Shoulder and Tricep Pain

Nagging shoulder pain can be a real pain to put up with throughout the day!

It impacts just about everything you want to be doing from reaching overhead, putting your seatbelt and jacket on to just name a few. It also can prevent you from performing you normal workout and fitness exercises as well.

In this case study from On Track Physio we are going to look at shoulder pain as well as tricep pain that caused a grabbing or catching pain in shoulder, as well as pain in elbow upon full extension of arm.

When we examined the shoulder he had pain with overhead motion as well as reaching across the body. Resistance testing indicated a few particular muscles in the shoulder that we wanted to address via soft tissue work as seen in video below.

We then followed this up with specific exercises that he was able to perform at home as opposed to visiting the clinic multiple times per week. Within less than 6 visits he has back to his normal fitness program with minimal to no limitations in the shoulder and confident to continue on without treatment.

At On Track Physio we don't waste time performing meaningless "filler" activities. We pick the most efficient treatment based upon our assessment to get you back to your goals the FASTEST.

If you are interested in Dry Needling we offer a discounted trial session $37 to see if you like it. 

To try your first session of Dry Needling, click here!

Ann Arbor, Mi

About the Author: Dr. Greg Schaible is a physical therapist/strength coach specializing in athletic performance. He attended The University of Findlay, graduating in 2013 with his Doctorate of Physical Therapy (DPT). As a Track and Field athlete, he was as a 5x Division II All-American and 6x Division II Academic All-American. Greg is the owner of On Track Physiotherapy in Ann Arbor, Mi. You can stay up to date with helpful information and news on Facebook.

Simple Shoulder Pain Test and Solution

Today I have a simple test for shoulder pain and dysfunction with a potential solution that has helped others who have had similar issues.

Below is a simple test you can do at home to assess for shoulder pathology. This is called a horizontal impingement test, often used in physical therapy clinics. The test is assessing for healthy joint movement. If there is pain or pinching involved, this is a positive test and may warrant further examination from a trusted healthcare provider.

If this test is positive, chances are you have difficulty reaching overhead, across and behind your body.

Below is a simple solution that has often cleared up this test and improved people's shoulder on numerous occasions. The rotator cuff, in particular the backside (posterior) of the shoulder consists of three muscles that tend to hold a lot of tension and contribute to a lot of movement related issues of the shoulder. They are the supraspinatus, infraspinatus, and teres minor. In addition to these three, the long head of the triceps can at times be involved as well. Here is a simple activity you can do at home to start addressing these soft tissue limitations.

Give it a try and let me know what you think!

Sports Specialist Physical Therapy Clinic| Ann Arbor, Mi | FREE Discovery Session|

About the Author: Dr. Greg Schaible is a physical therapist and strength coach specializing in athletic performance. He attended The University of Findlay as a student athlete. As an athlete he competed in both Indoor and Outdoor Track & Field where he earned honors as a 5x Division II All-American and 6x Division II Academic All-American. In 2013 he completed Graduate School earning his Doctorate of Physical Therapy (DPT). Greg is the owner of On Track Physical Therapy in Ann Arbor, Mi. Follow On Track PT and Performance on Facebook.

Do You Have "Tight" or "Stiff" Shoulders?

Often times I am told by a client that “things just feel stiff or tight.”  These reports tend to be most common in the hips, shoulders, and neck.

I usually will proceed to tell the patient that stiffness or tightness may actually be a good thing. As it could be the body’s response to a perception of threat in the area, and its protective mechanism is to tense up or hold on tight for security purposes.

I will also inform them that things may not actually be as “stiff” or “tight” as they believe.

Usually at this point I get a blank stare from the patient or a barrage of questions because nobody has ever explained these concept to them. So that will be my goal in this article. For simplicity sake, we will just be discussing the shoulder.

Stiffness is a sensation the body will produce, it is not an actual state of being. Three things that tend to impact the sensation of being “Tight” are: 1) Position 2) Nervous System 3) and Muscles. Usually in that order.

Position

Let’s use the analogy of a door frame here. A crooked door frame will not allow for a door to shut, obviously one of the corners will catch. The answer is not to stretch or force the door into a position it cannot achieve. The solution is to create a better door frame position so that the door will fit. Taking this back to the body, the shoulder and hips are really no different. Both are ball and socket joints. And if the ball (meaning your arm or leg) does not go through a full range. It could be because the position of your frame (or socket) is not optimal. 

