Reducing Shoulder Impingement
Many Yoga poses and flows involve large movements at the shoulder joint. Some of these movements have the potential to create shoulder impingement when improper technique and movements line are applied. If this shoulder impingement continues over time, chronic injury can form leading to pain and dysfunction.
What is Shoulder Impingement?
Shoulder impingement is caused when the arm is lifted above the line of the shoulder. The head of the arm bone (humerus) lifts and rotates into a portion of the shoulder blade (acromion on the scapula). Covering the head of the arm bone are the 4 rotator cuff muscles: the supraspinatus, the infraspinatus, the subscapularis, and the teres minor. Acting as cushioning against pressure and friction, there are bursa sacs that lie between the muscular capsule and the acromion.
When the arm is lifted high over the level of the shoulder, the head of the humerus presses into the acromion. This pressure and friction can develop into inflammation of the bursa (bursitis) or the tendons the muscles (tendonitis). This inflammation can worsen due to repeated impinging actions that can eventually lead to increased pain and limited movement.
Where can Shoulder Impingement Occur in a Yoga Practice?
Shoulder impingement can occur in variety of Yoga postures and flows. Here is list of common yoga postures that set the arm bone above the line of the shoulder and can generate damaging frictional forces in the shoulder joint if one is not mindful:
- Sun Salutations – the motion of folding into Mountain Pose (Tadasana) into Standing Forward Bend (Uttanasana) often incorporates a large sweeping motion of the arms over the head.
- Extended Side Angle Pose (Parsvottanasana)
- Extended arms in Child’s Pose (Balasana)
- Half Moon Side Stretch Pose (Ardha Chandrasana)
- Gate Pose (Parighasana)
How to Reduce the Incidence of Shoulder Impingement in Yoga Poses
The first method in reducing the pressure caused by shoulder impingement is to eliminate arms transitions that move the arm bone through large sweeping motions. In Sun Salutations, consider keeping arms in the forward plane, instead of lifting arms out to the side, back, up and then over head. By lifting the arms forward instead, there is less pressure being created against the head of the humerus as the arm bone moves back and up.
The greatest amount of pressure tends to occur where the arm is situated high above the shoulder line with the arm bone back in line with the neck and the arm bone rotated internally (medially) so the palm faces forward.
If the yoga posture requires the arm to be overhead and in line with the neck (like Extended Side Angle Pose), take extra note of the position of the hand. The hand should be turned inwards towards the body creating an external rotation of the arm bone. This external rotation has a tendency to draw the head of the humerus down from the acromion and scapular structures. This outward rotation of the arm bone offers secondary benefits as it encourages the shoulder blades to draw down away from the ears, thus bringing more integrity to the shoulder girdle and freedom to the trapezius and neck regions.
If you are ever experiencing regular pain in the shoulders, consult a health care professional to have your condition properly diagnosed and treated. Continue to acknowledge that Yoga poses are a means to create expansion and vitality. With mindful alignment and awareness to joint positioning, you can maintain space and energy flow through the shoulders and readily avoid impinging movements.
Yoga and Trauma
The benefits of a yoga practice include building flexibility, strength, agility, balance, and concentration. However, a regular yoga practice can help anyone dealing with the stress of facing military deployment, being homeless, being in prison or recovering from alcohol and substance abuse.
The commitment of yoga teachers and therapists for their work bringing trauma-sensitive yoga and meditation to veterans, prisoners, persons with eating disorders, and those in recovery from addictions — with powerful results — is deep and impressive. It is tempting for me to write a book about each of these worthy people. Instead, over the past four years, I’ve interviewed many of them for a Huffington Post blog series called “Yoga, How We Serve.”
