Explaining Pain

Pain is something many of us deal with everyday, whether it our own or working with others to help them overcome that pain.  At Elite Physical Therapy, we feel that it is very valuable for our patients to understand how pain works, and how we should deal with pain during the different stages of healing.  Chronic low back pain and neck pain are two very common cases where this new science is having a valuable impact.

This is a great video by Lorimer Moseley explaining pain and how it is processed by our brains.  Dr. Moseley and Dr. David Butler are definitely changing the way we think about pain in the medical professions.

https://www.youtube.com/watch?v=gwd-wLdIHjs&feature=player_detailpage

The take home message is that with chronic pain, the tissues are often completely healed, but the brain still perceives pain.  In this situation, movement and activity are often the best medicine.  You can’t hurt anything so try to do as much as you’re capable of doing without going overboard.  You may just gradually improve your functional abilities while decreasing pain using this approach.

 

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Elite Physical Therapy Exercise of the Week – Wall Posture Shoulder Mobility

originally posted on SportsRehabExpert.com

This article was originally written for physical therapists and other clinicians dealing with shoulder pain and loss of motion so excuse some of the medical terminology.  I know a number of them read this blog so I’m leaving the article as is. 

The jist of this article is as follows:  most of us have too much extension (arch) in our lower spines, and we go into even more extension any time we try to raise our arms overhead.  Over time this can lead to shoulder pain and low back pain.  The article below describes a great warm-up exercise to improve shoulder mobility while controlling spinal posture. 

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

Joe Heiler PT, CSCS

This is a great correction for the shoulder mobility movement patterns and also for the shoulder flexion component of the MS Extension pattern.  The lumbar spine frequently contributes excessive extension to the shoulder patterns when the shoulder itself is limited.  Mobility work is required to free up the shoulder, but this pattern will continue if motor control is not imparted to lock in the new range of motion.

I would not want to be her low back right about now!

The ‘wall posture’ as I describe it to the patient is an attempt to get the entire spine to touch the wall.  By having the feet out in front and knees slightly flexed it makes it easier to get the lumbar spine flat onto the wall which is really just a less extended, and probably more neutral position, for most folks. If you’re concerned that it is too much flexion, or if it is not well tolerated due to back pain, and towel roll/lumbar support could be used but contact must be kept at all times.

The cervical spine is a little trickier when it comes to proper positioning.  I will cue to get the spine to the wall, but to a point.  That cue will usually bring the chin down and back (into cervical retraction) which again will bring most folks to a more neutral posture.  Too ‘straight’ is not a normal position either and could affect the shoulder mobility component of this corrective so don’t force it.  If their forward head posture is so severe that their head won’t touch the wall without going into extension, then place a towel roll behind the head and require them to hold the towel in place as the arms go overhead.

Maintaining the proper positioning throughout the movement is the most important factor here.  The shoulder motions in the video are a challenge to that positioning.  When posture is lost, the movement is done.

Breathing is critical here as well.  My preferred way of cuing the breathing is to inhale at the bottom and slowly exhale during the overhead motion.  The more the ribs stay down in the front the better.  This can be incredibly hard for many people, and especially so for many overhead athletes, weight lifters, dancers, and gymnasts.

 

The order in which the motions are presented in the video go from easier to most challenging:

1)  Shoulder Flexion
2)  Shoulder Abduction (snow angels)
3)  Shoulder Abduction with External Rotation

If following the SFMA’s 4×4 matrix, this would be considered a level 4 posture, unloaded but with assistance (the wall as the positional cue) so 4:1.  Competency must be attained in each of the previous postural levels:  1)  supine/prone, 2)  quadruped, 3)  tall or half kneeling.

Progressions per the matrix:

4:2 – shoulder mobility work without the postural cuing or any activation
4:3 – loaded with cuing or activation.  Shoulder Flexion/Extension (reciprocal patterning) or pressing overhead with the spine against the wall or a corner (I prefer a corner to allow the shoulders to move more freely).
4:4 – loaded without cuing or activation – Shoulder Flexion/Extension in standing, any type of pressing.

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Annual Musculoskeletal Exam

You go to the dentist for check-ups and cleaning every six months.

