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What Is Shoulder Impingement? Factors Related To Shoulder Impingement.

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Shoulder impingement.

Tue, 9/21 9:25AM • 43:31


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Today I  want to talk a little about shoulder impingement what it is, ideas to help you fix shoulder impingement, what you should look for in a therapist to potentially help you with a shoulder impingement issue. So first off, what is shoulder impingement. Shoulder impingement is a generic term to describe a catching or a pinch in the shoulder as you move your arm into certain positions. Some type of a structure inside of the shoulder is impinging on another and it creates pain. It tells us that something's getting caught in that sense, but it doesn't really explain why it's getting caught. And that's why I say it's a generic explanation of what's happening, it doesn't give you a reason that it's happening doesn't even tell you what structures getting pinched. It just tells you that something's getting caught as you move your shoulder, which a lot of times is common sense.


 I think we kind of assume that if you know, the diagnosis, or the what the health professionals telling you as a shoulder impingement, we kind of assume that that usually means it's not a rotator cuff tear or labral tear, some type of arthritic change, you know, usually that's the case. The  basis behind the shoulder impingement is, when you look at the shoulder anatomy, the shoulder joint, if you will, is essentially two maybe three bones in that area. The shoulder itself is a ball and socket joint. The shoulder blade or the scapula has a socket called the glenoid. The upper bone of your arm is the ball part and is called the humerus. So we call the shoulder joint, the glenohumeral joint, right, and that's kind of the junction between the two. The other bone if you want to throw a third bone into the equation and the bone that sometimes fits into this as the clavicle, collarbone, because your collarbone comes across and actually attaches to the shoulder blade at a joint that we call the acromia clavicular joint. The acromion  is this little bird's beak, hook thing coming off of the scapula. So that's another joint that can sometimes get involved in on our shoulder impingement type scenarios, at least something that we need to think about when we look at shoulder impingement.


If we look at lifting the arm overhead a couple of things need to happen, the muscles around the shoulder need to activate to elevate the arm, the ball needs to rotate, slide glide inside of the socket, the ball is going to rotate and slide and glide inside of that socket as the arm goes overhead.   The other important factor is that the scapula needs to rotate.  If we're talking lifting the arm overhead, there needs to be an upward rotation of that scapula as I elevate the arm. We call that scapulohumeral rhythm. The idea is that as the arms going overhead, the scapula needs to rotate in coordination with that movement so that the ball of the humerus stays inside of the socket, if the timing is off ,  either the ball gliding or rotating too quickly, or the scapula is not upwardly rotating like it's supposed to. Well, now that's going to cause a problem, right? Because we're not getting that smooth, coordinated movement between the ball and socket join and now we can get a pinch. This is where that acromio clavicular joint, the acromion comes into play. Right above the ball and socket joint, you're going to have a joint right above that ball and socket joint, there is a little there's a bone that comes off the scapula called the acromion. And it really helps improve the congruency and see the socket right it makes it a little bigger socket gives it a little stability. But if the timings off if that glenohumeral rhythm is off, now the ball is going to is going to the timing of that is going to be off and the ball is going to pinch into that acromion as it comes overhead now in between the ball of the humerus and that acromion in the bone on the top of the scapula there, in between that space, we call it the subacromial space below the acromion. In that subacromial space, we have structures, you have a Bursa that sits underneath there. So you hear people say things like bursitis bursitis, is it meaning an inflammation of the bursa, but a Bursa is just kind of a fluid filled