Tips for Lifelong Shoulder Wellness – Part 1: The Cause

Tags

GHJ, labral tear, law of repetative motion, overuse, physical therapy, pull ups, push ups, RCT, reverse total shoulder, rotator cuff tear, RTSR, shoulder exercises, shoulder injury, shoulder instability, shoulder pain, thoracic mobility, tissue tolerance, total shoulder replacement, TSR, upper crossed syndrome, yoga downdogs

The Shoulder – a simple ball and socket joint that becomes very complicated when pathology strikes.  Compared to treating the spine, the shoulder has lot fewer and modifiable variables that can prevent chronic issues.  To simplify:  when I say the shoulder, I will be talking about the glenohumeral joint (GHJ) – where the humerus meets the scapula (upper arm to shoulder blade).  We are talking about pathology at the GHJ, but without mobility and stability from its partners (thoracic spine, cervical spine, scapulothoracic, acromioclavicular or the sternoclavicular joints) the shoulder will not function optimally.  Most patients I see in the clinic that present with chronic pathology around the GHJ could have been prevented.

Common Pathologies

1)  Labral tear

2)  Rotator cuff tear

3)  Instability (capsular)

4)  Biceps tear

The list above are the common irreversible conditions that can all be prevented from entering the symptomatic threshold and with proper training, posture, and management of injury.  If not managed correctly long term disability due to pain or loss of function result.  This leads to and includes inability to perform you favorite recreational activities, and surgery that may not end in optimal satisfaction.  If you look at baseball pitchers, 79% have abnormal shoulder MRI’s.  Most do not have shoulder pain.  This is because they train their body correctly to maintain good shoulder health for long careers.  Inefficient supporting structures, poor mobility and stability lead to that symptomatic threshold –> pathology.  Painters, on the other hand, typically do not train for their profession.  This is why often they end up with pathological rotator cuff tears over the years

Law of Repetative Motion

I = NF/AR or

Insult of injury = Number of reps  x Force or tension  /  Amplitude of reps X  Relaxation between bouts

In other words, too many movements or too forceful of movements with not enough rest in between is a recipe for overuse pathology.  The key for shoulder longevity is to find the balance between tissue tolerance and tissue loading.

Depending on the degree of damage in the pathologies above, surgery may be warranted.  What most people fail to understand is that the dysfunction in the structures around the GHJ are usually the culprits.  So if you repair something at the shoulder surgically, you are doing all that pain and hard rehab work injustice.  The problem is bound to return in the future.  Also, the surrounding dysfunctional structures are the ones that can be less painfully changed for better shoulder use.  These structures should be addressed in therapy the first time you have a painful episode or notice poor mobility.

As a Physical Therapist I see a lot of reversal of functioning between structures.  The thoracic spine (between the shoulder blades) is meant to be a mover.  The shoulder blades are meant to be stabilizers.  In today’s desk occupied sedentary lifestyle, the function becomes reversed and the thoracic spine becomes stiff (lacks extension and rotation) and the shoulder blades lack stability (muscle control).  Unfortunately the GHJ takes the brunt and is damaged during attempts at “exercising.”

Too many yoga downdogs, recreational softball or tennis, push-ups, pull-ups, P90X, Crossfit… before the shoulder has enough mobility and stability can lead to much worse problems then the 4 listed above:

5)  Joint changes and osteoarthritis

Total Shoulder Replacement

 

The big daddy:  total shoulder replacement (or reverse total shoulder replacement) is becoming more common of a treatment option for those who have gone through early trauma / injury that was not managed properly at the time.  This is the surgery you get because you are no longer able to stand the pain or the mobility is so bad you cannot perform simple daily activities like washing your hair or using the toilet.  The point I want to make in this blog is that, hopefully, total shoulder replacement can be avoided.  Although having a TSR can dramatically reduce pain and disability , the shoulder is far from being “new”.  Expectations after a TSR are to improve motion to slightly overhead (120-140 degrees flexion) and just behind the back for activities such as toileting.  There is no returning to tennis or freestyle swimming after these surgeries.

So, why do people get to the point of having to have a TSR?  As I say to many patients:  “overuse or underuse” and poor injury management early in life.  If you ever pushed through an injury or completely ignored an injury as you waited for it to “heal, ” you have mismanaged your shoulder health.

