April 17, 2024 • 23 mins
Have you ever wondered about the intricate dance between stability and mobility in your shoulders? Join us as we help shed light and solve issues with the rotator cuff and shoulder pain. In a detailed exploration, we dissect the roles of the supraspinatus, infraspinatus, teres minor, and subscapularis, and their crucial contributions to glenohumeral joint support. We tackle common issues like instability, delve into the delicate relationship with the labrum, and identify the usual suspects behind shoulder pain. But it's not just about identifying problems; we also chart a course toward effective remedies that address the root of discomfort, ensuring you walk away with more than just a deeper understanding of your anatomy.
Then, we take a step further into the realm of movement system impairments, shedding light on how seemingly unrelated imbalances can cascade into chronic musculoskeletal pain. Discover how improper muscle recruitment and compensatory patterns can wreak havoc on your body and why targeted exercises and manual therapy should be your go-to solutions. Plus, we don't stop at the shoulder — the scapula's role in overall function gets its moment in the spotlight, illustrating how dysfunctions there can ripple out to other areas like the lower back. For all athletes and active individuals seeking to fine-tune their performance and nip pain in the bud, our discussion provides actionable insights to elevate your understanding and care of your musculoskeletal health.
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Episode Transcript
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Speaker 1 (00:00):
If you're a driven, active person who wants to reach
and pursue a higher qualitylife with some ambition, then
guess what this podcast is foryou.
This is the Driven AthletePodcast.
What's up?
Y'all?
It's your man, dr Kyle.
Welcome back to the DrivenAthlete Podcast.
Today we're going to talk a veryfinite conversation about the
(00:20):
rotator cuff.
I wanted to shed some light andbring a little bit of education
to some people.
I'm a little bit confused butexactly what the rotator cuff is
, some of the common diagnoseswe see with rotator cuff issues,
and then what we do asclinicians, as sports physical
therapists, to actually treat it.
Just bring some insights to youguys of like, all right, what
should I keep in mind?
What should I look for?
And hopefully maybe bring someclarity and some hope, as in
(00:43):
like, this isn't a doomsdaything, it doesn't have to be at
least all right for the peoplethat we work with.
So anyway, the rotator cuffactually, four muscles
collectively make up the rotatorcuff.
All right, so when we sayrotator cuff, what they mean is
these four muscles collectivelymake up this group called the
rotator cuff the supraspinatus,which sits on top of your
(01:03):
shoulder up here, yourinfraspinatus, which is in the
back, your teres minor, also inthe back.
And then the last one is calledyour subscapularis and that's
on the front side of yourshoulder blade, between your
shoulder blade, your scapula andyour rib cage.
All right, so we call it likethe ventral side or the anterior
side of your scapula, sittingbetween your scapula and a rib
cage.
So those four muscles workcollectively together in
(01:25):
symphony to help compress yourshoulder joint.
When we say shoulder joint, whatI mean is your glenohumeral
joint.
The arm bone is called yourhumerus, your shoulder blade is
called your scapula.
The humerus attaches or has anarticulation contact point with
the scapula at something calledthe glenoid and that's the fossa
called the glenoid, and that'sthe fossa or the indention
(01:47):
component, it's the concavecomponent of that joint.
So it's a ball and socket joint.
This is your humeral head andthis is called your glenoid
surface of your scapula and yourglenohumeral joint.
Your humerus rotates aroundyour glenoid and your scapula
moves too.
All right, and we'll talk aboutthat in a minute, about the
influence of the scapularmobility as it relates to
glenohumeral hypermobility, butanyway.
(02:09):
So the four rotator cuffmuscles connect from your
scapula to your humerus andthey're small, they're not major
large muscles, they're smallstability guys but they all work
together in concert to helpsuck in your humerus and keep it
in place as it moves andgrooves and rotates and moves
overhead and stuff when a lackof rotator cuff activation or a
lack of help elsewhere fromscapular things, scapular
(02:32):
muscles, it's not as stable asit could be and it allows for
more translation of the humeralhead excessively in the glenoid,
which makes other things haveto compensate and maybe affect
neighboring structures, like thelabrum an example.
All right, and it causesfraying over time.
We'll talk about the labrumsoon too, but anyway.
So your glenohumeral joint hasa lot of mobility, all right,
(02:54):
and the rotator cuff just keepsit locked in and sucked in so
they move it.
It keeps it all stable in onecenter point of rotation and the
excessive translation is whereproblems come in and we would
call that maybe instability,right, if there's a shoulder,
instability is from that, themost commonly involved
structures that get painful,right?
(03:15):
People usually come in and likeman, my arm hurts right here,
it hurts on the top of myshoulder, it hurts down, my arm
hurts in the back of my shoulder, my trap, whatever.
People usually want to knowwhat's the angry tissue right?
What's the problem Like, what'shurting and usually the
structures that are contributingto the pain experience when
you're having shoulder pain isthe supraspinatus, the
infraspinatus or the bicepstendon.
(03:36):
The long head of your bicepstendon is another smaller
structure, all right, andusually at the origination point
as it passes across theanterior part of your shoulder
joint and your humerus right.
Here is your long head of yourbiceps tendon and it attaches to
the superior part of yourglenoid.
All right, and that's when thatgets involved and frayed and
displaced or separated off itsattachment site.
(03:58):
It has a strong attachment tothe superior part of your labrum
and that's called a slap tear,all right, the superior labrum,
anterior to posterior.
That's called a slap tear.
And it's when the biceps,anchor of the origination point
of your glenoid, becomesdetached or frayed and are
involved and vulnerable andthat's called a slap tear.
But anyway, so your long headof your biceps tendon gets lit
up and it gets very sensitiveand that can cause anterior
(04:22):
shoulder pain or lateral frontand anterior lateral front side
shoulder pain with reachingoverhead and doing bench press
or push-ups or burpees or dips,stuff like that in the front.