sac, right? It's a, it's a balloon, if you will, a little cushion in there to kind of provide a little buffer, a little shock absorption, a little bit of impact resistance in that area. And so, you know, one theory when you get a shoulder impingement is it inflames or irritates the bursa? Right? Because you you swish that Bursa that sits in the subacromial space and several chromium versa. So that's a possibility. The other structure that we think about I at least think about more commonly, is one of your rotator cuff tendons called the supersprint anus. Now, the supersprint anus is one of four rotator cuff muscles, your rotator cuff, is cuff, not cup cuff, your rotator cuff is one of four muscles that surrounds this glenohumeral joint. Each of those four muscles has their own individual function. The supraspinous is responsible for abduction, Ab duction, which is the action of lifting your arm out to your side. So as you lift your arm, kind of horizontally in the in the frontal plane, if you will, that that snow angel kind of motion, as you lift your arm out to your side, that's abduction. And that that's the the action of the responsibility, the supraspinous. The other three muscles, you have your infraspinatus and your teres minor. Those are both muscles that externally rotate or rotate your arm to the outside, kind of behind you. And then your subscapularis, which is more in the front, sits at the front of the scapula and runs to the front of the humerus, and it's going to rotate internally, so it kind of bring your hand towards your belly button if your arms exercise. So those four muscles, again, they each have their own independent actions. But as a group, the rotator cuff is responsible for holding the ball inside the socket. They're one of the things that dynamically control the stability of that glenohumeral ball and socket joint and kind of hold that ball in there. They keep it compressed. So we look at the supersprint. And it's again, it's sitting on top right, it's going to be an abductor runs from the top of the scapula, super spine as fossa, it attaches onto the greater tubercle on the outside of the humerus, kind of a bony bump on the outside margin of that ball. And it's going to lift the arm out to the side. Well, it runs through that subacromial space. So if you're not able to maintain the the timing and the concurrency of the ball inside the socket, and it slides into that a chromium, the super spin Adas is one of those muscles on top that tends to get pinched. And so when you come in with shoulder pain, the question quickly becomes, okay, did you just smoosh it in irritate it, you know, kind of like shutting your thumb in the door. And then every time you bring that arm overhead, it's kind of getting caught like you're shutting your thumb in the door. That would be your classic impingement, whether you're catching that burst, or you're catching the supraspinatus tendon. In either scenario, you're impinging on that tendon as it goes overhead and can get inflamed and it can get painful and those types of things. And so that one's that one's definitely a possibility. And probably the most likely, I shouldn't say most likely, but at least one of the likely culprits of what's getting caught when you deal with a shoulder impingement scenarios, you're dealing with that source money. So if it's just inflamed, then you just need to put shutting your thumb in the door, right? If you quit shutting your thumb in the door, your thumbnails, the same is true of that rotator cuff tendon if you quit irritating it, it's gonna get better right? Now, the secondary, the second layer of that question is did you actually damage the tendon. So if you think of the tendon, kind of like a nylon rope, right, when you start to fray a nylon rope, there's like little pieces that kind of peel off of it right? The same kind of thing can happen with a tendon, you can frayed a little bit and it gets this little crab meat look to it in little parts of it fray upwardly and if you you know, if you pinch it enough times, you kind of irritated enough times and inflamed, it can start to fray just like that Not on row, the generatively over time with aging and things, you know, it is possible that you fray all the way through that thing. And you end up with some type of rotator cuff tear that that's not naturally traumatic in nature. Most of the time they are you fall you catch yourself funny. you're lifting something awkwardly.


