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The Rotator Cuff

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What is it?

The rotator cuff (RTC) is located in your shoulder and is composed of four muscles. The suprasinatus, sucscapularis, infraspinatus, and teres minor. Many mistake the RTC for a singular structure that is similar to that of your labrum or meniscus. Mainly because these four muscles are talked about as a group oppose to individually. The main reason for this… They work as a group and rely on each other to complete the job they were designed for.

Rotator Cuff Injury
How the RTC works

Each individual muscle activates and moves the shoulder in different directions. Although they each have individual abilities their real purpose is to work in unison with one another. As larger muscles, such as the deltoid and trapezius, elevate the shoulder, the RTC provides stability. Think of the individual muscles like fingers reaching out and attaching around the head of the humerus. This is important because the shoulder joint is like a golf ball on a tee. A large sphere like structure attached to a small concave surface. This allows for great mobility but at the expense of stability. The RTC is one aspect that helps provide that stability while in motion.

Shoulder joint mechanics
What Does This Mean

When our static stabilizers (ligaments/ labrum) and dynamic stabilizers (muscles) are working, the shoulder functions as designed. However, as we age and put the joint through activity, things start to break down. We can have trauma to the RTC from acute injuries such as falls, lifting, or throwing without properly training. We can also have chronic damage to the RTC that developed with years of over use. Imagine one of the four muscles stops pulling its weight and starts to weaken. This may lead it to being damaged or put the other three muscles at risk for having to compensate. This imbalance can also lead to the shoulder shifting around more than desired through movements. Ultimately putting other structures at risk for injury.

What Can We Do?

There are two main ways to combat these changes our body will be forced to deal with. We can be proactive or reactive. If you have an acute or overuse injury already, you will have to react. Some serious injuries will require surgery. Many can be addressed through targeted treatment and strength training. If you have yet to experience a shoulder injury, don’t celebrate just yet. It is very possible there are potential imbalances that could lead to further issues down the road. Getting screened and identifying potential concerns can help reinforce your shoulder joint.

Why Is This Important?

Our shoulders make much of what we do in life possible. From throwing a baseball to picking up your children to putting dishes away, they need to be strong and mobile. In today’s world we are living much longer, and we need to ensure our shoulders are up to the task. Thankfully there is a lot we can do to reinforce our shoulder joints and ensure they are ready to take on whatever we put them through. The important thing is to work with someone who can not just identify where your pain or limitations are but determine why this is happening. This will allow you to know what is necessary to fix the root cause of the problem. Don’t push it off any more, set up a Free Discovery Call today to find out how you can improve your shoulder function.

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Direct Access

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What is it?

Direct access is a law about the requirement for referrals to attend physical therapy. Prior to this law, you would need to obtain a referral from your primary care physician before going to physical therapy. In most instances this is no longer the case. This allows for quick access for evaluations and a decrease in time between injury and rehabilitation. There are some limitation, that we will discuss, but this has been a huge advancement for the physical therapy profession.

Direct access physical therapy.
The Old Way

Prior to direct access, you would have to make an appointment to see a physician before attending therapy. You could pay more for an urgent care visit or wait the necessary time to get in to see your doctor. If the doctor felt there was no need for surgery, you would be referred to physical therapy. At physical therapy you would receive a much more in depth evaluation of your injury and begin the rehab process. It could be weeks of waiting to get in to see your doctor and then the PT clinic. Valuable time that could be spent on healing from your injury was lost through this process.

The New Way

The solution, direct access. The goal is get patients in our door quicker so we could begin providing care. This will cut down on medical costs and time from start to finish. Our training through school, has prepared us to determine if someone needs imaging or further medical treatment beyond our scope. In these instances, we will refer back to the doctor for more sever cases. Most of the time, the injury can be addressed through physical therapy.

All Roads to Therapy

At some point all roads lead to physical therapy. Initially after injury, you can come to our clinic to be treated. If a doctor feels you need an MRI, insurance will typically require you to receive PT first. Finally, if you get surgery, you will need rehab to get you back to doing the things you love. This all can be a very cumbersome and costly process. The idea of direct access is to get you into therapy sooner. When we feel we are not having success, we refer you to the doctors for further imaging and evaluation.

Current Limitations

Unfortunately, not all healthcare insurances approve direct access. All federal, such as Medicare, VA, and Medicaid, require a referral from your doctor. Few, but some, private insurances require a referral. Finally, there are different laws and restrictions within each state in regards to direct access. Here is a link for direct access laws in every state. If you have further questions about your state, you can reach out to us at any time. We recommend you contact your insurance company to find out how you can benefit from direct access.