I bet he’d rather be seeing his physical therapist!

The doctor sees you for an annual physical.

You see the eye doctor for an annual check up.

So why not see your physical therapist for an annual musculoskeletal health exam?

Here are a few startling statistics:

  • we lose .5%-1% of our muscle mass per year after the age of 30.
  • nerve conduction velocity decreases by 1m/s every 10 years
  • testosterone levels decline about one percent a year after age 30.  Growth hormone levels begin to decrease after the age of 20.

These are just a few examples of normal age related physiological changes.  The direct result is a decrease in strength and power with age.  Over time this can manifest itself as poor balance, poor movement ability, difficulty getting out of a chair or bed, limited endurance, and the list could go on and on.  These declines in performance can also lead to injuries and musculoskeletal problems over time which will lead to a further decline in performance.  The vicious cycle is in full swing now!

There is no way to stop these changes from happening, but we can certainly work to slow them down through smart exercise, nutritional strategies, proper recovery, etc.  The exercise component is where we come in.

Here is what this annual musculoskeletal exam would consist of:

The Functional Movement Screen (FMS) is a battery of 7 screens to determine movement competency – or how well you move.  The FMS has been shown in the research to be highly predictive of injury in athletics and in the military.  We can’t necessarily pin point what the injury will be, but we do know that the wheels are much more likely to come off at some point.

The FMS is being used in all the major sports, in the military, and even at the NFL combine to look at injury risk and prediction in these populations.  The beauty of the screen is twofold:  1)  ability to identify poor movement patterns, and then apply corrective exercises to improve competency within these patterns thereby reducing future injury risk; 2)  ability to identify acceptable movement, and create exercise programs to further strengthen and add capacity to these patterns.

The Y Balance Test looks at single limb balance, strength, and motor control.  Right to left symmetry and poor reach distance are both predictors in injury.  The Y Balance test is a great way to evaluate both, and to compare scores to peers in the same sport or activity level.  There is also an upper body Y Balance test for shoulder stability which is a great way to test overhead athletes.  Depending on your sport, one or both of these tests would be appropriate.

Power Output is a measure of work over time.  In other words, how much work can you get done in the shortest amount of time.  Athletic measures of power include the vertical jump, standing broad jump, and medicine ball throws.  There are other measures that could be used as well depending on your chosen sport(s) or activities, goals, age, etc.  For older adults it may be as simple as how quickly one can get up off the floor and walk a certain distance.

There are certainly other things that could be assessed and measured including strength,  balance, and endurance but those will be specific to each individual case.

When all the testing has been completed, a report is generated using the Move2Perform software providing a movement and injury risk baseline.

This report also helps to generate a program to specifically address the identified needs.  The program would address movement deficiencies through corrective exercises, and also include options for strength training, power production, cardiovascular conditioning, and more.

Follow up appointments are an option to track progress throughout the year and increase the intensity of the program as needed.  Or if you just need a few pointers to get started, we’ll see you again next year.

Give us a call at 231 421-5802312231 590-1364 or shoot me an email:  joe@elitepttc.com for more information including how to get started.

 

 

 

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Increasing Intensity Without Increasing Load

This is an article I originally posted on SportsRehabExpert.com, and thought it would be a great piece for the blog audience as well so I apologize ahead of time if some of the terminology is a bit too ‘medical’.

 

I’m constantly on the lookout for ways to challenge my patients and athletes, but without overloading their joints and tissues.  Many of them want to really push themselves, but sometimes they are at that point in their lives or careers where it’s just not appropriate for longevity sake.  In this article I’ll discuss some of the strategies I use to get the most out of strength training without overloading the weakest link.

There are 4 basic ‘solutions’ to this problem that I will use.  I think the best way to cover these would be to describe a couple cases for the lower body and upper body:

Case 1:  Active military gentleman with 2 episodes of disc hernation and radicular symptoms within a two year period.  Both episodes were brought about with heavy lifting, but he also spends quite a bit of time sitting in the back of a helicopter in a seat that’s about 6″ off the ground (his knees are practically in his face).

