August 27, 2025 • 21 mins
Shoulder pain might be the most common complaint we see in our clinic, but understanding its true origins requires looking beyond the obvious. What separates lasting solutions from temporary fixes is identifying not just what hurts, but why it started hurting in the first place.
Your shoulder functions as a complex system where the scapula (shoulder blade) serves as the foundation. When this keystone isn't positioned correctly or doesn't move with proper rhythm, it forces your rotator cuff muscles to overcompensate. These small muscles weren't designed to compete against powerhouses like your lats and pecs. The inevitable result? Fraying, impingement, and pain that persists until the underlying cause is addressed.
Most people don't realize that achieving full overhead motion requires perfect coordination between your shoulder joint (contributing 120 degrees) and your scapula (contributing 60 degrees). When this relationship breaks down, your body creates compensation patterns that might temporarily solve the movement problem but eventually lead to tissue breakdown. Add thoracic spine stiffness to the equation, and you've got the perfect recipe for chronic shoulder issues.
The medical path typically leads to MRIs revealing labrum tears, biceps tendon issues, or rotator cuff fraying. Here's the surprising truth: these structural abnormalities often exist without causing any pain whatsoever. Many people walk around with significant "tears" for years before experiencing symptoms. This raises a crucial question: is the structural abnormality truly causing your pain, and is surgery always necessary?
While surgery has its place, addressing the underlying movement patterns through specialized physical therapy often resolves symptoms without the risks and lengthy recovery time of invasive procedures. By fixing the "cause of the cause," we've helped countless patients return to full activity without surgical intervention.
Are you struggling with shoulder pain or facing a surgical recommendation? Reach out to discuss your options with specialists who understand how to identify and correct the fundamental movement issues at the heart of your pain. Contact us at 561-899-8725 or email team@athleteRC.com to take the first step toward lasting shoulder 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?
Welcome back to the DrivenAthlete Podcast.
I'm your man, dr Kyle.
A common thing we see a lot isshoulder pain.
(00:21):
All right, probably the mostcommon things that we see is
shoulder pain, back pain andthen a hit or miss, but those
are the two most common things,followed by, like, neck pain,
knee pain, hip impingement,ankle, elbow, wrist, but the
(00:45):
shoulder and the back are thetwo most common things we see.
So here's the recipe that weinvestigate and hypothesize, the
typical recipe to fix shoulderpain.
The first question we ask, wehave to figure out, is like
what's the problem?
What's causing the pain?
Why did that start?
What can we do to fix it?
And then how do we prevent itfor coming back again?
(01:08):
Right, those are the mainquestions that we need to figure
out and ask.
All right, so with ourevaluations, we're investigating
, like what is the actual what'scausing the pain?
Like what's the angry tissue,what's the what's the thing
that's causing pain?
But that's not enough to answer, that's not enough to fix the
problem we have to figure out.
Okay, let's say, your rotatorcuff is the problem.
If it's your supraspinatustendon, okay, maybe some
(01:30):
contributions of the bicepstendon, long head of the bicep,
we understand that.
It's not that hard to figureout.
Actually, here's what sets usapart.
I think that is really.
This is the way you fix it.
Why did it get irritated in thefirst place?
The cause of the pain is therotator cuff.
If it's, the supraspinatus andthe bicep tendon, that's an
(01:51):
example.
What is the cause of that causeof pain?
That's what we have to figureout and that's what we have to
fix.
Otherwise it comes back.
So the people that we mentor inour clinic physical therapists,
doctors of physical therapythat come to mentor with me,
that are in the fellowship,training or fellowship courses
and stuff we ask them what isthe cause of the cause?
And then if you are intervening, you're rehabbing this person
(02:15):
and you say, hey, you know whatperson?
Hey, patient, go out andexercise or do your sport, throw
and play the crop, run,whatever, full go.
If the pain comes back, thatmeans you didn't solve the
problem.
If it doesn't come back, itmeans you solved the problem
right.
And then solving the problemfirst comes with the right
diagnosis.
We have to have the right lensin which to perceive the problem
(02:37):
, to diagnose it accurately,which is going to totally change
the trajectory of treatment ofhow to fix the problem.
All right, totally change thetrajectory of treatment of how
to fix the problem?
All right, with manual therapyintervening at the right joints.
Soft tissue work If it's dryneedling can be included too.
That helps facilitate thehealing process and then
corrective exercise prescription.
That's going to solve theproblem.
(02:58):
And my question would be likewhy choose that exercise versus
something else?
What's the biomechanicalrationale linked with your
diagnosis of why you chose thatexercise to fix the problem, the
biomechanical rationale linkedwith your diagnosis of why you
chose that exercise to fix theproblem?
And if it's, if a clinician isnot able to answer that
concisely, then that meansthey're just throwing stuff
against the wall, blind.
All right, just like dark, darkroom trying to hit a dark board
, like maybe this will work,right.
So purposeful, right, we got tobe purposeful with our manual
(03:21):
interventions and also ourcorrective exercises.
So, with the shoulderspecifically, the things that we
check out usually that we haveto investigate, number one is
the shoulder blade, the scapula.
All right, that is the keystonefor the shoulder joint and the
shoulder girdle.
All right, the scapula has tomove enough.
It has to start in the rightposition in order for things to
(03:44):
move enough and accurately andthen it will F up.
All the muscles that originatebecause there's all four rotator
cuff muscles originate from thescapula and then insert to the
humerus, the arm bone at thehead of the humerus.
