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!

Doctor….DRE

When you are over 40 and male, DRE no longer represents your favourite Rap artist of your teenage years. DRE stands for Digital Rectal Exam which is a major barrier for men getting their regular physical exams. Many men just don’t want to go there, well actually they just don’t want the doctor going there and fair enough but having a DRE has been used clinically to help doctors look at your full prostate risk profile. The DRE is just a piece of the examination process and a full history is needed to make the best recommendations. Consult your doctor to make sure you are doing all you can to reduce your risk. UPDATED: We have removed the recommendation to include the PSA test with the DRE to meet the current best practice in Canada, based on the Canadian Task Force on Preventive Health Care

In Canada, On average, 58 Canadian men are diagnosed with prostate cancer every day; however, only 11 men die daily from this condition. That is why early detection is key to reducing the mortality rate and increasing the survival rate. We would all ignore below-the-belt issues if we could, however we need to continue talking about these concerns to keep the conversation on early detection going.

Men diagnosed with prostate cancer have many treatment options with today’s advanced medical practices.

Treatment Options:

  1. Multiple Surgery Options
  2. Radiation Therapy
  3. Hormone Therapy
  4. Chemotherapy
  5. High-intensity focused ultrasound

From some of these treatment options there are possible side effects. One of which is urinary incontinence (peeing yourself) following a below-the-belt surgery. However, this can be very treatable with pelvic health therapy by a qualified Physiotherapist.

In 2015 Dr. Patel, a Urologist, published results in the European Urology journal, concluding that “preoperative pelvic floor muscle exercises may help early continence recovery, but may not influence long-term incontinence rates beyond six months”. Essentially, pelvic health therapy can help you get back the control sooner than not doing it.

Keep your buddies accountable and make sure you get the necessary tests done and don’t ignore any below-the-belt concerns.

Low Back Pain EXPLAINED

Low back pain is a symptom NOT a disease! ​There are Acute and Persistent (Chronic) episodes of Low Back Pain. And sometimes there are acute episodes that happen on top of already persistent low back pain (ie. increased pain for a short period of time and then the pain goes back down to normal levels). What is the MOST likely cause of my pain?

  • 90% of cases have NO specific structure at fault (ie. it could be any or no structure causing the pain) 1​. This is called Non-specific Low Back Pain, I know this is an unsatisfying diagnosis! 

Patients and back pain sufferers have the most trouble with this diagnosis. We as patients are trained to want to know the faulty structure because then we think we could fix it better. What is the LEAST likely cause of my  low back pain?

  • compression fracture 4% 
  • spinal stenosis 3% 
  • organ disease 2% 
  • tumour or cancer 0.7% 
  • infection 0.01%  2

But potentially more accurately likely fewer than 1% of Acute Low Back pain cases have a specific cause 3. Should I get an X-ray or Image of my low back?

  • NO, unless your primary health care team suspects major risk factors (ie. cancer, spinal infection or cauda equina syndrome (loss in control of bowel or bladder) or a disease process that would be managed differently then Non-specific Low Back Pain
    • WHY?
      • Because the imaging guidelines created from extensive research reviewing the harmful effects of imaging discourage imaging unless there are any of the high risk factors listed above.
        • Harmful Effects of Imaging
          • radiation exposure
          • normal results interpreted as pathology 
          • costly and time consuming

​Imaging does not improve clinical outcomes, meaning they do not positively change your pain experience or treatment plan.* 4 So what can I do to change my pain without meds?

  • Multimodal/Multidisciplinary Treatment Package
    • Manual Therapy (any of Physio, Chiro, Osteopath)
    • Massage (better for Acute than Persistent Back Pain)
    • Cognitive Behavioural Therapy (better in short term)
  • Exercise (Kinesiologist guided, pilates, yoga, tai chi, motor control)
  • Return to Work Programmes
  • Acupuncture and Dry Needling (better in short term)

What should I not do to change my low back pain? 

  • Injections
  • Radiofrequency Neurotomy (severing the nerve to the spinal level)
  • ***Epidural Steroid injection (limited effect for small group of patients only)
  • Prolotherapy (injection of irritating solution, usually glucose based)
  • Antibiotic Prescription
  • Spinal Cord Stimulator or intrathecal pump (no research results)
  • Surgery Consult
    • most often surgery is the last resort for Persistent Low Back Pain but commonly the results are no better than conservative outcomes as mentioned in the above Do’s for Back Pain

All of the above Do’s and Don’t were summarized from the 2016 UK National Institute of Health and Care Excellence (NICE) draft guidelines 5, published Cochrane reviews 6-12 and American College of Physicians and the American Pain Society (ACP/APS) 13. What is my Prognosis for Recovery? The 42-72% of patient who undergo some of the above listed Do’s for managing and treating low back pain will have a FULL recovery by 12 months 14-15.

Get on your PATH TO RECOVERY today and seek out a well rounded approach to managing and treating of your low back pain. Above all, make sure EXERCISE is part of the plan.

REFERENCES Thank you to Chris Maher, Martin Underwood and Rachelle Buchbinder for summarizing a large amount of research into one comprehensive article in the Lancet on Non-specific Low Back Pain; October 10, 2016. 1. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006; 332:1430-34 2. Deyo RA, Weinstein JN. Low Back Pain. N Engl J Med 2001; 344:363-70 3. Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary car settings with acute low back pain Arthritis Rheum 2009; 60: 3072-80 4. Chou R, Fu R, Carrino JA Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet 2009; 373: 463-72 5. National Institute of Health and Care Excellence. Non-specific Low back pain and sciatica: management. NICE guideline: short version. March 2016. 6. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev 2005; 9: CD000335 7. Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M. Massage for low-back pain. Cochrane Database Syst Rev 2015; 9: CD001929 8. Furlan AD, van Turder MW, Cherkin DC, et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev 2005; 1: CD0001351 9. Henschke N, Ostelo RW, van Turder MW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev 2010; 7: CD002014 10. Kamper SJ, Apeldoorn AT, Chiarotto A, Et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev 2014; 9: CD000963 11. Maas T, Ostelo RW, Niemisto L, et al. Radiofrequency denervation for chronic low back pain. Cochrane Database Syst Rev 2015; 10: CD008572 12. Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low back pain. Cochrane Database Syst Rev 2011; 2: CD008112 13. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain : a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147: 478-91 14. Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ 2008; 337: a171 15. Costa Lda C, Maher CG, McAuley JH, et al. Prognosis for patients with chronic low back pain: inception cohort study. BMJ 2009; 339: b3829.

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