But so the three most commonthings that we find that are
that are broken down, lit up andcontributing to the pain in
your shoulder are thesupraspinatus, infraspinatus and
(04:42):
long head of the biceps tendon.
So, considering that, all right,let's consider this the
mechanics of the shoulder joint.
It's very, very mobile For theway evolution has developed us
as humans.
There's a lot of mobility and alack of inherent stability of
the glenohumeral joint, theshoulder joint, to allow for
freedom of movement, right,overhead motion, reaching behind
the car, all that stuff.
(05:02):
Right, full range of motion.
It's very excessive uhnecessary for the shoulder,
whereas the hip is a verysimilar uh joint structure.
It's a ball and socket jointbut it's very deep and for a lot
more stability because it's aheavy weight bearing and uh, it
needs a lot of stability in yourhip joint, um being being
required for a lot of uh weightbearing activity.
(05:23):
So the shoulder is a little bitdifferent a lot of instability
and um set up for failure forstability, which makes the
structures around it a lot morevulnerable to get affected and
then painful.
All right, I've had some mentorsdescribe the ball and socket
joint of your shoulder is asunstable as like a tennis ball
sitting on a golf tee.
Right, one little touch, Ithink it's off right, like
(05:45):
that's where the rotator cuffand keeping everything sucked in
and nice and stable in yourjoint to keep it center of
rotation is really important.
Okay, so let's say rotator cuffis getting overwhelmed, it's
trying its hardest to keep thatcenter rotation doing doing its
job right.
Um, for bench overhead,shoulder raises or shoulder
press burpees, throwing afootball, throwing a baseball,
(06:08):
swimming, which is an aggressiveoverhead mobility position,
volleyball right, hittingoverhead, overhead throwing
motions.
The rotator cuff is workingovertime all the time to keep
your shoulder joint in its place, okay, and they get lit up.
Usually the structures that aretrying to overcompensate and
they're overworking and workingovertime, those are the victims
(06:29):
and those are the ones thatusually get lit up, all right.
So, considering that, as re froma rehab standpoint, for as
sports physical therapists andtreatment interventions, how are
we going to fix this Right?
How are we going to get thingsbetter?
Are we going to help treat andwork and focus on the structures
that are overwhelmed,overcompensating, working
overtime, victims that are litup?
(06:51):
Are they the problem?
No, they're the victims.
Why are they the victims?
It's because other thingsaren't helping to contribute to
the range of motion required foroverhead or the stability
requirements for sports andexercise and lifting weights and
stuff like that.
Right, the dynamic activities.
The rotator cuff is doing toomuch.
That means that something elseisn't doing enough.
(07:12):
Right?
There's a con, there's a proand con.
There's like the inverse ratiohere we got too much going on
here and working and not enoughworking right.
So we have to even that out alittle bit and have these guys
contribute to help theoverwhelmed guys.
The analogy we like to give islike imagine there's a fire
alarm going off, right, thesmoke detector going off and
it's blaring.
Treating the rotator cuff froma rehab standpoint would be like
(07:35):
us putting a pillow and ducttaping it against the smoke
detector to muffle the sound.
Was that actually solving theproblem of why the fire is there
in the first place?
Let's just put out the fireright.
The fire is.
What's the problem?
That's causing the smokedetector to go off, versus just
trying to treat the smokedetector and muffle it with a
pillow.
Let's put out the fire rightand then that will follow suit
(07:56):
and help solve the smokedetector from stop blaring,
right.
That's kind of like how we liketo approach solving rotator
cuff issues.
All right, so, with that beingsaid, since they're the victims
the rotator cuff and the bicepstendon they're overwhelmed.
All right, so then, what's theproblem then?
Usually, it seems likeeverything comes down to the
scapula.
The scapula seems to be theproblem as in it's not doing
(08:18):
enough.
We need to help, have itcontribute to reaching overhead
and the overhead mobilityrequirements, the overhead range
of motion requirements, or thestability component to help
contribute to keeping thingsstable.
As it relates to a golf swing,a tennis overhand serve, a
baseball throw, football,shoulder press, burpees, all
those sports activities, itseems like the scapula is the
(08:42):
biggest culprit.
That's not helping enough Justbecause it's been learned.
It's the learned movementpattern over many, many episodes
of training, of months andyears and years and years, and
those learned movement patternsjust reinforce the same patterns
that cause more of a disparityin either range of motion and
mobility or more of a disparityin either range of motion and
mobility or more of a disparityin strength, stability and
activation requirements for allthe muscle tissue.
(09:03):
That's where we come in.
All right, that's what we do tofix the problem, versus just
putting a mask on the issue,taking Advil or just icing it.
It's not going to do anything.
That's not going to solve thescapular problem.
Does that make sense?
It's not going to solve thescapular compensation problem
and the rotator cuff beingoverwhelmed and getting lit up
constantly.
Does that make sense?
(09:24):
So, with that being said, we'regoing to intervene then and
focus our treatment at theproblem site.
That's not helping and that'susually the scapula.
Hardly ever do we actually treatthe rotator cuff right.
The thing's beat up, it'soverwhelmed and it's a victim
and it's getting broken downover time.
All right, are we going to do aton of rotator cuff
(09:44):
strengthening exercises andstrengthen something that's
already super lit up and beat upand a victim?
Of course not right.
That thing's just trying to dotoo much.
We need to get other things tohelp contribute and that's where
our exercise prescription andchoices come from and also our
manual therapy interventionchoices come from.
We're going to manuallyintervene to get the things that
aren't moving well to movebetter.
Soft tissue restrictions thatare limiting motion to getting
(10:05):
overhead are the positions youneed to.
We have to fix those softtissue restriction problems and
then activate and stimulate thethings that aren't active enough
to get contributing to themovements that are required for
your sport.
Overhead movement seems to bethe number one thing, followed
by, I mean, agmr is another one,so just glenohumeral stability
stuff, but it seems like thescapula is the root focus of our
(10:27):
treatment, because that's likethe problem.
