Are you Treating the Problem or The Result?  Shoulder “problems” are incredibly common amongst the athlete and active adult population that we see. As therapists, we see traditional diagnoses such as shoulder impingement, tendonitis, and rotator cuff injuries daily. Traditionally, these common issues are blamed on weak rotator cuff muscles, scapular winging, imbalance of muscle activity, etc. One major thing to understand about these diagnoses is that they are not the actual problem…they are a result. A result of deeper-rooted movement habits and mechanics that usually go unaddressed in the traditional rehab process. Typical solutions for these “results” are equally short- sighted. Frequently these solutions, which include stretching, rotator cuff strengthening, and general strength training, miss the mark as far as resolving pain. Why? Because they are addressing symptoms and not the thing that has caused the faulty mechanics, the need to over- use certain musculature or orient musculature in a disadvantageous position. To truly understand what the biggest missing piece is in resolving these common shoulder issues we first need to understand how the shoulder behaves.  A Quick Anatomy Lesson of the Shoulder Complex  The shoulder complex is made up of 4 major components: The glenohumeral joint (ball and socket), the scapula (shoulder blade), the sternum and clavicle, and the rib cage. Shoulder movement in any direction requires rotation of the humeral head (ball) within the glenoid (socket).  Because the shoulder has so much freedom of movement, stability of the joint needs to be ensured. That is why every shoulder movement is accompanied by scapular movement. Since the actual socket of the shoulder joint is on the scapula, its movement is vital in maintaining the humeral head centered within the glenoid during shoulder movement. When the humeral head doesn’t stay centered within the socket is when things like shoulder impingement occur, proximal biceps tendonitis rotator cuff injuries occur For a shoulder joint to move well, you need a scapula that can move in congruence with the humerus. What allows the scapula to move? The scapula has a slight curvature to its shape. The scapula sits on a rib cage that has a roundness to it due to normal thoracic kyphosis or curvature of the upper back. The roundness of the upper rib cage and the curvature of the scapula allow the two to maintain congruency with each and allows the scapula to rotate about its normal motion in support of the humeral head. The position of the rib cage and its ability to expand appropriately to support the scapula is essential for normal scapular movement that allows for normal shoulder movement without compensation.  Rib Cage Position and Expansion  The rib cage, under normal circumstances should be able to expand circumferentially (360 degrees) during normal breathing. During every inhale, the lower ribs should move outward in what’s called bucket handle movement while the upper ribs and sternum move up and out in a pump handle movement. The backside of the rib cage should reflect a similar movement, especially in the upper rib cage. It is when the rib cage lacks these normal, requite movements that things like scapular position and as a direct result, shoulder mobility, are negatively affected.  For example, when the back side of the upper rib cage becomes too restricted in its movement or flattened due to chronic muscular tension in the upper back you will see a limitation in scapular movement. A curved scapula on a flat surface does not achieve the same movement and rotational capabilities as one that is on rounded, congruent surface. Remember, without scapular movement the shoulder joint either cannot access normal movement or will have to move through compensatory mechanics to get there. Chronically moving in to ranges that you don’t have access to or compensating for movement limitations is exactly what leads to frequent pressure and tension in the same area i.e., shoulder impingement, biceps tendonitis, wear and tear of rotator cuff tendons, etc. How does one lose normal rib cage mechanics? This is easiest to see in an activity like resistance training. Most movements in the gym emphasize “shoulder blades back and down” for “stability.” No matter whether you’re pushing or pulling, back squatting or deadlifting, the rib cage and scapular position are relatively the same. A similar effect occurs from the ill-fitted advice to pull your shoulder blades back and down for “good posture.” Chronically spending time in a scapular retracted position will both prevent normal scapular movement and flatten the upper rib cage resulting in the need to compensate to achieve the desired shoulder movements.  The Solution To truly resolve shoulder pain, you must start at the source. Yes, there are many other factors involved in shoulder pain; rotator cuff strength, dynamic stability, local tissue inflammation, etc. Regardless of these issues you must understand and resolve what lead to these issues in the first place, otherwise you are just treating a symptom. If your goal is to improve the mechanics and motion at the shoulder joint, you need to ensure proper scapular movement. To have normal scapular movement requires a rib cage that is positioned properly and can expand in all directions to provide a foundation and support for the scapula. Once you have established a proper foundation, all factors mentioned before can be addressed with much greater success.  Below are 2 examples of drills to implement into your program to improve ribcage expansion: Seated Zercher Breathing Video [embed]https://www.youtube.com/watch?v=3CtDqIZnC_U[/embed] Seated Back Expansion Video  [embed]https://www.youtube.com/watch?v=24K6f7OMDXE[/embed]

Carpal tunnel syndrome is a collection of symptoms that most commonly appear in the thumb, index and middle fingers on the palm side of the hand.  The hallmark symptom of this is aching or a loss of sensation in those three fingers specifically.  Typically, these symptoms are arising because the median nerve is experiencing a prolonged compression where it crosses into the hand at the “carpal tunnel” – or a small loop of tendon overlapping several muscles that run into the hand and the median nerve at a very small space near the bones of your wrist. (Figure 1).  [caption id="" align="aligncenter" width="600"] Figure 1: Anatomy of the carpal tunnel region and the median nerve. The nerve in the middle that runs to the thumb and middle finger is the median nerve. Source: https://qph.fs.quoracdn.net/main-qimg-2effc0be8c4ff02f065339aebda08596-c[/caption] The most common courses of treatment that I see recommended are prolonged static stretches of the muscles on the front of the wrist and forearm, active range of motion exercises for the wrist and hand in all motions, stretching of the thumb muscles, and tendon and nerve glide activities.  