Baseball Throwing Injuries. Oh no…not me!!!

Throwing a baseball is the fastest known human movement. The speed of the throw from a professional baseball pitcher can be upwards of 7000 degrees per second. Now that’s fast! In addition to that, the shoulder is the most mobile joint in the human body. So what does this mean?

EXCESSIVE SPEED + EXCESSIVE MOBILITY = POTENTIAL PROBLEMS

Baseball Pitcher

Image courtesy of FreeDigitalPhotos.net

For those of you that “feel a need for speed”, you need to beware of the risks. In an article from the Journal of Sports Medicine, twenty-three professional pitchers were followed over three seasons. Those pitchers who were throwing at the highest maximum velocity suffered the highest incidence of elbow injuries. So how does that effect you? It is vitally important for the throwing athlete to understand the stresses that repetitive throwing places on young as well as mature joints. In the words of baseball trainer phenom Eric Cressey, “injuries occur when you ignore the things that need to be addressed, plain and simple.” In one of my previous blog posts, I talk about how it has been scientifically proven that strength training enhances athletic performance. Shoulders and elbows become problematic not only because of muscular weakness, but also from poor flexibility, poor tissue quality ie scar tissue and, of course, faulty mechanics.
For example, consider the dreaded inverted or upside down “W” exhibited by the Yankees’ Joba Chamberlain or the National’s Stephen Strasburg.

Click Here to see a Picture

Guess what happened to them? Yup….Tommy John surgery to fix a torn ligament in their elbows. So then…

EXCESSIVE SPEED + EXCESSIVE MOBILTY + BAD TECHNIQUE = DEFINITE PROBLEMS

Just because a joint is flexible does NOT mean that it is stable. Consider the six phases of throwing and all the potential areas of instability when throwing at maximum velocity. Our objective should be to achieve dynamic stability during ALL phases. Yes, if you are stiff we are going to stretch you and if you are loose we are going to stabilize you…but what about the gray areas? Every major league pitcher suffers from a loss of shoulder internal rotation for at least 3 days after an outing. This is a situation when you do NOT stretch. The resulting loss of motion is due to the micro-trauma of eccentric load during deceleration and needs time to heal. It has been shown that the posterior aspect (the back part) of the shoulder joint capsule actually thins out after repetitive throwing. So let me ask you, should we ever stretch the posterior aspect of the shoulder joint? Or should treatment focus more on the scar tissue that results in the decelerators?

So what are the most common upper extremity baseball throwing injuries? These injuries include the problems associated with overuse or improper training such as:
• Impingement syndrome
• Rotator cuff tendonitis
• Biceps tendonitis
• Medial elbow pain from flexor-pronator tendonitis

These overuse injuries can lead to more serious conditions such as:
• Rotator cuff tears
• Labral tears
• Ulnar collateral ligament (UCL) tears

We have many manual tests that we can perform in the clinic to differentiate and determine what structures may be involved in YOUR specific case. In the case of impingement syndrome, I have previously posted a BLOG article on the different types of impingement syndrome as well as a VIDEO demonstrating the tests that we use to differentiate rotator cuff versus labral dysfunction. It should be noted that a condition called scapular dyskinesis can lead to impingement syndrome. This condition is characterized by an imbalance of scapular motion relative to shoulder motion. It is the result of weakness in the muscles that stabilize the scapula during the throwing motion. I have also listed some of the best, evidence-based exercises in a previous post for specific shoulder and scapular retraining.

