Shoulder Rehab Part III

Posted on May 31, 2013 by Joe Heiler

In part I of this series I discussed how traditional physical therapy exercises for the rotator cuff often miss the mark, and then in part II how dysfunction and a lack of motor control in other areas of the body can significantly affect the shoulder and cause pain.  Be sure to read those, if you haven’t already, as this article will make much more sense.

In part III I want to talk about another concept that has taken the therapy world by storm – Scapular Retraction.

In a nutshell, scapular retraction means pulling the scapula (shoulder blade) closer to the spine, and often times the cuing from the therapist or physician is to pull the shoulder blades down and back (or “put your shoulder blades in your back pockets”).  Check out the picture below:

“Shoulder Blades down and back”

Now I’m not going to sit here and say that good things can’t happen from doing this, or deny that I used to buy this approach.  Some folks are just stuck with their shoulder girdle forward and scapulae protracted (spread apart) so far that they create a shoulder impingement with that faulty posture.  Working on scapular retraction can work in the short term in these cases, but I certainly don’t think it’s a permanent fix.  There are many therapists and physicians that feel this strategy will help in all cases.  Here are some reasons why it will not:

1)  The scapula is most cases just needs to be posteriorly tilted (or tipped).  Check out the photo below to get the visual, but the jist of it is that this creates more space in the glenohumeral (shoulder) joint to decrease impingement while also allowing for greater freedom of movement at the shoulder.

Try lifting your arm overhead maintaining your scapulae down and back like in the picture above.  It isn’t going to happen.  The scapulae are meant to upwardly rotate when going overhead to maintain the joint space and prevent impingement.  Too much ‘down and back’ will actually create more downward rotation and greater impingement (see picture above in the upper left).  Strike 1!

Scapular Reduction Test – the scapula is gently posteriorly tilted. This will often clear an impingement with shoulder elevation. Notice he is not pulling the scapula closer to the spine!

2)  Too much scapular retraction with common exercises like rows and pull-downs can result in an anterior glide of the humeral head.  Fancy term for the ‘ball’ of the shoulder sitting too far forward in the socket.  This can also lead to greater impingement, and for someone with the very common condition of bicipital tendinosis can be quite painful.

The top hand is palpating the borders of the scapula, while the bottom hand is palpating the front and back of the humeral head. Her humerus is seated anterior in the socket on both sides, but much more pronounced on the L shoulder. This is actually very common.

I’ve seen quite a few patients with this type of shoulder positioning fail miserably with scapular retraction programs.  You’re literally pulling the scapulae back and leaving the humeral head protruding even more to the front creating great impingement.  Strike 2!

3)  Remember in part II when I talked about regional interdependence?  Anything you do to the scapula could create a reaction somewhere else.  In the majority of cases the patient will overdo it, and you’ll end up with negative compensations elsewhere in the body.  Check out the picture below.  This is one of my all-time favorites, and I use this as a teaching tool with my students.

I know they say the picture on the right is ‘correct’, but look at what he had to do to his neck and back to get there (the arrows are mine).  He had to jack his neck and back into more extension, and over recruit his upper traps just to get there.  Nothing like creating a neck and back problem while trying to fix the shoulder.  It’s easy enough to do and I’ve seen many a therapist and trainer let this go.  Strike 3!

So what to do about this?

There is nothing wrong with a little scapular retraction to reposition the scapula on the thorax, but if some other issues are cleared up first this may just happen naturally.

1)  Cervical mobility – the neck should move freely and without pain.  I gave a great example of this in part II.  There are a number of muscles running between the neck and shoulder girdle so any tension resulting in cervical restrictions can alter scapular position.

2)  Thoracic mobility – the scapulae sit on the thorax so positioning and movement of the thoracic spine will definitely affect scapular positioning.  Poor mobility creates an inability to adjust the posture to the activity, and poor scapular mechanics result.

3)  Poor motor control – once mobility issues have been corrected (and it’s not just the cervical and thoracic spines), then scapular and spinal motor control often improve automatically.  Scapular retraction exercises aim to strengthen the scapular muscles, but motor control basically means the muscles are positioning and moving the scapula the right way at the right time.  See part 2 again for a more in-depth explanation.

This is by no means an exhaustive list of possible solutions, but it’s a start.

I plan on posting a couple videos next week showing how to perform pushing and pulling exercises correctly.  I’m on my way to Chicago right now for a Graston Technique training so those will have to wait until I get back.  Keep an eye out for those and part 4 – correcting scapular winging.