Reverse Total Shoulder Replacement

For patients who primarily have arthritis in the joint (wear and tear) and have a good functioning rotator cuff, Total Shoulder Replacement is sufficient (pictured right).  As you can see it resembles a normal ball and socket joint like where the upper arm meet the shoulder blade.  If the rotator cuff is too damaged to salvage, a Reverse Total Shoulder Replacement (RTSR) is performed (pictured left).  Notice how the ball and socket have been reversed to allow for improved lever arms allowing the humerus to elevate for overhead movement.  Common procedure is to use the latissimus dorsi (not a rotator cuff muscle) graft to offset the mechanics of the deltoid during overhead reaching.  It gets the job done, but limits the variability of movement over shoulder height = rotation.

How do you avoid a shoulder joint replacement?

a)  Rehab your shoulder WELL the first time it is injured — >  get your full range of motion back in the GHJ and if needed address your spine limitations.

b)  Do you shoulder exercises forever — > maybe not 6x/week but at least a couple of days / week.  Figure out how to incorporate your rehab exercises into your fitness program to save time.

c)  Address your ergonomics or work habits –>  Everyone is aware that we are becoming more sedentary as technology drives our business.  Make sure you set up your desk optimal posture and arrange your day so get enough activity for maintainance good scapulothoracic mobility and stability.  Avoid upper crossed syndrome.

Resources

Shoulder Anatomy and Exam

Total Shoulder specialists

Total Shoulder stats

Joint Replacement Background

Optimal Shoulder Performance Lecture by Mike Reinold

Exercise, Depression, and the Amygdala

Tags

amygdala, chronic pain, conditioning, depression, exercise, fight or flight

Many of you are saying: “The Amygdala?”  What the heck is that?  This tiny part of the brain processes and conditions our responses to fear, addictions, sex drive, search for comfort, anger and many primitive responses that in primitive times kept us safe from harm.   It is the part of the brain that has the power to inhibit the rest of the body systems so that you can accomplish the task at hand.  Super important little part of the brain, huh?  The following is a rough explanation of it’s function, how it becomes problematic, and how to outsmart it.

Good primitive response from the amygdala:

If you are walking down the street talking to your boss on the phone and someone pulls a gun on you.  The amygdala influences the flight or flight response to drop the phone and run.  Forget about the important conversation you are having and save yourself.

The Amygdala

In this example, the amygdala is highly conditioned in that it has formed a neural pathway that links gun to arm and the reaction to run.  Because it is such a powerful contributor to flight or flight or drastic responses and conditioning of them, it does not always use information from higher centers to weed out the abnormal processing.  The amygdala is a key player in chronic pain and depression because of the repetitive nature of the neural pathways formed during both.

Once a nerve pathway is formed, the connection becomes conditioned (stronger) and may become strong enough to control all your daily thoughts and actions.  The conditioned response creates a reaction similar to the reaction during potentially fearful or dangerous situations (even if they are not really dangerous) linking fear and pain to depressive mood.

Bad modern-day response from the amygdala:

If you have a car accident and experience a whiplash injury, the amygdala may overpower the other pathways in the brain convincing you that driving in the car is dangerous.  You knew before the injury that there is risk involved with driving and were comfortable taking that risk prior to the accident, but now you are all together fearful of driving.  If the whiplash injury was initially painful during movement, the amygdala invokes fear and communicates to the motor cortex that movement is dangerous.  Prolonged fear of movement leads to chronic pain. This is an example when the amygdala can become problematic with modern-day coping mechanisms.

If the person above also is unable to work due to whiplash related back pain, the preservation on the loss of their paycheck and FEAR of going broke sends an impulse to the amygdala.  The fear response inhibits the rest the systems and moods (hunger, happiness, immune system).  The back pain intensifies each time they receive the notice to pay rent.  The stress and depressed state intensifies the pain response because the pathway has become conditioned.  Eventually the nerves that process pain become more sensitive to stimuli causing that reaction to require less stimulus to create the pain.  Before you know it everything increases the depressive mood.

Exercise and Redirecting

The typical Physical Therapist solution is to recommend exercise to “cure” the depression and chronic pain.  In the example above, Yes, exercise will help.  Remember how I said that the stimulus telling your brain to experience pain sensitizes when the pathway is overstimulated or fear is involved.  The best way to cure this is to redirect the conditioned nerve pathway.  I am not telling you to ignore the pain, but to second guess your feared response to it.  In other words, DO NOT TRUST YOUR AMYGDALA.  Redirect the pathway and overcome the fear by with physical activity.  Not only will it create a new neural pathway to help you realize that movement is not damaging, it will stimulate endorphin release (which is a mood enhancer) and activate many other positive benefits of physical activity.