Learn More

The more prepared you are now, the less you will have to worry when you get injured. We are specialist of the body and how it functions. We can help you heal from an injury and educate you on how to avoid them. It is well within our scope of practice to work on aches and pains as well as injury prevention. We know physical therapy is not for everyone, but we are here to help educate you on how to best manage your pain and injuries.

Should I get Shoulder Surgery?

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IT DEPENDS!

Shoulder injuries lead to some of the more common joint surgeries along with knee, hip and back. But why? Our shoulder is a very mobile joint and is put through a lot of stress in our lifetime. So it has lots of opportunity to breakdown and require surgery due to acute and chronic injuries. However, not all pain is necessarily worth getting surgery. Lets dive into what causes these issues and when one may or may not consider surgery.

Shoulder surgery
What types of shoulder surgeries are there?

There is the total shoulder or reverse total shoulder replacement. This is where they replace the entire shoulder joint secondary to degeneration and arthritis. There are rotator cuff muscle/ tendon repairs. When the tear or pain is severe enough people will lose the ability to function and one would need surgery. There is the labrum, which is a cushion inside the joint. When this structure has a tear, it needs to be stitched back together or cleaned up. Outside of those three you have other debridements, decompression and structural type surgeries depending on the injuries sustained.

The Question

The main question each individual has to answer is how does my current situation and pain impact my life? What are the things I want to do in life and how much does this pain or limitation prevent me from accomplishing those goals?

If you are an electrician and have to lift your arm overhead, but are unable to do so because of pain, then surgery may be warranted. If you work at a desk all day and can manage the shoulder pain with conservative treatment, such as exercise and medication, then maybe you don’t need surgery.

At the end of the day, you have to answer this question for yourself. Take into consideration, the rehab time, stress from the surgery, and physical demands you are required to complete in life. Once think about those types of factors, you can determine if surgery is right for you.

It is also important to note if the injury will get worse or not. It is possible you will have a better outcome now than if you were to wait five years for the surgery. Or the injury could become so severe that the surgery they want to perform now, will no longer be an option in five years.

Your Options

There is essentially two main pathways once you are posed with this question. Either manage it conservatively or do surgery. If you do surgery, there will be an immediate healing phase where your motion will be restricted depending on what was performed. Once this stage is complete you will be referred to physical therapy to help the shoulder reduce pain, restore motion, and rebuild strength. In some instances the shoulder will never return to its previous function but theoretically the symptoms will improve.

The conservative route is no surgery and the use of physical therapy, medication, and potentially injections. Depending on the severity of the injury, pain can improve tremendously and sometime resolve completely. An individual can be a candidate for surgery yet still develop compensations with movement that are pain free. The question, is how much risk are you at for future injury or issues due to this compensation. And is that risk worth taking in your current situation.

At the end of the day, it is up to you. Take all the information provided by the doctors and healthcare professionals and apply it to your situation. Ask questions! Assess how independent you currently are and what steps you have already tried taking to correct the problem. If possible keep surgery as a last resort but know it is always an excellent tool to get you back to doing the things you love.

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Tennis Elbow

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What is it?

Everyone is familiar with the term tennis elbow. But what exactly is damaged when we experience this injury? The structure in question is the lateral epicondyle as seen in the picture. There are a few different reasons we might get tennis elbow which we will discuss below.

The Anatomy

There are many muscles that originate from the forearm to control the fingers, hand and wrist. Below is an image of the wrist extensor muscles with the extensor carpi radialis brevis being the most common muscle impacted with this diagnosis. As the image below shows, there are a lot of structures in the area of the lateral elbow. In addition to muscles, there are tendons, bones, and ligaments which all could be damaged.

The Damage

The main question we have to ask is exactly what structure is damaged in the lateral elbow. A torn tendon or ligament. A bone bruise from a fall. Or muscle damage due to overuse can all cause pain in the lateral elbow. If the symptoms are muscular in nature then determining which muscle is the next step. Lets discuss how these injuries may happen and what steps to take depending on the involved structure.

How This Happens

A bone bruise or trauma directly to the lateral elbow can occur due to a fall. If you land on your elbow the trauma can cause inflammation and irritation to any of the structures in the area. A traumatic force when falling on an outstretched arm can also cause tearing of ligaments or muscles. The ulnar nerve travels along the lateral elbow and can also be irritated or damaged.

Lastly, and most commonly, are the muscles in this region. Whether from a tear or overuse the muscles can be damaged or irritated. When this occurs, there can be additional tugging on the attachment site at the lateral epicondyle causing inflammation. This is the biggest question that needs to be answered when treating. What is causing this additional stress at the attachment site. It can be different from person to person. One of the main causes for irritation at this site is due to overuse. When the wrist extensors fire repetitively this can cause unwanted stress at the lateral epicondyle resulting in pain.

