Carpal tunnel syndrome is a collection of symptoms that most commonly appear in the thumb, index finger, and middle finger on the palm side of the hand. The hallmark symptom is aching, tingling, or a loss of sensation in those three fingers specifically. These symptoms most often occur because the median nerve is experiencing prolonged compression as it passes into the hand through the carpal tunnel. The carpal tunnel is a narrow passageway formed by bones and connective tissue near the wrist that also contains several tendons and muscles, along with the median nerve. Because this space is small, even subtle changes in position or tissue behavior can increase pressure on the nerve. (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 treatments I see recommended include prolonged static stretching of the muscles on the front of the wrist and forearm, active range of motion exercises for the wrist and hand in all directions, stretching of the thumb muscles, and tendon or nerve gliding activities. What all of these interventions have in common is their shared goal of reducing compression on the median nerve. Nerves thrive on movement, blood flow, and adequate space. The intent behind these treatments is sound, which is why the surgical option for severe cases involves cutting the connective tissue that runs across the carpal tunnel to create more room for the nerve. While there is nothing inherently wrong with these approaches, not all interventions produce the same effect. If the goal is to create space around the carpal tunnel, it is critical to consider the relationship between the position of the hand and the wrist. Many of the muscles and tendons that influence carpal tunnel pressure either cross through the tunnel or attach directly to the bones of the hand and wrist. Static stretching primarily increases a muscle’s tolerance to being lengthened. According to current research, it does very little to change how muscles or tendons behave or function in daily movement (PubMed ID# 28801950). In addition, applying prolonged tension to a nerve that is already compressed can be similar to stretching an already tight rubber band. Increasing tension does not reduce stress on the structure and may actually worsen symptoms. Rather than focusing solely on muscles that are labeled as tight, it is often more effective to focus on positioning the bones of the hand and wrist in a way that reduces tension on the nerve. This approach helps “unstretch” the rubber band and gives the median nerve more room to move freely. The image below shows an example of a thumb that is internally rotated relative to the wrist, highlighted in yellow. The blue arrow shows a thumb that is better able to externally rotate relative to the wrist. (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 produce a completely different result than stretching the blue hand? Applying the same solution to two different presentations does not lead to the same outcome. In the next part of this discussion, we will explore how to create a more effective strategy to improve space and movement around the median nerve. This approach may help reduce or eliminate carpal tunnel symptoms by addressing the specific presentation shown in 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, most notably ERA or earned run average. With the goal of striking out every batter who steps into the box, pitchers must not only possess elite skill and talent, but also the ability to generate an incredible amount of power. That power is repeated roughly one hundred times per game. Across sports, very few athletes are required to produce such high levels of force as frequently as baseball pitchers. When athletes specialize as pitchers at a young age and play across multiple teams each year, the volume of throwing and cumulative stress placed on the elbow and surrounding structures can take a serious toll. For a long time, this was believed to threaten a player’s future in the sport. These issues often begin as lower level conditions such as Little League Elbow, which is typically the result of inadequate rest between pitching outings, or acute bursitis, which involves inflammation of a localized fat pad. Over time, the elbow must repeatedly absorb tremendous force across seasons. This repetitive overhead throwing stresses the tendons and ligaments responsible for elbow stability and increases the risk of more serious injuries, including damage to the ulnar collateral ligament. As UCL injuries have become increasingly common in younger athletes over the past several years, organizations such as the American Sports Medicine Institute, USA Baseball, Little League Baseball, and Major League Baseball have implemented pitch count guidelines in an effort to protect developing players. Despite these efforts, higher level athletes continue to face significant risk. The Ulnar Collateral ligament (UCL) injury The ulnar collateral ligament is one of the most commonly injured ligaments in repetitive overhead and throwing athletes. To tolerate the high forces required to throw a baseball sixty feet, the ligament gradually stretches and elongates. Eventually, it may no longer be able to maintain the structural integrity of the elbow. Like most ligament injuries, UCL damage exists on a spectrum. Injuries can range from a mild sprain with inflammation to a complete tear that compromises elbow stability. 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 based on a combination of clinical presentation, physical examination findings, and diagnostic imaging such as X-ray or MRI. The next steps depend on the severity of the injury, healing potential, inflammation levels, and response to rehabilitation. Further assessment by a physical therapist or athletic trainer is often necessary to determine whether throwing mechanics, body positioning, sequencing, or compensatory strategies are placing excessive stress on the elbow. In many cases, limitations in shoulder mobility prevent a pitcher from generating force efficiently. When this happens, the body looks for power elsewhere. That power often comes from the inside of the elbow. Normal pitching mechanics already place approximately 300 newtons, or about 67 pounds, of torque on the inside of the elbow. Now imagine how much additional stress accumulates when mechanics are inefficient and that load is repeated one hundred pitches per game over the course of an entire season. Tommy John and His Influence Named after former Los Angeles Dodgers pitcher Tommy John, this surgical procedure has dramatically changed the outlook for throwing athletes. Once considered a career ending injury, UCL reconstruction is now a well established option for athletes who fail conservative treatment. Tommy John surgery involves replacing the damaged UCL with a tendon graft, often taken from the forearm or hamstring. This is followed by an extensive rehabilitation process that progresses through multiple phases and typically lasts between six and twelve months. What was once viewed as the end of a pitching career is now often seen as a pathway back to competitive play. Today, UCL reconstruction is commonly performed and heavily emphasized in rehabilitation and sports medicine education. If you have questions about UCL injuries, Tommy John surgery, or elbow pain related to throwing, consult your primary care physician or visit Next Level Physical Therapy. We are always happy to discuss your concerns and help guide you in the right direction.

