All posts in Shoulder

Rotator cuff injuries

The rotator cuff  include the supraspinatus muscle/tendon, infraspinatus muscle/tendon, teres muscles/tendon, and the subscapularis muscle/tendon. The supraspinatus is most often the muscle that causes pain. Ths is because of wear and tear that causes degeneration due to its close anatomical relationship with the acromian process. The small space between the humeral head and the acromian process houses the supraspinatus tendon, subacromial bursa and biceps tendon. If anything reduces that subacromial space, then the chances of something being pinched and worn down increases greatly. 

I have seen an increase in patients with shoulder impingment syndrome. There are many causes of the impingement: 1) can be from an osteophyte (spurs or bone growth) growing down from the underside of the acromian; 2) previous shoulder trauma that either disrupts the stabilising mechanism of the shoulder joint (as in shoulder dislocation) or 3) from a past injury or poor posture that causes a change in the firing patterns of the stabilising rotator cuff muscles that allow the humeral head to bounce around or shear too much within the ‘socket’  and this increases the chance for impingement. By far the most common cause of rotator cuff problems is altered scapula position due to muscle tightness or poor muscle firing.  This can influence the position of the acromian as the arm is lifted above the head. The key muscle to influence a poor scapula position is the pec minor. This muscle causes the scapula to sit in a downwardly rotated position at rest, bringing the acromian process closer to the humeral head.

The way I treat this problem is by teaching clients the proper exercises to influence the firing patterns of the dynamic stabilisers of the shoulder – the rotator cuff. For example  the simplest way to activate a subscapularis muscle is grab a 1-2 kg dumbbell and lie on the floor on your back. Place the arm up into 90 degrees abduction so the elbow supports the arm on the floor and the hand holding the weight is directly over the elbow. Slowly lower the dumbbell towards the floor moving towards the head (this is eccentric external rotation – controlled by subscapularis). Only lower to about 45 degrees and then return to the start (concentric internal rotation – again subscapularis). As an activation drill this can be done with a light weight and non fatiguing repetitions.

The easiest way to loosen an infraspinatus is to self massage it. Stand against a wall, place the hand behind the head and with the other hand, reach around and place a tennis ball in the back of the shoulder (between the shoulder blade and the wall). If it hurts then press on it. Hold the trigger point for about 1 minute and then move on to a different spot.

Furthermore, the pec minor and levator scapulae need to be loosened and stretched. And the muscles which work to upwardly rotate the scapula need to be strengthened (the trapezius and the serratus anterior).

I always recommend the foam roll to improve poor thoracic spine mobilty and extension. Lack of motion in the thoracic spine influences the scapula. I have also used the warm laser on most of these cases with very good results.

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Rotator cuff tears and shoulder pain

February 15, 2011 (San Diego, California) — A physical therapy program can effectively treat most patients who present with atraumatic full-thickness rotator cuff tears and shoulder pain, without the need for surgery, researchers announced at the American Academy of Orthopaedic Surgeons (AAOS) 2011 Annual Meeting.

“Our non-operative program is successful in over 90% of patients and the effect seems to last at least 2 years,” John E. Kuhn, MD, associate professor and chief of shoulder surgery at Vanderbilt University Medical Center in Nashville, Tennessee, and director of the Multicenter Orthopedic Outcomes Network (MOON) Shoulder Group, said.

In the United States, at least 10% of persons over age 60 years, or nearly 6 million people, will develop a rotator cuff tear.

Prospective Cohort Study

The study included 396 patients age 18 to 100 years who had atraumatic full-thickness tears documented by magnetic resonance imaging and no other abnormality. The primary symptom was pain in most patients.

Patients were assigned to a physical therapy program that included daily postural exercises, active-assisted motion, active training of scapula muscles, and active range of motion, along with anterior and posterior shoulder stretching. They also performed thrice-weekly rotator cuff and scapula exercises. The program has been shown to be effective in patients with impingement syndrome.

Study participants also did manual mobilization exercises with assistance from a therapist.

Patients returned at 6 and 12 weeks. At this point they could decide that 1) treatment was successful and they needed no formal follow-up, 2) they had improved but would like to continue therapy with scheduled reassessment in 6 weeks, or 3) nonoperative treatment had failed and they would undergo arthroscopic rotator cuff repair.

Patients were contacted by telephone at 1 and 2 years to determine whether they had undergone surgery since their last visit.

Improvements on Multiple Outcome Measures

Six-week data indicate that fewer than 10% of patients had decided to undergo surgery.

