OUCH!!…My shoulder hurts!!

Shoulder pain is the third most common musculoskeletal disorder, following low back and neck pain (Donatelli). Because of the mechanical demands placed on the shoulder, it is susceptible to numerous soft-tissue injuries. One of these injuries is called shoulder impingement syndrome. It is the result of compression of the soft tissues i.e. most typically, the rotator cuff tendon, within the sub-acromial space. Impingement results from the cumulative stresses of repetitive shoulder motion such as pitching or sustained overhead activity such as painting. This repetitive stress can lead to tendonitis, rotator cuff tears, bone spurs, or bursitis.

Impingement syndrome can be classified in two ways – external vs. internal and primary vs. secondary. An external impingement affects the superior surface of the humeral soft tissues in the sub-acromial or coraco-acromial region. Applicable clinical tests include the Neer and Hawkin’s/Kennedy tests. An internal impingement may affect the undersurface of the rotator cuff, the posterior labrum, and is, more specifically, a post/sup impingement. Clinical exam may produce post/sup shoulder pain with passive ER which can be alleviated with a passive posterior humeral glide. A primary impingement is caused by the structural anatomy of the sub-acromial region. X-Rays can determine an abnormal variation in the shape of the acromion process. A type 3 “hooked” acromion may require surgical intervention to correct. On the other hand, a secondary impingement is the result of dysfunctional biomechanics of the shoulder joint. It may be due to weakness of the rotator cuff muscles, poor posture, gleno-humeral joint stiffness, thoracic hypomobility, and/or in-coordination/weakness of the scapular stabilizing muscles. And that is what WE treat at OrthoWell?

“I play tennis and developed pain in my shoulder so strong that I could not even sleep, let alone play! After the very first treatment (ART combined with joint mobilization) 80% of my pain was gone! I am practically pain free now after 4 visits. Thank-you Chris! Great job!” – DK

Patellar Tendinopathy – The role of Eccentrics.

Patellar tendinopathy can be a resistant and recurrent condition in running and jumping sports. An important part of your patient’s physical therapy program should include eccentric exercise. What are eccentrics? Eccentric contractions occur when the muscle-tendon unit LENGTHENS during exercise, producing so-called “negative work”. Squatting down is an example of a quad eccentric. Eccentric force production may exceed concentric (shortening contraction) and isometric (tensing without motion) forces 2-3 times. (Stanish et al) Eccentric training drills stimulate mechanoreceptors in tenocytes to produce collagen. (Khan et al) This effect helps to reverse the tendinopathy cycle.

The eccentric exercise commonly recommended for the patellar tendon is the squat. What kind of squat is best? A mechanism that may decrease the eccentric load on the quad is active or passive calf tension. This tension may limit the forward movement of the tibia over the ankle while performing a squat. This effect can be minimized, and load on the patellar tendon maximized, by performing a squat on a 25 degree decline. (Purdam et al) In a small group of patients with patellar tendinopathy, eccentric squats on a decline board produced good clinical results in terms of pain reduction and return to function. (Purdam et al) In the flat-footed squat group, the results were poor.

The eccentric training protocol for patellar tendinopathy should include 3 sets of 15 reps, 2 times per day, for up to 12 weeks.

“I started therapy at a rehab close to home but was not getting results after 12 visits. I then came to Chris and within 2 weeks (4 visits) the results have been substantial. What a difference!” — Kristin M.

The P.R.I.C.E. is right! Patient Handout.

As your therapist, one of my most important roles in your recovery is teaching you the fundamentals of proper healing. Healing of injured tissue is a physiological process that can be inhibited by many factors. Pain management strategies, activity modification, and proper exercise are three such factors that need to be examined.

PAIN MANAGEMENT

All new injuries or aggravation of old injuries need to be addressed with the acronym P.R.I.C.E. – Protect, Rest, Ice, Compress, Elevate. We will talk about the protection aspect in the next section on activity modification. After an acute injury, there is resulting tissue trauma and inflammation. Inflammation is part of the healing process as the body attempts to bathe the injured tissue with protein rich fluid as well as cells that cleanse and repair the injured tissue. Inflammatory cells can be present up to 21 days after an injury, but are the most prevalent during the acute inflammatory stage i.e. first 7-10 days. Uncontrolled inflammation is what delays healing and it is what we attempt to control with R.I.C.E. Ice should be applied for 10-15 minutes only in order to prevent frostbite. You can use soft, gel cold packs, bags of frozen peas or ice, or submerge the injured part into an ice water bath. You can ice every hour if you wish, but at a minimum of 2-3 times per day, for at least the first 7-10 days. Remember that the inflammatory process (in the controlled environment) can last 21 days. The adage “ice for the first 48 hours only” does not make physiological sense. Icing is not only anti-inflammatory, but it is also a great pain reliever. You should also consult with your physician regarding an anti-inflammatory medicine. Examples would be medicines such as Aleve 2x/day or 600-800mg of ibuprofen i.e. Advil or Motrin 3x/day for at least 7-10 days. Compression and elevation of the injury helps to prevent uncontrolled inflammation as well. Athletic taping, neoprene or Acewrap sleeves for ankles or knees, and back braces are examples of compression as well stabilization of an injury. Heating tissue can be relaxing and pain relieving, but it also causes the blood vessels to dilate, hence, increasing the flow of fluids to the area. If you wish, heating for 15-20 minutes can be added after the first 7-10 days as long it does not increase the swelling.

