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           Pilates  Can  Help  After  a  Shoulder  Impingement  

and  Rotator  Cuff  Surgery                                                                                               Written  by:  Jannel  Krug                     Date:  February  2013                     Location:  Fit  from  the  Core                     Mountain  View,  CA    

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Abstract    I  would  like  to  explain  the  wonders  Pilates  rehabilitation  has  done  for  a  30-­‐year-­‐old  male.  

He  has  had  a  subacromial  decompression  and  rotator  cuff  surgery.  I  will  begin  with    

explaining  what  a  healthy  shoulder  looks  like  and  how  it  should  function.  Then  I  will    

explain  the  procedure  that  was  performed  and  the  limitations  and  slow  progress  of  a    

healing  shoulder.    Next  I  will  discuss  the  common  mistakes  that  the  client  made  following    

his  first  surgery.  After  that  I  will  discuss  goals  for  the  client,  followed  by  a  fundamental  

approach  to  the  BASI  block  system.  I  will  close  with  my  conclusion  and  success  of  the  client.  

 

 

 

 

 

 

 

 

 

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Table  of  Contents                                                    

Title  Page                       1  

Abstract                       2  

Table  of  Contents                     3  

Anatomy  of  the  Shoulder                   4-­‐9  

Case  study                       10-­‐12  

Goals                         13  

BASI  Program  repertoire                     14-­‐16  

Conclusion                       17  

Bibliography                       18  

 

 

 

 

 

 

4    

 

Anatomy  of  a  healthy  shoulder  

The  shoulder  is  a  spheroid  joint  which  is  referred  to  as  a  ball  and  socket  joint.  

Two  separate  joints  create  the  shoulder,  the  glenohumeral  and  acromioclavicular.  

The  glenohumeral  joint  is  formed  by  articulation  of  the  rounded  head  of  the  humorous    

into  a  cup  like  depression  of  the  scapula,  called  the  glenoid  fossa.  The  acromioclavicular    

joint  is  formed  by  an  articulation  of  the  lateral  clavicle  with  the  acromion  process  of  the    

scapula.    

 

These  joints  are  held  together  by  ligaments  and  muscle  attachments.  

The  shoulder  can  be  weakened  easily  by  certain  forces  and  is  vulnerable  to  dislocations.  

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The  rotator  cuff  consists  of  four  muscles  SITS,  (supraspinatus,  infraspinatus  teres  minor    

and  subscapulaires)  the  tendons  at  the  end  of  the  rotator  cuff  can  become  torn  which    

creates  pain  and  loss  of  functionality.      

 

 

The  tendons  of  the  rotator  cuff  pass  underneath  a  bony  area  on  their  way  to  attaching  the  

top  part  of  the  arm  bone.  When  these  tendons  become  inflamed,  they  can  become  more  

frayed  over  this  area  during  shoulder  movements.  Sometimes,  a  bone  spur  may  narrow  the  

space  even  more.  This  problem  is  called  rotator  cuff  tendinitis,  or  impingement  syndrome,  

and  is  due  to:    Playing  sports  requiring  the  arm  to  be  moved  over  the  head  repeatedly  as  in  

tennis,  baseball,  football  (particularly  pitching),  swimming,  and  lifting  weights  over  the  

head.  

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A  sudden  or  acute  tear  may  happen  when  you  fall  on  your  arm  while  it  is  stretched  out,  or  

after  a  sudden,  jerking  motion  when  you  try  to  lift  something  heavy.    A  chronic  tear  of  the  

rotator  cuff  tendon  occurs  slowly  over  time.  It  is  more  likely  in  those  with  chronic  

tendinitis  or  impingement  syndrome.  At  some  point,  the  tendon  wears  down  and  tears.  

There  are  two  types  of  rotator  cuff  tears:    A  partial  tear  is  when  a  tear  does  not  completely  

sever  the  attachments  to  the  bone.    A  complete  or  full  thickness  tear  refers  to  a  through  and  

through  tear.  It  may  be  as  small  as  a  pinpoint  or  all  of  the  muscle  tendon.  Complete  tears  

have  detachment  of  the  tendon  from  the  attachment  site  and  would  not  heal  very  well.  

Another  cause  of  shoulder  Impingement  syndrome  of  the  shoulder  is  very  commonly  

associated  with  aging.    

