With summer fast approaching, many of us are jumping back into one or more of our favourite fair weather activities, be it golfing with an orchard view, volleyball on the sandy beach, swimming in the crystal clear Okanagan lakes, playing tennis with friends or a little extra gardening for all of you green thumbs! Whatever the summer activity of choice, we all hope this warm weather finds us ready to tackle the ‘fun in the sun’ at full steam without having to worry about those pesky aches and pains that often set in over the winter.
One aspect that many summer activities have in common is that you will undoubtedly require a pair of healthy shoulders to fully enjoy them. As a practising physiotherapist treating patients with various conditions and injuries for almost a decade, I must say that shoulder pathology and dysfunction are some of the most common conditions walking in and out of our clinics on a daily basis.
When you dissect this shoulder issue further, there are a few key things that make the shoulder one of the most biomechanically impressive but also one of the most vulnerable regions to injury in our body.
First of all, the shoulder is the most mobile joint in the human body. The ‘ball and socket’ anatomy of the shoulder allow for movement that we see in no other body region. Whether it be flexing the shoulder 180 degrees overhead to smash a beach volleyball or fully externally rotating your shoulder during your golf swing follow-through, the shoulder girdle demonstrates phenomenal flexibility.
This fantastic mobility in the shoulder girdle however comes with a price. In order for this flexibility to be functional when teeing off with your driver on 18 or lifting heavy pot of flowers up on your deck, the shoulder requires a significant amount of dynamic stability. This dynamic stability is accomplished by work of a few important muscles that surround the very flexible shoulder joint…most notably, the rotator cuff as well as other scapular stabilizing muscles.
For our shoulders to remain healthy and function at the high levels required for our summer fun, this balance between flexibility and stability must be maintained. Some common conditions and injuries that we as physiotherapists assess and treat where shoulder flexibility and stability become compromised include; Shoulder Impingement, Tendinitis/Tendinopathy, Bursitis, Rotator Cuff Tears, Shoulder Dislocations/Separations, Frozen Shoulder, and Scapulothoracic Dysfunction.
If your summer involves getting or staying active and you want your shoulders to be ready for the action, book a consultation and some treatment with your physiotherapist to ensure your shoulders are ready to shoulder the load!
Jordan Ruder is a Registered Physiotherapist and Associate at the Downtown location of Sun City Physiotherapy. He is a member of the Canadian Physiotherapy Association and is also a Fellow of the Canadian Academy of Manipulative Physical Therapists (FCAMPT). He can be contacted by phone at (250) 861-8056 or by email at [email protected]
Do you lie awake at night with an aching shoulder? Do you feel sharp grabs of pain while reaching up into the cupboard or into the back seat of your car? Did your shoulder pain start one day without any injury that you can remember? Shoulder pain can keep us awake at night and limit our day-to-day activities – even the most basic ones like washing our hair or getting dressed. In this article we are going to talk about how shoulder problems can start and what there is to do about it.
First let’s talk about what is inside your shoulder. The shoulder is what we call a ‘ball and socket’ joint. This means that the top of the upper arm bone has a ‘ball’ like surface, and this ball connects with the concave surface of the shoulder blade, similar to a golf ball sitting on a tee. This type of joint (like your hip joint) is build for maximum mobility. Having so much mobility is a good thing because it allows our shoulder and arm to reach in all different directions. However, this excess mobility can also predispose the shoulder to injury.
Almost everyone has heard of the rotator cuff. The rotator cuff is a group of 4 muscles responsible for protecting the shoulder. These are often the muscles that are injured in the shoulder because they can become pinched inside the joint (referred to as ‘impingement’). The rotator cuff muscles work alongside the muscles of your shoulder blade to ensure that the ball is always positioned in the centre of the socket so as to avoid pinching, inflammation and pain. Impingement can occur if any of these shoulder muscles become tight or weak or if the neck and upper back are too stiff to allow for proper arm movement.
