Do you have pain in your shoulder and have no idea what could be causing it? Shoulder pain is actually one of the most common reasons people seek out physical therapy. Often times, the rotator cuff is the culprit. The rotator cuff is a group of four muscles: the infraspinatus, supraspinatus, subscapularis and teres minor. Together, these muscles provide stability for the shoulder joint as well as perform rotation of the shoulder. It is a very important muscle group that often wears down over time. The older we get, the more at risk we are for a rotator cuff tear whether it’s from overuse or a traumatic injury.

If you are diagnosed with a rotator cuff tear, physical therapy is typically the first line of treatment to work on improving the strength and stability of the shoulder complex. Often times, physical therapy is enough to regain normal function and allow for painless shoulder function. However, depending on the thickness of the tear and number of tendons involved, surgery may be needed. Maybe you’ve gotten to the point where you’ve tried PT and the next step is surgery. You’ve heard dozens of horror stories and are wondering what to expect… keep reading!

The surgical procedure to repair the rotator cuff is typically an arthroscopic surgery with very small incisions. The surgeon will insert an arthroscope, a small camera, which displays the picture onto a television screen and guides the surgeon through the repair. This is typically done as an outpatient procedure and is the least invasive surgical option. The complexity of the repair process will depend on whether the tear is a partial or full tear. If it is a partial tear, the area will be trimmed or smoothed, known as debridement. If it is a full thickness tear, the tendon will need to be reattached to the humeral head. The surgical incisions will be closed with stitches which will usually be removed around week two post-operative at your first follow up visit.

So you’ve gotten through the actual surgery, now what? You will typically be fitted to a sling and will go to your first physical therapy appointment two days post-operative. The sling is usually worn 24/7 for 4-6 weeks and provides protection for your arm while the tendons heal. During your first physical therapy visit, your therapist will remove the surgical dressing and evaluate the passive range of motion of your shoulder joint. Passive range of motion means your therapist will be moving your arm so your tendons and muscles are not contracting, potentially damaging the tendon repair. Each surgeon and protocol varies to some degree but the first few weeks of therapy will consist of your therapist stretching your shoulder passively.  The first few weeks of stretching are essential to restore the range of motion of your shoulder. One complication that can occur following surgery is adhesive capsulitis also known as frozen shoulder. This happens when the joint capsule “freezes” and tightens up, usually a result of your shoulder being immobilized in the sling all day. With adhesive capsulitis, restoring full range of motion can be very painful and take much longer. You might feel like you’re not doing much those first few weeks of therapy but being consistent with attendance and allowing your therapist to stretch the joint is essential to ensure full range of motion after surgery.

After the first few weeks of passive stretching, typically around week six, you can begin active range of motion and lifting weight equivalent to a coffee cup. Active range of motion means you are contracting your muscles to move your arm. You are no longer relying on your therapist to perform the motion. Your therapist will guide you through some gentle initial exercises and then begin to add in resistance for strengthening beginning around week 8-12. Together, you and your therapist will work to get you back to full strength and stability allowing your shoulder to withstand daily activities, work duties or athletics. The full rehab process can take 4-6 months or even longer so be patient with the process! Please don’t hesitate to reach out to us for any further questions or concerns regarding a rotator cuff repair.

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A great way to cool off and get some exercise this summer is to jump in a pool or lake. Swimming is a well-rounded workout with many great benefits including improving endurance, burning calories, and is a low impact workout which reduces stress and strain on our joints.  However, the shoulder is the joint that tends to take most of the load due to the repetitive overhead motion swimming requires, which can cause irritation and inflammation of the rotator cuff muscles causing the tissue to rub against bone. This is known as Shoulder Impingement.  This results in pain which can be experienced not only with activity but also at rest which may be confused with soreness.

Here are some symptoms to look out for:

• Shoulder stiffness
• Shoulder tenderness
• Weakness
• Decreased range of motion
• Pain when reaching above head
• Decreased activity tolerance

Stretching can be an effective tool to reduce the risk of injury and can be performed after your workout to ensure good mobility and recovery of the muscles used during swimming. The following stretches will focus on the lat muscles and pec muscles ,as well as improving mid back mobility to decrease excessive force on the shoulder and allow for proper alignment of the shoulder joint.