I worked with him after the first incident, cleared his movement and had no symptoms.  He resumed weightlifting and all other previous activities. After 6 months in the clear he went back to heavy squats and deadlifts, and after 2-3 months of that began noticing the radiating pain into his left leg again.

This guy is an absolute beast when it comes to his fitness level and his form has always been very good.  But because of his past and his work demands, this is a guy that I want to limit the load he is using, as well as the positions he puts himself in.

Solution #1 – Move from bilateral stance to split or single leg stance

This one is pretty obvious in that there is no way he is going to load single leg activities the way he can load a traditional squat or deadlift.  Single leg deadlifts and squats are great options here because of the extra stabilization needed just to balance and control the trunk.  There is only so much weight you’re going to pull with these single leg movements.

Solution #2 – Asymmetrical loading

An example of this would be a single leg deadlift in which the weight is held in the opposite hand (of the stance leg) so the trunk must work in an anti-rotation manner as well as anti-flexion (see video above).  Another great example would be a front squat with a kettlebell in one hand (see picture below) using either the traditional grip or bottoms up.  The demands on the core can be quite high loading in this manner so the athlete gets a great workout with less overall load.

Single Arm Kettlebell Squat

Solution #3 – Postural Assist

Split squats or rear foot elevated split squats (REESS) are ideal for this type of athlete because the positioning makes it easy to maintain an upright spine and therefore decrease the shearing type loads you would see with a traditional squat where the trunk is angled forward.  Mike Boyle (one of the top strength coaches in the world) has talked extensively about this and thus his programs have moved from back squats to front squats to RFESS over time.  This type of squat can easily be asymmetrically loaded as well (different weighted dumbbells in each hand).

Rear Foot Elevated Split Squat

Solution #4 – Bottoms Up

There are many reasons I like kettlebells, and the ability to go bottoms up is another one of those reasons.  I can instantly make any kettlebell exercise much more challenging to the athlete’s grip and stability.  The video above showing the KB front squat is a great example, plus I will frequently use this with Turkish Get-Ups, various carries, and presses.

Double Bottoms Up Kettlebell Squat

_________________________________________________________________

Case 2:  This is more of a general example here as I work with a number of adult athletes post rotator cuff repair looking to return to their sport and the gym.  Unless they are competing in powerlifting or weightlifting events, I really don’t need them putting a whole bunch of weight on the bar to bench or shoulder press any longer.

My #1 job is to protect the repair while they are seeing me in PT, but also when they are beyond my care.  Job #2 is to give them tools to enhance performance and get them back to the sports they enjoy.  Again I believe this can be done using the ‘Solutions’ mentioned above.  Here are some examples for the upper body (although in the clinical or performance setting I would never really divide them up this way).

Solution #1 – Move from bilateral to single arm exercises.

The same idea applies to upper body as lower.  The amount of stabilization and balance needed to perform single arm presses (horizontal and vertical) is going to make it quite difficult to really load up with weight.

The single arm bench press is one of my favorites.  I have the athlete scoot their hip and shoulder off the bench so they really have to fight the weight pulling them off the bench.  I usually have to start athletes at about 50% of what they could dumbbell bench using the traditional two arm method.  Athletes are not always happy about going down in weight but they feel right away this is going to make them work.

Solution #2 – Asymmetrical loading

In the case of upper body pushing and pulling, the ‘solution’ of asymmetrical loading is usually just a version of ‘Solution #1′.  Another way to inject greater asymmetrical loading into singe arm lifts would be to have the athlete lift from a single leg stance position.  This isn’t something I use real often but there have been times I’ve had to be cautious with someone’s shoulder and wanted to increase intensity without increasing load.  Single leg/single arm kettlebell presses fall into this category, as well as single leg rows (hamstring killer!).

Can’t believe I couldn’t find a better picture than this!

Solution #3 – Postural Assist

In this instance, requiring the athlete to stand to overhead press (or go tall or half kneeling) brings a lot of postural and stability requirements to the table.  It makes it more difficult again to really load up the lift when they don’t have a bench to press into.

Solution #4 – Bottoms Up

Same thing again using the kettlebell bottoms up to work the grip harder and force great stability from the upper quarter.

