: cupping the wrist flexors and extensors, mobilizing the pecs with a lacrosse ball, acupuncture, chiropractic care, and good old fashioned rest (not my strong suit but I'm working on it, and it helps). Pain:  If it hurts - in general - stop what you are doing and reassess.  How is your alignment through your wrists, elbows and shoulders?  Is your core engaged?  Are you dehydrated or tired?  If you are able to go through all these mechanical (and physical) stressors and still have pain, you may be injured.  Do yourself a favor and get it attended to sooner rather than later.  Unless you are a unicorn, magic likely won't fix your wrist pain. Consider your shoulders:  If you do not have full overhead shoulder elevation, chances are you are compensating somewhere else in your body... possibly your wrists.  Read the following case study to see how this situation may play out. Case study:  I am currently working with a high level acrobat who injured herself falling out of hand to hand several years ago.  While this fall was certainly a catalyst in her wrist pain, upon further investigation we discovered that she has a fairly significant deficit in overhead shoulder elevation.  In order to maintain her line over her base, she is compensating at her wrist, which is preventing her strain from getting better.  We have focused on addressing her shoulder mobility and strength deficits, while allowing her wrist to rest and recover.  Her exercises include:  using a lacrosse ball to increase the extensibility of her lats, posterior rotator cuff and pecs; strengthening her scapular stabilizing muscles with bands and weight shifting exercises; and isometrics for the wrists.  For a review of shoulder exercises, see my previous blog. Summary:  The hands and wrists are fairly complex, with at least 27 bones, multiple nerves (some say there are 48 named nerves including motor and sensory branches), over 120 ligaments, and ~34 muscles.  Our hands are how we interact with the world - please take good care of yours so you can continue to do amazing things with your body. Keep training, keep it safe, and we hope to see you soon! Upcoming events with Precision Acrobatics: Pelvic Floor and Bladder Control with Liz:  May 21st, Oakland 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 Divine Play Festival:  October 7th-9th, Portland, OR

Fostering a sustainable practice

Are you interested in training hard and hurting less?  Do you envision yourself in your sixties  balancing on your hands, or on your friends' hands or feet?   If the answer to either of these questions is a resounding "yes" read on for a few helpful tips on creating a sustainable acrobatics practice.

1.  Get regular self care:  Whether it is a monthly massage, daily foam rolling, or hot baths followed by soul-shaking yodeling, spend time on a regular basis taking care of your body and your mind.

Cupping to relieve shoulder pain, done by a physical therapist 

Note - if you are having pain when you practice - STOP, and get help.  Pushing through pain without knowing the source of it rarely leads to good results.  As aging athletes we rely upon a network of practitioners to keep us pushing hard and suffering less.  Here's a list of various modalities that we utilize to stay in the practice:

• Physical therapy:  to help diagnose the source of your pain and functional limitations, give corrective exercises to help you return to your chosen activity, offer manual therapy techniques to help you meet training and functional goals
• Massage therapy:  to maintain health of your muscles and maintain peace in your body mind
• Accupuncture:   for pain management; nervous system regulation; joint stabilization for AC and SC joint; dry needling for trigger point work; internal medicine and hormonal regulation 
• Chiropractic care:  for joint mobilization/adjustments to correct alignment

2.  Cross train for Acro with strength training: Strength training is a vital component to injury prevention and skill progression.  For those of you already doing this - good job and keep it up! If you don't know how to get stronger - hire a strength coach.  

3.  Work with a professional coach:  While jams are fun and YouTube and Instagram are groovy, there is no more efficient way to progress your practice than to work with a coach.  An experienced coach can break down a complex move into attainable steps and guide you through the learning process following the stages of motor learning.  If you don't know a coach - ask around ... they are out there, and they are waiting for you!

4.  Rest:  It is well known that resting improves recovery, and is therefore a necessary component of every training program.  Adequate sleep AND breaks from training are both important!  