Here are a few stretches that you can try:

Doorway pec stretch

Stand in a doorway with one foot in front of the other. Place both arms on either side of the doorframe, with shoulders at 90 degrees.  Keep your chest up and lean forward until comfortable stretch is felt along the front of your chest. Hold for 20 seconds and perform 3 times.

Child’s pose

Begin on your hands and knees, slowly lower your buttocks towards your feet. And your chest toward the floor as you reach out to one the side. Hold 20 seconds and perform 3 times.  Repeat reaching out to the other side.

Thread the Needle

Begin on your hands and knees. Slide one arm along the floor and lower your shoulder towards the ground until you feel a comfortable stretch along your mid back.  Next bring that same arm back to center and reach up towards the ceiling looking at your hand.  Perform 10 reps. Repeat on other side.

Kneeling Thoracic Extension Stretch

Begin in a kneeling position in front of a table, bench or bed and place your elbows shoulder width apart onto the surface you are using. Begin to kneel back towards your heels until comfortable stretch is felt along your mid back. Hold 15 seconds and perform 4 times. You can hold onto a pole or stick if you are having difficulty maintaining the proper position.

If you are experiencing pain and/or are limited in tolerance to swimming, Contact Rye Physical Therapy and schedule an evaluation to see one of our physical therapists. We can help get you back in the pool!                                                                                                                              (top photo by freepik)

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Proper posture is something most of us struggle with. For as long as I can remember, my mom used to frequently remind me to stand up straight with my shoulders back. As a kid I never understood the importance of good posture. However, maintaining good posture has a lot more benefits than just looking better! What exactly is posture? It’s our bodies alignment/positioning in relation to gravity. Gravity is constantly exerting force on our body regardless of what position we are in. Proper posture places the body in position so that no area is overstressed, decreasing susceptibility to pain and injury. It applies to standing, sitting and laying down. Good posture will place the body in a position in which our body weight is balanced throughout our spine and lower extremities, decreasing stress on muscles and ligaments.

Some of the benefits of good posture include improved breathing, decreased spine and shoulder pain and decreased headaches.

Breathing: When it comes to breathing, being in a forward slouched posture affects our lung’s ability to fully expand as the muscles in the front of the chest begin to shorten. Sitting up straight with the shoulders back can improve our bodies oxygen intake! Oxygen is very important in all cellular processes in our body and can help to improve energy and healing.

Back Pain: Back pain is another big culprit of poor posture. While maintaining good posture, our body should be in a neutral position so none of the muscles or ligaments are being overwork, shortened or excessively lengthening. The postural muscles should be in an optimal muscle position to work correctly, expending the least amount of energy. If we are constantly in a poor postural position, changes will occur to the spine and musculature overtime including changes to the blood vessels, nerves and ligaments. This will disrupt our body from performing with correct biomechanics increasing the chances of injury and spinal wear down over time.

Headaches: Most people with poor posture operate in a position in which the head sits forward. Your head is equivalent to the weight of a bowling ball so when the head is positioned forward, the muscles must work much harder to keep your head positioned on your spine! This increased stress placed on the muscles within the neck and upper back causes them to tighten. When the muscles tighten, headaches can occur.

Shoulder pain: It’s one of the most common things us PTs treat! Improving posture will decrease the risk of shoulder pain and dysfunction. Majority of people will allow their shoulders to roll forward which occurs most often in a seated position. This forward roll decreases the space within the shoulder joint. It also causes the front muscles to shorten while the back muscles will lengthen. Decreasing the space within the shoulder joint alters the shoulders normal biomechanics and can cause pinching of several soft tissue structures leading to pain and increased risk of injury.

So, what exactly does proper posture look like? When looking at yourself from the side, your body should follow your head. All your major weight bearing joints should be in line with your ear. Imagine a line going from your head to your feet. Your shoulders, hips, knees and middle of ankle should be right in line with the middle of your ear. You should also have a slight curve within your low back.