Of patients in whom follow-up data were available for at least 2 years, only 2% had opted for surgery.

The analysis also revealed that patients who decided to undergo surgery generally made their decision within 6 to 12 weeks of starting physical therapy. In addition, patients did most of their physical therapy at home and usually made only 1 weekly visit to the physical therapist.

Finally, Dr. Kuhn emphasized that the physical therapy program alleviated pain without “doing anything to the tear.” The finding suggests that pain may be a less suitable indication for rotator cuff repair than is weakness or loss of function.

American Academy of Orthopaedic Surgeons (AAOS) 2011 Annual Meeting; Abstract #319. Presented February 15, 2011.

 

These findings are typical of what I find in my rehab practice. Those clients that do the exercises improve.

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Laser Treatments

Laser therapy has been around for a long time but it is considered cutting edge treatment for musculoskeletal injuries and pain.
Laser therapy stimulates cellular activity, expediting the healing processes to reduce inflammation and repair damaged tissue. 

You can feel the warm deep tissue penetration. This deep heat significantly increases the body’s cellular production of ATP (Adenosine-triphosphate) to reduce inflammation and heal the inflamed area.

Here are some of the benefits of using the deep tissue penetration that laser provides safely and effectively:

Healing and pain relief with no side effects, drug interaction effects, or invasive surgery.

Treats acute and chronic conditions as well as post surgical pain.

Pain relief is often felt immediately.

Most laser treatments take only 10-20 minutes.

Are you a potential candidate?

  • If you have pain that is of musculo-skeletal origin, laser therapy may be for you:
    This includes sports injuries, back and neck pain, any joint pain (knee, shoulder, ankle, etc), bursitis, tendonitis, tennis elbow, contusions, strains and sprains, carpal tunnel syndrome, chondromalacia patellae, arthritis, fibromyalgia, heel spurs, plantar fascitis, migraine headaches, neck pain/whiplash, nerve root pain, postoperative pain, repetitive stress injuries, TM joint pain and more.
  • If you have the wound that is slow to heal and has been resistant to treatment, you may be a candidate for laser therapy. This includes slow healing fractures, as well as soft tissue injuries and ulcers.
  • If you have multiple trigger points (sore spots in the muscles) that do not go away, you may be a candidate for laser therapy. This includes areas associated with fibromyalgia.
  • If you have had Prolotherapy or PRP, and wish to accelerate the response of healing, you may be a candidate for laser therapy. This includes any area that has been treated with Prolotherapy/PRP injections.
  • If you need Prolotherapy or PRP therapy but are afraid of needles, you may be a candidate for laser therapy.
  • Laser therapy stimulates the same areas that Prolotherapy targets. It does it without needles, but requires a lot more time and repeated treatments to gain the result that can be gotten from Prolotherapy and laser together.

Feel free to call me directly at 310-473-2911 or call my cell phone at 310-339-0442

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Bad Tennis Shoulder Exercises Using Theraband

Thera-Band Tubing Exercises for Tennis: These exercises are designed to help improve strength and prevent injury.

Perform these exercises with a resistance that allows you to complete 15-20 repetitions to fatigue; start with one set and progress to 2 sets of 20. Increase to the next color resistance level when these exercises become easy.