That's not really helping.
Does that make sense?
So, and with that being in mind, the clinicians that we mentor
(10:49):
and help coach with fellowship,training and residence for
sports physical therapy, theclinicians that we mentor, we
ask them all right, you'retreating this patient right, you
went this direction right,which means that your diagnosis
was this since you chose this,this and this, and that's the
direction you went for treatment, and they feel better, okay,
and they're back to doing theirthing.
When they get back to 100%, gounrestricted full activities,
sports, exercise, lifting,baseball, swimming, whatever.
When they get back to 100%, howwell is the problem not coming
(11:11):
back?
If the problem comes back, thenthat means we didn't solve the
problem, which means it was adirectional choice of treatment
that wasn't as accurate as itcould have been or purposeful
and effective as it could havebeen, which also means that you
did that because the diagnosiswasn't as accurate as it could
have been, with the wrong, maybeclinical rationale or not the
best clinical rationale youcould have had.
(11:31):
So we have to backtrack all theway back to the diagnosis and
our clinical rationale.
What's the problem?
What is the cause of theproblem?
What is the cause of the cause?
That's what we need to fix andintervene.
And that can't happen in oneday, unfortunately, because
there's compensation patternsthat we have to unlearn, that
have been reinforced for a longtime.
We have to unlearn thosecompensation patterns.
(11:52):
We have to fix the mobilitydisparities.
If something's moving a ton thehyper mobile area and then
something's not moving enoughhypo mobile we have to fix and
intervene that.
And we also have to interveneat the muscle recruitment and
strength disparities.
If some things are very, veryactive and working overtime and
other things are dormant and nothelping contribute, we have to
(12:13):
fix those muscle recruitmentdisparities.
So it seems to always come downto like the combination of
mobility disparities and musclestrength activation disparities
with their activity in sportsand movement, their movement.
We would call that a movementsystem impairment, right?
So, like, what's the diagnosis?
It comes down to that movementsystem impairment as the cause
(12:34):
of the cause that's causing therotator cuff pain, right, pain
doesn't happen for no reason,right?
That's another thing we alwaystalk about with our patients For
musculoskeletal stuff we'vementioned this over the podcast
for neuromusculoskeletalproblems, neuromusculoskeletal
being like a tendon problem,joint pain.
Referred nerve pain right Likesciatica, is a trash can term
(12:54):
that we'll talk another time.
Sciatica is just a blankettrash can term that's not as
accurate as it could be.
It's just referred nerve painbecause of a problem in the low
back right or in the neck rightCervical radiculopathy.
But those things don't justhurt for no reason.
If we rule out systemicproblems and red flags think
musculoskeletal,neuromusculoskeletal problems
(13:15):
they don't just hurt for noreason.
They hurt because of something,something's going on right.
It's usually for athletes oractive people when things hurt
for no reason.
It's the way that they'removing and grooving and just the
(13:39):
compensation patterns withthose disparities and range of
motion and strength disparitiesthat's causing things to get
continually lit up right.
So it's either repetitivemovements or prolonged postures
that are the problem, that justreinforce things to get lit up
continually over and over again,which means we can intervene.
We can control both of those.
We can control our postures andpositioning and we can also
control what movement thingswe're doing right now.
We have to modify some stuff atthe beginning, of course, right
.
So we have to modify somethings totally, then we can
(13:59):
intervene appropriately Manualtherapy to correct the range of
motion problem and jointmobility disparities, and then
exercise prescription andchoices for correcting those
strength and movementdisparities, and that seems to
be the best way to help solvemusculoskeletal problems.
So anyway, with that being said,we hardly ever treat the
rotator cuff for rotator cuffand shoulder pain because
(14:21):
they're already beat up Like wedon't want to, we want to cause,
we want to intervene andoverwhelm them even more.
Right?
We're not going to have theovertime worker be like hey, can
you come back and work extra?
They're already doing enough,right?
So we need to, we need tointervene.
The guys aren't helping enough.
So that's where our choicescome from.
What we would do, though, forthe rotator cuff specifically,
(14:41):
we'll just mobilize the tissue,give it some love, right?
It stimulates hyaluronic acidto help with tendon gliding and
fiber gliding maybe realignfibers to be a little bit more
parallel, and it's knotted upfor tendon and muscle fiber
pliability, and then dryneedling to help stimulate a
healing response.
Dry needling definitely has tobe very helpful, right, we'll
dry needle the supraspinatus.
We'll dry needle theinfraspinatus.
(15:02):
We'll dry needle the teresminor.
We can also dry needle, thesubscapularis, for the purpose
of stimulating a healingresponse and pain modulation and
recruit endogenous opioids forpain to help things feel better,
right, and then mobilize thetissue to give us some love for
sure, biceps tendon included.
But we're not going tostrengthen those things or have
(15:24):
our treatment focus be on those,because we know that's not the
problem.
The problem is the scapula.
So when we talk about thescapula, when reaching overhead,
full overhead, range of motionfor the shoulder was 180 degrees
right, full, straight lineoverhead.
And if somebody can't get there, naturally, but they're able to
(15:44):
do jerk press, snatches,military press overhead,
throwing swimming, volleyball,all that stuff, that means that
if they can't get it just inpure range of motion, then
they're compensating somewhereand it's usually because the
scapula isn't helping enough toupwardly rotate and finish the
job to get the shoulder fullyoverhead.
(16:04):
A third of the total motionoverhead comes from the scapula
by itself.
So if 180 degrees is full, athird of that 60 degrees has to
come from the scapula alone.
So if it's limited a little bitfrom the scapula, there's not
much room for error and thatmeans that something else has to
compensate to finish the job,because athletes are the best
(16:24):
compensators.
We know that Athletes just getthe job done.
They'll do whatever it takes toget the job done.
So they're going to compensate,it's normal just to finish the
job.
