Rotator Cuff: What is it and do I have one?

This is not actually one thing it is a group of muscles often mis-named by terms like rotatory cuff, rotator cup, and just plain rotater or roter. So no surprise that this group of muscles is complicated and misunderstood.

You may have heard people talking about having “torn their rotator cuff” and how they have a ‘bum shoulder’ now because of it. What are they really talking about, is four muscles of the shoulder Supraspinatus, Infraspinatus, Teres minor, and Subscapularis that may not be working optimally together. We believe there is not really a ‘bum’ anything just something that has room for improvement. We aren’t expecting you to remember or even be able to pronounce those words, but know that the rotator cuff is a group of four muscles. We remember them as the SITS group to keep them straight. The four muscles work together to stabilize the shoulder joint because the joint is very shallow, like a golf ball (arm bone) on a tee (socket). Each muscle on their own is responsible for producing a specific movement of the arm.

Your Supraspinatus muscle runs from the top of your shoulder blade out to attach on to the top of your arm bone. Its main purpose is to start the motion of lifting your arm up at your side.

Your Infraspinatus muscle sits below the supraspinatus on the shoulder blade. This muscle covers most of your shoulder blade and is shaped like a fan. It is larger and attaches right next to the supraspinatus on the arm. It’s main movement is to rotate your arm to touch the back of your head.

Your Teres minor is the smallest muscle in the SITS group. It sits below the Infraspinatus muscle also attaching to arm bone with the two muscles above. Because it is so small it only helps Infraspinatus with its main functions.

Your Subscapularis is the only member of the rotator cuff group that sits on the front side of your shoulder blade, between the blade and the rib cage. This is the largest of the SITS muscles, and it fans over the whole front of your shoulder blade and attaches on the exact opposite side of the arm bone compared to the other three muscles. It’s main function is to internally rotate your arm to put it in the sleeve of your coat, scratch your back or squeeze your arm to your side.

Rotator Cuff Muscles of the Shoulder

Rotator cuff injuries are quite common, many people find out later in life that they have a tear from many years ago without ever knowing it. However, some result from falling and jarring your arm and shoulder or during some other incident that involved a lot of pressure or force being pushed/pulled through your shoulder (e.g. seatbelt during a motor vehicle collision). These impacts can result in anything from minor injuries like partial muscle tears to more severe injuries like full thickness muscle tears or even, in rare cases, the muscle being torn completely off from where it attaches to the bone. Even where the muscle has been completely torn off, surprisingly surgery is almost never the first option and often it’s not used at all. In all cases, appropriate exercises can help to re-train and strengthen the attached muscles back to full or near full function.

However, outside of the more traumatic injuries that can happen to your rotator cuff basic overuse/misuse injuries are much more common (e.g. tendinitis, bursitis or non-inflammatory injuries like Tendinopathies). Repetitive movements can often result in muscle and tendon irritation and you will often see athletes in sports like baseball, volleyball, and tennis having some problems with overuse injuries in their dominant shoulder. These injuries are most often not caused by inflammation meaning they are not an ‘itis’ like tendinitis instead they are a dysfunctional thickening of the tendon referred to as tendinopathy. With overuse/misuse injuries, the most effective treatment starts with the Physiotherapist diagnosing the areas for improvement in painful movements and muscle compensation patterns. The Physio will assess the extent of the injury and then create an appropriate treatment plan to stabilize, strengthen and return to activity.

Treatment for shoulders typically starts in the acute phase, days after the pain starts. In the acute phase treatments like massage therapy, acupuncture, soft tissue work, IMS (needling) and shoulder stabilizing exercises are often used. As the injury starts to improve, the treatment will shift into a more active approach where exercises are used to target the movement patterns that resulted in misuse in the first place.

Find a Physiotherapist and a Registered Massage Therapist, in your town, to help get you on the right track to getting back to the activities you love!

BOO!!! Don’t let scary medical words derail your progress.

With Halloween right around the corner, we thought it would be a great time to touch on some of those scary medical terms that patients hear everyday. If you’ve ever read the results of an X-ray, MRI or Ultrasound you most certainly have heard of some of these terms covered below.