As always feel free to email any questions to me:  joe@elitepttc.com

 

 

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Shoulder Rehab Part II

Posted on April 19, 2013 by Joe Heiler

In Part I, I discussed how physical therapy of the shoulder using traditional rotator cuff exercises really gets me fired up.  Traditional methods of shoulder rehab often train the muscles of the shoulder in a way that they are not really used in normal everyday function.  If you haven’t caught that article yet, I suggest you read that one first.

In this article I want to address a couple other pieces of the puzzle:  motor control and regional interdependence.

There are many cases in which a certain movement may look dysfunctional in a standing position, but may actually be completely functional in other positions where the patient is more unloaded like lying on their back or stomach, side lying, on hands and knees, or even in kneeling.  In these positions there are fewer joints and segments to control and in most of these cases less gravity to deal with.

Unless the movement pattern is tested in multiple positions, it is not possible to know with any certainty that the movement is limited because of a true mobility issue (think joint restriction or ‘tight’ muscle) or if it is because of a lack of motor control.

Here is a great example looking at a functional reaching pattern behind the back.  In standing, you should be able to reach up behind your back and touch the bottom of the opposite shoulder blade as in the picture below:

So this past week I had a patient come in that could only reach to just below her belt line.  She had been given stretches to increase that movement but they really hurt her shoulder to perform.  If you’ve ever had a shoulder problem or therapy after a shoulder surgery then this exercise will look very familiar:

Shoulder Internal Rotation Stretch

When I had her lie down on her left side, she could reach all the way up her back and touch the opposite shoulder blade!  So why could she not do it in standing but had no pain and no difficulty lying on her side?

By going to a more unloaded position in side lying, the other joints of the body are taken out of the equation, and there is much less to have to control.  In this position she could be successful.  This is a great example of poor motor control, not a loss of shoulder range of motion.  So of course the first question she asked me is why did she spend the last 4 weeks in therapy and at home trying to stretch out her shoulder?

During the evaluation is was also discovered that she had some loss of mobility in her neck.  Because the neck movements were not painful, these were addressed first using cervical manipulation and then I followed that up with some soft tissue work using the Graston Technique through her upper trapezius, levator, and rhomboids.

C1-2 Thrust Manipulation

GT to the Upper Trapezius

Here is where that term – Regional Interdependence – comes into play.  In simple terms, regional interdependence is the interplay between different regions of the body.  In this case its easy to see how limitations in the neck can affect the shoulder since there are a number of muscles that run between the spine and shoulder girdle.  In other cases it could be dysfunction even further down the spine, the pelvis, hip, and beyond that could affect alignment and function at the shoulder.  Without the proper evaluation, it would be nearly impossible to find these relationships.

Once her cervical mobility was restored, we immediately went to corrective exercises to improve motor control of the neck and shoulder girdle.  These were fairly simple non-painful exercises that allowed her to successfully work through her neck limitations in a more unloaded position (hands and knees in this case).

Following that first treatment she could reach behind her back and nearly touch her opposite shoulder blade!

When the patient returned for her next visit, she had maintained her neck mobility and behind the back reach without shoulder pain.  We progressed to kneeling and standing motor control exercises, and by the end of the treatment she could touch her opposite shoulder blade without difficulty.

Half kneeling chops and lifts are a great way to improve stability and motor control through the spine and hips.

Needless to say, this patient was quite happy with the results.  Sometimes it is as simple as being in the right place at the right time with your treatment.  We’ll see how the rest of her treatment goes but for now we’ve knocked out a major limitation in her shoulder function without directly targeting her sore shoulder.

Part III coming soon

If you have any questions, feel free to contact me:  joe@elitepttc.com

 

 

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Shoulder Rehab Part I

Posted on March 25, 2013 by Joe Heiler

Physical therapy of the shoulder using traditional rotator cuff exercises really gets me fired up, so I should probably warn any physical therapists, chiropractors, or physicians reading this to buckle up!  Actually I’m not going to try to offend anyone, I just like to challenge conventional thinking and ask questions – especially when it comes to dogma like rotator cuff exercises.

