Tag Archives: shoulder physical therapy

Shoulder Pain and Dry Needling

This past Friday we thought we’d have a little fun and treat out Shannon’s shoulder pain as part of our weekly in service.  This is a great way for all of us to put our heads together and solve some of our more challenging cases.

Check out the video below to see how we did:

It’s always cool to see significant improvements in range of motion and decreased shoulder pain – especially when the changes are immediate!

There is quite a bit more work to do here to get that shoulder moving right again but dry needling in combination with electrical stimulation can be the kick start that’s needed.

If you’ve been struggling with shoulder pain – and wondering if there is anything that can be done about it – give us a call (231 421-5805).  We’ve been able to help numerous clients with acute and chronic cases of shoulder pain (including those that have had PT elsewhere without success).

Or email questions to Joe@elitepttc.com

If you’re interested – check out the muscles/trigger points with their corresponding referral patterns below:

Rotator Cuff Trigger Points

Teres Minor Trigger Point

Teres Minor Trigger Point

For more information on shoulder pain and trigger points, please refer to a couple previous articles on our blog:

Trigger Points and Shoulder Pain

Trigger Points and Shoulder Pain – Part II

Occlusion Cuff

Blood Flow Restriction Training

Blood Flow Restriction training, aka BFR, has actually been around for awhile now but its finally starting to make its way into professional and collegiate sports as well as physical therapy.  Johnny Owens has been the driving force behind BFR in the U.S. after successfully using this technology with veterans recovering from devastating combat injuries.  Since that time he’s been training numerous professional sports teams in the use of blood flow restriction training including the Detroit Lions and Detroit Red Wings.

What the heck is it?

BFR training utilizes a tourniquet-like device which is placed proximally on a limb to limit arterial inflow to the limb while blocking venous outflow.

I should add a word of warning sooner rather than later.  There are commercial devices out there used by trained professionals for this type of training.  Do not make your own tourniquet and try this at home!

Benefits

I’m going to go a bit scientific on you here but just for a moment:

  • Training loads used are only 20-35% of 1 rep max, and often times are just body weight.  The same effects with weight lifting alone must be at least 70 – 85%.  Translation:  same results with less load = happier joints.
  • Higher release of growth hormone, insulin-like growth factor, and other substances known to speed tissue repair and create a positive environment for muscle hypertrophy.
  • Increased recruitment of Type II (fast-twitch) muscle fibers even with sub maximal loads
  • Increased muscle protein synthesis through the inhibition of catabolic substances.
  • Cell swelling : shift in fluid balance into the muscle cell creating a protective response to adapt and grow

Check out the chart below from Dr. Mario Novo at the LiftersClinic.com

LiftersClinic.com

Pretty cool stuff isn’t it?  Even with all the science thrown in.

How do you use it?

We work it into our rehab and training sessions closer to the end of the workout.  The build up of lactic acid will reproduce the ‘muscle burn’ sensation pretty quick causing a good amount of muscle fatigue with only body weight activities.  Body weight squats are usually a great place to start.  They are performed for 30 reps:15 reps:15reps:15 reps with 30 seconds between each set.  These will be the toughest body weight squats you’ve ever done!

The number of exercises performed and time training with blood flow restriction is gradually increased.  So far we’ve seen a rapid increase in tolerance to exercise among our athletes allowing them to do more and more work with BFR.  The results have been excellent too with quicker gains in muscle hypertrophy and strength.  If you notice the last column in the chart above – time to adaptation.  Within 2 weeks we are beginning to see positive changes compared to the traditional higher intensity training.

It might sound like I’m down playing the effects of higher intensity training regimens but I’m not at all.  There are tremendous benefits to lifting heavy and creating a great base level of strength.  BFR just offers a great way to increase training volume and intensity while decreasing load.  Over time the heavy weights will wear down your body – ask any collegiate or NFL football player – but this allows for a certain amount of unloading to happen and still reap all the benefits.

I know you want to try it!

Blood flow restriction training is safe when used with the right person at the right time and monitored appropriately.  It is also a pretty intense workout so definitely not for the faint of heart.

We are currently using BFR with athletes and patients post-knee injury, hamstring injuries, shoulder injuries, ankle sprains, and more.  Athletes that come in strictly to train have been having great success with it as well.  If you’ve struggled to make progress as a patient or hit a plateau in your training this would definitely be worth asking about.  We have a number of unique techniques to promote tissue healing and strength/power gains, and this is just one reason we have been setting ourselves apart from the competition!

