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In this article, we will take a look at an extremely common cause of shoulder pain: rotator cuff injuries. We will look first at the normal anatomy and movements of the shoulder. Then we will consider the epidemiology and Ayurvedic management of rotator cuff injuries.
The human shoulder is a remarkable piece of engineering and one of the most mobile joints in the human body. Shoulder joints of different species are adapted to a variety of functions, from flying in the case of avian shoulders to quadripedal walking and running in the case of most mammals. Human shoulders reflect both our phylogenetic heritage as tree-swinging primates (arboreals) as well as the unique needs of our species such as spear throwing, tool making and enhancing speech with gesture. "The dorsal position of a highly-mobile scapula and the lateral orientation of the small, shallow glenoid fossa articulating with a medially-directed large round humeral head open up a nearly complete sphere of motion allowing the hand to be positioned almost anywhere around the body." (1). The shoulder is a complex of several joints, including the sternoclavicular joint, acromioclavicular joint, glenohumeral ball and socket joint (GH) joint, and scapulothoracic (ST) joint or pseudoarticulation. These articulations work together to carry out normal shoulder motion. The majority of motion occurs at the GH and ST joints. (2,3).
Human shoulder joint movements include:
· Scapular retraction (squeezing the shoulder blades together) using rhomboideus major and minor and trapezius
· Scapular protraction (as in hugging yourself) using serratus anterior and pectoral muscles
· Scapular elevation (shrugging shoulders) using levator scapulae and upper trapezius
· Scapular depression (slumping shoulders) using pectoralis minor, latissimus dorsi and subclavius
· Arm abduction, lifting arms away from body to 90', (deltoid) followed by additional upward rotation of scapula to raise arms above the head (trapezius, serratus anterior).
· Arm adduction, first bringing arms back down to 90' via downward rotation of scapula using pectorals, subclavius and latissimus dorsi; followed by true adduction, which additionally uses teres major and deltoid.
· Arm flexion (reaching arm forward) using pectoralis major, coracobracialis, biceps, deltoid
· Arm extension (pointing humerus backwards) using latissimus dorsi, teres major, triceps and deltoid
· Medial rotation (turning upper arm in) using subscapularis, latissimus dorsi, teres major, pectoralis major and deltoid
· Lateral rotation (turning upper arm out) using infraspinatus, teres minor, deltoid
· Circumduction (circular movement of arms up to 90') using pectoralis major, subscapularis, coracobrachialis, biceps, supraspinatus, deltoid, latissimus dorsi, teres muscles, infraspinatus and triceps. (3).
Some authorities suggest that on leaving our arboreal lifestyle, we fail to use our shoulder joint to full capacity, thus creating a tendency to osteo-arthritis of the shoulder (4). If this hypothesis is true, it provides a powerful justification for activities such as hatha yoga and chi gong in maintaining shoulder joint health through movement. Elderly subjects have been shown to have reduced shoulder joint movement after a lifetimes of under-use of some movements and over-use of others (5).
The rotator cuff is composed of four muscles whose tendons splay out and interdigitate to form a common, continuous insertion on the humerus, providing stability to the shoulder joint (6). The four main muscles of the rotator cuff are suspraspinatus, infraspinatus, teres major and subscapularis. Originating above the spine of the scapula, supraspinatus inserts on the greater tuberosity of the humerus. As the deltoid abducts the shoulder joint, supraspinatus fires to stablize the joint (7). Infraspinatus, originating below the spine of the scapula, insets posteriorly on the greater tuberosity of the humerus and, as stated above, asssists in lateral rotation. Teres minor, originating on the lateral border of the scapular, inserts inferiorly on the greater tuberosity of the humerus and as we have seen, is involved in lateral rotation. Originating between the scapula and the ribs on the anterior surface of the scapula, subscapularis inserts on the lesser tuberosity of the humerus and is involved in medial rotation of the arm. However, although the rotator cuff muscles are associated with the above-mentioned shoulder motions, it is important to understand that their main function is to provide stability to the GH joint by compressing the humeral head on the glenoid (8).
Rotator cuff injuries are common in all ages and range from reversible tendinitis to massive tears involving supraspinatus, infraspinatus and subscapularis. Repetitive overhead movements such as pitching in baseball can cause rotator cuff injuries in younger people, or, less commonly, a trauma such as a fall or car accident can tear the rotator cuff (9). Older patients may present with a history of gradual onset of shoulder pain, with no clear history of trauma and yet are often shown on MRI to have significant partial or compete rotator cuff tears (10, 11). On cadaver studies, 39% of individuals over sixty were found to have full-thickness rotator cuff tears with an even higher incidence of partial tears (12). These injuries on elders are probably due to age related degeneration and compromised microvascular supply (13,14).
The main symptoms of rotator cuff injuries are shoulder pain and diminished range of motion; additional symptoms include weakness, swelling, instability and popping of the joint. In elders, a significant rotator cuff tear may present with insidious symptoms. Therefore, in patients over sixty-five, passive and active shoulder range of motion should routinely be examined, since rotator cuff injuries are prevalent in over a third of this population. When active elevation is less than passive elevation, this points to a rotator cuff injury.
Patients presenting with shoulder pain should have a full check up with a medical practitioner before proceeding ahead with Ayurvedic treatments for the rotator cuff. This is particularly important because both angina pectoris due to iscaemic heart disease and myocardial infarction (heart attack and its sequelae) are included in the differential diagnosis of shoulder pain. Additionally, the nature and extent of the tear can best be determined by imagining such as MRI.