It is very important for your therapist to differentiate between what we call active restraint or passive restraint structures. Active restraint structures are those things that contract and relax like your muscles and tendons. Passive restraint structures are things like ligaments ie UCL, cartilage ie labrum and meniscus, and discs ie intervertebral discs. I would like to highlight the UCL of the elbow as one example of this. For many pitchers, the first sign of impending trouble with the UCL is pain or stiffness in the flexors of the forearm. The flexors and pronators of the forearm are the active restraints and the UCL is the primary passive restraint to the extreme valgus forces that occur at the elbow during terminal cocking phase and early acceleration. Did you know that when the UCL is tested in isolation during cadaver studies that it only takes 32 newton/meters of force to rupture it? Guess how much valgus stress is on the inside part of the elbow during terminal cocking phase….64 newton/meters!! It has been shown that the UCL takes on 35 newton/meters of that force. Yikes!! So why doesn’t it rupture? It doesn’t rupture because the rest of that stress is controlled by the active restraints…your muscles in the forearm. You can probably guess what happens when you ignore your forearm muscles?

As mentioned earlier, imbalances in flexibility, tissue quality, biomechanics, or weakness can lead to stress on both active and passive restraints during the throwing motion. Invariably, the process of repetitive throwing leads to the development of scar tissue. There is a constant state of break-down and build-up that occurs during sport specific activity. I have blogged on problems with scar tissue  and the debate on whether pain arises from tendonitis or not. I have also explained the benefits of the Graston Technique  as a way to ensure that scar tissue does NOT inhibit your ability to throw.

Now, what blog post is complete without a little twist. After listing the most common injuries that we see in the throwing athlete, I would like to share a list of conditions that have been confirmed via MRI in athletes that have NO pain:

* 79% of overhead throwing athletes have labral tears
* 34% of athletes have rotator cuff tears
* 82% of athletes have disc herniations

Does this mean that you may ALREADY have a tear and that you are currently asymptomatic like the athletes in the previous studies? Yes, you may. Does this mean that your future hall of fame career is over? No, it doesn’t. Some practitioners are of the opinion that you may very well need a labral lesion to throw hard in the first place. The biggest challenge with this is ensuring that the throwing athlete develops all the things that we have talked about in this post:

• Dynamic stability
• Proper flexibility
• Maximum strength
• Proper tissue quality
• Proper throwing mechanics

It is ALL these reasons that make it vitally important to be as educated as you can about your shoulder mechanics and to be aware of the important role that training and physical therapy play in keeping you healthy.
Understanding throwing biomechanics in combination with a thorough knowledge of the anatomy and function of the shoulder and elbow is imperative to properly diagnose and treat the throwing athlete. Your prognosis for a healthy return to competition after arthroscopic surgery or ligament reconstruction has dramatically improved especially when you are in the right hands during recovery. My job as a physical therapist is not only to effectively rehabilitate your body after surgery but, more importantly, to help PREVENT the need for surgery in the first place. Of course, this is a two way street. I can only be your coach if you are a willing and motivated player.

SI Joint Pain & Dysfunction. Do U Have It?

The sacroiliac or SI joint is the articulation between the bone at the base of the spine called the sacrum and the bones on both sides of the pelvis called the ilium. Refer to the picture below.

Over 22 years of physical therapy, I have treated many patients with low back and buttock pain who were diagnosed with an SI joint dysfunction. The difficulty with diagnosing an SI joint dysfunction is that the SI joint has no specific distribution pattern of pain.  Pain directly over the SI joint does not necessarily mean that the joint itself is involved. SI joint pain can very often be referred pain from other structures such as the disc, nerve root, or facet joints of the lumbar spine. Many physical therapists or physicians attempt to diagnose an SI joint dysfunction through palpation of bony landmarks as well as assessment of SI joint mobility. There is only a very small amount of motion in the SI joint i.e. 2-3 mm or 2-3° of gliding or rotation thereby making an accurate diagnosis very difficult. In addition, evidence based research refutes the reliability and validity of accurately assessing bony landmarks and SI joint mobility. McGrath et al has published an article, entitled Palpation of the sacroiliac joint: an anatomical and sensory challenge in which the concept of SI joint palpation is scrutinized. Freburger and Riddle performed a literature review looking at our ability to perform SI joint motion testing. They found poor inter-tester reliability, low sensitivity, and low specificity in several commonly performed tests. Inter-rater reliability is essentially the ability for multiple practitioners to come to the same diagnostic conclusion. If you have multiple individuals perform the same test, the results should be the same. Riddle and Freburger in another study noted that the ability to detect positional faults of the SI joint also has poor reliability. At present, the only acceptable method of confirming or excluding a diagnosis of a symptomatic SI joint is a fluoroscope guided intra-articular anesthetic block ie an injection directly into the SI joint. (Laslett et al) So how can I, as your physical therapist, assist in the diagnosis of an SI joint dysfunction?  The answer: SI joint provocation tests!

