It’s always easier to understand a condition when we simplify it. This happens quite often in the world of physical rehabilitation. An example in the knee would be the diagnosis of patellofemoral syndrome. This is a term that many practitioners use to describe a patients knee pain, yet it doesn’t specifically distinguish between various causes of pain in this area. Quite often patients are diagnosed with a condition in the shoulder called impingement. Again, this is helpful for some patients so that they can understand their condition better, but it is still a very vague term.

Shoulder Impingement Causes

Impingement of the shoulder is much like the name implies; certain structures get pinched which causes pain. This is obviously a very simple explanation of a very complex topic. There are various different types and different causes of impingement in the shoulder. For the practitioners out there, we know there is internal and external impingement. Internal impingement involves compression of tendons (usually) between the head of the humerus and the glenoid labrum. External impingement involves compression of the rotator cuff tendons or the subacromial bursa between the humeral head and the acromion process.

Shoulder Impingement

Functional Shoulder Impingement

At this point I’ve probably already confused the average reader, so the rest of this blog will focus on something more interesting; the various causes of secondary or “functional” impingement. This category of impingement is somewhat fixable in a clinical setting with the help of a manual practitioner.

Decreased Shoulder Movement

For some people, their shoulder impingement is associated with a loss of movement in the shoulder. Specifically, it would be a loss of internal rotation (turning your arm inward). This is something we can detect clinically and can give us clues to various dysfunctions in a patients shoulder. Among other things, this loss of movement alters the axis of motion in the shoulder which can lead to impingement.

Altered Shoulder Blade Movement

The scapula (shoulder blade) can move in a sub-optimal pattern leading to impingement of the shoulder. Termed scapular dyskinesis, the altered movement has a cascading effect on various shoulder tissues. Scapular dyskinesis has various causes and types, but the take-home point is that it can eventually lead to internal impingement in the shoulder.

Rotator Cuff Dysfunction

The various rotator cuff muscles have different prime movements. Together they can serve to depress or hold the humeral head down during abduction. When there is dysfunction in the rotator cuff muscles you can lose this ability and the humerus can translate upwards (resulting in impingement). Of note, rotator cuff injury can also lead to external impingement.

SLAP Lesion

A SLAP lesion refers to damage in the cartilaginous labrum of the shoulder. The labrum lies directly against the head of the humerus, so damage in this area can “get in the way” when we move the shoulder.

Shoulder Instability

Some people have too much laxity in their shoulders. This can be from repeated trauma or can simply be the way they are “built”. In this case, the patient’s humerus translates upwards and compresses various tissues (which is impingement).

Treatment for Shoulder Impingement

In an effort to be more specific and delineate the various causes of shoulder impingement this blog may actually confuse many readers. The take-home point is that sometimes your practitioner may simplify things so you understand them easier. Impingement of the shoulder can be a very complex condition with various causes. Due to this, there are various different ways to properly fix it. For some people, manual treatment and the use of therapeutic modalities are necessary. For others, specific exercises and rehabilitation strategies are indicated.  Active Release Technique, Graston and Laser Therapy are all common methods for treating shoulder pain.  Unsure what to do? Give us a call!

To contact our Burlington clinic – info@burlingtonsportstherapy.com

References
Cools AM, Cambier D, Witvrouw EE. Screening the athletes shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. British Journal of Sports Medicine 2008; 42: 628-635.
Tate AR, McClure P, Kareha S, Irwin D. Effect of the scapula reposition test on shoulder impingement symptoms and elevation strength in overhead athletes. Journal of Orthopaedic & Sports Physical Therapy 2008; 38(1): 4-11.
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The rotator cuff is a general term used to describe four muscles in the shoulder that lie deep to the deltoid muscles. These muscles include the infraspinatus, supraspinatus, teres minor and subscapularis. Of these muscles, the supraspinatus is the most commonly injured.

Supraspinatus Tendon

The supraspinatus muscle is located on the top and back of your shoulder / shoulder blade. It does various functions, most notably bringing your arm up from your side. Shoulder pain is often due to supraspinatus Injury. It can occur in the tendon area of the supraspinatus tendon and can range from tendinosis to a tear.

Typical Pain Pattern For the Supraspinatus

Strengthening for the Supraspinatus

Traditionally it has been thought that “empty can” movement is what best challenges the supraspinatus muscle. To perform this exercise you would move your arm to approximately 45 degrees between your front and side and bring your arm upwards (with your thumb down).

