THE ROTATOR CUFF RESET

Olivia Robertson BASI Comprehensive Apparatus Program

2017

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ABSTRACT

With shoulder pain ranking as the third most common musculoskeletal complaint in the USA, it is important that we better understand the Rotator Cuff and its implications. In this paper, I outline a four-step program to reset the Rotator Cuff.

Totaling 12 weeks, the program is broken into 4 steps of 3 weeks each. In my experience, I have seen most gains with clients coming between 2 and 3 times per week.

Phase 1: Stretching Phase 2: Stabilization Phase 3: Strength Phase 4: Movement This felt, to me, like a logical structure, and is founded on understanding the

musculature and general skeletal structure of the shoulder girdle. Stretching and releasing the musculature allows imbalances to loosen and muscles to become pliable and ready for adaptive work. Once you have loosened previous muscular patterns, Phase 2 introduces a new and balanced range of motions that form the stable roots of the new movement patterns. Once the foundation of the Rotator Cuff is solid, Phase 3 strengthens the new movement patterns created and begins to incorporate primary shoulder muscles and scapular stabilizers, adding in complex and controlled movements. Phase 4 takes the client into a more advanced movement patterning, challenging foundations, strength and inviting exploration of movement.

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TABLE OF CONTENTS

The Shoulder Complex ……………………………………………… 4 The Rotator Cuff ……………………………………………………… 6 A Sad Rotator Cuff …………………………………………………… 8 Common Rotator Cuff Muscle Dynamics ………………………... 9 The Rotator Cuff Reset Program ………………………………….. 10 Conclusion …………………………………………………………… 14 Bibliography …………………………………………………………. 15

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THE SHOULDER: AN OVERVIEW

We have all heard or used the cue “Pull your shoulders down”. This cue

generally engages the lower trapezius to anchor the shoulder blade in place, forcing the

shoulders down. Goal achieved! This is generally alright until you want to raise your

arms and the shoulder blade is pinned down. Unable to move freely through its natural

range of motion, the muscles around the shoulder blade recruit other muscles to lever

the arm overhead. This compensatory action causes overdevelopment over time in

other muscles, leading to imbalance and poor shoulder mechanics.

This example highlights one small misunderstanding causing a lot of pain in what

should be an almost unconscious arm movement. When we think about the skeletal

structure of the arm - and how it hangs off one attachment at the base of the collar bone

(sternoclavicular joint) - we start to understand just how important the muscular

relationships in the shoulder become.

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The shoulders can be broken down into 3 basic categories: THE PRIMARY SHOULDER MUSCLES (Pectoralis Major, Deltoids, Latissimus Dorsi and Teres Major) SCAPULAR STABILIZERS (Trapezius, Rhomboids, Levator Scapulae, Pectoralis Minor, Serratus Anterior) ROTATOR CUFF (Teres Minor, Infraspinatus, Supraspinatus, Subscapularis)

*Note that not all muscles are shown on this image

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THE ROTATOR CUFF

A synergistic balance of the Rotator Cuff muscles “is imperative for shoulder

complex stability and function.” (*1) There are four muscles that make up the rotator

cuff; Teres Minor, Infraspinatus, Subscapularis and Supraspinatus. These muscles are

located strategically to ground the ball and socket joint where the head of the humerus

(upper arm bone) meets the collarbone. This point is called the Glenohumeral Joint.

The four muscles of the rotator cuff are strategically placed to keep the

glenohumeral joint functioning optimally and smoothly through arm movements. If any

one of these anchoring muscles is compromised (tighter, weaker, overused, etc.), the

floating bones of the shoulder joint could be pulled into one another, causing friction

within the shoulder girdle. This obviously results in the all-too-common rotator cuff

conditions ie. pain in the front of the shoulder.

INFRASPINATUS

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TERES MINOR

SUPRASPINATUS

SUBSCAPULARIS

(*Anterior view)

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A SAD ROTATOR CUFF

“Shoulder pain is the third most common musculoskeletal complaint reported to general practitioners in primary care settings.” (*1)

WOW! It is evident, based on this statistic, that our bodies adapt and

compensate to the technological world in which we live, not without its pitfalls. With

more and more people living in a virtual world, slouched behind desks, or logging

couch, phone, and/or study time, shoulders are rounding forward and impingement is

becoming more prevalent alongside “text-neck”.

Within our scope of Practice, the aim of the Pilates instructor is not to diagnose,

but to get our clients moving pain free as much as possible. We should, therefore, know

the underlying anatomy and general symptoms of rotator cuff impingement.

General Indicators of Rotator Cuff Dysfunction: (*1, 2)

● An acute injury to the shoulder ● Pain in the shoulder (specifically the front) ● Unable to abduct the shoulder, or lift the arm overhead ● Pain in the shoulder at night, or at rest ● Pain or catching when internally rotating the arm ● Look for shoulders slightly rounded forwards

~ Remember! These symptoms are warning signs! Refer out to specialists if your client

has not been diagnosed, and you suspect a rotator cuff issue. ~

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COMMON ROTATOR CUFF MUSCLE DYNAMICS THE ROTATOR CUFF DETECTIVE With Rotator Cuff injuries, the following are generally observed: (*1) TIGHT?