Osteoarthritis

X-rays are the easiest way to take a look at the bones and joints in our body. Osteoarthritis (OA) describes the often normal thinning of the cartilage (smooth gliding surface) on the bones of our joints. Hip and knee osteoarthritis is the most common lifestyle process in those aged 65 years and older. Although you hear a lot about arthritis pain, it does not mean it is always a painful or debilitating condition. In fact, up to 85% of adults with signs of knee OA on x-rays have NO knee pain. This means that seeing OA changes on x-ray doesn’t guarantee that you will have pain or dysfunction . Take a look at our past blog on how exercise is the best form of treatment for mild to moderate hip and knee OA but also safe for severe end stage OA, as well.

Rotator Cuff Tear

Ultrasound or MRIs are used to look at “soft tissue” such as tendons or ligaments. A tendon attaches muscle to bone and ligaments provide stability around our joints. The rotator cuff refers to tendons connecting important muscles of the shoulder to the upper arm. Tears of the rotator cuff are a common finding when imaging shoulders with ultrasound or MRI. So common in fact, it has been shown that up to half of those aged 60 and older showed rotator cuff tears on MRI without corresponding pain or disability. Rotator cuff tears are even common in high functioning athletes. A study of baseball pitchers revealed that over one third of all the pitchers had full or partial rotator cuff tears without having any reported pain or limitations.

Degenerative Disc Disease / Bulging Disc / Joint Space Narrowing

Any back disc injury has been made out to be a scary idea. However, degenerative disc disease (DDD) is not a disease at all, it actually refers to normal changes in the discs (pads that provide cushion between the bones) of our spines. It is the difference between PATHOLOGY and MORPHOLOGY. Pathology is a true disease process like cancer but Morphology describes normal change over our life time. DDD is most often found in our necks and low backs. Studies have shown DDD of the low back is present in over 30% of people aged 30 and younger and 90% in ages 50-55. In some cases, DDD can lead to disc bulges which sounds scary but up to 25% of healthy young adults (aged 20 to 22) have low back disc bulges with no back pain and nearly 50% have at least one degenerated disc on MRI. If DDD and bulging discs were the true cause of all back pain then we would all have back pain at 20 that would only get worse as we age!

This post isn’t meant to replace the medical advice of your doctor or medical professional. But rather to help inform people that these scary terms don’t automatically subject you to a life of pain and dysfunction. We as healthcare professionals are changing the way we use these words to try and educate our patients with fact-based knowledge that does not foster fear but encourages a focus on function and optimism. We are still not perfect at this yet, but being told you have the back of an 80 year old at 25 does not help anyone heal!!

Knowing that these findings are common in healthy young and old populations can help reduce the anxiety around what “degenerative disc disease”, “rotator cuff tear” or “osteoarthritis” may mean for your future. Remember, MRIs, X-rays and Ultrasound imaging are very good at ruling out major health concerns such as fractures, tumours and spinal cord injuries, but they are also very good at picking out normal changes in our body that we would never otherwise known were there. Use the results to know that there is likely nothing BIG and ScARy going on inside of your body. If you have had medical imaging and are concerned over the result, be sure to ask your medical professional what those changes mean for you.

Happy Halloween!

References

VOMIT poster LSP, Shoulder and kip/knee

Healthlink BC

Common knowledge or common misconception? Motion is lotion.

Raise your hand if you’ve been doing a squat or lunge and been told “don’t let your knees go past the front of your toes”. Or “never bend forward because you may cause a disc bulge”? Or “don’t squat to the floor because it’s bad for your hips and knees”

There are many misconceptions that we hear in the clinic and around the gym that in some cases, cause more limitation or fear than necessary. In some cases, if we were to follow all of the ‘rules’ we would be walking around like robots!

Now, there are certainly situations that warrant specific movement restrictions and attention to form i.e. after surgery, while lifting heavy weights or when performing high intensity repetitive movements. But in everyday life, our bodies are amazing machines and are made to move! In fact, our joints stay healthy through movement and help prevent and manage conditions such as osteoarthritis.

When you stop to think about it, there are many movements we just don’t do in our daily life. Maybe because our daily demands don’t warrant it or our jobs have us working at a desk all day, for example.

