Trigger Points and Shoulder Pain – Part II

originally posted on SportsRehabExpert.com

Joe Heiler PT

Shoulder pain is such a common diagnosis that we’ll see here at Elite Physical Therapy, and there are a number of structures that can be pain generators to the shoulder and arm. Last month I talked about trigger points in the posterior rotator cuff (Infraspinatous and Teres Minor) along with their common referral patterns. Another common shoulder muscle to find active trigger points is the supraspinatous. Active trigger points in this muscles can refer pain to the deltoid and down the lateral aspect of the arm.

Check out the typical trigger points and referral patterns below:

Supraspinatous Trigger Point Referral

Check out the video below for a demonstration of dry needling to the supraspinatous:

Case study:

Feel free to check out this case study but it was originally written for physical therapists and chiropractors. Ultimately the point is that a combination of dry needling and soft tissue mobilization, in addition to corrective exercises, can significantly decrease pain while improving range of motion and movement.

Current patient of mine presents with lateral arm pain of 3 months duration. No known cause of injury but diagnosed with tricep injury/tear.

Pre-Treatment

SFMA dysfunctional non-painful patterns:

  • all cervical patterns (mobility)
  • R shoulder medial rotation extension (mobility) – FN to the L
  • MS rotation R (motor control deficit) – FN to the L.

    SFMA dysfunctional painful patterns:

  • R shoulder lateral rotation flexion
  • MS extension (R UE pain)

    Special tests:

  • Hawkins + on the R
  • Passive shoulder IR 20 deg.

    Palpation:

  • Tenderness with palpation of both trigger point in the supraspinatous with referral of pain down the lateral upper extremity to the wrist (indicates that is the pain he gets into the upper arm)

    Treatment on Day 1 consisted of Functional Dry Needling to the supraspinatous (x2) with electrical stimulation followed by more superficial Graston technique to the R upper trap, supraspinatous, infraspinatous, and teres minor along with light strumming at the supraspinatous insertion. Corrective exercise included 3pt. thoracic rotation (UE positioned in internal rotation – hand behind the back) with manual assist to hold/relax work until pt. was able to control the full available range.

    Post-Treatment

    Functional Non-Painful patterns:

  • R shoulder medial rotation extension
  • MS rotation B

    SFMA dysfunctional non-painful patterns:

  • all cervical patterns (mobility)

    SFMA dysfunctional painful patterns :

  • R shoulder lateral rotation flexion
  • MS extension (R UE pain)

    ***both are still painful although intensity has decreased while motion has increased***

    Special tests:

  • Hawkins + on the R but much less intense
  • Passive shoulder IR 50 deg.
  • Graston Technique – Treating the Painful Shoulder

    Here is the video I promised on treating soft tissue dysfunction in the posterior shoulder girdle, and in particular the trigger points that can refer pain to the front of the shoulder and down the arm.

    If you haven’t read the previous article discussing why we would want to treat this area, you can check that out here:  http://www.elitepttc.com/blog/trigger-points-and-shoulder-pain/

    If you have any questions concerning Graston Technique, Dry Needling, or shoulder pain please contact us at 231 421-5805 or Joe@elitepttc.com

    Trigger Points and Shoulder Pain

    There are a number of manual therapy techniques we use here at Elite Physical Therapy and Sports Performance, including Graston Technique and Trigger Point Dry Needling, to address muscular pain.  What many people don’t realize is that taut bands of hyperirritable muscle (a.k.a. trigger points) can cause local and referred pain.

    This article is one I wrote for SportsRehabExpert.com awhile back showing how trigger points in the back of the shoulder, specifically the muscles of the posterior rotator cuff, can refer pain to the front of the shoulder and down the arm.

    If you have shoulder pain that has not responded to other types of treatment, then check out this article and please contact us with any questions you may have!

    Manual Therapy Technique of the Week – Treating the Infraspinatous and Teres Minor 

    Joe Heiler PT

    I’ve become much more familiar with trigger point referral patterns and treating these out the past couple years since taking the Kinetacore Functional Dry Needling course.  A couple of the more common trigger points I end up dry needling and/or using Graston Technique to treat in the shoulder are the infraspinatous and teres minor.  Active trigger points in these muscles can refer pain to the anterior and middle shoulder, and on occasion will also refer pain down the arm.