People that spend a large portion of their days sitting often become very weak in their shoulder blade muscles while at the same time also becoming tight in their chest, upper back and neck. Others spend a lot of their workday doing repetitive movements with their arm that also can create irritation and muscle imbalances in the shoulder. At night many of us tend to lay on our ‘favourite’ side while sleeping which squeezes the blood out of the shoulder thus causing further irritation and preventing recovery from the strain during the day.
If you start to have shoulder pain the best strategy is to avoid the movement that is creating the pain and to ice the shoulder for 15 minutes 2-3 times per day for the initial 3 days (after 3 days switch to heat for 20 mins, 2-3 times per day to increase blood flow/healing). Make sure to continue to move the shoulder in motions that don’t hurt in order to prevent your shoulder from getting stiff. Also try as best as you can to not sleep on the painful shoulder at night in order to allow healing.
If the pain does not subside within a week it is advisable to see your health care professional so that the specific reason for the shoulder pain can be diagnosed. In physiotherapy, pain control and stretching out tight muscles are usually the initial goals. Treatment then fairly quickly progresses to focusing on strengthening specific muscles as well as increasing overall flexibility. Often the conversation of prevention will focus on daily stretching or Yoga as well as emphasizing good posture while sitting.
I hope that you have learned a little bit about how the shoulder works and what can cause shoulder pain. If you are starting to have nagging shoulder pain or tightness, remember that it is much easier to deal now then ‘down the road’. Happy spring (summer) everyone!
Graham Gillies is a registered Physiotherapist at Sun City Physiotherapy Winfield and is a fellow of the Canadian Academy of Manipulative Therapy and a certified Gunn IMS and acupuncture practitioner.
With the May-long weekend marking the unofficial start of summer, and the weather quickly heating up, many people are hitting up the lake to take their swimming practices outdoors. Like any sport, aches and pains can occur in swimming, with shoulder pain being the most common complaint. The term swimmer’s shoulder is used to describe painful shoulder overuse conditions that occur in the sport. The shoulder is a ball-and-socket type of joint, which allows for a large amount of motion. This excessive mobility is balanced by surrounding tissues to make it more stable. Included in the structures that help stabilize the shoulder is a fibrous capsule that surrounds the head of the humerus (the arm bone), as well as the rotator cuff. Four muscles make up the rotator cuff, and serve to keep the humerus properly placed in the joint. The bony structure that you can feel on the top of your shoulder is called the acromion, where impingement can occur. Many movements occur at the shoulder during swimming, a lot of which is overhead. Different swimming strokes involve different patterns of motion, but all have some combination of rotation, circumduction and scapular movements. These positions can put the swimmer at risk of impingement, especially if the biomechanics are off. Injuries to the shoulder complex from swimming are typically microtrauma: small injuries over time from the repetitive activity rather than a macrotrauma from a one-time incident. There are many factors that can contribute to injury, typically described as intrinsic and extrinsic. Intrinsic factors can include the positioning of the joint itself; if the capsule surrounding the joint is tight at the back, it pushes the humerus forward, increasing the likelihood of impingement of the tissues under the acromion, and placing more stress on the tendons of surrounding muscles. Opposite of that would be if the joint is lax, which creates more demand on the rotator cuff muscles to provide stability. Another intrinsic factor is posture, with rounded shoulders and an increased forward bend in the upper back being common amongst swimmers. This lengthens and weakens muscles that stabilize the scapulae, can contribute to a tight posterior capsule in the shoulder, and decreased mobility in the spine. Extrinsic factors are related to the use of your shoulder: overuse (your training schedule), misuse (swimming form), abuse (too strong of demand placed on your shoulder), and disuse (time off from training). To maximize your season, it is worthwhile to assess your shoulder mechanics, preferably before injury occurs to be preventative. Any impairments should be addressed, which can include mobilizing stiff or tight structures, strengthening the rotator cuff and other supporting musculature, and improving technique. Be cautious of overtraining – don’t increase your distance, intensity or frequency of training too quickly. Give yourself adequate time to make strength and endurance gains, as well as time to recover. Consulting your physiotherapists to address shoulder and posture impairments, and a coach to look at your form, can help keep you swimming strong this summer.
