Tag Archives: traverse city sports therapy

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

Now at Elite Physical Therapy – Functional Dry Needling

Functional Dry Needling is a very effective manual therapy technique that I’ve been wanting to learn for some time now, and was recently trained though Kinetacore.  I’m very excited to be using this new technique and I’m already seeing some great results.

In this week’s blog post, I want to give some very basic background on what Dry Needling is, and is not.  The article below doesn’t mention this but I want to make it quite clear that this is not acupuncture.  The only similarity is the use of the same type of needle.  Dry Needling performed by a physical therapist requires a thorough musculoskeletal evaluation, and placement of the needle into specific taut bands of muscle (a.k.a. trigger points) that are pain generators and creating dysfunction within the system.

My knowledge of acupuncture is somewhat limited but generally speaking the points that are treated in the body are mapped out along ‘meridians’.  Needles are placed into these preset points and left for a certain amount of time.

There is a lot more to it than just this, and I think it is important to understand that there are differences.  The description of Functional Dry Needling below comes from the Kinetacore website.  It’s a quick primer on the technique.  If you want to see it in action, check out the video at the bottom of the page featuring Terry Bradshaw.

“Dry Needling is a general term for a therapeutic treatment procedure that involves multiple advances of a filament needle into the muscle in the area of the body which produces pain and typically contains a ‘Trigger Point’.   There is no injectable solution and typically the needle which is used is very thin. 

Most patients will not even feel the needle penetrate the skin, but once it has and is advanced into the muscle, the feeling of discomfort can vary drastically from patient to patient.  Usually a healthy muscle feels very little discomfort with insertion of the needle; however, if the muscle is sensitive and shortened or has active trigger points within it, the subject may feel a sensation much like a muscle cramp — which is often referred to as a ‘twitch response’.

The twitch response also has a biochemical characteristic to it which likely affects the reaction of the muscle, symptoms, and response of the tissue. Along with the health of the tissue, the expertise of the practitioner can also attribute to the variation of outcome and/or discomfort.  The patient may only feel the cramping sensation locally or they may feel a referral of pain or similar symptoms for which they are seeking treatment. A reproduction of their pain can be a helpful diagnostic indicator of the cause of the patient’s symptoms. Patients soon learn to recognize and even welcome this sensation as it results in deactivating the trigger point, thereby reducing pain and restoring normal length and function of the involved muscle.

Typically positive results are apparent within 2-4 treatment sessions but can vary depending on the cause and duration of the symptoms, overall health of the patient, and experience level of the practitioner. Dry needling is an effective treatment for acute and chronic pain, rehabilitation from injury, and even pain and injury prevention, with very few side effects. This technique is unequaled in finding and eliminating neuromuscular dysfunction that leads to pain and functional deficits.”

If you have further questions about the technique, or feel that this technique may work for you then feel free to contact us:  joe@elitepttc.com or 231 421-5805231 421-5805.

Elite Physical Therapy Exercise of the Week – Wall Posture Shoulder Mobility

originally posted on SportsRehabExpert.com

This article was originally written for physical therapists and other clinicians dealing with shoulder pain and loss of motion so excuse some of the medical terminology.  I know a number of them read this blog so I’m leaving the article as is. 

The jist of this article is as follows:  most of us have too much extension (arch) in our lower spines, and we go into even more extension any time we try to raise our arms overhead.  Over time this can lead to shoulder pain and low back pain.  The article below describes a great warm-up exercise to improve shoulder mobility while controlling spinal posture. 

As always if you have any questions feel free to email me:  joe@elitepttc.com

Joe Heiler PT, CSCS

This is a great correction for the shoulder mobility movement patterns and also for the shoulder flexion component of the MS Extension pattern.  The lumbar spine frequently contributes excessive extension to the shoulder patterns when the shoulder itself is limited.  Mobility work is required to free up the shoulder, but this pattern will continue if motor control is not imparted to lock in the new range of motion.

I would not want to be her low back right about now!

