The View from Sports Center

Two Things Golfers Must Have - Part 2

Last week I told you about one of two things golfers must have to solve a painful shoulder. The first thing was to find out the strength of your shoulder. I explained that golfers need to generate about 14 lbs. of force up to 100 times in the course of a typical 18 hole round. And, that 14lbs., represented about 40% of normal strength.

The second thing to know is your shoulder ratio.

The rotation motions of the shoulder are referred to as internal and external rotation. To best understand these two motions, try this:

1. Lie down on the floor on your back. Slide your right arm away from your body until it forms a 90 degree angle with your trunk.
2. In this position, bend your elbow until it forms a 90 degree angle with the hand pointing up. You are now in what we call "neutral".
3. From neutral, drop your hand back towards the ground. This motion is external rotation. When your hand hits the floor, you have moved through 90 degrees of motion.
4. From neutral, drop your hand towards the ground. At some point in the motion, your shoulder will come up off the ground. This is the end of your internal rotation (see figure for example). Normal motion of internal rotation, from the neutral position, is 70-80 degrees. This gives your shoulder about 160 degrees of rotation movement (90 of external plus 70 of internal rotation).

The shoulder ratio is the amount of external rotation to internal rotation: 90 degrees of external rotation to 70 degrees of internal rotation giving you an ideal shoulder ratio of 1.3. Most golfers with shoulder pain have a shoulder ratio greater than 1.8 and often over 2.0 (a higher ratio means you have less internal rotation motion). I know - a lot of numbers - but hang in there. Here's why it matters. The golf swing takes less than 2 seconds - start to finish. In less than 2 seconds, your shoulder muscles have to figure out how when to contract, how hard, and for how long and this is influenced by how much motion you have in your shoulder.  So, if you have a high shoulder ratio (or too little internal rotation motion), your muscles have less time to react. They have to work harder in a shorter period of time and your chance of injury then goes up.

To solve shoulder pain in golfers, you have to know at least shoulder strength and the shoulder ratio. These two numbers will help you understand why you hurt and what needs to change for you to play safely and pain-free.

Hit'em straight.

Doug Kelsey

Two Things Golfers Must Have

"So, how's the golf game?" I asked.

"Uhh..well..not so good. My left shoulder hurts every time I swing a little bit too hard and really hurts when I hit the ball but I'm on a new anti-inflammatory that seems to be helping some," replied my friend.

"Yeah? Well, you know, we could help you with that shoulder. We could look at your arm and tell you how much strength you have and how much you need to play." I said.

"I know. I know. But, the meds are ok and I just don't have the time to mess with it right now. I'll just swing easy for a while. Besides, I know those muscle tests - you know 'good, fair, poor' - those aren't helpful really at all, " my friend explained.

"Agreed. But, that's not how we test your strength," I said as he started walking away.

About eighteen months later, we had nearly the same discussion.

So much for the meds.

And, he's a physician. And, he knows about shoulders. He operates on them.

Too bad for him because he could solve his shoulder pain and play without worrying. But, he needs to know two things. Here's the first one:

What is his shoulder strength?

To play golf, you need to generate 14 lbs. of pain-free force, about 40% of normal strength, up to 100 times in a typical 18 hole round (of course, the lower your score the fewer swings you take). Normal strength for males is about 35 lbs (this will be a little lower in males over the age of 60). So, chances are, that my friend's shoulder strength was less than 14 lbs. since swinging the club and hitting the ball both hurt. Nearly all musculoskeletal symptoms are the result of a physical demand that is greater than the physical capacity. If you need to generate 14 lbs. of force and can generate 10lbs., there's a good chance that before very long, your shoulder will hurt.  If my friend had discovered that his shoulder strength was, say, 10 lbs (which by the way is the typical top end force production for someone with shoulder pain), he would at least understand why his shoulder hurt and have some idea of how much stronger he needs to be.

This test is very easy to perform, is non-invasive and takes less than one minute. It will tell you exactly how much more strength you need to play safely and pain-free.

Most people assume that if they don't hurt, all is well. But, medications can't change your strength. So, you may feel better after the anti-inflammatory (Motrin, Aleve, etc.), but if your shoulder strength is still too low, you'll end up with a sore shoulder all over again.