TJ shows us how it's done

With these long-term principles in mind, let's talk about how to manage a single practice session.  

1.  Warm up before you practice:

• Before you jump on someone's feet (or lift someone in the air) - warm up your body!  Dance, skip, walk or jog in circles, ride your bike ... do something to increase your heart rate and increase blood flow throughout your body.  
• Do a few exercises that target the muscles we use in Acro.  You can see my favorite shoulder exercises in this previous blog post.  Note the use of the foam roller.  I use the foam roller before, sometimes during, and often after a training session.  This helps keep soft tissues extensible and can, over time and with consistent use, help improve flexibility.  
• Warm up your core ... there are a million and one core exercises - in recent years I have focused on doing exercises with an "imprint" position or "flat" lumbar spine as this position is more relevant to my style of handstands.  Whatever you choose - make sure your mechanics are clean, and you aren't experiencing any pain in your lower back.  And, for the love of your body, unless you are a pilates expert, stop doing aggressive V-ups as a "core" warm up.  

2.  Warm up with a few partner calibrations:  Ariel and I have a fairly basic routine that we have done for years; we start with that routine then progress to calibrations specific to our chosen focus for the session.

• For foot to hand, we have a series of progressions that we start with, EVERY TIME.  
• For hand to hand, we start with 5 reps of each:  jump to low, tempo to low, jump to reverse, tempo to extended reverse.  We then choose a few other variations as a focal point for that session.  We warm up our grip, modify it as needed, check in along the way, and STOP our practice if one or the other of us feels a strain in the wrists.

3.  Practice and play to your heart's content:  You may want to choose a focus for each session; you may want to just wing it... or perhaps a mixture of both.  Not a lot of rules here - just remember to keep yourself and your Acro partners safe.  Avoid training to failure - working to failure in a partner practice may mean someone gets dropped or someone gets fallen upon - not good.  

4.  Save at least 10 minutes at the end of each session for self care:  While admittedly Ariel and I aren't perfect at this, we do put concerted efforts into taking care of each other on a regular basis with stretching, bodywork, or flying therapeutics.  The physical relief is great; the energetic care taking is perhaps even more beneficial to our partnership.

Finishing a 3-day intensive with therapeutics

We hope this information is helpful!  Join us at Bay Acro on April 18th for Shoulder rehab for Acrobats to learn about maintaining the health and strength of your shoulders. Stay tuned next month for a deeper dive into keeping the wrists happy and healthy.  Keep training, stay safe, and see you soon ...

Registration link for all workshops:  bayacro.com

Upcoming workshops (with FB event links):

Shoulder rehab for Acrobats with Liz:  April 18th
Beginner Acro Intensive:  April 28th-30th
Series 3:  POPS!:  May 2nd, 9th and 16th
Semi-private coaching:  June 6th
Master's Handstand Workshop with Ariel:  June 20th

Motor learning and Semi-Private Coaching

In this blog you will learn a bit about motor learning and its influence on our teaching style.  If you are a coach or teacher, this information may serve as a nice reminder of why you teach in the way that you do, and with any luck it will offer you a nugget or two of how to improve learning for your students.  If you are a student, this information might provide you with the motivation you need to keep doing the work.  Learning isn't always fun, but understanding the process may inspire you to work through the tough parts.  As the adage goes ... we didn't say it was going to be easy, we said it's going to be worth it.

Motor learning refers to a set of internal processes that facilitates acquisition and retention of a skill.  The widely agreed upon stages of motor learning are cognitive, associative, and autonomous.  During each stage of learning, the optimal amount and type of feedback varies, as does the amount of time spent before progressing to the next stage.