The ‘wall posture’ as I describe it to the patient is an attempt to get the entire spine to touch the wall.  By having the feet out in front and knees slightly flexed it makes it easier to get the lumbar spine flat onto the wall which is really just a less extended, and probably more neutral position, for most folks. If you’re concerned that it is too much flexion, or if it is not well tolerated due to back pain, and towel roll/lumbar support could be used but contact must be kept at all times.

The cervical spine is a little trickier when it comes to proper positioning.  I will cue to get the spine to the wall, but to a point.  That cue will usually bring the chin down and back (into cervical retraction) which again will bring most folks to a more neutral posture.  Too ‘straight’ is not a normal position either and could affect the shoulder mobility component of this corrective so don’t force it.  If their forward head posture is so severe that their head won’t touch the wall without going into extension, then place a towel roll behind the head and require them to hold the towel in place as the arms go overhead.

Maintaining the proper positioning throughout the movement is the most important factor here.  The shoulder motions in the video are a challenge to that positioning.  When posture is lost, the movement is done.

Breathing is critical here as well.  My preferred way of cuing the breathing is to inhale at the bottom and slowly exhale during the overhead motion.  The more the ribs stay down in the front the better.  This can be incredibly hard for many people, and especially so for many overhead athletes, weight lifters, dancers, and gymnasts.

 

The order in which the motions are presented in the video go from easier to most challenging:

1)  Shoulder Flexion
2)  Shoulder Abduction (snow angels)
3)  Shoulder Abduction with External Rotation

If following the SFMA’s 4×4 matrix, this would be considered a level 4 posture, unloaded but with assistance (the wall as the positional cue) so 4:1.  Competency must be attained in each of the previous postural levels:  1)  supine/prone, 2)  quadruped, 3)  tall or half kneeling.

Progressions per the matrix:

4:2 – shoulder mobility work without the postural cuing or any activation
4:3 – loaded with cuing or activation.  Shoulder Flexion/Extension (reciprocal patterning) or pressing overhead with the spine against the wall or a corner (I prefer a corner to allow the shoulders to move more freely).
4:4 – loaded without cuing or activation – Shoulder Flexion/Extension in standing, any type of pressing.

Increasing Intensity Without Increasing Load

This is an article I originally posted on SportsRehabExpert.com, and thought it would be a great piece for the blog audience as well so I apologize ahead of time if some of the terminology is a bit too ‘medical’.

 

I’m constantly on the lookout for ways to challenge my patients and athletes, but without overloading their joints and tissues.  Many of them want to really push themselves, but sometimes they are at that point in their lives or careers where it’s just not appropriate for longevity sake.  In this article I’ll discuss some of the strategies I use to get the most out of strength training without overloading the weakest link.

There are 4 basic ‘solutions’ to this problem that I will use.  I think the best way to cover these would be to describe a couple cases for the lower body and upper body:

Case 1:  Active military gentleman with 2 episodes of disc hernation and radicular symptoms within a two year period.  Both episodes were brought about with heavy lifting, but he also spends quite a bit of time sitting in the back of a helicopter in a seat that’s about 6″ off the ground (his knees are practically in his face).

I worked with him after the first incident, cleared his movement and had no symptoms.  He resumed weightlifting and all other previous activities. After 6 months in the clear he went back to heavy squats and deadlifts, and after 2-3 months of that began noticing the radiating pain into his left leg again.

This guy is an absolute beast when it comes to his fitness level and his form has always been very good.  But because of his past and his work demands, this is a guy that I want to limit the load he is using, as well as the positions he puts himself in.

Solution #1 – Move from bilateral stance to split or single leg stance

This one is pretty obvious in that there is no way he is going to load single leg activities the way he can load a traditional squat or deadlift.  Single leg deadlifts and squats are great options here because of the extra stabilization needed just to balance and control the trunk.  There is only so much weight you’re going to pull with these single leg movements.