    Check out the typical trigger points and referral patterns below:

    Infraspinatous Trigger Points and Pain Referral Pattern

    Infraspinatous Trigger Points and Pain Referral Pattern

    Teres Minor Trigger Point and Pain Referral Pattern

    Teres Minor Trigger Point and Pain Referral Pattern

     

    Case Study

    Current patient of mine presented with R shoulder and scapular pain of 2 year duration.  MS rotation limited to 50% bilaterally (DP) and R shoulder medial rotation extension (MRE) reach only to L4 (DP).  Palpation of the infraspinatous trigger point (most superior and lateral) referred significant pain to the anterior shoulder and slightly down the lateral arm reproducing her typical pain.  The teres minor trigger point referred pain to the middle deltoid area.

    Post trigger point dry needling of these trigger points the patient’s MS rotation improved to 90% (dysfunctional still but non-painful) and R shoulder MRE to T9 (still DP but much less pain).

    It’s not always this dramatic but this is also not the first time I’ve seen the great results like this.

    I’ll get a video up soon showing how we use Graston Technique to treat the posterior shoulder to reduce this type of pain and improve shoulder function.

    In the meantime feel free to contact us with any questions:  231 421-5805 or Joe@elitepttc.com

    Vastus Medialis Obliquus Muscle (VMO) “Isolation” Exercises Fact or Myth?

    At Elite Physical Therapy and Sports Performance we take pride in the fact the we are well ahead of the curve with out treatment techniques compared to the rest of the traditional PT world, but we also acknowledge that it is important to use evidence based treatment techniques.

    Evidence based practice is the buzz word in PT circles but despite this strengthening/isolating the VMO continues to be utilized as a way to decrease knee pain and improve function.   PT’s and physicians alike continue to prescribe strengthening for the VMO muscle of the quadriceps group even though the research has proven this concept to be faulty and ineffective.

    This short article was written by a couple PT friends of mine in New York (one of which is in the PT and Strength and Conditioning Halls of Fame!) showing once and for all that you can not isolate the VMO, nor should you bother trying when it comes to solving knee pain.

    Enjoy!

    Originally posted on SportsRehabExpert.com

    Robert A. Panariello MS, PT, ATC, CSCS
    Timothy J. Stump MS, PT, CSCS, USAW

    Professional Physical Therapy
    Professional Athletic Performance Center
    New York, New York

    Patellofemoral pathology is a fairly common condition observed in clinical setting. The treatment philosophy of some rehabilitation professionals to resolve this painful condition may include the prescription of exercises in the attempt to isolate the Vastus Medialis Obliquus muscle (VMO). Although this VMO exercise isolation “myth” has been negated at least 20 years ago (1, 2) it continues to presently endure.  During this attempt to isolate VMO activity, some designated exercises executed include but are not limited to the following:

    • Quad sets
    • Terminal open chain knee extension exercises
    • Straight leg raises (SLR) with external rotation of the lower extremity

    These exercises may or may not be performed with the adjunct application of electric stimulation.

    Although these exercises will enhance the strength of the quadriceps muscles, likely assisting in resolving the patient’s knee pathology, this is not due to isolation of the VMO. The case some clinicians formulate for the performance of SLR with external rotation is based on the false premise that by externally rotating the femur will result in further activation of the VMO.

    The knee is a hinge joint and during the execution of a SLR, the force of gravity will act in a perpendicular manner between the knee and ground surface. The quadriceps mechanism will now be required to resist the resultant force attempting to flex the knee as this is the only contractile soft tissue structure that is capable of resisting that force.  The quadriceps mechanism like any other dynamic structure can only resist this external force via the neural activation of the muscle group.  The external rotation of the femur gives rise to the placement of stress on medial collateral ligament (MCL), a static stabilizer of the knee.  This treatment philosophy actually removes stress from the very muscle(s) the clinician is attempting to enhance.  As an example a patient with a diagnosis of polio, a condition affecting the anterior horn of the femoral nerve or a patient with a quadriceps tendon rupture can still perform a SLR when externally rotating their femur based on the static stabilizing properties of the MCL.  Therefore one may inquire why would a clinician who is attempting to activate and enhance the quadriceps muscle group perform the SLR exercise in external rotation.