Maintaining good posture can be difficult to do and rather fatiguing. You might notice a burning sensation in your upper back after a while when you try to maintain correct posture. This is due to the fact the postural muscles are endurance muscles. Not only do they need to be strong, but they also need endurance to avoid resorting back to the rounded shoulder forward head positioning so many of us are susceptible to. In order to build endurance of the postural muscles, we should perform exercises at a lower weight with high repetition. This will allow those postural muscles to continue to contract over a longer period. Below are several exercises to get you started on improving your posture.

EXERCISES THAT HELP IMPROVE POSTURE:

Rows: While pulling back on the t-band, squeeze your shoulder blades together. Make sure you avoid your shoulders from elevating while you pull. You can perform this exercise with resistance bands or on a cable system. Remember to perform low weight and high resistance. Aim for 30 repetitions and when that becomes a piece of cake, increased the resistance or cable weight.

Prone scapular squeeze with extension: While laying on your stomach, squeeze your shoulder blades together and then elevate your arms a few inches off the table. Lower the arms followed by relaxing the shoulder blades. You can eventually add in dumbbells when you can fly through 30 reps with no fatigue.

Doorway stretch: This is a great exercise to perform to stretch out the anterior chest muscles which often become shortened. You will stand in the doorway with your shoulders and elbows up at 90 degrees. You will then step into the door until you feel a gentle stretch in the front of your chest. Hold each stretch for 30 seconds and perform 3-5 sets.

Bilateral external rotation: To perform, hold T-band in each hand with your palms facing each other and then slowly pull your hands apart. Keep your elbows at your side while you pull. Aim for 30 reps.

Physio Ball Y’s: To perform, lay across physio ball. You will then straighten out your arms and raise them up in line with your head and then lower them back down. Make sure you keep your head in a neutral position. You can add dumb bell weights to make this exercise more difficult when ready. Again, aim for 30 reps.

Give these exercises a try and if you feel you need further help or have any questions or concerns, please don’t hesitate to reach out to us here at Rye Physical Therapy!

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By Kate Dulac Serodio, DPT, OCS

Recently Powerhouse Sports reached out asking Rye Physical Therapy to partner with them in caring for their athletes.  They have a great Baseball/All athlete training program and work hard to provide the best care for their athletes.  They offer onsite Baseball pitching & hitting development programs and strength & conditioning programs for all sport athletes.  They take pride in the programs they offer and strive to make sure they’re offering the best programs and are practicing injury prevention. Injury prevention is a top priority for Powerhouse.  Mike Montville, owner of Powerhouse Sports who works directly with the Red Sox believes the only real difference in what he offers at his facility vs the Pro’s is the access to resources. Onsite manual arm care is one of those resources he believes can be game changing for the youth athletes.   Mike is pleased to now be able to offer Manual Arm Care with the onsite Partnership of Hampton PT!

What exactly is Arm Care? Unfortunately, if you don’t know, you’re actually in the majority.  If you or your child are not performing routine arm care in-season and off-season then you’re at risk of injury and decreased performance. Arm care is a simple group of exercises that typically should target the rotator cuff, scapula, and forearm muscles.  It is essential for baseball players from youth to the professionals to perform their arm care program.  According to Mike Reinold, owner of Champion PT and the go-to Physical Therapist for the Red Sox “An arm care program is one of the foundational pillars of any baseball player’s program, however, it is often one of the most neglected areas.”  Despite this knowledge many athletes neglect this part of their training.  Neglect from independent arm care will result in decreased performance and increased risk of injury.   If you want to be like the Pro’s, consider not only being compliant with your independent arm care but also making Manual arm care a part of your individual arm care program.