Solution #2 – Asymmetrical loading

An example of this would be a single leg deadlift in which the weight is held in the opposite hand (of the stance leg) so the trunk must work in an anti-rotation manner as well as anti-flexion (see video above).  Another great example would be a front squat with a kettlebell in one hand (see picture below) using either the traditional grip or bottoms up.  The demands on the core can be quite high loading in this manner so the athlete gets a great workout with less overall load.

Single Arm Kettlebell Squat

Solution #3 – Postural Assist

Split squats or rear foot elevated split squats (REESS) are ideal for this type of athlete because the positioning makes it easy to maintain an upright spine and therefore decrease the shearing type loads you would see with a traditional squat where the trunk is angled forward.  Mike Boyle (one of the top strength coaches in the world) has talked extensively about this and thus his programs have moved from back squats to front squats to RFESS over time.  This type of squat can easily be asymmetrically loaded as well (different weighted dumbbells in each hand).

Rear Foot Elevated Split Squat

Solution #4 – Bottoms Up

There are many reasons I like kettlebells, and the ability to go bottoms up is another one of those reasons.  I can instantly make any kettlebell exercise much more challenging to the athlete’s grip and stability.  The video above showing the KB front squat is a great example, plus I will frequently use this with Turkish Get-Ups, various carries, and presses.

Double Bottoms Up Kettlebell Squat

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Case 2:  This is more of a general example here as I work with a number of adult athletes post rotator cuff repair looking to return to their sport and the gym.  Unless they are competing in powerlifting or weightlifting events, I really don’t need them putting a whole bunch of weight on the bar to bench or shoulder press any longer.

My #1 job is to protect the repair while they are seeing me in PT, but also when they are beyond my care.  Job #2 is to give them tools to enhance performance and get them back to the sports they enjoy.  Again I believe this can be done using the ‘Solutions’ mentioned above.  Here are some examples for the upper body (although in the clinical or performance setting I would never really divide them up this way).

Solution #1 – Move from bilateral to single arm exercises.

The same idea applies to upper body as lower.  The amount of stabilization and balance needed to perform single arm presses (horizontal and vertical) is going to make it quite difficult to really load up with weight.

The single arm bench press is one of my favorites.  I have the athlete scoot their hip and shoulder off the bench so they really have to fight the weight pulling them off the bench.  I usually have to start athletes at about 50% of what they could dumbbell bench using the traditional two arm method.  Athletes are not always happy about going down in weight but they feel right away this is going to make them work.

Solution #2 – Asymmetrical loading

In the case of upper body pushing and pulling, the ‘solution’ of asymmetrical loading is usually just a version of ‘Solution #1’.  Another way to inject greater asymmetrical loading into singe arm lifts would be to have the athlete lift from a single leg stance position.  This isn’t something I use real often but there have been times I’ve had to be cautious with someone’s shoulder and wanted to increase intensity without increasing load.  Single leg/single arm kettlebell presses fall into this category, as well as single leg rows (hamstring killer!).

Can’t believe I couldn’t find a better picture than this!

Solution #3 – Postural Assist

In this instance, requiring the athlete to stand to overhead press (or go tall or half kneeling) brings a lot of postural and stability requirements to the table.  It makes it more difficult again to really load up the lift when they don’t have a bench to press into.

Solution #4 – Bottoms Up

Same thing again using the kettlebell bottoms up to work the grip harder and force great stability from the upper quarter.

Single Arm Press – Now that’s a picture! That KB is 55 KG by the way

Now don’t get me wrong, I still love to see big lifts.  There are just times when the person in front of you needs less loading so be creative and use these techniques to help create an optimal environment to make gains without risking injury.

Private Pay Physical Therapy

I’ve been meaning to write an article about this for awhile now, and since the New Year and the many changes in the insurance industry it’s prompted some action on my part.

The current trend in the health insurance industry is to increase the patient’s responsibility for their health care.  This shows up in rising co-pays that are as much as $60 per visit or deductibles that can be as high as $10,000.  This pretty much means you pay the first $10,000 of your medical expenses before the insurance company starts kicking in anything.  On top of that you max have an ‘out-of-pocket’ max to reach so that you may still have a co-pay or a co-insurance until you reach that magic number.