Adequate shoulder strength is one of the keys to playing golf without worrying about hurting yourself. There's one more thing to know and I'll tell you about it next week.

Doug Kelsey

Shoulder Pain: The Problem is Dem Bones

During his first season in the big leagues in 1998, the strong, young kid with the monster fastball noticed a nagging pain in his right elbow. He thought it would go away but it didn't. He played in pain through the remainder of the season. In the spring of 1999, he tore a ligament in his right elbow and had a Tommy John surgery. He missed the entire 1999 season spending much of it in rehab for his elbow.

After playing the first part of 2000 in the minor leagues, the Chicago Cubs added him to the roster in May. His debut with Cubs was promising but a new warning sign appeared: right shoulder pain. He was out for a month with a diagnosis of tendinitis and followed this with a triceps strain. He was on and off the disabled list about as often as Paris Hilton buys a new purse. In August 2005, he was headed for yet another surgery, this time on his right shoulder. He then spent several months in rehab.

Following the surgery, Kerry Wood spent four months in rehab for his shoulder to prepare for the 2006 season.  Then, in March of 2006, he had a "minor" arthroscopic procedure - a "cleaning up of his meniscus" -  on his right knee. He made it back to the mound May 18, 2006.

By early July 2006, it appeared that Kerry Wood's career as a professional baseball pitcher might be over. The Chicago Cub's once promising star pitcher tore the infraspinatus muscle, one of the rotator cuff muscles in the right shoulder. According to an article in the Chicago Tribune, Wood will go through more rehab and is debating about surgery. Again.

Do you see a trend? Is there somthing missing in his repeated bouts of rehab or is Kerry just an extremely unlucky guy?

If Kerry attempts a come back, he has a lot of work ahead of him. The obvious problems are in his shoulder but slinking around in the shadows is his right knee. His "minor" surgery in March was on one of the primary stabilizers of the knee - the meniscus - a crescent-moon shaped piece of cartilage tacked onto the top of your shin bone, the tibia.  The meniscus helps absorb shock in the knee and keeps the thigh bone (femur) and shin bone (tibia) from moving too much especially during a twisting action like baseball pitching.

Baseball pitchers need rock solid legs. It's where all the power comes from and when you don't have it in the legs, you steal it from the shoulder. Small changes in stability of the knee, like what happens when a portion of the meniscus is removed, rarely cause problems at low speeds and forces like tossing a baseball to your son in the back yard or even a slow jog around the neighborhood. But, pitching requires a lot of force over a short period of time. You need all you can get from your legs.

On the outer rim of the meniscus is a small bed of nerves. These nerves are now thought to play an important role in telling your brain how to coordinate muscles during complex tasks like pitching. Signals from the ankle, knee, and hip converge in the brain influencing how and when the various muscles contract. Think of a conference call with people giving their opinion of what you should do and imagine that you could actually listen and analyze everyone at once. This is what your brain does. It's listening to the advice from the joints. When a part of the meniscus is removed, some of the nerves may be damaged or removed as well. It's like someone hung up on your conference call. You don't have all the advice you need so, your brain does the best that it can. In most cases, the shoulder or elbow works harder to generate more force. The harder you try to throw with your arm, the easier it is to hurt your arm. This leads to periodic shoulder or elbow injuries. Anytime you have a repeated injury of the shoulder, you will usually find an unresolved problem in the hip, knee or ankle.

We are a society that likes to compartmentalize, reduce, isolate problems and then fix them. If you have shoulder pain, you see a shoulder specialist, maybe have shoulder surgery, go through shoulder rehab and move on. But, unfortunately, that's not how the body works. Your shoulder needs the "advice" of your hip, knee and ankle; your lower back depends on your butt muscles; your knee needs your ankle; your neck thrives from your upper back. You know the old song, Dem Dry Bones - "the ankle bone's connected to the knee bone, the knee bone's connected to the thigh bone...."? It's true. The body's joints and muscles work together. When it comes to rehab, joints and muscles that work together, win together.

If you're struggling with persistent shoulder pain and recurring injuries, like Kerry Wood is, make sure you have any nagging hip, knee or ankle problem addressed as part of your shoulder rehab. It could be the one thing that truly "fixes" your shoulder.

Make today count.