Treatment

Once the mechanism of injury is known we can progress to treating the pain and rebuilding the tissue in the best way possible. Using soft tissue mobilization, dry needling and cupping will help improve mechanics and reduce pain.

Once the pain and motion is addressed we can begin strengthening the muscles accordingly. When a muscle or joint is not working properly, over time it will become weak. So rebuilding the strength is a necessary part of the process. Starting with isometric activation to help with motor recruitment is the first step. Then working on concentric and eccentric muscle activation to help with strength training. Finally transitioning into work or sport specific activity to return to prior level of function.

When it is all said and done, knowing what was the original cause and how to correct for it will help prevent future issues. Addressing these issues early on is just as important as the initial phases.

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Carpal Tunnel Syndrome

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What is it?

Compression on the median nerve as it passes through the carpal tunnel will result in numbness and tingling in the hand. This can be from injury or chronic over use that results in direct irritation to the nerve. Refer to the image to the right to see a breakdown of the structures that make up the carpal tunnel.

The Anatomy

The carpal tunnel is composed of 10 structures. Nine tendons that attach to our muscles that flex the fingers and wrist along with gripping objects. In addition to the tendons, there is the median nerve which is the involved structure. The carpal tunnel boarder is created by carpal bones and the flexor retinaculum. All the tendons are covered by a synovial sheath to help with gliding back and fourth throughout the space.

The Damage

When the nerve is damaged one will experience numbness and tingling into the palm of the hand. The nerve itself can be damaged by a crush injury or stretching the structure beyond what it is able to move. When increased inflammation in the area occurs due to ligament, muscle, or bone damage that additional swelling can also cause pressure on the nerve. This ultimately leads to symptoms in the hand.

Carpal Tunnel Syndrome
How This Happens

Trauma to this area can be the due to many reasons. When someone types with poor ergonomics the nerve can be placed on stretch which will eventually lead to irritation. When someone strains or tears one of the wrist flexor muscles the tendons can become irritated. This will result in increased swelling in the carpal space. Another factor could be a dislocation or instability of the carpal bones that make up the boarder.

Any reason that could cause a decrease in carpal space will potentially result in compression on the median nerve. This is an important piece of information when dealing with this issue. It is necessary to know the root cause of the issue before getting an invasive treatments or surgeries.

Treatment

Many people have heard of carpal tunnel surgery or is aware of someone who has dealt with this issue. The purpose of the surgery is to cut the flexor retinaculum (one boarder) to increase space in the area to reduce pressure on the median nerve. However, if the underlying cause is not addressed then it is very likely the symptoms will eventually return.

Picture a city that has a sudden increase in population for an unknown cause. The solution is to cut down all the trees around the city limits to help create space. More people arrive and eventually fill in that added space and the population issue returns.

Now think of your carpal tunnel in the same way. Say there is wrist instability within the joints which causes increased irritation and inflammation. The surgery cuts the flexor retinaculum but the instability in the wrist bones are never addressed. It is very possible the symptoms never progress or return. But ask the question why do a surgery, or cut something in your body that isn’t the root cause. Do you want a temporary or a long term solution?

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De Quervain’s Tenosynovitis

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What is it?

De Quervain’s Tenosynovitis is compression or irritation of two tendons that run along the wrist and attach to the thumb. This injury is usually caused from overuse and can be debilitating.

The Anatomy

The abductor pollcis longus (APL) and the extensor pollcis brevis (EPB) muscles travel from the forearm and attach at the thumb. These two muscles are primary moves of the thumb. They also cross the wrist joint an, although are not the main movers, will be stretched and contracted as the wrist moves. In addition, the muscles have a sheath that helps protect and allow movement over the bones without additional shearing.

The Damage

When the muscle and tendon sheath become irritated the area below can develop inflammation. This will cause irritants to fill the area which will ultimately increase the pain. This damage is mainly due to overuse but can be from an acute injury to the muscle or tendon. When the wrist and thumb are put in an extended position for prolonged periods of time, the muscles can become irritated.

This is very common in new moms who are carrying their babies. When a mother holds the baby in one arm with a bent wrist the muscles are stressed more than they are prepared. Other instances involve shoveling, constant lifting of heavy objects, and manipulation of objects.

What To Do

Depending on the severity will determine the course of action for treatment. Many times people will require a splint for a few weeks. This will encourage decreased use and allow time for the inflammation to go down. Once the irritation has decreased strength training can begin to rebuild the muscle fibers and tissue.

Serious issues may require injections and more invasive procedures to help the healing process. It is important to try conservative efforts first before more aggressive treatments. Getting on a structured rehab process and routine to reduce irritation is the best case scenario to help resolve this issue.

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