Categories
Region Specific Uncategorized

Shoulder Pain: “Why does it hurt so much?”

There exists a lack of association between findings on MRIs and pain. In other words, what is seen and reported from an MRI may have all or nothing to do with the pain you are experiencing. There is plenty of evidence that people who have no pain will have positive findings on an MRI.

Much of the approach at Move Physio is geared towards addressing all the other structures in your body that may be causing undue stress on painful parts such as your shoulder. If we treat those other structures the shoulder eventually stops hurting. Pain is a “good” thing, a “sign” that should not be ignored.

But, (the reason you are reading this) why does your shoulder hurt so much? You can’t sleep, raise your arm, throw, etc. A sprain or strain (including partial and full tears of the rotator cuff) likely does not explain your level of pain. Instead, it’s your body’s healing and protective response.

Yes, healing hurts. Even though it hurts, inflammation is a good thing. It is your systems way of repairing by eating up the dead cells and laying down new tissue. During this process, a protein called interleukin is released to help the healing process. This protein alone may contribute to an abnormally increased sensitivity to pain known as hyperalgesia. Furthermore, those with rotator cuff-related pain have high concentrations of other substances (substance P and pro-inflammatory cytokines) released in response to stress for defense, protection, and repair purposes. Yes, healing hurts, and you’ll feel more pain relative to the actual damage. In my experience as a clinician, a healthy but exquisitely exacerbated shoulder is quite common and is unique among the other joints of your body.

A painful experience is further complicated by the brain. Your body is responding to heal the tissues and your brain is reporting the resulting pain. Pain is always an output from your brain. Your brain wants to protect you. Alarming you through the use of pain is one very powerful way for the brain to say, “Hey, don’t do that.” That is why re-establishing appropriate movement with less pain is effective for long-term outcome as it takes the threat away. Without that threat, your brain can relax and not output so much pain.

Here are some important steps to recognize during your path to recovery:

1. Shoulder pain is a sign. Have us figure out what is contributing to the reason for that pain.

2.  Understand that healing hurts and may take some time. Follow step one to keep it from having to constantly heal and return to pain.

3. Do not be afraid of appropriate movement with limited or no pain. Instead, stop movements that exacerbate the shoulder. “Motion is lotion” for joints as continued pain-free movement can decrease the threat. Too much inappropriate movement leads to increased healing and threat, perhaps resulting in why you decided to read this blog post.

Categories
Methodology & Techniques Region Specific Uncategorized

Access Your Ankles – Reduce Pain and Enhance Performance

Do you wish you could squat like that?

Proper ankle mobility is important for most of our functional and higher level movements. Specifically, decreased dorsiflexion, or bending of the ankle (the foot getting closer to your shin), will likely add undue stress on joints up the chain including knees, hips, and the spine. If you cannot access your ankles well, you will have to borrow (compensate) extra movement from those other structures. From lesser to greater extents, dorsiflexion is utilized during walking, running, stair negotiation, and squatting. Here is a classic example of a test that illustrates the impact of decreased dorsiflexion on deep squatting. This is a test that you can do yourself. This “deep squat” is limited in depth:

 

 

The addition of a 2×4 under the heels decreases the need for dorsiflexion, allowing for greater depth. Although there may be more to this including hip and spinal mobility and control limitations, the ankles in these pictures are the limiting factor in a functional squat:

Another test you can try yourself requires only a wall and floor. Keeping your foot completely flat, bring it away from the wall as far as you can while still being able to touch the wall slightly with your knee. Measure the distance between your toes and the wall. Roughly speaking, this measure should be approximately 3 to 6 inches depending on your specific needs. Take note of what you feel when you do this test, either a stretch feeling behind the ankle and into the calf, or tightness and possibly pinching in the front of the ankle. The first picture illustrates limited dorsiflexion.

This is better:

How much should you have? That depends on what you need it for. If you squat (whether it’s for strength training or tying your shoes) or walk or run up hills or stairs, you will likely need more. Many of my high level and younger clients are lacking this range of motion, which is likely a reflection of how we move or don’t move in our society. It is also what prompted me to write this blog post.