Doug Kelsey

PS - For those of you with shoulder pain, check out our next free seminar, Shoulder Pain: Why it Still Hurts to Throw, Swim, or Serve. Seating is limited - call 512-206-0433 to reserve your spot.

Why Dads Can't Play Catch

Playing catch is a sort of national pastime in the US. All you need is a baseball glove and a baseball. And, all you do is throw the ball, the other guy catches it and throws it back. Why all the fuss? Why do Dad's seem so set on playing catch with their sons?

Playing catch is like a rite of passage. It's something that fathers and sons have done for many years and it's a way Dads connect with their sons without the need for conversation (which as well all know is a must for most men). Dads become kids again, their sons grow up, and they both have a good time.

Until Dad can't throw anymore because his shoulder hurts.

We have seen a lot of Dads over the years who have shoulder pain ONLY when they throw and they feel a heavy pressure to get better quickly. Their sons are growing up and they know that playing catch will fade with age. Every other activity seems to be just fine but the pain from throwing is a stinker. It just won't go away.

Many Dads try things like creams, rub-downs, stretching, medication (Aleve, Motrin, Aspirin,etc.) to chase off the nasty pain pest. Sometimes it works; most of the time it doesn't. And there's a reason why these things fail. Actually, two reasons.

The first reason is that there are two motions in the shoulder that must be within a certain range and have a balance between them- a ratio. We call this the shoulder ratio (for more detail on the specific motions and how it effects the throwing motion, click here). It's similar to other motion ratios of the body (one of the reasons for back pain is an inadequate lower back ratio) and it's something you can restore with prescriptive exercise but never fix with creams, rub-downs or pills.

The second reason is your shoulder is weak. Dads often argue. "Look, I go to the gym, lift weights, and work out all the time. I hardly think I'm weak." But, when we test their strength in specific movements, they are often 50-80% less than normal. Numbers are a beautiful thing; very hard to argue with the facts. You may think you're strength training the right way and that your shoulder is tough and strong but the numbers don't lie. You're weak as a kitten.

If you're a Dad with a sore shoulder or a Mom who knows one, carve some time out of your day and come by Sports Center on May 16, 2006 to hear me talk about this issue. I'll explain the shoulder ratio, what having a strong shoulder really means and the two muscle groups critical for long term shoulder health (and they are not in your shoulder). It's a great talk (I know - I'm biased but it's true) and it's free. You'll get an inside look at how we tackle this issue and help Dads play catch again.

We're ready to play. Are you?

Make today count.
Doug Kelsey

The Curse of a Gift - A Must Read for Baseball Pitchers

As the ball flew from the hand of the young, agile baseball pitcher, he felt something odd in his right arm. It went numb; then it tingled. And, for a brief moment, his arm felt lifeless. It felt dead.

It had happened before. Normally, Jimmy could stall. He would walk around, call the catcher out to the mound and gently shake his arm. The feeling would come back and although his shoulder hurt, he usually could make it through the inning. Today, though, he knew he would not make it. His arm hung lifeless by his side. He was done.

Jimmy had "Dead Arm Syndrome".

Dead Arm Syndrome (DAS) is a pain induced paresis. The word paresis means "a partial or slight paralysis". DAS is a condition in which a pitcher throws so hard that he paralyzes his arm from pain. But, pain from what?

Have you ever noticed the extreme flexibility of a baseball pitcher's shoulder? At the start of the delivery phase of the pitch, the hand is well behind the head. Normal rotation of the shoulder in this direction is about 90 degrees or the hand pointing up to the sky (the position you use when being sworn in - like the President). It is not uncommon for a pitcher to possess 120 to 140 degrees of rotation.  This exceptional mobility is one of the attributes of great pitchers. It's a gift. A gift that sometimes comes with a curse.

The shoulder complex is very mobile by design. With four joints moving in three planes, you can place your hand in space through a very wide range of motion. Pitchers improve on the design partly from years of training (including stretching) and partly from their particular genetic profile. But, while this flexibility improves performance, it also increases the risk of a certain type of injury that typically occurs only in very flexible shoulders: a Bankart Lesion.