You know, whatever the case is, and you get a traumatic if you're going to tear your your supraspinatus tendon or a tear part of your rotator cuff. Usually there's a trauma involved. But there is a scenario where you just kind of frame and frame frame and frame and eventually it kind of knocks away loose you know outside of the scope of this topic but rotator cuff tear attendance and social status are fairly common. You know, I'm doing this podcast from the car, I don't have any resources in front of me. So I don't remember the stats off the top of my head here. But the percentage of men over a certain age with a rotator cuff tears extremely high, and not always painful, not always symptomatic. I know people that have had acute traumatic rotator cuff tears of the supraspinatus tendon, and being perfectly fine. So you know, it's not a panic button type scenario, but certainly exists. And maybe we'll do another, you know, if there's interest in it, we'll do another episode on talking specifically about rotator cuff tendon tears. But let's get back to the impingement scenario. So anyway, just like in real life, if you shut your thumb in the door, if you quit shutting your thumb in the door, your thumb heals, right, if you quit pinching that tendon, assuming there's not a lot of tissue damage, and all the actual structural damage to that tendon, you quit pinching it, it's going to get better, right. And so our goal has to be to figure out why it's getting caught in make that pitch to go away. The last structure that I want to talk a little bit about is the biceps tendon, the long head of the biceps tendon. So bicep muscle, of course, sits in the front of the arm there and flexes the elbow. bicep means to right, so there's two heads, there's a long head and the short head, the short head comes, you know up the humerus and attaches to a bone on the front of the scapula called the coracoid. Typically speaking, the short head of the biceps isn't going to cause Well, it's certainly not going to cause shoulder impingement. But it's not likely the primary cause of of your shoulder pain either. It can create other things like Thoracic Outlet scenarios and some anterior shoulder pain, but not that classic impingement in the in the top front of the shoulder. So we'll talk about the long head of the biceps, though it runs up through the humerus, it's going to go through the bicipital groove, which is this little groove in the bone kind of designed for that tendon to run through. And then it's going to attach on the inside of that socket, that glenoid that we talked about, it's going to attach to the top of that socket onto the labor, your labor is a lining. Think of it, you know, you've heard of a meniscus, right, it's kind of similar ish, it's a smooth surface, it adds some concurrency to the socket, it kind of gives it a lip, if you will, almost like a little seal kind of around the outside type of a thing just makes it fit in there creates a nice smooth surface for the ball to roll and slide and glide on and all that kind of stuff. And so it improves the function of the joint, right? It lets it move fits in there a little bit better, all those kinds of things. Well, your long head of the bicep after it runs through that bicipital groove is going to attach onto the top of that, on the top of the labor on the superior part of the labor on the glenoid. I also throw long head of the biceps irritation, biceps tendon tendinopathy, you'll hear it called a lot of times, I would throw that into your shoulder impingement scenario as well. Typically, that pain is going to be a little more with internal external rotation, and maybe even a little more with flexion, where you bring the arm straight up in front of you. But I would lump that right in there with my shoulder impingements my proximal bicep issues, so something another kind of factor to consider. And before we kind of dive into how do we fix it. One other kind of anatomic thing that we need to talk about, let's do two, but one of the other ones we need to talk about is that AC joint that a chromeo clavicular joint where the chromium the birds beak of the scapula, that roof of your your shoulder joint, the collarbone is going to attach to that. The collarbone is then going to come across and it's going to attach to your sternum on the front. As that arm elevates as you lift your arm up overhead, that collarbone in the scapula is is upwardly rotating, right? It's rotating out to the side and up as you lift your arm, that collarbone needs to move with the acromion. And it's actually going to do this little flip kind of motion, it's going to rotate upwardly and flip as that arm comes overhead at a certain range of


motion. So if that collarbones not moving like it's supposed to, and it's not flipping, that is potentially one cause of your shoulder impingement, right? Because that collarbones not allowing the chromium to move the way it should or something's off at that time in between the criminal in the collarbone. And so that's a potential issue with shoulder impingement. So we need to check both the acromion local Vicar joint the AC joint on the tip of your shoulder, as well as the sternoclavicular joint where the collarbone attaches to the sternum. Because every once in a while, something with that collarbone is not moving correctly. And that can be the cause of why that ball and socket joint ends up getting pinched inside of there. So that's an issue. And then the last thing that we need to talk about as far as biomechanics with arm elevation is the the rib cage and the thoracic spine. So as I bring that arm overhead, my thoracic spine or my kind of middle back, if you will, it needs to be able to extend or arch backwards ever so slightly to kind of get to that end range positioning. Okay, the first, the rib cage is attached to that thoracic spine. So a lot of times you will see rib issues also kind of playing into that positioning. So, if I alter my rib cage position, that's going to alter my thoracic