Why is the Rotator Cuff Important?

By Grant Uyemura, DPT Student

Rotator cuff tendinopathies affect 20-30% of the general population and becomes more prevalent and disabling with age. 1 The rotator cuff is made up of 4 muscles supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles help stabilize the humeral head within the glenoid fossa and prevent superior humeral head migration during overhead movements. 2

Weakness of the rotator cuff can lead to shoulder impingement, tendonitis, bursitis, and labral tears. Looking at Jobe’s instability continuum. 3
1. Rotator cuff weakness generally occurs first
2. Functional instability follows prolonged rotator cuff weakness
3. Capsular laxity, which develops over time
4. Subluxation due to inability of the humeral head to center in the glenoid during motion
5. Rotator cuff/labral tearing (late-stage disease of secondary impingement)

Best Exercises

Reinold et al., 2,4 found that the best supraspinatus exercise was a standing or prone full can. A standing full can was found to have decreased deltoid activation compared to the prone full can. Sidelying external rotation with 0º of abduction was found to be the best exercise to strengthen the infraspinatus and teres minor. Internal rotation at 0º or 90º of abduction was the best exercise to strengthen the subscapularis. Click here or photos for link to videos.

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These isolated exercises are a good starting point and are great for a basic home program.  However, for best results they should be used in conjunction with a more comprehensive and integrated rehab routine.

img_2534Blog post written by Grant Uyemura, DPT Student from University of St. Augustine. At the time of publishing Grant was in a clinical rotation with me at Catz PTI.

References:

1. Wies JT, Humphreys H, Latham M, et al. A randomized placebo-controlled trial of PT for RTC tendinopathies [abstract]. J Orthop Sports Phys Ther. 2005;35:A5.

2. Reinold MM, Escamilla R, Wilk KE. Current Concepts in the Scientific and Clinical
Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. J Orthop
Sport Phys Ther. 2009;39(2):105-117. doi:10.2519/jospt.2009.2835.

3. Page P, Frank C, Lardner R. Assessment And Treatment Of Muscle Imbalance. Champaign [etc.]: Human kinetics; 2010.

4. Reinold MM, Wilk KE, Fleisig GS, et al. Electromyographic Analysis of the Rotator Cuff
andDeltoid Musculature During Common Shoulder External Rotation Exercises. J Orthop
Sport Phys Ther. 2004;34(7):385-394. doi:10.2519/jospt.2004.34.7.385.

Forward Head Posture


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By Ashley Pena, DPT Student

Although “forward head posture” (FHP) has long been regarded as a problem leading to pain and disability, with increased time spent on smartphones in recent years, it is becoming a very common source of pain. In a study performed by Kim et. al. which studied the effect of duration of smartphone use on muscle fatigue and pain caused by forward head posture in adults using EMG analysis, it was found that prolonged smartphone use resulted in increased upper trapezius and cervical erector spinae fatigue.

As a result of FHP, compensatory motions occur such as severe extension of the upper cervical spine. Often seen in conjunction with FHP, rounded shoulder posture (RSP) occurs when the acromion protrudes anterior to the shoulder joint. Scapular elevation, protraction, and downward rotation are also seen. Several studies have found that this combination of FHP and RSP promote an imbalance in muscle strength and length leading to Janda’s Upper Crossed Syndrome:

  • Weakness of the deep neck flexors, middle and lower trapezius, and serratus anterior
  • Stiffness of the pecs, upper trapezius, levator scapulae, SCM and suboccipitals.

Together, these impairments can lead to dysfunctions at the OA joint, C4/C5 segment,  CT junction, or GH joint resulting in neck and/or shoulder pain and increased disability.

Below is a 3 part video series to help you gain mobility and build postural strength to combat our love affair with cell phones and laptops.

Blog Post written by Ashley Pena, DPT Student from Cal State Northridge. Ashley is currently in her final clinical rotation with me at Catz PTI.

