What do you do if you have continued pain after ROTATOR CUFF SURGERY
Continued shoulder pain even after a surgery for tears does happen. When complaints persist and have become an unresolved shoulder pain, I am called upon to help patients make decisions what to do next. Helping patients learn about the available treatment options and understand their choices is a discussion that needs to take place. When I discuss Rotator cuff surgery I refer to Lädermann A, et al. from the University Hospitals of Geneva. They state that “Tear recurrence can be related to various factors such as:
(1) Inadequate strength of the initial repair construct
(2) Biological failure to heal despite strong initial fixation (hardware and suture) and
(3) inappropriate postoperative rehabilitation causing structural failure of the repair” (1).
We always hope for good outcomes after a surgery but “The results of (rotator cuff) treatment are not as predictable as the patient (family, trainer, coach and doctor) would like to think” says Nickolas G et al. in the Physical Medicine and Rehabilitation Clinics of North America journal.
I talk to patients about the concept of cellular communication and how there could be a breakdown in the local tissue area and even the brain to stimulate proper healing. We have learned that certain therapies such as stem cell injections, shockwave, and laser can seem to jump start a non-healing area within a damaged shoulder or knee joint. The current thinking is that these therapies change the joint environment from non-healing (diseased) to healing by signaling the local native resident healing cells to get ready to rebuild.
How, can I as a Chiropractor change the joint environment from not healing to healing and working better?
- By inducing gentle non-painful motion into a poorly functioning joint.
- By re-awakening stem cells to change (plasticity) and activate (multipotency – the ability to change/morph into other cell types and multiply). I use shockwave to do this.
- Get the surrounding healthy cells to send signals to suppress inflammatory T–cell proliferation (inflammation) and provide an anti-inflammatory effect. I use laser to do this.
Maybe the above 3 points help activate stem cells to express various growth factors – it takes a lot of reawakening of molecules to stimulate local tissue repair. I like the concept of getting cells to communicate directly cell to cell (even to the resident remaining cartilage cells) in the joint. Seol et al did a study to show that stem cell activation regenerated cartilage in knees, why not the shoulders! (3)
- Lädermann A, Denard PJ, Burkhart SS. Management of failed rotator cuff repair: a systematic review. Journal of Isakos. 2016;1(1):32-37. doi:10.1136/jisakos-2015-000027.
- Nickolas G. Garbis, Edward G. McFarland. Understanding and Evaluating Shoulder Pain in the Throwing Athlete. Physical Medicine and Rehabilitation Clinics of North America, 2014; 25 (4): 735 DOI:10.1016/j.pmr.2014.06.009
- Seol D, Zhou C, et al. Characteristics of meniscus progenitor cells migrated from injured meniscus. J Orthop Res. 2016 Nov 3. doi: 10.1002/jor.23472.
Chiropractic manipulation does not reposition a vertebra from a misaligned position to an aligned position. Rather, it is likely that manipulation breaks up adhesions present in the joints of the spine, which improves movement asymmetries and/or stimulates mechanoreceptors – thereby reducing spinal muscle excitability, enhancing proprioception and reducing pain.
While manipulation has been proven effective for the management of acute low back pain, a prospective placebo-controlled study by Senna and Machaly demonstrates that long-term chronic low back pain sufferers respond best to maintenance manipulations performed bimonthly for up to nine months. The authors suggest the occasional (Chiropractic) manipulations may allow for the “early treatment of any emerging problem, thus preventing future episodes of low back pain.”
My sports medicine and chronic pain therapy approach of using the DMS (vibration, percussion), EnPuls (radial shockwave), Piezowave (acoustic shockwave) and massage in conjunction with chiropractic enhances the breaking up of disruptive and painful scar tissue.
- Tullberg T, Blomberg S, Branth B, et al. Manipulation does not alter the position of the sacroiliac joint: a roentgenstereophotogrammetric analysis. Spine, 1998;23:1124-1128.
- Cramer G, Tuck N, Knudsen J, et al. Effects of side-posture positioning anti-posture adjusting on the lumbar zygopophyseal joints as evaluated by magnetic resonance imaging: a before and after study with randomization. J Manip Phys Ther, 2000;23:380.