When considering the position of the shoulder, the socket would be the scapula or shoulder blade. Fortunately for our mobile arms, the scapula has a great deal of movement. The tricky part is that because the shoulder blade is so mobile, its foundation is more dependent on the ribcage than anything. The ribcage is the foundation the shoulder blade sits on and thus will ultimately dictate position of the shoulder.

Below is an example of a patient of mine who needed to have more approximation of his left ribcage and expansion of his right ribcage. By putting him in a position that would allow for this, and then having him establish proper breathing patterns in this position, you can see the change in range of motion after. Mind you this picture was taken right after the exercise which lasted at most 2 minutes. No stretching, massage, or dry needling was performed. Just positional breathing. Which is great, because now the patient can perform this activity at home and not rely on a medical professional to always make a change. 

(patient is lying on opposite ends of the table, which is why picture looks reversed). 

How is that big of a change possible? Just as we discussed. If a joint is in a poorly managed position, it can directly affect the length/tension relationship of the muscles that cross the joint. In this case, due to shoulder position, the muscles that crossed the joint were already on “prestretch”. Meaning these muscle were more than likely already on stretch to achieve a neutral position. So to establish full range of motion, the muscle would have to elongate further than what would typically be expected. By establishing a true neutral position of the joints we can take that “prestretch” off and allow the arm to access its full range of motion.

Sports Specialist Physical Therapy Clinic| Ann Arbor, Mi | FREE Discovery Session|

About the Author: Dr. Greg Schaible is a physical therapist and strength coach specializing in athletic performance. He attended The University of Findlay as a student athlete. As an athlete he competed in both Indoor and Outdoor Track & Field where he earned honors as a 5x Division II All-American and 6x Division II Academic All-American. In 2013 he completed Graduate School earning his Doctorate of Physical Therapy (DPT). Greg is the owner of On Track Physical Therapy in Ann Arbor, Mi. Follow On Track PT and Performance on Facebook.

Radial Nerve Glide

The Radial Nerve glide is often a neglected or forgotten assessment/treatment for a variety issues related to the neck, shoulder, elbow and, wrist. The radial nerve glide can have profound impact on improving shoulder internal rotation (reaching behind the back) and lateral elbow pain or tennis elbow. At On Track Physical Therapy, we also have found this to be very beneficial for a lot of rotator cuff repairs early on when used properly or performed through modified ranges of motions when restrictions exist.

Shoulder Rehab Part 3

In part I of this series I discussed how traditional physical therapy exercises for the rotator cuff often miss the mark, and then in part II how dysfunction and a lack of motor control in other areas of the body can significantly affect the shoulder and cause pain.  Be sure to read those, if you haven’t already, as this article will make much more sense. In part III I want to talk about another concept that has taken the therapy world by storm –Scapular Retraction.

In a nutshell, scapular retraction means pulling the scapula (shoulder blade) closer to the spine, and often times the cuing from the therapist or physician is to pull the shoulder blades down and back (or “put your shoulder blades in your back pockets”).  Check out the picture below:

Now I’m not going to sit here and say that good things can’t happen from doing this, or deny that I used to buy this approach.  Some folks are just stuck with their shoulder girdle forward and scapulae protracted (spread apart) so far that they create a shoulder impingement with that faulty posture.  Working on scapular retraction can work in the short term in these cases, but I certainly don’t think it’s a permanent fix.  There are many therapists and physicians that feel this strategy will help in all cases.  Here are some reasons why it will not:

1)  The scapula is most cases just needs to be posteriorly tilted (or tipped).  Check out the photo below to get the visual, but the jist of it is that this creates more space in the glenohumeral (shoulder) joint to decrease impingement while also allowing for greater freedom of movement at the shoulder.

Try pinching your shoulder blades down and back like in the picture above and try reaching overhead.  It isn’t going to happen.  The scapulae are meant to upwardly rotate when going overhead to maintain the joint space and prevent impingement.  Too much ‘down and back’ will actually create more downward rotation and greater impingement (see picture above in the upper left). 

Scapular Reduction Test – the scapula is gently posteriorly tilted. This will often clear an impingement with shoulder elevation. Notice he is not pulling the scapula closer to the spine! Rather he is tilting the scapula/shoulder blade backwards.

