How Can Physical Therapy Help with Shoulder Pain?

Shoulder impingement, rotator cuff tear, biceps tendonitis, shoulder bursitis? A variety of diagnoses associated with the shoulder share several characteristics, the most significant being a sharp pain preventing dressing, reaching, driving, and / or sleeping. How can a good physical therapist help treat a rotator cuff that is partially torn?

If you’ve been keeping up on previous posts from Optimal Movement Physical Therapy you’ll know that Physical Therapy is not focusing on repairing damaged tissue, rather the focus is on identifying the reason the tissue became damaged in the first place. Once the faulty movement is identified, it can be corrected, and once it is corrected the pain can be alleviated. After all, many studies have shown that individuals can have a tear with no pain at all. Even further, the amount of pain that one has is not proportional to the size of the tear.

Well if the tear is not causing the pain, then what is causing the pain?

Take a look at the following video to better understand faulty mechanics.

Ideally, we want the humerus and the shoulder blade to move together in order to optimize the sub-acromial space. In this video, you can see the scapula does not move as the humerus moves which results in pinching of the structures within the subacromial space.

This poor movement results in impingement of the bursa, biceps, and part of the rotator cuff. Therefore this movement pattern can be the underlying cause of impingement, rotator cuff tear, bursitis, biceps tendonitis, just to name a few.

The sub-acromial space is a small tunnel where several structures pass through. With optimal biomechanics none of these structures become impinged. When the space is smaller because of poor posture, muscle imbalances, and / or faulty movement, the structures can become irritated and painful. Evidence of poor posture and muscle imbalance can be identified by a physical therapist examining your posture and movements. The area of focus for the therapist is the scapula, as the resting position and movement of the scapula is what determines the size of the space. When we are looking at your scapula we are determining whether the resting position is downwardly rotated, anteriorly tilted, and / or depressed as all of these positions will cause impingement.

An anterior tilt of the scapula is one where the inferior border is more prominent than the superior border.

Downward Rotation of the Scapula is one where the inferior angle is more medial than the superior angle of the scapula.

In the examples above, the scapula is starting in a poor position. This poor starting position results in a higher likelihood of impingement because the scapula will have difficulty getting full upward rotation. The scapula is in fact starting behind the starting line.

All hope is not lost. The scapula and it’s resting position, as well as how it moves can be retrained. Typically the muscles which are not “pulling their weight” include the mid and lower trapezius as well as the serrates anterior. At Optimal Movement Physical Therapy, we are looking for faulty scapula movements, testing for weakness at these muscles, and prescribing corrective exercises to eliminate the faulty mechanics.

5 Common CrossFit Injuries

“WOD, Box, Kipping, muscle-up”.

When you first enter the crossFit world it seems like they’re speaking a different language. Then, you bravely take a step into a “box”, learn some new terms, and you realize, it is a different world. Take your next step into this world and now you’re doing “wall-ball’s, box-jumps, and dominating your WOD (workout of the day). But, like any high level physical activity, there are some common injuries to look out for, prevent, and treat if you are, or are going to be a crossFit athlete.

Let’s get one thing straight before we start talking common crossFit injuries. CrossFit is awesome. The sense of camaraderie and competition has helped tens of thousands of people move and exercise. CrossFit and the common injuries associated with it are far superior to the common injuries and diseases associated with a sedentary lifestyle. Look at other forms of recreational and competitive exercises including running, cycling, playing football and basketball; all are great forms of exercise, but they all have common injuries as well. Move better, listen to your body, and exercise smartly. Get in touch with a good physical therapist to help you initiate and maintain a healthy lifestyle.

With that disclaimer out of the way and without further adieu, here are the 5 most common injuries associated with crossFit, as well as tips you can do to treat and prevent them.

1) Low Back Pain

If you are going to participate in crossFit, get ready to squat. The squat is simply the best exercise to work the whole posterior chain (glutes, hamstrings), a vital area of the body that is typically ignored. For this reason, the inclusion of the squat in any exercise program is a great idea, as long as you have the flexibility and strength to pull it off. When one lacks hip flexion, or has poor abdominal and glut activation, or weakness of the glutes, the compensation is excessive trunk flexion and overuse of the lumbar spine paraspinals. This muscle group is simply not made to support the trunk during a squat, let alone several repetitions of the squat, and especially not with weight over the shoulders.

Treatment / Prevention

– Have your physical therapist check your hip flexion ROM as well as the strength and activation of your glutes during a squat.

– Ensure proper squat form without weight before adding weight. You may require corrective exercise for flexibility and muscle coordination before performing a multitude of squats with weight or for time.

2) Anterior Shoulder Pain

Shoulder pain amongst this group is due primarily to one of two factors (or a combination of the two). One factor is that many crossFit exercises including the overhead squat, the snatch, and the thruster all require the shoulder to move to its end range of motion into flexion and external rotation. If you don’t have this range of motion, then aggressively throwing your shoulder towards the end range of motion can result in shoulder impingement. The second factor is that many crossFit exercises place the weight anterior to the body which may result in excessive recruitment of the biceps and pecs. This imbalance between anterior musculature and slap stabilizers can, once again result in impingement at the shoulder.

