Hand balancing with a shoulder impingement: how pilates can help circus performers.

Kira DavisOctober 2016BASI comprehensive teacher training inPortland, OR &Tacoma, WA2015/2016

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Abstract

So many people push through pain to enjoy their passions in life. There are countless

injuries and roadblocks that we come up against, on a daily basis, that challenge us to

find ways to manage our bodies in a healthy way.

In this case study I examine a hand balancer/circus performer who has a shoulder

impingement in both rotator cuffs. Aggravation of this injury is caused when elevating

the arms and applying pressure; this is the exact movement that training handstands

requires.

This paper touches on basic shoulder anatomy, the definition of both shoulder

impingement syndrome and hand balancing.

Over an 8 week period we explore a pilates regimen incorporating stretching, breathing,

the BASI block system and every day body awareness.

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Table of contents

1. Abstract

2. What is the shoulder and how does it work?

3. What is a shoulder impingement and how does it occur?

4. Hand balancing and circus arts

5. When you put the two together…

6. Case study

7. Warm up

8. Suggested BASI training program

9. In conclusion

10. Bibliography

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What is the shoulder and how does it work?

The Shoulder is potentially the most mobile joint in the human body. It is comprised of

the humerus, scapula, acomion and clavicle. Articulation of this piece of the anatomy is

made possible by several muscles including the

subscapularis, supraspinatus, infraspinatus and teres

minor. These muscles are often referred to as the

rotator cuff muscles that operate the glenohumeral

joint. This is the primary joint of the shoulder, which

unites the head of the humerus with the gleaned fossa

of the scapula (Anatomy of movement).

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What is a shoulder impingement and how does it occur?

A shoulder impingement is compression and mechanical abrasion either on the rotator

cuff muscles or on their tendons as they pass

beneath the coracoacromial arch during

elevation of the arm (Trevor Bachmeyer).

When the arm is raised, the subacromial

space, (gap between the anterior edge of the

acromion and the head of the humerus)

through which the supraspinatus muscle

tendon passes, narrows. Anything that causes

further narrowing has the tendency to impinge the tendon and create an inflammatory

response, resulting in impingement syndrome. Causes of this can be bony structures

such as subacromial spurs (bony projections from the acromion), osteoarthritic spurs on

the acromioclavicular joint, and variations in the shape of the acromion. Thickening or

calcification of the coracoacromial ligament can

also cause impingement. Loss of function of the

rotator cuff muscles, due to injury or strength

loss, may cause the humerus to move superiorly,

resulting in impingement. As well as the

inflammation and subsequent thickening of the

subacromial bursa(Wikipedia).

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Hand balancing is:

Handstands!

Essentially the art of ‘hand

balancing’ is balancing on ones

hands in a variety of positions and

gradually moving between different poses. It requires meticulous training, strengthening

and concentration. It can take years to build up the stamina required to be able to

sustain a successful handstand.

Technically put, “a handstand is the act of supporting the body in a stable, inverted

vertical position by balancing on the hands. In a basic handstand the body is held

straight with arms and legs fully extended, with hands spaced approximately shoulder-

width apart. There are many variations of handstands, but in all cases a handstand

performer must possess adequate balance and upper body strength” (wikipedia).

Keph Shiren is a Portland Oregon movement teacher and retired hand balancer. When

asked to explain what hand balancing is and how it feels he provided this description,

”When done with proper form and technique Hand balancing can be one of the most

rewarding forms of exercise one can master. To master the handstand, and then to

master controlled movement within the handstand could be compared to learning to fly.

Many people would say that flying (without an apparatus) is impossible. I disagree.

I have flown many nights in my dreams, and I defy gravity every day in my practice. I do

not believe in impossible.”

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When you put the two together…

Individuals with subacromial impingement syndrome will

often have overdevelopment or tightness within some

muscles and weakness in other regions. A common

pattern of muscle imbalance is weakness within the

middle and lower fibers of the trapezius muscle, posterior

deltoid, serrates anterior and rotator cuff muscles with a

profound tightness or overdevelopment of the pectorals

major, upper trapezius and levator scapulae (Nicole

Geier).