If you’ve ever been to physical therapy for a shoulder rehab then you’ve probably seen this one:

Shoulder External Rotation

and this:

Shoulder Internal Rotation

These are just 2 of many exercises that supposedly target the rotator cuff that are commonly provided by your health care provider.  In fact, many of you have probably been handed 2-3 pages of these and told to do 3 sets of 15 up to 3x daily.  Ever heard of the shotgun approach?  Your health care provider is hoping and praying that one of these might just work and make you feel better.

Now here is the reality of the rotator cuff:  It’s job is to stabilize the humeral head (the ‘ball’ of the shoulder) in the glenoid fossa (the socket)

The 4 Muscles of the Rotator Cuff

What most health care providers are going on are EMG studies that measure how hard a muscle can fire in isolation during a specific activity.  There is certainly great evidence that the rotator cuff muscles are firing during these exercises.  The problem as I alluded to before is that these muscles do not function in this way in real life.

These smaller rotator cuff muscles are stabilizers, not movers (like the larger deltoids, pecs, lats, etc).  The traditional rotator cuff exercises train the muscles like ‘movers’ which is not their true function.  I’m not going to argue that someone can’t show increased strength over time within these exercises, but I will argue is that there is no transfer to improved function (i.e. lifting, reaching, carrying, pushing/pulling, etc).

The reality of the rotator cuff again is to stabilize the humeral head (the ‘ball’ of the shoulder) in the glenoid fossa (the socket).  It performs this task reflexively meaning it happens without you having to think about it.  All four muscles quickly fire and relax in a specific sequence (depending on the activity) to stabilize the shoulder joint.  They never work in isolation like you have been trained in the past.

So what are the best ways to fire the rotator cuff reflexively?

  • Compression – this means putting weight through the arm.  Examples would include exercises that involve hands or forearms on the ground holding your body weight, any type of pressing, holding a weight (on your back with the shoulder flexed 90 deg. – think top of a bench press position; or with a weight overhead) just to name a few.
  • Distraction – this would include anything that pulls downward or outward on the shoulder (think traction).  This would include carrying weight by your side, pull-ups, horizontal rows, lifting from the floor, etc.

In any of the above activities, the brain immediately recognizes the need for stability and reflexively fires the cuff to prevent bad things from happening like dislocating your shoulder or falling on your face.  Now obviously I’m not trying to actually do these things to you, but forcing muscles to fire reflexively always works better when there is some sense of urgency.

I’ll leave you with a few of my favorites below, and in part 2 I’ll tackle more of the dogma of shoulder rehab.

Arm/Leg Diagonals – a.k.a. the Bird Dog – Shoulder Compression for Reflex Stabilization

Farmer’s Walk – Shoulder Distraction to elicit reflex stabilization

 

Kettlebell Arm Bar – The goal is reflex stabilization of the glenohumeral joint through compression (using a kettlebell) while performing thoracic rotation.  Lots of great things happening here!

Feel free to email any comments or questions to me:  joe@elitepttc.com

 

 

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Ankle Rehab Update

Posted on March 15, 2013 by Joe Heiler

So last week I posted this message on Facebook:  “Limited ankle mobility is a very common reason for nagging foot, knee, hip, and back pain in runners. Unfortunately not too many PTs or doctors are looking there. Maybe it’s time to call us and rid yourself of that pain for good!”

In the past week I have been asked 3 separate times about what is the best way to check your own ankle mobility and then how to improve it.  So to bring you up to speed on why it is so important to have great ankle mobility I refer you to a previous blog post title “Movement Proficiency and the Ankle” which you can find here:  http://elitepttc.com/blog/?p=20

Now for the measuring and correcting!

The first video below shows how I measure ankle mobility in the clinic with the foot on the floor and controlling the ankle to prevent pronation (arch flattening out):

To measure your own ankle mobility, simply assume the kneeling position shown in the video.  Rock your knee over the foot to touch the wall measuring how far your big toe is from the wall with a simple tape measure.  The heel must stay down and arch not allowed to collapse.  The goal is 4 inches!

The next video demonstrates how you can quickly address the soft tissue component of the limitation.  Be sure to measure again as we did in the video as this is the only way you are going to know if it is effective or not.  Always follow the rolling with stretching.

If this does not result in an immediate improvement in ankle mobility, you may have a joint restriction that will not be resolved with rolling or stretching.  Another sure sign of joint restriction is pain or pinching in the front or side of the ankle during the testing.  This can often be resolved quickly with ankle joint manipulation and/or mobilization and certain taping techniques that I employ here at Elite Physical Therapy (in other words it’s time to call the professional).

