Here’s a list of exercises I may prescribe for a person who complains of shoulder pain. I’m sure I’m missing a few, but my point is to illustrate that “shoulder pain” is a symptom, not a diagnosis. There's no universal fix for pain in the shoulder just like there's no universal fix for head pain or chest pain. I evaluate the person, make a diagnosis, and find the specific exercise a patient needs. Patients almost always get just one exercise at a time.
-seated cervical retraction
-seated cervical retraction-extension
-seated cervical retraction-extension-rotation
-seated cervical extension
-seated cervical flexion
-seated cervical protrusion
-seated cervical lateral flexion toward
-seated cervical lateral flexion away
-seated cervical rotation toward
-seated cervical rotation away
[all of the above also in supine]
[all of the above also sustained]
-seated thoracic extension
-seated thoracic lateral flexion toward
-seated thoracic lateral flexion away
-seated thoracic rotation toward
-seated thoracic rotation away
-seated thoracic flexion
-prone cervical retraction
-prone cervical extension
-prone thoracic extension
-supine thoracic extension over a fulcrum
[all of the above also sustained]
-shoulder functional internal rotation
-shoulder internal rotation
-shoulder extension with internal rotation
-shoulder horizontal abduction
-shoulder horizontal adduction
-shoulder functional external rotation
-shoulder external rotation
-shoulder internal rotation in flexion or abduction
-shoulder external rotation in flexion or abduction
[shoulder exercises also with resistance]
-shoulder caudal glides
[all movements may also be performed as clinician mobilization]
When discussing athletic performance, we think of coaches, strength and conditioning specialists, trainers, and so on, but my role comprises the foundation. Power, balance, and mobility are certainly trainable, but if your body is not fully normal to begin with, training will only get you so far. If performance prowess is your goal, you need normal nerve conduction, nerve extensibility, strength, mobility, biomechanics, etc. first. (Having no symptoms doesn’t mean everything is functioning normally.)
Consider jumping. If there’s even a slight derangement (painful or not) in the lumbosacral spine, the electricity supplying necessary muscles can be impeded. Tiny malalignments in the foot, ankle, knee, hip, or spine joints can affect strength, mobility, balance, and movement patterns with jumping. Abnormalities with muscles or tendons themselves (rare) will also impact jumping.
My expertise is in ensuring people have normal physiology before they go train to make it exceptional. (There are, of course, some allowances.) Perhaps most importantly, I teach people how to self-assess and self-treat so they can always perform with optimized physiology. It takes only minutes. I believe that many “off” days are due to minor, transient joint malalignments - which can easily be self-detected and corrected if you learn how. --Laura
The primary law with tendons is first clinically (not via imaging) ruling out that it’s not a joint problem masquerading as a tendon problem. Joint misalignments (spine and extremities) can cause pain in tendinous areas and inhibit muscles, which unfortunately leads many clinicians to treat innocent tendons. If the “tendon” is taking forever to heal, it’s likely not the tendon. Tendon/muscle pathology comprises a small proportion of problems.
When it’s indeed a tendon, rehabilitation is relatively straightforward. A tendon’s collagen often needs to be remodeled to become functional again. This is accomplished by regularly (several times per day) loading the tendon for a few months. It may never look normal again, however. Causes why the tendon became dysfunctional initially should be addressed, and proper spine and extremity mechanics should be ensured.
The load a tendon needs is individual-specific. I find the load that creates pain (about 6/10) for 15-20 minutes following the exercise - which may be isometric, concentric, eccentric, or ballistic. Once a load doesn’t meet that criterion, the load is increased so it’s effective. Tendon rehabilitation is largely about 1) ensuring it’s a tendon, 2) educating the patient, and 3) encouraging briefly painful self-management with limited office visits. -- Laura
Running is a wonderful activity which exercises our body’s musculoskeletal system and others. I encourage running for nearly anyone interested, but don’t advocate it being one’s only form of exercise. (Movement variety is key!) There are differing opinions when it comes to running; unfortunately, many are incorrect.
First, there is a correct way to run, just like there’s a correct way to pitch a fastball or land a ski jump. Small variations exist - and may be allowable - but remaining mostly injury-free requires correct technique. Yes, we have a “natural” way of running, but the stresses we place on our bodies over time usually change how we move. These stresses, when imbalanced, often lead to misaligned joints, tight muscles, restricted nerves, etc. If we have any imperfections, running, an extremely repetitive sport, will expose them. Something will give.