While the most massive tears are usually referred for orthopedic surgery, most rotator cuff injuries are managed by conservative measures and can be addressed by systemic and localized Ayurvedic treatments. Therapy must address the cycle of pain/underuse/loss of conditioning/ joint laxity. First this cycle is broken by local and systemic measures to reduce inflammation. Then the shoulder muscles can be ongoingly conditioned to sustain maximum functioning.
For reducing pain and inflammation, herbs, home remedies and Ayurvedic bodywork can be applied. Anti-inflammatory herbs such as guduchi, kaishore guggulu, tulsi, turmeric and licorice can be given orally to reduce inflammation, pain and swelling (15). Anti-inflammatory home remedies include ginger tea and Trinity Tea (tulsi, turmeric and ginger tea). Localized home treatments can be applied using anti-inflammatory oils such as castor oil and mahanarayan tailam (15) prior to a hot shower. Alternate hot and cold packs can also be given, using a bowl of ice water, a bowl of hot mustard seed tea and two cloths. First a hot pack is applied, then a cold pack, then hot, then cold for a counter-irritant impact. Bath therapy can also be used, first massaging the shoulder with castor oil and then taking a ginger-baking soda tub.
Many classical Ayurvedic body treatments can be applied to the shoulder to reduce the pain and inflammation of a torn rotator cuff. Mardana or pressure massage is recommended for snayugata vata or vata invading tendons (16). After applying mahanarayan oil the therapist gives vijayamala hasta (straight pressure massage on neck), viparita vijayamala hasta (oblique pressure massage on neck), shaila hasta (massaging front of shoulder), dheera hasta (circular massage on shoulder) and chakra hasta (rotary massage on shoulder (17). Valuka sveda using a hot sand bag is helpful to alleviate pain and swelling (18). Patrapinda sveda can be offered using leaves of datura, abundant in the United States as Jimson weed or Angel trumpet. The datura leaves are fried in oil and placed in muslin bags. Then mahanarayana oil is applied to the shoulder the shoulder and the comfortable hot pinda packs are massaged over the area. This treatment is effective for muscle and tendon injuries (19). Nadi svedan therapy using localized steam medicated with nirgundi is also extremely valuable in rotator cuff injuries (20). Taila dhara treatments with mahanaryana oil can alos be applied locally to the shoulder using the same setup as for shirodhara but adjusting the positioning (21).
After pain and inflammation have been managed, yoga therapy can be employed to strengthen the shoulder and restore range of motion. A qualified yoga therapist should perform this function. Improving posture, especially with regard to thoracic kyphosis, is important in preventing rotator cuff impingement. Modified dog poses against a wall help stabilize the scapula. Cat Bow can be utilized to strengthen shoulder extensors (22, 23). Modified cobra poses can be helpful in strengthen the rotator cuff, as can shoulder shrugs and shoulder circles. Use of yoga therapy, physical therapy or Chi Gong is a vital part of the care cycle, which necessarily involves both reduction of inflammation and restoratio of range of motion.
As we have seen, rotator cuff injuries are extremely common and require careful assessment. All but the most severe cases can be well addressed by a combination of Ayurvedic treatment and skilled yoga therapy.
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2. Codman EA. The Shoulder. Boston, Mass: Thomas Todd; 1934.
3. Pronk GM, van der Helm FC, Rozendaal LA. Interaction between the joints in the shoulder mechanism: the function of the costoclavicular, conoid and trapezoid ligaments. Proc Inst Mech Eng H. 1993;207(4):219-29.
4. Alexander CJ, Utilisation of joint movement range in arboreal primates compared with human subjects: an evolutionary frame for primary osteoarthritis. Ann Rheum Dis 1994;53:720-725 doi:10.1136/ard.53.11.720
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6. Clark JM, Harryman DT 2nd. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy J Bone Joint Surg Am. 1992 Jun;74(5):713-25.
7. Steindler A. Kinesiology of Human Body Under Normal and Pathological Conditions. Springfield, Ill: Charles C Thomas Publishing; 1984.
8. Wuelker N, Korell M, Thren K. Dynamic glenohumeral joint stability. J Shoulder Elbow Surg. Jan-Feb 1998;7(1):43-52
9. Neer CS 2nd, Welsh RP. The shoulder in sports. Orthop Clin North Am. Jul 1977;8(3):583-91.
10. Cailliet R. Shoulder Pain. 3rd ed. Philadelphia, Pa: FA Davis Publishers; 1991:42-6.
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12. Bigliani LU, Morrison DS, April EW. The morphology of the acromion and its relationship to rotator cuff tears. Orthop Trans. 1986;10:228.
13. Yamanaka K, Fukda H. Aging process of the supraspinatus tendon in surgical disorders of the shoulder. In: Watson N, ed. Surgical Disorders of the Shoulder. New York, NY: Churchill Livingstone; 1991:247.
14. hr JF, Uhthoff HK. The microvascular pattern of the supraspinatus tendon. Clin Orthop Relat Res. May 1990;254:35-8.
15. Singh A, Malhotra S, Subban R Anti-inflammatory and analgesic agents from Indian medicinal plants Int. J. Integ. Biol., 2008, 3(1): 57-72
16. Shrinivasa Acharya G, Panchakarma Illustrated, Chaukhamba Sanskrit Pratishtan Delhi 2006 p167
17. ibid pp 169-171.
18. ibid pp 215-219
19. ibid 220-225
20. ibid p 226
21. Dash B, Massage therapy in Ayurveda, Concept Publishing Company, New Delhi, 1992 p 64
22. Hinnen BF Rotator Cuff and similar Shoulder Injuries Structural Yoga Therapy Research Paper
23. Stiles, Mukunda. Structural Yoga Therapy - Adapting to the Individual. Boston, Weiser Books, 2001