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 is the best exercise for patellar tendinosis?

Patellar tendon pathology or tendinosis can be a resistant and recurrent condition in running and jumping sports.  An important part of your  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 slowly or going down stairs are examples of  quad eccentrics.  Eccentric force production may exceed concentric (shortening contraction) and isometric (tensing without motion) forces 2-3 times. (Stanish et al)  Eccentric training drills stimulate the production of new collagen tissue-the main tissue in your achilles. (Khan et al)   This effect helps to reverse the tendinosis 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 tendinosis, 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 chronic patellar tendinosis 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.

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.

*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

*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

*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.

Do you really NEED that cortisone shot?

Our patients are our best advertisement. Word of mouth travels fast! But what happens when the doctor becomes the patient? Please read the testimonial below from one of your colleagues on the North Shore who was treated at WalkWell Rehabilitation.

As a family practitioner I thought I knew a fair bit about musculoskeletal problems and their treatments. But after a few treatments I had learned a tremendous amount of new things about physical medicine and I have not felt better in years. I now recommend Chris to all my patients who need physical therapy for treatment of conditions of the lower extremities.” – PhillipBurrer,MD of Family Medicine Associates


One of the most controversial topics in orthopedic medicine is the –ITIS versus -OSIS debate. Many health care practitioners feel that inflammation is the main source of pain in chronic conditions. This is apparent through the use of NSAIDS, steroid injections, and modalities such as iontophoresis. As a physical therapist with almost 2 decades of hands-on care, I have tried many approaches in treating chronic pain. Evidence-based treatment is the MAIN FOCUS in my clinic. Can we prevent the reoccurrence of pain by ONLY treating the inflammation?? 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 fasciotomies, “Histologic findings are presented to support the thesis that “plantar fasciitis” is a degenerative fasciosis WITHOUT inflammation, not a fasciitis.”

Almekinders, Temple, et al in “Etiology, Diagnosis, & Treatment of tendonitis: an analysis of the literature”, Med Sci Sports Exer 1998;30(8):1183-1190 state that they “found little evidence that NSAIDS and corticosteroids were helpful in treating tendinopathy.”

Because no inflammatory cells have been demonstrated in biopsies from chronic tendinopathy, some authors have abandoned the tendonitis “myth” as well as the use of steroids. Recent studies, however, have begun to question this new opinion. Recent placebo controlled, randomized studies of ultrasound-guided peritendinous steroid injections have been shown to be very effective in reducing the pain and thickness of Achilles and patellar tendons in athletes with chronic tendinopathy.

Fredberg et al in “Ultrasonography as a tool for diagnosis, guidance of local steroid injection..”, Scand J Rheumatol 2004; 33: 94-101 state that steroid injections “significantly reduced the average diameter of the affected tendons” and “in several cases the thickening of the tendon regresses completely.”

Koenig, et al in “Preliminary results of colour Doppler-guided intratendinous glucocorticoid injections..”, Scand J Med Sci Sports 2004: 14: 100-106 found that “neovascularization disappears” after ultrasound-guided, intratendinous injections.

Injection technique appears to play a pivotal role in the effect of the steroid on pathologic tissue. Should the practitioner continue to inject “blindly” or use ultrasonography to guide the precise placement of steroid? The next unanswered question is how to maximize the therapeutic benefit AFTER injection. Fredberg also states that steroids “cannot repair degenerative changes” and attempted to explain “the high frequency of relapse” 6 mo after the first injection. He now recommends 3-6 months of rehabilitation after injection. At WalkWell Rehabilitation, the functional regeneration of tissue is our goal.


Foot orthotic devices (FOD’s) are widely used and prescribed for foot conditions ranging from diabetes to overuse injuries to plantar fasciitis. A myriad of prefabricated and custom devices are now available. The method by which the practitioner prescribes a device is determined more by his or her previous clinical experience than by conclusive scientific evidence. The variability of FOD’s used in research as well as the prevalently small sample sizes (<20 subjects) makes it difficult to extrapolate useful clinical information. There is, however, strong evidence that selected FOD’s prevent injury reoccurrence in runners and athletes in general. FOD’s have also been shown to reduce impact loading by 10-20%. What research does NOT prove is that foot orthoses control alignment like we think they do!!

The majority of foot orthotic research focuses on control of rearfoot motion ie your heel turning in or turning out.  While there are numerous studies that demonstrate NO effect on rearfoot motion, most report that FOD’s result in control of some aspects of rear-foot motion such as total motion or speed of motion.  The average amount of rear-foot motion control reported in the literature is on the order of 2-3 degrees. That’s it! The question is whether this 2-3 degrees is clinically significant—or can the observed control be explained in a different way?

WalkWell Foot Orthotics
Is DIFFERENT from the competition!!!

At WalkWell you are evaluated by an orthopedic physical therapist with 20 years of experience treating disorders of the lower extremity and fabricating custom foot orthoses. The evaluation includes a gait analysis and a complete biomechanical assessment. Special materials of varying density and firmness are directly molded to the foot in order to create a completely CUSTOM orthotic WHILE YOU WAIT!! The process is complete in ONE HOUR.