I’ve had this type of insurance myself so I know full well how it works.  To be able to afford the monthly premiums anymore, some folks are forced to go this route and then pray that nothing bad happens to them or their family.

I’ve always offered what I think is a rather fair private pay rate since many people didn’t have insurance prior to the Affordable (laugh) Care Act.  Everyone is required to have insurance from this point forward or pay a fine.  Many younger folks are choosing to pay the fine for now since it is much cheaper than paying for insurance they probably will not use. In this case private pay for physical therapy is a no-brainer.

Now what about for those of you that do have insurance?  This is where is can be a little tricky.

The private pay rate here at Elite Physical Therapy is $75 per visit.  This was the lower end of what insurance companies would typically pay for a physical therapy session, although with cost cutting more companies are hovering around this point.  There are still companies that do pay significantly more than that depending on what is billed.

The typical session at Elite is 45 minutes (60 minutes day 1 with the evaluation), and is one on one with the physical therapist.  You have 45 minutes of my undivided attention plus access to me by phone or email with questions.  The typical frequency of visits is 2x per week, and in some cases 1x if cost, schedule, or distance are issues.

That being said, for a person who is private paying for physical therapy, that would come to $150 weekly.

Most clinics are going to see you at least 2-3x per week so if you have a $50 co-pay you’re already up to $100-150.  Not only that but most other clinics in this area will allow you 15 minutes with your therapist and the rest of the session is spent exercising on your own or with a tech.  You may save a little, but the quality of care may not be the same.

Here are a few other scenarios I have run into where someone chooses private pay over insurance:

  • They do not anticipate meeting their deductible and choose to pay the $75 private pay rate rather than what they would be charged if it were billed through the insurance.  Going through insurance can cost as much as $225 for the first visit and $90-120 for subsequent visits.
  • Some people would just rather keep their health information between them and their doctors so they request to private pay versus going through their insurance.  I’ve heard a number of valid reasons for this but the big one being concerns over the deductibles going up (much like claims against auto or home insurance).

Here are a couple other points to consider when choosing between private pay and insurance, or even which PT clinic is right for you:

  • My thought process with many injuries/conditions is that you should see substantial improvement within 4-6 sessions.  I tell my patients this right up front.  You may not be 100% that quickly but you should be well on your way.  I don’t want to waste your time and money so if things are not improving in that time frame its time to go back to your physician.  I hate to say this but I’ve had patients come to me with 20-30+ visits to PT under their belt already and no results.
  • Many clinics in this area do not give discounts for private pay physical therapy!  PT services, just like physician or hospital services, are billed out at a much higher rate than what would actually be paid out.  It’s a game we all have to play with the insurance companies unfortunately, but to bill a patient that same rate to me is ridiculous.  At a minimum you’re probably talking $150 for a 30-45 minute session.
  • This goes along with the point above – I’ve done some checking and as far as I know I have the cheapest private pay rate around.  I’ve even had a couple referrals from other PT’s because their ‘friend’ didn’t have insurance and I had the best rates.

The point of this article is to let you know that you have options!  Great care for a fair price is what it’s all about here.  If you have any questions at all feel free to contact me at 231 421-5805 or shoot me an email:  joe@elitepttc.com

 

 

 

 

Competing at a High Level after an ACL Injury

Big thanks to Dave Chalmers who wrote this guest blog post.  Dave is an athletic trainer who currently writes on behalf of DME Direct

 

It’s every athlete’s worst nightmare. Tearing your anterior cruciate ligament and sustaining a devastating ACL injury. The reason these injuries are so terrifying to athletes is that the road to recovery is long and arduous, and even then there is no guarantee you will ever be the same player and you always run the risk of re-injury. However, over the years there have been major advancements in ACL rehabilitation and it is now much more plausible to return to competition after an ACL injury and compete at a high level.

Prehab

One aspect of ACL rehabilitation that often gets overlooked is the important time following the injury prior to surgery. As more people are realizing the significance of getting a recovery program off to a good start, the practice of prehabilitation is being implemented more frequently.