Two recent studies by Laslett et al and Van der Wurff et al have demonstrated that there isn’t just one key or ideal SI joint provocation test. However, by performing several tests together, you can increase your sensitivity and specificity of detecting an SI joint dysfunction. Both studies reported that the accuracy of detecting SI joint dysfunction is increased if least 3 of the 5 tests are positive. Furthermore, if all 5 tests are negative, you can likely look at structures other that the SI joint. Van der Wurff et al reported that if at least 3/5 of these tests were positive, there was 85% sensitivity and 79% specificity for detecting the SI joint as the source of pain.  Interestingly, another study by Kokmeyer et al agreed with the previous findings, but also noted that the thigh trust test alone was almost as good at detecting SI joint dysfunction as the entire series performed together.

Combining the two studies, there are 5 provocation tests to perform when attempting to diagnose SI joint pain:

  1. Thigh thrust/Femoral Shear test
  2. SI Distraction Test
  3. SI Compression Test
  4. Gaenslen’s Test
  5. FABER / Patrick’s test

The following video will demonstrate these tests. I would like to thank Mike Reinold, PT for his blog information that was used to complete this explanation of SI Joint dysfunction.  Check out the video below!!

CORRECTION:  I would like to clarify the SI distraction test as described in Laslett. I believe that he considers the direct posterior shear of the innominates as a distractive force of the ilium away from the sacrum. I initially interpreted this test as a compression of the SI joint via a distraction of the ASIS’s. I guess it depends on HOW you apply the force to the ASIS’s.  Also, the sidelying “compression” test needs to be performed in a straight, linear fashion as well in order to compress the SI joint. It is important to place a towel roll under the lumbar spine in women in order to prevent sidebending stress t the lumbar spine. In OMT, we use the sidelying position to “distract” the SI joint using more of a rotational force on the lateral edge of the ilium in order to “open up” and distract the SI to get a feel for joint play. As you can see, these tests are not definitive for exactly HOW they stress the joint but they are specific for a stressing maneuver TO the SI joint.

 

Nerve Mobilization Techniques

I would like to highlight one of the unique treatment techniques that we offer at OrthoWell.  As many of you know, we spend a lot of quality time during our biomechanical evaluation trying to “figure things out”. This is the reason that several of our referring physicians call us “THINKERS”.  We pride ourselves in determining your functional diagnosis. This diagnosis is what we use to develop your plan of care and to educate you in how to alleviate your pain or dysfunction. Many of our patients have seen several physicians or therapists before hearing about us. For this reason, we offer specialized evaluation and treatment services that our patients may not have heard of and that may be appropriate to alleviate symptoms that have been unresponsive to prior interventions.  One of these is Nerve Mobilization or NeuroMobilization. So what is it?

What is NeuroMobilization?

NeuroMobilization or Nerve Mobilization is a technique that we utilize to treat nerves that may be adhered, irritated, or compressed.  Many patients that have been unresponsive to other physical therapy and present with a chronic history of referred symptoms like pain, numbness, or tingling into the arms or legs may respond to NeuroMobilization.  Every patient that presents with referred symptoms or pain that has been unresponsive to localized treatment receives a complete neural tension evaluation.  Neural tension testing is a way for your therapist to determine the extent of nerve involvement.  By mobilizing a nerve, we can determine, in combination with manual traction and sensitizing maneuvers, whether your pain is originating from the spine or the periphery.

