Yoga and Shoulder Joint Replacements

by Shari

Nina and Baxter asked me to finish up the total joint replacement series with a discussion about shoulder joint replacements. Like the other joint replacements previously discussed, people will consider shoulder joint replacement when all other conservative approaches have failed. The difference in shoulder joint replacement compared to hip or knee replacements is that this procedure is far less common. So if you are thinking about a shoulder replacement, it is considered a good idea to find a physician who has already done a significant number of these surgeries (one place to look is the American Shoulder and Elbow Surgeon’s Society).

Now let’s review why you might consider this treatment. Pain is often the most significant problem that an individual is suffering from. Other symptoms might include stiffness, loss of functional motion, inability to sleep on that shoulder, decreased range of motion and symptoms that are worsening with conservative treatment approaches (whether western or alternative methodologies).

Healthy Shoulder Joint

Regardless, your first step should be thorough diagnostic and physical evaluation from a qualified surgeon that includes X-rays and whatever other tests the physician orders. There has to be a differential diagnosis that separates out the cause of the pain. Rotator cuff tears or avulsions, frozen shoulder, cervical and thoracic spinal pain, shoulder bursitis and other forms of soft tissue inflammation, avascular necrosis (in which the blood supply to the joint is affected), and infections will all cause shoulder pain that can be unrelenting. Metastatic disease or other tumors can also be the cause of shoulder pain so the differential examination is critical in trying to pinpoint the problem. So only once it has been determined that your shoulder pain is due to arthritis (where the cartilage covering the joint surfaces is affected) should you explore your options for shoulder replacement. After you have determined that you’re a good candidate for the surgical joint replacement, you will probably wonder how is surgery this going to affect your yoga practice, including how longer after the surgery will you be able to do yoga again and, when you do resume practice, which poses should you avoid and for how long?

Shoulder With Joint Replacement

According to my research as well as my personal experience as a physical therapist, yoga practitioner and yoga teacher, this procedure has significant post-operative protocols. This means that there is a very specific healing algorithm that your surgeon will adhere to. It does not help if you are a “fast healer” because if you push too much and too fast, for this surgery in particular, you will be setting yourself up for significant problems in the future. This surgery is very complicated because the subscapularis is detached to expose the glenohumeral joint and then reattached after surgery. The rotator cuff may also need to be repaired because often in severe shoulder arthritis, the soft tissue ligaments and muscles are severely affected and may also need repair due to compromised biomechanics and impingement in the shoulder joint.

The literature I reviewed states conservatively a three-month recovery but more common is six to twelve months post-operative recovery with very strict dos and don’ts. And unfortunately I cannot go into what you can and can’t do here on this blog because that is totally dependent on your surgeon and which type of procedure he or she deems is appropriate for you (there are four different types of shoulder replacements).

But from a yogic perspective, here is what I can recommend. Start by being in the best possible health you can be before surgery. Understand that you will have a lot of work to do in your post-operative recovery, but believe 100% in your ability to recover and in your surgeon.

Have stress management techniques that you do regularly as part of your healing repertoire. Pain medication is not something to be shunned but used responsibly and respectfully as part of your healing process. But, because pain is a very subjective experience, yoga and stress management techniques, though not substitutions for pain medication, can be an adjunct in allowing you to “relax into the pain.” Deep breathing in particular does a world of good for your body post operatively and into your healing process. It allows your lungs to be used to prevent post-operative complications, and is also calming and a good focus for your mind when you might be counting the minutes until you can take your next pain medication dosage. Simple deep breathing also assists in decreasing muscle tension from unconscious holding and splinting because you are in pain. You may also want to work with lengthening your exhalation to assist in stimulating your parasympathetic system (triggering your relaxation response). Other stress management techniques you could explore include: meditation, Savasana (Relaxation pose), and Yoga Nidra.

Be familiar with restorative poses, such as Reclined Cobbler’s pose (Supta Baddha Konasana), Legs Up the Wall pose (Viparita Karani), and Supported Relaxation pose (Savasana) that you can do while adhering to the post-operative protocol. Shoulder positioning and propping is very important for your post-operative pain management, and your physical therapist or surgeon (or their support staff) should be able to assist you in ways to position for improved comfort. Once you understand how to position your arm in these poses (for example, using support under your arms and shoulders or having your arms in a neutral position) then you should be able to figure out how to set yourself up for restorative poses without putting your shoulder into a compromised position. Remember, how you go into and out of poses, including restorative poses is important. You may find that your bed is a perfect place to practice restorative poses because it is easier for you to position yourself.