Typically the aim of prehab is to reduce swelling and stabilize the knee prior to surgery. This can be achieved through cold therapy and wearing a knee support to compress and stabilize the knee. Some mobility exercises can be performed at this stage if you experience no pain while doing them.

Post-Surgery

After successful reconstructive surgery, the rehabilitation process begins. This process can be broken down into a timeline with various phases. It is important that you stick to this timeline and do not rush things and risk re-injury.

The first two weeks immediately following surgery should be spent focusing on reducing swelling and controlling swelling. Similar to the processes of prehab, icing and compression should be applied here and the use of crutches combined with rest is commonly advised. At this time you can begin with static strengthening exercises such as lying down quadriceps and hamstring contractions.

After these two weeks, you should being a second phase of recovery. Mobility and strengthening exercises should continue and you can start to introduce exercises like shallow lunges and half squats. You can also start implementing adduction and abduction exercises for hip flexor strengthening as well as begin proprioception and balancing exercises.

At about the six week mark you can begin another phase of the rehabilitation. At this stage you can advance to full lunges and squats. You can now start to add weight for increased resistance and begin straight line jogging exercises.

Approximately twelve weeks after surgery you can begin to mix in training activities specific to your sport. The key here is to gradually increase speed and intensity of drills. Along with sport-specific drills, you should also focus on exercises that strengthen hip abductors and external rotators such as monster walks and single leg glute bridges.

Return to Competition

When and only when, your surgeon gives you permission to return to competition will you be able to start competing again. If you follow the processes outlined here you will give yourself the best chance to return to competition physically capable of competing at a high level. However, there is also a mental aspect that many athletes overlook.

Even if your body is ready physically, you may not be mentally prepared to trust your knee in live competition. Again, it is important to be patient and avoid returning until you are fully ready. Use the exercises mentioned above at the end of your recovery program to test yourself a bit and build confidence in your repaired knee. Once you return to competition, wearing a trusted ACL knee brace can give you extra support both physically and mentally.

The long road to recovery after an ACL injury can seem overwhelming at times. Dedication and discipline are required to rehabilitate yourself successfully. However, if you put in the work to reach a level where you are properly prepared physically and mentally to return, you can begin competing at a high level again.

Dave Chalmers is an athletic trainer who currently writes on behalf of DME Direct on topics related to sports medicine and physical therapy. When he’s not writing, you will most likely find Dave at the Staples Center cheering on his beloved Lakers.

 

Shoulder Rehab Part III

In part I of this series I discussed how traditional physical therapy exercises for the rotator cuff often miss the mark, and then in part II how dysfunction and a lack of motor control in other areas of the body can significantly affect the shoulder and cause pain.  Be sure to read those, if you haven’t already, as this article will make much more sense.

In part III I want to talk about another concept that has taken the therapy world by storm – Scapular Retraction.

In a nutshell, scapular retraction means pulling the scapula (shoulder blade) closer to the spine, and often times the cuing from the therapist or physician is to pull the shoulder blades down and back (or “put your shoulder blades in your back pockets”).  Check out the picture below:

“Shoulder Blades down and back”

Now I’m not going to sit here and say that good things can’t happen from doing this, or deny that I used to buy this approach.  Some folks are just stuck with their shoulder girdle forward and scapulae protracted (spread apart) so far that they create a shoulder impingement with that faulty posture.  Working on scapular retraction can work in the short term in these cases, but I certainly don’t think it’s a permanent fix.  There are many therapists and physicians that feel this strategy will help in all cases.  Here are some reasons why it will not:

1)  The scapula is most cases just needs to be posteriorly tilted (or tipped).  Check out the photo below to get the visual, but the jist of it is that this creates more space in the glenohumeral (shoulder) joint to decrease impingement while also allowing for greater freedom of movement at the shoulder.

