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January 08, 2008

Shoulder Pain and Treatment Discussion

VTalk Radio's interview with Expert Rex Holden, physical therapist and owner of Fast Physical Therapy and Fast Fitness in Traverse City, Michigan.  Rex focuses his discussion on causes and treatments related to Shoulder injuries.  Listen below.

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ANNOUNCER: Welcome to VTalk Radio Local Business Spotlight. We now join John Bentley in the studio with Physical Therapist, Rex Holden, in an open discussion on shoulder pain and treatments.

JOHN: Good Morning. Welcome to the VTalk Radio Local Business Spotlight. Today we are in the studio with Rex Holden, he is a physical therapist and owner of Fast Physical Therapy and Fast Fitness. Welcome to VTalk Radio's Local Business Spotlight this morning, Rex.

REX: Good morning.

JOHN: Now tell us a little bit about what you do. What you're all about.

REX: Well, I'm a physical therapist and as you said I own Fast Physical Therapy and Fast Fitness, and so we do physical therapy. We work with anybody that has neck pain, back pain, shoulder pain, hip, knee, ankles. We see a lot of young athletes because we have the fast fitness which is a sports training clinic and that's what we do.

JOHN: We're here to kind of focus on shoulder injuries. Tell us what does the shoulder do?

REX: Well the shoulder is a really unique joint. What the shoulder does is it allows you to push and pull and throw objects. It also allows the hand to do fine motor movements by keeping the shoulder stable while your arm and hand can do those tiny movements. That's it in a nutshell.

JOHN: How common do people have shoulder pain?

REX: Shoulder pain is actually quite common. It's the third most common musculoskeletal disorder. It ranks third behind back pain and neck pain. And it's very, very common in people that do repetitive overhead activities. That includes athletes, especially swimmers, tennis players, volleyball players, and construction workers, drywall hangers, even painters. When you're reaching up over head and painting all day long, that causes a lot of shoulder problems. So any time you go above 90 degrees...reaching up over head and you do that repetitively, and you do it with a load, you have a potential for shoulder problems, especially as you age.

JOHN: How often do you see this kind of problem in your practice?

REX: In our practice, I'd say 15 - 20 % of the people come in for shoulder pain; however, many of our back patients and our neck patients or whatever else they come in for, we subsequently find that they have a shoulder problem that could potentially lead to pain or dysfunction.

JOHN: Can you give us some thoughts on the affects of chronic pain on a patient?

REX: Well, chronic pain not just with shoulders, but with backs and necks, causes people to be less active which can lead to other health problems. It can also lead to emotional problems or depression, especially when you're talking over a period of years. And that happens with a lot of people. And the other thing that can happen is they rely on medications and the medications can potentially cause problems. So if they're taking too much Tylenol; too much anti-inflamatorys, or IB prophin or whatever else. That can cause problems.

JOHN: Why do you think the shoulder is such a unique joint?

REX: Well it's a unique joint, because one it is the most mobile joint of the body, and we ask it to do so many things while we also ask it to be stable. So you take the most mobile joint in the body and then you push or pull or throw objects and you say, "Hey can you also be really strong for me?" Those don't always work together especially when you get into that repetitive type movements. It's also unique in that it's not really just one joint, its four joints. Because it's attached to the shoulder blade and it's also attached to the collar bone and the clavicle.

JOHN: Do you see a pattern of age for shoulder pain?

REX: We do. What we see is shoulder pain increases as you go from 30, 40, 50, 60 to 70, and it peaks from about the age of 40 - 45 and that may be because a lot of these people are doing the overhead activities and repetitive work at their jobs. That's why we see it at around 40 - 45. They might have been doing it for the last 10 or 15 years, but now all of a sudden their body says I can't do this anymore. And part of the thing that happens is what leads to a greater risk of developing shoulder pain is one, our postures start to deteriorate as we age. We get kind of flexed forward, and as you flex forward, that doesn't allow as much mobility through the shoulder joint, and it only seems like a small amount, but when you do that over and over and you're stressing that joint at the top of the range of motion, you do cause what we call impingement and start pinching those tissues in there. Those soft tissues which become aggravated and inflamed and then lead to shoulder pain. And again, along the same lines you can have poor scapular or shoulder blade range of motion which ends up affecting the shoulder joint itself. As you age you gradually get tightening of the capsular and the soft tissues making the should tighter so it doesn't want to move as well, but then we ask it to move really high and kind of push it into the end range and that causes more strain on it. And the other thing is is that as you age the tendons and ligaments and everything just becomes a little less pliable and we don't heal quite as well as we used to. So when we were 20 and we injured that shoulder, we could recover in a day or two. Now when we're 40 or 50 and we injure that shoulder, it may take up to weeks to recover from it.

