Archive for shoulder pain

Shoulder Rehabilitation

Shoulder Rehabilitation

Recently I had the opportunity while in India to work with a variety of people.  In the video that follows, this person was well recovered from a fracture of the proximal humerus.  They were still experiencing pain upon end range movement.  Here we will look at only one of the functions that proved bothersome–overhead movements with the left arm.  Their range of motion in this direction (shoulder flexion) was fairly good, though lacked the last 10 degrees–which were also a bit painful.

One thing to check is to see if the shoulder blade is participating sufficiently in these movements.  Since stretching of the arm overhead proved painful and since her prior rehabilitation had taken her in this direction, I thought we would explore more approximation or pressure into the shoulder joint.  (and this compressive movement was not painful and helped her to improve)

This concept of compressing the joint in these weight bearing positions that you will see in the video is a very good alternative for improving pain free terminal flexion.  Often in hatha yoga where there is today and emphasis in stretching, the stability work that is needed is often marginalized.  (This post is not about yoga but focuses on a case example of rehabilitation).

Another important aspect here is the emphasis on testing before and after exercises.  This testing can be accomplished quickly and easily before and after your session.  You will see it at the beginning of the video.  It would be wonderful if people found out things that they could not do easily and then determine the exercises that would help them function better (i.e. less pain and more gain).  In other words don’t just perform a bunch of exercises without seeing if they are appropriate and giving you the results that you want and need.

Also this is not a complete program, it is a first example of where one might start out in their journey of recovery.

Lets take a look at the video:

 Mobility

You can see there is not an emphasis on stretching out the shoulder at this point.  The place that we try to increase mobility is at the thoracic spine or rib spine.  This associated area of the middle back is often left out with rehabilitation of the shoulder.  Of course one should test the ability of rotation to take place here before prescribing the exercise.  Do note how much shoulder mobility is asked for in the down shoulder.  For some people you will need to support the space between their armpit/rib area and the floor.  For some people, without using the support–they will have too much stress on the bottom shoulder in flexion and abduction–they will not be able to relax or benefit from the spinal rotation.

It is interesting to note that in the side lying movement of reaching and rolling of the upper body–this person had difficulty in stabilizing the pelvis and lower trunk while accessing the middle spine area.  Again this difficulty is fairly typical.  We often over move from the lumbar and pelvic area especially in the side lying position.

There are many variations in sidelying that can be very helpful here.  This is only one of them.

Stability

From the above instability of the pelvis and lower trunk, you can see that this area will need to be addressed in follow up routines.

Notice the weight bearing aspect of being on hands and knees and prone on elbows (supported cobra asana).  These are just excellent positions to stimulate the shoulder complex and begin teaching stability.  Always consider there to be 3-5 ways to regress and progress any exercise.  That gives you a much wider appreciation of the functional relationships that are involved in rehabilitation.  It is also quite a challenge to come up with this range of movement possibilities.  This challenge is mainly for those who are teachers, trainers and therapists.

Conclusion

Do try out some of these movements.  You will find out that working with the mini-bands in the prone on elbow position can be fairly challenging.  Many people are quite weak in external rotation when the elbows are away from the body.  This variation opens up so many more ways to activate the rotator cuff musculature and the scapular stabilizers than just the standard “cuff” exercises with the elbow fixed to ones side.

This routine is only a beginning.  I hope it will be a continuation of the progress that has been made.

Best in Training–peter

 

Shoulder Stabilization in Asana/Posture and Movement

Shoulder Stabilization in Posture and Movement

In Yoga and many times in athletics/sports, we are often looking at physical flexibility.  This is great in the proper context.  Flexibility which is certainly stressed in yoga asanas has it’s compliment in stability.  We often talk a good line about balancing the body.  Often in practice we don’t notice what kind of balance we are creating or have created.  Since I often hear instructors in yoga class repetitively encouraging a student to go farther into the asana, I wish to focus on this incomplete perspective.

