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Injuries: Shoulder Impingement

12/19/2019

8 Comments

 
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This is part of a series about Injuries In Yoga.

Two common injuries in yoga happen in the shoulder. One is in the front of the shoulder---the biceps tendon---which we will address next time. The other is in the top of the shoulder, called impingement. It happens when the arm lifts up high; the arm bone can bump against the edge of the shoulder blade, called the acromion, and damage the tendon there.
​Let's start with a little anatomy. The supraspinatus muscle is one of the four rotator cuff muscles. It is located on top of the shoulder blade, weaving underneath the acromion to attach to the arm bone (humerus). The supraspinatus ​is pictured in blue on the right.

​As the arm lifts up and to the side in flexion and abduction, the arm bone gets closer and closer to the acromion. The supraspinatus​ actually helps in this process, pulling the arm bone up. Generally, as the arm lifts, the shoulder blade will rotate to give space in the joint. But if the shoulder blade muscles like the rhomboids or trapezius are tight, or if we hold the shoulder blades toward the spine, the arm bone (humerus) can bump into the acromion and damage the tendon of the supraspinatus​. See the picture below.
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HOW THIS CAN HAPPEN
​
In yoga, this happens most often when we force the arms overhead. Think of any time you link your hands together and then try to straighten your arms using force. As pictured below, it happens in Half Moon Backbend, Half Moon Sidebend, Balancing Stick and Half Tortoise, among others. (It also happens in Downward Facing Dog.) When we force our arms to straighten overhead, we usually use the triceps, a muscle mainly of the elbow, to compel movement in the shoulder. This is where we get into trouble and impingement can happen. You will feel a 'pinching' sensation in the top and outside of your shoulder. This is the bones bumping into each other, damaging the soft tissue.

If the shoulders become injured this way, they will be painful whenever lifting the arms sideways, and the breathing exercise pictured at the top will cause pain.
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Half Moon Backbend
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Half Moon Sidebend
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Balancing Stick
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Half Tortoise
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HOW TO HELP
The simplest and most effective way to avoid this injury is to not link your hands together. Just place them side by side without interlacing the fingers. Interlacing the fingers and forcing the arms straight overhead is the easiest way to create the injury. 

Or don't lift your arms overhead (pictured below left). Most postures can be done quite effectively without the arms overhead. All of the positions pictured above don't require the arms to get the primary benefit.

Alternatively, you can lift your arms forward and up (pictured below) instead of out to the side. This will help the shoulder blades move into the proper position and keep the shoulders healthy.

In the breathing exercise, pictured at the top, you can keep your elbows lower, not lifting them higher than the shoulders. This will prevent further irritation of this area.

To build strength in the area, postures like Full Locust will help (pictured below right). By pulling the shoulders back and together, we build strength in the back of the shoulder to help stabilize and balance the joint.

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CONCLUSION
The moral of the story is that we should be aware and careful when lifting the arms overhead, especially if we are gripping the hands together and straightening with force. If there is a 'pinching' sensation in the top of the shoulder, back off immediately. There is nothing there to 'stretch', and it is likely that we are impinging our supraspinatus tendon. Try adjusting your approach to the posture and using your shoulders a little differently.

Happy, healthy practicing.
8 Comments
Stefan Armstrong
12/22/2019 05:57:46 pm

Would you please elaborate on how stiffness in the rhomboids/trapezius makes this injury more likely?

In my own practice I have been thinking a lot about the role of the area between the shoulder blades to support a lifted ribcage. In the beautiful pranayama breathing photo you chose to lead the article, it's clear that the ribcage is lifted and widened to the sides. I feel like, with all the "breathing normal" references in the dialogue, we've obscured the benefits of mobility in the ribcage and really moving the ribs and diaphragm with the breathing.

Thanks for the great article!

Reply
Scott (Ghosh Yoga) link
12/23/2019 05:30:05 pm

When the rhomboids or trapezius are tight, they hold the shoulder blades closer to the spine and don't allow the shoulder blades to rotate onto the sides of the body, which is how they have to move when the arms are overhead. This is called protraction (away from the spine) and upward rotation. Without this movement from the shoulder blades, the arm bone is much more likely to impinge against the edge of the shoulder blade.

Regarding breathing: the shoulder blades and their muscles will not really help you breathe or move your ribcage. The muscles are quite separate. The shoulder blades get their stability from the spine and move the shoulders and arms. The muscles that move the ribcage are quite separate from the arms and shoulders. Ribcage/breathing muscles are the external intercostals and internal intercostals, along with the posterior serratus and of course the diaphragm. But none of these have a significant impact on the shoulders. In 'Standing Deep Breathing' as pictured, the lifted arms are misleading, because they are actually not helping to lift the ribcage or breathe. They draw the sides of the body tight, so it looks much more beautiful and impressive, but the arms don't help the ribcage move. What can be hugely useful is to leave the arms down by the sides or place the hands on the hips. Then take deep breaths into the chest, expanding the ribcage and lifting it up as much as you can. With practice you will find the intercostals and be able to expand and lift the ribcage independently.

Reply
Kratika link
12/23/2019 02:13:06 am

Thanks for sharing the information. I do quite a lot of stretches and now I'll focus on how I am placing my hands.

Reply
Laura Finnern, DPT, CYI
12/23/2019 04:06:01 pm

This is a wonderful explanation of shoulder impingement. I am a physical therapist and I love the detail in the reason

Reply
Yoga In School link
1/6/2020 07:09:06 am

nice blog thanks for the information

Reply
banii link
1/22/2023 11:28:40 am

Great extra tip and thank you for sharing carpal tunnel. My brother had suffering this hand problem, before five months he did hand surgery at tosh hospital Chennai, Now he was absolutely fine!

Reply
Yoga TTC in Goa link
1/29/2023 01:31:09 am

Thanks for sharing this wonderful article,

Reply
Victoria Winters link
3/21/2023 11:40:06 pm

Good topic, thank you for sharing this. Can’t wait to read more of your posts.

Reply



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