If you have any further questions feel free to contact me:  joe@elitepttc.com

 

 

 

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Great Lakes Burn Camp

Posted on March 8, 2013 by Joe Heiler

On Sunday February 24th the Traverse City Coast Guard station hosted the Great Lakes Burn Camp for the second time in as many years.  It was a great event where kids from all over the state come together for a couple days of fun activities and comradery with other kids, the Coast Guard members, and folks from our community that have donated their time and money to the cause.

As you can see from the video below, the kids are having a great time:

Cody Thorpe, a rescue swimmer with the Coast Guard, is the main man behind the scenes and does a great job putting everything together.  Cody has been a good friend to us here at Elite Physical Therapy so we were more than happy to help out.  He’s hoping to keep the momentum going bringing this camp back to the Traverse City area every year so keep your eyes open for him next fall as he checks in with local businesses for support.

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Does Gaining Range of Motion Really Have to Hurt???

Posted on December 14, 2012 by Joe Heiler

Not all physical therapists are created equal, nor does gaining range of motion have to be extremely painful!  I know there is this idea amongst the public that PT has to hurt to effective, but in most cases nothing could be further than the truth.  Sadly enough there are plenty of PT’s out there who also believe ‘No Pain, No Gain’ to be true.

Here is why it does not have to hurt:

-  When the brain starts feeling ‘stress’ it goes into protection mode.  Pain signals coming in to the brain result in signals back to muscles, fascia, and joint capsule to literally tighten down to protect the painful structure.  So the entire time your PT is cranking on your new Total Knee Replacement, or you are cranking on it at home per their instructions, your brain is busy fighting back.  The result is lots of pain and minimal progress.

- Pain fires up your sympathetic nervous system, the part of the system that handles ‘fight or flight’ situations.   My good friend and physical therapist/strength coach Charlie Weingroff has been consulting with Nike and their athletes on this very topic.  What they have found is that athletes who are in this sympathetic state even at rest exhibit increased stress hormone levels that result in poor sleep patterns and poor recovery from workouts and games.  This elevated level of stress over the long term can have some serious effects not only on athletes, but on the rest of us as well.

Balance is good!

The moral of the story here is that increased pain and stress levels can delay healing and recovery.  Some pain is going to be present when you’re dealing with an injury or surgery, but your therapy should not be making you consistently feel worse  Not what you want when trying to recover from an injury or surgery, and certainly not an ideal situation for someone trying to gain range of motion, strength, and returning to work or athletics.

At Elite Physical Therapy and Sports Performance, we recognize that there are a number of soft tissue and joint mobilization/manipulation techniques that can improve range of motion and quality movement without creating excessive pain.  Some techniques may be a bit uncomfortable at the time of application, but what little pain there is should go away quickly with an obvious increase in joint motion and overall movement quality.

Graston Technique can be used to break up scar tissue and improve range of motion of the knee.

 

Graston Technique is also very effective for treatment of tendinopathies – in this case treating the posterior rotator cuff.

In most cases, there are better ways to gain range of motion and strength than trying to push through restrictions and pain.  If you’ve got any questions concerning our soft tissue and joint manual techniques, feel free to contact us.

C1-2 Thrust Manipulation – this one is money for headaches!

Trigger Point Dry Needling – Coming Soon!

 

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The Best Mobility Drill Ever?

Posted on October 1, 2012 by Joe Heiler

I’m into exercises that give you more bang for your buck since I know most athletes are pressed for time, and there are plenty of other training skills they would rather be working on.  The ‘Spiderman’ exercise happens to be one of those exercises that can address everything from hip mobility to thoracic spine mobility to shoulder stability. It is absolutely one of the best warm-up drills you can perform and it’s a staple in our programs.

Check out the video below for a short tutorial on how to perform the exercise, what you should be feeling, and what to watch out for as far as ‘cheating’ through the movement.

Previously posted on SportsRehabExpert.com (the video was originally shot for physical therapists and sports performance professionals so I apologize for all the medical lingo)

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Elite Sports Performance

Posted on September 12, 2012 by Joe Heiler

Sports performance training is one of the favorite parts of my job.  We definitely do some unique things here, and I happen to think we get some pretty good results too.

I put together a compilation video that you can check out below.  I doubt you’re going to see anything else like this in Northern Michigan!