But if their scapula is notcontributing and they're not
able to get full range of motionoverhead, then where are they
going to compensate?
Two most common compensationplaces we see are the two most
(16:46):
painful sites that we usuallysee.
It's the shoulder right up inhere.
The shoulder is going tohyperflex because the scapula
can't continue.
So what structures are going toget lit up to hyperflex and
constantly help to overwork?
Supraspinatus and biceps tendonor infraspinatus, followed by
another really commoncompensation area is their
lumbar spine.
Their low back is going tohyperextend.
(17:07):
So what are the two most commonplaces we see all the time with
pain and people we treat,especially athletes, is shoulder
pain and back pain.
The scapula plays a huge rolewith that and that's what we
have to intervene.
So the lumbar hyperextension tofinish the job, to get overhead
, to hyperextend and bendbackwards just to get fully
overhead lumbar spine is goingto get lit up chronically.
So imagine doing thatrepetitively, many, many, many
(17:29):
reps of throwing right.
The lumbar spine is going tohyperextend and rotate or
snatches and jerk press forbarbell lifting and Olympic lift
, shoulder press, standingshoulder press, whatever.
I mean that's a lot of reps ina row of a lot of beat up
activity going on in the lumbarspine to hyperextend chronically
.
So it's something to considerand think about.
(17:49):
So when people come in with backpain and they say you know what
my back hurts when I dosnatches or when I jerk press,
we have to check the scapula.
And that's where that linkcomes in, because if the scapula
is not moving well enough, thenthe to let go.
(18:10):
We had to do a full body eval,a way to exam everything and see
how everything's moving.
Show me the motion that hurtsand we can check that out and
we'll see like, oh, your scapulais not really moving as well as
it could move, making yourlumbar spine overcompensate and
hyperextend.
The most common thing we see forlumbar pain is pain with
extension, pain with lumbarhyperextension.
So anyway, that's stuff we haveto check out, okay?
(18:33):
So the most common diagnosesthat we see when we see people
with shoulder pain is shouldertell me if you've heard of these
before.
I'm sure you have Shoulderimpingement, rotator cuff
impingement, biceps, tendonitis,biceps, impingement labrum,
tears, slap tear.
Those are all probably the mostcommon things, that posterior
(18:54):
impingement, those are probablythe most common thing.
Oh, a subacromial bursitis,shoulder bursitis, the bursitis
is a passive structure.
That thing is just that justhelps with gliding of the
tendons underneath the bonesurface so it doesn't just rub
against each other.
It's like a pillow that rubthat helps prevent um fraying
and rubbing against a hardsurface like a bone.
That's all.
(19:15):
The bursa is all right.
So the bursa gets lit up, whichyou can.
Is the bursa the problem?
But we're going to help solvelike bursas don't hurt for no
reason, right, it's because it'sgetting um inflamed, lit up.
It's getting.
It's getting inflamed, lit up.
It's getting jacked up becauseit's something else neighboring
it.
It's overcompensating becauseof a disparity somewhere else.
That's what we have to treat.
So bursa, that's the passivestructure, but it's kind of
(19:38):
meaningless in our treatmentapproach.
So bursitis, subacromialbursitis, impingement, rotator
cuff impingement, biceps,tendonitis, biceps impingement,
posterior impingement and labrumissues.
So those are the most commondiagnoses we see of coming from
other providers and stuff likeyep, he's got a bursitis problem
(20:00):
.
It's like, okay, I'm sure thebursa's lit up, but why?
What in the first place causedthe bursa to?
I get let up.
That's what we have toinvestigate, but that's where we
have the best results foractive athletic people to solve
the underlying problem so itdoesn't come back again, so they
can get back to exercising andjerk press and lifting weights
and baseball and all that stuff.
Versus you know what, just rest,take some advil and ice it and
(20:24):
then or maybe you know notgetting better, just stop.
Just don't work out anymore.
Shoulder press, it's not goodfor you.
There's no reason why it can'tbe.
It's actually a benefit, right?
You just have to fix theunderlying compensation patterns
first and then we can interveneand wean back into that
exercise for enjoyment of yourlife, right, and also for
athletes that are wanting totrain.
(20:45):
So, man, it's a bummer when wehear like you know what, I just
haven't done it.
My doc told me it's not goodfor me.
Same thing with running, right,that's another one too.
Like we'll just don't run.
It's like well, how many?
There's thousands, of millionsof people that run into their
late decades of life that arefine.
So why are they fine?
(21:07):
But then all their colleaguesand friends that are younger, in
their forties and thirties,having pain.
If it was like running isdetrimental for everybody, then
wouldn't everybody that tries torun have pain?
What are they doing differently?
That's what we have tointervene.
That's what we have toinvestigate and figure something
out.
There is a solution.
Things don't hurt for no reasonand there's plenty of people
that run and have no problems.
(21:28):
There's plenty of people thatthrow a baseball and have no
problems.
There's plenty of people thatdo shoulder press and jerk press
and they have no shoulder pain.
So what are they doingdifferent versus the people that
have pain with it?
What are they doing different?
That's what we need toinvestigate and that's where we
need to intervene.
So, anyway, if you have anyquestions, man, I'm always open
to answer questions and helpshed some light on some stuff,
clarify some things.
Don't hesitate to reach out tous if you have shoulder pain,
(21:53):
back pain, any pain.
If you're an athlete, we treatathletes.
We work with athletic activepeople to get them back to doing
the things they love in sportsthey love to do.
Oftentimes, people that comesee us after they've seen a
bunch of other providers notsaying they're bad people.
They're not set up for successwith the current healthcare
system model, unfortunately, butthe things that haven't worked
in the past or they've been toldyou know what.
You probably just shouldn't dothat anymore.
It's like what there's noreason why you can't do that.
(22:15):
There's plenty of people thatdo that stuff.
We just got to fix why.
Things don't hurt to reach out.
