by Jenni Tarma
Patti Berman, 68, is dressed in black yoga pants and top, and wearing stylish fuchsia lipstick, even though it’s a weekday morning. I’m meeting with Patti and Knekoh Frugé, her yoga teacher, to talk about a long-term collaboration of theirs: the miraculous rehabilitation of a vicious shoulder injury that had kept Patti in constant pain for forty years.
Patti begins by showing me her range of motion: both arms smoothly move overhead, back down to her sides, her shoulders easily come into full flexion and extension, and she can clasp her hands behind her back, which she proudly tells me is a very recent development. Most of us take this kind of functionality for granted as we move through the day, but Patti’s face is lit up with genuine excitement and happiness as she shows me what her shoulder can do, most of it unthinkable up until a few years ago. This is the result of meticulous, painstaking work with Knekoh; all in all, it has taken them thirteen years to bring Patti’s atrophied shoulder muscles back to life.
Backtracking: fifteen-year old Patti suffers a traumatic fall from a rocky outcrop during a family picnic. She recounts: “The ground simply crumbled and gave way underneath me. I wasn’t exactly keeping track on my way down, but [the fall] was certainly from a significant height.” On the way down, she instinctively reached up in an attempt to break her fall, and did momentarily manage to grab hold of something. Her grip did not hold; instead, the velocity and height of the fall “absolutely decimated” the rotator cuff muscles of her left shoulder. Astonishingly, it was the only significant injury she suffered.
Having eventually recovered from the initial trauma of the accident, Patti found herself coping with chronic pain, not to mention extremely limited functionality in the injured shoulder. While she could easily move her arm from back to front, attempting to lift it anywhere above shoulder height was an absolute no-go. Pain aside, the muscular strength needed for abduction specifically had simply vanished from the joint. More dramatically, there was a clearly visible, deep hole where the ruptured muscle had been. The location of the gash and her inability to raise the arm suggest that her supraspinatus had suffered a significant tear. Amazingly, the ligaments did not appear to have torn off of their attachments, although it was obvious there was massive damage to the tissues: Patti recalls that a ruptured section of the muscle had seemingly slid forward and below her collarbone, where it formed a large lump under the skin.
Multiple visits to various doctors, physiotherapists and chiropractors proved futile. The frustration in Patti’s voice is evident even fifty-plus years later as she recollects her attempts at getting treatment. “I was simply diagnosed as having “a football injury,” she says. [These kinds of rotator cuff injuries are common in players’ throwing arms]. “But because I wasn’t an actual football player making millions of dollars, no-one thought it worth their while to try to fix it.” Ideas for treatment included vaguely useless suggestions, such as wearing a sling, presumably permanently. Other doctors were more blunt, unhelpfully recommending that Patti simply get used to it and move on with her life.
But, with no other options available, Patti did get used to it. Gradually accepting her limitations, she found ways to work around the joint’s laxity, taking extra care when reaching for a purse from the back seat or grabbing something from a high shelf. Even mild impact was painful, so being pushed and shoved in crowded situations was a constant worry. Over time, Patti started to hold her left arm close to her belly, instinctively closing off the injured joint and shielding herself from being accidentally jostled.
These kinds of guarding patterns are typical in people dealing with chronic pain, and invariably come with their own set of issues. Injuries of this magnitude are rarely isolated to a single area, and before long, Patti started to notice the trickle-down effects as her body adapted to its permanently injured state. Her new defensive posture rounded her shoulders, straining her rhomboids and upper back. The forward hunch was also contributing to massive tension in her trapezius and neck muscles, which even now are rock-hard from years of poor posture. With some muscles overworking to compensate for the injured rotator cuff and others weakening from being under-utilized, her entire left shoulder gradually locked itself into a state of permanent semi-contraction, now limiting her range of motion in all directions. The “good” shoulder grew more and more tense as it took on more than its fair share of physical strain from simple daily activities. Eventually, the overworked right side of Patti’s back tightened up as even the lats and quadratus lumborum also made their dissatisfaction known.And yet, even with so much tension in evidence elsewhere, the affected shoulder joint was problematically lax and liable to pop out of its socket, straining the irritated tissues further.
In spite of all of this, Patti continued to go about her life, only somewhat allowing her injury to impede her. She remained active and even trained as a scuba diving instructor; being submerged in water lent some external support to her damaged shoulder, which actually made movement a little easier. Her only real limitation was an inability to pick up oxygen tanks, a problem easily solved by offering free diving lessons to anyone that would deal with the heavy lifting on her behalf.
Having basically accepted her limited-mobility fate, a chance conversation in 2003set Patti on a new path: a chiropractor treating her for TMJ suggested that she try yoga to heal her shoulder. Fatefully, it was just a week later that Patti met Knekoh, owner of Los Angeles’ Yoga Circle Downtown. Knekoh welcomed the opportunity to work with Patti, and even though the age and severity of the injury gave her pause, she was confident that she could at least offer freedom from the constant and pain. In addition to her own well-established practice, Knekoh was trained in acupressure massage, and had a particular affinity for feeling out and dissipating muscular tension.