 

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Michael Phelps talks Graston Technique and Training

Posted on July 12, 2012 by Joe Heiler

This article was sent to me yesterday, and I found it not only very interesting, but also validating what I do at the same time.

http://on.details.com/PLYA8S

Michael discusses the benefits of Graston Technique (GT) on relieving pain and freeing up his shoulders and back for swimming.  This is only his subjective report but who is more in tune with how they are performing and functioning than an elite Olympic athlete?  There is plenty of research being done on GT with great evidence based outcomes so I’m very confident that the benefits are real.

One more thing I do want to mention concerning the use of GT in the article, and Phelps’ comments on the pain and bruising that go along with treatment:  the research indicates that GT is just as effective without the pain and bruising.  Of course there will be some pain as you are trying to break up scar tissue, but there is no need to be ultra-aggressive and bruise.  The majority of my patients will tell you they have some mild to moderate discomfort during the treatment, but are rarely all that sore afterward.  The pain relief and improved motion following the treatment is well worth it.

On the subject of training, Michael talks about how his focus this time around has been on developing more power.  He specifically mentions performing the Olympic lifts and pulling/pushing sleds, both of which are mainstays in our sports performance programs.

At first glance you may wonder why in the world a swimmer would need to do power cleans and run with a sled?  Especially when he’s not even on his feet more than a split second to push off the platform.  Many of the benefits of this type of training are for the nervous system and the speed at which muscles can contract.  Training for power means moving a certain weight as quickly as possible.  The faster you can move it, the more powerful you are.  Strength is different in that time doesn’t matter, only how much weight can you move.  Strength is very important, but in swimming and pretty much every other sport out there, its the speed at which you can generate that force that is most important!

Here is a great example of a power clean (one of the Olympic Lifts – this from my buddy Cal Dietz at the University of Minnesota)

Aaron Studt Cleans 400lbs

Anyway, I hope you enjoy the article.  I can’t wait to see how he does this summer.

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Plank Exercise Progressions

Posted on May 2, 2012 by Joe Heiler

If you’ve mastered the front and side plank basics that I’ve discussed on here previously, now you’re ready for some challenging progressions that I feel really carry over to athletics and can get you closer to your training goals.

Each of the following plank progressions add hip motion to the equation so you will be supported on one limb for a period of time.  It’s the support leg that is most important for stability and will be working the hardest.  With all of these exercises, you must maintain a stable core.  So in other words, when you lift a leg your trunk should remain motionless.  If you have to lift your butt up or it sags down then either it is too much for you or you are getting fatigued and need a break.  Perfect reps, nothing less.

The other great thing about these exercises is that they give you a chance to look at symmetry.  By this I mean how does your right leg compare to your left leg when doing a front plank, or how about right and left sides when performing a side plank?  It should be just as easy or difficult on both sides.  Right-Left asymmetries are a huge predictor of injury so work to limit these.  Typically I will have patients or athletes perform an extra set on the weaker side to bring that side up to par.

Alright, done with the lecture.  Check out the plank progressions below.

Prone Plank with Hip Extension -alternate lifting legs about 4-6 inches off the floor.  Nothing moves but the hips.  Shoot for 10 solid reps each leg without losing form.  And if you’ve been paying attention in previous posts, hold the leg up long enough to cycle a breath, then set it back down.  That will be the true test of your inner and outer core working together.

Plank with Hip Extension

Side Plank with Hip Abduction – I really like the side planks as they test your entire lateral kinetic chain for stability.  Post up through the forearm by pressing it ‘through the floor’.  Now lift the top leg keeping the hips high.  Shoot for 10 quality reps with proper diaphragmatic (belly) breathing throughout.  When you can achieve that, now hold the leg at the top and cycle a breath before bringing it back down. 

Side Plank with Hip Abduction

Side Plank with Hip Adduction -this is another great variation that I think gets overlooked.  The bottom leg will be off the ground in this case so the adductors (inner thigh muscles) of the top leg will be carrying more of the load.  Breathing is crucial again so get it right.  Start with 10 second intervals if necessary shooting for 30 second holds ultimately.  If you’ve achieved that, then progress the exercise by moving that bottom leg back and forth.  It should look like a running stride – flex the hip up and then extend it back.  Adding the front to back movement will make your core have to work that much harder to remain stable.  I’ll shoot for 10 reps here again as well.

Side Plank – Hip Adduction

Three great ways to challenge yourself!  Remember to play close attention to those side-to-side differences.  Cleaning those up will bring the greatest benefits.

 

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