Yoga class (512 x 340)

My favorite thing to do in the morning is not having a cup of coffee or reading the newspaper (this usually depresses me or sends me into a rage)—it is exercising. Sounds pretty ascetic, requiring military discipline. But no, it actually isn’t; you should try it.

Start slow, either with a 30-minute walk outdoors or on a treadmill. I used to run in the morning, but since I screwed up my back, I switched to the elliptical. Either exercise is aerobic and beneficial. Your heart will thank you, your stiff lower back will loosen up, and your still somnolent brain will wake up to the torrent of oxygenated blood courtesy of your pumping heart.

Having finished the aerobic part, I usually stretch to further loosen up my lower back and then move on to resistance exercises, such as push-ups, pull-ups, and weight lifting.

And, therein, lies a big problem. Doing the resistance exercises, especially the weight lifting, somehow caused frequent episodes of shoulder pain. Initially, I thought I could “blast through” the pain. Mistake!!!

Pain is a signal that your body is sending: Stop! Something is going wrong. Acute pain can be due to a stretched tendon or a muscle spasm. If you stop and let the injured area rest, things will come back to normal very quickly. But if you ignore that signal and continue exercising—chronic inflammation sets in. Not only is the pain more severe, it takes weeks and sometimes months to resolve.

 

Rotator cuff injuries

One of the most frequent injuries of resistance exercises is the rotator cuff syndrome. The rotator cuff is a group of 4 muscles that attach to the shaft and head of the humerus (the bone of the upper arm) which participate in lifting the arm above the head.

muscles-of-rotator-cuff
Graphic from Physio Works http://physioworks.com.au/injuries-conditions-1/rotator-cuff-injuries

Actually, raising the arm up to 60- 80° is the responsibility of the deltoid muscle, not formally a member of the rotator cuff group. This muscle group, and especially the supraspinatus muscle, then take over and raise the arm to about 100°-120°, after which the deltoid takes over again all the way to 180°. It is not surprising then that irritation of the supraspinatus tendon, which anchors the muscle to the humerus shaft, would cause pain when elevating the arm; and repeated irritation would cause chronic inflammation.

An extreme tug on the muscle or tendon could cause a complete massive tear of the tendon and loss of the muscle’s mooring to the bone. All of which is a real pain in the shoulder, and elsewhere…(sorry, this blog is rated for G, for general audience).

 

Yoga

If I have learned anything from Elizabeth, my picky yoga instructor, I learned that form is everything. If you deviate from the perfect form, sooner or later you’ll pay for it. I used to follow a rigorous exercise regimen called P90X. You must have seen the infomercials promoting it; a truly great fitness program.

Elizabeth saw what I was doing and was horrified; several of the exercises had you lifting weights above the head. She had told me to NEVER lift weights higher than the shoulders (about 90°), and to always keep the elbows pinned to the waist. P90X violated her commandments, and hell hath no fury like my yoga trainer’s teachings being spurned.

Needless to say, I started getting nagging shoulder pain, which got worse as I stubbornly stuck with the program. Eventually, I simply couldn’t go on. I had to lay off for about 6 weeks until the shoulder healed.

Since then, even though I have been observing the “thou shalt not lift overhead” commandment, I would occasionally get shoulder pain which would resolve after two or three days of rest. Today, after doing a few sets of pushups (and pushing the envelope a bit, I must confess), I felt some pain in my left shoulder when I lifted my arm; nothing that rest would not fix.

But then, my eyes caught the headline of an August 2 NYT article by Jane Brody: Ancient Moves for Orthopedic Problems. Brody highlights the work of Doctor Loren Fishman, a physiatrist—a specialist in physical and rehabilitative medicine affiliated with NewYork-Presbyterian/Columbia hospital.

Dr. Fishman, a lifelong devotee of yoga who studied it for three years in India before going to medical school, is applying his knowledge to a variety of orthopedic conditions like osteoporosis, osteoarthritis, scoliosis, and…rotator cuff injury! I couldn’t suppress my curiosity; here I am with a freshly acquired shoulder injury—let’s see how good your “ancient moves” are.

Triangular-forearm-support-exercise
Triangular forearm support maneuver (TFS)

The maneuver he advocates is simple. It is called TFS, for Triangular Forearm Support. Claim: You do this simple thing, and relief is immediate! Yes, you read it right—immediate. And long lasting, as long as 2.5 years (maybe more; that’s as long as the observation period lasted).

Not wasting any time I tried it for the recommended 30 seconds. And guess what—it worked! I could immediately raise my arms over my head without much pain (just a twitch).