Once you are allowed to start exercises with your physical therapist, be very clear in asking when you can do which poses, bringing pictures to demonstrate. Taking your arms out to your sides in standing poses may or may not be possible because just the weight of your arm being statically held may be contraindicated. Then, before you return to your yoga class, please contact your yoga teacher and explain your limitations and restrictions. It is your responsibility to educate your yoga teacher on your particular needs and then he or she can help you keep your practice safe within the guidelines you understand from your physician.

Finally, please be gentle with yourself and don’t overuse your arm even just a little bit. When you are allowed to stop wearing your sling, you might find that you can practice with your sling on more successfully then with your arm out of it. Stay away from weight-bearing poses like Downward-Facing Dog pose until you have medical clearance (even Half Dog pose at the Wall). Night-time positioning and pain management are often the most challenging. Make sure you understand your pain medication recommendations and do what ever your surgeon tells you. After all, you only want to do this surgery once. So be patient and creative. And good luck!

Arthritis of the Shoulder and Yoga

by Baxter

If you have been following our blog for any amount of time, you’ve become familiar with the wide variety of joints and areas of our boney spine that can be affected by osteoarthritis. From your hands to your toes, any movable joint is subject to this condition of wear and tear on the end surfaces of the bones and their slick, cushiony covering, the cartilage. The older we get, the more likely we are to develop osteoarthritis somewhere in our bodies, including the shoulder area. Seems the magic age is sometime after 50, but if you have sustained a traumatic injury to your shoulder or have the rarer form of arthritis, rheumatoid arthritis (RA), you could develop the tell-tail symptoms of arthritis-pain, swelling and reduced movement at the shoulder.

I’ve worked with many students and patients over the years with arthritis, and I will mention that the shoulder area is less commonly affected than say the knees, hips or spine. But it does show up now and again. Turns out there are actually two joints in the lateral shoulder area that can develop arthritis.

The first one is where a finger-like projection of the shoulder blade or scapula meets the far end of your collarbone or clavicle at what is technically referred to as the acromioclavicular joint (the AC joint). You can actually feel to the top connection of this joint if you trace your collarbone from your breastbone toward your shoulder area. You’ll note a sudden drop off as you move laterally. That’s where the two bones meet. Arthritis in this joint usually refers pain to the front of the shoulder area.

Shoulder Joint from Gray's Anatomy

The second joint affected is where your arm bone, the humerus, meets the side of the scapula at something called the glenoid fossa (a shallow, cup-like area that is concave to fit the round end of the arm bone), forming the glenohumeral joint. Arthritis pain in this joint is usually referred to the back of the shoulder area. And like other forms of arthritis, a diagnosis is usually reached after a history and physical exam by your doc, possibly including X-rays to look for narrowing of the joint space or the development of bone spurs around the joint and, on rarer occasions, blood tests to rule out RA or drawing fluid from the joint to look for crystals or infection. Once diagnosed, usually with osteoarthritis, you’re likely to have rest, ice, anti-inflammatory meds and physical rherapy prescribed to help decrease swelling and pain, and increase your range of motion in the shoulder joints. On more rare occasions when these treatments are ineffective, injections or surgery may be recommended. Like the hip and knee joint, the surgeon may replace part of the joint with an artificial joint.

Humerous and Scapula from Gray's Anatomy

Where does yoga fit in? Well, since shoulder arthritis can result from chronic wear and tear action on the joints, it is possible that a yoga practice heavy on weight-bearing asana, such as Downward-Facing Dog pose, Push-Up pose, and arm balances, such as Crow or Heron, as well as vigorous repetitive practices that don’t vary much in their routine, could lead to this kind of shoulder problem. However, on average, yoga is more likely to be helpful as a tool for healing than the underlying cause of the problem. And if you suffer from shoulder arthritis, this is yet another setting in which working one-on-one with an experienced teacher could save you time in getting on the right course of practice to improving your symptoms.