spine positioning, which may affect shoulder positioning. Right. So you can quickly see how you know the old song the you know, the head bones connected to the neck bones connected to the knee bone kind of nonsense. You can quickly see how that plays, right. If this isn't moving right, then this starts to move funny, then this starts to move funny and, and so sometimes you really got to untangle a amaze, if you will, or a puzzle, we got to put the pieces of the puzzle together, we trying to figure out exactly why that shoulder impingements happening. But rib cage and thoracic spine mobility in positioning postural positioning can certainly play a role. Because as soon as I change my rib cage position or my thoracic spine position, now I change the orientation of the scapula, I might change the way the collarbone is going to rotate, the way the shorter blade is going to escape to the shorter blade is going to rotate, all of those things may lead to impingement through elevation or moving the hands. So a lot of times you'll see us check rib cage, first rib, fourth rib, kind of add to anything in this top five ribs and the upper thoracic spine, we're always going to check and certainly some of our postural things will will play there. And you can check this on yourself, right if you lift your arm up overhead, just kind of in your normal posture. And then you slouch or really round your shoulders, kind of go into that that hunched back position. And then maintain that hunchback position as you try to lift your arm, go slowly, because it's going to feel a little goofy, it's going to feel a little pinchy in there. And a lot of times you can you can kind of self create your own shoulder impingement, just by flexing or hunching your upper back. And it'll give you kind of an awareness of how much that scapular positioning and that thoracic positioning plays into your shoulder impingements. So we certainly need to assess that postural component or the mobility of those thoracic segments as it pertains to elevating the arm and the potential to impinge on that shoulder muscle. So all of those, those factors come into play. Right? So when we talk about fixing a shoulder impingement, or an irritation of one of those structures that sit in that subacromial space, whether we're talking the bursa, the supraspinatus tendon to the biceps tendon. When we're talking about trying to to fix or take that pain away off of that shoulder impingement, we need to figure out why it's getting caught. Right. And that that's honestly the hard part. To say somebody has a shoulder impingement. Pretty simple, right? Like you just look at it, you're like, Oh, it's getting caught it has, you know, there's tests that we do, there's a Hopkins Kennedy test. There's a painful arc, biceps near test, right? There's all these special tests that we can do. And the more of those that are positive, the more likely it is to be a shoulder impingement. But you know, not an AC problem. Not a rotator cuff tear, not a labral tear, not a cervical radiculopathy it's probably going to be a shoulder impingement. Right? So I feel like it's almost a it's almost a garbage ish term, if you will. It's kind of the, you know, alright, well, it's not one of these bad things. So we call it a shoulder impingement. Easy. piskei not hard to call it a shoulder impingement once you've ruled out some of those other things. And, you know, probably good to have the correlation of some of those other positive tests. Like, like I said, Hawkins Kennedy, or near impingement and painful art, you know, there's some other signs that look like a shoulder impingement that we'd look at clinically.


But the bigger question, as you're probably figuring out is, okay, what's causing the pinch? Is it a weakness in a muscle? Is it overuse of a certain muscle? Is it a postural problem? Is it a neck issue that's causing decreased tone or decreased activation or muscle or increased tone or guarding around a muscle? Is it something we call Thoracic Outlet where the bundle the brachial plexus of the nerves that go to all these muscles is getting in trapped? What factor is causing the in coordination of that scapula humeral rhythm that's causing the pinch in that joint or causing the impingement? That's the hard part. That's the challenge to figure out how to fix a shoulder impingement. Right? And so when we break that down, we have to have kind of a process to learn Look at to figure out okay, well, how do we chip away at this thing? and figure out which one of those factors may be causing that impingement? Right. So I know where the pain lives, what are all the reasons it can happen, any of those factors that we've previously thought and the anatomical factors that we previously talked about, could be potential of why we're getting that pain, that pain issue with with our melanesian. So a lot of options here, a lot of choices here. Now, personally speaking, I always like to clear the spine first. And here's why. If your spine position is off, now your rib cage position is off, your scapular position is going to be off, it's going to affect the shoulder, just positionally, right, and biomechanically partially, if the spine positions off, it's going to affect all those things downstream or, or towards the periphery. Like that's just part of the game, right? So clear the spine first. The other, I think even more important piece of that is coming out of the spine at each segment, or the power lines to the muscles and the sensory fibers of the shoulder. Right. So if there's an irritation of the power line, well, what the heck else am I going to do, right? If the if somebody cuts the power line to my house, I can work on the electronics in my house, all I want. But if I don't restore the power, you know, my electronics are never coming back to life. And so the same is true of the shoulder. If something's affecting the power supply, to the muscle, to the joint receptors to the sensory receptors around that shoulder, if something's affecting