Single Arm Press – Now that’s a picture! That KB is 55 KG by the way

Now don’t get me wrong, I still love to see big lifts.  There are just times when the person in front of you needs less loading so be creative and use these techniques to help create an optimal environment to make gains without risking injury.

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Private Pay Physical Therapy

I’ve been meaning to write an article about this for awhile now, and since the New Year and the many changes in the insurance industry it’s prompted some action on my part.

The current trend in the health insurance industry is to increase the patient’s responsibility for their health care.  This shows up in rising co-pays that are as much as $60 per visit or deductibles that can be as high as $10,000.  This pretty much means you pay the first $10,000 of your medical expenses before the insurance company starts kicking in anything.  On top of that you max have an ‘out-of-pocket’ max to reach so that you may still have a co-pay or a co-insurance until you reach that magic number.

I’ve had this type of insurance myself so I know full well how it works.  To be able to afford the monthly premiums anymore, some folks are forced to go this route and then pray that nothing bad happens to them or their family.

I’ve always offered what I think is a rather fair private pay rate since many people didn’t have insurance prior to the Affordable (laugh) Care Act.  Everyone is required to have insurance from this point forward or pay a fine.  Many younger folks are choosing to pay the fine for now since it is much cheaper than paying for insurance they probably will not use. In this case private pay for physical therapy is a no-brainer.

Now what about for those of you that do have insurance?  This is where is can be a little tricky.

The private pay rate here at Elite Physical Therapy is $75 per visit.  This was the lower end of what insurance companies would typically pay for a physical therapy session, although with cost cutting more companies are hovering around this point.  There are still companies that do pay significantly more than that depending on what is billed.

The typical session at Elite is 45 minutes (60 minutes day 1 with the evaluation), and is one on one with the physical therapist.  You have 45 minutes of my undivided attention plus access to me by phone or email with questions.  The typical frequency of visits is 2x per week, and in some cases 1x if cost, schedule, or distance are issues.

That being said, for a person who is private paying for physical therapy, that would come to $150 weekly.

Most clinics are going to see you at least 2-3x per week so if you have a $50 co-pay you’re already up to $100-150.  Not only that but most other clinics in this area will allow you 15 minutes with your therapist and the rest of the session is spent exercising on your own or with a tech.  You may save a little, but the quality of care may not be the same.

Here are a few other scenarios I have run into where someone chooses private pay over insurance:

  • They do not anticipate meeting their deductible and choose to pay the $75 private pay rate rather than what they would be charged if it were billed through the insurance.  Going through insurance can cost as much as $225 for the first visit and $90-120 for subsequent visits.
  • Some people would just rather keep their health information between them and their doctors so they request to private pay versus going through their insurance.  I’ve heard a number of valid reasons for this but the big one being concerns over the deductibles going up (much like claims against auto or home insurance).

Here are a couple other points to consider when choosing between private pay and insurance, or even which PT clinic is right for you:

  • My thought process with many injuries/conditions is that you should see substantial improvement within 4-6 sessions.  I tell my patients this right up front.  You may not be 100% that quickly but you should be well on your way.  I don’t want to waste your time and money so if things are not improving in that time frame its time to go back to your physician.  I hate to say this but I’ve had patients come to me with 20-30+ visits to PT under their belt already and no results.
  • Many clinics in this area do not give discounts for private pay physical therapy!  PT services, just like physician or hospital services, are billed out at a much higher rate than what would actually be paid out.  It’s a game we all have to play with the insurance companies unfortunately, but to bill a patient that same rate to me is ridiculous.  At a minimum you’re probably talking $150 for a 30-45 minute session.
  • This goes along with the point above – I’ve done some checking and as far as I know I have the cheapest private pay rate around.  I’ve even had a couple referrals from other PT’s because their ‘friend’ didn’t have insurance and I had the best rates.