Just as we discussed in arthritis of the hip, even with the abnormal changes to the joint that accompany arthritis, it is still essential to keep mobility in the affected joints. In the situation where symptoms are already present, you will want to proceed slowly and mindfully as you begin to experiment with yoga postures that are exclusively non-weight bearing (at least at first). Many of the standing poses, such as Triangle, Extended Side Angle (being cautious not to bear too much weight with the bottom arm for both of those), Warrior 1, 2 and 3 would all be reasonable choices.

Poses that involve more pressure around the shoulder joint, in which there are additional rotational forces, such as Prayer position behind the back, or Eagle arms, may not be appropriate, as they could more likely aggravate the joint than help it. However, working with a teacher, you may gradually be able to add in more complex arm movements if your symptoms stay quiet. Versions of poses you would be likely to encounter in class, such as the ubiquitous Downward-Facing Dog, may be added later if you are progressing, with wall versions, such as Half Downward-Facing Dog at the Wall (see here).  And since it is not unusual for the muscles around the affected joint to be atrophied from lack of use when the joint is initially inflamed, holding the arm positions, like Warrior 2 arms, for 30-60 seconds can add strengthening of the muscles to the goal of maintaining mobility in the joint.

In addition, the pain-diminishing effects of pranayama and meditation practices could be very helpful along with your physical poses, and could be substituted for asana during times when your shoulder symptoms flare up and resting your body makes more sense for a while.  And, as always, we welcome your comments and experiences with the topics we share with you. So if you have some yoga insights on arthritis of the shoulders, we are all ears (and shoulders, of course!).  

Arthritis of the Knee and Yoga

by Baxter

While in Montreal for a weekend workshop, I found myself attending a modern dance performance.  I’d say the average age of the performers was about 30, and all looked very fit and flexible.  As part of their performance, they did a move in which they leapt forward while spinning and landed on the floor in a Pigeon-pose like stance.  The first time they did this, I found myself wincing, as I imagined the impact on their knees on the firm, uncarpeted dance floor.  I’d have to guess they did this at least five more times, and usually always landing on the same knee.  My host and I spoke about this after the show, and we were both of the opinion that no good could come of this for the future health of these dancers’ knees. 

Trauma to the knee is one of several risk factors for the development of arthritis of the knees later in life.  It was no coincidence that one of the attendees at my weekend Anatomy and Yoga workshop has arthritis in his knees at the ripe age of 40, as he had been dancing for over 20 years and had suffered numerous injuries to both knees over that time.  But since starting his yoga a few years back, his knee pain had improved to the point that after a hiatus of almost 10 years, he was gradually returning to some dance.

In addition to trauma, other risk factors for developing osteoarthritis (the most common form of arthritis) of the knee include:;

• weight, as in more body weight, more stress on the knee joint
• sedentary lifestyle, as it seems that some activity is better for the knee joint than no activity
• work or hobbies that involve repetitive demands on the knees, such as horseback riding, which encourages a bowing outward at the knee joint and places unusual stress on the knee joint
• bone abnormalities, which some people are born with and could include skeletal issues such as bow legs or knock knees
• other diseases like hypothyroidism and Paget’s disease, which could lead to arthritis over time advancing age
• gender, that is, women, for reasons that are not yet clear, have a higher incidence of arthritis than men

Typically, in a healthy knee joint, just as in the hips, the surfaces of the top bone, the femur, and the bottom bone, the tibia, are covered in a layer of protective connective tissue known as cartilage. The cartilage acts as both a shock absorber when the bones move close to one another, as when you are walking or running, and also as a smooth, slick surface for the bones to slide over one another when you are doing any knee bending activities.

If any or several of the risk factors are present, the usually smooth surfaces can become rough, like sandpaper, which may or may not produce pain, but could produce some grinding sounds from the knees. Eventually, the cartilage could wear through and expose the underlying bone, which is even rougher. When bone on bone contact starts to occur, it usually results in inflammation in the joint, which then swells, can become hot to touch and limited in movement and painful. Since the condition usually worsens over time, especially if you don’t seek help for it, it could eventually lead to significant immobility and pain. I am going to assume you have had the common sense to see you family MD to get an accurate diagnosis and have tried some of the western treatment options, such as medications, physical therapy, and braces, and such and are looking for alternative ways to work with the knees to avoid worsening of your situation and surgery.