So if the scapula isdysfunctional, it starts in the
wrong position.
It's not the rhythm of thescapular activation isn't there,
(04:05):
it's not moving enough.
What do you think the musclesthat start from there are going
to do?
They're going to bedysfunctional.
They're not going to activateright, they're going to be
overly.
Usually those rotator cuffmuscles are over-performing,
they're overcompensating to makeup for a lack of scapular
mobility.
All right.
So if the supraspinatus is themain rotator cuff muscle on the
(04:27):
top of the shoulder that getspainful the most, followed by
the infraspinatus, followed bythe teres minor, followed by the
subscapularis, that thesupraspinatus is getting
involved, and so is theinfraspinatus a little bit.
Why?
Right?
And there's a huge commonalitythat the scapula is not starting
in the right position andthere's other muscles that help
to activate the scapula thataren't contributing enough.
(04:48):
That's making the supraspinatushave to overcompensate to make
up for that lack of movement inthe poor starting position, and
we would call that scapularrhythm, all right.
So the scapular rhythm needs tobe working well, all right,
otherwise the rotator cuff isgoing to be overcompensating.
So here's just in.
The rotator cuff is going to beovercompensating.
So here's this.
And the rotator cuff is a groupof four muscles that are very
small, they're not massive andthey work in concert together to
(05:11):
suck in the arm bone and keepit in place while you move and
groove and do stuff withexercise and pushups and
shoulder press and throwing afootball and baseball, whatever.
So they work in concerttogether and they're not big and
they don't massive muscles.
If they have to overwork andcompete against the scapula,
that's not moving well.
And other major muscles likeyour latissimus dorsi, your lat
(05:35):
and your pectoralis major, yourpec, and Terry's major is
another big player too forcreating internal rotation.
That's a big, strong muscle.
If that little muscle and thosetwo small muscles are competing
against big muscles that arereally strong and dominant and
tight, who's going to win?
What's going to happen to therotator cuff?
It's going to get broken downover time.
(05:55):
It's going to get frayed, it'sgoing to get overwhelmed, it's
going to get broken down.
And what does that look?
What does that feel like?
It hurts, it causes impingement, right.
So shoulder impingement,rotator cuff-based pain and
classic signs and symptoms forreferred rotator cuff-based pain
is pain down the lateralshoulder down to the arm and
like it feels like down my arm,my arm hurts.
(06:16):
That's classic referred painfrom the rotator cuff, or front
pain where the biceps tendon isgetting irritated and sensitive
and overwhelmed.
Because the biceps tendon isgetting irritated and sensitive
and overwhelmed Because thebiceps tendon also is going to
contribute to help prevent theshoulder from dysfunctioning too
much.
But that's not really the jobof the long head of the biceps
tendon.
It's going to get overwhelmedand it's going to get overly
stressed and strained and that'sgoing to cause it to get
(06:38):
painful and irritated as well.
All right, on top of that, thejoint capsule of the
glenohumeral joint, the shoulderjoint, there's a small membrane
that unsheathes the shoulderjoint itself up in here and that
is also.
This has tons of nerve endingson the undersurface membrane
called the synovium and that'sgoing to get irritated and lit
up too.
So the rotator cuff is lit up,the supraspinatus and
(06:59):
infraspinatus, particularly thelong head of the biceps tendon,
gets lit up, very sensitive, andthen the capsule itself gets
overwhelmed, stressed and thensensitive and painful too and
that creates like shoulder pain.
All right, so that's a classicthing.
So, key considerations we haveto investigate the scapula.
All right, that's the firstthing we're looking at.
That's what I educate myclinicians that come in, the
doctors of physical therapy thatcome mentor with me in the
(07:22):
clinic.
That's one of the first thingswe check out and investigate.
All right, we have to look atthe scapula first.
Like I said, all those musclesoriginate from the scapula, and
then the next thing is just theglenohumeral joint itself and
the humeral positioning.
So if the humerus starts moreanterior, more forwardly tilted
(07:42):
or more forwardly shifted,that's a great recipe for an
anterior shift or a forwardshift of the shoulder ball and
socket joint.
What do you think the frontstructures that span over the
anterior part of the shoulderjoint are going to be like?
They're going to beoverstressed and strained and
painful.
Right, so that looks like withthrowers as an example, if they
have pain when they reach backat layback or late cocking of
(08:05):
the throw and they have pain intheir shoulder with early
acceleration.
That's a classic sign foranterior hypermobility.
All right, where the biceptendon and the anterior capsule
are getting lit up and therotator cuff is way
overcompensating to hang on fordear life and we got to fix that
stuff, all right.
(08:26):
So, and then also the scapularrhythm, like I mentioned,
compared with the ratio of rangeof motion contributed from the
ball and socket joint, theglenohumeral joint and the
scapula itself, to get fullyoverhead in the shoulder joint,
you need 180, the considerationwould be you need 180 degrees of
full range of motion overhead.
(08:47):
That'd be a straight line whenyou reach your arm straight
overhead.
Is that a straight linestraight down your rib cage,
like the mid rib cage line?
We call that the mid axillaryline.
Okay, the axilla is like yourarmpit region.
So in the mid axillary line, isit a straight line from your
arm bone straight down?
Very uncommon, that's.
A lot of people actually notmany people have full range of
(09:09):
motion, okay, and if they do,it's usually because they're
overcompensating.