Incredible: How does it work? I went to the original publication (July/September issue of Topics in Geriatric Rehabilitation) and without getting into the gory anatomical details, the bottom line is that the other three muscles that make up the rotator cuff are trained to take over from the injured supraspinatus and raise the arm through the gap of 80°-120° before the deltoid could take over again.

You have to repeat this exercise for at least 2-3 times a week for 3 weeks, but I intend to incorporate it into my daily stretching routine forever. After all, isn’t a pain-free shoulder worth 30 seconds?

I never fail to marvel at the wisdom of the ancients. A supraspinatus tendon tear is treated today with either open or arthroscopic surgery. But regardless of how successful the surgery is, the clinical improvement in function is pretty spotty.

The ancient yogis could not repair the torn tendon—didn’t have access to sophisticated surgery; they probably wouldn’t have used it anyway. Instead, they trained the other muscles to take over the function of injured one. Their belief that “everything is connected” and their focus on the correct form led them to the most amazing insights.

Forget the spiritual mumbo-jumbo—there is real wisdom in them thar poses.

Dov Michaeli, MD, PhD
Dov Michaeli, MD, PhD loves to write about the brain and human behavior as well as translate complicated basic science concepts into entertainment for the rest of us. He was a professor at the University of California San Francisco before leaving to enter the world of biotech. He served as the Chief Medical Officer of biotech companies, including Aphton Corporation. He also founded and served as the CEO of Madah Medica, an early stage biotech company developing products to improve post-surgical pain control. He is now retired and enjoys working out, following the stock market, travelling the world, and, of course, writing for TDWI.

22 COMMENTS

  1. Oh man, I’m really suffering here. Lack of sleep is starting to make me feel kind of ill and I’m missing out on things I love like yoga, tutoring, socializing etc. It’s hard to teach ESL when you sleep an average of 3 or 4 hours per night..total. Last night my shoulder hurt all night. I went to bed around 8:30, was awake by 10:30.

  2. Hi, I’ve had a shoulder issue since March. I think my heavy teaching bag was the culprit. I don’t remember any sudden injury. I’ve had physio, massage, a cortisone shot, anti-inflammatory pills, ice…..yoga. But, lately the shoulder won’t even let me sleep and I’m kind of scared of yoga now, esp. poses like downward dog. And yet, the non-shoulder yoga feels so good. I’m being referred to a surgeon. I’m so weary of pain and not sleeping.

    • Hi Sara, I am so sorry you are in such terrible pain. I had a persistent pain in the upper part of my back that kept me awake and lasted for months. I now realize it was probably from carrying a too-heavy cross-body purse. I ditched the purse and then spent the next couple of months stretching my neck in each of the range of motion positions. The pain gradually went away – thank heavens. That is not to say that my problem is the same as your problem, but to let you know that it is possible to get relief once you finally figure out the right intervention. Be sure to talk to the surgeon about whether referral to a good physical therapist might be helpful before surgery.

      • Hi Patricia, thank you so much. I have 2 small tears: one in my supraspinatus tendon and another in my infra spinatus. :-( Is a physical therapist the same as a physio therapist? I’ve been working with an amazing physiotherapist since July and also with an amazing massage therapist. The massages, esp. seem to help the most. Sara

        • Hi Sara, we don’t give medical advice on this site, rather we try to provide you with information that you can use, perhaps in consultation with your physician.Re: physical therapist vs physiotherapist. There is some confusion about the terminology. Some people think they are the same, others think they have different approaches, and some point out that neither is the same as a physiatrist. To make it even more confusing, some PTs specialize and some don’t. When I fractured my shoulder a few years ago I saw a PT who specialized in shoulder rehab. Seeing someone who knows their stuff and you like and trust is important. Pat

        • Sara, I think you are doing the right thing. Tendons are notoriously slow to heal because they are poorly vascularized. But the good news: they do heal! From the sound of it, you have only small tears, and these heal without surgical intervention. NSAID like ibuprofen may help by cutting down on the local inflammation. But time is the best healer. In my case, I dealt with a similar problem with Yoga stretches, occasional ibuprofen and lots of patience.

          • Thanks Dov and Pat, It will be interesting to talk to the surgeon. I won’t rush into surgery. You make me feel that there is hope for this sleepless painful time to pass!

  3. I suppose I should have phrased my question in a more general format.
    When fearing a rotator cuff tear, is it possible for range of motion — specifically reaching behind the back — to return without surgery? Or, is this type of motion limitation indicative of an injury not repairable with exercise rehab alone?
    Thank you!!

