Tag Archives: SFMA

Shoulder Rehab Part II

In Part I, I discussed how physical therapy of the shoulder using traditional rotator cuff exercises really gets me fired up.  Traditional methods of shoulder rehab often train the muscles of the shoulder in a way that they are not really used in normal everyday function.  If you haven’t caught that article yet, I suggest you read that one first.

In this article I want to address a couple other pieces of the puzzle:  motor control and regional interdependence.

There are many cases in which a certain movement may look dysfunctional in a standing position, but may actually be completely functional in other positions where the patient is more unloaded like lying on their back or stomach, side lying, on hands and knees, or even in kneeling.  In these positions there are fewer joints and segments to control and in most of these cases less gravity to deal with.

Unless the movement pattern is tested in multiple positions, it is not possible to know with any certainty that the movement is limited because of a true mobility issue (think joint restriction or ‘tight’ muscle) or if it is because of a lack of motor control.

Here is a great example looking at a functional reaching pattern behind the back.  In standing, you should be able to reach up behind your back and touch the bottom of the opposite shoulder blade as in the picture below:

So this past week I had a patient come in that could only reach to just below her belt line.  She had been given stretches to increase that movement but they really hurt her shoulder to perform.  If you’ve ever had a shoulder problem or therapy after a shoulder surgery then this exercise will look very familiar:

Shoulder Internal Rotation Stretch

When I had her lie down on her left side, she could reach all the way up her back and touch the opposite shoulder blade!  So why could she not do it in standing but had no pain and no difficulty lying on her side?

By going to a more unloaded position in side lying, the other joints of the body are taken out of the equation, and there is much less to have to control.  In this position she could be successful.  This is a great example of poor motor control, not a loss of shoulder range of motion.  So of course the first question she asked me is why did she spend the last 4 weeks in therapy and at home trying to stretch out her shoulder?

During the evaluation is was also discovered that she had some loss of mobility in her neck.  Because the neck movements were not painful, these were addressed first using cervical manipulation and then I followed that up with some soft tissue work using the Graston Technique through her upper trapezius, levator, and rhomboids.

C1-2 Thrust Manipulation

GT to the Upper Trapezius

Here is where that term – Regional Interdependence – comes into play.  In simple terms, regional interdependence is the interplay between different regions of the body.  In this case its easy to see how limitations in the neck can affect the shoulder since there are a number of muscles that run between the spine and shoulder girdle.  In other cases it could be dysfunction even further down the spine, the pelvis, hip, and beyond that could affect alignment and function at the shoulder.  Without the proper evaluation, it would be nearly impossible to find these relationships.

Once her cervical mobility was restored, we immediately went to corrective exercises to improve motor control of the neck and shoulder girdle.  These were fairly simple non-painful exercises that allowed her to successfully work through her neck limitations in a more unloaded position (hands and knees in this case).

Following that first treatment she could reach behind her back and nearly touch her opposite shoulder blade!

When the patient returned for her next visit, she had maintained her neck mobility and behind the back reach without shoulder pain.  We progressed to kneeling and standing motor control exercises, and by the end of the treatment she could touch her opposite shoulder blade without difficulty.

Half kneeling chops and lifts are a great way to improve stability and motor control through the spine and hips.

Needless to say, this patient was quite happy with the results.  Sometimes it is as simple as being in the right place at the right time with your treatment.  We’ll see how the rest of her treatment goes but for now we’ve knocked out a major limitation in her shoulder function without directly targeting her sore shoulder.

Part III coming soon

If you have any questions, feel free to contact me:  joe@elitepttc.com

 

 

Physical Therapy – Traverse City

So what should Physical Therapy in Traverse City look like?

There are many things to consider when choosing which physical therapy clinic is right for you.  Over the next few weeks I’m going to offer a few suggestions for things to think about, or even ask other therapists about, prior to beginning a course of physical therapy.

Some things should be fairly obvious such as how many different therapists will you see, time spent with your therapist, number of visits per week, and so forth.  What I want to discuss are the things most people would not normally consider (in fact, most therapists and physicians aren’t thinking this way either!)

1) A Movement Based Approach:  my previous blog entries  Don’t Put Fitness on Dysfunction and Movement Proficiency and the Ankle describe how looking at patterns of movement are critical to narrowing down where the cause of the pain is coming from.  Just because your back hurts doesn’t mean it’s the back’s fault.  Your back may just be the victim of poor hip mobility below and poor shoulder mobility above just to name a couple.

A simple model I discuss in those previous posts is the Joint-by-Joint model of alternating mobility and stability requirements.

Following the traditional physical therapy model, you’re probably not going to find the connection.  Instead the pain in the low back is the focus.  Not that the low back does not deserve to be treated to reduce pain and inflammation.  That absolutely must be done, but if that is all then chances are your low back symptoms will be back sooner than later.

 

The Selective Functional Movement Assessment is a quick and effective way to determine the person’s most dysfunctional movement pattern.

The object is to determine which pattern is the most dysfunction, and then break that pattern down into it’s component parts to find the impairment.  So for example, if someone cannot touch their toes, it could be a lack of mobility in the spine or hips, a lack of hamstring flexibility, or even a lack of core stability.  Your therapist must have a way to find that answer!

If you’ve ever been to physical therapy for your back, I can almost guarantee you were told you must stretch your hamstrings.  Well if you can’t touch your toes of course your hamstrings will feel tight.  Lacking mobility in your spine or hips will limit your toe touch and make it seem like your hamstrings are tight.  It’s probably only the hamstrings 25% of the time at the most.

Unfortunately many people are spinning their wheels in physical therapy because they are not working in the right place at the right time.  Could be why I’ve become the ‘physical therapist of last resort’.  I can’t tell you how many people have been referred to me over the past few years after that have failed a trial or two of traditional PT, injections, massage, etc.

2)  A Soft Tissue System:  at Elite Physical Therapy and Sports Performance I prefer the Graston Technique because of the great results I’ve had treating all types of soft tissue injuries from tendinopathies, to plantarfasciitis, to contusions, scar management, and more.  This is my tried and proven method and there are other systems out there that do work, but you really should be looking for someone with a system in place.

The majority of the time exercise alone will not fix the problem.  Some sort of soft tissue release is typically needed in and around the site of pain.  Very often even above and below the site of pain there will be significant soft tissue restrictions that should be addressed.  As I mentioned in #1, only by using a movement based approach will a physical therapist be able to detect these other restrictions.

For example, we know from the literature that very often trigger points in the gastroc/soleus complex (calf) will contribute to plantarfasciitis and even radiate pain to the bottom of the foot.  Limitations in hip extension and glute strength will also contribute to the condition.  Is your therapist looking that far up the chain?

So what difference does all this make?  Ultimately it can be the difference between actually ‘fixing’ the problem or just addressing symptoms.  When we can ‘fix’ the problem (the ultimate cause of your pain), we may never see you again and that’s a good thing.  When only the site of pain is addressed, very often you will find yourself back in the Dr. office and back for another bout of physical therapy a few months down the road.

At Elite Physical Therapy and Sports Performance, our goal is to ‘fix’ the problem, and to give the patient the tools necessary to prevent a recurrence.  Call us anytime with questions about our methods, and how we can help you if you’ve been unsuccessful with other methods of treatment in the past.