Shoulder Rotator Cuff, Shoulder Impingement, and After Shoulder Surgery...

It is estimated that Rotator Cuff (RTC) Disease increases with age and affects roughly 4% to 32% of the population.  The Rotator Cuff muscles and tendons keep your shoulder in its socket and much more.  The Scapula also known as the "Shoulder Blade" is probably one of the most unassuming yet critical of all components of the shoulder.  Most of the population believes it's just part of their back yet it is extremely complex.  There are 18 Muscles that connect to the scapula but the specific muscles of "The Cuff" region:  Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis (SITS) join a set of critical tendons which are often what surgeons are assessing when they discuss Rotator Cuff (RTC) injury. 

Shoulder Impingement is typically a compression or entrapment of the Rotator Cuff (RTC) Tendons leading to inflammation.  This is happening roughly at the end of your collar bone by your shoulder joint.  This is believed to be one way that the RTC Tendons become injured and even torn (other thoughts are aging, overload, etc..)  Most often shoulder complaints from shoulder irritation are brought on through sports and occupation- the latter likely due to repetitive stresses.  Raising the arms above shoulder level in an occupation or sport, regularly and repetitively, increases the probability of shoulder problems.  Irrespective of initial insult to RTC tissues, poor movement patterns can exacerbate a shoulder problem and should be corrected.  Sometimes we go from an inflamed tendon to a torn tendon because we don't address faulty movement patterns.  *Cumulative trauma to RTC tendons are believed to cause the majority of Rotator Cuff Tears. (Fig.6)

The Rotator Cuff tendons are always at risk and should be protected through methodical shoulder movements, correct posture, stretching, and minimizing overuse and trauma.  Forward slumped shoulders/posture closes the space around RTC tendons.  Improper posture does play a role in shoulder pain and shoulder problems.  Muscle weaknesses, muscle strength imbalances, poor posture/ form, injury, etc... all alter mechanical balances and load distributions which can negatively affect the Shoulder tissues leading to pain, weakness, loss of function, debilitation, and possibly surgery if not corrected.    

Shoulder Physical Therapy Programs are often asserted to improve the area around the RTC Tendons and usually include highly specific stretching and strengthening.  Initial goals may be to relieve pain but ultimately to correct dysfunction, return to proper functioning, and keep the RTC muscles and associated tendons safe from injury.  

Post-Operative Shoulder Rehabilitation Programs are very specific to the surgeon and dependent on to what and where their repair is performed.  Surgeons have their own protocol to follow after surgery and it is imperative to listen.  Typically for a Rotator Cuff Repair the primary goal is maintaining the integrity of the repair while: gradually increasing Range of Motion, Lowering Pain and Inflammation, and minimizing Muscle Atrophy.  Most RTC Rehabilitation protocols Do Not allow: heavy lifting, supporting bodyweight with hands and arms, jerking motions, nor excessive behind-the-back movements even at 6 weeks post-op.  "Repair tissue does not reach maximal tensile strength for a minimum of 12–16 weeks post repair." (Int J Sports Phys Ther. 2012 April; 7(2): 197–218.)  It is important to understand what "Passive Range of Motion" means.  For a surgeon-defined time after your surgery, only your therapist will be moving your arm.  This could be 4 weeks.  In this defined time period the surgical repair site cannot stand active muscle contractions by the patient--the forces are too great on the surgical repair.  Active motion of the arm by the patient is added later in your rehabilitation.  Your Physical Therapist will carry out your surgeon's protocol so no worries.

Keep your shoulders healthy.  One good practice is to "Love what You Lift" carrying objects close to your body.  When surgery is needed listen to your Therapist and Surgeon carefully to guide you through Physical Therapy with the best results.

Rotator Cuff Tear.  (Credit: Nature.com)

A little about that Trick Knee, OA, DJD, and ROM!

Knee Replacement , Knee Resurfacing, TKA, TKR, etc....  Approximately 650,000 of these were done in the year 2009.  63% percent of these were women and 96% were due to Osteoarthritis- aka, OA, DJD.  DJD is "Degenerative Joint Disease" and this speaks to the nature of the condition.  It is a normal aging process but you can definitely arm yourself to lessen the inflammation associated with this progressive condition.  

Ok, so what do I do to take care of my knee and what should I expect if I do have surgery?