You can call us at 561-899-8725or email us at team T-E-A-M at
(22:38):
athleteRCcom AthleteRC short forAthlete Restoration Company.
So, team at athleteRCcom, orgive us a call.
We would definitely love tochat with you and, um, start the
process of investigating maybewhy you have some issues and
then bring some concrete answersand some solutions.
So, uh, don't hesitate to reachout.
Um, we're always open tosuggestions and, uh, other
topics too.
We'll catch y'all next time.
(23:00):
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(23:21):
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If you're a driven, active person who wants to reach
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This is the Driven AthletePodcast.
What's up?
Y'all?
It's your man, dr Kyle.
Welcome back to the DrivenAthlete Podcast.
Today we're going to talk a veryfinite conversation about the
(00:20):
rotator cuff.
I wanted to shed some light andbring a little bit of education
to some people.
I'm a little bit confused butexactly what the rotator cuff is
, some of the common diagnoseswe see with rotator cuff issues,
and then what we do asclinicians, as sports physical
therapists, to actually treat it.
Just bring some insights to youguys of like, all right, what
should I keep in mind?
What should I look for?
And hopefully maybe bring someclarity and some hope, as in
(00:43):
like, this isn't a doomsdaything, it doesn't have to be at
least all right for the peoplethat we work with.
So anyway, the rotator cuffactually, four muscles
collectively make up the rotatorcuff.
All right, so when we sayrotator cuff, what they mean is
these four muscles collectivelymake up this group called the
rotator cuff the supraspinatus,which sits on top of your
(01:03):
shoulder up here, yourinfraspinatus, which is in the
back, your teres minor, also inthe back.
And then the last one is calledyour subscapularis and that's
on the front side of yourshoulder blade, between your
shoulder blade, your scapula andyour rib cage.
All right, so we call it likethe ventral side or the anterior
side of your scapula, sittingbetween your scapula and a rib
cage.
So those four muscles workcollectively together in
(01:25):
symphony to help compress yourshoulder joint.
When we say shoulder joint, whatI mean is your glenohumeral
joint.
The arm bone is called yourhumerus, your shoulder blade is
called your scapula.
The humerus attaches or has anarticulation contact point with
the scapula at something calledthe glenoid and that's the fossa
called the glenoid, and that'sthe fossa or the indention
(01:47):
component, it's the concavecomponent of that joint.
So it's a ball and socket joint.
This is your humeral head andthis is called your glenoid
surface of your scapula and yourglenohumeral joint.
Your humerus rotates aroundyour glenoid and your scapula
moves too.
All right, and we'll talk aboutthat in a minute, about the
influence of the scapularmobility as it relates to
glenohumeral hypermobility, butanyway.
(02:09):
So the four rotator cuffmuscles connect from your
scapula to your humerus andthey're small, they're not major
large muscles, they're smallstability guys but they all work
together in concert to helpsuck in your humerus and keep it
in place as it moves andgrooves and rotates and moves
overhead and stuff when a lackof rotator cuff activation or a
lack of help elsewhere fromscapular things, scapular
(02:32):
muscles, it's not as stable asit could be and it allows for
more translation of the humeralhead excessively in the glenoid,
which makes other things haveto compensate and maybe affect
neighboring structures, like thelabrum an example.
All right, and it causesfraying over time.
We'll talk about the labrumsoon too, but anyway.
So your glenohumeral joint hasa lot of mobility, all right,
(02:54):
and the rotator cuff just keepsit locked in and sucked in so
they move it.
It keeps it all stable in onecenter point of rotation and the
excessive translation is whereproblems come in and we would
call that maybe instability,right, if there's a shoulder,
instability is from that, themost commonly involved
structures that get painful,right?
(03:15):
People usually come in and likeman, my arm hurts right here,
it hurts on the top of myshoulder, it hurts down, my arm
hurts in the back of my shoulder, my trap, whatever.
People usually want to knowwhat's the angry tissue right?
What's the problem Like, what'shurting and usually the
structures that are contributingto the pain experience when
you're having shoulder pain isthe supraspinatus, the
infraspinatus or the bicepstendon.
(03:36):
The long head of your bicepstendon is another smaller
structure, all right, andusually at the origination point
as it passes across theanterior part of your shoulder
joint and your humerus right.
Here is your long head of yourbiceps tendon and it attaches to
the superior part of yourglenoid.
All right, and that's when thatgets involved and frayed and
displaced or separated off itsattachment site.
(03:58):
It has a strong attachment tothe superior part of your labrum
and that's called a slap tear,all right, the superior labrum,
anterior to posterior.
That's called a slap tear.
And it's when the biceps,anchor of the origination point
of your glenoid, becomesdetached or frayed and are
involved and vulnerable andthat's called a slap tear.
But anyway, so your long headof your biceps tendon gets lit
up and it gets very sensitiveand that can cause anterior
(04:22):
shoulder pain or lateral frontand anterior lateral front side
shoulder pain with reachingoverhead and doing bench press
or push-ups or burpees or dips,stuff like that in the front.
But so the three most commonthings that we find that are
that are broken down, lit up andcontributing to the pain in
your shoulder are thesupraspinatus, infraspinatus and
(04:42):
long head of the biceps tendon.
So, considering that, all right,let's consider this the
mechanics of the shoulder joint.
It's very, very mobile For theway evolution has developed us
as humans.
There's a lot of mobility and alack of inherent stability of
the glenohumeral joint, theshoulder joint, to allow for
freedom of movement, right,overhead motion, reaching behind
the car, all that stuff.
(05:02):
Right, full range of motion.
It's very excessive uhnecessary for the shoulder,
whereas the hip is a verysimilar uh joint structure.
It's a ball and socket jointbut it's very deep and for a lot
more stability because it's aheavy weight bearing and uh, it
needs a lot of stability in yourhip joint, um being being
required for a lot of uh weightbearing activity.