    The anatomy and neuroanatomy of the quadriceps muscle group

    The quadriceps muscle group is comprised of the rectus femoris, vastus lateralis, vastus intermedius, and vastus medialis. The vastus medialis (VM) is located at the medial aspect of this muscle group and has been reported to consist of two separate components, the proximal vastus medialis longus (VML) and the distal vastus medialis obliquus (VMO) (4). The neuroanatomy of the quadriceps muscle complex reveals an innervation from the femoral nerve.  The femoral nerve is comprised of large motor units that innervate all four heads of the quadriceps without individual fine motor unit innervation of the separate muscle heads.  Therefore, since the VMO does not have a distinct and separate nerve innervation, it is not possible to “isolate” this muscle from the other quadriceps muscles via a specific exercise performance. The most beneficial way to enhance the VMO is to incorporate the same exercise philosophy used to improve any other muscle or muscle group, the application of unaccustomed stress. The application of unaccustomed yet safe levels of stress is simply known as the “overload principle”. This may be accomplished in two ways; expose the patient to higher levels of unaccustomed resistance or overload them by increasing the velocity of the movement. Both methods will result in a positive adaption of the entire quadriceps muscle group.

    Since stress transpires throughout the kinetic chain of the lower extremity during the performance of ADL’s as well as athletic endeavors, the activities prescribed for patellofemoral pathology should also include exercises for both the hip and ankle. “Critical thinking” is a requirement for the approach to the patient’s optimal exercise selection and treatment design. The health care professional’s obligation to provide optimal treatment does not include the application of myths during the patient’s plan of care.

    References

    1. Cerny K “Vastus medialis oblique/vastus lateralis muscle activity ratios for selected exercises in persons with and without patellofemoral pain syndrome”, Phys Ther (8):672-83, 1995
    2. Malone T, Davies G, Walsh WM, “Muscular control of the patella” Clin Sports Med 21(3); 349-362, 2002.
    3. Hubbard JK, Sampson HW, Elledge JR, “The Vastus Medialis Oblique Muscle and Its Relationship to Patellofemoral Joint Deterioration in Human Cadavers”, J Ortho Sports Phys Ther 28(6):384-391, 1998.
    4. Weinstabl R, Scharf W, and Firbas W, “The extensor apparatus of the knee joint and its peripheral vasti: anatomic investigation and clinical relevance”, Surg and Radiological Anat  11(2): 17-22, 1989

    Robert A. Panariello MS, PT, ATC, CSCS
    Rob Panariello PicRob is a Founding Partner and Chief Clinical Officer with Professional Physical Therapy presently with 44 facilities in the New York and New Jersey Metro areas and the Professional Athletic Performance Center located in Garden City, New York. He has Bachelor Degrees in Physical Therapy and Physical Education/Athletic Training from Ithaca College in Ithaca, NY. He also holds his Master’s Degree in Exercise Physiology from Queens College in Queens, NY.

    Rob has more than 30 years of experience in the related fields of Sports Physical Therapy, Athletic Training, and the Performance Training of Athletes. His experience includes the study of the Science of Strength and Conditioning of weightlifters and various sport athletes in Bulgaria, the former Soviet Union, and former East Germany. He previously held the positions as the Head Strength and Conditioning Coach at St. John’s University of New York (1986-1995), the World League of American Football NY/NJ Knights (1991), and the WUSA NY POWER Women’s Professional Soccer League (2001-2002). He continues to rehabilitate, athletic performance train, as well as serve as a consultant to many NFL, NBA, MLB, NHL, Collegiate and University teams, coaches, and players.