“An arm care program is one of the foundational pillars of any baseball player’s program, however, it is often one of the most neglected areas.” Mike Reinold, Champion PT

Why would I need Manual Arm Care? Unfortunately, even with a dedicated independent arm care program athletes will often require or simply benefit from hands on therapy.   The literature shows that the more you throw the tighter and more tired you get.   It is very important that you maintain your strength with your routine arm care program but the reduction in mobility may benefit quickly and significantly from manual arm care.   Repetitive throwing results in posterior cuff tightness which can immediately result in a 10-degree reduction of internal rotation.   Cumulatively not addressing this can not only affect performance but can result in injury.  Manual treatment would be beneficial to target the pec minor, teres major and subscapularis as these are all muscles that internally rotate the shoulder while throwing and may require stretching or soft tissue release.  Again, adding this to your routine could be game changing for performance and injury prevention.

What are the different Manual arm care treatments? Hampton PT therapists have numerous techniques/certifications to address pain, joint mobility restrictions, muscle restrictions. Treatment options are:

DRY NEEDLINGhttps://ryephysicaltherapy.com/treatments/dry-needling/

Graston Technique® https://ryephysicaltherapy.com/treatments/graston-iastm-technique/

MANUAL MANIPULATION https://ryephysicaltherapy.com/treatments/spinal-manipulation

CUPPING https://ryephysicaltherapy.com/treatments/cupping

Manual Treatments “Arm Care” https://ryephysicaltherapy.com/treatments/manual-arm-care

We look forward to not only partnering with Powerhouse Sports but also with you.  We are eager to help you achieve your performance goals with a goal of being injury free! Give Rye Physical Therapy a call to discuss your young athlete’s (or your) arm care treatment.

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BY DYLAN CHISHOLM, DPT

As swell season is here for the avid surfer of the Northeast. We want to help make sure the biggest pain you have is getting in and out of the 6mm wetsuit and not your shoulders.  Due to the nature of the sport, surfing requires extensive strain through the shoulders.  Both paddling and the pop up are stressful repetitive movements of the shoulder.  Frequently, in the surfer, shoulder pain is the result of sub-acromial impingement syndrome.   Impingement is due to chronic and repetitive compression or “impingement” of the rotator-cuff tendons and the bursa in the shoulder, causing tendinitis, bursitis, and if left untreated rotator cuff tears.

Surfing requires good mobility of the shoulders as well as the thoracic and lumbar spine in addition to significant strength of the shoulders and core.  If mobility or strength deficits are present, movement pattern dysfunction will occur and result in excess stress placed on the soft tissue structures causing tendinopathies.

Below I will introduce 3 mobility-focused exercises and 3 strength-based exercises that if done consistently will help ensure shoulder pain won’t keep you out of the water this year.

MOBILITY

Foam roller pec stretch: Lie on a foam roller with your knees bent and feet flat on the ground. Your palms are facing up and your arms are abducted to a T position. As your flexibility progresses you can change the position of the arms lower and higher to target more muscle fibers.  Hold the position for 3-5 minutes.

Thoracic Rotation Stretch: Lie on your side with the top knee bent on a foam roller. Press down in the foam roller with the knee. Both hands are placed together in front of your chest. Keep the bottom arm on the floor, roll back and have the top arm reach back toward the floor, opening up the chest. Make sure you keep your arm in line with the collar bone to preserve the shoulder’s integrity. Think about bringing your shoulder blade down to the floor. Maintain the position as recommended and return slowly to the starting position.

Prone Press Up: Start with your hands under your shoulders. Press up one vertebral level at a time, while keeping your low back and buttocks relaxed. Perform the exercise as far as you comfortably can trying to achieve a good C shape curve, and pause, making sure your buttocks are relaxed. Then return to the starting position.

STRENGTH

T’s and Y’s: Lie on your stomach on a swiss ball or bench with your arms straight and below shoulder level.  Squeeze your shoulder blades together as you raise your arms parallel to the floor in a “T” position. Keep your thumbs up and your shoulders and neck relaxed. Repeat into Y position bringing arms 45 degrees above shoulder height.

Plank + serratus PU – core & serratus anterior: Start in a plank position on your toes and forearms—your torso and thighs should form a straight line. Tuck your chin: you don’t want your head to move forward when you do the exercise. Start by lowering your torso toward the ground and then by lifting your torso up to round your upper back to protract your scapula. Keep the body in a straight line at all times during the exercise.