The foremost principle that guides rehabilitation is the SAID Principle, or Specific Adaptations to Imposed Demands. Simply put, this principle of physiology tells us that the body adapts to the specific demands placed upon it. Perform enough aerobic exercise and your heart adapts by increasing the size of the muscles in the left ventricle. This allows more blood to be pumped with each contraction, lowering resting heart rate over time. Similar adaptations occur within the nervous and hormonal systems and often lead to decreases in resting blood pressure as well.¹ The tendons of sprinters become increasingly stiff as they train to run faster. This is a positive adaptation. Think about the last time you struggled to change the roll of bathroom tissue because the spring was stiff and kept snapping back quickly. A stiffer spring, much like a stiffer tendon, releases more energy when stretched and recoils, helping the sprinter move faster and more efficiently. When an injury occurs to a muscle, tendon, or another joint structure, it is usually because that tissue was exposed to a level of stress that exceeded its ability to adapt positively. When you trip and roll your ankle in the classic position shown below in Image 1, the ligaments and muscles on the outside of the ankle are injured because they were loaded too quickly and with too much force for what they were prepared to handle. Meanwhile, there are well documented examples of martial artists being able to break stone with their shins without injury because they have spent years gradually adapting their bodies to those compressive forces. [caption id="" align="aligncenter" width="652"] Image 1: Despite this being Klay Thompson of the Golden State Warriors, my left ankle was in this same exact situation about a year ago. Source: https://i2.wp.com/b-reddy.org/wp-content/uploads/2016/07/klay-thompson-right-ankle-sprain.jpg?ssl=1[/caption] How does this relate to a shoulder injury? If we want to restore shoulder function and allow the joint to tolerate increasing physical stress without negative adaptations like pain or injury, we need to apply the Goldilocks Principle of rehabilitation shown in Image 2. The stress must be just right. Too little will not create change, and too much will drive setbacks. The chart below is a helpful way to visualize this concept when restoring strength and range of motion following injury. Image 2:  Volume vs intensity threshold for gaining an adaptation. (Joel Jamieson’s “Ultimate MMA Conditioning”)  Resistance tubing, often referred to by the commercial name Theraband, is one of the most common tools people associate with physical therapy. Despite the title of this article, I am not against the use of resistance bands. For individuals in the early stages of shoulder rehabilitation, tubing can be extremely useful. It provides a low level of resistance that may be enough to rebuild initial strength or improve control of the arm through a safe range of motion. Bands can also help provide external feedback so you can better feel your shoulder moving into different positions, which can be valuable when restoring range of motion. However, if the goal is to build a shoulder that can produce and absorb meaningful force, bands alone are often not enough. At some point, greater resistance is needed to apply the appropriate combination of volume and intensity required for long term strength gains.   Sidelying Kettlebell Arm Bar Exercises like the kettlebell or dumbbell arm bar are an excellent entry point for retraining shoulder rotation with heavier loads. They also help retrain coordinated movement of the shoulder blade, allowing smoother and more controlled motion of the arm. Hooklying Dumbbell Pullover The hooklying dumbbell pullover is another effective way to improve overhead range of motion while building strength through a large arc of movement. This exercise is commonly used to help clients regain overhead motion without compensating through excessive lower back arching. It also builds confidence when holding weight overhead. Staggered Stance Landmine Press Landmine pressing is a highly effective way to load the muscles around the shoulder with progressively heavier resistance. This variation also allows easy modification to train coordination between ribcage rotation and shoulder movement, which is critical for many athletic and daily activities. If you are returning from a shoulder injury, it is important to understand the purpose behind each exercise you choose. Not all rehabilitation needs to look like bands and two pound weights. Your program should be challenging enough to prepare your shoulder for the real world demands you place on it. Make sure the time you invest in rehabilitation is producing the adaptations your shoulder actually needs. References Farrell C, Turgeon DR. Normal Versus Chronic Adaptations To Aerobic Exercise. [Updated 2021 Jul 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572066/