• irst, today you stand (or sit) with all of the physical experiences you have encountered dating back to your birth.  This is deep, I know...  Accumulative stresses and past injuries can result in dysfunction.  If these affect the biomechanics of your knee it will likely lead to inflammation.  So first thing is to make sure we are assessed by a Physical Therapist if your doctor suggests dysfunction.  Recent research actually suggest Runners may not be accelerating Osteoarthritis as once believed.  But there is research to support High Level athletes and Performing Artists accelerating Osteoarthritis., e.g, Soccer Players, Ballet Dancers, Weight Lifters, and Table Tennis players.  It is likely that excessive "cutting", jumping, and rapid deceleration "degenerates" your joint while running has become a convenient scapegoat.  See Links Page.
• o what is knee Range of Motion and why do I care?  Well, you require a certain Arc at your knee to function- e.g., after Knee Replacement (TKA) many (but not all) people struggle for months to regain this Arc.  One of the most important measures is getting it Straight!  Why?  Bend your knee for a prolonged period and feel your thigh wanting to burst.  Straightening the knee moves a substantial load off the muscles.  It has been my experience that most TKA surgeons expect the knee to be straight by one month post-op.  All doctors have different protocols.  Some use CPM machines and others do not.  The most popular reason for a CPM seems to be early motion and blood clot prevention.
• What about bending my knee?  If you notice, sitting in a chair requires the knee to bend 90 degrees.  Climbing stairs requires about 80 degrees of bend.  Furthermore, tying your shoe demands 117 degrees of bend at your knee.  You can quickly see how important motion is to your everyday life.  Knee Replacement Surgery restores substantial function and reduces pain according to The American Academy of Orthopedic Surgeons.  Following surgery expect excessive Physical Therapy and the use of a cane or walker for weeks.  Avoid Smoking as it slows healing.  If you are not in Rehabilitation almost immediately after surgery-- ask questions...  In the first month, typically there is no: jumping, kneeling, or bending. 
• Can I prevent OA?  Likely not as there is a genetic component and it is a natural aging process...  But you could slow it down dramatically if you maintain proper form and function through your life while correcting your body mechanics as necessary through rehab--minimizing excessive "cutting" according to the research.  Most knee replacements are metal.  Through airports show your knee to inspectors.  And a trick I noticed is that most airlines will allow the bag to be free of charge if you have a brace or medical device in your bag ;)

​(Credit: American Association of Orthopedic Surgeons)

​(Credit: American Association of Orthopedic Surgeons)

Joint Pain, Muscle Pain, Back Pain, Posture...

Whether discussing Acute Pain (rapid onset) or Chronic Pain (prolonged), we almost all experience it at some point.  The problem with ignoring it is that often without intervention, the pain can cause loss of function, injury, and/ or disability.  Perhaps the pain starts limiting your physical function and inhibits you from daily tasks like rising from a chair or even maneuvering stairs.  The American Physical Therapy Association reports about 1/3 of all of us have back or joint pain.  This is an alarming statistic.

This does not just happen in the elderly.  This happens from the active to the inactive and we likely all know someone experiencing it right now.  There is typically an underlying series of events that brought the pain on.  This could be simply overuse or underuse.  Often our bodies simply need to be re-educated.  If we move early to correct this pain we can often avoid surgery and injury.  If you look past symptoms, you can sometimes find faulty biomechanics that can be corrected with the proper Physical Therapy through a Rehabilitation Program.

Mechanical discrepancies within our bodies as the result of muscle imbalances can often be to blame for dysfunction.  Think of your posture and how it affects your lower back and your neck.  Sometimes muscles are shortened and tight while the opposing muscle becomes weak and elongated.  This piggybacks off of the stretching blog I posted recently.  Stretching in the proper manner can assist in rectifying these imbalances.  I must emphasize proper manner as improper stretching can injure you.  I recently heard a lecture that discussed a slumped inward posture even affects our hormones.  This is likely why when people stand erect and talk on the phone they feel more confident than when they are sitting and slouched.  Fatigue and depression seem associated with poor posture.  Whether depression or hormones caused the poor posture is not the point.  The point is that you are training your muscular and nervous system to follow this incorrect pattern that can lead to Pain.

Think about Golf or a Baseball pitcher.  They are often using one side repeatedly and this can cause a one-side imbalance.  For the most part our bodies crave symmetrical movements that allow normal function.  Think of this next time you repeatedly do a movement within a single direction on a single side repetitively.  Whether muscle lengths, scar tissue, or a host of other factors are causing you pain and dysfunction needs to be explored.  Find out today and perhaps you can avoid future injury.