ACTIVITY MODIFICATION

Protecting the injury will prevent uncontrolled inflammation, thus encouraging proper healing. Pain is a warning sign. It is your body’s attempt to remind you that something is wrong. Pushing “through the pain” is NEVER a good idea. When a lower extremity joint is injured and walking becomes painful or limited, we advise and instruct patients in using crutches or canes. This is a temporary modification of activity in order to prevent reoccurrences of pain as the body is healing. Our patients use an assistive device as long as is needed, but most typically for the first 7-10 days. Proper posture and body mechanics are also very important in removing the stresses to an injured back or spinal condition. Remember that causing pain during activity is like taking a hammer and “banging” on the injured tissue. Take frequent breaks and pace your activity as to not provoke your pain. It is important to wean slowly back into walking or running. We will help to guide you in that process.

PROPER EXERCISE

Proper exercise can be initiated after the acute inflammatory stage. Movement of joints and tissues during exercise causes a mechanical “pumping”. This “pumping” can help to “push in the good and push out the bad”, prevent post-traumatic stiffness, and encourage a quicker return to function. Proper technique in these early stages would entail pain free, high rep, and low weight exercises. We will guide you in that process. Creating a global circulatory effect via pain free cardiovascular exercise is also beneficial to healing as it helps to cleanse and nourish the injured area.

I hope that helps!!

Chris Dukarski, PT

The Missing Link – SCAR TISSUE

 

Scar Tissue

All physical therapy is NOT created equal. As a physical therapist with 2 decades of hands-on care, I have tried many approaches in treating soft tissue dysfunction. Tissue stress can be identified objectively through a comprehensive biomechanical evaluation and well as subjectively through a thorough interview with the patient. Patient compliance and therapist experience is paramount in achieving maximum results in minimum time. I strongly feel that the “missing link” in achieving permanent, maximum results is inadequate treatment of soft tissue fibrosis i.e. scar tissue throughout the kinetic chain. Let me explain!

One of the most contentious debates that I have had with physicians as well as physical therapists is the inflammation versus fibrosis debate. Many health care practitioners feel that inflammation is the main source of pain in chronic conditions (greater than 3 weeks). This is evidenced through their long-term use of anti-inflammatory meds, cortisone shots, and the over-use of anti-inflammatory modalities in physical therapy such as iontophoresis and phonophoresis. My main adage as a physical therapist is “there better be a good reason for everything you do!” Evidence-based or research-based treatment is fundamental to our professional growth. I feel that using anti-inflammatory procedures is a very effective strategy in the short-term. It is true that we are our own worst enemies during our hectic lives. Intermittent, acute inflammation can certainly occur. However, what underlying dysfunction is present that predisposes us to this chronic, intermittent pain? What does the research tell us?

Karim Khan,MD in “Time to abandon the “tendonitis” myth”, BMJ, 2002, 324(7338):626-7 reports that “animal studies conclusively demonstrate that, within 2-3 weeks of insult to tendon tissue, inflammatory cells are not present.”

Karim Khan,MD in “Histopathology of common tendinopathies”, SportsMed 1999;27(6):393-408 states that “We conclude that effective treatment of athletes with tendinopathies must target the most common underlying histopathology, TENDINOSIS, a non-inflammatory condition.”

Harvey Lemont,DPM in “Plantar fasciitis”, JAPMA 2003;93(3):234-237 states that, after analyzing tissue samples from 50 plantar fascia surgeries, “Histologic findings are presented to support the thesis that “plantar fasciitis” is a degenerative fasciosis WITHOUT inflammation, not a fasciitis.”

Although the literature states that inflammation is not present in chronic soft tissue lesions, many practitioners continue to get positive results with anti-inflammatory procedures. Why? Steroids have been shown to inhibit the early stages as well as the later manifestations of the inflammatory process. (Fredberg 96) Ultrasound guided peritendinous injections of achilles and patella tendonitis have shown a significant reduction in the average diameter of the affected tendons (Fredberg 04) as well as a disappearance of neovascularization. (Koenig 04) What this last statement means is that steroids have the ability to “shrink” pathological tissue. This “shrinking” has been associated with a decrease in pain, but it does not stimulate tissue regeneration and strengthening of the pathological tissue. As a result, the patient is susceptible to chronic reinjury. So how does the therapist stimulate tissue regeneration?