Summary of stages of Motor Learning (1)

During the cognitive stage of learning individuals are aiming to understand what is being asked of them, so it is imperative that they receive detailed information on what the skill entails.   As such, this stage requires a lot of visual and verbal feedback; tools such as video analysis and slow motion drills will come in handy here.  For example:  when we first start working on a new trick, our coach Dom gives us A LOT of feedback.  There is nearly consistent talking about, and dissection of, the various components involved in the trick.  The cognitive stage can be rather messy, as trial-and-error is a crucial component.  Controlling the environment by removing distractions will facilitate learning during this stage.  Note:  large gains in performance will be seen during the cognitive phase, however skill execution will be inconsistent.

Once someone knows what to do, they need to know how to do it, and thus begins the associative stage of learning.  Feedback during the associative stage is mostly proprioceptive - meaning that learning occurs through practice, and by developing an understanding of what is going on in the body from a more kinesthetic and internal sense.  When we train with Dom, we do the same trick over, and over, and over again... usually in lines, and often we will do the trick 4 or 5 times without any talking.  In fact, Dom will often tell us to stop over-thinking it and just get the feeling for it. The associative stage of learning is defined by refining skills with small adjustments and stringing together movement patterns.    We spent almost two years working with Master Lu Yi at the circus center, on hand-to- hand, every week, doing the same drills, getting similar variations on the same feedback.  The associative stage can take a long time, and will often be frustrating for students.  Remember - learning as adults often involves a process of re-learning ... and this simply takes time.

The final stage of learning may take years, but once attained allows for attention to details beyond the movement task itself.  During the autonomous stage of learning the student can perform the skill with very little thinking or processing.  Imagine being performance ready - once in this stage of learning the body responds automatically, leaving you available to attend to your audience and respond to your fellow performers.  As an example - being in the autonomous stage of learning is when we start to play with leg variations in hand to hand.

With Niko Douwes 2014

With Master Lu Yi 2013

So how does motor learning relate to the semi-private coaching workshops we are offering?!?  Perfectly.  Working with a coach or trainer who is familiar with this process will improve your efficiency.  Our semi-private coaching sessions will help progress you from the cognitive stage into the associative stage of learning.

For the majority of our acrobatic career we have sought out private instruction from coaches.  These sessions offer us direct and immediate feedback on our "performance" which allows us to progress our skills and develop a deeper wisdom of the mechanics of acrobatics.  This style of learning has been invaluable to us, and we want to share it with our students.

Why train with Precision Acrobatics?  Because we teach as a duo, we can specify the program to include base and flyer beta (i.e. we can provide you with detailed information on the skill based on your specific role).  In addition, drawing from Liz's experience as a physical therapist, and Ariel's years of experience with personal trainers and handstand coaches, we have a bevy of strength training drills and injury prevention strategies to share.

What to expect:  Before each session students fill out a short questionnaire  about their practice and their goals for the session.  This allows us the time to devise a customized program for each student and pair.

The session itself is structured as follows:

• Warm up
• Flyer and base specific strength training
• Skills assessment, practice and training
• Clarification of progressions for home program
• Cool down/self care

We have two more of these workshops scheduled:  4/4 and 6/6.

Our semi-private coaching sessions are limited to four pairs, which provides a learning environment with fewer distractions.  This allows ample time for individual instruction and feedback, safety through spotting, and time to practice for skill refinement.

We have loved this style of training and hope that you will too!  Follow the link below to register and join us in April for our next semi-private coaching session.  Keep training and see you soon!

Registration link for all workshops:  bayacro.com

Upcoming workshops (with FB event links):

Hand to Hand Series:  March 7th, 14th, and 21st
Semi-private coaching:  April 4th, June 6th
Shoulder rehab for Acrobats with Liz:  April 18th
Beginner Acro Intensive:  April 28th-30th
Series 3:  POPS!:  May 2nd, 9th and 16th
Master's Handstand Workshop with Ariel:  June 20th

References:
(1) http://www.humankinetics.com/excerpts/excerpts/understanding-motor-learning-stages-improves-skill-instruction

(2) Physical Rehabilitation: Assessment and Treatment. O’Sullivan, S. B., Schmitz, T. J. 1994. pgs 366-367