So if you need 180 degrees ofoverhead range of motion, 120
degrees of that should come frompure glenohumeral roll and
glide and the remaining 60degrees should come from your
scapula by itself.
So usually it's the scapulathat's athletic.
(09:32):
The scapula is usually limited,partly because it's starting
too far stuck in the mud downand it's not starting in the
right position.
And then the muscles thatactivate and move the scapula
upward rotation, to rotate itupwardly aren't activating and
functioning strongly, they'renot recruited enough.
And then there's also softtissue restrictions that are
(09:54):
limiting the motion on top ofthat and therefore the rotator
cuff has to compete againstthose things.
To move your arm overhead enough.
And imagine doing thatrepetitively with like shoulder
press and jerk press andsnatches and hand cleans, power
cleans to jerk press stuff likethat Military press, right,
inclined push-ups, inclinedbench, repetitively, over and
(10:15):
over again right push-ups,inclined bench, repetitively
over and over again right.
And then if the glenohumeraljoint isn't rotating enough too
because of soft tissuerestrictions, that's also going
to be limited and the rotatorcuff has to compete against that
also All right.
So get full overhead range ofmotion.
A person needs 180 degreesstraight up and down with their
arm, okay.
They also need to get enoughfull external rotation of their
(10:38):
arm, all right, their arm has torotate externally, feeling like
longitudinally overhead, andthen their elbows need to get
fully straight.
So here's a quiz question Tryright now Can you reach your arm
straight overhead and get 180degrees with your elbow straight
and your hand rotated outwards?
If the answer is no, thenyou're not getting full range of
motion.
I haven't really met one personyet.
(10:58):
I haven't met many people.
I probably have, but I haven'tmet many people that can do that
, so it's kind of uncommon.
So imagine, then, an athlete whoneeds to get overhead with
shoulder press, jerk press orsnatches, push press, incline
bench, whatever.
They need to get fully overhead, but they're limited in range
of motion in their shoulder.
(11:19):
Where's the rest of the rangeof motion going to be made up
for?
What they do is they're usuallyhypermobile in their shoulder
joint, they hyperflex in theirglenohumeral joint because the
scapula can't continue, and then, in addition to that, they
hyperextend their lumbar spine,their low back, so they extend
their low back and then theirshoulder joint itself will
(11:40):
hyperflex.
Okay, because of lack ofmobility elsewhere.
That's going to create a lot ofa cascade of things that are
going to overcompensate and getirritated in your low back and
in the shoulder joint itself.
Okay, and what are the two mostcommon things that we see, the
most cases that we seeconsistently is low back pain
and shoulder pain.
Anyway, there's a link betweenthe two.
(12:02):
One other thing we can't neglectis that we had to investigate
the thoracic spine.
The thoracic spine region is 12vertebrae in the middle of your
back, the upper back, and therehas to be enough of extension,
for sure, and rib mobility.
Add the relationship betweenthe scapula and the thoracic
spine, and then some of themuscles connect from the rib
(12:23):
cage in the thoracic region tothe scapula and also to the
shoulder joint.
So the thoracic spine needs tobe pliable and mobile as well.
Okay, so that's something weinvestigate also.
So, anyway, that's like, that'slike the recipe that we
investigate.
And one more thing on top ofthat Okay, so what's the usual
(12:45):
step when somebody has shoulderpain?
What do they do?
They go to the doc.
What's the doc say?
We need to get an x-ray.
Okay, if it's soft tissue,they're not going to find
anything.
Anyway, they just had to dothat.
They had to do an x-ray firstto satisfy insurance
requirements to then have an MRI.
Okay, so now it's like x-raycame back negative, schedule an
MRI, come back and schedule afollow up with the doc later.
(13:05):
All right, that's at least athree week process and in the
meantime of those three weeksthey're not having any benefit.
They're not doing anythingabout their shoulder pain,
they're just waiting for the MRIresults.
They're waiting for theappointment to have a consult
and then usually in the consultthe doc's like you're not a
surgical candidate, go get PT.
So I'm like, bro, just come inright away, we can fix the
problem earlier.
And that's a three week.
And then the schedule of PT isanother week to wait.
(13:26):
That's a four week timeframewhere, like that, four weeks
could have had someinterventions and feel better
already, some answers and thenactually feel better and back to
some of the functional activityyou like to do, without that
delay.
You know what I mean, becauseyou can't get your time back,
but anyway.
So what do they usually find inMRI?
All right, so there's internalderangement that can be totally
present, where the labrum canget involved, the biceps tendon
(13:48):
and the biceps anchor can getinvolved, that rotator cuff can
get involved and frayed thoseare the most common ones.
And the joint capsule.
There can be edema andincreased signaling and swelling
present in the joint capsuleitself.
Synovitis all right,tenosynovitis and then capsular
synovitis as well.
That represents, like synovium,the synovial soft tissues that
(14:14):
allow for fiber gliding, thatensheath the tendinous and joint
capsule structures.
So imagine, with these flawedshoulder mechanics and
biomechanical compensationpatterns, with thousands and
thousands of reps over many,many weeks and months and years,
with those flawed mechanics andundue stress being placed on
(14:36):
certain structures andinstability or hypermobility in
certain directions incompensation patterns, what do
you think is going to happen?
The labrum is repetitivelygoing to have stress placed on
it and undue stress in certainpositions, certain areas of the
labrum.
