During the past five months I have experienced lingering discomfort, low to moderate level pain associated with my upper right arm and shoulder.
OCTOBER
FIREFLY VARIATION
I recall feeling a slight pressure in my upper right arm documenting the above challenging Firefly asana - the evening before my 11th Yoga Anniversary.
It took several attempts to position my feet and hands in the appropriate position to execute the movements from a deep squat (Malasana) within a ten second exposure delay using my cell phone camera.
Being able to open up both palms, fingers compromised by Dupuytren's Contracture, my pelvic girdle and back while supporting full body weight as elevating both legs was exciting.
ASSESSING MY MOBILITY
A decade of focused yoga activities made it easy to 'listen' to my body, to know when whole body asanas were compromised, limited: being able to perceive a source of pressure, discomfort or possibly pain.
Despite the arm discomfort, it was encouraging being able to easily move my right arm, shoulder daily each morning:
- circular arm rotations in both directions
- yoga strap motions from (a) abdominals to overhead to lower back, (b) doing Figure 8 movements in both directions
I contacted my Primary Care Physician on October 27th online about discomfort in the upper right arm soft tissues.
Dr. Faucher responded: "It could be shoulder related, rotator cuff possibly." ... and added some suggestions about limiting shoulder activities, to consider using ice, possibly taking Tylenol for pain and providing an update.
NOVEMBER
Discomfort in my right upper arm continued throughout the month.
I also began to experience uncomfortable neck and shoulder strain at times walking wearing a winter jacket with hood.
Morning and evening yoga sessions continued but which asanas were done, the sequence of movements depended on how I felt.
Little or no benefits were perceived in my upper arm using ice, a heating pad, various analgesics, even Tylenol on several occasions - these treatments were deemed ineffective and all discontinued.
DECEMBER
As during the previous six weeks, I continued both daily yoga sessions and further modified the sequence of selected asanas.
Movements done easily over many years became limited: for example, in Gomukhasana -the clasping of hands behind my back with the right elbow moved towards a vertical position; in a standing forward shoulder asana - moving arms parallel to my yoga mat.
Not doing specific movements in some cases (see below) reduced the likelihood of possible arm, shoulder trauma.
ALSO
- Local walks wearing a heavy winter jacket with a hood led to increased pain in my neck and upper right arm
- Obtaining restful sleep became more difficult given the pain associated with my right arm and shoulder.
On December 21st I contacted Dr. Faucher: providing an update on my status and asked about obtaining a referral to have imaging on my upper right arm.
X-Rays of my right humerus (2 views) and right shoulder (3 views) were taken at St. Vincent Hospital on December 22nd.
At my request, I was able to obtain a copy of the Radiologist report shared below:
FINDINGS
- Osseous mineralization and alignment are normal
- There is no evidence of fracture or dislocation
- There are mild degenerative changes to the right acromioclavicular joint
&
- The right glenohumeral joint is well-preserved
- Images soft tissues are unremarkable
- Visualized lung parenchyma is clear
IMPRESSION
No acute osseous abnormality of the right shoulder or humerus
Mild degenerative changes of the right acromioclavicular joint.
A
FUTURE
MRI REMAINED AN OPTION
Details of possible soft tissue trauma including tissue tears would be disclosed with this diagnostic imaging.
JANUARY
After reading the comments prepared by the Radiologist, my request for a referral to see a physical therapist (PT) was approved leading to a first session on January 19th.
As during the last week in December, experiencing pain at night in my upper right arm made sleeping difficult, at times impossible.
Uncomfortable pain in my right upper arm, neck at times continued while walking - the pain became worse when I walked with hands in my coat pockets.
INITAL
PHYSICAL THERAPY
MEETINGS
I first met PT Jennifer Dietz, affiliated with St. Vincent Hospital Grove Medical Associates in Auburn, MA.
My initial assessments included inquiries into medical history along with evaluations of arm & shoulder mobility (range of motions).
Also evaluated were muscle strength and weakness in various positions (standing, sitting prone).
I mentioned my long, decade plus active yoga practice and several movements I had been doing for years easily and safely that were now more restricted and a source of discomfort and pain.
Two examples of compromised movements are shown below:
TORTOISE
Entering this asana requires the joints of arms, shoulder to move in a way that was usually comfortable but now, at times, a source of pain.
Likewise, twisting my torso and fully extending my right arm outwards away from body to a position parallel to the floor was compromised.
REVOLVED
HAND FOOT ARM EXTENSION
BOTH INVOLVED
ABDUCTION
DEFINED
AS
MOVEMENTS
AWAY TO SIDE
FROM THE MIDLINE OF THE BODY
The supraspinatus, deltoid, trapezius and serratus anterior muscles are involved in arm abduction at different times.
Jennifer responded to my inquiries and suggested a shoulder impairment involving a rotator cuff muscle (supraspinatus) was a reasonable explanation for the referred pain experienced mostly in my upper right arm based on the assessments.
We also addressed issues with my posture as noted below.
BACKGROUND
For many years I referred to several yoga anatomy books, online articles and videos to obtain a better understanding of the biology related to my mobility.
Ray Long's book THE KEY MUSCLES OF YOGA was a useful reference source to visualize the complex association of the arm, shoulder joint: bones, ligaments, muscles and tendons along with excellent illustrations of diverse asanas.