Occlusion Cuff Shoulder

If you’re really into the science behind blood flow restriction training and would like to learn more, you can check out the two podcasts with Eoin Cremen (creator of the OcclusionCuff) on SportsRehabExpert.com

Questions?  Joe@eliteptt.com or give me a call at 231 421-5805

Advanced Kettlebell Carries

We love kettlebell carries here at Elite Physical Therapy and Sports Performance as they have numerous benefits to our patients and athletes including:

  • improved shoulder girdle and trunk stability
  • increased grip strength
  • improved core control and strength

My current PT student, Mitch Babcock, has brought some new ideas to the table to make our carries even more challenging as far as the stability demands go so thought I’d share those with you.

Check out the videos here:  http://www.sportsrehabexpert.com/public/1181.cfm?sd=2

Bio

Mitch Babcock Kettlebell CarriesMitch Babcock SPT is a final year Doctor of Physical Therapy candidate from the University of Michigan — Flint. Mitch received his Bachelor’s Degree from Saginaw Valley State University in Mitch BabcockExercise Science and pursued his passion for movement and exercise to the graduate level. Mitch is certified in the Selective Functional Movement Assessment (SFMA) and the Functional Movement Screen (FMS), as well as a RockTape FMT Level II professional. He has also spent time with clinical rotations in a manual-based orthopedic clinic in mid-Michigan, a sports clinic in Charlotte, NC, and an outpatient neurological rehabilitation clinic in mid-Michigan. With a passion for full human optimization, Mitch is ready to help you get moving, get out of pain, and get back in the game.

Exercise of the Week – Wall Slides for Shoulder Pain

At Elite Physical Therapy we know that shoulder pain and rotator cuff dysfunction is often the result of multiple factors such as poor scapular stability, loss of cervical and/or thoracic mobility, and poor trunk stability just to name a few.  Wall slides are one of those exercises that will address each of these areas of concern in one shot.

I’ve featured wall slides here in the past with the back up against the wall, but in this version there isn’t the input for the wall to correct posture and there is more of a focus on scapular upward rotation.

  • Posture – get tall and press away from the wall. You’ll notice in the video how this even assists with a bit of cervical retraction.
  • keep the forearms vertical to keep the posterior rotator cuff and scapular stabilizers engaged – this will be much more difficult with the band.
  • only go as far as the forearms can stay on the wall – this forces you to work through the lats and stiff upper back muscles.

You should feel a lot of muscle activation in the back of the shoulders and between the shoulder blades.  At no time should you have shoulder pain.  If so, this exercise may not be appropriate and probably a good time to have your physical therapist or physician take a look.

Any questions feel free to email me:  joe@elitepttc.com or call 231 421-5805.

Originally posted on SportsRehabExpert.com

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 using Graston Technique to treat soft tissue dysfunction in the posterior shoulder girdle using 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

    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.

    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!

    Elite PT Exercise of the Week – Landmine Front Squat to Press

    Joe Heiler PT and Nick Lucius SPT

    At Elite Physical Therapy and Sports Performance we’re always looking for new ways to challenge our patients and athletes.  The landmine squat to press is one of those exercises that can be used to really stress the entire system without having to utilize a lot of loading so it fits in nicely in higher level rehab and during the training process.

    Reasons to use this squat variation include:

    1)  Having the weight in front allows the athlete to sit deeper into the squat with a more upright trunk which is great for those dealing with, or recovering from, low back pain.

    2)  Keeping both hands on the bar keeps things more symmetrical with the squatting and pressing movement.  Stability requirements are increased with the use of this exercise but are balanced right to left.

    3)  Hold the bar in one hand for an asymmetrical loading pattern.  This will load the body differently demanding greater stability throughout the movement.  This is a more advanced technique so 2 hands on the bar to begin.

    Technique:

    1)  Do not squat lower than your mobility allows!  The weight in front often allows for a deeper movement but do not let the pelvis tuck under and low back to round out.

    2)  Heels must stay flat on the floor.

    3)  Elbows between the knees (this keeps the knees wide).

    4)  When using the asymmetrical single arm loading pattern, you must keep the body centrally aligned – no shifting, leaning, etc.

    Give this one a shot and you’ll see what we mean!

    BIO

    Nick Lucius PicNick Lucius SPT is completing his final year in the physical therapy program at UM-Flint.  Nick is a certified strength and conditioning specialist (CSCS) through the National Strength and Conditioning Association (NSCA), and also works as a strength coach at Barwis Method in Plymouth, MI.  After graduation Nick plans on returning to Barwis Method to work with patients affected by orthopedic and neurological conditions.

    Nick played Linebacker at Grand Valley State University in his undergraduate days, and now enjoys anything active from running to weight training, and is always going through a good book.