Try lifting your arm overhead maintaining your scapulae down and back like in the picture above.  It isn’t going to happen.  The scapulae are meant to upwardly rotate when going overhead to maintain the joint space and prevent impingement.  Too much ‘down and back’ will actually create more downward rotation and greater impingement (see picture above in the upper left).  Strike 1!

Scapular Reduction Test – the scapula is gently posteriorly tilted. This will often clear an impingement with shoulder elevation. Notice he is not pulling the scapula closer to the spine!

2)  Too much scapular retraction with common exercises like rows and pull-downs can result in an anterior glide of the humeral head.  Fancy term for the ‘ball’ of the shoulder sitting too far forward in the socket.  This can also lead to greater impingement, and for someone with the very common condition of bicipital tendinosis can be quite painful.

The top hand is palpating the borders of the scapula, while the bottom hand is palpating the front and back of the humeral head. Her humerus is seated anterior in the socket on both sides, but much more pronounced on the L shoulder. This is actually very common.

I’ve seen quite a few patients with this type of shoulder positioning fail miserably with scapular retraction programs.  You’re literally pulling the scapulae back and leaving the humeral head protruding even more to the front creating great impingement.  Strike 2!

3)  Remember in part II when I talked about regional interdependence?  Anything you do to the scapula could create a reaction somewhere else.  In the majority of cases the patient will overdo it, and you’ll end up with negative compensations elsewhere in the body.  Check out the picture below.  This is one of my all-time favorites, and I use this as a teaching tool with my students.

I know they say the picture on the right is ‘correct’, but look at what he had to do to his neck and back to get there (the arrows are mine).  He had to jack his neck and back into more extension, and over recruit his upper traps just to get there.  Nothing like creating a neck and back problem while trying to fix the shoulder.  It’s easy enough to do and I’ve seen many a therapist and trainer let this go.  Strike 3!

So what to do about this?

There is nothing wrong with a little scapular retraction to reposition the scapula on the thorax, but if some other issues are cleared up first this may just happen naturally.

1)  Cervical mobility – the neck should move freely and without pain.  I gave a great example of this in part II.  There are a number of muscles running between the neck and shoulder girdle so any tension resulting in cervical restrictions can alter scapular position.

2)  Thoracic mobility – the scapulae sit on the thorax so positioning and movement of the thoracic spine will definitely affect scapular positioning.  Poor mobility creates an inability to adjust the posture to the activity, and poor scapular mechanics result.

3)  Poor motor control – once mobility issues have been corrected (and it’s not just the cervical and thoracic spines), then scapular and spinal motor control often improve automatically.  Scapular retraction exercises aim to strengthen the scapular muscles, but motor control basically means the muscles are positioning and moving the scapula the right way at the right time.  See part 2 again for a more in-depth explanation.

This is by no means an exhaustive list of possible solutions, but it’s a start.

I plan on posting a couple videos next week showing how to perform pushing and pulling exercises correctly.  I’m on my way to Chicago right now for a Graston Technique training so those will have to wait until I get back.  Keep an eye out for those and part 4 – correcting scapular winging.

As always feel free to email any questions to me:  joe@elitepttc.com

 

 

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

 

 

Shoulder Rehab Part I

Physical therapy of the shoulder using traditional rotator cuff exercises really gets me fired up, so I should probably warn any physical therapists, chiropractors, or physicians reading this to buckle up!  Actually I’m not going to try to offend anyone, I just like to challenge conventional thinking and ask questions – especially when it comes to dogma like rotator cuff exercises.

If you’ve ever been to physical therapy for a shoulder rehab then you’ve probably seen this one:

Shoulder External Rotation

and this:

Shoulder Internal Rotation

These are just 2 of many exercises that supposedly target the rotator cuff that are commonly provided by your health care provider.  In fact, many of you have probably been handed 2-3 pages of these and told to do 3 sets of 15 up to 3x daily.  Ever heard of the shotgun approach?  Your health care provider is hoping and praying that one of these might just work and make you feel better.