A great example to think of this is how often do we ever bend our hips and knees past 90 degrees (i.e. deeper than chair height)? Or our ankles past neutral? For a lot of us, really not often, especially when we work standing at a till, sitting at a desk or driving in a car.

Here is a great tip from a well respected physiotherapist, Bahram Jam, to help keep you feeling young and your joints mobile while reducing the dread of bending down to pick something off the floor

Practice unloaded deep squatting everyday.

  1. Try holding onto a kitchen counter, banister or rail and gently lower yourself until your bum touches your heels and your armpits touch your knees
  2. Hold it for a few seconds while you get comfortable
  3. Then repeat 5-10 times using your arms throughout to help with the movement, if needed
Deep Squats for mobility

This is a simple yet great way to keep your back, hips, knees and ankles healthy and mobile by using their available range of motion!

Obviously this goes against what we may hear about not bending our hips past 90 degrees and knees past our toes. The movement itself is not damaging. In fact, it helps keep the mobility in our joints while making things like getting on and off the floor or squatting to pick things up much easier.

Of course this should not replace any medical advice but if you have any concerns or would like ideas to help stay mobile and keep your joints healthy and strong visit a local physiotherapist or kinesiologist!

Road Trip: Stop neck and arm pain at the pass

Whether you are driving your ‘big rig’ or your family car, van or truck, use the posture that best suits neutral spine alignment.

Neck or rather arm pain is very common when driving! Everyone thinks it is due to how their arms are up on the steering wheel or that they are gripping too hard or that gravity is reducing the circulation. All of these things are possible but if they were the case, the feeling should go away completely when you bring your arms into a more relaxed driving position or when you change activities.

What can commonly be occuring is that you might be experiencing ‘referred’ feelings coming from your neck or your shoulder.

What is a referred feeling (pain, tingling, numbness, etc.)?

Referred feelings are sensations that are felt in an area that is not the origin of the feeling. For example, most people have heard of Sciatica. This is a referred feeling often but not always coming from irritated nerves in the lower back and then causing downstream feelings like pain in the thigh, calf, ankle, etc. You can also get referred feelings from tight muscles.

So how do we tackle referred feelings?

Most often there is an irritant or two in the activities that you may do everyday. Unbeknownst to you the way you are doing those activities, stretches or postures you might be contributing to the referred feeling sticking around way too long! Pay attention to the feeling when it is really subtle and what activity you are doing at the time. Make a mental note to avoid that activity for a least a week and see if that decreases those annoying referred feelings. For example, it might be as simple as not crossing your legs or putting your hand on your hip.

So how do we get rid of the neck and/or arm pain while driving?

Try these Three Tips:

1. Make sure your seat is at about 100 degrees of incline

+ So set the backrest not perfectly straight but not sloped way back

2. Make sure the back of your head is touching or nearly touching the head rest

+If it is a long way back and when you get your head there and you are looking up to the ceiling then just try to keep your chin tucked in and get as close to the head rest as you can while still having your eye level with the horizon (see below)

Driving Posture

3. Make sure your arms have at least a little bend in them

+Your arms should not be fully extended where your elbows are locked, they should have at least a relaxed bend at the elbow

Neutral Driving Posture

Enjoy your summer road trip and remember to get out and stretch your legs and enjoy the sights, the viewpoints and the monuments.

Have a GREAT Summer and drive SAFELY!

Does Physiotherapy, Physical Therapy, Physio, PT, etc, confuse you just like everyone else!!!

We fall short of clarity even in our name…what do you call us…well Physio is easy here in Canada but if you are in the USA this means nothing. You have to say Physical Therapist to be slightly better understood as to what we do as a profession. But still fundamentally there is a lack of understanding as to what our role is in the healthcare system.

I hear all the time, I have _(fill in the blank)_ pain and I need a Massage or I have back or neck pain and I need to see my Chiropractor. Very rarely do I hear I have ____ pain and I need to see a Physio to get help.

So I ask myself why are people not thinking about Physiotherapy as being on their list of professionals that can help with____ pain.