NeuroMobilization Techniques

We can then perform NeuroMobilization techniques utilizing controlled neural tension maneuvers to mobilize the nerve up and down.  David Butler,PT, has been at the forefront of these techniques for over 20 years.  Although we still do not completely understand the exact mechanism, he proposes that NeuroMobilization (what David Butler calls Neurodynamics) can accelerate nerve healing and quiet down what he calls an “altered impulse generating system (AIGs)”.  These AIGs may respond to the oscillations of NeuroMobilization by enhancing circulatory exchange or ion transfer in and around the nerve.  You can read more about the techniques and science in David Butler’s book The Sensitive Nervous System.

Here is a video that highlights a sciatic nerve tension test and Neuromobilization.

 

PUMP YOU UP!!

So how important is resistance training? I have had the privilege of working with one of my peers, a fellow PT, and strength and conditioning specialist, Mike Stare from Spectrum Fitness in Beverly, both professionally as well as personally. Mike helped to redirect MY fitness program while I was recovering from my knee injuries 1.5 years ago. Mike is on top of his game from a fitness training standpoint. He has devoted a lot of time and resources in developing an evidence-based approach to fitness and weight loss in ALL age groups. You can see this for yourself at his website. It is important for clients in a fitness program as well as our patients in physical therapy at OrthoWell to understand HOW to strengthen muscles.

The physiological principle of “overload” is what makes the difference between strength gains and stagnation. Resistance training is hard work! I tell my patients “If it’s easy, then you’re doing something wrong!” Is it true that people will lose 5-10% of muscle strength in every decade of life after the age of 40? Studies have shown that people can retain 100% of their muscle mass and strength from age 40 through their 80s with exercise! (Wrobelski, A. et al. The Phys and Sports Med, Sept 2011) You can read more on the Anti-Aging movement at Mike’s BLOG as well.

However, during exercise, you need to challenge your muscles physiologically. You need to provide a “load” that goes “over” your muscles comfort zone. In order for a muscle (including the heart) to increase strength, it must be gradually stressed by working against a load greater than it is used to. So how do you do this? There are many books and magazines such as Muscle Fitness that advocate all kinds of strategies for maximizing strength and muscle mass. Strength gains can be accomplished by performing a one-repetition maximum as well as via the typical 10 rep set approach. My approach, with the fine-tuning of Mike, is to instruct my patients in 2-3 sets of 8-12 repetitions per exercise. The most important factors to consider are the utilization of proper technique in order to isolate the specific muscle as well as to use the idea of the “loss of technical form” as your maximum output point. By the time you reach the 8-12th rep you should be tiring and on the verge of a loss of technical form. You should not work to fatigue as this will compromise your technique and become a safety concern. Regarding the frequency of strengthening exercise, studies show that strength gains are maximized at a frequency of 2-3x per week. The American College of Sport Medicine (ACSM) recommends working out a MINIMUM of 2x per week at an intensity that is equal to 70-85 percent of your one rep maximum (maximum weight you can use for one rep) for 8-10 reps and 1-3 sets. A program that comprises repetitions over 12 is considered endurance training. For cardiovascular benefits, the ASCM recommends exercising for a frequency of 3-5 times per week, at an intensity equal to 60-85 percent of your maximum heart rate for a time of 20-60 minutes. Research has shown that you’ll get the same beneficial results by exercising at 50-60% of your maximum heart rate that you would get exercising at an intensity 80% of your maximum heart rate.

At OrthoWell, as part of your physical therapy, we get you started on a strengthening program that targets your problem area. Finding the right practitioner to design a complete, individualized fitness program can be a very rewarding thing and Spectrum Fitness is definitely one of our choices. As Mike points out, “If there is one thing to do to improve the quality of life as we age, strength training would be it.”

For our athletes and runners, don’t forget that strength training has been PROVEN to enhance athletic performance. Read the following to get the facts!

