Download Pilates Can Help After Shoulder Impingement and Rotator Cuff

 Pilates Can Help After a Shoulder Impingement and Rotator Cuff Surgery Written by: Jannel Krug Date: February 2013 Location: Fit from the Core Mountain View, CA 1 Abstract I would like to explain the wonders Pilates rehabilitation has done for a 30-­‐year-­‐old male. He has had a subacromial decompression and rotator cuff surgery. I will begin with explaining what a healthy shoulder looks like and how it should function. Then I will explain the procedure that was performed and the limitations and slow progress of a healing shoulder. Next I will discuss the common mistakes that the client made following his first surgery. After that I will discuss goals for the client, followed by a fundamental approach to the BASI block system. I will close with my conclusion and success of the client. 2 Table of Contents Title Page 1 Abstract 2 3 Anatomy of the Shoulder 4-­‐9 Case study 10-­‐12 Goals 13 BASI Program repertoire 14-­‐16 Conclusion Table of Contents 17 Bibliography 18 3 Anatomy of a healthy shoulder The shoulder is a spheroid joint which is referred to as a ball and socket joint. Two separate joints create the shoulder, the glenohumeral and acromioclavicular. The glenohumeral joint is formed by articulation of the rounded head of the humorous into a cup like depression of the scapula, called the glenoid fossa. The acromioclavicular joint is formed by an articulation of the lateral clavicle with the acromion process of the scapula. These joints are held together by ligaments and muscle attachments. The shoulder can be weakened easily by certain forces and is vulnerable to dislocations. 4 The rotator cuff consists of four muscles SITS, (supraspinatus, infraspinatus teres minor and subscapulaires) the tendons at the end of the rotator cuff can become torn which creates pain and loss of functionality. The tendons of the rotator cuff pass underneath a bony area on their way to attaching the top part of the arm bone. When these tendons become inflamed, they can become more frayed over this area during shoulder movements. Sometimes, a bone spur may narrow the space even more. This problem is called rotator cuff tendinitis, or impingement syndrome, and is due to: Playing sports requiring the arm to be moved over the head repeatedly as in tennis, baseball, football (particularly pitching), swimming, and lifting weights over the head. 5 A sudden or acute tear may happen when you fall on your arm while it is stretched out, or after a sudden, jerking motion when you try to lift something heavy. A chronic tear of the rotator cuff tendon occurs slowly over time. It is more likely in those with chronic tendinitis or impingement syndrome. At some point, the tendon wears down and tears. There are two types of rotator cuff tears: A partial tear is when a tear does not completely sever the attachments to the bone. A complete or full thickness tear refers to a through and through tear. It may be as small as a pinpoint or all of the muscle tendon. Complete tears have detachment of the tendon from the attachment site and would not heal very well. Another cause of shoulder Impingement syndrome of the shoulder is very commonly associated with aging. The impingement causes scarring of the bursa in the subacromial space of the shoulder between the undersurface of the acromion and the superior surface of the rotator cuff. During the aging is a forming of osteophytes (bone spurs) on both the undersurface of the distal clavicle and the anterior aspect of the acromion which can further lead to scar tissue and pinching of the rotator cuff tissues. As patients develop these changes, repetitive 6 overhead activities may cause irritation of the subacromial space. With time, this chronic irritation can lead to irritation and degeneration of the rotator cuff, which over time, can lead to rotator cuff tears. Currently, the majority of subacromial decompressions are performed arthroscopically. In this technique, the surgeon enters the glenohumeral (shoulder) joint with an arthroscope to make sure that there aren't any problems inside the shoulder which could be contributing to pain associated with the impingement syndrome. Any pathology that is seen in the shoulder can be treated with trimming or repairing the injured structures (if possible). Once all necessary treatment has been performed in the glenohumeral joint, the arthroscopic camera is then inserted into the subacromial space or lateral to it. 7 Arthroscopic shavers and