Are you Treating the Problem or The Result?  Shoulder problems are incredibly common among the athletes and active adults we see. As therapists, we regularly encounter diagnoses such as shoulder impingement, tendonitis, and rotator cuff injuries. These conditions are often blamed on weak rotator cuff muscles, scapular winging, or muscle imbalances. One major thing to understand about these diagnoses is that they are not the actual problem. They are the result. They are the result of deeper rooted movement habits and mechanics that often go unaddressed in traditional rehabilitation. Common solutions for these issues are often just as short sighted. Stretching, rotator cuff strengthening, and general strength training are frequently prescribed, yet they often miss the mark when it comes to truly resolving pain. Why? Because they address symptoms rather than the cause of the faulty mechanics, overuse of certain muscles, or positioning muscles in disadvantaged positions. To understand the biggest missing piece in resolving shoulder pain, we first need to understand how the shoulder actually works. A Quick Anatomy Lesson of the Shoulder Complex  The shoulder complex is made up of four major components: the glenohumeral joint, which is the ball and socket, the scapula or shoulder blade, the sternum and clavicle, and the rib cage. Shoulder movement in any direction requires rotation of the humeral head within the glenoid socket. Because the shoulder has so much freedom of movement, stability of the joint must be maintained. This is why every shoulder movement is accompanied by scapular movement. Since the socket of the shoulder joint is part of the scapula, its motion is essential for keeping the humeral head centered within the socket during movement. When the humeral head does not stay centered, issues such as shoulder impingement, proximal biceps tendonitis, and rotator cuff injuries can occur. For the shoulder to move well, the scapula must move in coordination with the humerus. The scapula has a natural curvature and sits on a rib cage that also has curvature due to normal thoracic spine shape. The rounded rib cage and curved scapula allow these structures to stay congruent and permit normal scapular rotation in support of shoulder movement. The position of the rib cage and its ability to expand properly to support the scapula is essential for normal shoulder motion without compensation. Rib Cage Position and Expansion  Under normal circumstances, the rib cage should be able to expand in all directions during breathing. With each inhale, the lower ribs should move outward in what is known as bucket handle motion, while the upper ribs and sternum move up and outward in a pump handle motion. The back side of the rib cage should demonstrate similar movement, particularly in the upper ribs. When the rib cage lacks these normal movements, scapular position and shoulder mobility are negatively affected. For example, when the back side of the upper rib cage becomes restricted or flattened due to chronic tension in the upper back, scapular movement becomes limited. A curved scapula resting on a flat surface cannot move or rotate the same way it would on a rounded, congruent rib cage. Without proper scapular movement, the shoulder either loses access to normal motion or must rely on compensatory mechanics. Repeatedly moving into ranges you do not truly have or compensating for restrictions is exactly what leads to repeated stress in the same tissues. This often shows up as shoulder impingement, biceps tendonitis, or gradual wear of the rotator cuff tendons. How Rib Cage Mechanics Are Lost Loss of normal rib cage mechanics is commonly seen in resistance training. Many gym movements emphasize pulling the shoulder blades back and down for stability. Whether pushing, pulling, squatting, or deadlifting, rib cage and scapular position often remain the same. A similar issue comes from the common advice to pull the shoulders back and down for good posture. Spending excessive time in a retracted scapular position limits normal scapular motion and flattens the upper rib cage. This forces the shoulder to compensate to achieve desired movements. The Solution To truly resolve shoulder pain, you must start at the source. While factors such as rotator cuff strength, dynamic stability, and local tissue irritation matter, they should not be addressed in isolation. If you do not resolve what led to these issues in the first place, you are simply treating symptoms. To improve shoulder joint mechanics and motion, proper scapular movement must be restored. Normal scapular movement depends on a rib cage that is positioned correctly and able to expand in all directions to provide a stable foundation. Once this foundation is in place, other components of shoulder rehabilitation 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]