Has the Physiotherapy Association failed to make the message clear as to how integral Physios are? Have Physios failed themselves in not being able to convey their wide array of scientifically proven abilities? Have other professions done a better job at marketing themselves as the “expert” at ____ pain? How do we change the conversation to include Physiotherapy as part of the list of “experts” at helping with____ pain?

The fundamental underlying problem is that we as a Physiotherapy profession have such a broad scope of skills and vast areas of practice. Most people, even Doctors, do not know exactly what we can do and how varied it is. Here is just a simple list of some of the areas we Physiotherapists can practice in:

Private Clinics – that is the clinic down the street that might also have Massage Therapists, Chiropractors, Kinesiologists, Acupuncturists, etc.

ALL Physio’s can:

  1. Assess and diagnose injuries
  2. Determine a proven treatment plan
  3. Improve Quality of Life
  4. Treat vertigo and balance
  5. Needle trigger points/’knots’ in muscles
  6. ‘Crack’/manipulate joints
  7. Use massage techniques
  8. Perform acupuncture
  9. Manage Sports Injuries
  10. Pre and post surgical rehab i.e. hip replacement, ACL repair
  11. Help with pelvic pain and loss of bowel/bladder control
  12. Go inside you mouth and help with jaw pain

And the list goes on for Private Practice skills.

Hospital Work (Public Practice Settings ie. paid for by Healthcare)

Physio’s work in:

  1. Spinal Cord Rehab
  2. Post Surgical Rehab
  3. Burns and wounds management and care
  4. Cardiorespiratory rehab
  5. Heart and Lung Rehab
  6. Emergency Rooms
  7. Community Outreach
  8. Stroke Rehab
  9. Pediatrics (like, Children’s Hospital or Queen Alexandra Centre)
  • Neonatal Intensive Care
  • Scoliosis
  • Cystic Fibrosis
  • Juvenile Arthritis

Again the list goes on and on as to the list of all the things that we can do. Our profession prides ourselves on continuing education and maintaining evidence-based practice which is why we are continually ‘morphing’ our profession and losing the clarity of exactly what it is we do.

Our fundamental principle that covers all areas of practice is that we are always physical movement ‘experts’. Meaning, whatever condition, injury, illness and/or surgery (pre or post) a patient is living with, we are the professional in charge of figuring out how to get you back to optimal movement.

In the Private Clinic setting Physiotherapists’ main responsibilities are taking information from the patient to determine a diagnosis, to create the problem list, to facilitate goal setting and to create & implement a plan to reach those goals.

It is very simple. You go to a Physio to find out what is going on and how to fix it.

So why is it so confusing?

For a couple reasons:

  1. Our Profession holds us to extremely high ethical standards and so it should! But with this comes some limitations that start to make our expertise unclear;
    1. For example;
      1. we are for the most part not able to call ourselves an ‘expert’ at anything!
      2. we are not allowed to use testimonials to convey our success
      3. we are not allowed to endorse a product that we passionately feel works
      4. we are not allowed to ask for reviews (Google, Facebook, etc.)

All of these are in place so that we do not mislead the public in anyway. But many of these factors make it difficult to lead the public in our direction as well. Therefore, our profession gets stuck in the Classic ‘Catch 22’. Our Profession morphs over time with changes in research, advances in medicine, stresses on the healthcare system to spread out the workload, etc. Our profession started out as Nurses and morphed into its own regulated, recognized healthcare profession, Physiotherapists.

If you look at the other successful professions in our industry you will notice that they have positioned themselves as ‘experts’ at something with little room for morphing.

  1. Chiropractors: experts at ‘cracking’ joints and fixing back and neck pain… but did you know that most Physiotherapists can do this as well? However we are not allowed to say we can ‘fix’ anything…but we can say that we can improve ____ pain or quality of life.
  2. Registered Massage Therapists: experts at massage which is easy to visualize and very clear…but did you know that Physiotherapists learn numerous soft tissue/massage techniques and most of us use them in our treatments every day?
  3. Kinesiologists: experts at exercise for rehabilitation…but a large portion of Physiotherapy training is in exercises for improving movement. This one most patients do seem to know, as they always ask for ‘Homework’ ie. exercises to do at home and we love to prescribe them!
  4. Acupuncturists: experts at using needles in traditional holistic ways to treat the whole body… but did you know that many Physiotherapist learn acupuncture and/or dry needling, too?
  5. Nurses: experts in day-to-day patient care, the status keeper of all the pieces of a patient’s current healthcare needs…but did you know that Physiotherapist have some overlap in this area as well with wound care, suture/staple removal, suctioning airways, etc.