Tess Mihell is a Registered Physiotherapist at Sun City Physiotherapy in Winfield
It’s well known that pain in your neck, radiating down the arm can be a result of an irritated nerve root in your neck. What’s often overlooked, is that compression can occur further down the nerve continuum as they bundle together and exit the neck. These nerve bundles are partnered with major blood vessels as they travel through the shoulder and further into the upper arm. As they exit the neck, these neurovascular structures become susceptible to compression. Knowing this, we now consider the possibility of compression of not just the nerves, but the blood vessels too.
Thoracic Outlet Syndrome (TOS) is a complex presentation of signs and symptoms that result from compression of the neurovascular bundle as it emerges from the thorax and enters the upper limb. The thoracic outlet is the space bordered by the scalene muscles, first rib, and clavicle. The neurovascular structures pass from the neck and thorax into the axilla (arm pit region), and continue to branch further into the upper arm, to forearm, and hand. TOS is more common in women, particularly those with poor muscular development, poor posture, or both.
In the office, we assess and diagnose injuries related to repetitive upper extremity use or trauma. Swimming, baseball, tennis, and volleyball, are common sports that may bring on symptoms of TOS. Functional and biomechanical assessment of these patients who engage in repetitive and extreme abduction (out to side) and external rotation (outward rotation) of the shoulder, often demonstrate TOS signs and symptoms. Other patient populations who may develop TOS include those who are in sustained poor postures in their activities of daily living and work, and tend to develop shortened chest and shoulder structures, and weak/lengthened neck and upper back structures.
Anatomically, TOS can be a result of bony and soft tissue factors. Bony causes often involve rudimentary or “extra” ribs which increases the risk of compression, e.g. cervical rib. Soft tissue factors can include muscular tightness or hypertrophy related to sport. Trauma or mechanical stress to the neck, shoulders, upper back, or upper extremities can bring on signs and symptoms.
The common presentation of TOS includes a high degree of variability. Most people describe a vague and often confusing source. Pain can originate from the root of the neck and radiate to the entire arm. Strength loss can occur. Depending on the structures being compressed, people can also experience numbness, swelling, tingling in the arm and hand, heaviness in the arm, loss of movement, rapid fatigue, dull aching, cold and discolouration.
Our challenge as physical therapists is to distinguish by specific testing, whether or not you present with a true TOS. From the comprehensive list of signs and symptoms above, we can easily see how TOS can mimic neck injury (disc, nerve root pain), and even shoulder and elbow injury.
Physical therapy treatment addresses postural abnormalities and muscle imbalance, in order to assist in alleviating symptoms by relieving pressure on the thoracic outlet. We work to minimize tension directly around the nerve entrapment points. Manual therapy and exercise strategies would assist in correcting muscles that have shortened or lengthened because of poor posture. It is also important to take into consideration a patient’s activities of daily living, work environment, sleep positions, etc. Surgical intervention is often considered in severe cases of blood vessel compression and compromise.
Symptoms often resolve with conservative physical therapy in 90% of individuals, with good ability to return to previous lifestyle with little difficulty.
Vince Cunanan is a registered physiotherapist and associate at Sun City Physiotherapy. He can be contacted at our Downtown St. Paul Street location or email [email protected]
Ever had pain radiating from your neck to your shoulder and down your arm? Perhaps losing strength in your arm or a feeling of numbness or tingling in the fingers? Chances are that you have irritated a nerve in your neck and that nerve is sending these painful or distressing symptoms down your arm.
The neck, or cervical spine, is comprised of the top seven vertebrae of the spine. These vertebrae form a solid yet fluid structure – solid to encase the spinal cord which runs down the centre of the spine, and fluid as the vertebrae move on each other as the neck bends and rotates. In between each vertebrae there is a opening called the intervertebral foramen, and it is here where the nerves that branch off the spinal cord exit the spine. These are called the nerve roots and the ones from the lower half of the cervical spine combine to form a group of nerves that travel into the arm, giving us sensation and muscle power.