Now here is the reality of the rotator cuff:  It’s job is to stabilize the humeral head (the ‘ball’ of the shoulder) in the glenoid fossa (the socket)

The 4 Muscles of the Rotator Cuff

What most health care providers are going on are EMG studies that measure how hard a muscle can fire in isolation during a specific activity.  There is certainly great evidence that the rotator cuff muscles are firing during these exercises.  The problem as I alluded to before is that these muscles do not function in this way in real life.

These smaller rotator cuff muscles are stabilizers, not movers (like the larger deltoids, pecs, lats, etc).  The traditional rotator cuff exercises train the muscles like ‘movers’ which is not their true function.  I’m not going to argue that someone can’t show increased strength over time within these exercises, but I will argue is that there is no transfer to improved function (i.e. lifting, reaching, carrying, pushing/pulling, etc).

The reality of the rotator cuff again is to stabilize the humeral head (the ‘ball’ of the shoulder) in the glenoid fossa (the socket).  It performs this task reflexively meaning it happens without you having to think about it.  All four muscles quickly fire and relax in a specific sequence (depending on the activity) to stabilize the shoulder joint.  They never work in isolation like you have been trained in the past.

So what are the best ways to fire the rotator cuff reflexively?

  • Compression – this means putting weight through the arm.  Examples would include exercises that involve hands or forearms on the ground holding your body weight, any type of pressing, holding a weight (on your back with the shoulder flexed 90 deg. – think top of a bench press position; or with a weight overhead) just to name a few.
  • Distraction – this would include anything that pulls downward or outward on the shoulder (think traction).  This would include carrying weight by your side, pull-ups, horizontal rows, lifting from the floor, etc.

In any of the above activities, the brain immediately recognizes the need for stability and reflexively fires the cuff to prevent bad things from happening like dislocating your shoulder or falling on your face.  Now obviously I’m not trying to actually do these things to you, but forcing muscles to fire reflexively always works better when there is some sense of urgency.

I’ll leave you with a few of my favorites below, and in part 2 I’ll tackle more of the dogma of shoulder rehab.

Arm/Leg Diagonals – a.k.a. the Bird Dog – Shoulder Compression for Reflex Stabilization

Farmer’s Walk – Shoulder Distraction to elicit reflex stabilization

 

Kettlebell Arm Bar – The goal is reflex stabilization of the glenohumeral joint through compression (using a kettlebell) while performing thoracic rotation.  Lots of great things happening here!

Feel free to email any comments or questions to me:  joe@elitepttc.com

 

 

Ankle Rehab Update

So last week I posted this message on Facebook:  “Limited ankle mobility is a very common reason for nagging foot, knee, hip, and back pain in runners. Unfortunately not too many PTs or doctors are looking there. Maybe it’s time to call us and rid yourself of that pain for good!”

In the past week I have been asked 3 separate times about what is the best way to check your own ankle mobility and then how to improve it.  So to bring you up to speed on why it is so important to have great ankle mobility I refer you to a previous blog post title “Movement Proficiency and the Ankle” which you can find here:  http://www.elitepttc.com/blog/?p=20

Now for the measuring and correcting!

The first video below shows how I measure ankle mobility in the clinic with the foot on the floor and controlling the ankle to prevent pronation (arch flattening out):

To measure your own ankle mobility, simply assume the kneeling position shown in the video.  Rock your knee over the foot to touch the wall measuring how far your big toe is from the wall with a simple tape measure.  The heel must stay down and arch not allowed to collapse.  The goal is 4 inches!

The next video demonstrates how you can quickly address the soft tissue component of the limitation.  Be sure to measure again as we did in the video as this is the only way you are going to know if it is effective or not.  Always follow the rolling with stretching.

If this does not result in an immediate improvement in ankle mobility, you may have a joint restriction that will not be resolved with rolling or stretching.  Another sure sign of joint restriction is pain or pinching in the front or side of the ankle during the testing.  This can often be resolved quickly with ankle joint manipulation and/or mobilization and certain taping techniques that I employ here at Elite Physical Therapy (in other words it’s time to call the professional).

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