References:

  1. Kim E-K, Kim JS. Correlation between rounded shoulder posture, neck disability indices, and degree of forward head posture. Journal of Physical Therapy Science. 2016;28(10):2929-2932. doi:10.1589/jpts.28.2929.
  2. Kim S-Y, Koo S-J. Effect of duration of smartphone use on muscle fatigue and pain caused by forward head posture in adults. Journal of Physical Therapy Science. 2016;28(6):1669-1672. doi:10.1589/jpts.28.1669.
  3. Kwon JW, Son SM, Lee NK. Changes in upper-extremity muscle activities due to head position in subjects with a forward head posture and rounded shoulders. Journal of Physical Therapy Science. 2015;27(6):1739-1742. doi:10.1589/jpts.27.1739.
  4. Upper Crossed Syndrome. Muscle Imbalance Syndromes RSS. http://www.muscleimbalancesyndromes.com/janda-syndromes/upper-crossed-syndrome/. Accessed June 13, 2017.

Is Your Lack of Ankle Mobility Increasing Your Risk for Knee Injury?

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By Ashley Pena, DPT Student
 According to the NCAA Injury Surveillance system, knee internal derangements accounted for the highest percentage of more severe injuries sustained by college athletes (44.1% in games and 25.5% in practices) and approximately 70% of all game and practice injuries affected the lower extremities. As a result of these studies, much thought has gone into what factors contribute to this in an attempt to prevent, or rehabilitate these injuries while decreasing pain and improving performance. Although there are many factors which have been found to contribute such as muscle weakness, body type, training factors and others, little thought is given to the ankle joint unless it is giving the athlete pain.
When a person lacks dorsiflexion range of motion, often times compensations begin to manifest such as excessive pronation or “fallen arch”,  hip external rotation or “out-toeing” during walking, or lack of knee flexion with landing, all of which can increase the valgus forces on the knee and decrease shock absorption which can place a person more at risk for ACL injury, meniscus injury, or collateral ligament strains. In a systematic literature review done by Mason-McKay et. al, strong evidence was found that a restriction in DF ROM alters landing mechanics with specific studies reporting that altered frontal plane ankle motion (inversion and eversion), reduced sagittal knee excursion, and greater peak knee valgus.
 Blog Post written by Ashley Pena, DPT Student from Cal State Northridge.  Ashley is currently in her final clinical rotation with me at Catz PTI.

Sources:

  1. Arendt E, Dick R. Knee Injury Patterns Among Men and Women in Collegiate Basketball and Soccer. The American Journal of Sports Medicine. 1995;23(6):694-701.
  2. Dick RM, Putukian M. Descriptive Epidemiology of Collegiate Women’s Soccer Injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 Through 2002–2003. Journal of Athletic Training. 2007;42(2):278-285.
  3. Kerr ZY, Marshall SW. College Sports–Related Injuries — United States, 2009–10 Through 2013–14 Academic Years. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448a2.htm. Published December 11, 2015. Accessed June 5, 2017.
  4. Mason-Mackay A, Whatman C, Reid D. The effect of reduced ankle dorsiflexion on lower extremity mechanics during landing: A systematic review. Journal of Science and Medicine in Sport. 2017;20(5):451-458. doi:10.1016/j.jsams.2015.06.006.
  5. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Llyod-Smith DF, Zumbo BD.  A retrospective case-control analysis of 2002 running injuries.  Br J Sports Med 2002; 36: 95-101.

5 Things to Do Before Going on a Run

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By Meggie Morley, DPT Student

It is well known that exercise is crucial for living a long and healthy life, but recent studies have shown that running may actually be the most effective exercise for increasing life expectancy. In a recent study by Lee et al., it was found that running can increase a person’s life span by 3 years, and reduces the risk of premature death by 40%. The researchers also noted that the benefits are the same regardless of pace, mileage, drinking and smoking or being overweight.

Hopefully studies such as this one encourage people to take up running, so here are a few things to do before going on a run to boost performance and minimize the risk of injury. The idea behind these exercises are to warm up the muscles and joints before running as well as “turn on” the muscles we want to be active while running.

1. Warm Up

Start by simply walking for a few minutes to increase blood flow and prime the joints and muscles for motion.

2. Walking Lunges with Torso Twist-Works: Quads, gluts, hamstrings


Step forward with the right leg into a lunge. Place your right hand next to the right foot then twist your trunk to the left while reaching the left arm up towards the ceiling.

3. Planks with Knee Drive-Works: Abdominals, hip flexors


Hold a high plank with the shoulder directly over the wrists. Alternate driving the knees towards the chest ten times. Then perform ten knee drives toward the same side elbow and ten toward the opposite elbow in order to engage both the rectus abdominus and the obliques.