Shoulder pain is a common issue for many people, from high level athletes to weekend warriors and everyone in between. Despite how common it is, shoulder pain can come from many different causes. Some of the most frequent contributors include overuse conditions, which are often seen in athletes such as baseball pitchers, degenerative changes from gradual wear and tear over time, or acute injuries like falling on an outstretched arm. Regardless of the cause, one of the most effective ways to reduce shoulder pain and allow healing to begin is by changing the position and posture of the body. Improving posture can help create more space in the shoulder joint, reducing stress on irritated tissues and allowing the area to calm down. If you are currently dealing with shoulder pain, I always recommend being evaluated by a licensed professional so you can receive a customized plan tailored to your specific needs. In the meantime, here are my top 5 exercises for instant shoulder pain relief. These are not meant to be a long-term solution, but they can help you feel better so you can get through your day and your workouts without pain holding you back. 1. Banded Shoulder Distraction 3 sets x 30 sec hold [embed]https://www.youtube.com/watch?v=foTgEqbKGUQ[/embed] 3 sets x 30 second hold Grab hold of a resistance band, straighten your arm, and bend forward slightly at the hips. Try to relax into the position and allow the band to gently pull your shoulder away from the joint. This creates a traction force that helps open up space in the shoulder joint and reduce pressure on irritated or impinged tissues. You should also feel a strong stretch through the lat muscles, which is an area many gym-goers tend to have tightness. 2. Banded Bully Stretch [embed]https://www.youtube.com/watch?v=7JHZwYrSDoY[/embed] 3 sets x 30 second hold Hang a 1 to 1.5 inch resistance band from a squat rack, pull-up bar, or another sturdy overhead surface. Place the band around the upper part of your humerus as close as possible to where the arm meets the shoulder. Face away from the band and place your hand behind your back as if you were being handcuffed. Step forward until you feel a strong but tolerable stretch deep in the shoulder. This exercise is excellent for opening up space within the shoulder joint and often provides quick relief. It can be especially helpful before or after an upper body workout. 3. Seated Back Expansion [embed]https://www.youtube.com/watch?v=OCUzQOT0Ij0[/embed] 5 sets x 5 breath cycles Set up in a chair at a table that is roughly knee height. Place your elbows on the table directly in front of you, making sure they are aligned under your shoulders. Your palms should be facing you. Lean slightly forward and reach your chest away from the table while keeping your abdominal muscles engaged. Hold this position and take five slow, deep breaths. You should feel a stretch between your shoulder blades and throughout your upper back. Cranky shoulders are often linked to stiffness in the thoracic spine, also known as the upper back. The following two exercises focus on improving upper back mobility to help your shoulders move more freely. 4. ½ Kneeling T-Spine Rotation [embed]https://www.youtube.com/watch?v=njY2DlYMnPo[/embed] 3 sets x 8 reps each direction Find a wall and a foam roller. Set up in a half kneeling position as close to the wall as possible. Place the foam roller between the wall and your outside knee, keeping steady pressure against the wall throughout the movement. Hold both arms straight out in front of you at shoulder height, with your inside arm against the wall. Rotate your torso and outside arm, reaching back toward the wall behind you. Rotate as far as you can while keeping your knee pressed into the foam roller. Be sure to perform this exercise on both sides. 5. T-Spine Bench Mobility [embed]https://www.youtube.com/watch?v=n2iwe5LNVmY[/embed] 3 sets x 10 reps, 3 second hold Grab a PVC pipe or dowel and a weight bench. Kneel in front of the bench and hold the PVC with both hands, palms facing up. Place your elbows on the bench in front of you. Slowly sit your hips back while dropping your head and bending at the elbows. You should feel a deep stretch through your upper back and mid spine. Pause for three seconds at the bottom of each repetition before returning to the starting position. These exercises can be a helpful starting point for reducing shoulder pain and improving movement. If your symptoms persist or continue to worsen, a thorough evaluation can help identify the underlying cause and guide a more comprehensive plan for lasting relief.