 

The  impingement  causes  scarring  of  the  bursa  in  the  subacromial  space  of  the  shoulder  

between  the  undersurface  of  the  acromion  and  the  superior  surface  of  the  rotator  cuff.  

During  the  aging  is  a  forming  of  osteophytes  (bone  spurs)  on  both  the  undersurface  of  the  

distal  clavicle  and  the  anterior  aspect  of  the  acromion  which  can  further  lead  to  scar  tissue  

and  pinching  of  the  rotator  cuff  tissues.  As  patients  develop  these  changes,  repetitive  

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overhead  activities  may  cause  irritation  of  the  subacromial  space.  With  time,  this  chronic  

irritation  can  lead  to  irritation  and  degeneration  of  the  rotator  cuff,  which  over  time,  can  

lead  to  rotator  cuff  tears.  

 

Currently,  the  majority  of  subacromial  decompressions  are  performed  arthroscopically.    

In  this  technique,  the  surgeon  enters  the  glenohumeral  (shoulder)  joint  with  an  

arthroscope  to  make  sure  that  there  aren't  any  problems  inside  the  shoulder  which  could  

be  contributing  to  pain  associated  with  the  impingement  syndrome.  Any  pathology  that  is  

seen  in  the  shoulder  can  be  treated  with  trimming  or  repairing  the  injured  structures  (if  

possible).  Once  all  necessary  treatment  has  been  performed  in  the  glenohumeral  joint,  the  

arthroscopic  camera  is  then  inserted  into  the  subacromial  space  or  lateral  to  it.  

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Arthroscopic  shavers  and  coagulators  are  used  to  remove  the  scar  tissue  and  to  clean  off  

the  undersurface  of  the  bone  under  the  acromion  (and  distal  clavicle  when  indicated).  An  

arthroscopic  bur  is  then  used  to  smooth  off  the  osteophytes  (bone  spurs)  under  the  

acromion  to  remove  this  as  a  source  of  impingement.  Once  the  entire  acromion  has  been  

visualized  and  it's  verified  that  all  scar  tissue  has  been  removed  as  well  as  all  spurs,  the  

procedure  is  ended.  The  glenohumeral  joint  and  the  subacromial  space  would  be  injected  

with  a  local  anaesthetic  and  steristrips  with  or  without  subcutaneous  sutures  are  used  to  

close  the  small  surgical  incisions.  

There  are  several  causes  for  the  clients  shoulder  impingement.  Ten  years  ago  began  a  

series  of  very  common  injuries  of  the  shoulder  girdle.  Chronic  wear  and  tear  of  the  

shoulder  while  playing  football  with  repetitive  over-­‐  head  shoulder  movements  led  to  

rotator  cuff  inflammation  (tendonitis).  Later  on  this  lead  to  a  rotator  cuff  tear  a  well  as  a  

labrum  tear.  Surgery  was  then  performed  on  the  rotator  cuff  as  well  as  the  labrum  tear  

inside  the  glenohumeral  joint.    

 

 

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Physical  therapy  was  then  instructed  on  a  daily  basis  to  regain  full  range  of  mobility  in  the  

shoulder  joint.    The  client  lacked  at  performing  the  rehabilitation  of  the  shoulder.    Over  

time  the  shoulder  began  to  heal  however  it  lost  a  lot  of  mobility  and  strength.  In  order  to  

build  strength  the  client  began  to  lift  weights  with  more  repetitive  over  the  shoulder  

movements  which  then  created  bursitis  in  the  shoulder.  Along  with  lifting  weights  the  

client  chose  to  golf  and  play  softball.  Both  activities  include  overhead  movements  of  

swinging  a  golf  club  and  a  softball  bat.  This  repetitive  movement  created  Osteoarthritis  

(bone  on  bone  friction)  due  to  the  ligaments  being  worn  down.  The  continuous  bone  on  

bone  action  created  bone  spurs  witch  further  added  to  the  impingement  and  pain.  After  the  

client  had  his  second  surgery  he  began  his  physical  therapy  with  a  vengeance  and  furthered  

his  shoulder  strength  and  mobility  with  Pilates.  If  physical  therapy  and  Pilates  were  highly  

encouraged  after  the  first  surgery  the  30  year  old  would  not  have  needed  the  second  

surgery.  From  a  former  football  player,  softball  player,  golf  player  and  weight  lifter  Pilates  

is  the  only  type  of  exercise  the  client  was  able  to  perform.  He  would  have  never  chosen  

Pilates  as  his  physical  movement  of  choice  prior  to  his  injuries,  however,  being  able  to  see  

the  benefits  of  Pilates  he  will  continue  on  his  journey  of  stretching,  strength  and  and  

gaining  full  range  of  mobility.  