- Nansel DD, Peneff A, Quitoriano J. Effectiveness of upper versus lower cervical adjustments with respect to the amelioration of passive rotational versus lateral-flexion end-range asymmetries in otherwise asymptomatic subjects. J Manip Phys Ther, 1992;15:99-105.
- Nansel D, Waldorf T, Cooperstein R. Time course effect of cervical spinal adjustments on lumbar paraspinal muscle tone: evidence for facilitation of intersegmental tonic neck reflexes. J Manip Phys Ther, 1993;16:91-95.
- Lehman GJ, McGill SM. Spinal manipulation causes variable spine kinematic and trunk muscle electromyographic responses. Clin Biomech, 2001;16:293-9.
- Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med, 2004;141:920-928.
- Cleland J, Fritz J, Whitman J, et al. The use of a lumbar spinal manipulation technique by physical therapists in patients who satisfy a clinical prediction rule: a case series. J Orthop Sports Phys Ther, 2006;36:209-214.
- Senna M, Machaly S. Does maintenance spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcomes? Spine, 2011 Aug 15; 36(18):1427-37.
Chiropractic. The goal of this treatment is to significantly decrease symptoms such as pain, tightness, stiffness, soreness, aches, and improve athletic performance, mobility, and your ability to perform general activities.
Laser. Evidence for the effectiveness of laser is strong. Patients feel the relief especially for knee pain and TMJ pain
Shockwave therapy. This form of medical treatment is acknowledged as a means for enhancing scar tissue mobility and breaking up muscle tightness and muscle and joint adhesions. It is also helpful for chronic pain reduction and improved mobility. It helps osteoarthritic symptoms with improved functional mobility and quality of life.
Along with laser, Deep Muscle Stimulator (DMS), shockwave therapy is effective for pain control of osteoarthritis of the knee, neck pain, low back pain, and increasing mobility.
Deep Muscle Stimulator Massage. Followed by hands on therapy, DMS is the most commonly utilized treatment in my office. Patients feel better after this type of massage than receiving a regular hand massage. They have significant improvements in pain, stiffness, and physical function.
Dietary supplements. I use a variety of products from Metagenics, Xymogen, Designs for Heath, and Standard Process for joint pain, arthritis, inflammation, and weight loss.
Widening the integrative approach to treatment
There is emerging evidence that integrating multiple conventional and alternative therapies such as chiropractic, exercise, laser, shockwave, DMS, lymph therapy provide the best results for patients.
If you are a person who still has pain and diminished mobility who has already explored other therapies and doctors but have been disappointed, I would like the opportunity for you and I to meet. I continuously evaluate the increasing body of evidence in support of new therapies, and I am confident in offering my patients a wider range of choices than standard chiropractic care.
Call 310-444-9393 for an appointment
If you have any of the above, have you tried Pneumatic Lymphatic Pump Therapy?
One of the most neglected systems of the body is the Lymphatic system. An innovative treatment for chronic pain, foot pain, hip pain, inflammation, neck pain, shoulder pain, & TMJ pain is Lymph Drainage Therapy (DLT). In my office I use state of the art technology called LymphaTouch for DLT. Benefits of the LympaTouch Pump Therapy include reduction in limb circumference, pain, increase in range of motion, scar mobility and improved functioning of the immune system. The immune system is stimulated through increased lymph flow. The additional flow carries more antigens to the lymph nodes, thereby increasing antibody/antigen contact. This has been found to help with chronic or subacute inflammatory processes — chronic fatigue syndrome, autoimmune disease, bronchitis, sinusitis, tonsillitis, laryngitis, arthritis, acne and eczema.
Call 310-444-9393 to schedule an appointment
Managing postmastectomy lymphedema with low-level laser therapy.
Lau RW, Cheing GL.
A prospective, single-blinded, controlled clinical trial was conducted to examine the effectiveness of LLLT on managing PML.
METHODS: Twenty-one women suffering from unilateral PML. Outcome measures were assessed before and after the treatment period and at the 4 wk follow-up.
RESULTS: Reduction in arm volume and increase in tissue softening was found in the laser group only. The laser group had a 16% reduction in the arm volume at the end of the treatment period, that dropped to 28% in the follow-up. Moreover, the laser group demonstrated a cumulative increase from 15% to 33% in the tonometry readings over the forearm and anterior torso. The DASH score of the laser group showed progressive improvement over time.