What is the best way to Strengthen the Supraspinatus?

A 2007 study published in the Journal of Athletic Training investigated the activity of the supraspinatus during various exercises. The exercises investigated were the standing full can (thumb up), standing empty can (thumb down) and prone full can (lying on the stomach with the thumb up). The results found that each exercise activated the supraspinatus to the same extent; however the standing full can isolated the supraspinatus the best.

Conflicting Results?

To cloud the picture, a different study published in 2009 found that the supraspinatus was activated equally with various exercises but the deltoid activity was decreased with the prone full can exercise. Unfortunately, this is an example of two studies with different results and therefore different specific recommendations for isolating the supraspinatus. Regardless, it seems that either the standing full can exercise or the prone full can exercise may be your best options, depending on the patient’s symptoms. It seems that the balance of the literature is no longer advocating empty can testing or strengthening for specifically isolating the supraspinatus muscle. Keeping the thumb upwards (full can) seems to be a better option for rehabilitating or investigating the integrity of the supraspinatus.

Treatment for Shoulder Pain

Our clinic uses a variety of treatment methods for injury to the rotator cuff muscles (like the supraspinatus). Active Release, Laser Therapy, Graston, IFC (interferential current) and acupuncture are frequently used for this condition.

For more information or for an appointment with our chiropractor or physiotherapist, please call or email us. info@burlingtonsportstherapy.com

References
Boettcher CE, Ginn KA, Cathers I. Which is the optimal exercise to strengthen the supraspinatus? Medicine & Science in Sports & Exercise 2009; 41(11): 1979-1983.
Brookham R et al. Construct validity of muscle force tests of the rotator cuff muscles: an electromyographic investigation. Physical Therapy 2010; 90(4): 572-580.
Hughes PC, Taylor NF, Green RA. Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review. Australian Journal of Physiotherapy 2008; 54: 159-170.
Kibler WB et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. American Journal of Sports Medicine 2008; 36(9): 1789-1798.
Reinold MM, Macrina LC, Fleisig GS, Ellerbusch MT. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. Journal of Athletic Training 2007; 4: 464-469.
Reinold MM, Escamilla R, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. Journal of Orthopaedic and Sports Physical Therapy 2009; 39(2): 105-117.
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The supraspinatus, infraspinatus, teres minor and subscapularis muscles are often referred to as the rotator cuff muscles. Injury to the rotator cuff musculature is one of the more common conditions affecting the shoulder, ranging from mild strains to complete tendon rupture.

Symptoms of Supraspinatus Tear

Rotator cuff injury (including rotator cuff tear) can cause significant pain, weakness and reduced range of motion. Quite often, it causes difficulty with common daily tasks like putting your arm in a coat sleeve, putting your seat-belt on or reaching in the back seat of your car. Of course, there are many different conditions affecting the shoulder that can make these daily activities difficult and painful, so it is important to have this condition properly diagnosed.

Diagnosing Shoulder Pain

Soft tissue imaging (like diagnostic ultrasound or magnetic resonance imaging) is the optimal way to diagnose rotator cuff tears. Unfortunately, there is often a waiting list for these diagnostic tests so the preliminary diagnosis is made clinically in your health practitioner’s office. This is not always a simple step, since the commonly used clinical tests are not always easy to interpret. According to the scientific literature, there does not seem to be a reliable correlation between symptoms and tearing of the rotator cuff muscles. In other words, studies have found that many patients with minimal pain and normal function of the shoulder often have imaging results indicating partial thickness tear of the supraspinatus or full thickness tear of the supraspinatus.

Rotator Cuff Treatment

Consulting with a knowledgeable and skillful diagnostician can eliminate wasted time by deciphering which tissue is likely damaged and focusing treatment on the appropriate structures as quickly as possible.  That’s the first step as it helps to determine what avenue of treatment is best.  For some, surgery is necessary.  For most, conservative treatment like physiotherapy or chiropractic is the best choice.  What is right for you?  There are many factors to consider and we can assist you with that process.  For example, a recent injury might benefit from laser therapy or gentle exercises with our physiotherapist.  For others with more chronic rotator cuff injury (like supraspinatus tendinosis or tendinopathy) active release or graston technique with one of our chiropractors would be the best treatment.  Unsure?  Give us a call or send us an email…we can help you!  905.220.7858  email - info@burlingtonsportstherapy.com

References

Ainsworth R, Lewis JS. Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. British Journal of Sports Medicine 2007; 41: 200-210.