Thera-Band Tubing with Door Anchor
Pull webbing of Door Anchor through clasp to create 2 loops at end opposite of disk. Slide one   handle of the tubing up through one loop and then down through the second loop of the Door Anchor. Pull and tighten the Door Anchor loops down securely on the tubing to fix length as needed.
  Thera-Band Tubing Forearm Pronation
Secure the middle of the tubing under one foot. Grasp the handle with your wrist facing upward and forearm resting on your thigh. Slowly rotate your forearm so your palm faces downward. Hold and slowly return.
  Thera-Band Tubing Forearm Supination
Secure the middle of the tubing under one foot. Grasp the handle with your wrist facing down and forearm resting on your thigh. Slowly rotate your forearm so your wrist faces upward. Hold and slowly return.
  Thera-Band Tubing Wrist Extension
Secure the middle of the tubing under one foot. Grasp the handle with your wrist facing downward and forearm resting on your thigh. Slowly extend your wrist upward. Hold and slowly return.
  Thera-Band Tubing Wrist Flexion
Secure the middle of the tubing under one foot. Grasp the handle with your wrist facing upward and forearm resting on your thigh. Slowly bend your wrist upward. Hold and slowly return.
  Thera-Band Tubing Reverse Fly
Hold one handle in each hand, and grasp tubing about a shoulder-width apart. Extend your arms at shoulder level and keep your elbows straight, stretching the tubing. Hold and slowly return. Keep your head and trunk upright.
  Thera-Band Tubing Lat Pull Down
Secure the middle of the tubing to a door or sturdy object above shoulder level. Grasp the handles at shoulder-level and pull backwards, bending your elbows. Bring your hands to your shoulders. Hold and slowly return. Keep your head and trunk upright.
  Thera-Band Tubing Shoulder Dynamic Hug
Grasp both handles and wrap the tubing around your upper back. Bend your elbows and slightly abduct your shoulders. Bring the handles together, and cross over the other forearm. Keep your wrist straight and elbows slightly bent. Hold and slowly return.
  Thera-Band Tubing Bent-over Row
Stand on the middle of the tubing. Slightly stagger your step and lean forward at your hips. Don’t arch your back. Grasp both ends of the tubing with your elbows extended at your side. Pull one end of the tubing upward, bending your elbow. Hold and slowly return. Brace your abdominals and don’t rotate your trunk.
  Thera-Band Tubing Shoulder External Rotation
Securely attach the middle of the tubing to a door or sturdy object. Place a rolled-up towel under your arm. Bend your elbow at your side and bring your forearm in front of your body. Grasp handle and pull outward, keeping your elbow by your side, and forearm parallel to the ground. Hold and slowly return. Keep your wrist straight.
  Thera-Band Tubing Shoulder Scaption
Grasp both handles and stand on the middle of the tubing. Lift your arm out to your side and slightly forward (about 30 degrees from your body). Keep your elbow straight and palm facing forward. Lift to shoulder level, hold and slowly return.
  Thera-Band Tubing Elbow Extension
Stand on the middle of the tubing. Extend your shoulder and grasp handle with your elbow bent behind you. Straighten your elbow, keeping your shoulder extended. Hold and slowly return.
  Thera-Band Tubing Elbow Flexion
Stand on the middle of the tubing. Grasp the handles with your palms facing upward. Bend your elbows upward, keeping your elbows by your side and your wrist straight. Hold and slowly return.
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Shoulder Impingement – subacromial impingement

Dear Dr.Tucker
I enjoyed your helpful article in Dynamic Chiropractic on shoulder evaluation & scauplar positioning.
I am 60 yrs old and have practised 37 years. I am kyphotic and have worked hard in both diversified adjusting and forcing down the lever for distraction adjusting on Cox tables a long time now. After a couple firm jolts I now find myself with acromial impingement, MRI recently shows a small osteophyte subacromial with supra spinatus impingement. There is no calcification nor cuff tears.
An orthopedic friend suggested a scope cleaning. Im afraid of any sequela which would be low I think.
What muscles would you emphasize to work on to realign the scapula-glenoid complex?Your article specifies some,but am slightly confused.Thanks for any suggestions.
Dr. Tucker’s response: For years we were taught that the supraspinatus muscle strengthening exercise was the “empty can” or “full can”. Controversy exists about that maneuver in the literature.  I think a good rotator cuff exercise should produce the greatest supraspinatus activity while minimizing the deltoid activation. Theoretically, reducing deltoid activation decreases the upward shear of the humerus during arm elevation, which may be desirable when prescribing exercise to strengthen the suprapsinatus in impingement patients.  
In a study published in Medicine and Science and Sports and Exercise, subjects performed 5 isometric exercises in random order while measuring the EMG activity of the deltoid, supraspinatus, and infraspinatus. The exercises were: full can, empty can, prone elevation, elastic external rotation, and prone external rotation. The researchers noted that all exercises produced similar high levels of supraspinatus activity, while the full and empty can exercises also had higher levels of deltoid activity.
The researchers concluded that shoulder external rotation at 0° of abduction with an elastic band and prone external  rotation were preferable exercises for the supraspinatus. While the full- and empty-can exercises are traditionally favored to isolate the supraspinatus, the authors noted that elastic external rotation and prone external rotation did not activate the deltoid at high levels compared to the full- and empty-can exercises. In addition, the exercises also exhibited high levels of infraspinatus activation.
In summary, clinicians should consider using Thera-Band® exercise bands for resisted external rotation and isotonic prone shoulder external rotation exercises because they preferentially activate the supraspinatus and infraspinatus without activating the deltoid, which may be more beneficial for patients with impingement.
Reference: Boettcher CE, Ginn KA, Cathers I. Which is the optimal exercise to strengthen supraspinatus? Med Sci Sports Exerc. 2009;41(11):1979-83.  
If you are not sure how to perform these exercises, google the name of each one and you will get photos; or go to the theraband website for photos. I would be diligent in performing these exercises every other day, beginning with 3 sets of 10, progress to 3 sets of 20. Try it for 5-6 weeks before making any surgical decisions.  Good luck, Jeff  www.DrJeffreyTucker.com 
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Researchers encourage proprioceptive exercises for shoulder rehabilitation