    Rob has more than 60 peer reviewed Orthopedic and Sports Medicine Research, Sports Physical Therapy Research, and Strength and Conditioning Journal Articles and Book Chapter publications. He has also presented his research at the International World Confederation of Physical Therapy in Washington, D.C. He is nationally renowned and lectures throughout the country with regard to the related fields of Sports Physical Therapy and the Performance Training of Athletes.

    Rob received the 2015 APTA Sports Physical Therapy Section Lynn Wallace Award for Excellence in Clinical Education, the prestigious National Strength and Conditioning Association’s Presidents Award in 1998 and was elected to the USA Strength and Conditioning Coaches Hall of Fame in 2003.

    Tim StumpTimothy J. Stump is a partner with Professional Physical Therapy, and is also a founding partner with the Professional Athletic Performance Center. He  has more than 20 years of experience in the related fields of Orthopedic and Sports Physical Therapy, Strength & Conditioning, and Performance Training of Athletes of all levels of competition. Tim’s experience includes the successful participation as a nationally ranked competitive strength athlete in the sports of Powerlifting and Weightlifting from 1990-2010. He continues to actively participate in these sports as a coach and mentor to many athletes.

    Tim has published several peer-reviewed original research articles and has presented his research at the APTA National Conference and at CSM. Tim was also awarded the Jacob & Valeria Langeloth Foundation research grant for studies on ACL functional outcomes while employed at the Hospital for Special Surgery. Tim was the 2012 recipient of Columbia University’s Award for “Leadership in Clinical Education” and co-chairs Professional’s Clinical Affiliation Program with over 64 school contracts providing PT, PTA, ATC and Exercise Physiology students with quality clinical affiliation experiences.

    Bunke Plank Regressions

    Joe Heiler PT

    Originally posted on SportsRehabExpert.com

    ‘Core’ strengthening is always a popular topic so figured I’d highlight another set of exercises that we use here at Elite Physical Therapy and Sports Performance.

    I’ve been playing around with the Bunke planks for awhile now as part of the discharge criteria for my runners and other select athletes.  It’s just one more way to gauge symmetry and in this case its looking at stability through the fascial lines of the body.  My only problem has been that the tests can be too difficult for larger athletes, older patients, and those with shoulder dysfunction so I needed to regress these planks a bit to allow all my athletes and patients a safer place to start and to give them a shot at being successful.

    (Click the link below to check out the original Bunke plank series:  Bunkie Tests)

    The goal of the Bunke Test is for the athlete to be able to hold each test position 40 seconds.  You’ll see in the videos below how I use some different positions to regress the planks, but you’ll also want to consider these other regressions within the positions:

    –  hold the plank with both legs 40 seconds
    –  perform leg lifts – either alternating or just with one leg depending on the type of plank
    –  finally hold on one leg up to 40 seconds

    Bunke Plank Variations – Knees

    Bunke Plank Variations – Elevated

    The hamstring planks can be modified by putting the forearms on a bench with the feet on the floor and then running through the progressions above.  If the shoulders are the problem, then we typically have to go to lying supine with feet up on a box or ball.

    If you have any questions or want to get tested as part of our Annual Musculoskeletal Exam, just email joe@elitepttc.com or give us a call at 231 421-5805.

     

    When Pain Happens

    Great blog post from my friend and former PT student Greg Schaible on understanding pain.  This is an exciting new area of study and lots of potential here to help folks overcome pain and restore function.  Enjoy!

    Greg Schaible PT, CSCS – On Track PT and Performance in Ann Arbor.

    Here’s a riddle.  Nobody wants it, but everybody has experienced it at some point in time. It acts oddly and seems to come on for no rhyme or reason.  It is vastly misunderstood by the general population as well as healthcare professionals from all fields.

    You guessed right, the answer is pain.

    If you are reading this post and currently in pain, I genuinely am sorry and have empathy for your situation.  But understanding pain is the first step in combating it, so you are in the right place.  My goal is to educate people on pain. In my profession I deal with pain every day, so in order to treat it, I need to do my best to understand its complexity. I have learned a great deal about the subject of pain from books by David Butler and Lorimer Moseley. These two guys are at the forefront of the research on this subject.