That's going to cause frayingof the labrum and that
repetitive fraying over time canbecome enough to a point where
(14:59):
it causes pain.
But there's plenty of peoplethat have a lot of fraying
evident in their labrum, ortears, if you want to call it
that, and they have no pain.
So it's not always thestructural abnormality that
causing the pain problem.
Okay, it just representsunderlying shoulder instability
over many, many chronic episodes.
Okay.
(15:20):
And then same thing with thebiceps anchor.
So the biceps, the long head ofthe biceps tendon, you have two
tendons in your bicep bymeaning two and the long head
goes up in the shoulder jointand it connects to the, to the
super glenoid tubercle Okay, ofthe scapula, all right, it
attaches to the inside of yourshoulder joint and it anchors
with the top part of your labrum.
Okay, issues with that, ordetachment, or fraying, or
(15:45):
stress and tears, that canhappen.
There would be a slap tear,okay, that's where the word slap
tear comes from, slap meaningS-L-A-P, superior labrum,
anterior to posterior, and thathas to do with the biceps anchor
as it attaches to your shoulderjoint and that would be a slap.
Involvement is what we wouldcall that.
Okay.
But that again representsflawed mechanics with a lot of
(16:10):
chronic high volume activitywith underlying shoulder
hypermobility.
In certain directions it'susually in the anterior forward
direction of the humeral head ismore hypermobile, okay.
And then also the rotator cuff.
The tendons of the rotator cuffcan get, with all the
repetitive stress andcompensation patterns and flawed
(16:31):
mechanics.
It can get frayed over many,many episodes and that fraying
is termed a tear as well.
And enough of a tear is gradedin certain ways in certain
vocabulary descriptions, andthat fraying leading to a tear
can seem scary.
But that's also what can befound as well is the tendons can
(16:52):
get frayed over time Like arope gets frayed enough to the
point where it causes symptoms,and enough symptoms that then go
to the doc to get the image inthe first place and they're like
oh, you have a rotator cufftear and a labrum tear.
It's like, oh my God, I had noidea.
Well, that tear might have beenthere for years.
Okay, from all the repetitivemicrotrauma, micro injuries and
repetitive stress placed on them, from all the compensation
(17:14):
patterns for many, many years,where the image of that MRI
currently looks like you have alabrum tear, slap tear and a
rotator cuff tear.
Whatever that image.
Imagine if you would have got animage three years ago of your
shoulder.
It very confidently and verycommonly the image would be
identical.
(17:34):
But you didn't have pain threeyears ago, but now you have pain
for the past six months.
All right, three years ago, butnow you have pain for the past
six months, all right.
So is the structure actuallycausing the pain enough to have
a structural intervention like asurgery?
I'm just saying like I don'thate surgery.
Surgery is necessary, sometimestotally, but we don't have to
jump the gun and it sounds scary.
We don't want to be fearmongered into getting surgery,
(17:56):
though sometimes, all right, wedon't have to do that.
It's important to get anopinion.
Sometimes, all right, you canget a second opinion.
Of course we're a little biasedbecause we're conservative
therapists that work withathletes and active people.
We're naturally optimisticindividuals Because we've had
really good results of peoplethat have had imaging that
doesn't look great.
(18:17):
But if we look at the cause ofthe cause, why did this happen
in the first place?
If we fix the cause of thecause and keep the structure as
is, we've had plenty of peoplethat feel totally fine and back
to no functional restrictions.
And the question would be likeafter surgery, would your
functional capacity be betterthan what we were to do now, if
we were to work together for sixweeks, would the functional
(18:38):
capacity be higher and betterthan what it would be if we did
this, if we fixed thosecompensation patterns?
Cause after surgery, like alleverything's off the table, like
everything changes as in, likethe compensation patterns
haven't changed, the neuralrecruitment patterns haven't
changed, but now there's likewe're just starting over and
starting from scratch.
But um, the things it's notuncommon for stuff to just like
(19:01):
proliferate in the samedirection Again if you don't fix
the underlying compensation,compensation patterns that led
to the derangement in the firstplace.
But anyway, would your funk?
Here's the question, here's thefilter yes or no, to have
surgery or not surgery?
Would your functional capacitybe better than what it would be
if we were to work together fora month?
If the answer is like maybe not,or the same, then why not just
(19:22):
do the conservative and sparethe risk and the time and the
pain.
It's like it's painful aftersurgery, but I'm not sure if you
know, but like you need.
That's why you have pain medsafter rotator cuff repair.
Oh my gosh, you're.
It's just, it's asappropriately necessary happens
and expectedly, as expected,someone's going to be very
(19:43):
sensitive and painful and sleepis the number one thing.
That's very challenging for thefirst six to eight weeks of
surgery.
I've seen a ton of them.
All right, but anyway.
So that's just something toconsider, right?
I don't hate surgery.
Sometimes you got to havesurgery, but it's never a bad
idea to get multiple opinions,all right, and then just look at
it from a different, reframedangle of like, what's the
(20:03):
decision here?
What's the best decision?
But anyway, if you have anyquestions, that's a little bit
of breakdown of the recipe ofshoulder pain Usually.
If you have any questions,comments, concerns or
conflicting opinions, pleasereach out.
Come, step into my office.
Let's have a conversation,discussion, I'm all about it.
I love to hear differentopinions and have a arousing
conversation about some stuff.
And if you have any pain orissues and you want to work with
(20:24):
a specialist, please reach out.
We'd love to at least talk.