Uhthoff HK, Sarkar K. An algorithm for shoulder pain caused by soft-tissue disorders. Clin Orthop Relat Res 1990; 254: 121-127.

Frost P, Andersen JH et al. Is supraspinatus pathology as defined by magnetic resonance imaging associated with clinical sign of shoulder impingement? Journal Shoulder Elbow Surgery 1999; 8(6): 565-568.

Schibany N, Zehetgruber H, Kainberger F et al. Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study. Eur J. Radiol; 2004; 51(3): 263-268.

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Shoulder pain is very common among active individuals.  Although there are many different causes of shoulder pain, many studies have been published in recent years which link scapular (shoulder blade) position and the activity patterns of the muscles around the scapula to many types of shoulder injury. Among the evidence is the consistent finding of delayed lower trapezius activity in dysfunctional shoulders. 

Lower Trapezius Exercises

A 2009 study published in the Journal of Orthopaedic and Sports Physical Therapy used EMG analysis to examine muscular timing in the trapezius muscles during various exercises. The results of the study indicate that the prone extension exercise and the prone horizontal abduction (with external rotation) both promote early firing of the middle and lower trapezius muscles (when compared to the other muscles that move the shoulder).  This is a good thing for those of you who might be confused…in other words, many shoulders have weakness in this area and we now have scientific evidence as to the best way to strengthen these muscles.

Shoulder Exercises – Lower Trapezius

In the prone extension exercise, you simply lie on your stomach (on a bench) with your shoulders flexed to ninety degrees. You then extend your shoulders to achieve the end-position pictured below. (Don’t use a stick as pictured below…it is recommended to use dumbbells).

In the second exercise, you start in the same starting position as the first exercise but you bring your arms out to the side (as pictured below).  Finish the exercise with your thumbs pointing up to the ceiling. 

Treatment for Shoulder Pain

As always, we do our best to bring you the most current and accurate information both in our clinic and on our website.  References are provided below.  If you’re experiencing shoulder pain we suggest that you have your condition examined by one of our doctors; jumping into a strengthening program without being diagnosed is not recommended.  Most cases of shoulder pain not only benefit from strengthening the right areas, but they also require focused treatment at the dysfunctional structures.  Laser therapy is one of our popular treatment methods for shoulder pain and can be applied by either our physiotherapists or our chiropractors.  For more information, call 905.220.7858 or email us at info@burlingtonsportstherapy.com. 

References

Cools AM, Dewitte V, Lanszweert F et al. Rehabilitation of scapular muscle balance: which exercises to prescribe? The American Journal of Sports Medicine 2007; 35(10): 1744-1751.

De Mey K, Cagnie B, Van De Velde A et al. Trapezius muscle timing during selected shoulder rehabilitation exercises. Journal of Orthopaedic and Sports Physical Therapy 2009; 39(10): 743-752.

Hirashima M, Kadota H, Saraurai S et al. Sequential muscle activity and its functional role in the upper extremity and trunk during overarm throwing. Journal of Sports Science 2002; 20: 310-310.

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There is no question that the bench press is a very popular exercise for strengthening the pectorals. Although effective, this exercise can prove painful for many people so attention needs to be given to proper technique. Here are a few tips that are supported by published research…

Shoulder Tendons and Benching Too Low…

That burning stretch you feel at the bottom of the bench press is not necessarily the good type of “burn”. If you lower the bar to touch your chest, you’re likely to be straining the end of the pectoral muscle at the musculotendinous junction instead of targeting the pectoral muscle tissue. It’s recommended that you keep the bar 4 to 6 centimetres above your chest when performing this exercise. You can roll up a towel and place it on your chest if you need the reminder!

Shoulder Ligament Injury and a Wide Grip

A grip that is too wide forces your shoulder into excessive external rotation. This can damage the passive structures in the front of your shoulder joint leading to chronic capsular laxity. If you’re someone who has dislocated your shoulder in the past or if you are known to have “loose” joints, a wide grip may increase the likelihood for certain types of injury. The recommended grip width is no wider than 1.5 times your acromial width (the acromions are the bumps on the top of your shoulder). Worried that this will reduce your strength too much? According to the literature, you should expect only a 5% deficit in strength with this change.