THE SHOULDER GIRDLE
The shoulder girdle is compromised of the following structures (Long, p.17):
- Scapula (shoulder blade)
- Scapulothoracic joint
- Clavicle
- Sternoclavicular, Acromioclavicular joints
- Humerus (upper-arm bone)
- Glenohumeral joint
SIMPLIFIED ANATOMY
UPPER ARM, SHOULDER
&
SUPRASPINATUS
AREA OF ILLUSTRATION
FROM
ONLINE ARTICLE BY TIM MORRISON
The above image is an enlarged view of the shoulder joint that highlights the supraspinatus muscle, tendon attachment to the humerus and relative positions of the joint bursa and the scapula (shoulder blade) projection known as the acromion.
SUPRRASPINATUS
(Long, p.175)
"This muscle originates from the back (dorsal) surface of the scapula and inserts on ... the humerus ..."
This muscle "initiates arm abduction"
'It is ... frequently injured, due to impingement of its tendon ... (by) the acromion process of the scapula."
IMPINGEMENT
(LONG, p. 184)
"The subacromial bursa is a sac-like, fluid-filled structure that facilitates the gliding of the rotator cuff under the acromion."
"Impingement involves compression of the subacromial bursa between (the supraspinatus tendon attachment) of the humerus and the acromion."
" This can result in shoulder pain."
It is likely the acromion has been causing inflammation to the bursa, tendon of supraspinatus.
ROLE OF POSTURE
Jennifer and I also spoke about my compromised posture, the forward position of shoulders resulting in 'rounded shoulders' - a condition I have been aware of for many years.
I mentioned a suspicion of the reconstructive thoracic surgery (pectus excavatum) in June, 2001 to address a debilitating structural deformity compromising breathing may have contributed to this poor posture.
Our conversations noted the difference between the greater muscle strength of my chest (pectoralis major, minor) and weaker back muscles.
Use of a shoulder harness as a reminder to adjust posture was discussed and considered an reasonable option.
Walking with a lighter jacket, with shoulders upright and arms at sides significantly decreased my neck, right arm referred pain.
😊
FEBRUARY
FOUR
PT SESSIONS
Jennifer continued to manually move the right shoulder joint during each session, to use different props to help address shoulder issues, reduce pain.
Photos of my whole body movements from 2013 to the present, demonstration of selective asanas led Jen to better understand how I moved yet express caution: that some of the shoulder movements I was capable of doing could have a negative outcome.
I acknowledged her comments and indicated my approach to yoga mobility for over a decade was guided by "less is more" to avoid trauma, potential injury.
Evidence of this was indicated by my daily modification of asanas during both morning and evening sessions - for example: either modifying or not doing a specific movement (tortoise, firefly variation, balance with arm abduction movements)
MOVEMENTS
TO
STRENGTHEN
SHOULDER, BACK MUSCLES
Suggested movements introduced by Jen during physical therapy sessions and done daily at home have included the following:
[1]
> ELASTIC BAND Use (At Door), Standing<
[1] Rows, parallel to floor
[2] Lat Pulls: downward motions
[3] Scapular Retractions with Mini Shoulder Extensions, at quad level, arms straight
[2]
> ELASTIC BAND Use (On Mat, Use Mirror)<
[1] Bilateral Horizontal Arm Abduction
[2] R & L Diagonal Arm Stretches
[3]
> SCAPULAR RETRACTION, PRONE<
ON MAT, EXERCISE BALL
Raising Shoulders At Four Arm Positions (with and without 2 pound barbell)
[4]
> *SNOW ANGELS, SUPINE<
On FOAM ROLLER, MAT
[5]
>EXERCISE BALL PRONE WALKOUT<
SEVERAL VARIATIONS
* Snow Angel movements resulted in most discomfort, lessened by elevating right arm
KUDOS
TO
JENNIFER DIETZ, PT
I was fortunate to interact and to receive excellent professional services from Jen during our six sessions.
Jen's skills were apparent in the various manipulations I benefitted from during each meeting, the specific exercises and props selected to address my right shoulder mobility, upper arm pain issues.
Being able to share photos of my whole body yoga mobility abilities during the past decade were appreciated, facilitating her understanding of what were normal, safe movements for me.
As a source of knowledge and effective communicator, I would highly recommend Jen to anyone seeking professional physical therapy assessment and treatment.
I remain grateful for Jen's contributions to my ongoing recovery.
AMONG
CURRENT
PROPS FACILITATING MOBILITY
A 65 cm exercise ball, a long foam roller, various sized yoga blocks, a yoga strap, wrist supports, an abdominal/back support belt, sandbags, several elastic bands of different resistance, two pound dumbbells and a tennis ball were some of the props I have used for years, recently to address my whole body mobility.
HIGHER QUALITY SLEEP
My ability to sleep better at night during February has been a significant, positive and welcomed consequence of doing all of these various movements suggested by Jen.
Adjusting to sleeping differently: on my back with the right arm in a pain neutral position, at times using a cushion under my right shoulder, instead of on my sides has been effective to significantly reduce shoulder discomfort and pain.
A shoulder harness has been ordered to help remind me to maintain a better posture.
OPTIMISTIC WITH PROGRESS TO DATE
Incorporating the movements identified above, others I have examined in online videos will continue moving forward.
I anticipate making future additional adjustments to both morning and evening yoga sessions in response to what I can do safely.
ANTICIPATING
A
FUTURE MASSAGE
WITH
RAY HOYT
Looking forward to an opening with my former talented hatha yoga instructor and Tui-Na bodyworks massage specialist.
Using a tennis ball, foam roller to massage my arm, shoulder and back muscles are no substitutes for the hands of a skilled practitioner.
SHARE YOUR THOUGHTS
I will provide an update of my status next month on my 70th birthday.
#BobCrowther #NUTRITION #YOGA