JOHN: What do you thing causes most shoulder pain, or what do you see causing most shoulder pain?

REX: If you're looking at what causes it, it's really the impingement on the tissues itself. So impingement on the rotator cuff or impingement on the bursa. Other things, you could have a pinched nerve in the neck that refers pain into the shoulder. You could have a adhesive capsulitus which is also known as frozen shoulder. That could cause pain. So those are potential causes for pain, but what probably started were the other issues that I mentioned earlier. Those repetitive motions, over head motions so when you look at it that way, that's probably what really caused it. Lack of good posture, muscles that are weak in the scapular or shoulder blade region. Weak muscles in the spine. Those actually can all contribute to the shoulder problem. So when we see a shoulder problem, we have to look at a lot of different things and hit a lot of different variables to try to correct that problem.

JOHN: Now you mentioned rotator cuff. I think a lot of us don't really know what a rotator cuff is. I know we hear about it a lot in baseball, pitcher's arms. What exactly is a rotator cuff?

REX: Well, it's not the rotator cup which a lot of people...a lot of people will come up to me and go, "I got a rotator cup problem." It is a cuff and the reason they call it a cuff is because it is made up of four muscles that actually cuff the shoulder joint. They surround the shoulder joint, and they are actually what allow us to have the mobility and the stability that we do with the shoulder joint. So they protect it. They keep it moving like it should move and that's actually one of the causes of the problem is that when that cuff gets weak or you get an impingement, that top muscle on the rotator cuff becomes weak and fatigued and when you try to reach up over your head and do things, it now doesn't function properly because now what it needs to do is push the head of the shoulder downward and it doesn't. It actually lets it ride up and it causes impingement. So that's why the rotator cuff is so important, because if it doesn't work properly, you're going to get impingement. You're going to get that head riding up into the joint pinching those tissues, the bursa and the superspinatis muscle which is one of the ones in the rotator cuff.

JOHN: Now you use the term impingement. There is a syndrome involved with that. What is impingement syndrome?

REX: Basically, impingement syndrome is what I was referring to there. It's when the bursa and the tendons of the rotator cuff get pinched between the top and of the shoulder and the upper part of the head of the humorous. So they pinch that area, they cause more swelling, more inflammation, they cause that tissue to start to breakdown and then the tissue will actually become so inflamed that it starts getting thicker. So now you don't have as much space in there so you get more impingement so it's a really bad cycle. If the person that's having the problem doesn't back off on their overhead repetitive activities, it's just going to keep getting worse. Some of the common symptoms of impingement syndrome are night time pain, the pain with overhead activities, and pain over the lateral or upper part of the arm.

JOHN: You know, I woke up with just a little bit of a tinge in my shoulder this morning. I'm sure I just slept on it wrong. How well does physical therapy work for the rotator cuff tendonitis?

REX: It works very, very well. Especially in people that listen to what you tell them to do. If you listen to the physician and you listen to the physical therapist plan of care, you can actually relieve a lot of the pain, if not all of the pain in anywhere from three to eight weeks. The biggest problem that we have is that one, if people take pain medications that mask the problem and they keep doing that repetitive activity, it's actually going to get worse in the long run. And then the other thing is is there is certain areas of the body that we need to focus on, but I mentioned them earlier, but it is posture and it is strengthening those scapular or shoulder blade muscles to put the whole shoulder joint in a better position so you don't get impingement. And the people that really do that and work on that they get better. That's what we see in the clinic.

JOHN: We are in the studio with Rex Holden. He is a physical therapist and owner of Fast Physical Therapy and Fast Fitness and you're listening to the VTalk Radio Local Business Spotlight. We're going to step aside for these important messages, we'll be right back.

ANNOUNCER: Accelerated Mobility Physical Therapy has changed its name to Fast Physical Therapy. Rex Holden and the staff at Fast Physical Therapy would like you to know that they not only provide physical therapy services, but also have Fast Fitness which provides personal fitness training for all ages. Sports training for athletes and are now offering the fast meltdown in conjunction with the Anytime Fitness to improve weight loss and quality of life. They also have a massage therapist who specializes in medical massage therapy and sports massage. You can reach them on the web at www.fastfitnesstc.com or by the telephone (231) 932-9014.