(05:23):
So the shoulder is a little bitdifferent a lot of instability
and um set up for failure forstability, which makes the
structures around it a lot morevulnerable to get affected and
then painful.
All right, I've had some mentorsdescribe the ball and socket
joint of your shoulder is asunstable as like a tennis ball
sitting on a golf tee.
Right, one little touch, Ithink it's off right, like
(05:45):
that's where the rotator cuffand keeping everything sucked in
and nice and stable in yourjoint to keep it center of
rotation is really important.
Okay, so let's say rotator cuffis getting overwhelmed, it's
trying its hardest to keep thatcenter rotation doing doing its
job right.
Um, for bench overhead,shoulder raises or shoulder
press burpees, throwing afootball, throwing a baseball,
(06:08):
swimming, which is an aggressiveoverhead mobility position,
volleyball right, hittingoverhead, overhead throwing
motions.
The rotator cuff is workingovertime all the time to keep
your shoulder joint in its place, okay, and they get lit up.
Usually the structures that aretrying to overcompensate and
they're overworking and workingovertime, those are the victims
(06:29):
and those are the ones thatusually get lit up, all right.
So, considering that, as re froma rehab standpoint, for as
sports physical therapists andtreatment interventions, how are
we going to fix this Right?
How are we going to get thingsbetter?
Are we going to help treat andwork and focus on the structures
that are overwhelmed,overcompensating, working
overtime, victims that are litup?
(06:51):
Are they the problem?
No, they're the victims.
Why are they the victims?
It's because other thingsaren't helping to contribute to
the range of motion required foroverhead or the stability
requirements for sports andexercise and lifting weights and
stuff like that.
Right, the dynamic activities.
The rotator cuff is doing toomuch.
That means that something elseisn't doing enough.
(07:12):
Right?
There's a con, there's a proand con.
There's like the inverse ratiohere we got too much going on
here and working and not enoughworking right.
So we have to even that out alittle bit and have these guys
contribute to help theoverwhelmed guys.
The analogy we like to give islike imagine there's a fire
alarm going off, right, thesmoke detector going off and
it's blaring.
Treating the rotator cuff froma rehab standpoint would be like
(07:35):
us putting a pillow and ducttaping it against the smoke
detector to muffle the sound.
Was that actually solving theproblem of why the fire is there
in the first place?
Let's just put out the fireright.
The fire is.
What's the problem?
That's causing the smokedetector to go off, versus just
trying to treat the smokedetector and muffle it with a
pillow.
Let's put out the fire rightand then that will follow suit
(07:56):
and help solve the smokedetector from stop blaring,
right.
That's kind of like how we liketo approach solving rotator
cuff issues.
All right, so, with that beingsaid, since they're the victims
the rotator cuff and the bicepstendon they're overwhelmed.
All right, so then, what's theproblem then?
Usually, it seems likeeverything comes down to the
scapula.
The scapula seems to be theproblem as in it's not doing
(08:18):
enough.
We need to help, have itcontribute to reaching overhead
and the overhead mobilityrequirements, the overhead range
of motion requirements, or thestability component to help
contribute to keeping thingsstable.
As it relates to a golf swing,a tennis overhand serve, a
baseball throw, football,shoulder press, burpees, all
those sports activities, itseems like the scapula is the
(08:42):
biggest culprit.
That's not helping enough Justbecause it's been learned.
It's the learned movementpattern over many, many episodes
of training, of months andyears and years and years, and
those learned movement patternsjust reinforce the same patterns
that cause more of a disparityin either range of motion and
mobility or more of a disparityin either range of motion and
mobility or more of a disparityin strength, stability and
activation requirements for allthe muscle tissue.
(09:03):
That's where we come in.
All right, that's what we do tofix the problem, versus just
putting a mask on the issue,taking Advil or just icing it.
It's not going to do anything.
That's not going to solve thescapular problem.
Does that make sense?
It's not going to solve thescapular compensation problem
and the rotator cuff beingoverwhelmed and getting lit up
constantly.
Does that make sense?
(09:24):
So, with that being said, we'regoing to intervene then and
focus our treatment at theproblem site.
That's not helping and that'susually the scapula.
Hardly ever do we actually treatthe rotator cuff right.
The thing's beat up, it'soverwhelmed and it's a victim
and it's getting broken downover time.
All right, are we going to do aton of rotator cuff
(09:44):
strengthening exercises andstrengthen something that's
already super lit up and beat upand a victim?
Of course not right.
That thing's just trying to dotoo much.
We need to get other things tohelp contribute and that's where
our exercise prescription andchoices come from and also our
manual therapy interventionchoices come from.
We're going to manuallyintervene to get the things that
aren't moving well to movebetter.
Soft tissue restrictions thatare limiting motion to getting
(10:05):
overhead are the positions youneed to.
We have to fix those softtissue restriction problems and
then activate and stimulate thethings that aren't active enough
to get contributing to themovements that are required for
your sport.
Overhead movement seems to bethe number one thing, followed
by, I mean, agmr is another one,so just glenohumeral stability
stuff, but it seems like thescapula is the root focus of our
(10:27):
treatment, because that's likethe problem.
That's not really helping.
Does that make sense?
So, and with that being in mind, the clinicians that we mentor
(10:49):
and help coach with fellowship,training and residence for
sports physical therapy, theclinicians that we mentor, we
ask them all right, you'retreating this patient right, you
went this direction right,which means that your diagnosis
was this since you chose this,this and this, and that's the
direction you went for treatment, and they feel better, okay,
and they're back to doing theirthing.
When they get back to 100%, gounrestricted full activities,
sports, exercise, lifting,baseball, swimming, whatever.
When they get back to 100%, howwell is the problem not coming
(11:11):
back?
If the problem comes back, thenthat means we didn't solve the
problem, which means it was adirectional choice of treatment
that wasn't as accurate as itcould have been or purposeful
and effective as it could havebeen, which also means that you
did that because the diagnosiswasn't as accurate as it could
have been, with the wrong, maybeclinical rationale or not the
best clinical rationale youcould have had.