Chronic Shoulder Injury and Flat Bench Press

When you place the bench on an incline it forces your shoulder into external rotation. If you’re someone with a structural deficit in the front of the shoulder joint (perhaps due to the aforementioned laxity or a history of dislocation) you’ll find that this increases the likelihood of pain or injury. Try keeping the bench flat and see if that makes a difference. Worried about strengthening your upper chest? According to some literature, inclining the bench does not alter the activity of the upper pectoral. Instead, it decreases the activation of the sternal portion of the pectoral (in the midline of your chest).

Treatment for Shoulder Pain

Our chiropractic and physiotherapy clinic in Burlington can help you with your shoulder pain. We offer various methods of treatment; which one is best for you depends on a variety of factors. For more information please contact us at 905.220.7858 or email us at info@burlingtonsportstherapy.com

References

Glass SC, Armstrong T. Electromyographical activation of the pectoralis muscle during incline and decline bench press. Journal of Strength and Conditioning Research 1997; 11: 163-167.

Green C, Comfort P. The affect of grip width on bench press performance and risk of injury. Strength and Conditioning Journal 2007; 29 (5): 10-14.

Lantz J, McCrain M. Modifying chest press exercises for athletes with shoulder pathology. Strength and Conditioning Journal 2005; 27 (3): 69-72.

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As mentioned in previous posts, certain sports are associated with certain injuries.  As baseball season is upon us, it may be a good time to introduce you to some of the newer concepts associated with dysfunction in the throwing shoulder.  Repeatedly throwing (as with baseball) places an enormous demand on the different tissues of the shoulder.  Ask any competitive baseball player if their shoulder has ever been sore and you’ll soon understand why much of the research on athletic shoulder injuries is performed on pitchers.  Over the last few years there have been some interesting articles and studies published in sports medicine journals that have changed the way that many practitioners assess, diagnose and treat these injuries.

Dead Arm in Baseball

Many baseball players come to our clinic complaining of pain in the shoulder while throwing that makes them unable to throw at their usual velocity and accuracy.  Often referred to as the “dead arm” in throwing athletes, clinicians now have some useful ways to detect changes in the shoulder that may be causing the problem.  Although not the actual clinical tests we would use, the following may give you an idea as to whether you have a shoulder at risk…

Decreased External Rotation

Is there a difference from left to right in how far you can bring your arm backwards?

Decreased Internal Rotation

Is there a difference from left to right in how far you can reach up your back?

Scapular Dyskinesis and Altered Shoulder Function

Do the contours of your shoulder blades look different when you’re at rest?

Do the contours of your shoulder blades look different when you move your arms?

Treatment for Shoulder Pain

Although some of the above findings may help detect the shoulder at risk of injury, it’s important that you have your condition properly diagnosed by your chiropractor or sports medicine doctor.  If you experience pain, stiffness, the dreaded “dead arm”, or if you simply plan on throwing a lot this summer, give us a call…there’s lots we can do to help!  Active Release Technique and Graston Technique (when combined with the appropriate stretching and strengthening exercises) have been shown to be quite effective for shoulder pain, especially in throwing athletes.  For more information or to schedule an appointment please call us at 905.220.7858 or info@burlingtonsportstherapy.com

References

Burkhart SS, Morgan CD, Kibler B. The disabled throwing shoulder: spectrum of pathology part 1: pathoanatomy and biomechanics. The Journal of Arthroscopic and Related Surgery 2003; 19(4): 404-420.

Burkhart SS, Morgan CD, Kibler B. The disabled throwing shoulder: spectrum of pathology part 3: the SICK scapula, scapular dyskinesis, the kinetic chain and rehabilitation. The Journal of Arthroscopic and Related Surgery 2003; 19(6): 641-661.

McClure P, Tate A, Kareha S et al. A clinical method for identifying scapular dyskinesis, part 1: reliability. Journal of Athletic Training 2009; 44(2): 160-164.

Tate A, McClure P, Kareha S et al. A clinical method for identifying scapular dyskinesis, part 2: validity. Journal of Athletic Training 2009; 44(2): 165-173.

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