The Golf Ball Analogy
Shoulder pain can be a delicate game, much like balancing a golf ball on a cue. For the size of the ball, the cue is quite small, which introduces an element of instability. The same goes for the ball and socket joint of the shoulder.
In the shoulder, the ball is secured in the socket by four rotator cuff muscles on each shoulder. The rotator cuff muscles orchestrate a harmonious force that propels the humeral head (arm bone) into the socket, facilitating seamless and pain-free motion.
Understanding the Root Cause of Most Shoulder Issues
When the integrity of a rotator cuff muscle is compromised through weakening or tearing, the shoulder's stability undergoes a decline, setting off a chain reaction of issues. In fact, a compromised rotator cuff may serve as the underlying culprit behind various complications such as muscle strains, impingement, bursitis, labral tears, and even arthritis. The aging process and overuse contribute to the weakening of the rotator cuff muscles, amplifying the vulnerability of the shoulder's stability. This instability, in turn, triggers shearing forces in the joint, causing microtrauma to the underlying structures.
The specific repercussions, whether manifesting as impingement, bursitis, labral tears, or other conditions, hinge on the nature of the rotator cuff issue and the individual's activities. Fundamentally, the interplay of genetics and force vectors becomes the determining factor in the manifestation of shoulder complications. Understanding these intricate dynamics is crucial in addressing and managing shoulder issues effectively.
Fixing the Root Cause
If it all stems back to the rotator cuff, why not fix the cuff? First and foremost, surgery has various outcomes and once you have surgery, there’s no going back. Also, it’s the only treatment option with a risk of death. Furthermore, the root cause of most rotator cuff issues is fatty infiltration of the cuff which leads to deterioration of the muscle. This is largely genetic and surgery does not stop fatty infiltration. While research is underway, there is currently no treatment option for fatty infiltration of the cuff.
So why not simply strengthen the rotator cuff muscles? While good in theory from a physics perspective, this also fails to address the issue of fatty infiltration. The rotator cuff has a mileage expiration date. If something has a mileage expiration date, you do not want to run it into the ground. Unfortunately this is why most therapy fails, but there is a solution.
A Scientific Approach Backed by Quality Research
The solution lies in understanding the difference between symptomatic versus asymptomatic rotator cuff tears. If you are to MRI a thousand shoulders, you will find hundreds of rotator cuff tears, but maybe only half of these people will have pain. The other half of these people will have no idea that anything is wrong with their shoulder despite having a rotator cuff tear. This indicates alternative forces at play, such as the anterior deltoid and teres minor.
The anterior deltoid and teres minor collectively produce a force vector akin to the rotator cuff muscles. This takes the burden off of the torn rotator cuff and allows for non-injurious pain-free shoulder motion. Furthermore, the anterior deltoid and teres minor are not commonly affected by fatty infiltration and focusing on these muscles offers a holistic approach to treatment. By reestablishing the proper force vectors in the shoulder, this addresses a root cause and can therefore lead to improvements with strains, bursitis, impingement, instability, labral tears, cuff tears, and arthritis.
Step 1: Becoming Pain Free
In the realm of injuries and joint issues, a cardinal rule persists: if it causes pain, abstain. Regrettably, a prevalent misconception emerged in America, championing the mantra of "no pain, no gain." It's time for a paradigm shift—a motto that advocates "less pain, more gain." Steer clear of repetitive overhead motions, particularly those involving rotational movements, as this can lead to overuse and subsequent wear and tear of your rotator cuff muscles. Also, exercise caution with activities like bicep curls, upright rows, and shoulder presses.
Sadly, numerous therapists still prescribe these exercises, even witnessed in nursing home rehab sessions, which is not only egregiously misguided but also a major contributor to cuff tears. Beware of ill-informed advice; these exercises are proven culprits in causing issues rather than offering a cure.
Beyond injury prevention, modifying your movement patterns is imperative. Assume a position with your arms outstretched in front, thumbs up and approximately a yardstick apart. This places your shoulders in scaption, which activates the anterior deltoid. Conversely if you turn your thumbs down, this stresses your rotator cuff which is ill-advised. Maintaining a yardstick distance opens up the shoulder joint, creating an open-packed position that minimizes friction and wear and tear. So when you raise your arms, keep your thumbs up and about a yardstick apart. For an in-depth understanding, explore the concept of the scaption plane of motion.
Step 2: Regaining Pain-Free Motion
Leveraging electromyography (EMG) data, we've identified specific exercises that isolate the anterior deltoid and teres minor, providing proven compensation for the rotator cuff. What sets these exercises apart is their ability to focus on the therapeutically beneficial muscles without stressing the injurious rotator cuff muscles. This unique approach not only enhances strength but concurrently fosters joint health, restores functional stability, and relieves pain.
Supine arm elevation (anterior deltoid): Lay on your back. With your thumbs pointed up, slowly raise your arm to 90° without surpassing the height of your shoulder. Then slowly lower your arm to the starting position. Work up to 4 sets or 12 reps.
Serratus punch in plank (serratus anterior): Assume a plank position on your forearms. Now thrust your shoulders towards the floor and concentrate the contraction in your upper back. Then draw your shoulders back, pinching your shoulder blades together. Your elbows should not move the entire time. Your shoulders and shoulder blades create the movement. A “pushup plus” is the more advanced version of this exercise. 4 sets, 12 reps.
Supine external rotation (teres minor): Lay on your back. With your elbows maintaining a 90° bend, rotate both shoulders outward so that your hands move towards the floor. Your elbows should remain pressed to your body and act as the hinge of a door. The movement occurs in the shoulders and should mimic a door opening and closing. Focus the contraction on the back parts of your shoulders. You may use a TheraBand for added resistance as safely tolerated. You may place a towel roll between your elbows and body for added comfort as needed. 3 sets of 12 with light resistance.
Now, while abstaining from a detailed breakdown, it's essential to acknowledge the significance of the serratus anterior and mid and lower trapezius in your shoulder health journey. Strengthening these muscles contributes positively to overall shoulder function as well. Additionally, engaging in targeted stretches for the posterior capsule of the shoulder can yield favorable outcomes in most cases.
Supine band pull aparts (middle and lower trapezius): Lay on your back. Hold a taunt TheraBand above your chest with your arms straight and your thumbs pointed up. While maintaining straight arms, pull the band apart across your chest and concentrate the contraction in your upper back by pinching your shoulder blades together. Then slowly return to the starting position. Your arms should remain straight the entire time. Your shoulders and shoulder blades create the movement. 4 sets, 12 reps.
Conclusion
If you're experiencing shoulder pain and seeking expert guidance, explore my online therapy platform, PTrehabdoc.com, or visit my brick-and-mortar clinic (info at MiddletownPT.com). Don't let persistent shoulder pain hold you back; with evidence-based methods and a proper diagnosis, there's hope for improvement. Your journey to pain-free shoulders begins with the right guidance.
Note: The information provided in this blog post is for educational purposes and should not replace professional medical advice. Always consult with a qualified healthcare professional for personalized guidance.