We can at least talk on thephone and figure out if you have
an issue that we can help ormaybe point you in the right
direction.
And the best way to reach us is561-899-8725 or our email,
which is team at athleteRCcom.
That's the best way to reachout to us.
Um, but yeah, if you have anypain, you want to work with a
specialist, you need someanswers.
(20:45):
You're not sure what to do.
You've been told by multipleproviders that you need like
you're screwed.
You'll never be back to doingthis.
You're in pain forever.
You need to take pain meds,surgery.
This isn't working whatever.
We hear that very often.
We can at least have aconversation right and then
point you in the right direction.
If you don't feel like we'rethe right fit, or you don't feel
like if we don't feel likeyou're right fit for us, you
(21:05):
don't feel like we're right foryou, totally understandable we
at least point in the rightdirection.
But if it's something you wantto investigate with a specialist
, please reach out.
All right, I look forward tohearing from you and we'll catch
y'all next time.
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?
Welcome back to the DrivenAthlete Podcast.
I'm your man, dr Kyle.
A common thing we see a lot isshoulder pain.
(00:21):
All right, probably the mostcommon things that we see is
shoulder pain, back pain andthen a hit or miss, but those
are the two most common things,followed by, like, neck pain,
knee pain, hip impingement,ankle, elbow, wrist, but the
(00:45):
shoulder and the back are thetwo most common things we see.
So here's the recipe that weinvestigate and hypothesize, the
typical recipe to fix shoulderpain.
The first question we ask, wehave to figure out, is like
what's the problem?
What's causing the pain?
Why did that start?
What can we do to fix it?
And then how do we prevent itfor coming back again?
(01:08):
Right, those are the mainquestions that we need to figure
out and ask.
All right, so with ourevaluations, we're investigating
, like what is the actual what'scausing the pain?
Like what's the angry tissue,what's the what's the thing
that's causing pain?
But that's not enough to answer, that's not enough to fix the
problem we have to figure out.
Okay, let's say, your rotatorcuff is the problem.
If it's your supraspinatustendon, okay, maybe some
(01:30):
contributions of the bicepstendon, long head of the bicep,
we understand that.
It's not that hard to figureout.
Actually, here's what sets usapart.
I think that is really.
This is the way you fix it.
Why did it get irritated in thefirst place?
The cause of the pain is therotator cuff.
If it's, the supraspinatus andthe bicep tendon, that's an
(01:51):
example.
What is the cause of that causeof pain?
That's what we have to figureout and that's what we have to
fix.
Otherwise it comes back.
So the people that we mentor inour clinic physical therapists,
doctors of physical therapythat come to mentor with me,
that are in the fellowship,training or fellowship courses
and stuff we ask them what isthe cause of the cause?
And then if you are intervening, you're rehabbing this person
(02:15):
and you say, hey, you know whatperson?
Hey, patient, go out andexercise or do your sport, throw
and play the crop, run,whatever, full go.
If the pain comes back, thatmeans you didn't solve the
problem.
If it doesn't come back, itmeans you solved the problem
right.
And then solving the problemfirst comes with the right
diagnosis.
We have to have the right lensin which to perceive the problem
(02:37):
, to diagnose it accurately,which is going to totally change
the trajectory of treatment ofhow to fix the problem.
All right, totally change thetrajectory of treatment of how
to fix the problem?
All right, with manual therapyintervening at the right joints.
Soft tissue work If it's dryneedling can be included too.
That helps facilitate thehealing process and then
corrective exercise prescription.
That's going to solve theproblem.
(02:58):
And my question would be likewhy choose that exercise versus
something else?
What's the biomechanicalrationale linked with your
diagnosis of why you chose thatexercise to fix the problem, the
biomechanical rationale linkedwith your diagnosis of why you
chose that exercise to fix theproblem?
And if it's, if a clinician isnot able to answer that
concisely, then that meansthey're just throwing stuff
against the wall, blind.
All right, just like dark, darkroom trying to hit a dark board
, like maybe this will work,right.
So purposeful, right, we got tobe purposeful with our manual
(03:21):
interventions and also ourcorrective exercises.
So, with the shoulderspecifically, the things that we
check out usually that we haveto investigate, number one is
the shoulder blade, the scapula.
All right, that is the keystonefor the shoulder joint and the
shoulder girdle.
All right, the scapula has tomove enough.
It has to start in the rightposition in order for things to
(03:44):
move enough and accurately andthen it will F up.
All the muscles that originatebecause there's all four rotator
cuff muscles originate from thescapula and then insert to the
humerus, the arm bone at thehead of the humerus.
So if the scapula isdysfunctional, it starts in the
wrong position.
It's not the rhythm of thescapular activation isn't there,
(04:05):
it's not moving enough.
What do you think the musclesthat start from there are going
to do?
They're going to bedysfunctional.
They're not going to activateright, they're going to be
overly.
Usually those rotator cuffmuscles are over-performing,
they're overcompensating to makeup for a lack of scapular
mobility.
All right.
So if the supraspinatus is themain rotator cuff muscle on the
(04:27):
top of the shoulder that getspainful the most, followed by
the infraspinatus, followed bythe teres minor, followed by the
subscapularis, that thesupraspinatus is getting
involved, and so is theinfraspinatus a little bit.
Why?
Right?
And there's a huge commonalitythat the scapula is not starting
in the right position andthere's other muscles that help
to activate the scapula thataren't contributing enough.