We will look at a case example from my Physical Therapy clinic.  Before moving into looking at this specific example of shoulder instability, let’s speak more of this flexibility vs instability issue.  Is it that one is better than another.  (of course it is and of course it is not)

Posture or Asana Guidelines

This is old material for many who know it, but a brief review will be stated.  The first of the three Yoga Sutras of Patanjali on asana starts out as:

Sthira-sukham asanam

Asana or posture is steady/stable and easeful/comfortable.  I don’t know how many teachers and students who can recite this and more, still persist in having someone focus over and over again in trying to stretch further.  Many people will look at a picture of someone who has tremendous physical flexibility, and they will effort to accomplish more range of movement.  (Just like in the picture of their mind)

This perspective of overdoing the flexibility aspect of asana is not being balanced out by proper training of the needed stability.  There must be good reasons why such an authoritative text like the Yoga Sutras has started out with stability and not about flexibility per se.  (I know the context is stability of the mind–but we are starting with the body part of the mind here)

Developmental Guidelines

When babies start to move around, what is the first thing they do?  In one way they start just moving.  They seem to come equipped with great flexibility, right? (Wouldn’t some of us love to have that now days.)  Well they don’t get very far until they develop significant stability.  They do a ton of core work on their backs while seemingly flaying around their limbs for example.  I will not get into the large amount of work they do sucking and orienting their eyes and head, etc.  I just want to focus on this idea and observation–they don’t get up and get around until they develop their stability.

So if someone has the proper mobility then stability comes in conjunction to complete many of the functional movement patterns or exercise/sport  patterns that we are involved in.  What if we don’t have the flexibility, let’s say for the a particular asana.

We need to have movement.  What is the relationship with movement and stability?  Does one come before another?  Well—it depends.  (great words of wisdom : ))

Flexibility Problems and Of Course Stability Problems

Flexibility and Stability are both needed.  It is the prescription of how, when, and where–including dosage amounts and timings.

For the past several weeks I have been seeing a client for shoulder and neck pain.  Basically when he raised his arm above shoulder level in abduction, he has a painful arc of movement from about 110-150 degrees.  Also this is his limit of movement on first examination.  He can stretch it farther into the ends of range to 160, but it is just more painful in this case (not a true painful arc, per se).  His neck movements were slightly limited in rotation and side bending away from the affected side.  Mainly stiff lower cervical segments as a group.  Also his thoracic spine rotation was markedly restricted bilaterally.

All his movements demonstrated poor sequencing of the scapular component.  He was very weak in scapular retraction against resisted rowing movements, especially on his affected side.   (The gleno-humeral joint was  also anteriorly subluxed slightly)  He was unable to retract or move his scapula’s together with resisted pulling movements when his forearms were more vertical.

I often use a mini band at this point to see if they can maintain their forearms in more of a vertical position as they pull the band apart and try to retract the shoulders.

Often they are grabbing this mini-band with their hands vs just wrapped around their wrists.  You can see here that the band is at the top of the chest level.  If you try to have them start at their nose level and then try to pull it apart–you will often see them only able to pull it while allowing it to come to their chest level again.  Their scapular stabilizers with abduction of the arms are quite weak.  The classic testing of shoulder stability with the elbows at the sides of the trunk are for very weak folks.  Much of compromised work is with the hands/arms raised over his head.

Flexibility and Stability Retesting

Once I found both a flexibility and a stability problem, I will start to stimulate one area like the above scapular retraction with the mini bands.  (As this scapular component could be at the base of his flexibility problem–as the shoulder blade is literally the base of the arm AND it was the most asymmetrical problem).   Then I will retest their original complaint.  In this case, he had pain with limited shoulder abduction.  He immediately showed improvement.  So then just for an experiment in his case, I tried doing some gleno-humeral (shoulder ball and socket) mobilization and mobility exercises.  He didn’t respond as well upon retesting.  I  also tried improving his thoracic rotation.  We used combined active movements of rotation and side bending of his trunk in sitting.  He improved in shoulder abduction a few degrees, but not nearly the improvement as seen with the direct scapular resistance.

This particular fellow is rock climber and surfer, etc.  He is very active and very strong in other ways.  In other words, when I asked him to do a push up, he just dropped to the floor and pushed away with no problem.  Please note that in this push up position, he locked his upper arms in close to his side.  His scapula’s were quite stable, with no winging or instability.  Very impressive.

Note that his instability (and seemingly inflexibility) is when his arm and hand are above his head.

Stability Rehab

This client case is just to emphasize that some people will have a lack of movement.  Their lack of movement does not always respond to stretching.  In this particular case it made no difference, except it was actually more uncomfortable with end range stretching.

He has responded well to starting with side plank positions.  He is fairly unstable and has very weak endurance in this side plank position.  The forward plank did not demonstrate enough change.  The bulk of his program that has proved most helpful has been with these pulling movements at different angles.  We often focus on holding the pulling movement and then working on eccentric/concentric contractions of this movement pattern.  We change the angles over time, trying to find the weakest and most unstable position.  We back away from it slightly and work before that place and after that place and then through that place that is difficult.  He still uses thoracic mobility exercise to his advantage too.