that power supply, well, I'm never going to win the game, right, I can do whatever I want at that shoulder. But if the power lines are messed up, I'm gonna have a problem. So we can have different scenarios, we can have what we call a ridiculous apathy, where that nerve root to that power line coming out of the neck is so compressed, that literally, we're not getting power to the muscle. This is a bigger problem, right? This is something that if you're experiencing, you know, a significant weakness that kind of came on out of nowhere, you're noticing atrophy, you're noticing changes in your sensation or the feeling in your hand, you're starting to a little numb, tingly, that kind of stuff. Look this that just needs evaluated by medical professional, you need to figure out what that is why it's there, and get rid of it before it turns into a bigger problem. So you know, a ridiculous the compression of the nerve root, a compression of that power line, big problem, get that evaluated, go see somebody, I would lump any kind of numbness tingling into that that situation, right? If it's starting to go numb and tingling, your hands fall asleep for no reason. Just go get checked, right, you also need to check your reflexes that's hard to do on yourself. But reflex is being affected or another sign that we're actually getting true compression of that nerve root as it exits the spine. When we're talking shoulder, we're talking mid cervical. So your neck, cervical spine, it there are seven bones coming through there. Eight nerve root seven bones, that mid chunk, the middle of the neck kind of your mid, you know, not not quite at the base of your head, not right at the base of your head, not kind of where it attaches to your your mid back. But you know that middle piece is typically what's going to be affected. So if you're getting neck pain that go along that goes along with your shoulder, certainly you need to get that assess, right because now the neck might be driving some of that power signal to the shoulder. And that might be creating part of the problem. So that always needs cleared first. Now, you don't have to have just a ridic like a ridiculous empathy. If there are compression on that nerve. It is not the only reason that the neck might affect the shoulder.


You can get inflammation in the rotation of those nerve roots as they as they exit, it'll create pain and muscle tone and guarding around those segments that maybe the nerve signals not working as well as it should or it's a little more inhibited or protective than it normally would be. It's not a true nerve loss, right? We didn't cut the power cord. It's just inflamed. It's irritating practitioner friend of mine, Chris Chris Davis from New Orleans. Or I should say Lafayette New Orleans so yell at me, Chris, from the Lafayette area are Katie Katie a pain science pain clinics. He's a physical therapist, brewing guy, super talented manual therapist. But he talks about a garden hose analogy. Where okay, right? I didn't completely pinch the hose off. But I'm squeezing the hose. So now I'm getting a little less water. I'm getting a little less input maybe than I normally would. And I kind of like that. So if you think of a ridiculously as I pinched the hose off completely, I'm getting no water, I'm getting no signal, big problem. versus just kind of a squeeze of the hose where Yeah, I'm still getting some water. I'm still getting some signal to that area. But maybe it's affected to a degree and I kind of like that analogy, right? It's simple. It's easy to understand. So those are good things. So in that scenario, I need to figure out okay, well, if that nerve, if those nerves that go to the muscles, right, if those nerves are being affected, irritated and flame compressed. I got to fix the power line, right? I got to be an electrician in that scenario and I got to figure out okay, Well wise, where is this? Where is the block in the power line? Right? Where am I losing power? How do I get that off of there, there are certain areas that are commonly irritated when we talk about nerve pathways, like I talked about in the neck, C, four c, five C, six nerve roots, maybe even c seven nerve root, commonly called shoulder issues. So those are the first places that I would look in the neck. The second place that I would tend to look is something that we call thoracic outlet. So as those nerves come out of the neck, they run underneath that collarbone over top of the first rib as they go to feed the shoulder. If that first rib elevates, or the muscles that kind of run through that space, your pec minor, your shorthead, your biceps corgo brachialis. If those muscles squeeze that area where that nerve bundles running between the collarbone and the first rib, that's a potential entrapment point. Okay, they can also catch in the scalenes, a little higher in the neck. So it's certainly a place to check, but I tend to think the scalenes get tight more reactively than then as the cause. But anyway, so if that if that thoracic outlet is getting compressed, that can cause an entrapment or an irritation as it goes to the shoulder, and then we could get nerve irritation or inflammation locally in and around the shoulder itself. Again, I tend not to think of that as commonly as frequently but but certainly a consideration when we're talking shoulder pain. So again, we got to clear the power lines, we got to check spine first, follow that nerve pathway all the way to the muscle, and if there's anywhere where that nerves getting affected. Fix the powerline first, right, that's got to be that's got to be contention number one when we're dealing with a with a with a shoulder impingement kind of scenario. Okay, the next thing I look at is kind of gross positioning posture, if you will. So powerlines are working. Now what's the positioning or the posture doing? The reason I like to look at posture next is because there's a situation in the body that we call muscle length relationship, or muscle tension relationships.


