Archive for February 2011

Shoulder Pain: Case Example Using Mini-Bands

Background

Shoulder problems are one of the big money makers for people in the medical field.  As with many problems there are many factors and different categories of these problems.  This statement of shoulder pain is a very poor title for discussion.  It is the common moniker that many of us use for a wide variety of different problems.  In other words, shoulder pain does not even describe the problem, only the symptom.  Only subsequent questioning and discussions can bring clarity to what is the problem.  Shoulder pain can be referred pain from other sources like the neck, ribs, heart and lungs and many other problems.  These origins of the shoulder pain don’t even have to be in the neighborhood of the shoulder.

Here I just wish to talk about a particular case illustrating some basic principles of movement and stability of the shoulder complex and using mini bands.   If you are experiencing painful shoulders, please do not limit your assessment to what is given below.  Remember what is said in the above paragraph.  First ask other questions.  If there is any doubt in your mind have your doctor clear you first before embarking on trying out a musculoskeletal approach only.

Case Example

This young man who works a sedentary job and participates in weekly yoga class had been noticing increasing discomfort  of both shoulders but especially the left one.  Simple lifting the arms above the head would reproduce his symptoms.  They would get better on the right with continued movements but not on the left.

A brief assessment showed the following.  His posture looked casually very erect.  (Although is head was slightly forward and his thoraco-lumbar area was over extended, and his scapula’s winged bilaterally).  His neck demonstrated limited rotation and sidebending bilaterally especially to the left, his more affected side.  His lower neck spinal mobility was more restricted in these movements.  His shoulder mobility was with a flexion deviation in abduction. End ranges in abduction and external or outward rotation were slightly limited.   Resisted testing was weaker in extension and external rotation with arm above the head.

His mid to lower thoracic mobility was restricted in rotation–his mid to upper thoracic  was restricted more in extension.

In all his shoulder mobility testing, he demonstrated poor initiation of the scapula, especially on his affected, left side

Basic Approach

We worked on basic joints and glands (calisthenic type) exercises and foam roller to help restore some of his spinal mobility.  He improved so that his mobility was more normalized in his spine and shoulder.  His most provocative test now was his resistance to external rotation of his left shoulder when his hand was above his head.

It is interesting to note that in the classic muscle test position of external rotation with his elbow at his side, he had no problem.  I find it always helpful to hunt around to see if different positions will provoke his symptoms.  Also during these movements the scapula had a lag or latency in it’s sequential recruitment.

Mini Bands

Since he was essentially not activating his scapula enough in order to move his arm, work on this provided the changes he needed.  By working on basic pulling activities and cueing the scapula to perform better he was able to complete his recovery.

One problem I find in recommending exercises is compliance.  The simpler and easier the exercise the more compliance you will have.  This is a real struggle for me as there are so many areas that a person needs to learn about to move effectively.  If you can start the movement and break it into pieces, you can sometimes deal with this compliance issue effectively over several sessions of training.

This photo shows the 9 inch long loop called the mini band in action.  Here we started with simple setting of the posterior shoulder muscles.  We can emphasize scapular retraction while loading more of the external rotators to act as stabilizers.  This movement reminds me of the ole chest expanders we used as kids.  (Hoping to become like Charles Atlas and rule on the beaches).

Mini bands are great.  I constantly refer my clients to an online store called Perform Better.com.  Here is the link to their mini-bands.  They are a closed loop and give you what thera-band still gives (sans the knot, tying the ends together).   I just find I use these a lot more and they are so easy, portable and just fit the bill so well.  (no I don’t have any financial relationship with this company–except when I give them my money for their products)

We used a variation of this set up that is shown in the above photo.  What you see here is the mini-band looped around his wrists while pulling on another band (monster band, listed under mini-bands in the above link)–this monster band is 20 inches vs 9 inches in the mini-band.  You can use them separately or together as shown here.

One of the advantages of using a closed loop to do any type of rowing movement is that you can develop two directions at once.  This combined movement is very good for activating the stabilizers in this case.  You see on regular rowing you work on mainly retraction/extension of the shoulder.  Here with a closed loop (and the addition of the mini band) you emphasize this external rotation with a variation of horizontal abduction.  Turning on multiple planes of movement will really drive the shoulder complex to be more stable with proper cueing.

Another advantage to this arrangement is that it is very simple to set up and take down.  Space and equipment considerations are minimal.  Just get in there and do the work.

Progressions

The mini bands come in a variety of resistance.  I often have my clients purchase the yellow, green and blue mini bands.  Also buying the 20 inch loop (called a monster band with in the mini band section), will give you a large variety to try many different things.

  1. First I will start with a yellow or green band in the upper body for sedentary folks
  2. Next I will add the two bands as in the second photo
  3. For people who have issues in grip–whether arthritic hands or other problems, you can easily use the loops around the forearms
  4. Also the loops placed more proximal will reduce the force needed–this makes it very doable for anyone–I even use these ideas with a 93 yo woman who is progressive working just with the mini bands and also a 40 inch loop.
  5. This rowing movement for those who have issues of rotatory instability with the arms above their heads need to further progress.
    1. We start from simple rowing movements where the elbows are pulled closer to the sides while the forearms are more parallel to the floor
    2. Next we work into getting around a 90/90 degree position of shoulder abduction with external rotation while the elbows are around 90 degrees
    3. I’m not too strict here about the 90/90, just having them move towards this position and have their forearms more vertical works quite well

Summary

Retesting will clearly show if we are in the right direction.  I will immediately retest their provocative movement pattern.  If it is better, that is stronger, better movement of the scapula/humerus and thoracic spine–I know this has been a good choice.

There are of course many ways to deal with this problem of instability.  Try out this variation if you haven’t.  Let me know what you find.

Best in training.

As always, contact me if I can be of further assistance–Peter