If you noticed tightness or a stretch feeling behind your ankle and/or in your calf, then the muscles and tissues of your calf and Achilles are likely the limiting factor. You may try adding a typical runner’s wall calf stretch (not shown) to your routine. However, soft tissue mobility may be restricted. We find it helpful to gently loosen these tissues and calm the muscles down with some self mobility using either a rumble roller:

– Or a lacrosse or tennis ball:

There is no need to force anything. Keeping your calf relaxed, slowly roll your muscles over the points of the rumble roller or over the ball until you find a stiff or semi-tender spot. Let that spot “melt” over the point for 30 seconds or so. You can then get those tissues to move by slowly dorsiflexing your ankle back and forth.

If you had felt a pinch, stiffness or block in the front of the ankle during the test, then it’s possible the ankle joint (talocrural joint) is the restriction. One optional self-mobility technique I prescribe for this uses a pull-up assistance band. This is a great tool for mobilizing ankles and hips and can be purchased fairly cheap in stores or online. Just make sure you anchor it to something very stable (such as a squat rack):

In this position, keeping your foot and heel flat on the ground and keeping the band where the ankle meets the foot, gently lunge your knee forward thereby dorsiflexing. Perform 10-20 times.

This serves only as a basic guide to self-assessing your ankles and does not discuss other reasons you may have difficulty with your ankle mobility or functional movements such as a squat. The numerous bones and tissues of the ankle and foot, the knees, hips, pelvis, spine and trunk may all be factors. Only a thorough assessment can help identify these factors. Once found, manual and exercise therapy directed at these problem sites can help make your movements looser and more efficient.

 

Categories
Condition-Specific Region Specific Uncategorized

Close the Gap – Preganancy and Diastasis Recti

Notice a bulge in your abdomen post delivery? It could be diastasis recti, which develops initially post-pregnancy due to lack of strength in your lower abdominal muscles (transverse abdominis, obliques, deep fibers of psoas and quadratus lumborum) that work as a corset to support the anterior structures and lumbo-pelvic spine. In the third trimester as the baby grows, if there is not enough strength and stability in those muscles, it pulls on the anterior wall – which can lead to the diastasis recti.

You can self-assess by laying on the back with knees bent, putting three fingers across midline at the level of belly button and lifting your head off the surface about an inch. If you notice a gap of over 1 finger width… that confirms diastasis recti!  But don’t worry!  It can very well be treated successfully with manual therapy, which focuses on assessing and treating specific visceral organ restrictions during and after pregnancy. Training the deep core stabilizers after manual therapy can prevent back pain and make future pregnancies much easier on the body.

Categories
Condition-Specific Region Specific Uncategorized

Pregnancy is no excuse for back pain

Pregnant with low back pain? Uncomfortable with being in one position for long? Afraid to keep taking medications because you are worried you’ll hurt the baby? Difficult to continue to function and keep up with physical activities? Back pain during pregnancy is very common. You are going through a lot physiological changes in your body, but you have been wondering why is it just on one side more than the other or why is there tingling/numbness only on one side?

Back pain is usually caused by underlying mechanical restrictions in the tailbone, pelvis or hips and their connecting structures.

With pregnancy as the pelvis widens to prepare for birth all these structures need to be efficient enough to go through the normal physiological change BUT if there is a restriction (which didn’t present itself before pregnancy) now as the body is under more load starts to present itself as pain, stiffness or tingling and numbness in the legs.

Hands on therapy can help you find the root cause of the pain and treat the dysfunction to allow the natural change in the system to occur efficiently and without pain to prepare you for easier childbirth.

Categories
Region Specific Uncategorized

Your Neck Isn’t the Problem

Your neck hurts and yet it’s not the problem.  If anything, your neck has been doing a great job of picking up more than its fair share of load and range of motion.  Neck pain results from the neck compensating for other structures in the body.  The structures are not doing their job. Restrictions and decreased mobility of the tissues of the chest and sternum, ribcage, shoulders and thoracic spine (upper and mid back) force the neck (cervical spine) to over-exert.  Moreover, this increased compensation and exertion is further exacerbated as it works over-time over the course of a long day. It is important to identify and treat all the associated structures responsible.