So we look at muscle length relationship. If a muscle is in its middle length, the muscle has these cross bridges actin and myosin. They're like these little globular heads that kind of grab each other and they pull against each other to create a muscle contraction almost like rowers in a boat. So if you think of a oars hitting the water, the more oars you put in the water, the harder you can pool. Well, when the muscles in its middle length, it's really strong because all of those little actin myosin cross bridges are overlapping each other. And they're able to grab each other and pool. I do have a YouTube video, this is really hard to explain on on a podcast setting. But our YouTube page at fit function calm, there's a YouTube video, if you want to watch me explain this on a markerboard, maybe a little bit easier to understand anyway. So middle length best, if the muscles in a shortened position, right, we've closed down the the length of the muscle and we shorten it. Well, it's so overlap, that there's less overlap of those active mice and cross bridges. It's like having less oars in the water, I'm not going to be as strong, right? If I'm in a completely lengthened position, again, there's less overlap of those active mice cross bridges. Again, less oars in the water, because of the opposite reason, they're just not able to reach each other. And now, again, I'm weak. We know this, if you try to jump on a pull up bar, right, you're hanging from the pull up bar, chin up bar, whatever, when you go to start the pull up, it's really hard, right? That's why we never want to go to the bottom. Because at the bottom, when I'm completely at that dead hang, my muscles are as long as they're going to be so there's less overlap, it's kind of hard. Once you get it started, you get to that midway point you're you're strong, right, you can pull through that nobody ever gets stuck in the middle of a pull up, you start to get stuck again when you get close to the top because now you've shortened the muscles as short as they're going to be. And now again, we got less of that that overlap less cross projection. So now the muscle is perceived as weaker in that shortened range of motion. So this is this is the idea behind your your, your tension length relationships. So from a postural standpoint, if my, let's just use the shorter blade as an example, if my shoulders rolled forward, well, now all the muscles in the front are going to be in a shortened position, all the muscles in the back are going to be in a lengthened position. So I'm going to have positional weakness of those muscles. When I go to do a motion when I go to do an activity. Now my brain is in the business of doing things as efficiently and as easily as possible. So it's going to make the decision based on ease. And so whichever muscle is in the right position is able to generate the most force in that moment. That's the muscle that the brain the nervous system is going to decide to use. So if I'm in a posture that puts certain muscles in a way position, well, I'm not going to use those muscles because they're not strong here, right, they're just not able to generate force because of that length tension relationship. So I'm gonna use a different muscle that's in a better position to be able to fire. And so now we see different muscle, muscular activation patterns of the shoulder as a response of changing in those postural positions, and so forth. And so, to me, kind of like what we talked about in the power line scenario, say I manually muscle test your, your your shoulder. But I do it in a in a, you know, a midline position. All right, cool, you're strong, and you're weak. But if I change the posture, if I change the length of that, that muscle, if the activation pattern changes, well, it doesn't matter how strong or weak that muscle is, because I've changed the decision making of how my brain wants to move that shoulder, just based on my starting point. And so