Secondly, though these frequent running injuries appear common for the recreational runner, I argue they’re not normal. When running correctly, every joint, tendon, etc. from our head to our toes moves in the biomechanical way it was intended. To ensure someone is moving correctly, I teach starting with the joints of the spine (the body’s fuse box) and going from there. -- Laura
Learn more about Robin McKenzie and the method he developed for treating patients. Dr. Yoav Suprun, DPT, Dip. MDT talks to Robin regarding posture, MRI use, exercise versus passive care, and more. Enjoy! --Laura
I have fielded this question a few times from people once I mention that I treat patients using movement. The difference lies mainly in the fact that I treat patients using a specific movement or two based on the patient’s individual issue. Yoga, on the other hand, includes many different movements. Yoga, additionally, is not meant to be medical intervention.
Do some people’s aches and pains go away with yoga? Of course. However, many people’s do not. And some people’s get worse. Certain movements within the course of a yoga class may be beneficial, some may be harmful, some may be inconsequential. When many movements are thrown one’s way, it is often difficult, if there is a change, to know what produced the change.
I appreciate yoga for getting people to adopt different postures and movements, apart from its other attributes. It is quite obvious that our daily movement lacks the variability found in a yoga class. I advocate any initiative that gets people to move more, especially in diverse patterns. I therefore believe yoga offers a wonderful form of exercise or self-care. In contrast, I do not believe it offers a wonderful form of therapy for a musculoskeletal problem.
I find the large majority of patients’ problems come from joints being slightly misaligned. These problems are commonly misdiagnosed, however, since out-of-whack joints can send signals along nerves to soft tissue. The soft tissue is then frequently deemed to be the culprit when it is not. I treat faulty joints by using movement to help them sit right again. This requires a movement with a specific direction, force, and time. I determine those variables as I assess the patient. That movement is then tweaked based on the patient’s response. Generally, within 5 visits, the headache, shoulder pain, sciatica, leg tightness, foot numbness, or low back pain is relieved.
Lastly, what I do is different from yoga simply because I am trained to diagnose and treat musculoskeletal disorders (also known as orthopedic disorders). That means I know how much joints should move, how much strength is normal, how bodies should move, and so on. Importantly, I understand when pain is a temporary necessity for therapeutic purposes and when pain is a warning sign and needs to be avoided. A large part of my job is teaching patients what is normal so they can self-monitor and prevent symptoms from returning in the future.
So please keep moving - in circles, up and down, side to side, and especially backwards. Its benefit cannot be overstated. But in the presence of a problem, remember that your problem is unique and thus requires a unique solution tailored to you. -- Laura
"Feeling better" and "getting better" are different. If you've been doing something for weeks/months/years that makes you "feel better," it might be time to learn how to actually "get better." Stretches and foam rolling that provide that temporary relief, for example, are RARELY getting to the root of the problem.
Do you stretch or foam roll consistently to alleviate symptoms? Leave a comment below or contact me if you want to brainstorm what's going on. --Laura
Just as important as the mechanical therapy I provide to patients to eliminate their symptoms is the education I provide regarding how to keep their spines healthy in the future. A terrific analogy I've learned from mentors enlists teeth brushing. Just as we recognize the significance of keeping our teeth healthy via flossing, brushing, and dietary habits, we should acknowledge that devoting a few minutes a day to our spines is a worthy endeavor. My goal with patients in this educational arena has two facets.
The first is simply teaching people to be aware of the movements and positions our spines adopt on a daily basis. Unlike our peripheral joints which tend to get a fair amount of both bending and straightening throughout the day, when we look at spines, the majority of people in the US spend their days in an imbalance in favor of forward bending (flexion). (The upper neck, however, is often hanging out more in a backward bent (extension) posture. Why? Because our lower necks are stuck forward, and we need to see ahead!) To be sure, certain manual jobs, or desk jobs in which the computer monitor absolutely has to be to your side, create movement imbalances in other directions. Likewise for someone who takes hundreds of right-handed baseball or golf swings per day or throws overhead regularly. Once this observational ability sets in - which undoubtedly takes time - the plan of attack is straightforward: reduce the imbalance. This is akin to reducing your teeth's exposure to deleterious foods and drinks.
The second piece to keeping our spines healthy, and preventing re-injury, is intentional movement. As I tell my patients, just as you brush your teeth twice a day, give your spine some good, healthy movement twice a day. In the most common scenario, this translates to bending backwards - all the way backwards - about ten times twice a day. Sometimes it is rotation or even bending forward. My patients leave my care knowing what their specific movement is.