Treatment / Prevention

– Have your passive ROM assessed by your therapist. If you don’t have 180 degrees of passive flexion while lying on the table, don’t expect to lift to 180 degrees during a snatch.

– Assess the activation and strength of your middle trapezius, lower trapezius, and serrates anterior. These guys should be working to counteract the pull of the biceps and pecs.

3) Wrist Pain

Once again, crossFit is bound to incorporate squats, and lots of them. One version of the squat is the front squat where you place the barbell in front of you in the rack position. This position places your wrist into maximal wrist extension while holding a load. This is very similar to any plank work you may do, again a favorite amongst crossFit trainers.

Treatment / Prevention

This one is pretty simple. You need full wrist extension range of motion to get into this position. Without it, you will have discomfort every time you place your wrist in maximal extension.

4) Knee Pain

Squats, squats, and more squats. And some times lunges. Once again, squats are great for the posterior chain and they are a very functional exercise. That myth that squats are bad for your knees is completely false. Let’s change the phrase to “bad squats are bad for your knees”. Squatting with excessive knee flexion compared to hip flexion, and/or excessive femoral adduction, and/or poor gluteal activation can result in a high amount of stress on the knee joint. Read this previous blog for more specifics on Physical Therapy and knee pain here.

Treatment / Prevention

– Have your physical therapist assess your squat

– Have your glute strength assessed and perform corrective exercises to activate your glutes in order to avoid the excessive knee flexion and/or femoral adduction compensations.

5) Elbow Pain

One of the most common causes for elbow pain is excessive gripping, something crossFit athletes do a lot of when they begin adding weight to their exercise program. All of the muscles responsible for gripping originate at the elbow. Repetitive gripping therefore results in overuse injuries at the elbow.

Treatment / Prevention

A new focus for treatment of lateral epicondylitis, or elbow pain with gripping, is strengthening of the scapula stabilizers. Improving the stability at the proximal shoulder has resulted in a decreased amount of stress at the elbow and may therefore eliminate elbow discomfort with gripping tasks. For more on scapula stability for the lateral elbow, check out this article.

TRX Corrective Exercises for Pitchers

You don’t run to get in shape, you get in shape so that you can run. Simply running every day will not improve your running ability. Cross training, improving muscle imbalances through corrective exercises, and strength training are all required in order to improve performance with running, and minimize the risk of overuse injuries.

You can take the same concept with any activity which requires repetitive motion, especially pitching. Simply throwing every day as hard as you can will only decrease performance and increase the likelihood of injury. There is a certain amount of core strength, rotator cuff stability, hip flexibility, and lower quarter stability that is required to optimize the movement of an overhead athlete. When an athlete has reached a certain level of strength and flexibility, I encourage using a TRX suspension strap to train these elements of pitching. My favorite TRX exercises for pitchers are listed below, but with a disclaimer: as healthcare professionals, we cannot simply prescribe exercises without a thorough examination of the athlete. These exercises should only be performed after an assessment and under the instruction of your healthcare specialist.

1) TRX Side Lunge

The stride phase of the pitch may be the most important phase of pitching. The stride length of a professional pitcher is approximately the length of the pitchers height, and the shoulder has to move towards end range of external rotation. Needless to say, in order to maintain proper mechanics the pitcher requires a certain amount of trunk control. Therefore, the TRX side lunge becomes a great exercise to work on adductor length of the stance leg (ensuring increased stride length) and trunk control during this motion.

2. TRX W Deltoid Fly

This exercise is named for the large deltoid muscle which assists with the abduction of the shoulder, but I like to use it to work the external rotators of the shoulder. This is also important for the stride phase of pitching, and requires a certain amount of instruction without the TRX before it can be done appropriately. After a pitcher learns appropriate joint centration of the glen0-humeral joint (to be discussed in a future blog) he can begin to train the rotator cuff to maintain the stability of the joint during pure external rotation. Again, all of this is being done while maintaining trunk control.

3. TRX T-Deltoid Fly

The cocking phase of the pitch requires scapula adduction and full external rotation of the gleno-humeral joint. At this phase of throwing, the middle trapezius operates at approximately 50% Maximal Voluntary Isometric Contraction (MVIC) and the Infraspinatus works at 74% MVIC. This exercise places works on these muscles to place the scapula and glen-humeral joint in the appropriate position for this phase of throwing.

4. TRX Lunge

 

Of particular note, at this time all exercises have focused on  phases of pitching before the ball is released (showing the emphasis I place on the early phases of pitching). The most important component of the pitch after the ball is released is the follow through. Flexing through the hip and trunk can attenuate the force developed in prior phases from the shoulder. The TRX lunge can work on strengthening the gluteals and hinging from the hip to assist with this phase of throwing.

This form of training requires appropriate flexibility, strength, and supervision, but it can greatly improve your pitching mechanics. If you live in the Redlands area, a great spot for TRX training is at The Energy Lab. Check them out for their TRX classes and all fitness goals.

For rehabilitation, movement screenings, and to work towards your fitness goals, check out OMPT and email me at alan@optimalmovementpt.com

 

http://www.optimalmovementpt.com