    • Kelly, here is some (relatively) good news. Having pain reaching the the back is not unusual -it is part of the whole syndrome, and does not necessarily indicate a tear. You should let your shoulder rest as much as possible, avoiding movements that cause pain. To accelerate healing you might consider ibuprofen, which is an anti inflammatory. As everything else in life -it takes time. And rotator cuff injury is notorious for that. You could also some range of motion exercises, but be careful to to overdo it; stop at the first sign of pain. If you are concerned that you have a tear, then you should see a doctor. Good luck.

  4. Last October I was pulling a Pilates Reformer cord across my chest (not anchoring my elbow to my side) and heard a “pop” in my bicep/shoulder area. There was no pain but I eventually lost range of motion in my shoulder — I can’t raise my arm above my head, can’t raise my arm behind my back to touch my waistband, can’t put hand on hip. Initially treated with ice for 2 weeks and then a couple of weeks of heat. I have not seen a doctor (no insurance) and I fear a rotator cuff tear. Is there ANY way to regain range of motion??! I am miserable. Just miserable.

  5. Hi, I had MRI and it shows that I have a complete tear on my suprastinatus tendon and surgery is recommended. The shoulder injury has a lot to do with my job . I love yoga so much and the thought of leaving it just kill me!! I tried your TFS and it ease the pain. I still go to yoga with an open minded .. please let me know how soon I can ease back to my practice after the surgery?
    Thank you.

  6. Hello, I was in a car accident in October and had severe shoulder/neck pain, after MRI revealed only minor rotator cuff tendonitis and arthritis in my AC joint and moderate ferominal narrowing in my neck joints and I have degenerative disc in my SI joint (tailbone). I was prescribed Gabapentin which did get rid of the burning radiating pain but left me with a foggy head and a lot of weight gain. I decided to get off of that and I am now doing acupuncture, I’ve only had three sessions and I think it has relaxed some muscles and helped the tailbone but my shoulder still hurts. I was hoping I could try Yoga but if I am reading the previous messages correctly, I shouldn’t start until I am pain free??? Is that correct?

  7. I rested my torn rotator cuff and ended up with a frozen shoulder and intense pain. I should have kept moving my arm.

  8. I’ve had a rotator cuff repair just before Christmas. I’m 5weeks into physio am doing very well.
    I’ve done yoga for the last 8 years and I really miss it. I also do a lot of swimming. But this also seems a no no.
    Is there anything I can do to exercise beside walking. I’m sure some of the yoga exercises which are non weight would do me some good.
    Sheila

    • Any non weight bearing exercise is OK. Be sure to stop at the first suggestion of pain. I would avoid any exercise that requires raising your arms above shoulder level, especially with weights.

  9. I’m so glad I found this article! For the last few nights I’ve had trouble sleeping because of pain in my shoulders. I too have (had) been a serious p90x groupie never realizing the overhead weight lifting was contributing to the pain. I tried the yoga move you described thinking I had nothing to lose…and to my disbelief, it actually worked! Thank you so much!

  10. Thank you! I can’t do Dolphin pose on my mat but doing that tonight against the wall has made 3 months of pain wash away. I’m so thankful I found this page!!!! Thank you!

  11. Hi. I have never had shoulder problems before, bu managed to injure my right rotator cuff during a yoga class. It was a hot summer day, the studio was steamy, I was sweating (with no towel!!) and my mat was wet. I went into downward dog and my right arm slid out suddenly from under me, jamming my shoulder joint. I have full range of motion, but do get pain with use of that arm, especially with weight bearing moves during yoga. (my physio told me that I had a mildly jammed/inflamed rotator cuff, and to AVOID YOGA altogether which I don’t want to do. Are there any moves that I should avoid altogether (I already know about arm balances and head stand prep as I did these yesterday and my shoulder is killing me…STUPID!!). And also any tips about doing the postures more safely to avoid further injury (aside from keeping the shoulder blade back and the arms in and externally rotated…) Thanks, I am enjoying yoga up at my cottage and don’t want to give it up entirely. Thanks, elaine

  12. I am interested in learning yoga for rotator cuff problems, as I have problems in both shoulders. Please send info. Thank you.

    • The best “treatment” is rest. Don’t use the rotator cuff muscles as long as there is even a hint of pain or stiffnes. Most people get impatient and start exercising too early, and they invariably pay the price. You can shorten the recovery period by taking ibuprofen or aspirin. Also, do some shoulder stretches. You can click on the link to the NYT article in my post.

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