● Pectroalis Minor (SEE BELOW) ● Infraspinatus or supraspinatus or both

WEAK?

● Serratus Anterior ● Lower Trapezius (Unless being cued to “Pull your shoulders down”!) ● Scapular Stabilizers

THE PECTORALIS MINOR AND THORACIC SPINE

“A shortened pectoralis minor muscle at rest has been indirectly correlated with RC [Rotator

Cuff] tendinopathy, functional deficits, and pain.” This particular reference continues;

“research supports strengthening the scapular stabilizers and RC muscles, addressing

flexibility of the posterior shoulder structures, pectoralis minor muscle, the thoracic spine (with

postural education), and activity modifications.[...]” (*2)

According to this citation, in order to address rotator cuff dysfunction, we must also

address the musculature of the upper back (thoracic spine) and release tight pectoralis

major and minor muscles. This relationship between upper abdominal contraction,

thoracic spine and the shoulder joint is complex and one that I will only mention here (as

it requires an entirely different paper and set of research!).

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THE ROTATOR CUFF RESET PROGRAM

1. Each phase is 3 weeks

2. Each week you can plan anywhere between one and 3 sessions. (This is

determined by a number of factors; economic, time, the functional level that your

client is coming in at, etc.)

3. Depending on your client, you may need to dial down the initial foundational

work, adding in education around lateral breathing, abdominal connection and

neutral spine/pelvis, which I assume in my Reset program the practitioner and

client have already established.

4. I am offering guidelines. It is important to remember each body is different. Feel

free to eliminate or add whatever you need to the program as you work with your

client.

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PHASE 1: STRETCHING AND RANGE OF MOTION

WEEK 1 WEEK 2 WEEK 3

Warm Up Basic Mat *Emphasis on Lateral Breathing

Footwork Reformer (REF)

Abdominals (Reformer) (REF) Hundred Prep (REF) Hundred and

Coordination (REF) Hundred prep, Hundred

and Coordination

Hips (REF) Supine Leg Series: Frog, Circles Down, Up, Openings

Spinal Articulation

Stretch Stretching with a Pole. *Focus on Pec Major and Minor (ie. front of the chest - a lot of

expansion)

FBI 1

Knee Stretch Round Back and Knee Stretch Flat Back *Focus on the dynamic between shoulder stabilization

and spinal flexion/extension (REF) Scooter

Arms

*Nothing over shoulder height for the first 3 weeks and no weight, or even a Theraband* (Ped-A-Pul) Extension, Adduction,

Circles Up, Down, Triceps.

*Introduce idea of scapular Adduction and Abduction. No weight to start, then add 1lb hand weights if progressing.

(Ped-a-Pul) Extension, Adduction, Circles Up,

Down, Triceps

*Continue to work scapular adduction and abduction. Add the (REF) Supine Arms Series.

Add Cross Arm Pull with a Theraband

Legs (WC) Standing Balance (WC) Standing Balance Gluteals Side Lying Series

FBI 2

Lateral Flexion/ Rotation

(REF) Mermaid (LB) Side Over Prep

Back Extension

(MAT) Back Extension (MAT) Swimmer Just focus

on reaches with a soft shoulder.

(MAT) Swimmer

NOTES:

- Try to avoid Pectoralis Major or Minor Strengtheners for the first 2 Phases (ie. Plank, Push Ups, Hug-A-Tree or Punching)

- Invite your client to start developing awareness around their anatomy. This could take some time, be patient and encouraging!

- Allow the client’s shoulder to raise up naturally with arm movement, watching for hypermobility as needed, but try not to cue “Pull your shoulders down” as much as you cue to “soften” specific muscles.

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PHASE 2: STABILIZATION and MUSCLE RECRUITMENT PATTERNS

WEEK 5 WEEK 5 WEEK 6

Warm Up Basic *Focusing on depth and control

Footwork Reformer (WC) with Arm Stretches (WC) with Arm Stretches

Abdominals (CAD) Roll up with

RUB (CAD) Bottom Lift with RUB and

(WC) Standing Pike (WC) Standing Pike Reverse and

Sitting Pike

Hips (CAD) Basic Leg Springs

Spinal Articulation (REF) Bottom Lift (REF) Bottom Lift with Extension

Stretch (LB) Shoulder Stretch 1 and 2

FBI 1

(CAD) Push Through Series (Sitting

Forward and Side Reach)

(REF) Up Stretch 1 and/or Elephant (REF) Down Stretch

Arms

(REF) Sitting Series *Without Hug-A-Tree

(REF) Sitting Series *Without Hug-A-Tree. *ADD Arms

Overhead from Side Arms Kneeling Series with 1lb weight

(REF) Sitting Series *Without Hug-A-Tree. Add (REF) Cross

arm Pull from Side Arms Kneeling Series and (WC)

Triceps Seated Prone

Legs (REF) Single Leg

Skating (REF) Side Split Gluteals Kneeling Series

FBI 2

Lateral Flexion/ Rotation

(WC) Side Stretch (REF) Mermaid (Spine Corrector) Side over with Extended Arms

Back Extension (LB) Swan Prep MAGIC CIRCLE Swan Prep (CAD) prone 1

NOTES:

- Try to avoid Pectoralis Major or Minor Strengtheners for the first 2 Phases (ie. Plank, Push Ups, Hug-A-Tree or Punching)

- Slight focus on mobilizing through the Thoracic Spine as the shoulders start to open up.