 

 

 

 

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Case  Study  

Clients  Name:  Tim  Krug  

Age:  30  

Physical  activities:  Football,  softball,  golf  and  weight  lifting  

Medical  Problems:  Left  Rotator  cuff  tendonitis,  left  rotator  cuff  tear,  left  labrum  tear.  Left  

Shoulder  impingement  and  Left  shoulder  subacromial  decompression  surgery.  History  of  

the  shoulder  falling  out  of  the  socket,  tendonitis,  bursitis,  bone  spurs  shoulder  mobility  

extremely  limited.    

Cause  of  injury:  extreme  pain  and  almost  complete  loss  of  mobility  in  shoulder  10    

years  after  the  first  rotator  cuff  surgery.  Lack  of  physical  therapy  along  with  repetitive    

overhead  movement  such  as  sports  and  weight  lifting.  

Diagnosis:  The  subcromial  or  sub  deltoid    bursa,  supraspinatus  tendon  and  the  long  head    

of  the  biceps  were  compressed  and  inflamed  which  lead  to  bursitis.  The  clients  anatomical  

structure  of  the  acromnion  process  was  abnormally  shaped  and  lead  to  shoulder  

impingement.  There  was  bone  on  bone  friction  (osteoarthiritis)  which  caused  bone  spurs.    

Surgery:    Arthroscopic  Keyhole    subacromial  decompression  

In  this  technique,  the  surgeon  enters  the  glenohumeral  (shoulder)  joint  with  an  

arthroscope    to  make  sure  that  there  aren't  any  other  problems  inside  the  shoulder  which  

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could  be  contributing  to  pain  associated  with  the  impingement  syndrome.  All  pathology  

that  was  seen  in  the  shoulder  was  treated  with  trimming  and  repairing  the  injured  

structures.  Once  all  necessary  treatment  was  performed  in  the  glenohumeral  joint,  the  

arthroscopic  camera  was  inserted  into  the  subacromial  space  or  lateral  to  it.  Were  used  to  

remove  the  scar  tissue  and  to  clean  off  the  undersurface  of  the  bone  under  the  acromion  

(and  distal  clavicle).  An  arthroscopic  bur  was  then  used  to  smooth  off  the  osteophytes  

(bone  spurs)  under  the  acromion  to  remove  this  as  a  source  of  impingement.  Once  the  

entire  acromion  had  been  visualized  and  it's  verified  that  all  scar  tissue  has  been  removed  

as  well  as  all  spurs,  the  procedure  ended.  The  glenohumeral  joint  and  the  subacromial  

space  was  injected  with  a  local  anaesthetic  and  steristrips  to  close  the  small  surgical  

incisions.  

Treatment:    

When  there  are  no  structures  which  need  to  be  repaired  in  the  joint,  the  patient  is  

encouraged  to  use  the  shoulder  as  tolerated  in  attempt  to  get  the  range  of  motion  back    

as  soon  as  possible.  It  is  well  documented  that  one  of  the  most  important  things  to    

achieve  after  a  shoulder  surgery  is  to  achieve  the  full  range  of  motion  back  as  soon  as    

possible.  If  it  is  not  done,  even  if  the  initial  problem  has  been  treated  by  the  surgeon,    

commonly  the  patient  will  have  shoulder  pain  develop  due  to  stiffness.  This  pain  may    

sometimes  be  just  as  bad  as  the  initial  problem.  For  that  reason,  we  emphasize  trying  to    

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obtain  full  range  of  motion  of  the  shoulder  as  soon  as  possible.    

Precautions  are  based  on  clients  pain  tolerance.  Gradually  progress  to  full  range  of    

motion.  Avoid  over  head  exercises  and  laterally  holding  arm  out  to  a    90  degree    

angle.  

Pilates  program  

The  Pilates  program  will  consist  of  a  fundamental  full  body  program  designed  by  the  block  

system.  Emphasizing  the  focus  on  the  muscle  groups  that  act  on  the  shoulder  which  are  

Muscles  of  scapula  stabilization,  the  rotator  cuff  muscles  and  the  large  shoulder  muscles.    