Like most people, over my lifetime, my spine scale was heavily tipped in favor of forward bending. Sitting slouched at desks over books, slumping "comfortably" into couches and chairs, and later bending over patients added up to a lot of spine flexion. Did I ever bend all the way backward? Maybe a handful of times. It's no wonder I injured myself. Once I learned to look at how we position ourselves, however, I adopted several changes to narrow the gap between the amount of my spine's flexion and extension. Firstly, I almost always sit with a lumbar roll which places my lower spine (except L5-S1, which remains in 60% flexion in sitting) in extension, or at least neutral. If I don't have something to support me, I sit up straight, slouching only occasionally. Secondly, I spend more time lying on my stomach propped up on elbows while reading, watching television, or using electronic devices. Thirdly, given the choice, I often choose to stand instead of sit; for example, I will stand when using my computer on my high counter or when out at places like bars or concerts.
As far as the second component - deliberate movements - I have two go-tos. A few times a month, I'll notice I need to rotate my spine to one side so I'll do that. Most days, though, I move my neck, mid back, and low back into extension a few times. This tallies up to roughly 5 minutes per day, which is a more than reasonable price to pay to keep what I call the "body's fuse box" working correctly. -Laura
In late January I met a patient who had fallen in September, suffering the “terrible triad” at the elbow (coronoid and radial head fractures and a dislocation). After two surgeries to repair the damage, she contracted a staph infection which led to a third surgery and then a fourth when the wound didn’t close. Later she had physical therapy elsewhere which at times was extremely painful and at times disillusioning due to lack of attention.
At our first visit her elbow was stuck at a 90-degree angle, with a lack of forearm supination. Her shoulder on that side also demonstrated mild/moderate losses of motion in several planes consistent with adhesive capsulitis/frozen shoulder. Lastly, her neck was lacking motion in several planes. Subjectively, she did not report pain, but that it felt like a vice was around her elbow. Her ability to use her extremity for almost all tasks was obviously severely limited.
During our evaluation, I determined her homework would be pushing her elbow into extension and pushing her shoulder into flexion over the next few weeks, repeatedly. I asked her to push her elbow 10 times every 2 hours and her shoulder 10 times every 2 hours. The only equipment required was a surface like a table, and it would only take 2 minutes. A key ingredient to this exercise prescription was that it SHOULD produce pain when it was performed, but that the pain SHOULD NOT last outside of a mild aggravation up to about 15 minutes. An important piece of our encounter was also setting expectations. I explained that restoring motion in her extremity would take many months of her diligent work and that I was only needed very intermittently - mostly to steer the home program in the right direction.
This approach to physical therapy treatment was vastly different from what I had employed earlier as a clinician. Before, I would have prescribed a home exercise routine to be performed once or twice per day, including several motions at each joint. I would have recommended clinic visits 2-3 times per week. I likely would have used heat and then, after causing the patient pain, used ice. Now, instead, I was teaching the patient how to treat herself using one simple, quick exercise for each problem repeatedly throughout the day. I called a mentor to ask if this would really do the trick. Didn’t the patient need me? Soft tissue work? Mobilization? She advised me to give this approach time; if things didn’t improve then I would explore other options.
Our second visit was 6 weeks later. Due to having to take care of her mother, my patient related she had only done the exercises about once a day. However, the elbow had gained about 15 degrees; the shoulder was the same. I didn’t change her homework. At our third visit (in June) her elbow had opened an additional 30 degrees and gained a significant amount of supination. Her shoulder now lacked only about 5% of its total motion. She reported that the discomfort was decreasing and that she was gaining more use of her extremity, most notably with typing. During visits 4 and 5 this month I focused more on restoring neck and upper back mobility, giving her an additional exercise for homework. While I did some manual stretching of her elbow during our sessions, she was making herself better by doing a specific exercise repeatedly throughout the day.
The goal is to continue to improve motion at the elbow and spine and then reestablish strength. We’ll need to make sure there is no residual nerve tension as well. Despite the four surgeries and internal hardware, I am aiming for full restoration of motion and strength as I have learned the body has an amazing way of healing if it is consistently given the correct stimulus. This treatment approach (outlined by the McKenzie method of mechanical diagnosis and therapy) doesn’t just promote patient empowerment through self-treatment. It’s also safe, allows the patient to avoid unnecessary pain, and requires little to no bells and whistles. It’s a treatment model I wholeheartedly support. --Laura
I got to give my two cents for this article. My number one piece of advice made the cut: give your spine some extension (backward bending) to combat all the flexion (forward bending) you give it! All that flexion with workouts and daily life usually leads to an imbalance in your spine and injury.
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