that's something that I think is fundamental to changing the way the shoulder moves is just changing the orientation of the positioning of it. In part, I mean, I think there's multiple factors there. But I think in part is because of, of our length tension relationships. So something to pay attention to. And I think if we can get to where that shoulder starting more in the mid point, it's going to normalize that activation pattern, hopefully keep the ball inside of the sock and kind of improve that congruency. And then, you know, see what effect that has. So that's going to be my my second check only because I think it's going to change the patterning in the perceived strength of certain muscles, irrelevant of what their actual mobility capabilities are. So we want to fix that first or after spine, that's the next thing that I want to look at is posture and positioning. The third thing that I then like to look at his local factors, are there local things, because of maybe using a certain position for long enough, where we actually have tissue change, or injury type scenarios, that may be causing a change in that activation pattern that's causing the impingement. So let's say that I'm afraid that supraspinatus tendon enough that I've actually created a little mini tear, or maybe I've inflamed or just kind of irritated enough that I've created a tear. Well, now that local problem, that irritation of that tendon is going to cause a protective response from the body where we tighten muscles around the shoulder to protect that injury or to protect that problem. If my brain is trying to protect something, and it creates a splint, to kind of guard around it, it's going to lock everything up, it's going to tighten everything up. And you've kind of felt that spasm feeling after an injury. Well, now we're bracing, obviously, that's going to change the activation pattern around the shoulder, it's going to change the way that shoulder moves, because I'm protecting something. So if that's the scenario, well, now I need to figure out whatever that local generator is, that's causing the guarding pattern that's causing that that decision to change the movement patterns. And I call those local irritation. So I inflamed the biceps tendon, I inflamed the supraspinatus tendon, maybe it is a bursal irritation. Maybe I landed on my shoulder funny, whatever that case might be if those local structures are inflamed, if that's causing either inhibition of the muscle where my brain doesn't want to use it, because it's hurt, or guarding or splinting around that muscle where it's bracing and protecting. That's going to change my activation pattern that's going to change the way my shoulder decides to move and might be a factor in my in my impingement. Some people will also throw weaknesses into this equation here, right? So your post your rotator cuff is weak. And that's why you your shoulders not moving the correct way. I do think in long term situations, if you've been dealing with something for a long time, that this can be a factor. And in certainly there's a place for local strengthening of the muscle, especially when talking about long term holding new positions, holding new postures, to where those new postures become our resting baseline. That's where I think that stuff shines. Do I think that, you know, in the short term in that first couple of weeks of trying to get that pain out of there, that that's my first go to is just Oh, let me strengthen the heck out of this thing and it'll be gone. It's not going to give you that short term pain relief that a lot of times we're looking for. Long term, it's a it's a solution, right? Like, I always classify my problems as short, medium long term goals. You walk in with a shoulder impingement pain in that subacromial space is the short term goal. Because pain creates guarding guarding is going to change my activation pattern, so I can't get the pain to go away. How am I ever going to normalize the movement pattern? This is just my theory. So I think pain is kind of our trump card. I actually put on one of our vows Is there a pain trump card is pain trumping your movement path If pains trumping the movement pattern, if it's an acute, newish onset pain, we need to figure that out first. So I'm gonna look at those other factors preemptively to get the pain out of there, before I start trying to strengthen certain muscles. Because what I, as a clinician, if I test somebody, and I say they're weak, they might be weak. But it might just be inhibition, inhibition, or the brain not activating that muscle because of the pain. So I need to get the pain out of there first, once the pains gone now to keep it from coming back, right to change that pattern that caused the pain to happen in the first place. Now I need to go into my strengthening exercises, right and figure out what's weak. So there being strong fixes a lot of things right, let's not let's not make, I'm not trying to say it's not important to get strong.


