Rotator Cuff Tendonitis and Impingement Syndrome

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By: Joan Takacs, D.O., Leslie Cox

A common orthopedic shoulder problem is rotator cuff and/or biceps tendinitis with associated impingement of the tendons between the acromion and the head and greater tubercal of the humerus (figure 1). Trauma or poor mechanics of the shoulder over time leads to wear on the cuff muscles and their tendons. This can be compounded by a downward sloping acromial process on its lateral margins. Trauma, occupational factors, faulty posture, emotional factors leading to poor movement, and altered mechanics are all causes.

In treating large numbers of these patients, this author has noticed that conventional physical therapy is often ineffective and occasionally harmful, especially when carried out with disregard for grace and higher quality of movement. Better results are achieved with spatial dynamic exercises and therapeutic eurythmy.

Spatial dynamics (developed by Jaimen McMillan) combines the in-depth understanding of Bothmer exercises, joint mechanics, and movement gestalt (movement streams). Count Fritz von Bothmer was the individual whom Rudolf Steiner asked to teach gymnastics in the first Waldorf school in 1919. He developed approximately thirty exercises to practice the archetypal relationship of the free human being to space. Spatial dynamics was more recently developed to study human developmental stages of movement. It uses the Bothmer exercises and others for pedagogy and the development of free movement.

Spatial dynamics also incorporates the movement streams described by Margarethe Hauschka, MD.* She illustrated the movement stream of the shoulder as a massage technique (figure 2). This can be also be seen as arm movements streaming from the head down and across the scapula, which drops and moves laterally, then down the arms, extending out through the fifth digit. However there is also a counter movement that comes back to the head beginning in the thumb and extending up the lateral aspect of the arm. The axis of movement of the scapula (and limb movement in general) originates from the point of the solar plexus, but correct movement should be bi­directional. When you reach for an object there is a movement from your center to the periphery towards the object. If only this half of the movement is accomplished the scapula will rise, tending to follow the shoulder and hand towards the object, creating poor mechanics. This movement should be balanced by a counter movement which occurs as you invoke a movement from the object (periphery) to your center. In fact, this is the image of the will moving from the periphery towards you.

This motion is illustrated by Rudolf Steiner in Study of Man (figure 3), "The limbs system has its center in the whole circum­ference—the center of the limb system is a sphere—the opposite of a point. In fact, the center is everywhere, hence you can turn in every direction and radii ray in from all sides, uniting themselves in you."

Patients with altered scapular mechanics, instead of correctly moving from the metabolic/will point in the solar plexus, displace the entire axis of movement up to their head, moving the arm and shoulder girdle as if the movement originated up there. This is often further augmented by significant anterior neck carriage. The process which should take place in the metabolic/limb pole and has been displaced to the upper (nerve/sense) pole appears due to a weakness in the middle or rhythmic/chest area. The chest is held back, the ribs often compress downward and there is poor respiration. The soul gesture of these patients often also mirror this disturbed relationship. They frequently push out from their center, forcing their will activities at the world without allowing their interest or intent to draw their movements from the periphery.

In order to allow the tendons to heal, the continual trauma of altered mechanics must be corrected. First, depression must be treated, if present. Depression causes all movement to be towards the self. Learning to reach out in a way which allows the will to be drawn intentionally from the periphery and the world can be helpful. When both movement streams, the one originating from the center and the other from the periphery, can be done simultaneously, the scapula will begin to drop and move laterally. A rich imaginative picture must be developed together with the patient to achieve this. Joint positions can be achieved through the intellect, but muscles are fluid and can only be moved correctly with the help of imagination.

After learning to reach correctly, several other basic spatial dynamics exercises are needed to re-establish a balance in a threefold way. The power of the metabolic/limb system needs its axis moved down from the head to the solar plexus. The head must rest quietly on the shoulder, and the rib cage and the chest must expand and become fluid in movement to allow the harmonizing of these two poles. Some specific exercises are beneficial:

1. Correcting the arch of the foot. Flat feet are associated with anterior compression of the chest, increased thoracic kyphosis, and limited scapular movement.

2. Develop a relaxed upright posture. This can be done by learning to push down against the earth with the feet. This particular movement will unlock the knees. Locked knees cause increased lumbar lordosis and often increase thoracic kyphosis.

3. Instruction in correct etheric streams of movement. This includes the stream from the medial arch of the foot to the knee along the sartorius muscle to the pelvis, across the flank and out the arms. The patient also needs to experience the stream from the head down to the chest, giving the scapulas weight.

4. Correcting the posture of the rib cage, chest, neck, etc.

5. Giving weight to the elbows.

After 4-6 spatial dynamic sessions, the patient is usually able to progress on to therapeutic eurythmy, the details of which will be outlined in a later article. There are also various anthroposophic/ homeopathic remedies which the supervising physician can prescribe.

The simplistic notion that remedies and manipulation alone are thera­peutically adequate belies the tremendous insight and anthroposophical scope of understanding of shoulder mechanics and rehabilitation. For adequate recovery, the patient must become a conscious active participant.

Joan Takacs, DO is board certified in physical medicine and rehabilitation with a practice in Portland OR. She is agraegate of the Spatial Dynamic Institute. Lesley Cox, a therapeutic eurythmist, teaches at the Portland Waldorf School and has a private practice. For more information call (503) 234-1531.

*M. Hauschka is the founder of the Rhythmical Massage Method.

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