In 2003 (when data was last collected), almost 14 million Americans sought the help of a doctor to deal with a shoulder problem. The types of injury, and the treatment for these problems varies, so it is important for the yoga teacher to have a good working knowledge of shoulder anatomy and the common injuries that occur. With such a high prevalence of shoulder injury, it is only a matter of time before a teacher will be required to call upon that knowledge to help a student experiencing one of these injuries. While referring students to a doctor for a complete diagnosis is the first step, there are ways to work with the various conditions as well as preventative measures that can be utilized during a yoga class.
The shoulder actually consists of several joints that combine to allow the arm to rotate over a very wide range of motion. The main joint, the glenohumeral joint, connects the humerus to the glenoid cavity of the scapula. The ligaments around the glenohumeral joint allow for a lot of motion, but as a consequence are not very stable. Surrounding the ligaments are a group of muscles called the rotator cuff which act to support and stabilize the shoulder as it moves. The acromioclavicular joint connects the clavical to the acromion process of the scapula. The clavical is the scapula’s only connection with the axial skeleton, allowing it to glide over the ribs in elevation, depression, retraction, protraction, and rotation. Finally, the sternoclavicular joint connects the clavical to the sternum at the Manubrium.
A large number of muscles attach to the bones of the shoulder via tendons and are responsible for movement of the arm. Because of the amount of arm movement, there are a number of bursa (fluid filled sacs) surrounding the joints of the shoulder which serve to reduce the friction caused by those movements.
The most common categories of shoulder pain are tendinitis and bursitis, instability, and arthritis . Each has their own unique considerations and should be well understood when working with clients as the recommended treatments can differ according to the type of injury.
Tendinitis is usually the result of a wearing down process that can take years to develop, but can also be caused by a sudden tear or split of the tendon as a result of an acute injury, or as the result of a degenerative disease. Typically, problems occur from a motion that is repeated again and again over the course of many years that eventually splits or tears the tendon. Rotator cuff injuries are the most common of this type. Injuries to the rotator cuff can result in pain located in the front or outside of the shoulder and is often felt strongly when lifting the arm overhead.
Like tendinitis, bursitis is usually a result of either overuse or acute injury . This can lead to a swelling and inflammation of the bursa, and actually often occurs alongside tendonitis . One of the more common causes of bursitis is when the rotator cuff and the bone above it (the acromion process of the scapula) are too close together, resulting in an impingement. Bursitis can cause shoulder movement to be limited and painful and can also be accompanied by a noticeable swelling.
Instability of the shoulder is when the humerus in unable to maintain its position in the socket of the scapula (the glenoid fossa). This is often referred to as a dislocation. Anterior dislocation is common in yoga because of repeated motions such as the movement from Chaturanga to Upward Dog. Instability can cause pain and unsteadiness of the shoulder and is also usually accompanied by sprains, inflammation, and joint immobilization. Repeated dislocations are common because loose ligaments are not able to provide the reinforcement the joint requires. People might develop instability slowly over time, in which case it might be felt as if the shoulder were slipping out of place or simply an unusual and uncomfortable feeling sometimes referred to as a dead arm. Dislocations can also occur as the result of an acute trauma where the shoulder is suddenly forced out of the socket.
Arthritis is a catch all term for a variety of inflammatory and degenerative diseases that damage the joint, but the most common forms are osteoarthritis, rheumatoid arthritis, and posttraumatic arthritis. Osteoarthritis is a degenerative condition, which destroys the articular cartilage of bone and is most common in badly aligned or overworked joints. Rheumatoid arthritis is an autoimmune disease where the body’s immune system attacks its own tissues and in the shoulder may result in a systemic inflammatory condition of the joint lining. Posttraumatic arthritis is actually a form of osteoarthritis brought about after an injury.
There are a number of things that can be done to help prevent shoulder injuries before they occur. The most important preventative measures are proper alignment and balanced strength. Developing proper alignment can be tricky and elusive. Without it, however, students run an increased risk of injury. Standing in Tadasana is a good way to practice the basic principles of shoulder alignment. You might begin by having students roll the head of the arm bones back, while drawing the shoulder blades down. The shoulder blades should lie flat on the back, which requires the serratus anterior muscle (covering the lateral ribcage) to be engaged. Resist pulling the shoulder blades together, instead keeping them wide and pressed into your back. To develop the proper alignment for postures with the arms in front or overhead, such as downward dog or plank, you can practice raising the arms in Tadasana, rotating your arm bones externally to keep the armbones in the socket, and engaging the infraspinatus and teres minor muscles. This will also help to spare the supraspinatus from impingement.
Muscle imbalances often develop in yoga due to the over-preponderance of push type exercises such as Chaturangas that most practices entail, without sufficient counter poses. Over the long run, this can lead to muscle imbalances and instability. A great counter pose to Chaturanga is Purvottanasana (upward plank). This pose helps to stretch the muscles that Chaturanga stretches, and vice versa. Dhanurasana (Bow pose) is also a great way to stretch the front of the shoulders and build strength on the posterior side. Setu Bandha Sarvangasana (bridge pose) is another great chest and anterior shoulder opener. Another beneficial pose is Jathara Parivartanasana (revolved abdomen pose). By keeping your arms and shoulders pressed into the floor, you strengthen the back of the rotator cuff. Other counter poses include Ustrasana (camel), and Gomukhasana (cow face pose). Off the yoga mat, practices that require a pulling motion and thus strengthen the backside of the shoulder might include rowing or pull-ups. The idea is to provide a balance of strengthening and stretching across both the front and back of the shoulder. The increased stability will help to both minimize the occurrence of dislocations as well as protect the shoulder girdle from tendinitis, bursitis, and certain forms of arthritis.
When a practitioner does experience shoulder pain, it is important to go see a medical professional for a diagnosis. Since many of the symptoms are shared between injury types, yet the prescriptions may be different, it is important to understand exactly what you are dealing with before working with the injury. Until a diagnosis is obtained, you might modify poses to lessen intensity and recommend avoiding overexertion. Tendinitis and Bursitis often respond well to a combination of rest, anti-inflammatory medication, and altering activities (i.e. switching up your yoga practice), though in some cases, surgery to repair the tear might be required. Instability is often treated by strengthening exercises, though the type of exercise prescribed will depend on the instability being anterior (common) or posterior (much less common). The main treatment for arthritis is exercises to maintain range of motion, though the type and amount should be determined in consultation with your doctor. Various medications are also commonly used to treat arthritis as well. It is important to listen to the body and not try and push through pain that you or your student might be experiencing. If certain poses result in shoulder pain, provide modifications until the pain goes away.
While shoulder injuries are relatively common in yoga, with proper alignment and practice, yoga can be very beneficial, both in prevention and treatment of shoulder injuries. By providing increased muscle tone, a properly designed yoga practice can help to stabilize the joints, protect against trauma and acute injury, and allow for fully supported movement of the arms.
Calais-Germain, Anatomy of movement, pg 102-118
Marieb and Hoehn, Anatomy and Physiology, seventh edition, pg 273, 274, 275