A Bankart Lesion is a tear of the cartilage (called the glenoid labrum) that forms the shoulder socket. In most cases of DAS, the pitcher has a Bankart Lesion. The pain comes from tearing the cartilage (although it has a meager blood supply, the upper margin does have small blood vessels and nerves), over stretching the attaching tendon (biceps), joint capsule and, in some cases, a mild stretch injury to the axillary nerve.  When the tear is large enough, surgery is required to repair it.

One of the secrets to reducing your risk of a Bankart Lesion or for other problems associated with pitching is in the balance between the two rotation motions of the shoulder.

I have to get technical for a few moments. No way around it. But, if you have had DAS or know someone who does, this information is critical. So, take your time as you read this.

The rotation motions of the shoulder are referred to as internal and external rotation. To best understand these two motions, try this:

1. Lie down on the floor on your back. Slide your right arm away from your body until it forms a 90 degree angle with your trunk.
2. In this position, bend your elbow until it forms a 90 degree angle with the hand pointing up. You are now in what we call "neutral".
3. From neutral, drop your hand back towards the ground. This motion is external rotation. When your hand hits the floor, you have moved through 90 degrees of motion.
4. From neutral, drop your hand towards the ground. At some point in the motion, your shoulder will come up off the ground. This is the end of your internal rotation (see figure for example). Normal motion of internal rotation, from the neutral position, is 70-80 degrees. This gives your shoulder about 160 degrees of rotation movement (90 of external plus 70 of internal rotation).

Baseball pitchers with DAS, in nearly every case, have less then 45 degrees of shoulder internal rotation but still have a combined motion of at least 160 degrees. They just have way too much motion in one direction and not enough in another. 

The speed of a fastball for most college level baseball pitchers is 35 meters / second. The force exerted on the back of the shoulder to slow the arm moving through a normal amount of internal rotation (at this point, the ball has left the hand) is approximately 90 lbs. But, when a pitcher has 45 degrees of internal rotation, the time to slow the arm is reduced by nearly 50%. So, he has to generate a lot of force in much less time (this principle of force applied over a period of time is why airbags work so well).  As a result, the force to slow the arm climbs to 162 lbs. Any wonder why injuries might occur?

If you or someone you know has DAS, be forewarned. This is, in nearly every case, secondary to tears to the glenoid labrum. Have your motion checked by a physical therapist or athletic trainer who works with sports related injuries. If you ignore it, you will very likely end up in surgery, a year of rehabilitation and may never throw a smoking fastball again.

Make today count.

Doug Kelsey
Author. Speaker. Therapist.

P.S. If you are a PT or ATC and would like to learn more about how we use the Sports Center Training System to rebuild athletes with shoulder tendonitis, tendonosis, and rotator cuff tears, join us for our next professional education seminar on August 4th-5th at Sports Center. Only 12 clinicians get access to this seminar this year and there are only a few spots left. Take advantage of the early registration period ending June 29th and save. As always, graduates get 20% off any seminar. Call Angie Francis at 512-206-0433 or email her at afrancis@sportscenteraustin.com to register today.

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Shoulder Pain, Ice and Needles

Have you ever noticed how long the needle is when you get inoculated for something like tetanus? If you have even the slightest needle phobia, you might pass out. The needles are long - about 1.5 inches.

Injections delivered into your upper arm must penetrate into the muscle belly of the Deltoid muscle. There is a considerable amount of research on just how long a needle needs to be to penetrate most adults' Deltoid muscle. The average needle is between 1.0 and 1.5 inches long. Remember this. You will need it later.

I was watching a major league baseball game recently and happened to notice a pitcher sitting in the dugout with what looked like a small mountain of ice strapped to his shoulder. A few questions came to mind. Why do we use ice for a sore shoulder? How much ice do you really need? Is a thick pile of ice better than one of those gel ice packs you store in your freezer? How long should you use ice? And, how deeply does the cold penetrate? Does it get to the tissue that supposedly needs it?

Ice is probably the most commonly used physical agent in the sports injury world. When a baseball pitcher injures his shoulder, in most cases, the injured tissue is the rotator cuff muscle group. These small muscles (four in total - Supraspinatus, Infraspinatus, Teres Minor and Subscapularis), buried deep in the shoulder, control the finer motions of the shoulder. They blend together to form a large tendon that anchors to the top part of your arm. When you throw too hard, too long or too much, you strain the tendon and develop a deep, aching soreness. This can lead to rotator cuff tendonitis or tendonopathy (a weakness of the tendon).

