Rotator Cuff Tears: Physical Therapy vs. Surgery, Is There A Difference?

The Rotator Cuff and Shoulder Girdle

By Megan Morgan, DPT

A recent study that was conducted in Finland determined that Physical Therapy alone for non-traumatic rotator cuff tears (supraspinatus) results in equal functional outcomes at one year compared to surgically repaired tears. All of the groups in the study received the same Physical Therapy (PT) instruction and prescription of a home exercise program as well as 10 PT sessions. The study found that patient’s who did receive surgery did not report any superior results than those who only received PT.

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Role of the Rotator Cuff and Scapular Stabilizers

The rotator cuff is a group of four muscles that connect the humerus (upper arm) to the scapular (shoulder blade). These muscles not only create movement of the arm but they play an integral role in providing stability to the shoulder joint. The tendons of these muscles form together to create the cuff; which work together to create a force couple relationship that results in the humerus to remain centered on its base of the scapula (also known as glenoid). When a muscle of the rotator cuff is torn dysfunction of this force couple relationship results and the shoulder has difficulty maintaining its stability.

Another critical component of a healthy functioning shoulder is scapular strength and proper muscle activation. The scapula is the base that connects our humerus to our body via the placement of the humeral head on the glenoid of the scapula. There are multiple muscles that connect our scapula to our spine and these are referred to as our scapula stabilizers. A common analogy for the role of these stabilizers is a seal trying to balance a ball on its’ nose; they have the role of creating a stable base so the ball (humeral head) can stay balanced for the humerus to move on. These muscles are just as important to providing stability to the shoulder joint, as the rotator cuff. Therefore it is important to strengthen these stabilizers and create the proper awareness of one’s scapula position. Physical Therapists are here to help develop your awareness and the appropriate individualized strengthening program.

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The study was limited in that it only incorporated individuals whose tears were <75%. Therefore, we cannot apply these findings for all rotator cuff tears, as the severity of tears varies between individual cases. But an important take away message from this study is that for partial rotator cuff tears PT and a home exercise program can independently get you back to your prior activities of choice.

References:
https://www.apta.org/PTinMotion/NewsNow/2014/3/12/RotatorCuffTears/?blogid=10737418615

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Skier’s Knee Injury Prevention

The overall injury rate related to ski injuries has declined due to the improvement of ski equipment in recent years; such as decreased extremity fractures and other severe injuries. However, the incidence of knee sprains has increased; and according to a recent survey study by the Orthopaedic Journal of Sports Medicine knee injuries account for 1/3 of skiing injuries. The top causes of injury include mechanical forces that occur during a fall, collisions and equipment induced injury.

The two most common injuries are medial collateral ligament (MCL) sprains (15-20% of ski injuries) and anterior cruciate ligament (ACL) tears (~100,000 reported annually from skiing). The MCL is a ligament that stabilizes the inner portion of your knee from valgus forces (lateral to medial). The ACL is an internal ligament in the center of your knee, which stabilizes your knee to maintain proper alignment. With injury to your ACL, your knee becomes unstable.

Regardless of the severity of a ligament sprain, physical therapy is an integral part of your rehabilitation. In certain cases surgery is the treatment of choice due to the severity of the tear and patient’s desired return to physical activity. Physical therapy is important for surgical cases, pre-operatively and post-operatively. Less involved tears can be treated successfully with conservative care (non-operatively) with the help from physical therapy to normalize an individual’s knee range of motion, strength, proprioception and walking pattern. All of these factors are important variables for an individual to return to their prior level of physical activity; such as the ski slopes.