Having such tightness in and around the shoulder makes

it very difficult to engage the right groups of muscles that can sustain a successful

handstand while maintaining proper form. Hand balancing with a shoulder impingement

is extremely sensitive given that it requires the balancer to be in the exact position that

aggravates this condition. The two do not mix and can cause excruciating pain.

Elevation of the arms past the chest, over the head and applying pressure is probably

the most painful form of movement an individual can do when they have developed a

shoulder impingement.

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Case study:

Sarah Murphy is a 32 year old circus artist

residing in Portland Oregon. She has been

training hand balancing for the past 3 years.

“I enjoy exercising and being active but do not

enjoy the typical gym scene or the mind frames

that often accompany it. Hand balancing is a

form of artistic athleticism. A way of expressing oneself physically, like dance. It comes

with infinite subtleties, the likes of which only those involved in the practice will be

familiar with, creating a very specific community of people. I enjoy the satisfaction that

comes with navigating these subtleties and the strength gained (both physically and

mentally) from overcoming the challenges within them. It's fun, challenging, an

excellent form of fitness, and it looks dynamic and interesting” (Sarah Murphey).

She was diagnosed with shoulder impingement syndrome a couple years ago. It exists

mostly in her right shoulder but she has pain in her left as well.

Sarah stands about 5’8”. She has a slightly forward head that tilts to the right held up by

a very tense jaw and neck. Her trapizus and pectorals are so tight that they pull her

shoulders forward and down resulting in a slightly kyphotic thoracic spine. Her greater

trocanter is forward of the plumb line and her lumbar region is fairly locked exhibiting

very little articulation. Her pelvis has a slight anterior tilt, lift on the left and twerk

forward. Her left glute has a hard time firing and her hip flexors are extremely tight and

have trouble turning off at all. Her quadaceps, hamstrings and calves muscles are all

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very strong and toned as well as extremely tight. She has great ankle mobility and

stands fairly stable on all four corners of her feet in a natural turn out.

Warm up & assessment:

To begin with I gave Sarah some homework to add to her usual foam rolling and

stretching. I started her out with some stretching by giving her the auxiliary pole

series. Shoulder stretch targets the lower traps, overhead stretch focuses on the

pectoral muscles while side stretch and spine twist begin to open up and turn on the

front body abdominals and obliques.

Next I had her work on some protraction and retraction in a quadruped position to

start familiarizing herself with this motion in the shoulders. Working on mobility here will

allow more synovial fluid to flow freely through the glenohumeral joint, lubricating the

area.

Using a half deflated purple ball she did a simple arm squees with the ball placed in-

between her hand and greater trochanter. Doing little pulses and working on pulling

down helps to activate the serrates which I suspected was being under used.

Back extension seemed key so I set her up with some basic back extension on the

mat and had her play around with floating the arms around to different positions while

staying in extension.

Also, using the purple ball, she worked on some thoracic lateral flexion and rotation

laying on her side. Hugging the purple ball with the top hand, elbow up, she could

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practice opening up her trapezius, pectorals and create some space in her ribs to get a

little more mobility in rotation to start us off with.

Lastly I taught her side bend on the mat to throw in a little challenge of something more

graceful and officially BASI.

Suggested BASI training program:

After establishing a solid, at home daily warm up routine we moved into the studio.

Meeting twice a week we began to focus on the retraction and depression of her

shoulders in order to avoid more scapular tilting. My goal was to try and create a little

leeway in the coracoacromial arch or subacromial space where the tendons, in both

shoulders, were likely being impinged. After exploring more about her condition I

learned that weighted external rotation of the shoulders, whenever possible, could

potentially help. I also wanted to target her weaker muscles, such as her rhomboids,

serrates and lower abdominals, to put some power back in the correct places.

Diving right in we started with a roll downs at the start of each session and the basic

BASI warm up. This warm up includes the following:

Pelvic curl, Spine twist supine, Chest lift, Chest lift with rotation.

We moved through footwork on all the machines and found that the Cadillac provided

the most support for her and gave a better calf and hamstring stretch than any of the

others.