2)  Many people will often mistake this scapular position fault as an actual shoulder problem and label it as "scapular winging". However they are missing the boat here! The scapula sits on top of the rib cage. So if your scapula is improperly positioned, more than likely it is due to a ribcage that is in a faulty position. Think of it like putting hinges on a crooked door frame....it just wont work. The convex surface of the ribcage needs to meet properly with the concave surface of the scapula. Once a better relationship is established we can start talking more about "shoulder exercises."

Yes, the position of your ribs matter!

There is nothing wrong with a little scapular retraction to reposition the scapula on the thorax, but it is not the be all end all solution, and some other issues may need to be cleared up first in order to function correctly.

Sports Specialist Physical Therapy Clinic| Ann Arbor, Mi | FREE Discovery Session|

About the Author: Dr. Greg Schaible is a physical therapist and strength coach specializing in athletic performance. He attended The University of Findlay as a student athlete. As an athlete he competed in both Indoor and Outdoor Track & Field where he earned honors as a 5x Division II All-American and 6x Division II Academic All-American. In 2013 he completed Graduate School earning his Doctorate of Physical Therapy (DPT). Greg is the owner of On Track Physical Therapy in Ann Arbor, Mi. Follow On Track PT and Performance on Facebook.

Shoulder Rehab Part 2

In Part I, I discussed why physical therapy of the shoulder using traditional rotator cuff exercises does not always work .  Traditional methods of shoulder rehab often train the muscles of the shoulder in a way that they are not really used in normal everyday function.  If you haven’t caught that article yet, I suggest you read that one first. In this article I want to address a couple other pieces of the puzzle:  motor control and regional interdependence.

There are many cases in which a certain movements may look dysfunctional in a standing position, but may actually be completely functional in other positions where the patient is more unloaded like lying on their back, stomach, side lying, on hands and knees, or even in kneeling.  In these positions there are fewer joints and segments to control and in most of these cases less gravity to deal with.

Unless the movement pattern is tested in multiple positions, it is not possible to know with any certainty that the movement is limited because of a true mobility issue (think joint restriction or ‘tight’ muscle) or if it is because of a lack of motor control.

Here is a great example looking at a functional reaching pattern behind the back.  In standing, you should be able to reach up behind your back and touch the bottom of the opposite shoulder blade as in the picture below:

Previously I had a patient come in that could only reach to just below her belt line.  She had been given stretches to increase that movement but they really hurt her shoulder to perform.  If you’ve ever had a shoulder problem or therapy after a shoulder surgery then this exercise will look very familiar:

When I had her lie down on her left side, she could reach all the way up her back and touch the opposite shoulder blade!  So why could she not do it in standing but had no pain and no difficulty lying on her side?

By going to a more unloaded position in side lying, the other joints of the body are taken out of the equation, and there is much less to have to control.  In this position she could be successful.  This is a great example of poor motor control, not a loss of shoulder range of motion.  So of course the first question she asked me is why did she spend the last 4 weeks in therapy and at home trying to stretch out her shoulder?

During the evaluation is was also discovered that she had some loss of mobility in her neck.  Because the neck movements were not painful, these were addressed first using some IASTM soft tissue work to her upper trapezius, levator, and rhomboids.

Another soft tissue treatment modality we offer at On Track Physical Therapy is Dry Needling.

Here is where that term – Regional Interdependence – comes into play.  In simple terms, regional interdependence is the interplay between different regions of the body.  In this case its easy to see how limitations in the neck can affect the shoulder since there are a number of muscles that run between the spine and shoulder girdle.  In other cases it could be dysfunction even further down the spine, the pelvis, hip, and beyond that could affect alignment and function at the shoulder.  Without the proper evaluation, it would be nearly impossible to find these relationships.

Once her cervical mobility was restored, we immediately went to corrective exercises to improve motor control of the neck and shoulder girdle.  These were fairly simple non-painful exercises that allowed her to successfully work through her neck limitations in a more unloaded position (hands and knees in this case).

Following that first treatment she could reach behind her back and nearly touch her opposite shoulder blade!

When the patient returned for her next visit, she had maintained her neck mobility and behind the back reach without shoulder pain.  We progressed to kneeling and standing motor control exercises, and by the end of the treatment she could touch her opposite shoulder blade without difficulty.