General Reminders to Avoiding Ski Injuries:

  1. Preparation: Lower extremity strengthening and proprioceptive exercises should be a part of your work-out routine in the couple months leading up to ski season. Follow the link below for strengthening exercises, use exercise code: KJ8UHAT Preventative Exercises
  2. Appropriate equipment and equipment settings: bindings should be adjusted to your level of skiing experience
  3. Stay on slopes appropriate to your skill level
  4. Consider taking lessons: it never hurts to get tips from the professionals on the mountain to work on your form
  5. Fatigue: last run of the day, only you know your body and if you feel fatigued, do not push yourself to squeeze in one last run, as this is the most common time injuries occur

To see the original article click here (http://ojs.sagepub.com/content/2/1/2325967113519741.full.pdf+html) and to read more on tips for knee friendly skiing click here (http://www.vermontskisafety.com/kneefriendly.php)

Pelvic Floor Physical Therapy: It’s more than just Kegals

Did you know that physical therapy can be an effective treatment for a variety of pelvic floor disorders such as incontinence, urinary frequency and pelvic pain? As experts of the musculoskeletal system, a pelvic floor physical therapist is trained to evaluate pelvic floor muscle function in order to determine an individualized course of treatment to optimize muscle function.

The most common reason for a person to be referred for evaluation by a pelvic floor specialist is urinary incontinence. Both men and women can suffer from incontinence for various reasons such as childbirth or surgery, however some patients suffer from incontinence for no apparent reason. One misconception is that all patients with incontinence should simply do kegals (pelvic floor contractions). This, however, is not always the best advice.

Incontinence can occur due to a weakness of the pelvic floor musculature, however it can also be due to an overactive pelvic floor. A hypertonic pelvic floor can cause the pelvic floor muscles to become less effective when the intra-abdominal pressure increases, such as with laughing, sneezing or coughing. Therefore, symptomatically, stress incontinence due to weakness and overactivity can appear similar, however the treatments can be very different.

The only way to asses whether a patient’s incontinence is due to weakness or over active pelvic floor muscles is to perform an examination to determine the strength and tone of the pelvic floor. Based on that information, a pelvic floor specialist can determine whether strength training, or relaxation training (or a combination of both) will be most effective in treating the patient’s symptoms. 

 

There is also a large behavioral component to physical therapy for pelvic floor dysfunction. Patients can have triggers causing them to feel the need to urinate more frequently. This can be due to an overactive/irritable bladder, or it can be caused by the fact that the bladder is not fully emptying during urination. Proper pelvic floor training can help determine the best treatment for urinary frequency.

 

Whether the symptoms are due to weakness or overactive pelvic floor muscles, pelvic floor physical therapy can be an effective treatment for pelvic floor dysfunction. To schedule an appointment or to ask specific questions, please call our office at 415-388-8166 or email Whitney Rogers, our women’s health expert, at http://www.activemarin.com.  

 

Side Planking for Scoliosis

Side Planking for Scoliosis

by Dylan Bartley, MSPT, CMP

Researchers at Columbia College of Physicians and Surgeons in New York produced some promising results in the treatment of scoliosis with just one simple exercise: a side plank. This common yoga pose was performed on the convex side of the curve. So if your scoliosis bows out to the right, you should put your right arm down and lift your right hip up off the floor. They offered variations to accommodate varying levels of fitness and different types of curves. The poses were held for as long as possible, once a day, starting at 10-20 seconds.

To measure the success of their intervention, they took x-rays before and afterwards and measured the degree of curvature in their subjects. After 6 months, they found a significant improvement of an average of 41%. They tried to see if there was a difference between younger subjects and older subjects with more degenerative changes and both groups responded well with no significant difference between the two groups.

Scoliosis is a problem of imbalance and asymmetry that tends to progress as we age and can lead to debilitating arthritis and muscle spasm if it goes unchecked. Over the years doctors have tried to stabilize it with complicated surgeries involving rods or uncomfortable braces. Physical therapists have tried to correct it with stretches and strengthening the core and spinal muscles. It would make sense that to treat this problem of asymmetry one would need to attack it with a set of asymmetrical exercises. Unfortunately, there has been little research to back up these hunches until now.

If you are interested in getting an assessment of your spine to see if you have scoliosis or if you’re ready to treat a scoliosis you’ve always known you’ve had, physical therapy is a great place to start. We can set up a custom protocol that would match your current level of fitness and show you how to progress things as you get stronger. Furthermore, structural factors such as a leg length discrepancy or pelvic/sacroiliac dysfunction can be the driving force behind your scoliosis and may be treatable with physical therapy.