So why would you go to anyone other than a Physiotherapist?

Firstly, why just access one professional when there is room for all the professions to have their niche technique and be successful at helping you reach your goals, ie. spread the love! We are all better off having each other to rely on for second opinions, a different approach and a focused expertise that a patient might need.

Secondly, there are times when you may need a longer session of treatment in just one of these areas and then you would go to see the ‘expert’ for that technique. For example, you might see your Massage Therapist for the soft tissue work on your painful calf from running, while you also see your Acupuncturist for stress management and calf inflammation control, while you see your Physio for run retraining techniques and hands on ankle work and your Kinesiologist for strength and conditioning exercises to return to running.

The big thing that Physiotherapists can do above all the other professionals and more inline with Doctors, as we are also Primary Healthcare professionals, is that we can give a Physiotherapy Diagnoses for physical conditions. For example we can say, “you have a Full ACL tear in your Right knee” or “you likely have a disc bulge at L4-5 causing your sciatica”. We have more time with you to explain the situation and promote the optimal recovery. We are also trained in knowing when to refer to the Doctor and what questions to ask in order to rule out ‘big scary things’ like cancer, heart conditions, diabetes, etc. that might be masquerading as back pain, arm pain, shortness of breath, etc.

We are the professionals to be trusted with knowing what you need, who you need, how we can help and when you need what. Call us the ‘Triage Professional’ that has the ability to take in all the information and integrate it into one cohesive treatment plan that will likely include the use of many of the professionals mentioned above and more.

Find a Physiotherapist in your community and ask them how they can help you reach your next goal or tackle that long standing ____ pain or movement limitation! Just remember we are the experts at nothing…because we aren’t allowed to say it, but we are the best generalists at improving all movement related goals!

Do you hurt after a day at your desk?

Computer Desk Ergonomics

Do you finish work at your desk sore every day? Take a look at your workstation! It’s easy to tell the reason for pain when it is associated with a broken bone or sprained ankle, but what about the less obvious causes of the aches and pains we all get when we sit behind a desk all day? Spending time in the gym or working out outside can go far to keeping you healthy and fit, but 30+ minutes of exercise each day is no match for 6+ hours of being seated while we work. The advent of the sit-stand workstation has been helpful in promoting some movement, but standing still is also considered a static posture, which can lead to significant muscle strain and soreness.

So what can you do about your ergonomics?

First, take a look at your desk: Is your computer screen directly in front or is it off to the side? What about the equipment you use most often – pens, post-its, phone, are the all within easy reach? Ideally, you want whatever you are working on to be directly in front of you and at eye level when you are sitting up straight. If you have to twist to see your screen, lunge to reach your phone and other equipment, then you are putting additional pressure on your body.  WorkSafe BC offers some helpful hints for how to set up your workstation here: https://www.worksafebc.com/en/resources/health-safety/books-guides/how-to-make-your-computer-workstation-fit-you?lang=en

In addition to adjusting your workstation to fit you as well as possible, there are a few ideas to keep in mind throughout your day:

  1. Take frequent micro-breaks: Not long, just enough time to move, stretch, have a sip of water, and shake out some of the kinks.
  2. Posture posture posture: Remember to sit and stand straight. This helps to relieve pressure on your neck and shoulders and to avoid the dreaded “desk hunch”.
  3. Take your scheduled breaks on time, and try to incorporate some movement. Resist the temptation to eat at your desk and work through your breaks, and take a quick walk or just step outside and get some fresh air.

If you have tried everything on your own to make sure that your workstation is fit for your body and still find that you are uncomfortable throughout the day, it might be worth getting an ergonomic assessment of your office to see if there are additional tweaks that could be made to improve your working conditions.

Is Surgery my BEST option for Knee OsteoArthritis?