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Phase #1 week 1-4:

Midway through our program we settled on the Intermediate equipment warm up as

being the most beneficial for Sarah. This warm up included: Roll up with the roll up

bar, Spine twist supine, Mini roll ups, Mini roll up oblique and finally Roll up top

loaded. Continuing with footwork on the Cadillac we moved onto the following

exercises.

EQUIPMENT

Abdominals

Hips Spinal Articulation

Stretches

Full Body Integration #1

Arms Full Body Integration #2

Legs Lateral Flexion & Rotation

Back Extension

REFORMER

Short Box Series

Frog, Circle up/down & Openings

Bottom Lift + Extension

Supine & Sitting Arms Series

Mermaid

Pulling Straps #1 & #2, Breaststroke Prep

CADILLAC

Teaser, Breathing w/ the PTB

Shoulder Stretch

Side Reach, Kneeling Cat Stretch, Sitting Forward & Saw

Sitting Side Prep & Sitting Side

WUNDA Torso Press Sit

Frog Front

OTHER Shoulder Stretch Laying Side & Pole Series

Spine Twist & Side Bend

Swimming

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Phase #2 week 5-8

EQUIPMENT

Abdominal

Hips Spinal Articulation

Stretches

Full Body Integration #1

Arms Full Body Integration #2

Legs Lateral Flexion & Rotation

Back Extension

REFORMER

Coordination

Extended Frog + Reverse

Semicircle

Kneeling Lunge, Side Split

Up Stretch #2 &#3

Side Kneeling Arms Series

Balance Control Front

Single Leg Skate

Side Over on Box

Breaststroke

CADILLAC

Warm Up Series

Shoulder Stretch

Sitting Back & Forward, Side Reach & Saw

Shoulder Adduction Sitting Forward & Side

Prone #1

WUNDA Sitting Pike

Tendon Stretch

Frog Front

Side Stretch

Swan Basic & Back Extension Single Arm

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In conclusion.

Sarah was an amazing case study. She worked diligently alongside me to try and

discover some new training habits and strengthening techniques that will help her body

generate less pain. Using the framework of the BASI block system we worked hard to

loosen her up, stretch her out, relax some extremely tight areas in her body and create

some more space in her rotator cuff in the hope that this would allow her to train hand

balancing with more ease. Over the 8 weeks I saw some improvement in her range of

motion and certainly with her body awareness. Her hip flexors used to grip with every

roll up and now, only grip sometimes; she can access her deep low abs a little quicker

than before; her spinal articulation is coming along and the best of all is she had a

training day totally without pain!!

This process was extremely educational for me and it taught me so much about working

one on one with a client. Along with all the anatomical research was a strengthening of

intuition, practice of both tactile and verbal cueing. In the end it was so satisfying to feel

that with repetition and dedication positive results were achieved.

“Working with Kira on this project has really allowed me to tune in to my shoulders and

the things I need to work on. I've incorporated many of the exercises she showed me

into my training routine and have definitely seen improvement in our targeted areas.

And most importantly, it was fun!” (Sarah Murphy)

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Bibliography.

Owner/author of site

Page title/ book title

Year published

Title of website/chapter

Date viewd URL/publishing location

Wikimedia Foundation, Inc.

Impingement Syndrome

Edited 9/29/2016

Wikipedia 10/15/2016 https://en.wikipedia.org/wiki/Impingement_syndrome

Trevor Bachmeyer

Anterior Shoulder Impingement? Fix It ASAP

8/9/2016 Youtube 10/1/2016 https://www.youtube.com/watch?v=CDSLWU2DCUI

Blandine Calais-Germain

Anatomy of movement

Revised 2013

The shoulder

8/12/2016 Seattle, WA

Sarah Murphey

Individual participating in case study

1984 Personal quote

6/29/2016 Portland, OR

Nicole Geier Subacromial Shoulder Impingement Syndrome

2015 Patterns & signs subacromial impingement syndrome

7/2/2016 http://pivotalphysio.com/subacromial-shoulder-impingement-syndrome/

Wikimedia Foundation, Inc.

Handstands Edited9/10/2016

Wikipedia 10/16/16 https://en.wikipedia.org/wiki/Handstand

Keph Shiren Verbal quote 10/2016 10/2016 Studio Blue Portland Oregon

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