    So what is pain?…….  A short but loaded question.

    First let’s get some context. The body is constantly gathering information from sensory receptors about the body’s internal and external environments.  It is also interpreting how these two environments are interacting and how they relate to one another. All these signals are ultimately sent to the brain to make heads or tails of the information. These inputs can range from actual tissue damage, chemical changes, past experiences, emotional/psychological distress, lack of sleep, hunger, your mother yelling at you, or seeing a snake on a plane.

    Snakes on a Plane

    The brain’s job is to then interpret all of these signals and determine if a threat is present. If the body perceives there is a threat, a number of different responses are possible.  One of the possible responses is pain.

    Or in the case of snakes, call Sam!

    Pain is felt as a survival mechanism to encourage you to take action. However, it does not always mean damage has actually occurred.

    Consider this example Lorimer Mosley gives: A fractured wrist is often very painful until it is put in a cast. Once casted, the pain is almost always gone quickly thereafter.

    Interesting!

    The problem with this is that we know that bone will take 6-8 weeks to fully heal (depending on age and other factors).  Yet, pain is no longer present, and in some cases instantaneously gone once placed into a cast.  So why is this? Very simply, the need for protection is now gone because the cast acts as an external protective device.

    In this example the pain is gone but damage is very much still present. The opposite can also be true. The body can be in pain, but no longer damaged.

    We must consider other factors such as social influence, past history, fear, future consequences, stress to name a few. All these signals can trigger the body to feel it is under threat and notify you via pain. For this reason you can experience pain with no tissue damage at all.  I’m sure you have heard the term phantom limb pain.  Even though the limb is gone, the body still has the ability to sense pain in this area.  This reinforces the fact that if you can experience pain without a body limb, then tissue damage is not necessarily a prerequisite for pain. Furthermore, just because you are experiencing pain in a particular area does not mean that is in fact the source of the pain.  This is why it is important to find a clinician who does not focus solely on the area of pain, but looks for other areas of dysfunction which may contribute to the brains overall perception of threat.

    Another possibility is that tissue damage could have very well occurred which initially started the pain cycle.  However, because the body is great at healing itself at the cellular level. It is also possible that the tissue may have healed. Yet the brain still has the perception of threat because non-threatening inputs were never sent up to the brain to override the previously painful threats.  This may explain why people often feel pain long after normal tissue healing time has passed. This is also why it is important to not treat pain with pain.

    Here is some research that backs the theory: tissue damage does not equal pain. Jensen and colleagues performed a study titled: MRI of lumbar Spine in People without Back Pain. They found that 52% of people without back pain had at least one bulging disc or MRI abnormality.  Templehof and colleagues performed a study titled: Age-related prevalence of rotator cuff tears in asymptomatic shoulders.  The authors found that 23% of people with asymptomatic (non painful) shoulders actually had a rotator cuff tear. These are just two examples. Numerous other studies could be cited to help support that tissue damage does not have to cause pain.

    So the next time you experience pain, please understand that there may be a number of contributing factors. Remember that pain is perfectly normal, it’s your body’s alarm system. Pain can be present with or without tissue damage. Providing the body with novel non-threatening stimulus’s to remove the body’s need to produce a protective response is a great place to start if you are currently experiencing pain.

    Let’s take the example of elbow pain, lateral epicondylitis a.k.a tennis elbow. It’s not uncommon for lifters to experience elbow pain. I have noticed it becoming more prevalent now as people spend more time on their tablets using their fingers instead of a mouse.

    tablet

    Holding a tablet in one hand, and constantly using your fingers to swipe, type, navigate, etc. will place your wrist/elbow musculature on constant stress. Over a prolonged period, this can be perceived as a threat to the brain. Especially if you are lifting heavy weight in conjunction and require a high volume of grip strength for your workouts.

    So applying the knowledge we learned about pain, and how it may or may not relate to tissue damage.  Here is a very simple and extremely effective solution to a lot of cases.

    1st) Reduce the threat. In this example altering body mechanics while using a tablet and modify your workout routine with less grip intensive activities for the time being.