Single Leg Single Arm Row: Stand with your feet hip width apart and hold a weight in one hand. Bend forward on one foot (opposite to weight) to the airplane position and pull the weight towards you by bending at the elbow focusing on squeezing shoulder blade to the spine. Slowly return to the initial position and repeat.

Surfers, give Rye Physical Therapy a call to help you master those waves even better!

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By Michael Brezak, DPT – Rye Physical Therapy, Hampton NH Clinic –

There are many different types of joints in the human body. Some are more fixated while others tend to have higher mobility. This of course comes at a cost as the joint with higher degrees of mobility can also experience more traumatic injuries. The shoulder joint is one such highly mobile joint that often times experiences various injuries from falling, sport related activities, or from repeated motions. The shoulder is classified as a ball-and-socket joint with almost a full 360 degrees in a plane of motion. To support this joint, it is encapsulated in a fibrous band of connective tissue and deepened with a ring of connective tissue known as a labrum. The joint is then stabilized further by a system of four muscles that also are the basis for movement called a rotator cuff (Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis). When there is an excessive amount of force applied, the shoulder becomes displaced causing a dislocation either forwards or backwards that requires medical attention. This article aims to give insight on the three types of shoulder dislocations, treatment approach, and prognosis.

Anterior Shoulder Dislocation: This type of shoulder injury is whenever a blunt traumatic force is directed from behind the joint itself or from falling on an outstretched arm. This injury is usually the most common experienced resulting into upwards of 95% of shoulder dislocations. Determination is performed via X-ray diagnostics and presents with the individual holding their shoulder slightly away from their body.

Posterior Shoulder Dislocation: When a force is applied to the frontal aspect of shoulder, the ‘ball’ of the socket has a high chance to become displaced posteriorly. This type of dislocation is less common than an anterior dislocation, but can be more severe due to becoming lodged behind a bony prominence of the shoulder blade. This type of dislocation is usually the most common in the elderly.

Inferior Shoulder Dislocation: This type of dislocation is the least common of the various types. In this dislocation the joint is directed downward while the arm is rapidly forced upward. An example of this is falling from a height while the arm hits and object forcing it upward. While the least likely, this type of dislocation can be further complicated by compression of nerves and numerous blood vessels in the area.

What can physical therapy do?
Once you have received confirmation of your shoulder being dislocated, you may be placed into a shoulder sling to limit excessive movement and referred to physical therapy. Each patient receives patient focused goals based on their personal goals, but the aim is to restore functional, strength, and stability. Some initial exercises that can be performed at home without significant discomfort are found below:

Isometric pushes: Standing at a wall, place a soft pillow against the wall with your injured arm holding it in place. Your injured arm should be resting at your side with your elbow bent to 90 degrees. Push into the pillow with 50% intensity holding for 3 seconds, rest, repeat.

Scapular Squeezes: While standing or sitting, squeeze your shoulder blades together as if rowing a boat. Let your arms either hang at your side or have your elbows bent to 90 degrees simulating rowing a boat. Hold each squeeze for 3 seconds, rest, repeat.At Rye Physical Therapy we apply the latest in research-based interventions to get patients back to their previous level of function in the shortest amount of time. We create rehab goals based on the patient’s interests/desires while improving on your ability to return to those activities. We have two locations in both Hampton and Seabrook to provide you with a level of care and service needed to get you back where you want to be. If you still have questions feel free to call either location or sign up for a FREE Discovery Visit and speak with a therapist to learn how physical therapy can help you.

References:

1. 1. Shoulder Dislocation-Harvard Health. Harvard Health Publishing-https://www.health.harvard.edu/diseases-and-conditions/shoulder-dislocation-
2. 2. Edmiston, Julie PA-C , RT. Distinguishing three types of shoulder dislocations. Journal of the American Academy of PAs. May 2013. 26:5. p 60, 62-63.

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By Kristin Keafer DeRousse, PT, DPT – Rye Physical Therapy, Hampton, NH clinic

What is Shoulder impingement?