Yoga is both helpful in addressing the acute problems of swelling and pain, and the longer-term issues of improving mobility, strength and stability of the knee joints. 

In acute situations, restorative practices or reclining sequences can allow for you to maintain some gentle movement of the knee while reducing the effects of gravity on the knee that occurs when you stand. A regular favorite when the knee is swollen is any reclining posture that elevates the leg higher than the chest. My personal favorite is Legs Up the Wall pose (Vipariti Karani). Another is the door jam version of Reclined Leg Stretch (Supta Padangustasana_, where you lie down on the floor on your back at a doorway, your hips lined up with the doorway, and take the affected leg up in the air and rest the heel on the door jam.  This allows for a more passive approach to this pose that we usually do with a strap on the foot of the lifted leg.

In addition, a whole slew of other reclining poses can be performed that are safe for the knee and allow you to get some of the stress-reducing benefits of a regular home practice (see Timothy’s post from yesterday Home Practice: The Best Way to Improve Your Health and Well-Being).  On top of helping to quiet down an inflamed knee, you can use your practice to strengthen the muscular/tendonous support around the knee. Engaging the muscles that surround the knees simultaneously has been shown to benefit the joints, as Shari noted in a post a while back on hips.  So I recommend starting with poses in which the knees are extended or straight, as this reduces sheering actions on the cartilage. This includes Mountain pose (Tadasana), Triangle pose (Utthita Trikonasana), Pyramid pose (Parsvottanasana), Wide-Spread Standing Forward Bend (Prasarita Padottanasana), and such.  If these are done successfully, without aggravating your knees, and are hopefully bringing some gradual improvement in your symptoms, you can add in standing poses with knees bent.  This will require that you pay special attention to the trajectory of the knee as you flex it.  Ideally, you will want to bend the knee directly in line with your mid-foot, so the knee is tracking in the most anatomically correct way.  You may want to have your local yoga teacher help you to figure this out, as it is a bit difficult to sense on your own at first.

Another potential way to modify seated poses to allow you to do them pain free is to use some sort of a spacer tucked into the back of your knees before you deeply flex (bend) the knees. You can use a rolled up washcloth, or a thinly folded yoga blanket.  Once you place the spacer in the fold of the back of the knee, mindfully bend the knee and see how it feels.  There should be no pain.  If you have a history of ACL repair (anterior cruciate ligament), then never use a spacer, as it could loosen this precious repaired tear. 

Since every arthritic knee is going to be a bit different, these suggestions are offered to get you thinking about ways yoga could be helpful for you. As I always say, it would be a good idea to do some one-on-one work with an experienced teacher to guide you safely on your way.

And skip the Flying Twist Dropping Pigeon from your repertoire until next lifetime!

Arthritis of the Hip Joint

In past posts, we have shared with you poses that can open tight hips, as well as discussed hips in a few specialized settings, but we have not addressed perhaps the most common aging concern for hips: the development of arthritis in the hip joint. The hip joint is a synovial joint, meaning the pelvic bone and the femur, or upper leg bone, connect with one another via a closed system. A sock-like sleeve of connective tissue holds the two bones relatively close together via what is called the joint capsule. The inner lining of this structure is lined with a specialized tissue called the synovial membrane, which secretes a special liquid, not unlike a lubricant such as oil in you car engine, to allow the bones to move over each other more smoothly. In addition, the ends of the bones are coated in a layer of cartilage—also a kind of connective tissue—that acts as a tough barrier over the bone for shock absorption, and is smooth and slick, so the bones again can glide over each other more smoothly. Finally, the inner surface of the acetabulum, the hollowed out part of the pelvic bone that the head of the femur bone fits into, has an additional cushion of cartilage lining it called the labrum. This provides a better fit for the two bones and a lot more shock absorbing potential.

Now that you have some idea of what makes up the hip joint, we can talk a bit about arthritis of the hip. As with arthritis anywhere in the body, there are two broad types. The wear and tear type of arthritis, which could be a result of repeated movements over a long time, or complicated by some old trauma, infection or injury to the joint, is called osteoarthritis (OA). In this, the most common form of arthritis, the cartilage covering on the ends of the bones is worn away gradually, exposing sensitive raw bone, which, when rubbing against another raw bone, leads to inflammation inside that closed synovial joint described above. This results in swelling, stiffness, tightness, decreased movement and pain.