(04:48):
That's making the supraspinatushave to overcompensate to make
up for that lack of movement inthe poor starting position, and
we would call that scapularrhythm, all right.
So the scapular rhythm needs tobe working well, all right,
otherwise the rotator cuff isgoing to be overcompensating.
So here's just in.
The rotator cuff is going to beovercompensating.
So here's this.
And the rotator cuff is a groupof four muscles that are very
small, they're not massive andthey work in concert together to
(05:11):
suck in the arm bone and keepit in place while you move and
groove and do stuff withexercise and pushups and
shoulder press and throwing afootball and baseball, whatever.
So they work in concerttogether and they're not big and
they don't massive muscles.
If they have to overwork andcompete against the scapula,
that's not moving well.
And other major muscles likeyour latissimus dorsi, your lat
(05:35):
and your pectoralis major, yourpec, and Terry's major is
another big player too forcreating internal rotation.
That's a big, strong muscle.
If that little muscle and thosetwo small muscles are competing
against big muscles that arereally strong and dominant and
tight, who's going to win?
What's going to happen to therotator cuff?
It's going to get broken downover time.
(05:55):
It's going to get frayed, it'sgoing to get overwhelmed, it's
going to get broken down.
And what does that look?
What does that feel like?
It hurts, it causes impingement, right.
So shoulder impingement,rotator cuff-based pain and
classic signs and symptoms forreferred rotator cuff-based pain
is pain down the lateralshoulder down to the arm and
like it feels like down my arm,my arm hurts.
(06:16):
That's classic referred painfrom the rotator cuff, or front
pain where the biceps tendon isgetting irritated and sensitive
and overwhelmed.
Because the biceps tendon isgetting irritated and sensitive
and overwhelmed Because thebiceps tendon also is going to
contribute to help prevent theshoulder from dysfunctioning too
much.
But that's not really the jobof the long head of the biceps
tendon.
It's going to get overwhelmedand it's going to get overly
stressed and strained and that'sgoing to cause it to get
(06:38):
painful and irritated as well.
All right, on top of that, thejoint capsule of the
glenohumeral joint, the shoulderjoint, there's a small membrane
that unsheathes the shoulderjoint itself up in here and that
is also.
This has tons of nerve endingson the undersurface membrane
called the synovium and that'sgoing to get irritated and lit
up too.
So the rotator cuff is lit up,the supraspinatus and
(06:59):
infraspinatus, particularly thelong head of the biceps tendon,
gets lit up, very sensitive, andthen the capsule itself gets
overwhelmed, stressed and thensensitive and painful too and
that creates like shoulder pain.
All right, so that's a classicthing.
So, key considerations we haveto investigate the scapula.
All right, that's the firstthing we're looking at.
That's what I educate myclinicians that come in, the
doctors of physical therapy thatcome mentor with me in the
(07:22):
clinic.
That's one of the first thingswe check out and investigate.
All right, we have to look atthe scapula first.
Like I said, all those musclesoriginate from the scapula, and
then the next thing is just theglenohumeral joint itself and
the humeral positioning.
So if the humerus starts moreanterior, more forwardly tilted
(07:42):
or more forwardly shifted,that's a great recipe for an
anterior shift or a forwardshift of the shoulder ball and
socket joint.
What do you think the frontstructures that span over the
anterior part of the shoulderjoint are going to be like?
They're going to beoverstressed and strained and
painful.
Right, so that looks like withthrowers as an example, if they
have pain when they reach backat layback or late cocking of
(08:05):
the throw and they have pain intheir shoulder with early
acceleration.
That's a classic sign foranterior hypermobility.
All right, where the biceptendon and the anterior capsule
are getting lit up and therotator cuff is way
overcompensating to hang on fordear life and we got to fix that
stuff, all right.
(08:26):
So, and then also the scapularrhythm, like I mentioned,
compared with the ratio of rangeof motion contributed from the
ball and socket joint, theglenohumeral joint and the
scapula itself, to get fullyoverhead in the shoulder joint,
you need 180, the considerationwould be you need 180 degrees of
full range of motion overhead.
(08:47):
That'd be a straight line whenyou reach your arm straight
overhead.
Is that a straight linestraight down your rib cage,
like the mid rib cage line?
We call that the mid axillaryline.
Okay, the axilla is like yourarmpit region.
So in the mid axillary line, isit a straight line from your
arm bone straight down?
Very uncommon, that's.
A lot of people actually notmany people have full range of
(09:09):
motion, okay, and if they do,it's usually because they're
overcompensating.
So if you need 180 degrees ofoverhead range of motion, 120
degrees of that should come frompure glenohumeral roll and
glide and the remaining 60degrees should come from your
scapula by itself.
So usually it's the scapulathat's athletic.
(09:32):
The scapula is usually limited,partly because it's starting
too far stuck in the mud downand it's not starting in the
right position.
And then the muscles thatactivate and move the scapula
upward rotation, to rotate itupwardly aren't activating and
functioning strongly, they'renot recruited enough.
And then there's also softtissue restrictions that are
(09:54):
limiting the motion on top ofthat and therefore the rotator
cuff has to compete againstthose things.
To move your arm overhead enough.
And imagine doing thatrepetitively with like shoulder
press and jerk press andsnatches and hand cleans, power
cleans to jerk press stuff likethat Military press, right,
inclined push-ups, inclinedbench, repetitively, over and
(10:15):
over again right push-ups,inclined bench, repetitively
over and over again right.