Shoulder impingement syndrome is the most common musculoskeletal diagnosis related to shoulder injuries. There has been an ongoing debate on the etiology of impingement and rotator cuff tears, but it is likely to be multifactorial(4). Impingement indicates that there is a narrowed space underneath the acromion (see diagram 1). Structures that may be involved in this diagnosis include the rotator cuff tendons, bicep tendon, subacromial bursa, and the coracoacromial ligament. Sometimes bone spurs develop within this space and cause inflammation to these structures, however other times there may be evidence of degenerative “wear and tear” of the rotator cuff tendon that is causing the pain.

The shoulder is a multidirectional joint and therefore the assessment of the joint capsule, scapular movement patterns, and shoulder muscles should be performed to determine the extent to each individual injury. A clinical examination and movement-based assessment should be used to determine the reason for underlying pain and inflammation.

Signs and symptoms
If inflammation exists within the subacromial space, the mechanics of the shoulder brakes down causing pain and movement dysfunction. This will typically result in anterolateral arm pain. Common exacerbating movements include laying on the affected side, stretching and reaching for overhead objects. A painful arc will be present when raising the arm between 60 and 120 degrees.

Rotator cuff anatomy
More than likely you will have involvement of the rotator cuff tendons. There are 4 muscles part of the rotator cuff: supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles are responsible for stabilizing and gliding the shoulder properly when you move and raise your arm away from your body. The most common rotator cuff muscle involved is the supraspinatus since it travels directly under the acromion. Pain, inflammation, and weakness at any of these muscles will decrease the ability to raise your arm overhead.

Treatment
Research indicates that conservative treatment methods are the most effective if you do not have a full thickness tear of the rotator cuff. Physical therapy is a critical component to your recovery of shoulder impingement and rotator cuff tendon injuries.

Supervised exercise that includes range of motion activities, stretching, and strengthening is imperative in the rehabilitation process (2). Research also indicates that manual therapy in addition to exercise is better than just exercise alone (1). This may include joint mobilization to address the joint capsule as well as soft tissue mobilization treatments to address pain and muscular dysfunction. There is also research to support the use of cervical and thoracic manipulation to reduce pain and improve range of motion through the shoulder(5). All of our therapists are well trained in these manual treatments.

Corticosteroids are also commonly used as an avenue for conservative treatment by physicians. However, research indicates that these patients require additional doctors visits and multiple steroid injections as compared to those patients who receive physical therapy alone (3). Many times patients that receive injections require physical therapy additionally anyways.

Surgical intervention is not recommended unless there is a large rotator cuff tear and is most always the last resort as a treatment option.

Recommendations
Physical therapy should be the initial step to treating shoulder impingement and rotator cuff pathology. This ultimately allows for reduced healthcare costs and provides a conservative effective avenue for returning patients to their daily activities without pain.

Direct access allows for many patients to come directly to physical therapy without a physician referral to evaluate and treat a musculoskeletal dysfunction. If you have a pain in your shoulder, please call Rye Physical Therapy with clinics in both Hampton, NH and Seabrook, NH to schedule a comprehensive assessment!

References

1. Bang, MD, et al. Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement Syndrome. J Orthop Sports Phys Ther 2000;30:126–137.

2. Halk, MN, et al. Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials. Br J Sports Med. 2016 Sep;50(18):1124-34.

3. Rhon, DI, et al. One-Year Outcome of Subacromial Corticosteroid Injection Compared With Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome: A Pragmatic Randomized Trial. Ann Intern Med. 2014;161(3):161-169.

4. Singh, B, et al. Current Concepts in the Diagnosis and Treatment of Shoulder Impingement. Indian J Orthop. 2017 Sep-Oct; 51(5): 516–523.

5. Vinuesa-Montoya, S, et al. A Preliminary Randomized Clinical Trial on the Effect of Cervicothoracic Manipulation Plus Supervised Exercises vs a Home Exercise Program for the Treatment of Shoulder Impingement. J Chiropr Med. 2017 Jun;16(2):85-93.

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