CONCLUSION: LLLT was effective in the management of PML, and the effects were maintained to the 4 wk follow-up.
Clin Rehabil. 2009 Feb;23(2):117-24
We are the first office in Los Angeles to offer the PiezoWave therapy. The PiezoWave machine supplies an acoustic wave used to target tissues at varying depths (0 to 20 mm). It is a very focused, precise, deep tissue therapy. The device locates myofascial trigger points in the muscles. These are hyper-irritable spots located in a taut band of skeletal muscle. They generate pain, both locally and in referred pain patterns, and often accompany chronic musculoskeletal disorders. PiezoWave is being used for regional pain, especially in the neck, shoulders, low back and hip areas. If you know you have tension headaches, temporomandibular joint pain, decreased range of motion in the legs, and low back pain, even if you have tried other therapies like laser I would suggest a trial of PiezoWave.
To Your Health December, 2011 (Vol. 05, Issue 12) Share | By Jeffrey Tucker, DC, DACRB
The most common injury sites for golfers are the low back, shoulder, knee, elbow and wrist. Golfers who have low back pain demonstrate a decrease in range of motion for hip internal rotation on the lead leg (left leg for a right-handed golfer) and lumbar extension, and decreased activation and/or timing of the abdominal obliques, erector spinae and knee extensors. A good golf swing uses the left side of the body as much as the right. The hips initiate movement into the ball. The feet pushing against the ground cause a ground reaction force that sequentially travels up through the hips, the trunk and finally out the arms. The most noticeable difference between pros and amateurs is trunk rotation. Trunk rotation and flexibility are enormously important in golf. Older and less skilled players tend to use less than half the trunk rotation of younger or more skilled players.
Golfers who are looking to maximize their performance and avoid and/or rehabilitate following common golf-related injuries should try these exercises in consultation with their doctor of chiropractic:
Active Warm-Up Exercises Bend forward at the hips to touch the fingers to the floor.
Step into a stride position, extending the right leg (lunge).
Lift the right arm, rotate the spine and the head – hold this pose for 10 seconds.
Return to the stride position.
With hands on the left thigh, drop the back knee toward the floor and reach both arms overhead.
Twist the torso toward flexed front knee and hold.
Return to the hip flexor stretch position then put both hands on the floor.
Go to push-up position.
Sweep the left foot across in front – sit into the stretch and hold for 10 seconds.
Return to the push-up position.
Step forward into a forward bend and hold.
Sit into a deep squat with open knees.
Lift hands overhead, stand up and bring arms back to your side.
Now repeat this on the opposite side: Bend forward at the hips to touch the fingers to the floor. Step into a stride position, extending the left leg (lunge). Lift the right arm – rotate the spine and the head – hold this pose for 10 seconds. Return to the stride position. Hands on right thigh, drop the back knee toward the floor and reach both arms overhead. Twist the torso toward flexed front knee and hold. Return to the hip flexor stretch position then put both hands on the floor. Go to push-up position. Sweep the right foot across in front – sit into the stretch and hold for 10 seconds. Return to the push-up position. Step forward into a forward bend and hold. Sit into a deep squat with open knees. Lift hands overhead, stand up and bring arms back to your side.
The shoulder is the key anatomical structure involved in every phase of the golf swing. If you’ve suffered a shoulder injury related to golf or are just looking to improve shoulder rotation and performance, ask your doctor of chiropractic about these exercises:
Wing stretch: Place the back of your right hand on the outside upper gluteal (buttock) region so the elbow sticks out to the side. The back of the hand touches above your “pants pocket” area. Grab the right elbow with the left hand and pull it the elbow forward, simultaneously resisting the pull by stabilizing your shoulder girdle backward on the stretching shoulder. Hold this stretch for one minute.
Open book: Lie on your left side with your knees bent and your arms straight out in front of you, palms together. Keeping your knees on the ground, take your top arm and rotate your upper body all the way in the opposite direction. Perform 15 reps. Repeat on the other side.