    2nd) Provide a novel and nonthreatening stimulus.  In this example, I will use a wrist extensor stretch.

    While this exercise may not seem like much, it’s very effective when applied correctly.  Flexing your wrist and turning it to the side obviously places a stretch on the outside of the elbow or to the wrist extensors.  In addition, you are also placing some tension and loading a nerve which flosses through the tissues at the elbow called the radial nerve.

    So we now have our novel/nonthreatening stimulus.

    3rd) Here is the kicker. You can do all the above, and get zero results unless you get this third step correct.  You MUST perform the novel/nonthreatening stimulus frequently.  To the tune of every 1-2 hours for best results.  Here is why it’s so important.  When the body is in pain, it is very good at making memories of pain.  This is because the body is very protective over itself, and rightfully so.  The only way to reduce the threat is to perform a stimulus frequently enough that if no longer feels the need for protection.

    This example can be applied to many other pain scenarios as well if you follow the steps correctly. 1) Remove as many threats as possible while in pain 2) Pick a novel/nonthreatening stretch or exercise 3) The exercise should be simple enough so that you can perform it frequently throughout the day (in some cases every 1-2 hours).

    Bio

    Greg SchaibleGreg Schaible is a Doctor of Physical Therapy (DPT) and Certified Strength and Conditioning Specialist (CSCS), and runs On Track PT and Performance in Ann Arbor.  He attended The University of Findlay as a Student Athlete.  As an athlete he competed in both Indoor and Outdoor Track & Field where he earned honors as a 5x Division II All-American and a 6x Division II Academic All-American. In 2013 he completed Graduate School earning his Doctorate of Physical Therapy (DPT).  Greg is an avid Lions, Pistons, and most importantly a Michigan Wolverines fan.  When you don’t find Greg in the clinic treating patients, he enjoys spending time with family and friends, living an active lifestyle, coaching, and playing sports.

    Ankle Mobility Drills for Runners

    This is the last in our series of dynamic warm-up drills for runners that we use here at Elite Physical Therapy and Sports Performance.  In this video Scott McKeel demonstrates some of our favorite ankle mobility drills to get those ankles moving which will help with a number of common injuries like plantarfascitis, Achilles tendinopathy, IT band syndrome, knee pain, and low back pain.

     

    We do small group, and even individual, training sessions for runners which includes the Functional Movement Screen plus other critical tests to find the weak links in mobility and flexibility, strength, and running technique.  If you’re interested contact us:  joe@elitepttc.com

    Dynamic Warm-Up for Runners Part III

    In this episode Scott McKeel continues with the dynamic warm-up series including drills for lower body warm up and running technique.  These drills are great for those who have been battling common running injuries like plantarfascitis, hip bursitis, IT band syndrome or low back pain.

     

    We do small group, and even individual, training sessions for runners which includes the Functional Movement Screen plus other critical tests to find the weak links in mobility and flexibility, strength, and running technique.  If you’re interested contact us:  joe@elitepttc.com

    Dynamic Warm-Up for Runners Part II

    Part II of Scott McKeel’s series on dynamic warm-up drills for runners.  In this episode Scott takes you through some of our favorite lower body warm up and run technique drills here at Elite Physical Therapy and Sports Performance. These drills are great for those who have been battling common running injuries like plantarfascitis, hip bursitis, IT band syndrome or low back pain.

     

    We do small group, and even individual, training sessions for runners which includes the Functional Movement Screen plus other critical tests to find the weak links in mobility and flexibility, strength, and running technique.  If you’re interested contact us:  joe@elitepttc.com

    Dynamic Warm-up for Runners

    I’ve made it a practice to have my PT students contribute to the Elite PT blog and SportsRehabExpert.com so without further delay this is my most recent student, and ridiculously good runner, Scott McKeel, demonstrating some of our favorite dynamic warm-up drills.  In this episode, Scott will hit on the upper body warm-ups and then in subsequent episodes we’ll work through lower body warm-ups, running technique, and ankle mobility drills.

    Enjoy!