Ice is often used as treatment for rotator cuff tendonitis. So, for the cold to work it must actually reach the tendon (how it helps or does not help tendonitis is for another time). Cold penetrates about 1 cm or slightly less than 1/2 inch. The rotator cuff is buried under your Deltoid muscle. Remember the needle length for injections? It was over 1 inch to get into the Deltoid. If the rotator cuff is under the Deltoid, and the cold of ice only penetrates 1/2 inch after a thirty minute exposure, how does the rotator cuff ever benefit from the ice? It doesn't. While the baseball pitcher sits with a pile of ice strapped to his shoulder, he is nicely cooling his Deltoid while his rotator cuff remains toasty warm.

Cold is cold. A pile of ice is not any better than a gel ice pack other than perhaps it will stay colder for a longer period of time. Ice helps reduce the pain of a sore shoulder, but if you think it helps prevent or treat rotator cuff tendonitis, you're wrong. The cold never gets there.

If your shoulder is sore, ice it if you want to temporarily reduce the pain. Perhaps a better choice is to figure out why you have a sore shoulder and what you can do to prevent it. Want to know more? Sign up for our June 14th free seminar on this very subject "Shoulder Pain: Why You Still Cannot Throw, Swim or Hit" and for all of the clinicians out there, reserve a spot in our upcoming professional seminar on August 4th-5th at Sports Center entitled "The Shoulder: Rehab for Rotator Cuff Tendonitis, Tendonosis, and Repair".

Ice is OK. Knowledge is better.

Make today count.

Doug Kelsey
Author. Speaker. Therapist.

P.S. I promised I would share with you some of the comments from our inaugural graduating class from Sports Center.  Click here to read their amazing comments.

References:
Chiodini J (2000) Vaccine administration. Nursing Standard. 14, 43, 38-42. April 2000.

Enwemeka, C. S., C. Allen, et al. (2002). "Soft tissue thermodynamics before, during, and after cold pack therapy." Med Sci Sports Exerc 34(1): 45-50.

Otte, J. W., M. A. Merrick, et al. (2002). "Subcutaneous adipose tissue thickness alters cooling time during cryotherapy." Arch Phys Med Rehabil 83(11): 1501-5.

Thawing a Frozen Shoulder

In the View last week, I told the story of Johanna who had determined her mother lived in her shoulder (and for those of you have not read or may be not as familiar with Blindsiding Broca, read the Visioneer View "Our Buddy Broca Part 1&2" from our web site under the archives section. Johanna used all of the principles outlined in those two Views in describing her conditon to me). We learned she had a "Frozen Shoulder" and also learned about the nature of the disease. The story ended with an invitation to come back and learn about the three dimensional solution for the Frozen Shoulder - the topic for this week.

All musculoskeletal conditions of the human body have at least three dimensions in which they manifest themselves: pathophysiologic, pathomechanical and psychodynamic. I think of these dimensions as three intersecting circles and its the interplay between these dimensions which creates difficult cases.

As an example, the three circles of the client with a Frozen Shoulder are the following:

1. Pathophysiology - the disease process is an inflammatory reaction of the synovium and surrounding soft tissues creating more pain than loss of movement in the initial stages of the disease. Accompanying the inflammatory reaction is an apparent disturbance in the sympathetic nervous system. There appears to be a relationship between the onset of the disease and onset of menopause implying a possible hormonal connection. To date, the evidence suggests a combination of a hormonal and sympathetic nervous system changes as the etiologic factors.

2. Pathomechanics - the person with this disease will not have a normally moving shoulder due to the pain and gradual loss of tissue extensibility. The scapula will move well before it should during lifting of the arm. Nearly all motions of the shoulder are affected.

3. Psychodynamics - the person with a Frozen Shoulder often has high levels of anxiety, may have mild to moderate levels of depression, is typically a woman in the 40-60 age range, a high achiever, and has recently experienced an increase in stress either positive or negative.

The question I am asked the most at Techniques, Tools and Tips for Tough Patients or at SportsCenter about frozen shoulder is "what do you do"? Here are the five things I do at the beginning or "freezing" stage of rebuilding the person with a Frozen Shoulder.