Patti and Knekoh began working together regularly. Class sizes in Knekoh’s brand-new studio were small, so Patti could attend public classes and still receive the individualized attention her injury necessitated. Since the ruptured supraspinatus had never properly healed, the gap in Patti’s musculature was still very much there, and Knekoh recalls having to use her fingers to physically fill the hole anytime Patti lifted her arm overhead, in effect contributing the support the missing muscle fibers would have normally provided. With this additional support, the atrophied muscle was essentially taken out of the equation, allowing it to start healing. Acting mostly on gut instinct, Knekoh slowly worked to strengthen the surrounding tissues, all the while keeping any strain off the supraspinatus. To both their amazement, the gap in Patti’s shoulder slowly filled in as her ability to lift her arm higher and higher on her own strength also grew.
Through a regular but gentle yoga practice, the tight parts of Patti’s body started to release as weaker areas became stronger. Knekoh understood that building strength in the scapular stabilizers was critical, as the rhomboids and serratus anterior muscles provide the foundation for safe function and movement in the rotator cuff. In their current state, Patti’s scapular stabilizers were weakened from years of inactivity. Putting her yogic observation skills to use, Knekoh instinctively worked to strengthen these muscles; she noticed, for example, that the injured glenohumeral joint would stabilize and stop “clunking” whenever the scapula was manually held in place. Incorporating movements such as standing cat/cow allowed Patti to re-learn the actions of consciously turning these muscles on and off, without any unnecessary weight-bearing on the arms. Eventually, some of the tension in Patti’s neck started to dissipate. Her anterior shoulder muscles, locked into a shortened and weak position from years of tense forward hunching, also started to loosen with regular, gentle chest-opening asana.
Cut back to present day: Knekoh is leading Patti through what could be described as a combination of a private class and an interactive workshop. The interactive part is for my benefit: I’m sitting off to the side and taking notes as Knekoh points out details in Patti’s alignment of the (now healed) shoulder, explains her customized adjustments, and occasionally pauses the practice so we can palpate specific areas where tension or scar tissue remain. Even without seeing the injured “before”, the rehabilitated “after” is nothing less than remarkable. 68-year old Patti easily flows through sun salutations, with full and effortless range of motion in her shoulders. Her Warrior I is strong, and shows only small signs of the tension in her back and side that previously prevented her from squaring her torso forward. Knekoh points out Patti’s Downward-Facing Dog: her shoulders are level and fully externally rotated, something formerly impossible due to the torn supraspinatus and lack of stability in the scapulae. And although Patti still suffers from excess tightness in her traps and neck, her shoulders are even and her arms perfectly abducted in Warrior II.
As Patti moves into restorative poses, it becomes clear that this portion of the practice is where the challenges lie for her. Even though the rotator cuff is now functional, the deeper connective tissues are slow to release years’ worth of built-up tension, and it’s obvious even to me that relaxing into the poses is difficult for her. Tight muscles aside, Patti and Knekoh have also spent a lot of time gradually breaking up scar tissue buildup around the injury, a process that is often excruciatingly painful with an injury this severe. Knekoh has developed an arsenal of heavily-propped restorative poses to get Patti as comfortable as possible for this work. One pose, for example, has Patti laying on her side, with blankets and bolsters supporting her waist, shoulder and neck; this effectively keeps her spine and upper body in a neutral position while Knekoh gently manipulates both shoulders through their passive range of motion. Other reclined poses prop the legs, so that Patti’s tense back muscles are encouraged to release.
When their weekly practice is complete, we sit and chat some more. After years of working together, Patti and Knekoh finish each others’ sentences, and clearly share a near-telepathic connection as student and teacher. Patti emphasizes that Knekoh’s specific skillset has been crucial to her recovery, and points out that Knekoh was effectively combining a variety of healing modalities in a therapeutic manner well before “yoga therapy” itself had reached any kind of mainstream status. “Necessity is the mother of invention,” Knekoh says with regards to the heavily-adapted poses she uses on Patti. “I can’t tell you the number of times I wished I had an extra arm for adjustments!” she adds with a laugh.
For her part, Patti says that “yoga has become a lifestyle for me, and it’s very helpful in dealing with some of the discomforts that come with getting older.” She is well-versed in pranayama and meditation, and thoroughly understands asana as a tool, rather than a destination to strive for. Knekoh also credits Patti with fully engaging in the therapeutic practice by “doing her homework and believing in the process,” making her an active participant in her own healing. “We view yoga as energy work, rather than as an extension of the fitness industry,” Knekoh explains. “We need to think of the yoga practice the same way that we think of brushing our teeth: both are essential components of routine self-care.” Both speak of “real yoga” as a means of encouraging contentment, and Patti, having already spent years living with an injury that she believed to be irreparable, is nothing if not skilled at finding acceptance in challenging circumstances. If anything, Knekoh and Patti’s story exemplifies real-life yoga in action: surely, the best thing any of us can hope to cultivate in our practice is not acrobatics or the perfect handstand, but rather, a mindset of gratitude and contentment.