Limitation of Yoga Asana

He has done very well.  It is interesting to note that in traditional Yoga Asanas:

…most asanas develop forward pressure movements involving the upper body

He was originally trying stretch it out for weeks and weeks.  There wasn’t much change.  All forward pressure movements did not significantly help him either.

Summary

Realize this is a case example–speaking to the importance of assessing both mobility and stability.  Certain protocols/sports/movement paradigms are biased in direction of movements and particular activities.  These are constraints that can lead to significant imbalances.  It is not that something is bad or good for you directly.  There has to be an evaluation of what are your weaknesses and strengths.  Often we are involved in activities that strengthen our strengths and do not do much for our weaknesses.

I know that in other people, they have more of a mobility restriction in their particular case.  Therefore work more on mobility.  Remember it is identifying the problem(s) and then a key is to RETEST.  This retest provides the feedback.  It isn’t this paradigm vs that paradigm.  These topics of controversy, if they truly are, only should lead to examination not to reverential following.

Strengthening your ability to observe is paramount.  Also you must ask a lot of questions.  Be systematic in your focus of questions and answers–(most really are not–their mind immediately jumps away to a more familiar aspect of their inquiry–more to say about this in another post)

OK, make some comments.  Share what you find works.  Let’s build a community together.

Strong Mind and Body–Peter


 

 

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

Anterior Shoulder Pain!

The following is an interesting sequence of events of a new granddad who had recently been carrying around his 20+ pound grandson.

Case Presentation

A young grandfather was in my office the other day and his main complaint was left anterior (front) shoulder joint pain.  He denied any neck symptoms and no complaint of radiating symptoms.

Observation

He sat with his left shoulder lower than right.  His trunk was side bent to the left.  His shoulder elevation was limited by 15 degrees but not painful.  Resisted flexion and rotation of his shoulder reproduced his anterior shoulder symptoms and were weakened (probably inhibited/interfered with by pain and malposition?).  Also his left shoulder was protracted and slightly subluxed anteriorly.

His neck was blocked in left side bending and rotation of the lower neck segments.  He was not aware of this difference until formal testing.  Passive range was also blocked in the lower cervical spine in this left direction.

Also when I tried to side bend him to his left from caudal (head to tail) pressure on top of his shoulder he was easily moved.  Side bending to the right was markedly restricted in the mid thoracic (rib) spine.

Immediate investigation

I started with the hypothesis that there was a strain to the shoulder, possible due to poor stabilization of the shoulder complex–that was brought out in a more pronounced way due to having to carry around his grandson for long periods.  He could have over recruited his neck and set up very poor neurmuscular motor and sensory flow to the upper quadrant area.   Since he had such a pronounced movement dysfunction in thoracic side bending, I thought it would be interesting to see what if anything this lack of side bending may have to contribute.  (Both to mal-position of the shoulder on the opposite side and poor transference of stabilizing forces through the trunk).

  1. Tried to initiate active assisted trunk side bending to his right (remember he was already in a left side bent position).   This did not occur readily so looked lower.
  2. His right hip was carried in external rotation in sitting, his right hip internal rotation was limited.
  3. In sitting:  immediately had him place his right hip in internal rotation (foot out to the right side)–until we could cause him to shift his weight onto his left IT (sit bone) and gently start encouraging his trunk to side bend to the right–slowly as this side bending became easier we facilitated left side bending also of his lower neck segments.
  4. Had him sit straight again and noticed:  His shoulder less protracted and less subluxed.  He gained 10 degrees in shoulder elevation.  His resisted movements were much less provocative but still weak in external rotation.
  5. Finished with some activating/strengthening/stabilizing exercises for the scapula and shoulder complex.  Included cervical and thoracic active mobility also.
  6. Upon completion of the exercises, there were no reported symptoms with the previous provocative movements.

Summary

OK, not everything that walks into my office has such an easy resolution.  I just thought this case at least demonstrates some of the interesting connections that I find in working with people.  Also it has been my experience over many years that once could have started in different places and shown success.  I think success does not necessarily always mean such a quick resolution to a person’s problem.

One of the most important points I find is to see the relationships that exist.  Possibly an isolated approach of the shoulder or neck may have proved helpful.  If the whole pattern that is involved is not understood/recognized, then in more protracted cases, important elements may be ignored.

Now

Let me know what you think.  If there is any way I can be of service, please contact me here, for a consultation.  Thank you.