1. Women nearing menopause should consult with their physician regarding analysis of hormone levels and options to achieve optimal balance.

2. All movements of the body should create a sense of relaxation and well being. At least part of the disorder involves the sympathetic nervous system. Reducing the sympathetic tone will reduce the magnitude of pain.

3. Use a light, assistive, repetitive, motion performed at regular intervals through the day (every 2-3 hours) in positions of comfort. I avoid over stressing the shoulder especially in the initial stages. I use an OnX - a tool which combines elastic tubing with a pulley to help clients move their arms easier (http://www.gyminabag.com). For example, Johanna attaches the elastic end of the OnX in the door frame and lies down on the floor with padding or pillows under her head and knees. She then performs a variety of motions with her arms: circular, up and down, side to side in any sequence or combination she chooses. She moves through a range of motion which is comfortable to her. She performs this drill for 3-4 minutes then rests for 1-2 minutes and repeats. While doing this, she closes her eyes and imagines her shoulder moving gracefully through the air. With each motion, she "sees" herself moving with greater and greater ease. The imagery utilizes descending pat hways from the brain to lower the sympathetic activity.

In the second stage of the disease, the shoulder has "frozen". Johanna will hurt less but will feel more restricted in her motion. Her glenohumeral joint will have lost the ability to rotate freely. I focus on rotation in the transverse plane first since it is often the most difficult to regain. To improve the motion, I do the following:

4. In a standing position with feet staggerred, hold onto a rod about 2 inches in diameter and 6 feet long with the frozen shoulder side. Place the rod mid way between the side of the body and the front of the body (in the plane of the scapula). Grip the rod at a height that is just shy of the comfortable range of motion for the shoulder (we call this the "Moses" drill). Now the fun begins. Put on some music, use a cd player/walkman. The music should inspire movement. Something that makes you want to dance even if you cannot. To the beat of the music, reach under the arm holding the rod turning the entire body. swing the the arm under the arm holding the rod and then back up and out to the opposite side. Over and over. Keep swinging the arm while maintaining the rod in an upright position. This motion creates a rotation in the glenohumeral joint but includes all of the body. The sensory input from the music both distracts the brain from any pain signals and also cre ates a motor cascade recruiting muscles in a more functional manner. Johanna will do this for several minutes at a time for a total of 20-30 minutes. Her joint needs to move and the capsule needs to be stressed. To frob this drill, adjust the angle of the rod, the height of the hand, change the music, add forces against the body, alter the base of suport, or stand on one leg. Adjust your expectations to match those of the body. Remember, dense connective tissue changes slowly at only 3-5 degrees per week at best. Be patient.

5. Manage the mind. The brain is the great interpreter and can easily become filled with the dark cloud of doubt. Johnna needs to know she will get better and needs frequent, positive praise for her efforts and determination. Nothing extinguishes the fire of desire like isolation and doubt. This is what makes the recovery process so challenging. If I become impatient, Johanna will immediatley sense it and feel the same way before I can even blink. As a good friend of mine once said, "In the ER, take your own pulse first." Your calm, confident attitude will be infectious. Watch for words of doubt, despair, frustration and slowly begin carving them out of her vocabulary. Gentle reminders for a positive mental push.

Thawing a Frozen Shoulder is possible. Come back next week to discover how long the journey takes and what to expect along the way.

Make today count.

Doug Kelsey
Author. Teacher. Therapist.

Rotator Cuff Tear: How Do You Know?

Jim didn't see the large mogul ahead of him. He was watching his three friends dash down the mountain and suddenly found himself face first in the powdery three inches of the morning snowfall. He struggled to roll over and then managed to get on his knees. Leisurely dusting himself off, he looked up and realized it was snowing. In a matter of a few minutes, he could barely see three feet in front of him. He wished now he had stayed on the trail instead of following his friends. After slowly skiing down the mountain, Jim realized he wasn't sure which way to go. After about twenty minutes, he knew he was lost. Lost in a blinding snow storm, cold and scared.

I know of very few feelings worse than the feeling of being lost. Students I work with spend a large amount of mental energy and time fighting the feeling of being lost. When they exit the initial interview, they aren't sure what the problem is and consequently spend too much time during subsequent visits searching for an answer. Each day is another journey into the blizzard looking for something recognizable. I know. I've been there too.