4. Bridges-Works: Abdominals, gluts, hamstrings


The gluteal muscles are crucial for generating power and maintaining proper biomechanics down the entire lower extremity while running. Do three sets of bridges with a focus on keeping the core engaged and lifting the hips with the gluts in order to prepare the muscles to be active during running.

5. Alternating Lunge with Medial Reach-Works: Quads, hamstrings, gluteus maximus, gluteus medius


Step forward with the right leg into a lunge and reach out to the left with the left arm. Perform ten lunges then switch sides. This places more demand on the gluteus medius, which is important for maintaining proper pelvis alignment during running.

FullSizeRender 9 Blog Post written by Meggie Morley, DPT Student at Columbia University. Meggie is currently in her final Clinical Rotation with me at Catz Physical Therapy Institute.

References

  1. Lee DC, Brellenthin AG, Thompson PD, Sui X, Lee IM, Lavie CJ. Running as a Key Lifestyle Medicine for Longevity. Progress in Cardiovascular Diseases. 2017 Mar 30.
  1. https://www.nytimes.com/2017/04/12/well/move/an-hour-of-running-may-add-seven-hours-to-your-life.html
  1. Yamaguchi T, Takizawa K, Shibata K. Acute effect of dynamic stretching on endurance running performance in well-trained male runners. The Journal of Strength & Conditioning Research. 2015 Nov 1;29(11):3045-52.

Hamstring Strains: Article Review & Application

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By Tom Sutton, DPT Student

Before the 2016 Summer Olympics in Rio began, there was some speculation as to whether or not Usain Bolt would make an appearance in the Games. Reports had come out saying that he had sustained a grade I hamstring muscle strain during the Olympic Trials. Fortunately, injuries such as this are the most mild of hamstring strains and are very treatable in physical therapy. A hamstring strain is a common injury from activities such as sprinting because for better performance in sport, the hamstrings require power and increased activation. However, there are ways to prevent and rehabilitate this injury, which a physical therapist can help with. In a study by Valle et al, the investigators evaluate rehabilitation essentials for two different types of hamstring strain injuries.

Hamstring Muscle Injuries, a Rehabilitation Protocol PurposeBy Xavier Valle, Johannes I.Tol, Bruce Hamilton, Gil Rodas, Peter Malliaras, Nikos Malliaropoulos, Vicenc Rizo, Marcel Moreno, and Jaume Jardi

Hamstring strains can be classified as two different types when it comes to the mechanism of injury: sprinting or stretching injuries. Stretching injuries have been seen to have a higher time loss than sprinting injuries and involves movements of the lower extremity with the hip flexed and the knee extended.(3) The stretching injury is mostly located at the proximal attachment of the semimembranosus muscle.(3) As for the sprinting type of injury, it mostly involves the biceps femoris long head and the time it takes the athlete or patient to return to activities is shorter in relation to stretching.(2) This type of hamstring injury can become the focus of a physical therapist to analyze and evaluate the mechanics of a patient or athlete’s running. For example, the hamstrings play a huge role in the running cycle, with muscle activation peaking during terminal swing and early stance phases.(4) The therapist will also know to address hamstring pain, muscle length with stretching, strength and control during rehabilitation because if the patient wants to return to running, power will increase with speed.(4)

Addressing a hamstring strain will involve key physical therapy principles involving normalizing the patient’s muscle length, strengthening the muscles of the lower extremity through functional exercises and neuromuscular re-education for improved coordination of the hip and knee. Injuries have protocols and rehabilitative guidelines that can give the young clinician an idea of how a patient can progress, so minding the patient’s stage of condition and tissue reactivity is important before beginning an exercise program. One interesting point made in Valle et al’s study is the concept of elongation stress on hamstrings (ESH). This can be applied clinically by subtracting the knee flexion angle from the hip flexion angle by evaluating hamstring muscle stretch during functional activities. If the ESH is larger, then there is higher stress placed on the hamstrings. A therapist can apply ESH to the running cycle by knowing that the hip ROM goes from 70 degrees of flexion to 45 degrees extension and the knee ROM goes from 30-130 degrees of flexion.