Scapular  stabilization  will  focus  on  trapzeius,  rhomboids,  levator  scapulae,  pectoralis    

minor  and  serratus  anterior.  

 The  rotator  cuff  which  is  comprised  of  supraspinatus,    infraspinatus,  teres  minor  and  

subscapularies  connects  the  scapulae  to  the  humerus.  We  were  sure  to  beware  of  

contraindications  of  the  supraspinatus.  

Lastly,  the  larger  shoulder  muscles  will  be  strengthened.  These  muscles  are  the  pectoralis    

major,    deltoids,  latissimus  dorsi  and  teres  major.  In  the  future  working  on  these  muscles  

will  produce  scapulohumeral  rhythm  with  attention  to  coordinated  use  of  the  rotator  cuff  

while  arms  are  elevated.  

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Goals:  

Full  range  of  motion  will  eventually  be  executed  while  not  compromising  the  quality  of    

movement  for  ROM.  The  client  learned  proper  muscle  recruitment  patterns  with  correct    

mechanics.  Strength  exercises  began  with  light  resistance  on  the  shoulder  then    

progressively  increase  resistance  with  range  of  motion  when  correct  mechanics  are  in    

place.    

Closed  kinetic  chain  exercises  will  be  utilized  as  the  shoulder  becomes  stronger.  

There  is  a  emphasis  and  strong  focus  on  Stabilization  by  performing  isometric  exercises  as  

well  as  eccentric  and  concentric  contractions.    

We  will  emphasize  on  maximizing  movement  upon  pain  tolerance  of  the  client.  

Our  main  focus  was  to  work  the  entire  body  while  achieving  proper  body  alignment  and  

correcting  any  muscle  imbalances.  

 

 

 

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Block  system  program  repertoire    

REFORMER  

Foot  Work    

Parellel  Heels  

Parallel  Toes  

V-­‐position  toes  

Open  V-­‐Position  Heels  

Open  V-­‐Position  toes  

Calf  raises  

Prances  

Single  leg  heel  

Single  leg  toes  

Prehensile  

 

Abdominal  work  

Hundred  Prep  

Coordination  

 

Hip  Work  

Frog  

Down  Circles  

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Up  Circles  

Openings  

Extended  Frog  

Extended  Frog  Reverse  

 

Spinal  Articulation  

Bottom  lift  

Bottom  lift  with  extension  

 

Stretches  

(Hamstring  Stretch  Series)  

Standing  Lunge  

Kneeling  Lunge  

 

Full  Body  Integration  1  

(Knee  Stretch  Series)  

Scooter  

Round  back  

reverse  knee  stretch  

   

Arm  Work  

(Arms  sitting  series)  

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Chest  expansion  

biceps  

Rhomboids  

Hug-­‐a-­‐tree  

(emphasis  on  keeping  elbows  

slightly  in  front  of  shoulders,  

eliminating  salute  due  to  

overhead  movement)  

Leg  Work  

skating  single  leg  

 

Mat  

Lateral  Flexion  and  Rotation  

corkscrew  

 

Back  Extension  

cat  stretch  

 

 

 

 

 

 

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Conclusion:  

Pilates  rehabilitation  for  a  shoulder  decompression  and  rotator  cuff  surgery  was  a    

success.  The  pain  tolerance  was  determined  by  the  client  and  communicated  with    

the  instructor.  Light  resistance  was  added  to  the  sessions  slowly.  The  clients  

strength  and  mobility  was  quickly  increased.    The  physical  therapist  and  physician  granted    

authorization  for  closed  chain  weight  bearing  exercises  as  well  as  over  head    and  lateral    

exercises.  

 

There  are  currently  no  restrictions  with  the  client,  thus  the  real  work  can  now  begin!

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Bibliography  

Body  Arts  and  Science  International,  2000-­‐2008,  Study  guide  Comprehensive  Course,  

California  USA.    

 

Body  Arts  and  Science  International,  2012,    Pilates  for  Injuries  and  Pathologies,  California  

USA.  

 

Manske  C  Robert,  2006,  Postsurgical  Orthopedic  Sports  Rehabilitation,  Knee  and  shoulder,  

Mosby  Inc,  Missouri  USA.  

 

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