And then if the glenohumeraljoint isn't rotating enough too
because of soft tissuerestrictions, that's also going
to be limited and the rotatorcuff has to compete against that
also All right.
So get full overhead range ofmotion.
A person needs 180 degreesstraight up and down with their
arm, okay.
They also need to get enoughfull external rotation of their
(10:38):
arm, all right, their arm has torotate externally, feeling like
longitudinally overhead, andthen their elbows need to get
fully straight.
So here's a quiz question Tryright now Can you reach your arm
straight overhead and get 180degrees with your elbow straight
and your hand rotated outwards?
If the answer is no, thenyou're not getting full range of
motion.
I haven't really met one personyet.
(10:58):
I haven't met many people.
I probably have, but I haven'tmet many people that can do that
, so it's kind of uncommon.
So imagine, then, an athlete whoneeds to get overhead with
shoulder press, jerk press orsnatches, push press, incline
bench, whatever.
They need to get fully overhead, but they're limited in range
of motion in their shoulder.
(11:19):
Where's the rest of the rangeof motion going to be made up
for?
What they do is they're usuallyhypermobile in their shoulder
joint, they hyperflex in theirglenohumeral joint because the
scapula can't continue, and then, in addition to that, they
hyperextend their lumbar spine,their low back, so they extend
their low back and then theirshoulder joint itself will
(11:40):
hyperflex.
Okay, because of lack ofmobility elsewhere.
That's going to create a lot ofa cascade of things that are
going to overcompensate and getirritated in your low back and
in the shoulder joint itself.
Okay, and what are the two mostcommon things that we see, the
most cases that we seeconsistently is low back pain
and shoulder pain.
Anyway, there's a link betweenthe two.
(12:02):
One other thing we can't neglectis that we had to investigate
the thoracic spine.
The thoracic spine region is 12vertebrae in the middle of your
back, the upper back, and therehas to be enough of extension,
for sure, and rib mobility.
Add the relationship betweenthe scapula and the thoracic
spine, and then some of themuscles connect from the rib
(12:23):
cage in the thoracic region tothe scapula and also to the
shoulder joint.
So the thoracic spine needs tobe pliable and mobile as well.
Okay, so that's something weinvestigate also.
So, anyway, that's like, that'slike the recipe that we
investigate.
And one more thing on top ofthat Okay, so what's the usual
(12:45):
step when somebody has shoulderpain?
What do they do?
They go to the doc.
What's the doc say?
We need to get an x-ray.
Okay, if it's soft tissue,they're not going to find
anything.
Anyway, they just had to dothat.
They had to do an x-ray firstto satisfy insurance
requirements to then have an MRI.
Okay, so now it's like x-raycame back negative, schedule an
MRI, come back and schedule afollow up with the doc later.
(13:05):
All right, that's at least athree week process and in the
meantime of those three weeksthey're not having any benefit.
They're not doing anythingabout their shoulder pain,
they're just waiting for the MRIresults.
They're waiting for theappointment to have a consult
and then usually in the consultthe doc's like you're not a
surgical candidate, go get PT.
So I'm like, bro, just come inright away, we can fix the
problem earlier.
And that's a three week.
And then the schedule of PT isanother week to wait.
(13:26):
That's a four week timeframewhere, like that, four weeks
could have had someinterventions and feel better
already, some answers and thenactually feel better and back to
some of the functional activityyou like to do, without that
delay.
You know what I mean, becauseyou can't get your time back,
but anyway.
So what do they usually find inMRI?
All right, so there's internalderangement that can be totally
present, where the labrum canget involved, the biceps tendon
(13:48):
and the biceps anchor can getinvolved, that rotator cuff can
get involved and frayed thoseare the most common ones.
And the joint capsule.
There can be edema andincreased signaling and swelling
present in the joint capsuleitself.
Synovitis all right,tenosynovitis and then capsular
synovitis as well.
That represents, like synovium,the synovial soft tissues that
(14:14):
allow for fiber gliding, thatensheath the tendinous and joint
capsule structures.
So imagine, with these flawedshoulder mechanics and
biomechanical compensationpatterns, with thousands and
thousands of reps over many,many weeks and months and years,
with those flawed mechanics andundue stress being placed on
(14:36):
certain structures andinstability or hypermobility in
certain directions incompensation patterns, what do
you think is going to happen?
The labrum is repetitivelygoing to have stress placed on
it and undue stress in certainpositions, certain areas of the
labrum.
That's going to cause frayingof the labrum and that
repetitive fraying over time canbecome enough to a point where
(14:59):
it causes pain.
But there's plenty of peoplethat have a lot of fraying
evident in their labrum, ortears, if you want to call it
that, and they have no pain.
So it's not always thestructural abnormality that
causing the pain problem.
Okay, it just representsunderlying shoulder instability
over many, many chronic episodes.
Okay.
(15:20):
And then same thing with thebiceps anchor.
So the biceps, the long head ofthe biceps tendon, you have two
tendons in your bicep bymeaning two and the long head
goes up in the shoulder jointand it connects to the, to the
super glenoid tubercle Okay, ofthe scapula, all right, it
attaches to the inside of yourshoulder joint and it anchors
with the top part of your labrum.
Okay, issues with that, ordetachment, or fraying, or
(15:45):
stress and tears, that canhappen.