To see the original article, click here

A Modern Take on Rotator Cuff Injuries

A Modern Take on Rotator Cuff Injuries

by Cindy Dehan, MS PT 

The shoulder is considered to be one of the most intricate joint systems in the entire human body, with interactions between the upper arm (the humerus), the scapula, and the thoracic spine, in addition to the complex neurovascular system. The rotator cuff plays a vital role in proper shoulder function. Specifically, the rotation cuff system consists of the interaction of four major muscles: the supraspinatus, the subscapularis, the teres minor and the infraspinatus. The primary roll of the rotator cuff is to center the shoulder joint and allow for proper joint motion.

Identifying the reasons for shoulder pain can be just as complex as the shoulder system itself. Similar to the spine, it is difficult to determine a true pathoanatomical “culprit” for shoulder pain, and it may be more beneficial to conceptualize issues found in the shoulder with regards to functional limitations. The American Physical Therapy Association recently published a clinical guideline article regarding the shoulder and outlined three separate types of classifications that shoulder issues may fall into. Shoulder pain and mobility deficits/adhesive capsulitis (frozen shoulder), shoulder stability and movement coordination impairments/dislocation of the shoulder joint, and shoulder pain and muscle power deficits/rotator cuff syndrome. Any of these conditions can impact the rotator cuff, but for the purposes of this article, we will focus on the muscle power deficits/rotator cuff syndrome (RCS) classification.

Traditionally, pathology of the rotator cuff was thought to be almost always be related to issues with impingement, where compression and high levels of friction were associated with the pain and dysfunction often reported by patients. More recent evidence suggests that mechanical loading of the tissue may cause changes to the tendon quality and contribute to the sensitivity of the tissue. Overhead movements such as throwing, can increase tensile load. Reaching overhead can increase the compressive forces in part of the shoulder complex. It is not uncommon to find pain while catching at midrange when lifting the arm. In fact, pain and weakness are common when performing movements that place any stress onto the rotatory cuff system.

Very few things in life have a specific protocol that you can follow from start to finish without having to adjust a little. Managing rotator cuff issues is no different. Given the fact that underlying cause of shoulder pain and dysfunction can be multifactorial the interventions should be selected to treat the impairments, not necessarily the diagnosis. Specific exercises which address the scapula and rotator cuff, in conjunction with manual therapy, has been shown to be beneficial for patients with RCS. It is also of benefit to look at the mechanics and relationship of the thoracic spine to the shoulder, as treatment to the thoracic spine may improve certain shoulder impairments. Core/midline stabilization can also contribute to issues seen in the shoulder based upon the specific activities someone participates in.

In an ideal world, we could develop a series of movements, exercises or hands on treatment that could fix everyone just the same. But the challenge is that we all are very unique and while we might share a common complaint of shoulder pain, the underlying cause is very different from person to person. That is why it is important to have a thorough, comprehensive exam so that the individual characteristics associated with your shoulder can be addressed and a detailed, personalized approach can be implemented.

The Infamous and Irritable Iliotibial Band

The Infamous and Irritable Iliotibial Band

by Dylan Bartley, MSPT, CMP

Iliotibial Band Syndrome (ITBS) is one of the most common overuse injuries among runners, cyclists, and athletes alike. It can manifest in pain on the outside of the knee or hip. Maybe you’ve seen one of the many rollers or massagers on the market designed to loosen up the IT Band. But do you know the anatomy and biomechanics behind the IT Band? Understanding why it can become such a problem helps guide us in treating it comprehensively and making sure we can run and climb stairs well into the golden years.

ITB

The IT Band is the body’s largest tendon, connecting the muscles gluteus maximus in the back and the tensor fascia latae in the front of the hip down to the knee. It passes past the outside of the knee to attach on the outside of the upper tibia. As it passes over the outside of the hip near a protrusion called the greater trochanter it can cause friction and irritate the trochanteric bursa. Bursae are designed to reduce friction, but they can only take so much before they get inflamed and become a source of pain. Further down the line, as the IT Band crosses the knee there are more bursae that can become irritated and cause you knee pain.