You are thoroughly educated in proper footwear, stretching, and pain management strategies. All of the above PLUS any follow-up adjustments for a very affordable price!!

ART gets you better – QUICKER!!

Active Release Technique or ART is a patented and proven manual therapy technique that can speed recovery from injury or surgery. ART can alleviate symptoms that have been unresponsive to other treatments. Certified practitioners for the NBA, NFL, PGA Tour, and Ironman events utilize Active Release Technique. It is a hands-on system that allows the practitioner to diagnose and treat soft tissue injuries and peripheral nerve entrapments. ART uses the fundamentals of anatomy and biomechanics to determine and to treat dysfunction in the system. The “touch” is developed through a comprehensive certification process. At OrthoWell/WalkWell, we are certified in Active Release Technique.

So how does it work? As repetitive injury or cumulative stress occurs to soft tissue, the normal longitudinal arrangement of fibers can become disrupted via the haphazard and erratic formation of scar tissue. Stretching a muscle with scar tissue only stretches the area above and below the “knot”. Hence, more stress occurs at the point of dysfunction. ART entails the application of specific pressure via one’s thumbs or hands on an area of fibrosis or adhesion as the patient actively or passively moves through a specific, guided range of motion. The “knot” will release through the applied tension.


After 13 months of suffering through debilitating left hamstring pain, I had given up hope. Two courses of PT and multiple trips to my primary and orthopedic specialist brought little relief. WalkWell changed all that! Throughout the entire process of evaluation and treatment, I believed from the start that I would one day be painfree. Today, I have never felt better!”
Chad Konecky, Program Manager for ESPN

GRASTON versus Scar Tissue!! Any bets??

The first step in treatment is to identify scar tissue. 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. Picture below.

During palpation, fibrosis will feel gritty or knotted. At OrthoWell/WalkWell, we may use Graston’s instrument assisted soft tissue mobilization (IASTM)  to “break up” restrictions. This deep massage creates a reactive inflammation which “jump starts” healing. Keep in mind that inflammation can occur without healing, but healing cannot occur without inflammation. During the inflammatory stage, scar tissue can be reabsorbed by the body. During the fibroblastic or re-growth phase of healing, the damaged tissue is replaced by new collagen. This new collagen is reformatted through proper exercise. This “process” can take 3-6 months in chronic cases. So what does the research tell us about IASTM?

Instruments of Assisted Soft Tissue Mobilization

Craig Davidson et al in “Morphologic and functional changes in rat Achilles tendon following collagenase and GASTM”, J Am College Sports Med, 1995;27 showed increased fibroblast proliferation in the IASTM group and stated that “the study suggests that IASTM may promote healing via increased fibroblast recruitment.”

Gale Gehlsen et al in “Fibroblasts responses to variation in soft tissue mobilization pressure”, Med Sci Sports Exer, 1999;31:531-535 showed morphological evidence indicating that “the application of heavy pressure during IASTM promoted more fibroblastic proliferation compared to light or moderate pressure.”

Mary Loghmani et al in a 2006 research project at Indiana University (pending publication) revealed that “ligaments treated with IASTM were found to be 31% stronger and 34% stiffer than untreated ligaments” using Graston Technique instruments.

As a result of almost 2 decades of asking questions and critically appraising my successes and failures, I have become convinced that the “missing link” in the treatment of soft tissue lesions is the proper release of scar tissue. Rehabilitation is accomplished through the functional integration of deep massage, 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!

Graston Technique:

Are you SURE it’s plantar fasciitis?

Heel pain is multi-factorial. What needs to be determined in physical therapy is whether the origin of the pain is local, referred, or both. As our population becomes heavier, more de-conditioned, and more susceptible to concurrent orthopedic dysfunction, the chance of referred symptoms arising from the low back and/or a pinch along the sciatic nerve is greater. If your symptoms are not significantly improving after 4 visits of localized soft tissue treatment, then referring sources of pain need to be considered. If nerve involvement is suspected, then it is easier to perform manual differentiation testing after the nerve has been sensitized. You may be instructed to return to PT when you are most symptomatic. Neural tension testing of the sciatic nerve may elicit heel pain or a “doorbell” sign may be elicited along the course of the sciatic or tibial nerve. See below.

Our patients may be susceptible to the “double-crush” phenomenon.  The “double-crush” means that you are more susceptible to nerve entrapment in one area if you already have an entrapment in an adjacent area.  A pinched nerve in your low back due to a herniated disc may make you more vulnerable to a “pinch” along the sciatic nerve as it courses through the lower part of your leg.   Active Release Techniques, as performed at OrthoWell/WalkWell, are very effective in resolving these entrapments.

The importance of closed-chain exercise.

Closed chain exercises for the lower extremities (exercise with you feet contacting the floor) 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 you 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

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