The point of this article is to let you know that you have options!  Great care for a fair price is what it’s all about here.  If you have any questions at all feel free to contact me at 231 421-5805 or shoot me an email:  joe@elitepttc.com

 

 

 

 

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Competing at a High Level after an ACL Injury

Big thanks to Dave Chalmers who wrote this guest blog post.  Dave is an athletic trainer who currently writes on behalf of DME Direct

 

It’s every athlete’s worst nightmare. Tearing your anterior cruciate ligament and sustaining a devastating ACL injury. The reason these injuries are so terrifying to athletes is that the road to recovery is long and arduous, and even then there is no guarantee you will ever be the same player and you always run the risk of re-injury. However, over the years there have been major advancements in ACL rehabilitation and it is now much more plausible to return to competition after an ACL injury and compete at a high level.

Prehab

One aspect of ACL rehabilitation that often gets overlooked is the important time following the injury prior to surgery. As more people are realizing the significance of getting a recovery program off to a good start, the practice of prehabilitation is being implemented more frequently.

Typically the aim of prehab is to reduce swelling and stabilize the knee prior to surgery. This can be achieved through cold therapy and wearing a knee support to compress and stabilize the knee. Some mobility exercises can be performed at this stage if you experience no pain while doing them.

Post-Surgery

After successful reconstructive surgery, the rehabilitation process begins. This process can be broken down into a timeline with various phases. It is important that you stick to this timeline and do not rush things and risk re-injury.

The first two weeks immediately following surgery should be spent focusing on reducing swelling and controlling swelling. Similar to the processes of prehab, icing and compression should be applied here and the use of crutches combined with rest is commonly advised. At this time you can begin with static strengthening exercises such as lying down quadriceps and hamstring contractions.

After these two weeks, you should being a second phase of recovery. Mobility and strengthening exercises should continue and you can start to introduce exercises like shallow lunges and half squats. You can also start implementing adduction and abduction exercises for hip flexor strengthening as well as begin proprioception and balancing exercises.

At about the six week mark you can begin another phase of the rehabilitation. At this stage you can advance to full lunges and squats. You can now start to add weight for increased resistance and begin straight line jogging exercises.

Approximately twelve weeks after surgery you can begin to mix in training activities specific to your sport. The key here is to gradually increase speed and intensity of drills. Along with sport-specific drills, you should also focus on exercises that strengthen hip abductors and external rotators such as monster walks and single leg glute bridges.

Return to Competition

When and only when, your surgeon gives you permission to return to competition will you be able to start competing again. If you follow the processes outlined here you will give yourself the best chance to return to competition physically capable of competing at a high level. However, there is also a mental aspect that many athletes overlook.

Even if your body is ready physically, you may not be mentally prepared to trust your knee in live competition. Again, it is important to be patient and avoid returning until you are fully ready. Use the exercises mentioned above at the end of your recovery program to test yourself a bit and build confidence in your repaired knee. Once you return to competition, wearing a trusted ACL knee brace can give you extra support both physically and mentally.

The long road to recovery after an ACL injury can seem overwhelming at times. Dedication and discipline are required to rehabilitate yourself successfully. However, if you put in the work to reach a level where you are properly prepared physically and mentally to return, you can begin competing at a high level again.

Dave Chalmers is an athletic trainer who currently writes on behalf of DME Direct on topics related to sports medicine and physical therapy. When he’s not writing, you will most likely find Dave at the Staples Center cheering on his beloved Lakers.

 

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Low Back Pain and Asymmetries

I was just looking back through the last two years of blog posts and realized I really hadn’t written anything specifically discussing low back pain.  Low back pain ranks second only to the common cold when it comes to work days missed every year, and is also the second most costly ailment to treat.  Low back pain is also the most common complaint that I treat here at Elite Physical Therapy and Sports Performance.

I will admit there was a time when I dreaded seeing that diagnosis on the physician’s order, and I guarantee you most other PT’s would agree with me.  The spine is so intricate, there are so many muscles that attach throughout that area, and so much freedom of movement through the spine, pelvis, and hips that it used to be hard to know where to start.

Over the past five years I’ve learned a few more things and have really come to enjoy treating low back pain.  When you really study human movement and learn to detect common asymmetries in how we are aligned and move, it really isn’t that hard anymore to know where to start and make quicker changes in how someone feels and moves.

There are a number of great examples but today I want to look at one of the most prevalent:

Asymmetry #1 – Inability to Internally Rotate over the Left Hip

Check out the pictures below – seeing it will probably make more sense than me trying to describe it although I’m going to try anyway.