In their interviews, these women and men shared the unique needs of survivors of trauma, lessons learned in doing this work and how existing resources and treatments generally do not adequately address the needs of these populations. Here is just one of many extraordinary comments from a Vietnam War veteran in a program called Mindful Yoga Therapy:
“As I started to practice daily, I noticed several things happening. First, I began to sleep better. Next, I was getting to know myself, for the first time ever. Slowly I came off all of my psych meds. That was big! For the first time in over 40 years, I was medication free. Over the years, I’ve been on over 23 different kinds of medications, from Ativan to Xanax! Yoga is now my therapy.”
Vietnam War Veteran
This veteran went on to say he hopes that yoga will someday be offered to all veterans, and offered to our troops during basic training.
I very much share this hope, because the costs of treating trauma—whether it occurred 40 years ago or in the past decade, have become a major concern in our society. According to the Centers for Disease Control and Prevention, the economic burden of trauma is more than $585 billion annually in the U.S., including both health care costs and lost productivity.
The CDC also measures “Life Years Lost,” used to account for the age at which deaths occur, which gives greater weight to deaths occurring at younger ages and lower weights to deaths that occur at older ages. It turns out that the impact on life-years lost from trauma is equal to the life-years lost from cancer, heart disease, and HIV combined.
Statistics can’t say much about the personal burdens of individuals and families, of how individual sufferers are impacted, but it’s still instructive to mention one or two more here. For instance, there is an average of 293,066 victims of sexual assault or rape each year in the US, with someone in the United States being sexually assaulted every 107 seconds. And roughly 22 veterans commit suicide every day from the effects of PTS symptoms, one every 65 minutes.
What is Trauma?
The word “trauma” comes from the Greek, and means “a wound” resulting from an emotional or psychological injury or experience that causes someone to have mental or emotional problems, usually for a long time. According to Bessel van der Kolk, “Trauma, by definition, is unbearable and intolerable. Most rape victims, combat soldiers, and children who have been molested become so upset when they think about what they experienced that they try to push it out of their minds…The survivor’s energy now becomes focused on suppressing inner chaos, at the expense of spontaneous involvement in their lives.”
Yoga for Recovery
The lives of many trauma survivors revolve around coping with the constant sense of danger they feel in their bodies. It is typically difficult for them to feel completely relaxed and physically safe in their bodies. As Yoga of 12-Step Recovery (Y12SR) founder Nikki Myers puts it, “Sustainable addiction recovery is about more than the mind…the issues live in our tissues.” Y12SR is a rich framework for integrating the wisdom of yoga and the practical tools of 12-step programs, with Y12SR meetings available nationwide, and the curriculum quickly becoming a feature of addiction recovery treatment centers across the United States.
Yoga helps one reconnect with the body, giving the opportunity to discharge accumulated stress and anxiety, and restoring the human organism to safety. Sabrina Seronello’s story paints this picture: she was on active duty in the Air Force from March 2000-March 2006, working as a medic in the emergency department of a Level 1 trauma center at Wilford Hall Medical Center, Lackland AFB. Sabrina deployed to Iraq in January 2005 to the Air Force Theater Hospital, a Level III (injured patients and emergency operations) trauma center. Given what she saw and experienced taking care of the wounded in Iraq, and being a victim of sexual assault while in active duty, she had been suffering anxiety and panic attacks. Upon returning from Iraq she was introduced to yoga and saw how it helped her deal with post-traumatic stress, anxiety and depression. In 2013 she started teaching a regular weekly yoga class to incarcerated veterans at San Quentin State Prison in CA under the Prison Yoga Project.
Trauma-sensitive yoga programs are becoming more available at domestic violence shelters, and universities are offering them for survivors of sexual assault. Caitlin Lanier was sexually assaulted during her freshman year of college. This assault led to issues with anorexia, cutting and otherwise trying to numb her uncomfortable feelings. According to Caitlin, “those were just outward manifestations. Inside, I felt broken, ugly, lost, like I couldn’t trust anyone, and so sad.” Caitlin has recently pioneered several trauma-sensitive yoga programs in the Boise, Idaho, area, including at a domestic violence shelter, and at Boise State and the College of Idaho. She also trains local yoga teachers on the neuroscience of trauma and how to integrate trauma-sensitive practices into their teaching. She has woven breathing techniques and mindfulness into a weekly support group for survivors of domestic violence that she co-leads with a licensed clinical social worker.