Thoracic rotation: Get down on all fours, place your right hand behind your head, and point your right elbow out to the side. Brace your core and rotate your right shoulder (think about moving through the shoulder blade) toward your left arm. Follow your elbow with your eyes as you reverse the movement until your right elbow points toward the ceiling. That’s one repetition. Do 20 reps right and left.
Band diagonal raise: Attach a band or handle to the low pulley of a cable station. Standing with your left side toward the pulley, grab the handle with your right hand in front of your left hip and bend your elbow slightly. Pull the handle up and across your body until your hand is over your head and your thumb is pointing up (a Statue of Liberty pose). Return to the starting position. Complete 10-15 reps and repeat with your left arm.
Scaption: Perform this exercise standing in front of a mirror to monitor their form. Hang the arms down by the thighs and rotate both hands to a thumbs-up position. Retract and depress the scapulae as you lift the arms up to shoulder-height at a 45-degree angle from the trunk. The arms should make a Y in front of them. Make sure that the upper trapezius isn’t pulling the shoulders into the ears. If it is, work on pulling the shoulders down in order to push the arms up. Perform two sets of 15 reps per set.
Lie face down on a bench with your upper shoulders off the bench to perform these exercises, which involve raising the arms / shoulders to mimic the shape of a Y, T, W and L (e.g., arms up over the head forms a Y; arms straight out to the sides forms a T; etc.). Standing Y-T-W-L exercises can also be performed using a stretch strap, which allows you to maintain a consistent arm position.
One More Great Exercise:
If you’re suffering from increased thoracic kyphosis (rounded upper back / shoulders), protracted shoulder blades and/or forward chin position, ask your doctor of chiropractic about this corrective exercise: Stand, feet together, looking straight ahead. The feet should remain in this position for the duration of the exercise. Put one hand beneath your collarbone and one hand on your belly button. Keeping your hands in that position, lift the chest with the hand under the collarbone while simultaneously pulling down with the belly button hand. This will help to lengthen the spine and reduce the slouched position. Holding the achieved position, level the pelvis by raising the middle of the pelvis with the lower abdominals. Lengthen the neck by slightly tucking the chin and imagining the crown of the head is being pulled toward the sky. Bend your knees very slightly, just enough to remove any tension from the posterior knee. Holding the achieved position, lean forward slightly to shift the center of gravity to the midfoot instead of the heel. Practice this frequently to improve posture. This opens the chest and allows for more natural breathing as well. While non-golfers may not realize it, the physical challenge of golf can be more daunting than the mental part of the game, particularly if you don’t use proper mechanics during every part of the swing. Injuries are common, which will either affect your game dramatically or stop you from playing altogether.
Talk to your chiropractor about these and other exercise strategies to improve your golf game and avoid injury. ——————————————————————————– Jeffrey Tucker, DC, is a rehabilitation specialist who integrates chiropractic, exercise and nutrition into his practice in West Los Angeles. He is also a speaker for Performance Health/Thera-Band, NASM and FMS.com .
Watch this one minute video to learn which exercise to perform
Aching and stiffness in the shoulders and neck are an extremely common problem, especially for those involved in desk and computer working. If you feel like you need a daily massage, the real cause tends to be postural. Whilst seated, staring at a screen for hours on end, it is easy to fall into a slumped position, with rounded shoulders and the neck protruding forwards. Assuming this position day-in, day-out can result in shortening of the chest muscles and weakening of the small, postural upper back and neck muscles which work to pull the shoulders back. This results in the larger back and neck muscles such as Trapezius and the Rhomboids working harder and becoming tight and achy. Working on correcting these imbalances, by stretching the chest muscles and building endurance strength in the postural muscles such as the lower Trapz and Serratus Anterior can result in a long-term fix.
I treat neck and shoulder pain with soft tissue therapy, mobilization of the stiff joints, corrective exercises, stretching, and posture training.
Shoulder impingement injuries occur when the space in the shoulder joint is decreased, resulting in pinching of one or more of the tendons which pass through this space. The reason for the decrease in space is often related to poor posture. If the chest muscles are tight and the upper back muscles such as the lower Trapezius and the Serratus Anterior are weak, through extended periods of sitting slouched at a desk, then this can cause the shoulder joint to sit in a forwards position.
I treat shoulder impingement with warm laser, muscle therapy and corrective exercsies.