In closing, addressing the patient holistically is the approach to take. Functional exercise programs that involve the entire body as opposed to just the hamstrings will probably benefit the patient more (Examples shown below in video). One of the more common pillars of exercise treatment include core muscle activation/strengthening due to the influence of lumbo-pelvic muscles during activities such as running.(1) With this, the therapist can address things such as anterior or posterior pelvic tilt, core muscle activation and education to maintain neutral spine during exercise and activities. Additionally, there is published work in recent literature stating that neuromuscular training which includes balance training and stability can decrease the risk of lower extremity and hamstring injuries specifically.(5) Knowing the patient’s mechanism of injury, presentation and impairments will help the clinician to apply the knowledge from this study properly and design an exercise program suitable for their patient.

For more information on Valle et al’s suggestions for examination, diagnosis and treatment, please visit this link here (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4691307/)

Below are some sample exercises, the key is to apply an appropriate load to healing tissues, ranging from isolated isometrics to closed chain, multi joint, multi plane complex movements.  

  1.  Hamstring Curl with BFR- Light load, tissue specific, no muscle breakdown and Growth Hormone release to promote collagen synthesis.
  2. Supine Dolly Curls- Bilateral sagittal plane loading with a focus on simultaneous eccentric hip flexion and knee extension.
  3. Single Leg TRX Squat- Assisted single leg sagittal plane deep squat loading without a balance challenge.
  4. Barbell Side Lunge- Asymmetrical frontal plane loading, hip mobility and tissue stretching with balance.
  5. Traveling Lunge + Anterior Medial Reach- Multi plane functional application of the hamstrings in eccentric and concentric closed chain loading.

img_7501 This blog post was written by Tom Sutton, DPT during his final internship with me at Catz Physical Therapy Institute as a DPT Student.  You can find Tom here @twsutt

References

  1. Valle X, L.Tol J, Hamilton B, et al. Hamstring muscle injuries, a rehabilitation protocol purpose. 2015;6(4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4691307/. Accessed March 23, 2017.
  2. Askling CM, Malliaropoulos N, Karlsson J. High-speed running type or stretching-type of hamstring injuries makes a di erence to treatment and prognosis. Br J Sports Med. 2012;46(2):86–7.
  3. Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain a ects  exibility, strength, and time to return to pre-inju- ry level. Br J Sports Med. 2006;40(1):40–4.
  4. Chumanov ES, Heiderscheit BC, Thelen DG. Hamstring musculo- tendon dynamics during stance and swing phases of high-speed running. Med Sci Sports Exerc. 2011;43(3):525–32.
  5. Hubscher M, Refshauge KM. Neuromuscular training strategies for preventing lower limb injuries: what’s new and what are the practical implications of what we already know? Br J Sports Med. 2013;47(15):939–40.

Physical Therapy as an Alternative to Opioids for Chronic Pain Management

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By Meggie Morley, DPT Student

In recent years there has been a rise of prescription opioid use in the United States. On the average day, 650,000 opioid prescriptions are dispensed and between the years 2000 and 2010 the amount of opioid prescriptions nearly doubled from 11.3% to 19.6% among all pain visits .  There are patient scenarios when opioid prescription and use is appropriate such as hospice, palliative care, and acute pain management, but for the treatment of chronic pain (pain lasting three months or greater) there is not clear evidence suggesting that opioid use is beneficial.

As the rise in opioid use becomes a national epidemic, the CDC has released guidelines for prescribing opioids for chronic pain.  The guidelines also recommend chronic pain management with non-drug choices such as physical therapy, cognitive behavioral therapy and weight loss. As opioids have side effects such as sedation, dizziness, nausea, dependence and respiratory depression, treatments such as physical therapy may be a beneficial alternative.

In a systematic review by Hayden et al, sixty-six studies were reviewed to examine the effects of exercise therapy for low back pain versus other conservative treatments or no treatment. 

Sixty-one randomized control trials met the inclusion criteria of evaluating the effectiveness of exercise on acute, sub-acute, and chronic low back pain. The outcome measures for patient improvement were both pain and functional scales. The authors concluded that exercise therapy is effective for decreasing pain and improving patient function among adults with chronic low back pain. The results for sub-acute low back pain were inconclusive, and exercise therapy for acute low back pain was determined to have the same effectiveness of other conservative treatments or no treatment.

The management of chronic pain is a complex issue, but education for both healthcare providers and patients on the various treatment options is critical for addressing the rise of opioid use in the United States. More information can be found on the APTA website, where they have started a campaign titled #ChoosePT to further discuss physical therapy as a method for treating chronic pain.