The role of the amygdala has morphed in modern times as our society has become more civilized and less environmentally dangerous.  Our motor processing (higher centers in our brain) needs to out smart it so that we can avoid abnormal pain processing and conditioning.  Are you allowing a conditioned response to control your reactions or are you assessing each separate situation to make the most appropriate response?  Begin getting control of your amygdala by becoming more aware of your responses to stressful situations.  And exercise to re-direct your neural pathways and reactions that may be creating pain in your body.

The inspiration to write this blog was in part from reading Linchpin and after attending numerous presentations on pain mechanisms at APTA Combined Section Meeting last month .  Information how the amygdala (or lizard brain) can affect fear with work and life situations is well explained in Linchpin, the new release by Seth Godin.  In addition, there are many websites explaining  the function of the amygdala.

Enjoy.

Climbing Injuries

Tags

bouldering, Climbing techniques, injury prevention, knee injuries, physical therapy, Rock Climbing, shoulder injuries, sport climbing

Rock Climbing has become a passion of mine since I joined Mission Cliffs in San Francisco 4 years ago.  Although I do not do any outdoor climbing, bouldering has become a primary source of exercise for me. When consistently hitting the wall I see immediate strength and body composition changes.  As a Physical Therapist I have a unique perspective on the training effect and injuries occurring due to trauma and more importantly, overuse.  Although many varieties of climbing exist (bouldering, soloing, sport climbing with belay, competition climbing, and alpine) we will be referring primarily to sport climbing (short belay) and bouldering because these styles are used indoors at gyms.

The Sport and related Injuries

Rock Climbing is becoming increasingly popular among not adrenaline type fitness seekers.  It was known more as an extreme sport, but as more gyms are incorporating climbing walls the sport has grown to 9 million participants each year.  With the surge in interest among non skilled climbers comes increased risk of injury.  The most common injuries in rock climbing are caused by falls and include fractures, sprains, and strains that occur in the lower extremities.  Ankle sprains make up the majority of acute injuries in climbers.  Overuse injuries were reported at 44%, 19% at more than one site in a study published in the British Journal of Sports Medicine.

I am more interested in overuse component because as a physical therapist I have seen an increasing number (or shoulder and knee injuries) in this population.  Hand and wrist iuries are by far the most common overuse injuries, but is not my expertise so I will be focusing on shoulder and knee injuries I have seen in climbers.  This sport requires power strength, endurance strength, flexibility, technique, patience, and TECHNIQUE.  Those who lack technique or are untrained (poor core and shoulder stability or flexibility deficits) are at risk for overuse injury.  At the same time, many seasoned climbers are solely die-hard climbers.  Just as any other sport, climbing requires cross training and balance maintenance through flexibility and strength training.  Climbers develop shortened latissimus dorsi, increased kyphosis and “climbers neck (forward head posture)” which can lead to Upper Crossed Syndrome.  Other injuries include elbow, wrist and hand tendonopathies, and Spinal Pain (which is beyond the scope in this blog).  In addition to overuse, some of the skilled techniques used in climbing can also be problematic.

Problematic Skills

1)  Edging – Refers to placing the leg in external rotation (frog leg position) with the majority of the load through the big toe.  At same time incorporating a lift in the heel will provide additional foot stability for ascending and creating power more securely.  If there is not enough hip mobility/ stability or calf/foot stability the knee can become the fulcrum point leading to sprains, strains or imbalances.

Edging Technique

2)  Stemming –  Refers to using counterforce to support yourself between two spots.  This requires flexibility at the hip and shoulder and joint stability to facilitate extremity stability on the wall when there is minimal  holds available in a corner or between two rocks.  Lack of either can lead to shoulder, hip, or knee injuries.

Stemming Technique

3) Manteling and downpressure –  Refers to the downward pressure through your arms to create counter force or to match your feet to your hands to get higher.  Both of these techniques require a downward pressure and depression of the scapula (serratus activation).  Lack of shoulder or core stability  or enough flexibility may lead to shoulder injuries.

Mantel Technique

4) Straight armed resting, lieback, or “using bone, not muscle” – Refers to locking out your elbows and using counter force with the feet while leaning away from the wall.  Although this technique saves energy and allows you to rest, much of the rest may be going through the shoulder capsular stabilizing structures

Injury Trends seen in Physical Therapy

1) Shoulder Impingement – This is probably the most common overuse injury I see in climbers and is also the most treatable and preventable.  Once the rotator cuff or bicipital tendon become injured or painful, the best thing to do is “active rest.”  As stated before, many avid climbers do not train their imbalances with cross training and will usually get away with it.  With shoulder impingement, rest from climbing is imperative.  In addition, get in the wight room to strengthen the rotator cuff and scapular stabilizers for improved balance around the shoulder.  If posture is the problem, then get on the foam roller and do your corrective exercises to align the tissues around the glenohumeral and scapulothoracic joints (shoulder and shoulder blade).