Shoulder pain is one of the most common musculoskeletal complaints encountered in an outpatient healthcare setting. With over 23 physical examination tests for the shoulder alone, there is plenty of information available. The question is what information is the most helpful?

Whether shoulder pain is related to a gall bladder problem, heart, tendinosis or a rotator cuff tear, wouldn't it be nice to know? The good news is that when it comes to rotator cuff tears, you only need three physical examination tests to help you predict if a person actually has a tear (there's that number three again!).

A positive impingement sign, weakness in external rotation and supraspinatus weakness when found together in a person with shoulder pain create a high degree of suspicion of a rotator cuff tear. When you add the age of the individual along with pain at night, the suspicion goes up even more. The older the person the more likely the presence of a cuff tear. (Murrell G, Wlaton J (2001): Diagnosis of Rotator Cuff Tears. Lancet 357: 769-770) .

Although the blizzard has cleared, the path down the mountain is still not well defined. We still don't know the degree or magnitude of the tear. Large or complete tears of the rotator cuff do not respond as well to rehab as do smaller and less complete tears. In order to position yourself for maximal success, consider a referral to the appropriate source to help you further define the tear. Once you know, you can make a better decision and get on the right path.

Make Today Count.

Doug Kelsey
Author. Teacher. Therapist.

Really Tough Stuff

The surgeon called me about one of his baseball pitchers who recently had a surgical repair of his shoulder.

"Don't stretch his posterior capsule yet. I want to wait for 6 or 8 weeks first," said the surgeon.

"Sure. I don't stretch the capsule anyway," I replied.

"Well, I want you to stretch it in 6 weeks. I mean you need to then," the surgeon said with his voice rising in volume and pitch.

"You know, could we get together for lunch sometime? I would love to talk about this more," I replied.

"Sure. But, if you don't stretch the capsule, how will he ever get his motion back?"

"I'll explain it at lunch. It takes a little while," I replied.

A few days later, the surgeon and I were sitting at a round table in a small, quiet cafe. We had arrived before the crush of the lunch crowd. After a few minutes of small talk, the surgeon asked, "So, why don't you stretch the joint capsule? I have never run into anyone in orthopedics who doesn't stretch the joint capsule after a rotator cuff repair."

The shoulder joint is actually three bones: the humerus, the scapula and the clavicle. The surgeon was really interested in only two: the humerus and the scapula. The scapula and the humerus are bound by a tough, dense fibrous tissue called the joint capsule. Joint capsules are designed to be stubborn. They fight stretching. The joint capsules' job is to help hold the bones together and to house the lubricating liquid, synovial fluid, ensuring all motions are smooth and easy.

"Well, first tell me why stretching the joint capsule is important to you. What are we trying to accomplish?" I asked.

"The problem I see is that most of these pitchers cannot internally rotate their arm enough. The capsule is too tight in the back of the shoulder and this forces the humerus forward causing all sorts of problems. So, I have them stretch the capsule to give the humerus some more room," replied the surgeon.

"I understand. So, how do you stretch it?" I asked.

The surgeon then reached across his body and grabbed the upper part of his right arm with his left hand. He then pulled the right arm across his chest and held it. "Like this. You don't know this stretch? Everybody knows this stretch," said the surgeon.

"I know the stretch. How long do you hold the stretch?" I asked.

"Oh, you know, a few seconds. Maybe 10 or 15 and do it 6 to 10 times. That should do it," she replied.

"Does it work? Does it change the capsule?" I asked.

"Well, their motion gets better so yeah it probably does."

"So, it sounds like our goal is to increase the motion."

"Right - correct and that's why I want you to stretch the capsule."

"Well, I agree with you and I think we can achieve the same outcome. But, here's the problem with stretching the joint capsule. It is next to impossible. It's breaking strength is about 3000 pounds per square inch. It just doesn't want to stretch. If it stretched that easily, in 10 or 15 seconds, then it would not withstand the tremendous forces created during pitching. If just pulling the arm across the chest can stretch it, the high speeds of pitching would easily tear it. Am I making sense?" I asked.