There would be a slap tear,okay, that's where the word slap
tear comes from, slap meaningS-L-A-P, superior labrum,
anterior to posterior, and thathas to do with the biceps anchor
as it attaches to your shoulderjoint and that would be a slap.
Involvement is what we wouldcall that.
Okay.
But that again representsflawed mechanics with a lot of
(16:10):
chronic high volume activitywith underlying shoulder
hypermobility.
In certain directions it'susually in the anterior forward
direction of the humeral head ismore hypermobile, okay.
And then also the rotator cuff.
The tendons of the rotator cuffcan get, with all the
repetitive stress andcompensation patterns and flawed
(16:31):
mechanics.
It can get frayed over many,many episodes and that fraying
is termed a tear as well.
And enough of a tear is gradedin certain ways in certain
vocabulary descriptions, andthat fraying leading to a tear
can seem scary.
But that's also what can befound as well is the tendons can
(16:52):
get frayed over time Like arope gets frayed enough to the
point where it causes symptoms,and enough symptoms that then go
to the doc to get the image inthe first place and they're like
oh, you have a rotator cufftear and a labrum tear.
It's like, oh my God, I had noidea.
Well, that tear might have beenthere for years.
Okay, from all the repetitivemicrotrauma, micro injuries and
repetitive stress placed on them, from all the compensation
(17:14):
patterns for many, many years,where the image of that MRI
currently looks like you have alabrum tear, slap tear and a
rotator cuff tear.
Whatever that image.
Imagine if you would have got animage three years ago of your
shoulder.
It very confidently and verycommonly the image would be
identical.
(17:34):
But you didn't have pain threeyears ago, but now you have pain
for the past six months.
All right, three years ago, butnow you have pain for the past
six months, all right.
So is the structure actuallycausing the pain enough to have
a structural intervention like asurgery?
I'm just saying like I don'thate surgery.
Surgery is necessary, sometimestotally, but we don't have to
jump the gun and it sounds scary.
We don't want to be fearmongered into getting surgery,
(17:56):
though sometimes, all right, wedon't have to do that.
It's important to get anopinion.
Sometimes, all right, you canget a second opinion.
Of course we're a little biasedbecause we're conservative
therapists that work withathletes and active people.
We're naturally optimisticindividuals Because we've had
really good results of peoplethat have had imaging that
doesn't look great.
(18:17):
But if we look at the cause ofthe cause, why did this happen
in the first place?
If we fix the cause of thecause and keep the structure as
is, we've had plenty of peoplethat feel totally fine and back
to no functional restrictions.
And the question would be likeafter surgery, would your
functional capacity be betterthan what we were to do now, if
we were to work together for sixweeks, would the functional
(18:38):
capacity be higher and betterthan what it would be if we did
this, if we fixed thosecompensation patterns?
Cause after surgery, like alleverything's off the table, like
everything changes as in, likethe compensation patterns
haven't changed, the neuralrecruitment patterns haven't
changed, but now there's likewe're just starting over and
starting from scratch.
But um, the things it's notuncommon for stuff to just like
(19:01):
proliferate in the samedirection Again if you don't fix
the underlying compensation,compensation patterns that led
to the derangement in the firstplace.
But anyway, would your funk?
Here's the question, here's thefilter yes or no, to have
surgery or not surgery?
Would your functional capacitybe better than what it would be
if we were to work together fora month?
If the answer is like maybe not,or the same, then why not just
(19:22):
do the conservative and sparethe risk and the time and the
pain.
It's like it's painful aftersurgery, but I'm not sure if you
know, but like you need.
That's why you have pain medsafter rotator cuff repair.
Oh my gosh, you're.
It's just, it's asappropriately necessary happens
and expectedly, as expected,someone's going to be very
(19:43):
sensitive and painful and sleepis the number one thing.
That's very challenging for thefirst six to eight weeks of
surgery.
I've seen a ton of them.
All right, but anyway.
So that's just something toconsider, right?
I don't hate surgery.
Sometimes you got to havesurgery, but it's never a bad
idea to get multiple opinions,all right, and then just look at
it from a different, reframedangle of like, what's the
(20:03):
decision here?
What's the best decision?
But anyway, if you have anyquestions, that's a little bit
of breakdown of the recipe ofshoulder pain Usually.
If you have any questions,comments, concerns or
conflicting opinions, pleasereach out.
Come, step into my office.
Let's have a conversation,discussion, I'm all about it.
I love to hear differentopinions and have a arousing
conversation about some stuff.
And if you have any pain orissues and you want to work with
(20:24):
a specialist, please reach out.
We'd love to at least talk.
We can at least talk on thephone and figure out if you have
an issue that we can help ormaybe point you in the right
direction.
And the best way to reach us is561-899-8725 or our email,
which is team at athleteRCcom.
That's the best way to reachout to us.
Um, but yeah, if you have anypain, you want to work with a
specialist, you need someanswers.
(20:45):
You're not sure what to do.
You've been told by multipleproviders that you need like
you're screwed.
You'll never be back to doingthis.
You're in pain forever.
You need to take pain meds,surgery.
This isn't working whatever.
We hear that very often.
We can at least have aconversation right and then
point you in the right direction.
If you don't feel like we'rethe right fit, or you don't feel
like if we don't feel likeyou're right fit for us, you
(21:05):
don't feel like we're right foryou, totally understandable we
at least point in the rightdirection.
But if it's something you wantto investigate with a specialist
, please reach out.
All right, I look forward tohearing from you and we'll catch
y'all next time.
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