Proprioceptive exercises are commonly prescribed for lower extremity rehabilitation. More recently, sensorimotor (SMT) proprioceptive exercises have been used for shoulder rehabilitation. It’s thought that shoulder injury (in particular, shoulder instability) is related to proprioceptive deficits. Researchers speculate that deafferentation (loss of sensory information) from the mechanoreceptors of the shoulder joint capsule and altered proprioceptive information create these sensorimotor deficits (Lephart et al. 1997; Tibone et al. 1997)

A review paper in Athletic Training and Sports Healthcare discussed the adaptations of the sensorimotor system following shoulder rehabilitation. The authors used the PEDro system for inclusion criteria to review 23 articles. The most common techniques the paper reviewed included:

  • Joint repositioning
  • Closed-kinetic chain exercises
  • Proprioceptive Neuromuscular Facilitation (PNF)
  • Plyometrics
  • Joint Perturbations
  • Activation of muscle through elastic tubing, free weights or oscillation

The authors concluded that sensorimotor rehabilitation after shoulder injury is crucial, and that the sensorimotor system is, in fact, trainable. A proprioceptive and sensorimotor training program including Thera-Band® elastic bands and tubing, FlexBar® Oscillation, and closed-kinetic shoulder exercises with Stability Trainers should be included as part of a shoulder rehabilitation or prevention program.

Reference: Myers JB, and Oyama S. 2009. Sensorimotor training for shoulder injury. Athletic Training & Sports Health Care. 1(5):199-208.

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Practical advice on achieving healthy shoulder development

Chronic shoulder injuries are common. Balanced workouts, stretching exercises and strengthening the rotator-cuff will help decrease the incidence of shoulder injuries. Here’s practical advice 

Step 1: equalise front and rear strength: the starting point is a balanced program for front and rear shoulder muscle development. Opposing muscle groups are trained equally. While exercises for the anterior shoulder and pectorals develop power, to train just these muscles will unbalance the shoulder.

Step 2: develop good pulling form: it is essential to perform pull or row exercises with correct technique in order to ensure that the middle trapezius, rhomboids and lower trapezius muscles are properly recruited.

Step 3: isolate the rotator cuff: the small but crucial muscles of the rotator cuff are targeted alongside the lower traps to avoid developing dysfunction or weakness.

To achieve the above strategy, these four exercise groups need training:

  1. Subscapularis and pectoralis minor, the shoulder’s medial rotators
  2. Infraspinatus and teres minor, the shoulder’s external rotators
  3. Supraspinatus (top of the rotator cuff), assisted by the deltoid and infraspinatus
  4. Lower trapezius, focusing on scapular depression
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Shoulder Rehabilitation

12 O’clock Arm Raises

Lie face down with arms forward. Lower shoulder blades and raise both arms as high as possible. Be sure to keep arms in the “I” position.

Hold for 1-2 seconds.
Repeat 10 times per set.
Three sets per session.
Complete 2 sessions per day.

10 & 2 O’clock Arm Raises

With or without weights, arms are in a 10 and 2 o’clock position. Lift/raise both outstretched arms as far as possible. Be sure to lower the scapula when performing this exercise.

Hold for 1-2 seconds.
Repeat 10 times per set.
Three sets per session.
Complete 2 sessions per day.

3 & 9 O’clock Arm Raises

With or without weights, arms are in a 3 and 9 o’clock position. Raise both outstretched arms as far as possible. Keep the scapula down while performing this exercise.

Hold for 1-2 seconds.
Repeat 10 times per set.
Three sets per session.
Complete 2 sessions per day.

Wall Angels

Stand against wall, upper arms at shoulder level and elbows bent to 90°. Raise arms over head keeping arms, forearms and hands against wall.

Hold for 2 breaths.
Repeat 10 times per set.
Two sets per session.
Complete 2-3 sessions per day.

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