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PHASE 3: STRENGTH with CONCENTRIC and ECCENTRIC FOCUS

WEEK 7 WEEK 8 WEEK 9

Warm Up Warm up on the Cadillac

Footwork (WC) with pole stretch? (CAD) (CAD)

Abdominals

(WC) Cat Stretch Kneeling

(REF) Abdominals Legs in Straps (Double leg and

Double leg with Rotation) (CAD) Roll up Top Loaded

Hips (CAD) Single Leg Supine (Spine Corrector) Supine

Legs Series * No Springs

(Spine Corrector) Frog, Openings, Scissors, Helicopter

*Springs

Spinal Articulation (CAD) Tower Prep (WC) Pelvic Curl (REF) Semi-circle

Stretch (REF) Standing Lunge (REF) Kneeling Lunge

FBI 1 (REF) Up Stretch 2 (REF) Up Stretch 2 (CAD) Sitting Back

Arms Rowing Back Series (1

and 2) Modified Kneeling Side Arms

Series with Theraband Rowing Front Series (1 and 2)

Legs Magic Circle Supine

Series (WC) Backward Step Down Magic Circle Prone Series

FBI 2 (REF) Long Back Stretch

Lateral Flexion/ Rotation

(CAD) Side Lift (WC) Side Kneeling Stretch (LB) Side Overs

Back Extension (CAD) Prone 1 (WC) Swan on Floor (LB) Swan Prep

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PHASE 4: MOVEMENT!

WEEK 10 WEEK 11 WEEK 12

Warm Up Warm up on the Cadillac

Footwork (CAD) (CAD) (CAD)

Abdominals (WC) Full Pike MAT Neck Pull (CAD) Roll up Bottom Loaded

Hips

(REF) Extended Frog, Extended Frog Reverse

(Spine Corrector) Frog, Openings, Scissors, Helicopter *Springs

(REF) Supine Legs Series

Spinal Articulation (WC) Jack knife (CAD) Tower (REF) Long Spine

Stretch (REF) Side Split (Spine Corrector) Kneeling Lunge (REF) Side Split

FBI 1 (REF) Long Stretch (REF) Up Stretch 3 (REF) Down Stretch

Arms Side Arms Kneeling Series Side Arms Kneeling Series

Legs (WC) Frog Front (CAD) Single Leg Side Series

FBI 2 (REF) Balance Control

Front (WC/REF) Tendon Stretch (Spine Corrector) Push Up

Lateral Flexion/ Rotation

(REF) Side Over on Box (CAD) Side Lift (WC) Side Pike

Back Extension (LB) Swan (CAD) Prone 1 (CAD) Prone 2

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CONCLUSION

While Rotator Cuff pain and injuries are prominent in today’s society, we are very privileged to be able to help our clients re-learn their bodies and more specifically their shoulders with a unique variety of equipment and specialized knowledge. The four-step Rotator Cuff Reset Program breaks down the sometimes overwhelming process of where and how to start with your client, walking you through a progression of exercises with the main focus around healthy shoulder mechanics. Branching the program into the rest of the body, and allows both the practitioner and the client to engage in the dialogue around the shoulder girdle and how it relates to the rest of the body.

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BIBLIOGRAPHY

Websites (*1) Int J Sports Pays Ther. 2016 Apr; 11(2): 279-301; Exercise Rehabilitation in the Non-Operative Management of Rotator Cuff Tears: A review of the Literature; Peter Edwards, MSc, Jaty Ebert, PhD, Brendan Jones, PhD, Get Bhabra, FRCS, Tim Ackland, PhD, Allan Wang, PhD, FRACS https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827371/ ** (*2) Int J Sports Phys Ther. 2014 Apr; 9 (2): 274-288; Current Concepts of Rotator Cuff Tendinopathy; David Factor, DPT, EMPT-P and Barry Dale PT, PhD, DPT, ATCSCS, OCS, CSCS. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4004132/ Study Materials/ Books Human Kinetics. Champaign, IL; Pilates / Rael Isacowitz -- Second Edition. 1955-. Isacowitz, Rael. Study Guide (Reformer, Mat, Auxillary, Cadillac, Wunda Chair): Comprehensive Course. Costa Mesa CA.: Body Arts and Science International.

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