coagulators are used to remove the scar tissue and to clean off the undersurface of the bone under the acromion (and distal clavicle when indicated). An arthroscopic bur is then used to smooth off the osteophytes (bone spurs) under the acromion to remove this as a source of impingement. Once the entire acromion has been visualized and it's verified that all scar tissue has been removed as well as all spurs, the procedure is ended. The glenohumeral joint and the subacromial space would be injected with a local anaesthetic and steristrips with or without subcutaneous sutures are used to close the small surgical incisions. There are several causes for the clients shoulder impingement. Ten years ago began a series of very common injuries of the shoulder girdle. Chronic wear and tear of the shoulder while playing football with repetitive over-­‐ head shoulder movements led to rotator cuff inflammation (tendonitis). Later on this lead to a rotator cuff tear a well as a labrum tear. Surgery was then performed on the rotator cuff as well as the labrum tear inside the glenohumeral joint. 8 Physical therapy was then instructed on a daily basis to regain full range of mobility in the shoulder joint. The client lacked at performing the rehabilitation of the shoulder. Over time the shoulder began to heal however it lost a lot of mobility and strength. In order to build strength the client began to lift weights with more repetitive over the shoulder movements which then created bursitis in the shoulder. Along with lifting weights the client chose to golf and play softball. Both activities include overhead movements of swinging a golf club and a softball bat. This repetitive movement created Osteoarthritis (bone on bone friction) due to the ligaments being worn down. The continuous bone on bone action created bone spurs witch further added to the impingement and pain. After the client had his second surgery he began his physical therapy with a vengeance and furthered his shoulder strength and mobility with Pilates. If physical therapy and Pilates were highly encouraged after the first surgery the 30 year old would not have needed the second surgery. From a former football player, softball player, golf player and weight lifter Pilates is the only type of exercise the client was able to perform. He would have never chosen Pilates as his physical movement of choice prior to his injuries, however, being able to see the benefits of Pilates he will continue on his journey of stretching, strength and and gaining full range of mobility. 9 Case Study Clients Name: Tim Krug Age: 30 Physical activities: Football, softball, golf and weight lifting Medical Problems: Left Rotator cuff tendonitis, left rotator cuff tear, left labrum tear. Left Shoulder impingement and Left shoulder subacromial decompression surgery. History of the shoulder falling out of the socket, tendonitis, bursitis, bone spurs shoulder mobility extremely limited. Cause of injury: extreme pain and almost complete loss of mobility in shoulder 10 years after the first rotator cuff surgery. Lack of physical therapy along with repetitive overhead movement such as sports and weight lifting. Diagnosis: The subcromial or sub deltoid bursa, supraspinatus tendon and the long head of the biceps were compressed and inflamed which lead to bursitis. The clients anatomical structure of the acromnion process was abnormally shaped and lead to shoulder impingement. There was bone on bone friction (osteoarthiritis) which caused bone spurs. Surgery: Arthroscopic Keyhole subacromial decompression In this technique, the surgeon enters the glenohumeral (shoulder) joint with an arthroscope to make sure that there aren't any other problems inside the shoulder which 10 could be contributing to pain associated with the impingement syndrome. All pathology that was seen in the shoulder was treated with trimming and repairing the injured structures. Once all necessary treatment was performed in the glenohumeral joint, the arthroscopic camera was inserted into the subacromial space or lateral to it. Were used to remove the scar tissue and to clean off the undersurface of the bone under the acromion (and distal clavicle). An arthroscopic bur was then used to smooth off the osteophytes (bone spurs) under the acromion to remove this as a source of impingement. Once the entire acromion had been visualized and it's verified that all scar tissue has been removed as well as all spurs, the procedure ended. The glenohumeral joint and the subacromial space was