-A University of Alabama meta-analysis of the endurance training scientific literature revealed that 10 weeks of resistance training in trained distance runners improves running economy by 8-10%.  For the mathematicians in the crowd, that’s about 20-24 minutes off a four-hour marathon – and likely more if you’re not a well-trained endurance athlete in the first place.

-French researchers found that the addition of two weight-training sessions per week for 14 weeks significantly increased maximal strength and running economy while maintaining peak power in triathletes.  Meanwhile, the control group – which only did endurance training – gained no maximal strength or running economy, and their peak power actually decreased (who do you think would win that all-out sprint at the finish line?).  And, interestingly, the combined endurance with resistance training group saw greater increases in VO2max over the course of the intervention.

-Scientists at the Research Institute for Olympic Sports at the University of Jyvaskyla in Finland found that replacing 32% of regular endurance training volume with explosive resistance training for nine weeks improved 5km times, running economy, VO2max, maximal 20m speed, and performance on a 5-jump test.  With the exception of VO2max, none of these measures improved in the control group that just did endurance training.  How do you think they felt knowing that a good 1/3 of their entire training volume was largely unnecessary, and would have been better spent on other initiatives?

-University of Illinois researchers found that addition of three resistance training sessions for ten weeks improved short-term endurance performance by 11% and 13% during cycling and running, respectively.  Additionally, the researchers noted that “long-term cycling to exhaustion at 80% VO2max increased from 71 to 85 min after the addition of strength training”

KinesioTape-The Evidence

I have received several comments from bloggers that “there is no evidence” regarding the effectiveness of Kinesiology Taping or KinesioTaping Techniques. I would like to share with you some very detailed clinical study outcomes that are present, and copied here, from the SpiderTech website. This post is definitely more clinical in nature, but it can certainly help any interested patient or practitioner in understanding the evidence behind the WHY and HOW of KinesioTaping.

The Clinically Proven Effectiveness of Kinesiology Taping

Taping is widely used in the field of rehabilitation as both a means of treatment and prevention of sports-related injuries. The essential function of most tape is to provide support during movement. Some believe that tape serves to enhance proprioception and, therefore, to reduce the occurrence of injuries. The most commonly used tape applications are done with non-stretch tape. The rationale is to provide protection and support to a joint or a muscle. Utilizing existing stretch tape, investigators have shown clinical improvement in patients with grade III acromioclavicular separations, anterior shoulder impingement, and hemiplegic shoulders. In recent years, kinesiology tape has become increasingly popular as a therapeutic treatment option in North America and Europe. Kinesiology tape was developed in the 1970’s and was engineered to mimic the qualities of human skin. It has roughly the same thickness as the epidermis and can be stretched between 130% and 140% of its resting length longitudinally. The application techniques were developed through the use of applied kinesiology taping, which
logically gave the therapy and material its name. The tape reportedly has several benefits, depending on the amount of stretch applied to the tape during application: (1) to provide a positional stimulus through the skin, (2) to align fascial tissues, (3) to create more space by lifting fascia and soft tissue above the area of pain/inflammation, (4) to provide sensory stimulation to assist or limit motion, and (5) to assist in the removal of edema by directing exudates toward a lymph duct. The clinical information on kinesiology tape suggests improved function, pain, stability, and proprioception in pediatrics and patients with acute patellar dislocation, stroke, ankle and shoulder pain, and trunk dysfunction. The respective information comes from case series and pilot studies, the most important of which are summarized in the following:

In a prospective, randomized, double-blinded, clinical trial using a repeated-measures design Thelen et al. investigated the clinical efficacy of kinesiology tape for shoulder pain. Forty-two subjects clinically diagnosed with rotator cuff tendonitis/impingement were randomly assigned to 1 of 2 groups: A therapeutic kinesiology tape group or a sham kinesiology tape group. The therapeutic kinesiology tape group showed immediate improvement in pain-free should abduction after tape application. It was concluded that kinesiology tape may be of some assistance to clinicians in improving pain-free active range of motion immediately after tape application for patients with shoulder pain.