The other main type of arthritis, rheumatoid arthritis (RA), in an auto-immune disease, meaning your body mistakes itself (in this case, the joint lining) as a foreign invader and mounts an immune response to fight it off. This response is an inflammatory one, resulting in damage to the ends of the bones, sometimes even at a young age. It is quite a bit less common than osteoarthritis, but still seen enough to be aware of it. 

It almost goes without saying that this condition can be painful. What other symptoms would you look for? Because of the damage to the cartilage, people with arthritis may feel as though their hip is stiff and their motion is limited. Sometimes people feel a catching or clicking within the hip. The pain usually gets worse when the hip joint is strained by walking long distances, standing for a long time or climbing stairs. The pain is usually felt in the groin, but also may be felt on the side of the hip, the buttock and sometimes into the knee.

Here in the US, we start to diagnose the condition via the history and physical exam, with the aid of X-rays, which often reveal diminished space between the bones. If surgery is being considered, an MRI of the joint will also likely be ordered. Treatment offered by your family MD or arthritis specialist could include medications for pain and inflammation, recommendations to change activities to reduce the stress on the joint, a plan for weight loss which also reduces joint stress, assistive devices like a cane if needed, and surgery to clean out the joint or to replace the joint. 

At the start of any treatment regimen, conservative recommendations are made, which include rest and avoiding any repetitive activity that may have strained the joint or muscle, as well as working with a physical therapist who can help increase your range of motion or strengthen muscles to increase stability on the joint. Here is where yoga can fit into your healing regimen. But first, you want to take a good look at what you are already doing in your yoga practice to see if any of the poses or vinyasa practices you do now could be contributing to your pain and dysfunction. Do you get pain while doing certain poses, like the front leg hip joint in a Lunge pose? Do you have a flare of pain in the hip after class or the next morning? Yes to any of these questions requires you consider suspending the offending practice, at least temporarily.

On the other hand, it is not uncommon for a student to start yoga because they have heard it could help their condition. In this setting, you will want to begin at the beginning, with a gentle practice as your entry into yoga. A one-on-one session would also be a good way to start. If you are having chronic, persistent pain, start out by lying on the floor and moving through our Dynamic Reclined Hip Stretches, in which you take the joint through many of the movements it is capable of. Add to this Snow Angel Legs, where you are lying supine (on your back) and you spread your legs wide on the floor, without rolling your thighs in or out, and then bring them back to center. Follow this with by Dynamic Locust pose, which is done on your belly, lifting one leg up off the floor without bending your knee. Lift up on your inhale and lower down on your exhale. These three explorations will give you a better sense of the range of motion of your hips, right and left, as well as movements that cause immediate pain. This is very useful information as you explore other poses in different positions. 

It is considered important in arthritis care to keep the joint as mobile as you can and keep the supporting muscles as strong as they can be in order to keep you functional and prolong the time before surgery has to be considered (surgery is not inevitable, by the way).  Since you can do many yoga poses without bearing direct weight on the joint, either prone or supine poses, seated poses and inversions, yoga provides lots of opportunity to work on range of motion and some strengthening of the joint. The pose Reclined Leg Stretch (Supta Padangusthasana) and its variations are good example of both goals being met.  Each time you lift your leg straight up to begin the pose, you are strengthening the quad muscles and the psoas, for instance. And even the standing poses can be done in a fairly weight free manner if your do them with your pelvis supported on a chair. Poses like Lunge, Warrior 1 and 2, and Extended Side Angle, all have chair variations that could be helpful when full weight on the joint needs to be avoided. And as always, breath work and meditation can be helpful with pain management, as well as yoga nidra.  I understand that yoga is even being taught in swimming pool settings, where weightlessness is beneficial for arthritic hip joints.  Sounds potentially helpful, but I’d skip the inversions class!

When your symptoms are milder, movement practices like Sun and Moon Salutations done slowly, mindfully and with the idea of soft foot landings might be safely added to your home practice. If your yoga practice can diminish your pain, improve your mobility and delay any invasive treatments, you’ll be getting your moneys worth! And the mental equanimity that is a result of a balanced yoga practice can hopefully guide any difficult decisions you may need to make about your hip toward the best outcome.