(11:31):
So we have to backtrack all theway back to the diagnosis and
our clinical rationale.
What's the problem?
What is the cause of theproblem?
What is the cause of the cause?
That's what we need to fix andintervene.
And that can't happen in oneday, unfortunately, because
there's compensation patternsthat we have to unlearn, that
have been reinforced for a longtime.
We have to unlearn thosecompensation patterns.
(11:52):
We have to fix the mobilitydisparities.
If something's moving a ton thehyper mobile area and then
something's not moving enoughhypo mobile we have to fix and
intervene that.
And we also have to interveneat the muscle recruitment and
strength disparities.
If some things are very, veryactive and working overtime and
other things are dormant and nothelping contribute, we have to
(12:13):
fix those muscle recruitmentdisparities.
So it seems to always come downto like the combination of
mobility disparities and musclestrength activation disparities
with their activity in sportsand movement, their movement.
We would call that a movementsystem impairment, right?
So, like, what's the diagnosis?
It comes down to that movementsystem impairment as the cause
(12:34):
of the cause that's causing therotator cuff pain, right, pain
doesn't happen for no reason,right?
That's another thing we alwaystalk about with our patients For
musculoskeletal stuff we'vementioned this over the podcast
for neuromusculoskeletalproblems, neuromusculoskeletal
being like a tendon problem,joint pain.
Referred nerve pain right Likesciatica, is a trash can term
(12:54):
that we'll talk another time.
Sciatica is just a blankettrash can term that's not as
accurate as it could be.
It's just referred nerve painbecause of a problem in the low
back right or in the neck rightCervical radiculopathy.
But those things don't justhurt for no reason.
If we rule out systemicproblems and red flags think
musculoskeletal,neuromusculoskeletal problems
(13:15):
they don't just hurt for noreason.
They hurt because of something,something's going on right.
It's usually for athletes oractive people when things hurt
for no reason.
It's the way that they'removing and grooving and just the
(13:39):
compensation patterns withthose disparities and range of
motion and strength disparitiesthat's causing things to get
continually lit up right.
So it's either repetitivemovements or prolonged postures
that are the problem, that justreinforce things to get lit up
continually over and over again,which means we can intervene.
We can control both of those.
We can control our postures andpositioning and we can also
control what movement thingswe're doing right now.
We have to modify some stuff atthe beginning, of course, right
.
So we have to modify somethings totally, then we can
(13:59):
intervene appropriately Manualtherapy to correct the range of
motion problem and jointmobility disparities, and then
exercise prescription andchoices for correcting those
strength and movementdisparities, and that seems to
be the best way to help solvemusculoskeletal problems.
So anyway, with that being said,we hardly ever treat the
rotator cuff for rotator cuffand shoulder pain because
(14:21):
they're already beat up Like wedon't want to, we want to cause,
we want to intervene andoverwhelm them even more.
Right?
We're not going to have theovertime worker be like hey, can
you come back and work extra?
They're already doing enough,right?
So we need to, we need tointervene.
The guys aren't helping enough.
So that's where our choicescome from.
What we would do, though, forthe rotator cuff specifically,
(14:41):
we'll just mobilize the tissue,give it some love, right?
It stimulates hyaluronic acidto help with tendon gliding and
fiber gliding maybe realignfibers to be a little bit more
parallel, and it's knotted upfor tendon and muscle fiber
pliability, and then dryneedling to help stimulate a
healing response.
Dry needling definitely has tobe very helpful, right, we'll
dry needle the supraspinatus.
We'll dry needle theinfraspinatus.
(15:02):
We'll dry needle the teresminor.
We can also dry needle, thesubscapularis, for the purpose
of stimulating a healingresponse and pain modulation and
recruit endogenous opioids forpain to help things feel better,
right, and then mobilize thetissue to give us some love for
sure, biceps tendon included.
But we're not going tostrengthen those things or have
(15:24):
our treatment focus be on those,because we know that's not the
problem.
The problem is the scapula.
So when we talk about thescapula, when reaching overhead,
full overhead, range of motionfor the shoulder was 180 degrees
right, full, straight lineoverhead.
And if somebody can't get there, naturally, but they're able to
(15:44):
do jerk press, snatches,military press overhead,
throwing swimming, volleyball,all that stuff, that means that
if they can't get it just inpure range of motion, then
they're compensating somewhereand it's usually because the
scapula isn't helping enough toupwardly rotate and finish the
job to get the shoulder fullyoverhead.
(16:04):
A third of the total motionoverhead comes from the scapula
by itself.
So if 180 degrees is full, athird of that 60 degrees has to
come from the scapula alone.
So if it's limited a little bitfrom the scapula, there's not
much room for error and thatmeans that something else has to
compensate to finish the job,because athletes are the best
(16:24):
compensators.
We know that Athletes just getthe job done.
They'll do whatever it takes toget the job done.
So they're going to compensate,it's normal just to finish the
job.
But if their scapula is notcontributing and they're not
able to get full range of motionoverhead, then where are they
going to compensate?
Two most common compensationplaces we see are the two most
(16:46):
painful sites that we usuallysee.
It's the shoulder right up inhere.
The shoulder is going tohyperflex because the scapula
can't continue.
So what structures are going toget lit up to hyperflex and
constantly help to overwork?
Supraspinatus and biceps tendonor infraspinatus, followed by
another really commoncompensation area is their
lumbar spine.
Their low back is going tohyperextend.
(17:07):
So what are the two most commonplaces we see all the time with
pain and people we treat,especially athletes, is shoulder
pain and back pain.
The scapula plays a huge rolewith that and that's what we
have to intervene.
So the lumbar hyperextension tofinish the job, to get overhead
, to hyperextend and bendbackwards just to get fully
overhead lumbar spine is goingto get lit up chronically.