Each nerve will follow a specific pathway from the neck to the arm, and nerves like to have space to slide and glide along that pathway. If at any point the nerve is compressed or pinched, then the nerve signal can be affected and as a result we can experience some of the symptoms mentioned above – pain, altered sensation, or reduced power in the arm.
There are certain areas where the nerve is more likely to become pinched in the neck. The intervertebral foramen that it travels through to exit the spine is the first. Anything that encroaches on the foramen such as a disc bulge or a bone spur can reduce the space available for the nerve causing compression. Then once it is through the foramen, the nerve travels between some tightly packed muscles in the neck so any increase in tension in these muscles can also cause compression of the nerve as it moves through this area.
If these symptoms ring a bell with you, a physiotherapist can perform a series of tests that will determine exactly which nerve is irritated and exactly where it is getting pinched. The location of your symptoms or the specific muscles that have lost power will help to determine the area of your neck that needs to be treated. There are several treatment options to resolve your symptoms, and which treatment will be most effective for you will depend on the findings from the assessment. Some common techniques used to treat cervical radiculopathy are manual therapy to create more space for the nerve, traction to take the pressure off the nerve, and acupuncture to stimulate the nerve in order to fully restore the nerve signal. Once there is no compression on the nerve and any inflammation around it has settled, then your arm symptoms should subside and full function should be restored.
Motor vehicle accidents (MVA) are sometimes an unfortunate consequence of modern reliance we have on automobile transportation. Previous to the invention of the car, there was “railroad neck”, and also a whiplash variation termed “roller-coaster neck”. Motor Vehicle accidents are sometimes termed “motor vehicle crashes” to suggest the preventable nature of some accidents. When a crash does occur, there is usually a chain of events including visits to the auto body shops, ongoing communication with insurance claims agents, and visits to many different health care professionals.
Despite advancement in sophisticated safety equipment for cars, bodily injury can sometimes result from accidents. Although the impact can occur in less than a second, the resulting injuries can persist for weeks or months. The neck (cervical spine) is the most common area of involvement, however, the mid back or low back can also sustain trauma. The shoulder or chest area can also be bruised by the restraint effect of the seat belt.
Injuries to the cervical spine are termed “whiplash-associated disorder’ or WAD for short. As with most conditions and injuries, there is a spectrum of severity. Following much consultation, the Quebec Task Force on Clinical Classification of WAD developed a five point scale of severity in 1995, which is well recognized within the health care and insurance fields. With Grade 0, or WAD 0, there are no physical signs, and the person does not complain of symptoms or usually seek help. At the other extreme end of the spectrum is the most severe WAD IV injury in which X-rays indicate a fracture or dislocation and require urgent medical attention. WAD classification is determined by a detailed and comprehensive clinical examination. Fortunately, most of the whiplash injuries sustained in a crash are classified as WAD II or III, and are commonly treated in physiotherapy practice. Clinical features include pain, and limited range of motion due to muscle spasm, sprained ligaments, and inflamed joints. Irritation of the neurological system can manifest as symptoms of numbness or tingling extending into the upper or lower extremities.
Physical therapists are very familiar with performing a detailed assessment and can help with determining the degree of injury that a person has sustained. A physiotherapy treatment plan is determined based on the degree of injury and time since the accident. Early in treatment when the condition is still very acute, it is common to suggest use of ice to decrease inflammation and pain relieving physical electrical modalities can also be used. As the person’s symptoms decrease, gentle mobilization, range of motion exercises, and progressive strengthening exercises are commonly introduced. Progress with treatment is individual and dependent on many factors. There are numerous practice guidelines, however, which suggest a return to normal daily activities as soon as possible, and treatment that promotes return of function is most helpful. A physical therapist is well trained to help assess your whiplash condition and provide an individualized treatment plan.