A recently published article in a peer reviewed journal, discusses medical exercise as an alternate option to surgery for a degenerative meniscal tear in the knee, otherwise known as Arthritis. Now they are not just talking about doing any exercise but working with a trained healthcare professional (ie. Physiotherapist, Kinesiologist, Chiropractor or Athletic Therapist) supervising specific exercises for rehabilitation. However, we do already know that staying fit and active will always improve your health and reduce your risk for arthritis.

So they took a group of 17 patients who had degenerative meniscal tears and they either underwent a 3 months medically supervised exercise training program or an arthroscopic partial meniscectomy surgery. They measured their pain and quality of life at time points up to 1 year after the enrolment. Both groups showed similar reductions in the pain and increases in function and quality of life. However, the group who participated in the exercise program showed significantly greater improvements in anxiety and depression.

So if you want to avoid surgery for your knee arthritis then ascribe to the old adage “Motion is Lotion…” with supervision. Try our GLA:D Supervised Exercise Program for Knee and Hip pain and stiffness. Register for a FREE education class today. If you have questions about the exercises you currently do or want to start exercising for prevention, function and pain reduction then contact a healthcare professional in your area to start medically supervised exercise today. 

3 Tips for Managing Knee Arthritis

  • Weight Lose: lose 5 lb if you are over weight, it can reduce the load on your joint by 2.2 times
  • Exercise: find a safe exercise you enjoy and do it 3-5 days a week
  • Prolonged Sitting: if you have been sitting in a restaurant or at a movie, move your knee before you try to stand on it

Most of all get out and enjoy life even with knee arthritis!

Cortisone Shot…is it worth the risk?

Cortisone Shot or Not?

Corticosteroid shots have been used for many decades now for treating pain in many joints. Corticosteroid is known to provide short-term symptomatic relief in some patients for knee arthritis, inflammation, hip bursitis, shoulder pain, etc. There is a lot of evidence that supports the short term relief and improved quality of life for 6-9months. But the long-term evidence shows some potential adverse effect of repeated corticosteroid injections, such as, disrupted collagen repair and increased risk of tendon rupture.

But getting back to the knee there has not been much high level research looking at the long-term effect of repeated corticosteroid shots and its effect on the collagen cartilage in the knee. In May, there was an article published that reported on the long-term repeated exposure to multiple corticosteroid shots over a two year period. There was two groups of participants who were all diagnosed with similar levels of knee osteoarthritis. One group was given a corticosteroid injection every 12 weeks and the other group was given a saline injection without corticosteroids every 12 weeks.  Both groups had no idea to which group they were assigned. This type of research design results in the highest quality of evidence also known as a Randomized Controlled Trial. 

The results of this trial indicated that corticosteroid treatments led to a greater loss of cartilage at 2 years compared to the saline group, with no significant differences in pain outcomes between groups.

There were some limitations to this study. There were only 140 participants which was not a large enough group to make clinical guideline changes. Also the treatment providers may not have be adequately blinded to the type of injection they were giving, which could bias the treatment effect.

However, there is significant high quality evidence coming out of Denmark on the effect of Hip and Knee osteoarthritis management using Physiotherapist led group-based exercise and education.

How to chose the best treatment?

1. Ask your clinician about the short and long-term risks and benefits

2. Ask what it will feel like

3. Ask about alternate treatment options

4. Ask how long the effect will last

Cupping

Cupping therapy is an ancient form of alternative medicine in which a Physiotherapist or Registered Massage Therapist puts special cups on your skin for a few minutes to create suction. People get it for many purposes, including to help with pain, inflammation, blood flow, relaxation and well-being, and as a type of deep-tissue massage. Cupping can leave behind very dark skin bruising but this is not typical bruising as it is not painful. You might remember seeing the post-cupping bruising on Michael Phelps during the Rio 2016 Olympics. Physiotherapist typically use plastic or silicone cups that suction with manually applied pressure. Alternative medicine therapist tend to use glass cups with the help of fire to create the suction. Clinically, I have used cupping on chronically dysfunctional scar tissue to reduce the stickiness between the layers of skin, soft tissue and muscles. If a patient is experiencing persistent pain that seems soft tissue in origin I find that cupping can be great at reducing the pain response.