injected with a local anaesthetic and steristrips to close the small surgical incisions. Treatment: When there are no structures which need to be repaired in the joint, the patient is encouraged to use the shoulder as tolerated in attempt to get the range of motion back as soon as possible. It is well documented that one of the most important things to achieve after a shoulder surgery is to achieve the full range of motion back as soon as possible. If it is not done, even if the initial problem has been treated by the surgeon, commonly the patient will have shoulder pain develop due to stiffness. This pain may sometimes be just as bad as the initial problem. For that reason, we emphasize trying to 11 obtain full range of motion of the shoulder as soon as possible. Precautions are based on clients pain tolerance. Gradually progress to full range of motion. Avoid over head exercises and laterally holding arm out to a 90 degree angle. Pilates program The Pilates program will consist of a fundamental full body program designed by the block system. Emphasizing the focus on the muscle groups that act on the shoulder which are Muscles of scapula stabilization, the rotator cuff muscles and the large shoulder muscles. Scapular stabilization will focus on trapzeius, rhomboids, levator scapulae, pectoralis minor and serratus anterior. The rotator cuff which is comprised of supraspinatus, infraspinatus, teres minor and subscapularies connects the scapulae to the humerus. We were sure to beware of contraindications of the supraspinatus. Lastly, the larger shoulder muscles will be strengthened. These muscles are the pectoralis major, deltoids, latissimus dorsi and teres major. In the future working on these muscles will produce scapulohumeral rhythm with attention to coordinated use of the rotator cuff while arms are elevated. 12 Goals: Full range of motion will eventually be executed while not compromising the quality of movement for ROM. The client learned proper muscle recruitment patterns with correct mechanics. Strength exercises began with light resistance on the shoulder then progressively increase resistance with range of motion when correct mechanics are in place. Closed kinetic chain exercises will be utilized as the shoulder becomes stronger. There is a emphasis and strong focus on Stabilization by performing isometric exercises as well as eccentric and concentric contractions. We will emphasize on maximizing movement upon pain tolerance of the client. Our main focus was to work the entire body while achieving proper body alignment and correcting any muscle imbalances. 13 Block system program repertoire REFORMER Foot Work Parellel Heels Parallel Toes V-­‐position toes Open V-­‐Position Heels Open V-­‐Position toes Calf raises Prances Single leg heel Single leg toes Prehensile Abdominal work Hundred Prep Coordination Hip Work Frog Down Circles 14 Up Circles Openings Extended Frog Extended Frog Reverse Spinal Articulation Bottom lift Bottom lift with extension Stretches (Hamstring Stretch Series) Standing Lunge Kneeling Lunge Full Body Integration 1 (Knee Stretch Series) Scooter Round back reverse knee stretch Arm Work (Arms sitting series) 15 Chest expansion biceps Rhomboids Hug-­‐a-­‐tree (emphasis on keeping elbows slightly in front of shoulders, eliminating salute due to overhead movement) Leg Work skating single leg Mat Lateral Flexion and Rotation corkscrew Back Extension cat stretch 16 Conclusion: Pilates rehabilitation for a shoulder decompression and rotator cuff surgery was a success. The pain tolerance was determined by the client and communicated with the instructor. Light resistance was added to the sessions slowly. The clients strength and mobility was quickly increased. The physical therapist and physician granted authorization for closed chain weight bearing exercises as well as over head and lateral exercises. There are currently no restrictions with the client, thus the real work can now begin!
17 Bibliography Body Arts and Science International, 2000-­‐2008, Study guide Comprehensive Course, California USA. Body Arts and Science International, 2012, Pilates for Injuries and Pathologies, California USA. Manske C Robert, 2006, Postsurgical Orthopedic Sports Rehabilitation, Knee and shoulder, Mosby Inc, Missouri USA. Ellenbecker S Todd, 2004, Clinical Examination of the shoulder, Elsevier Saunders, Philidelphia USA. [email protected] Creativerehab.net http://pages.uoregon.edu/esorens1/hphy362.pbwiki.com/Musculotendinous+and+Labral
+Pathologies.html 18