ANNOUNCER: For more information on shoulder pain, shoulder injury, shoulder treatments, and the night time mobilization brace, please visit www.shoulderpainandrotator.typepad.com.

ANNOUNCER: We now return you to the VTalk Radio Local Business Spotlight with your host, John Bentley.

JOHN: We are in the studio with Rex Holden. He is a physical therapist and owner of Fast Physical Therapy and Fast Fitness and you're listening to VTalk Radio's Local Business Spotlight. Welcome back to the program, Rex.

REX: Hello.

JOHN: Well, we've been talking about rotator cuff tendonitis and you had mentioned how some physical therapy can help that. Can you elaborate on that a little bit?

REX: One of the things that we've discovered with local physician in town, Dr. Mike Carroll, of Creekside Clinic, is that he developed a night time brace for specifically impingement problems and we've started to use that. We started using it several months ago, and we've actually had excellent results with it. So with that complimenting our physical therapy program, we're getting even better results. And so everyone that comes into our client that has night time pain any type of pain related to shoulder impingement, then we give them the brace and we're seeing some really, really good results.

JOHN: So you're telling me that some people can alleviate this problem without surgery. How many people are able to get better without surgery?

REX: Actually, everybody can get somewhat better without surgery. Some people get totally better without surgery. The problem in our society today which actually John and I were talking about this earlier, is that people are impatient and they want a quick fix. So those people, again, that don't follow the physician or physical therapist plan of care and really heed what we are saying, they're the ones that might end up and going and having surgery because they won't take the time to do the exercises or to wear the brace and a lot of times, those people that have the surgery because they didn't do all those other things we told them to anyways, the problem returns. So they are back at my clinic anyways and it becomes a chronic problem. So, even if people have surgery, we recommend that they go through physical therapy because they will prepare the body for the surgery. They'll put the shoulder blade and they'll get their posture more upright so they'll put everything into a better position to allow the surgery to be more successful.

JOHN: What kind of exercises should patients with shoulder pain do?

REX: Again, I'm going to go back to what I've been harping on all morning here is really working on the posture, the spine, scapular strengthening exercises, and some exercises that we call pendulum exercises which basically put traction on the shoulder while they're going through range of motion dangling the arm with it...a small weight in the hand. But key is the scapular muscles. Getting those very, very strong to position the shoulder so you don't have impingement.

JOHN: Now, are their certain exercises that would be considered bad for the shoulder?

REX: Yeah, again we're going to go back to the overhead activities and if you play tennis or swim and you're having shoulder problems, you're going to need to modify the swim stroke or your tennis stroke or back down for a while. Go see a physical therapist. Do you strengthening exercises for those scapular muscles so you can prepare your body to do those sports or activities that you want to do. A good example though is swimming. A lot of times we find that if we modify that swim stroke just a little bit, we can alleviate some of the problems in the shoulder. The other thing that some people do that we've been taught for years and years is they'll put a five or ten pound weight in their hand, hold their arms out straight and then reach up over head. This is...it's one of the worse exercises you could ever do on your shoulders because it puts such a huge force through that shoulder joint, and if you already have impingement that's exactly what you're doing with that. You're impinging it even more. So it's just been handed down or passed on down through the years because it does make a nice big deltoid muscle, but it is also very bad on the shoulder joint itself.

JOHN: We live in a society that likes to use medication to alleviate problems, can medication help in a situation like this?

REX: Definitely. Especially if you hit it early on and you get rid of the inflammation. It's good to reduce the pain, but at the same time, if you reduce the pain, don't go out and do those activities that you know cause your pain. And that's so easy to say and it sounds like common sense, but people will still go out once they take that pain reliever and it feels good. They'll go out and do the sport or activity again. So that's the problem with the pain mediation is that it masks the symptoms and then they continue to do the repetitive activity that caused the problem.

JOHN: It seems to me that a lot of my pain shows up at night. Why is that?