What all these activities have in common is that they are being prescribed with the goal of reducing the compression on the median nerve. Nerves love movement, blood flow, and space around them. The intent of what needs to happen during treatment is spot on – it’s why the surgical option to try to alleviate the symptoms is to cut that white-colored tendon you see running between the thumb and pinky muscles, to make more space over the median nerve.  While there is nothing wrong with these activities, not all interventions have the same effect. If we are trying to create room around the carpal tunnel, we need to appreciate the position of the hand versus the wrist, because many of the muscles that cross the carpal tunnel cross or directly attach to these bones.  Stretching muscles statically mostly just increases the tolerance of a muscle to being lengthened, and does not do much to address the qualities or behavior of muscles or tendons from what the latest research on stretching tells us (PubMed ID# 28801950). Plus, prolonged tension put onto a nerve that is already compressed can be like stretching an already taut rubber band more – it’s not going to help to reduce the tension in that structure. So, instead of just focusing on a muscle or muscles that are “tight”, let’s instead focus on helping the bones of the hand and wrist be able to get into a position to “unstretch” the rubber band and help give that nerve more space around it to help it be able to move more freely.  The picture below shows an example of a thumb that is internally rotated (the yellow area) relative to the position of the wrist. The blue arrow shows a thumb that is better able to externally rotate relative to the wrist than the yellow arrow. (Figure 2) [caption id="" align="aligncenter" width="960"] Figure 2: An example of differing thumb and wrist orientations. Source: https://i2.wp.com/plasticsurgerykey.com/wp-content/uploads/2020/06/10-1055-b-002-98003_c049_f001.jpg?w=960[/caption] Can you see how stretching the muscles of the yellow hand might have a completely different result than the blue hand?  The same solution applied to these two different hands does not yield the same outcome.  In the next part of this discussion, we’re going to talk about how to tackle getting a more effective solution to create space and movement around the median nerve and possibly eliminate symptoms in the carpal tunnel that are tailored to the specific presentation of the yellow hand. 

If you were to assess how great a pitcher in baseball truly is, you might find yourself looking at a lot of statistics…specifically the ERA or Earned Run Average. With the goal to strike out everyone who dares to step into the box against them, they must not only possess a superior amount of talent and skills, but an ability to demonstrate a large amount of power. Multiplied by about 100…pitches that is. Across sports, only a small number of athletes have to exert the same level of power quite as frequently as a baseball pitcher. Now, if specialized at a young age to be a pitcher and across several teams per year, this amount of power, volume and overall stress placed on the elbow and its surrounding structures can not only take a toll, but potentially wreak havoc on the players future…at least that is what we thought.  Typically beginning as a low level condition, such as Little League Elbow (a condition that is simply a byproduct of insufficient rest periods between pitching outings) or Acute bursitis (inflammation of localized fat pad), a baseball player’s elbow joint has to be able to absorb a tremendous amount of force and repetitive stress across seasons. This type of overhead throwing irritates not only surrounding tendons and ligaments that are responsible for support, but predisposes pitchers to more serious issues, such as an Ulnar Collateral ligament (UCL) injury.  As a result of increasingly large prevalence in young players over the last few years, this once seen injury in mostly adults has prompted many governing bodies to change the rules. The American Sports Medicine Institute (ASMI), USA Baseball, Little League Baseball, Major League Baseball organizations to establish Pitch Count Guidelines.  With many efforts being made to protect the new generations of baseball, higher level players continue to remain at risk.  The Ulnar Collateral ligament (UCL) injury The ulnar collateral ligament (UCL) has been amongst the most commonly injured ligament in repetitive throwing / overhead athletes. In order to accommodate the large volume of power that is created to throw a baseball 60 feet, the ligaments stretch and elongate until it can no longer bear the capacity to maintain the elbow’s integrity. Like any ligamentous injury they can range in severity and true structural damage/complexity. They range from a minor sprain with light damage and inflammation to a complete tear.  UCL Symptoms Include:  Pain with throwing or inside of the elbow Instability  Decreased strength or power in throwing Increased sensitivity around the ulnar nerve “funny bone” causing numbness and tingling in the ring and pinky finger Diagnosis and Treatment A UCL injury is diagnosed following the results and clinical presentation together after a physical examination, in conjunction with diagnostic imaging, such as X-ray & MRI. Indications on next best step are contingent upon severity of structural damage, healing time, rehabilitative exercises, inflammation management, further evaluation may be indicated. Further assessment with a physical therapist or athletic trainer may be warranted to determine if throwing mechanics, inefficient body positioning, compensatory techniques/strategies, and sequencing caused excessive stress on the elbow. Oftentimes if a pitcher does not have full access to shoulder motions required to pitch effectively, the torque to generate the power required needs to come from another place…I bet you know where that is! INSIDE THE ELBOW!  Yes, inside the elbow. Now, normal pitching mechanics on average require 300 N (67 lbs) of torque along the inside elbow… normal. Can you imagine the level of stress taken on by the elbow due to abnormal pitching mechanics multiplied by 100 pitches per game over the course of a full season? Tommy John and His Influence Named after former LA Dodgers Pitcher, Tommy John, the surgery has dramatically impacted baseball and throwing athletes. Used as a last resort now for UCL injuries, outcome measures have drastically increased since this surgery gained traction in the baseball community. TJ Surgery is a surgical graft procedure where the injured UCL is replaced by a tendon graft taken from the forearm or hamstring tendons. The procedure is followed by an intense rehab program that consists of several phases on average lasting 6 to 12 months.  What was once a career ending injury is now a symbol of hope for many overhead athletes looking to continue the sport they love! Today the UCL Reconstruction is a commonly performed procedure and emphasized in rehabilitation education programs.  If you have any questions regarding this topic please consult your primary care physician or stop by Next Level Physical Therapy and we will gladly speak with you about it.