2) Shoulder Labral damage – Unfortunately this injury is becoming more common and if too severe cannot be treated without surgery.  There are several ways the labrum (the connective tissue surrounding the socket of the shoulder that provides stability) is injured depending on the location of the lesion.  SLAP (Superior Labrum Anterior to Posterior), Bankart, or Hill Sachs Lesion involve different pathologies in the capsule of the shoulder.  SLAP tears may occur from overuse of the bicep tendon (common with pulling movements) or from putting the shoulder in awkward reaching back positions used in stemming.  Bankart and Hill Sachs lesions are usually seen in hypermobility or dislocations which may occur during manteling/down pressure or during falls.

3)  “Lateral and posterior knee pain” – I have seen a myriad of injuries at the knee presenting as IT band Syndrome, hamstring tendonitis or ligamentous instability.  Many of the patients believe the injuries are related to other activities (no trauma during climbing).  However I believe the hip rotation movements seen with toe in and out holds eventually leads to microtrauma in any of the structures mentioned above.  Many people do not know that there are actually three joints at the knee (Patellafemoral, Tibiofemoral and the overlooked proximal Tibiofibula joint).  When technique gets sloppy or there are flexibility deficits at the hip, the proximal tib-fib joint may be repetitively strained and lead to instability.    This combined with excessive calf work required for the heel up technique (mentioned above) leads to dysfunction, cysts, or joint changes.  The same mechanism of injury can also lead to meniscus tears.

The Patellafemoral, Tibiofemoral and Proximial Tibiofemoral Joints

Treatment = Prevention

1. Warm up and Stretch: This may involve several minutes on the bike or dynamic sub maximal movements to heat the muscles.  Many climbers will start with easy routes.  Because these emphasize using the already dominant muscles it is not optimal for waking up the muscles that control balance in the joints.  For warm up and stretching I recommend doing yoga (sun salutations) or lunge matrices with arm movements to loosen up the whole body.  Here is a video of the Gary Gray common lunge matrix.

2. Work on your Imbalances: If your hamstrings or hips are tight, stretch them.  If your lats or pecs are tight, stretch them.  Again this can all be accomplished by doing regular yoga.  Every climber should be doing preventative shoulder stability and core/hip stability exercises.  This doesn’t mean doing more climbing to strengthen your body.  It means finding the exercises that isolate the weaknesses (usually the rotator cuff, middle/lower traps and deep hip rotators).  If you are not sure what your imbalances are, find a trainer or physical therapist.

3. Rest between climbs: I recommend climbing no more than every other day in order to prevent injury resulting from fatigue.  It is best to do your imbalance correction exercises on the days you do not climb which will ultimately enhance your performance and prevent injury.

4. Off Season: Just as you should rest your body between work outs, you should take 1-3 months off every year for recovery.  Every other sport requires an off season in order to allow the body to recover…so does climbing.  This is all part of periodization and strength training professionals have this down to a science.  It works not only for injury prevention, but will also enhance your performance in the long run.

5.  Power Training:  If you do not currently have an injury such as the one described above, power training may be necessary.  For beginner or advanced climbers who are looking to advance their performance this may be the missing link in training.

6. Improve your technique – practice, practice and practice.  Take beginner and intermediate courses. Work out with experienced climbers.  This is by far the most important component of prevention.

Other Options

Unfortunately if prevention does not keep these common injuries from occurring, Rest and Rehab is a necessity.  From Experience, overuse injuries can be frustrating with sports requiring the amount of power used in Rock Climbing.  Many shoulder and knee injuries may ultimately require surgery if not treated conservatively early into the pathology.

Thanks to one of my loyal patients encouraging me to climb, I was hooked.  It is my hopes that the sport continues to grow safely.  The benefits to recreational and fitness climbing are numerous if you train correctly.  Check out the links below for more information on Rock Climbing injuries and fitness.

http://www.rock-climbing-for-life.com/climbing-injury.html

http://abcnews.go.com/Health/story?id=8165004&page=1

http://www.bodyresults.com/s2climbing-flexibility.asp

http://www.climbinginjuries.com/page/shoulders

http://orthoinfo.aaos.org/topic.cfm?topic=A00015

http://www.hyperstrike.com/Rock-Climbing-Workout-Article-105.aspx