This guy is standing with more weight on his Right leg and pelvis rotated to the right. Check out how his trunk rotates back to the Left to compensate. You can even see how the rotation torques his abdominals and chest!

Almost all of us tend to stand more on our Right leg, and when we do our pelvis shifts and rotates over that hip just fine (this is relative internal rotation of the hip).  The pelvis in this instance is rotated to the Right just like in the  picture above and below.

Here is another great example from my friend Michael Mullin with some arrows drawn in to help you get the idea of the torque it can create in the body:

When we do stand on our Left leg, our pelvis tends to stay rotated to the right (this is relative external rotation of the hip).  This tendency results in a loss of internal rotation ability of the Left hip and a pelvis that does not rotate correctly when we walk or run.  Lots of other bad things happen right up the spine and down the lower extremities because of this.

Check out what happens with this runner who is stuck in this pattern.

No problem rotating into his Right hip during stance. No such luck on the Left.

Notice how when he is on his right leg, his right foot is directly under his body (in the mid-line) and his foot lands in a fairly neutral position.  Now check out his positioning on the left leg.  His left foot is more under his left hip than directly under him causing his knee and foot to roll inward to support him.  He cannot get over his left hip and rotate his pelvis as efficiently on the left as he can on the right.

This picture shows the proper positioning over the Left leg with the pelvis facing Left.

Michael is looking pretty content on his Left leg now

An inability to move out of this pattern will change the way we stand, walk, and run, and can potentially lead to a host of injuries even beyond the lower back.  Fortunately this asymmetry is manageable with some simple exercises that can be worked into warm-ups or between sets when at the gym.

If you’ve been suffering from chronic back, SI joint, or hip problems that have failed traditional treatment, then it may be because the underlying asymmetry has not been addressed.  I’ve had some great success treating these areas by identifying and correcting these asymmetries so definitely something to think about.

Stay tuned and next time I’ll talk about why your ribs flare more on the left than on the right (I’m such a geek!).  If you have any questions feel free to email me:  joe@elitepttc.com

 

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Elite PT and Sports Performance Exercise of the Week – The Whip Snatch

I wrote this article for my SportsRehabExpert.com site a few weeks back, and figured it would be good to share here as well just to give you an idea of some of the more advanced strength and power methods we use here at Elite Physical Therapy and Sports Performance.

 

I picked up this exercise from strength coach Paul Longo at Central Michigan University about 8 years ago (and now at Notre Dame). This was one of his favorites since it was so simple to teach and really hard to do incorrectly. I’ve used this exercise over the years with my more advanced athletes, and they’ve really like it so thought I would share.

Couple prerequisites here:

1) Deadlift is first and foremost. As you’ll see in the video, a great hip hinge is a requirement so the athlete must be technically sound in the deadlift.

2) Swings are a favorite of mine and I really just see them as deadlifts for speed and power. The athlete must demonstrate a perfect hip hinge, good power as they drive the hips into extension, and also must be able to stop the kettlebell on a dime and throw it back down. The last point here just shows me that the athlete has the ability to coordinate and stabilize through the entire body in an instant. This is important to me now that they will be going overhead with a bar.

3) Hard Style Overhead Presses are also important, not just for upper body strength, but also for that ability to learn how to stabilize the entire body while driving a weight overhead. It’s one thing to press a weight, and an entirely different thing to catch a weight overhead. I want to know my athletes are rock sold with their arms overhead.

Now on to the Whip Snatch:

Teaching Tips:

1) I don’t get real technical with measuring for grip on the bar for this lift. Have the athlete get their hands at just the right width that the bar sits at the level of their hip crease.

2) Push the hips back with the bar as far as possible. I will have them just do reps of this hip hinge initially.

3) Jump and shrug!

4) Catch overhead.

I find that if we have the start position correct and we’ve worked through the progressions, the rest of the lift usually falls in place. The only other cue I find I need at times is ‘elbows to the ceiling’ after the jump shrug to keep the bar close to the body.

The whip snatch is a great power move and one that falls in line with many of the other lifts we talk about here on the site. Definitely one to give a try!

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Shoulder Rehab Part III

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

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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