 

A big question we ask next is, “Why does it get so tight”?  , If the abdominals, gluts and/or hip flexors are weak and not supporting the body when standing on one leg mid-stride, the IT Band steps in and says, I’ll do it! When there is too much load through the IT band, it can become scarred down and the friction and pain begins. At the knee, when the inner quads are weak, the IT Band has no opposing force. It pulls the patella too far to the outside. This causes breakdown of the cartilage on the outside of the patella. The patella rides like a train moving on one rail. Of course, things aren’t always so simple. Pain in the outside of the thigh may not be from the IT Band at all. A physical therapist can assess the situation and make sure that the pain is not referred from a pinched nerve in your back or a stress fracture. Alternatively, you may have great strength but there may be errors in footwear, the fit of your bike, or just how you have learned to run over the years.
How do we treat it? In the short-term, massaging it with a foam roller or other massage tool will help break up the adhesions and bring some circulation to the tendon. This can often produce immediate relief in knee and hip pain. Long-term, however, you need to strengthen the muscles around the IT Band. Squats, double- or single-leg bridges, side leg lifts, and clamshells are just a few exercises that your physical therapist may recommend to strengthen some of the hip and quadricep muscles. We will do an assessment of your movement patterns and identify areas of specific muscle weakness to help develop a routine that will address your unique deficits.

Running in Minimalist Footwear

by Dylan Bartley, MSPT

You may have heard of the class action lawsuit against the Vibram FiveFingers that resulted in a settlement. If you’re a runner who tried the iconic FiveFingers shoes and developed an injury such as plantar fasciitis or achilles tendonitis, this may be sweet validation for you. If you’re one of the many people who used them and loved them either casually or as a running shoe, then maybe you’re left wondering, is it just a matter of time before I develop an injury? Should I go back to those cushy, supportive Brooks shoes my Podiatrist said I should use? Are all minimalist shoes such as the Nike Free and the New Balance Minimus risky to run in? In 2013 we saw sales of minimialist footwear stop their climb and begin to decline, replaced, of course, by sales of motion control shoes and stability shoes.

Well, let me shed a little light on some of those questions. Let’s start with anatomy: there is a variability in the morphology of our ankle bones that predisposes one towards having a low or a high arch. Structurally some of us have the type of arch that wants to collapse and pronate while others are just blessed with a normal or high arch that supinates well. And there is a fourth category: those that have a structurally normal or supinated foot but when they stand and move, they pronate and collapse too much. Let’s call them functional pronators. A knowledgeable physical therapist should be able to assess what kind of foot you have exactly and guide you through the process of choosing footwear.

If you are in the first category of structural pronators, then you may not fare well in your attempt to run in minimalist shoes. There are just too many biomechanical forces to overcome when your foot hits the ground and eventually your tendons and ligaments get strained. Using a stability shoe or motion control shoe or orthotic placed in a minimalist shoe will reduce your risk of injury. Your level of strength and conditioning (or simply personal preference) determines which of those shoes will work best for you. If you are genetically blessed enough to have a neutral, supinated, or functionally pronating foot, then you may be able to slip some minimalist shoes on and get your foot in shape. You can rely on your foot’s ability to naturally pronate and absorb the shock of landing without over-taxing your soft tissues.

By the way, I say “get your foot in shape” because the wean-in process with this kind of thing is real. That is, of course, why even people with perfect arches often get injured when wearing Vibram FiveFingers. Those of us with sedentary jobs or feet that have been living the life of luxury supported by rigid orthotics and supportive running shoes will have an even greater challenge. Functional pronators may need extra time to strengthen their foot muscles. It can take anywhere from 6 months to a year to really build up enough strength to wear a minimalist shoe for an entire 10k or just walking around town all day. There are so many fine motor intrinsic muscles in your foot like the flexor digiti minimi brevis that you probably have never been asked to use unless you were a modern dancer or you grew up walking barefoot in Africa. So be patient as you gradually increase the distance of your runs in minimalist shoes. Wear them half the day at work, and bring a cushy old pair of shoes to switch into at lunchtime. Alternate wearing your minimalist shoe on short runs while wearing supportive shoes on long runs. And listen to pain. See a physical therapist to help diagnose and treat even minor injuries before they become chronic, severe ones. Stretch after your runs and employ a little self-massage and strength training to help your body through any strains. Your new and improved feet will thank you.