People with post-traumatic stress (PTS) who practice yoga report better sleep, improved focus and concentration, less anger and irritability, and exhibit an overall greater ability to enjoy life in the present moment. The Mindful Yoga Therapy has been found to be especially helpful for veterans who are also participating in evidence-based psychotherapy for PTS. “Yoga is like a gyro that brings me back into equilibrium when dealing with the effects of my disorder,” says Paul, a Vietnam War veteran.
Yoga for Prisoners
Breath work, three extended exhales, is part and parcel of the Prison Yoga Project protocol for addressing symptoms of un-discharged traumatic stress, according to James Fox, Founder and Director. He says “the extended exhale serves as the body’s built-in release valve to discharge stress and anxiety.” This is confirmed from current and former prisoners at San Quentin State Prison who have been part of the yoga program. “It was mainly because of the inner peace and trust that I have developed and nurtured through my yoga practice that I was able to respond to a confrontational situation with calm.”—B.B. Or “I’m able to stay grounded by getting into my breathing which takes my focus off stressful, traumatic events such as flashbacks. It keeps me mindful mentally and physically and enhances my self control.” –D.B.
Yoga & Eating Disorders
Finally, yoga can become a game-changer in combating eating disorders. An estimated 24 million Americans suffer from an eating disorder (anorexia, bulimia, or binge eating). Chelsea Roff took her first yoga class at the suggestion of a therapist just a few months after getting out of the hospital for eating disorder treatment. “The short story is that yoga brought me to a place in my recovery that no form of talk therapy or medical treatment ever had before. Downward dog certainly didn’t cure my eating disorder, but the practice did teach me how to relate to my body in a more compassionate way. And more importantly, perhaps, going to yoga introduced me to community–to the people I soon came to consider family–and I suppose that’s exactly what I needed to fully step into recovery,“ she says.
Health Care Costs
What if the over one-half of teenage girls and nearly one-third of teenage boys who use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, and taking laxatives, were offered regular yoga classes? Regular trauma-sensitive yoga classes for victims of trauma can help reduce our nation’s health care costs on a larger scale, as they address cognitive, emotional, and physiological symptoms associated with trauma. But a cultural change is required to make this happen. The current system is broken, because it overly relies on medical therapy and cognitive behavioral therapy, both of which are very costly without commensurate relief from symptoms.
According to Kantar Media, the heath care industry spent $14 billion on advertising alone in 2014, enough to fund over 215,000 trauma sensitive yoga classes. Especially for PTS, mainstream therapies have resulted in patients remaining significantly symptomatic after treatment, with additional problems including addiction, difficulties maintaining work, and homelessness.
The results are adding up to a national calamity that leaves human lives in ruins, particularly for men and women who have risked their lives to serve our country and need our help. According the Congressional Budget Office’s report on PTSD and Traumatic Brain Injury among recent combat veterans, the average cost of treatment in the first year is $8,300 per patient and $4,100 in the following years. The average cost of treating an eating disorder is $1,250 per day, and only 1 in 10 sufferers ever receive treatment. Eating disorders have the highest mortality rate of any mental illness. Such treatment is expensive not only for patients, but for insurance companies, and society at large.
The evidence base for the effectiveness of yoga in addressing trauma is extensive. Here are some resources for further reading: the textbook on trauma and body-mind practices by Bessel van der Kolk, MD, The Body Keeps The Score: Memory and Psychobiology of Post Traumatic Stress; Overcoming Trauma Through Yoga by David Emerson and Elizabeth Hopper; The Trauma Toolkit: Healing PTSD From The Inside Out by Susan Pease Banitt; and Intelligence In The Flesh by Guy Claxton.
Learn more about Give Back Yoga Foundation and how you can get involved.