A pregnant pause followed. This is where conversations become crucial. I knew something he did not know. Whatever he said next would be pivotal. If we shared the same objective, if we shared a mutual respect then he would wonder. He would stop and think about what I had said. If not, I would very likely never see a client from him again.

"Do you have proof about that? How do you know that? But, you know, hmm...wow. I hadn't really thought about it, but ahhh...yeah I guess so. Makes sense. It is pretty tough stuff. But, how does the motion get better?" he finally said.

"I can send you the reference on the breaking strength. The only way you gain motion from such short term stretching is from changing the muscle tension. I completely agree with you about your thoughts on helping pitchers protect their joints. I just get there in a different way. Sometimes, a stretch as you described and sometimes using movements but the end result is the same. More motion," I explained.

"Yeah. Makes sense. I have an article for you too on the mechanics of the shoulder. I'll send it to you and maybe we could get together again and talk about it."

"I'd love to. Anytime," I said.

There are a lot of days behind me when crucial conversations crashed and burned leaving me not with a stronger, deeper bond but alone. The key to shifting conversations from crashing to soaring is to recognize when they become crucial. Take your own pulse first and if you feel your heart begin to thump, slow down and ask questions. Fight the urge to win; to be right. Let it come to you and win a friend.

Make Today Count.

Doug Kelsey
Author. Teacher. Therapist.

Reference: Capsular properties of the shoulder. Itoi E, Grabowski JJ, Morrey BF, An KN Tohoku J Exp Med 1993 Nov 171:203-10

My Mother Lives in My Shoulder

“I think I know now why my shoulder pain seems to fluctuate so much,” said Johanna. “My mother lives in my shoulder.”

Johanna developed left shoulder pain a few months ago. She noticed it one day as she tried to wash her hair. The 51 year old woman discovered ignoring it was an ineffective technique. The pain gradually worsened, sleeping became difficult and each day was glazed with an achy hue. She lost a few degrees of motion each day until suddenly she had a stiff shoulder.

No injury, no overuse, insidious onset, gradually worsening pain and a loss of motion, Johanna had a case of idiopathic adhesive capsulitis or more commonly known as Frozen Shoulder.

Frozen Shoulder tempts practitioners unlike any other disease. It begs you to do something; ultrasound, electrical stimulation, stretching, mobilization. Something. The person with the condition hurts and is losing motion. Surely there must be something that can be done quickly to reverse the process. To date, no such thing exists.

Most believe the problem with Frozen Shoulder is the joint capsule. The condition causes a fibrosis or a contracture of the capsule resulting in loss of motion. Hence, the notion of stretching or mobilizing the capsule seems to make sense. But laboratory studies have shown the changes and restrictions from a Frozen Shoulder are largely in tissues outside the joint (coracohumeral ligament, rotator interval tissues and bursa). Frozen Shoulder is a disease process effecting nearly all tissues of the shoulder and has its own timeline for recovery: one to two years.

Stress, physical and emotional, amplifies the disease. Worry and despair fan the flames of pain and contracture. The first thing to do to help someone with a Frozen Shoulder is to tell the truth as uncomfortable as that my be. The truth is liberating only when you know what it is.

Johanna responded very well to my explanation of the disease process. She would likely get worse before she got better. She may not have all of her motion at the end of the process but I would help her maintain and regain as much as possible. The process may take as long as two years to run its course but she would get better. I explained stress seemed to be associated with the disease and asked her about any stressful events in her life over the past few months. From her view, she had less stress since she was leaving her job to do volunteer work. She did not see anything in her life as a negative stress until her follow-up consult.

“My mother lives in my shoulder. I understand now what you meant about the stress. My mother has recently been diagnosed with Alzheimer’s and it is very difficult to go through. I noticed that when I am thinking about this or am dealing with some part of her situation, my shoulder begins to ache. And it just seems to get worse. But, I can make it better by doing what you told me to do,” Johanna said.

The solution for a person with a Frozen Shoulder is counter intuitive. The loss of motion tugs at your brain teasing you to stretch, to mobilize, to extend the shoulder. Yet, the very thing that seems to be so logical is the last thing to do. The solution is both simple and complex. Simple in design and complex in execution. Tune in next week for Part II - the three dimensional solution for the Frozen Shoulder.

Make today count.

Doug Kelsey
Author. Teacher. Therapist.