FullSizeRender 9Blog Post written by Meggie Morley, DPT Student at Columbia University. Meggie is currently in her final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources

Daubresse M, Chang HY, Yu Y, Viswanathan S, Shah ND, Stafford RS, Kruszewski SP, Alexander GC. Ambulatory diagnosis and treatment of non-malignant pain in the United States, 2000–2010. Medical care. 2013 Oct;51(10).

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opiods for Chronic Pain –  United Staes, 2016. MMWR Recomm Rep 2016;65(No. RR-1):49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.

Hayden J, Van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non‐specific low back pain. The Cochrane Library. 2005 Jul 20.

http://www.moveforwardpt.com/Resources/Detail/physical-therapy-vs-opioids-when-to-choose-physica

Dynamic Scapular Stability

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By Meggie Morley, DPT Student

A solid foundation of scapular stability is not only important for optimizing shoulder mechanics, but also the motions of the elbow, wrist, and hand. There are traditional methods of assessing and treating scapular stability, but several articles and studies are exploring new ideas and approaches.  In an article by McQuade et al, scapular stability was defined as “’normal’ scapula movement on the thorax during upper extremity motions.”

One of the core principles of scapular motion is the concept of scapulohumeral rhythm. The idea is that for every two degrees of humeral elevation there is a corresponding one degree of motion of the scapula.   For example, 180 degrees of shoulder abduction is comprised of 120 degrees of arm elevation and 60 degrees of scapular upward rotation. However, recent studies have shown that scapulohumeral rhythm can actually vary from anywhere between a 1:1 to a 6:1 ratio. Several factors such as external load, speed, fatigue, pain, and plain of elevation of the arm where all shown to affect scapulohumeral rhythm.

Traditional treatment methods have also tended to focus on identifying postural “abnormalities” in the scapula and correcting them through strengthening and stretching. However, a systematic review by Ratcliffe et al. studied patterns in subacromial impingement, and found that no ideal scapula position exists and deviations in scapula motion do not cause or contribute to subacromial impingement.  They found that there was evidence for scapula kinematic alterations in people with impingement, but the type and prevalence of those alterations were inconsistent. In other words, one person could present with the same kind of movement pattern and static scapular posture as the next person, but one could have impingement and the other could show no symptoms at all.

After taking these new studies into account there are several ways to optimize scapular mobility and stability for each individual patient. Regardless of the individual’s scapular posture or movement patterns, it is critical that the scapular stabilizers and upward rotators are properly firing before moving the upper extremity, specifically the trapezius and serratus anterior muscles.  Warming up the scapular stabilizers before a shoulder workout is important in order to ensure that the scapula will be optimally supporting the upper extremity.  Single Arm Plank variations are activities that require the scapular muscles of the stabilizing arm to activate in order to keep the rest of the body steady.


It is also important to train the muscles in the range of motion that is weak or required for certain sports and activities. This is demonstrated in the Isometric Band Hold + Rhythmic Stabilization drill. Demand is put on the stabilizing muscles of the scapula and core by holding the band steady as the practitioner attempts to move the arm out of position.

The concept of dynamic scapular stability is continuing to evolve as more studies are published. A focus on optimal scapular stability and mobility with an attention to each patient’s individuals needs is one way to incorporate both new and traditional treatment methods in order to achieve the patient’s goals.

 

FullSizeRender 9Blog Post written by Meggie Morley, DPT Student at Columbia University.  Meggie is currently in her final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources

  1. McQuade KJ, Borstad J, Siriani de Oliveira, A. Critical and Theoretical Perspective on Scapular Stabilization: What Does It Really Mean, and Are We on the Right Track? Phys Ther. 2016. 96:1162-1169.
  2. Inman VT, Saunders JB, Abbott LC. Observations of the function of the shoulder joint. 1944. Clin Orthop Relat Res. 1996; 330:3-12.
  3. McQuade KJ, Smidt GL. Dynamic scapulohumeral rhythm: the effects of external resistance during elevation of the arm in the scapular plane. J Orthop Sports Phys Ther. 1998 Feb; 27(2): 125-33.
  4. Mottram, SL. Dynamic stability of the scapula. Manual Therapy. 1997 Aug 31; 2(3): 123-131.
  5. Ratcliffe E, Pickering S, McLean S, Lewis J. Is there a relationship between subacromial impingement syndrome and scapular orientation: a systematic review [erratum in: Br J Sports Med. 2014;48:1396]. Br J Sports Med. 2014; 48: 1251-1256.