In 2009, Fraizer et al. examined in a case series the clinical outcomes for patients with shoulder disorders who were treated with a comprehensive physical therapy program that included kinesiology taping techniques. Five patients
were treated with this taping method among other interventions. All patients demonstrated clinically important improvements in function. The authors concluded that kinesiology taping should be considered as an optional clinical
adjunct in the treatment of shoulder pain as part of a comprehensive physical therapy regimen.

Also in 2007, Yoshida et al. studied the effect of kinesiology tape on lower trunk range of motions. Thirty healthy subjects with no history of lower trunk or back issues participated in the study. Based on their findings, the authors determined that the application of kinesiology tape applied over the lower trunk may increase active lower trunk flexion range of motion.

In 2007, Lie et al. studied the application of kinesiology tape in patients with lateral epicondylitis. The experimental results indicated that wearing kinesiology tape causes the motions of muscle on the ultrasonic images to be enhanced which the authors believe to indicate that the performance of muscle motion was improved.

The effect of taping using kinesiology tape in an acute pediatric rehabilitation setting was investigated in a 2006 pilot study by Yasukawa et al. The purpose of this pilot study was to describe the use of the kinesiology tape for the upper extremity in enhancing functional motor skills in children admitted into an acute rehabilitation program. Fifteen children (4 to 16 years of age), who were receiving rehabilitation services participated in this study. The improvement from pre- to post-taping was statistically significant. These results suggest that kinesiology tape may be associated with improvements in upper-extremity motor control and function in the acute pediatric rehabilitation setting. The authors concluded that the use of kinesiology tape as an adjunct to treatment may assist with the goal-focused occupational therapy treatment during the child’s inpatient stay.

In 2009, Tsai et al. evaluated the effects of a bandage replacement by kinesiology tape in decongestive lymphatic therapy (DLT) for breast-cancer-related lymphoedema. Forty-one patients with unilateral breast-cancer-related lymphoedema for at least 3 months were included in this study. The study results suggested that kinesiology tape could replace the bandage in DLT, and it could be an alternative choice for the breast-cancer-related lymphoedema patient with poor short-stretch bandage compliance after 1-month intervention.

As published in the journal Top Stroke Rehab., Jaraczewska et al. indicated that kinesiology tape could improve the upper extremity function in the adult with hemiplegia. The article discusses various therapeutic methods used in the treatment of stroke patients to achieve a functional upper extremity. The only taping technique for various upper extremity conditions that had previously been described in the literature is the athletic taping technique. The authors concluded that kinesiology taping in conjunction with other therapeutic interventions could facilitate or inhibit muscle function, support joint structure, reduce pain, and provide proprioceptive feedback to achieve and maintain preferred body alignment. Restoring trunk and scapula alignment after the stroke is critical in developing an effective treatment program for the upper extremity in hemiplegia.

The clinical efficacy of kinesiology taping in reducing edema of the lower limbs in patients treated with the Ilizarov method was investigated by Bialoszewski et al. The study involved 24 patients of both sexes subjected to lower limb lengthening using the Ilizarov method who had developed edema of the thigh or leg of the lengthened extremity. The mean age of the patients was 21 years. The patients were randomized into two groups of twelve, which were then subjected to 10 days of standard physiotherapy. The study group was additionally treated with kinesiology taping (lymphatic application), while the control group received standard lymphatic drainage. The application of kinesiology taping in the study group produced a decrease in the circumference of the thigh and leg statistically more significant than that following lymphatic drainage. It was concluded that kinesiology taping significantly reduced lower limb edema in patients treated by the Ilizarov method and that the application of kinesiology taping produced a significantly faster re-education of the edema compared to standard lymphatic massage.