REX: There's a couple of reasons. We think the main reason and Dr. Carroll explained this very well when he developed the night time brace, because he was actually experiencing shoulder pain himself at night. That's how he came by developing this brace. During the day, the weight of your arm causes traction on the shoulder joint so it separates it so there's more space in there. So, we feel that's one reason you don't get the shoulder pain. When you go to bed at night, if you have an irritated shoulder joint, and you have impingement, when you go to bed at night, now you don't have that traction or distraction on the arm so those tissues are getting pinched again. And when those tissues get pinched, it causes pain. It also causes pain. It also decreases the blood flow to that area so you don't get the healing that you should get. And you're in bed all night, you know, 8 - 10 hours and so it would be nice for you to heal at that time rather than having that shoulder pain. So he developed that night time brace to put some traction on that joint, open up that space in there and now you get more blood flow to the area so you get more nutrition to the area. That promotes healing and you're not getting the compression on it. And that's why it's working so well with patients.

JOHN: Are there any new developments regarding non-surgical treatment?

REX: Basically the new development is what I just went over that the night time brace. That's the newest thing that we've seen and Dr. Carroll, I think he's really on to something here and I think all the physical therapy clinics in the country will eventually use it, because it's another tool in your toolbox to help that client with impingement get rid of it. So the more tools that we have, the more able we are to get rid of that shoulder pain and make them happy.

JOHN: I want to thank you for joining us today, Rex, on Local Business Spotlight.

REX: Thank you. I appreciate it.

JOHN: Now, before I let you go, though, do you have a website or contact information for Fast Physical Therapy and Fast Fitness?

REX: We do, and what I'd like to also say, is that Fast Physical Therapy was formerly called Accelerated Mobility Physical Therapy. We do have a website. You can get to it at www.fastfitnesstc.com. The phone number is (231) 932-9014.

JOHN: Great. We've been in the studio with Rex Holden. He is a physical therapist and owner of Fast Physical Therapy and Fast Fitness and you've been listening to VTalk Radio's Local Business Spotlight. Have a great day everyone.

ANNOUNCER: You've been listening to the VTalk Radio Spotlight only on www.Vtalkradio.com radio for the 21st century.


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I had total shoulder replacement on my left side on September 24,2006. I have followed all of my surgeons ideas with the exception of an EMG. The pain that i feel everyday is the same i felt after i walked out of the hospitol. My movement is minimal at best. I can't think about raising my arm up or to the side. My next stop is an arthogram on the 31 of this month. The pain is constant.If you have any ideas please pass them on to me. I gave up on pain medicine. Pain management has not worked. Thank you for your time.

Gary Steinman

Disappointing results from a major surgery.

Obviously you want to exhaust all of the options prior to further surgery. The EMG is not likely to be helpful but probably important to do anyway. The EMG basically allows you to see if the source of the pain is from that spinal cord and not from the joint. Obviously your pain is likely from the joint so this will be low yield.

To state the obvious you want to make sure you are in the hands of good physical therapy. I am sure you have been to PT a lot. Perhaps you should request a different physical therapy clinic to work with you.

If it were me I would so some acupuncture prior to getting another surgery. Basically I think it is worth a try as it is so low risk.

Finally, if you need more surgery then I would have the shoulder replacement guy at Mayo clinic do it. When I last checked he had done about 500 shoulder replacement surgeries and I would bet that he has done almost 50 redo shoulder surgeries.

Sounds tough. If you are getting depressed please talk to your primary physician about it. Good luck.

Thank you for your comments regarding my shoulder. I have now gone for all the recommended tests. EMG was a time to forget. It did not yield any new answers. The pain does continue to be an issue. The Doctor feels that we are now trying to hunt for the reasons. He simply does not know. PT will start me on a weight program of 1 LB. To try and allow the mucles to take up the slack. In addition, it just might figure out to be an impingement at the shoulder.Total Joint Replacement is no day at the park.Thank you for your time.

Doctor John,
I just came back from NYU medical center. I had a visit with a surgeon who looked over all the xrays. He told me that my problem is that the Person who did my surgery in september. Left me with an unstable shoulder that keeps shifting the joint to the rear(my back). That is why i have constant pain. He also told me that the success rate for a redo on my shoulder is about a 40%. If it does not work i will be left with a very painful shoulder. That will most likely have to be replaced at a faster rate. I don't know where to go to have a better success rate.Do you have any ideas? I really need help!
Thank you,

I would imagine the guy at NYU is very good. 40% success rate is a tough number. Given that I do think you may want to talk to someone else. Hard to trackdown who has done the most redo jobs on shoulder replacement, but it is probably the who has done the most shoulder replacements. I do not know who that is. In my region of country the guy at Mayo clinic has done the most. Good luck.

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