The first step in the process is to identify tissue texture abnormalities. Microscopically, healthy tissue is smooth, longitudinal, and symmetrical in presentation. Scar tissue i.e. fibrosis is laid down by our bodies in a very haphazard and erratic fashion. During palpation, both the clinician and the patient can detect areas of grittiness, nodules, and “knots”. A partial tear in the Achilles tendon is thicker, harder, and gritty compared to the healthy side. Fibrosis in the plantar fascia can be felt and heard as you stroke the edge of a coffee mug along the central band of the fascia. Once a lesion is detected, I utilize patented and proven techniques such as instrument assisted soft tissue mobilization(IASTM) and Active Release Technique to “break up” cross-links, adhesions, and/or restrictions in the tissue. Please read my links for Graston’s New IASTM and Active Release Technique for more information.

As a result of 2 decades of asking questions and critically appraising my successes and failures, I have become convinced that the “missing link” in the treatment of chronic pain is the release of scar tissue adhesions. In conjunction with IASTM and Active Release Technique, rehabilitation is accomplished through the functional integration of strengthening, stretching, joint mobilization, cardiovascular exercise, and compliance with a home exercise program. Correcting biomechanical deficiencies with foot orthotics is also a consideration. Most physical therapists do an adequate job of treating pain. Acute pain usually resolves with the most innocuous of therapy interventions. However, the only way to prevent reoccurrence of symptoms is to ensure that every aspect of the dysfunction is being treated in the most comprehensive manner. At OrthoWell/WalkWell, we do just that!

CLOSED CHAIN CREATIVITY

Closed chain exercises for the lower extremities should be an integral part of your rehabilitation program. They are important in terms of regaining dynamic stability and improving neuromuscular control. Co-contraction of the muscles on all sides of a joint occurs only thru closed chain or weight bearing activities. An effective program for a patient with an ACL tear of the knee should include exercises such as squats, lunges, and step-ups. A patient recovering from an ankle sprain should perform balance board activities. In terms of patello-femoral dysfunction or pain in the region of your kneecap, the literature describes a strong link between hip weakness (especially the hip abductors and external rotators) and P-F pain. Open chain exercises such as straight leg raises should be performed in every plane of motion. Closed chain exercises should incorporate multi-planar strengthening as well. The following exercises include hip abductor resistance during a functional squat exercise and hip adductor resistance during a lunge. Creativity is the key to devising a more functional and sport specific program.

At OrthoWell/WalkWell, we use evidence-based and creative strategies to get our patients better- FASTER!   The following testimonial is from a recent “graduate”.

“I’ve had major ankle issues for over 15 years and have seen several PT’s and specialists but saw no progress until I came to WalkWell. After only 10 visits, I have made more progress than in the 15 years combined. The individual attention and rehab is without peer. And on the 8th day, God created WalkWell!” – Tom Lynch, Ipswich, MA

Shoulder Exercises: The Evidence

Everything we do at OrthoWell is evidence-based! Maximizing results in minimal time depends on the expertise of the clinician. As our knowledge of biomechanics and muscle function improves, more of an emphasis is placed on scientifically based rehabilitation protocols. This is particularly true regarding the shoulder and scapulothoracic complex. In the February 2009 volume of JOSPT, Mike Reinold, the Boston Red Sox team physical therapist, presented a thorough analysis of the shoulder and scapular stabilization exercise literature. One of the most effective exercises for each muscle will be presented.


Supraspinatus
*Full Can Exercise
*Enhances scapular position>
*Decreased deltoid compared to empty can
*Minimizes superior humeral translation

Infraspinatus/Teres Minor
*Side-lying ER
*Minimal capsular strain
*25% increased EMG using towel roll
*Highest EMG for infraspinatus

Subscapularis
*IR at 90 deg abd
*Position of shoulder stability
*Enhanced scapular postion
*Less pectoralis activity than 0 deg abd

Serratus Anterior
*Push-up with plus
*Easy position to resist protraction
*High EMG activity
*Also activates subscapularis

Lower Trapezius
*Prone full can at 135 deg abd
*Full can = horiz abd with ER(thumbs up)
*High EMG activity
*Also activates infraspinatus, teres minor, Mid traps, supraspinatus

Middle Trapezius
*Prone Full Can at 90 deg abd
*High EMG activity
*Also activates infraspinatus, teres minor, Mid traps, supraspinatus

Rhomboids
*Prone Row
*Below 90 deg abduction
*High EMG activity
*Good ratio of upper, mid, low traps

Combo Exercise
*Bilateral T-band ER
*25% increased EMG ER’s with towel roll
*Good ratio upper:lower traps per McCabe
*Emphasize scapula retraction and post tilting

In addition, it is clinically imperative to ensure proper technique during all therapeutic exercises especially as your patient is progressed to plyometrics, closed chain UE exercises, and sport- specific exercise training. Proper exercise TECHNIQUE and proper exercise CHOICE is required to effectively treat the muscular imbalances seen in most shoulder pathologies.