Needless to say, this patient was quite happy with the results.  Sometimes it is as simple as being in the right place at the right time with your treatment.  

Sports Specialist Physical Therapy Clinic| Ann Arbor, Mi | FREE Discovery Session|

About the Author: Dr. Greg Schaible is a physical therapist and strength coach specializing in athletic performance. He attended The University of Findlay as a student athlete. As an athlete he competed in both Indoor and Outdoor Track & Field where he earned honors as a 5x Division II All-American and 6x Division II Academic All-American. In 2013 he completed Graduate School earning his Doctorate of Physical Therapy (DPT). Greg is the owner of On Track Physical Therapy in Ann Arbor, Mi. Follow On Track PT and Performance on Facebook.

Shoulder Rehab Part 1

Chances are if you have been to Physical therapy, you have probably seen someone performing the exercise below working on their shoulder. Okay, so maybe not with their shirt off. But nevertheless it seems to be a staple of every physical therapy program for the shoulder.

While this is certainly a useful exercise, and it will defiantly get some patients feeling better. However, the vast majority of the patients that walk through the door need a more comprehensive program than this.

Maybe just as bad, the physical therapist or assistant will hand you 2-3 pages of similar exercises, tell you to do 3 sets of 15, 2-3x per day.  Ever heard of the shotgun approach?  Your health care provider is hoping and praying that one of these might just work and make you feel better. That being said, the exercises do have some legitimacy and are very useful for the sedentary population. However, if you are reading this then chances are you take an active roll in your health and you have found these exercises work, but don't always cut it when it comes to getting you back to 100%.

So here is the reality of the rotator cuff:  It’s job is to stabilize the humeral head (the ‘ball’ of the shoulder) in the glenoid fossa (the socket). Its secondary job is to assist with actual movement.

What most health care providers are going on are fancy EMG studies that measure how hard a muscle can fire in isolation during a specific activity.  There is certainly great evidence that the rotator cuff muscles are firing during these exercises.  The problem as I alluded to before is that these muscles do not function solely in this way in real life.

These smaller rotator cuff muscles are stabilizers, not movers(like the larger deltoids, pecs, lats, etc).  The traditional rotator cuff exercises train the muscles like ‘movers’ which is not their true function.  

The reality of the rotator cuff again is to stabilize the humeral head (the ‘ball’ of the shoulder) in the glenoid fossa (the socket).  It performs this task reflexively, meaning it happens without you having to think about it.  All four muscles quickly fire and relax in a specific sequence (depending on the activity) to stabilize the shoulder joint.  They never work in isolation.

So what are the best ways to fire the rotator cuff reflexively?

1) Compression – this means putting weight through the arm.  Examples would include exercises that involve hands or forearms on the ground holding your body weight up (think pushup, plank, or a variety of other variations. Another example would be actually pressing a weight when deemed appropriate.  

2) Distraction – this would include anything that pulls downward or outward on the shoulder (think traction).  This would include carrying weight by your side, pull-ups, horizontal rows, lifting from the floor, etc.

In any of the above activities, the brain immediately recognizes the need for stability and reflexively fires the cuff to prevent bad things from happening like dislocating your shoulder or falling on your face.  Now obviously I’m not trying to actually do these things to you, but forcing muscles to fire reflexively always works better when there is some sense of urgency.

I’ll leave you with a few of my favorites below, and in part 2 I’ll tackle more as we start to look deeper.

Arm/Leg Diagonals – a.k.a. the Bird Dog – Shoulder Compression for Reflex Stabilization

Bottoms up Carry – Downward distraction with instability to elicit reflex stabilization

Sports Specialist Physical Therapy Clinic| Ann Arbor, Mi | FREE Discovery Session|

About the Author: Dr. Greg Schaible is a physical therapist and strength coach specializing in athletic performance. He attended The University of Findlay as a student athlete. As an athlete he competed in both Indoor and Outdoor Track & Field where he earned honors as a 5x Division II All-American and 6x Division II Academic All-American. In 2013 he completed Graduate School earning his Doctorate of Physical Therapy (DPT). Greg is the owner of On Track Physical Therapy in Ann Arbor, Mi. Follow On Track PT and Performance on Facebook.