So imagine doing thatrepetitively, many, many, many
(17:29):
reps of throwing right.
The lumbar spine is going tohyperextend and rotate or
snatches and jerk press forbarbell lifting and Olympic lift
, shoulder press, standingshoulder press, whatever.
I mean that's a lot of reps ina row of a lot of beat up
activity going on in the lumbarspine to hyperextend chronically
.
So it's something to considerand think about.
(17:49):
So when people come in with backpain and they say you know what
my back hurts when I dosnatches or when I jerk press,
we have to check the scapula.
And that's where that linkcomes in, because if the scapula
is not moving well enough, thenthe to let go.
(18:10):
We had to do a full body eval,a way to exam everything and see
how everything's moving.
Show me the motion that hurtsand we can check that out and
we'll see like, oh, your scapulais not really moving as well as
it could move, making yourlumbar spine overcompensate and
hyperextend.
The most common thing we see forlumbar pain is pain with
extension, pain with lumbarhyperextension.
So anyway, that's stuff we haveto check out, okay?
(18:33):
So the most common diagnosesthat we see when we see people
with shoulder pain is shouldertell me if you've heard of these
before.
I'm sure you have Shoulderimpingement, rotator cuff
impingement, biceps, tendonitis,biceps, impingement labrum,
tears, slap tear.
Those are all probably the mostcommon things, that posterior
(18:54):
impingement, those are probablythe most common thing.
Oh, a subacromial bursitis,shoulder bursitis, the bursitis
is a passive structure.
That thing is just that justhelps with gliding of the
tendons underneath the bonesurface so it doesn't just rub
against each other.
It's like a pillow that rubthat helps prevent um fraying
and rubbing against a hardsurface like a bone.
That's all.
(19:15):
The bursa is all right.
So the bursa gets lit up, whichyou can.
Is the bursa the problem?
But we're going to help solvelike bursas don't hurt for no
reason, right, it's because it'sgetting um inflamed, lit up.
It's getting.
It's getting inflamed, lit up.
It's getting jacked up becauseit's something else neighboring
it.
It's overcompensating becauseof a disparity somewhere else.
That's what we have to treat.
So bursa, that's the passivestructure, but it's kind of
(19:38):
meaningless in our treatmentapproach.
So bursitis, subacromialbursitis, impingement, rotator
cuff impingement, biceps,tendonitis, biceps impingement,
posterior impingement and labrumissues.
So those are the most commondiagnoses we see of coming from
other providers and stuff likeyep, he's got a bursitis problem
(20:00):
.
It's like, okay, I'm sure thebursa's lit up, but why?
What in the first place causedthe bursa to?
I get let up.
That's what we have toinvestigate, but that's where we
have the best results foractive athletic people to solve
the underlying problem so itdoesn't come back again, so they
can get back to exercising andjerk press and lifting weights
and baseball and all that stuff.
Versus you know what, just rest,take some advil and ice it and
(20:24):
then or maybe you know notgetting better, just stop.
Just don't work out anymore.
Shoulder press, it's not goodfor you.
There's no reason why it can'tbe.
It's actually a benefit, right?
You just have to fix theunderlying compensation patterns
first and then we can interveneand wean back into that
exercise for enjoyment of yourlife, right, and also for
athletes that are wanting totrain.
(20:45):
So, man, it's a bummer when wehear like you know what, I just
haven't done it.
My doc told me it's not goodfor me.
Same thing with running, right,that's another one too.
Like we'll just don't run.
It's like well, how many?
There's thousands, of millionsof people that run into their
late decades of life that arefine.
So why are they fine?
(21:07):
But then all their colleaguesand friends that are younger, in
their forties and thirties,having pain.
If it was like running isdetrimental for everybody, then
wouldn't everybody that tries torun have pain?
What are they doing differently?
That's what we have tointervene.
That's what we have toinvestigate and figure something
out.
There is a solution.
Things don't hurt for no reasonand there's plenty of people
that run and have no problems.
(21:28):
There's plenty of people thatthrow a baseball and have no
problems.
There's plenty of people thatdo shoulder press and jerk press
and they have no shoulder pain.
So what are they doingdifferent versus the people that
have pain with it?
What are they doing different?
That's what we need toinvestigate and that's where we
need to intervene.
So, anyway, if you have anyquestions, man, I'm always open
to answer questions and helpshed some light on some stuff,
clarify some things.
Don't hesitate to reach out tous if you have shoulder pain,
(21:53):
back pain, any pain.
If you're an athlete, we treatathletes.
We work with athletic activepeople to get them back to doing
the things they love in sportsthey love to do.
Oftentimes, people that comesee us after they've seen a
bunch of other providers notsaying they're bad people.
They're not set up for successwith the current healthcare
system model, unfortunately, butthe things that haven't worked
in the past or they've been toldyou know what.
You probably just shouldn't dothat anymore.
It's like what there's noreason why you can't do that.
(22:15):
There's plenty of people thatdo that stuff.
We just got to fix why.
Things don't hurt to reach out.
You can call us at 561-899-8725or email us at team T-E-A-M at
(22:38):
athleteRCcom AthleteRC short forAthlete Restoration Company.
So, team at athleteRCcom, orgive us a call.
We would definitely love tochat with you and, um, start the
process of investigating maybewhy you have some issues and
then bring some concrete answersand some solutions.
So, uh, don't hesitate to reachout.
Um, we're always open tosuggestions and, uh, other
topics too.
We'll catch y'all next time.
(23:00):
Hey, hold up.
As you know, we're a smalllocal practice and we don't run
any ads or something on thispodcast, but it would mean the
world if you could share, writea post or word of mouth
recommendation for somebody justlike you that's athletic and
active, that wants to live theirdynamic lifestyle and pay some
good karma and pay it forward tosomebody else just like you.
(23:21):
And, who knows, you couldchange their world and a 10
second review could be thatavenue.
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