A proper examination will identify associated structures that are not performing as intended.  Once these structures “free up,” the neck may also need some hands-on work and exercise to restore full and efficient movement.

Categories
Principles Region Specific Uncategorized

Cut It Out: Hamstring Stretches!

It’s got to be the most common stretch of all time…and potentially the most worthless.

“…but my hamstrings are always so tight!”

 

First, let’s explore why most people have tightness in the back of their thighs.  In my experience it usually involves poor mobility of your Sciatic Nerve.  This thick nerve runs down the back of your leg and is most known for the symptoms of ‘Sciatica’, where it gets squished, pulled or trapped by some other structure. When you sit a lot (most of us), the soft tissues get mashed together and lose their ability to slide and glide on one another (mobility).  If the nerve gets stuck and can’t slide with the movements of your joints, it gives the nerve a pull.

Nerves don’t like to be stretched, because too much pulling can damage them.  So, your brain will protect a nerve from being stretched by tightening the tissues around it and limiting your movement…which gives you that tight feeling.  Want to know if it’s your nerve you’re feeling?  Bring your chin to your chest, then back up while you’re in a stretch…if the intensity changes, it’s the nerves you’re pulling on!

“Stretching can’t be bad, right?”

 

How do prolonged stretches actually work?  After about 30 seconds or so, the muscle is forced to relax, allowing it to lengthen.  So, by holding those Hamstring stretches, you are actually turning off the Brain’s way of protecting the Sciatic nerve!  So, yes…stretching can be bad.  We have had far too many cases of clients with back pain or Sciatica that come to see us because their therapist or trainer kept making their pain much worse.  The most common reason: they were yanking on nerves.

 

PRO-TIP:

Work on the mobility of your soft tissues.  Self-massage using your fist or a tool can help separate the layers of tissues, regaining that much-needed slide and glide…just go easy on yourself.😉

Categories
Region Specific Uncategorized

3 of the Worst Shoulder Exercises for Shoulder Pain

Rotator cuff exercises (internal or external rotation) with a band.  Your rotator cuff is probably not weak or the reason you’re in pain  It is stressed out and overworking. Rotator cuff exercises for a painful shoulder will likely make things worse.  Almost every time a client who comes to us after having failed somewhere else reports that they were doing rotator cuff exercises. 

Deltoid raises.  Front or lateral, efficient and safe deltoid raises require your entire shoulder girdle, spine, and core to be mechanically sound and responsive.  This probably isn’t the case if you are having pain. Without these characteristics, more compensation will occur at the shoulder joint and painful structures.

Pec stretching.  Lengthening limitations in pectoralis minor and major may be part of why your shoulder hurts, but stretching a taut, protective muscle probably will not loosen it up.  A typical corner or wall pec minor stretch puts pressure on the front structures of your shoulder including the capsule and ligaments. This could create more mobility where you do not want it or further irritate already painful structures.

What you SHOULD do…

Is find out WHY your shoulder is being overworked! Sometimes its your ribcage, the neck, or the nerves that are responsible.  When the true cause is identified and fixed, the shoulder becomes instantly more stable, strong and mobile…without pain

Our Physios perform a full-body assessment and can tell you what parts of your system need work.

Categories
Region Specific Uncategorized

Weak Ankles?

At Move Physio, we see a variety of orthopedic conditions in which we determine that the ankles and feet are at least partially responsible for. These conditions include knee, hip and even back pain. But what happens when the ankle has been injured, is weak or painful? As often as we see ankles with limited mobility, we also hear patients describe a history of “weak ankles” resulting in or from ankle sprains. Traditional rehabilitation in a typical physical therapy facility may incorporate an elastic exercise band for strengthening of the ankle musculature directly involved with the ankle. Even Consumer Reports published these exercises for preventing or fixing ankle sprains:

In terms of the big picture, I have a problem with these. These exercises do not resemble movements that we make in real life: walking, running, stair negotiation, or any functional activity that consists of our feet being on the ground. Look again at the pictures above. Do these resemble anything you do in real life? The gas and brake pedal are about the only things I can think of. Exercise band and ankle isolation exercises may be an appropriate start if weight-bearing is not allowed or is too painful. However, there is a lot more likely involved when a person describes his or her ankles as “weak.” The trunk (including the core), pelvis, hips, and the rest of the lower extremities, although far from the ankles, contribute greatly to overall function of the ankle. These regions “act on” the ankle. Greater efficiency above makes for less demand on the foot and ankles. As you’ve probably heard: “It’s all connected.”
Why is this important? It is because too many rehabilitation programs for “weak” or sprained ankles rely primarily on the exercises above. I question whether these types of exercises are doing anything at all. Minimal strengthening of the small muscles around the ankle will likely do very little the next time you run, jump, pivot or negotiate steps.
Do your ankles feel weak, roll or sprain easily? The key dysfunction may be from up above. If true weakness is found in the ankles then functional, foot-on-the-floor activities and exercises that target these muscles may be more appropriate.

Dr. John De Noyelles, PT, OCS, CSCS

Categories
Region Specific Uncategorized

Knee Pain? Treat the hip.

Your knee hurts.  It’s been annoying you for a few weeks or months now, but you’ve been too busy to get it checked out.  Finally, you schedule an appointment with an orthopedist who gives you a knee-related diagnosis and writes you a prescription for physical therapy.  Or, you were aware that you could skip this step and you venture directly into an orthopaedic Physical Therapy clinic.  You tell your PT that something is wrong with your knee including when it started and what you were doing when it started.  After a thorough examination, the PT tells you that your hip muscles are weak and your hip and ankle mobility are limited.  Apparently, the PT did not understand that it’s your knee that hurts.  Time for a second opinion?  Probably not.

We often experience pain in a location that’s actually not the problem, while the true problem spot hides its devious self.  In the physical therapy world this is called Regional Interdependence, where one dysfunctional region is responsible for pain in another region.  The knee and hip relationship is no exception to this and provides a great example.

The knee is a joint that works in three planes of motion and is not limited to simply bending and straightening.  In fact, it rotates when you bend and straighten your leg and when you pivot.  This rotation is not a lot, but it’s significant enough so that you don’t walk around like a robot.  The hip on the other hand is a ball and socket joint that specializes in rotation.  But what happens if the hip, for one reason or another, loses some rotational mobility?  Well, if you were to pivot, squat, or perform an activity that requires rotation of the hip it’s not going to be there.  Something else, such as the knee, has to pick up the slack.  So now the knee is responsible for more rotation than it’s used to and it begins to let you know.  Again, that pain is like your car’s check engine light and you need to bring your car into the shop (or more appropriately, a physical therapy clinic) before things get worse.  You may have heard this: “It’s all connected.”  Truly, the knee and hip are connected.  The femur (thigh bone) is the same bone that makes up the hip and knee joints.  That means that hip muscles function for the knee, helping to promote and control our movements including rotation. 

Please recognize that this is only an example before you Google to find hip exercises, stretches, and mobility techniques for your knee pain.  The problem spot may be beyond your hips and involve your foot, ankle, pelvis, spine, and possibly more.  The problem may also be right at your knee, requiring treatment to where it actually hurts.  Only a thorough examination will tell. 

Dr. John De Noyelles, PT, OCS, CSCS

Categories
Region Specific Uncategorized

Nagging Shoulder Pain?

If you have undergone previous therapy for shoulder pain then this exercise may look familiar:

If it looks familiar and you still have a painful shoulder, then maybe this exercise was not the most effective or appropriate. This exercise is one of several cookie-cutter activities for the rotator cuff. It is a standard go-to in the majority of orthopaedic and sports physical therapy clinics and proclaimed “cure” when searching for self-help for shoulder pain on the Internet.

More often than not, I find that these exercises do not help and may even increase pain. For most, the rotator cuff is already on fire and overworked. Trying to strengthen muscles that are working over-time is not the best method. Instead, addressing other limitations (such shoulder or spine mobility, for example) is a great first step.

Rotator cuff exercises are not necessarily “bad.” They may be appropriate with decreased pain AND strength. If I use them (which is rare), I like to customize and have my patients perform them in more functional patterns that mimic daily activities required of that patient.

The bottom line: there is so much more that can be done, with either exercise or manual therapy, which may better address your shoulder pain.

Dr. John De Noyelles, PT, OCS, CSCS