Hsu et al investigated the effect of elastic taping on kinematics, muscle activity and strength of the scapular region in baseball players with shoulder impingement. Seventeen baseball players with shoulder impingement were recruited from three amateur baseball teams. All subjects were taped with both the kinesiology tape and a placebo tape over the lower trapezius muscle. The kinesiology tape resulted in positive changes in scapular motion and muscle performance. The results supported its use as a treatment aid in managing shoulder impingement problems.

The Subscapularis Release Miracle!! Impingement And Beyond….

Subscapularis Release for Shoulder Pain

The main purpose of the rotator cuff is to keep the head of the humerus bone centered within the shoulder joint  The subscapularis muscle functions as the internal rotator of the rotator cuff.  It serves to hold the head of the humerus down and to limit forward glide of the humerus while the arm is raised.  It is a powerful stabilizer of the shoulder.  Repetitive overhead activity such as throwing or swimming may create micro-trauma to the fibers of the subscapularis.  The healing process may lead to adhesion formation with a subsequent imbalance of the rotator cuff leading to altered shoulder biomechanics.  The genesis of shoulder impingement syndrome!

Subscapularis Treatment

Manual therapy plays a pivotal role in the effective and expeditious treatment of impingement syndrome as well as recovery from a Type II SLAP repair surgery.  Active Release Technique has been clinically shown to resolve the impingement pain caused by a subscapularis dysfunction in as few as 2-6 sessions.  We assess the length of the muscle from the lesser tuberosity of the humerus to the subscapular fossa in order to locate the lesion.  The lesion is tensioned in a slackened position as the arm is taken through a range of external rotation and elevation in order to release the adhesion.  Refer to pictures below.  The release is also demonstrated on my website at orthowellpt.com.

Standard Type II SLAP repair protocols limit the PROM of external rotation from 0-30 degrees for the first 4 weeks post-op.  Most patients are placed in a sling in an internally rotated position.  Therefore, this limits the mobility of the subscapularis.  Trevor Winnege,DPT demonstrated that massage of the subscapularis in combination with PROM during the first post-op month improved the external rotation motion of the shoulder by 24-25 degrees at the 4 week mark compared to a control group that received PROM only. Check out the free shoulder pain treatment guide to learn more.

Keeping you informed of the latest and most efficacious physical therapy interventions is our goal at OrthoWell Orthopedic and Sports Physical Therapy and WalkWell Rehabilitation.  Please call if you have any questions about our subscapularis release and whether it would be right for you.

All the best!

Chris Dukarski,PT, Owner of OrthoWell and WalkWell

Shoulder Impingement Syndrome

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

How do you get shoulder impingement syndrome?

The shoulder joint is called the glenohumeral joint.  It is the articulation of the top of the humerus bone with the glenoid fossa of the shoulder blade.  It is one of the most complex and most mobile joints in the body.  In fact, 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 between the top of the humerus and the undersurface of the acromion process of the shoulder blade.  The most commonly traumatized soft tissue is the rotator cuff tendon.  Impingement results from the cumulative stresses of repetitive shoulder motion such as pitching or sustained overhead activity such as painting a ceiling.  This repetitive stress can lead to tendonitis, rotator cuff tears, bone spurs, or bursitis.

Your physician may classify the syndrome as either a primary or secondary impingement.  A primary impingement is caused by the structural anatomy of the area below the acromial process.  Your physician may determine through X-ray that you have an abnormal variation in the shape of your acromion process.  A type 3 “hooked” acromion makes you more susceptible to impingement and this may require surgical intervention to correct.  On the other hand, a secondary impingement is mostly the result of dysfunctional biomechanics of the shoulder joint.  It may be due to weakness of the rotator cuff muscles, poor posture, shoulder joint stiffness, and/or incoordination/weakness of the scapular stabilizing muscles.  So how do we treat shoulder impingement syndrome at OrthoWell?   Click on the “How do we treat?” link, and click on shoulder impingement syndrome.

“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

What are the BEST shoulder exercises?

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 you progress to other exercises such as 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.