As far as preventative and positional danger and keeping ourselves from getting hurt. I think strength exercises are probably one of the only things that work well. But when we're trying to fix a painful pattern, it's not my first go to write I think it serves a place you know, in that medium to long term goals of your your fixing your shoulder impingement, your medium long term solutions are going to be more of the find out what's what's become weak due to changes in those activation patterns, changes in those postural things over the long term, what's become weak. Now let's build some some strength there so that you can hold these new patterns, fantastic love and need to do it. Short term pain resolution, and maybe not so much. Right, in my opinion. So we got to have both. Coincidentally, I think that's the problem with our cortisone injections, and even some of the bill do surgeries where they kind of clean out and create space and that impingement area. I think the problem with those is they do provide that short term pain relief, I think there's a million ways we can get short term pain relief, I think dry needling is starting to show as good as improvements with as a cortisone injection or PRP in certain situations. And as that becomes more prevalent, you know, fantastic, right, but short term pain relief is awesome. But if you don't change the posture positioning, look at the neural pathways, figure out if there is a weakness or a flexibility thing that that's kind of resulted from those things. If you don't fix that, then eventually you're gonna go back into that same pattern, that same muscle activation pattern, and eventually the impingement is going to come back. Right. So you know, when you're looking at ways to fix a shoulder impingement, I think you need to a figure out what's causing it, I address that to get the pain to go away. And then long term build strength, build awareness of that positioning, build the freedom of mobility in and around that shoulder, so that it doesn't come back in the long term. Right. And I think that's the that's the part that requires more work, right. So as a as a client as the as the patient. You know, I go get a cortisone injection, I go get needles to cut the scrapes, whatever it is to get the pain to go away. But if you don't put in the work to build the strength and improve your positioning, that pain is going to come back, right. And so as long as you have the right plan in place, let's keep it away. To build the strength that doesn't come back. Now I think you're going to be long term successful in addition to your short term pain relief. So we need both we need short term pain relief to be able to normalize that muscle activation pattern. And then we need to reinforce the posture positioning, the neuro freedom, the the muscle tissue freedom, whatever it might be, that we identified, we need to build strength and build normalcy in those patterns, that normalcy is not the right word, build the ability to kind of use those new patterns in the long term. So those are kind of the big things. So when I when I think about fixing a shoulder In summary, let's figure out what's causing it clear spine first, follow, look for any entrapments along the neural pathway, then look at local structures that might be pain generators, medium term goal start to create some freedom of motion to where your brain feels that that movement is now normal and pain free and it releases some of that guarding releasing some of that tension starts to normalize that pattern, long term goal, build strength around the postural considerations around the spine considerations or around the local tissue considerations that allow you to maintain that that normal range of motion so it doesn't come back as you get back into your activities. That's the quick summary. If you made it this long to hear the quick summary, thank you. When you're looking when you're looking for somebody to help you fix your shoulder impingement In my opinion, need to have somebody that's able willing and capable as the knowledge base in the the clinical ability, the freedom in their their clinical setup to help you with all of those layers. You need to be able to get out of short term pain, right? We get a lot of exercise specialists that can help you with the strengthening piece, but they don't know how to how to get out of the pain part and the front end. You got to be able to get rid of the pain part on the front end. On the flip side, we get a lot of times, we spend some I'm trying to get rid of the pain that we don't build the strength and the movement freedom to keep it away. So we need to have the ability to clear the pain on the front end, and then build that program and that repositioning of the the reengagement of some of those shoulder muscles, thoracic freedom, first grip scan leads by right, we got to be able to hit all those regional factors that might be causing the impeachment in the first place and build those back as well. So if you can find somebody that can do all of those things for you, fantastic. And if not, just find a team, right. So find a team, somebody that's really good, a really good manual therapists, that's able to do dry needling, cupping, tissue work, joint manipulation, mobilization, whatever it is to kind of get the pain to go away. But then also have an exercise specialist that can help you build a an appropriate


rehab plan that not only focuses on strengthening your shoulder, right, like, we can all do theraband exercises that we find on YouTube, but can build you a rehab program that addresses those spine components, those postural positioning components, the rib cage position, and maybe some breathing things because your diaphragm can affect the rib cage position, right can look at all those external factors as well. To build a complete plan that that helps you keep that shoulder impingement out of there. So thank you for listening. I know this is another episode from in the car. Hopefully with the rain in the traffic and the just vehicle noise the the audio came out. Okay. Appreciate you guys. Joining me on my car ride to the office this morning. Hope that helps explain a few things around some shoulder impingement. For some exercises, some some postural in different types of exercises, we do have some on our YouTube channel, at fit for function PHYT fit for function. We also offer if you you know, if you have a specific shoulder problem and you're looking for a health professional. We do do free phone consults, we'd be happy to chat with you about your shoulder. And if it's a situation in a scenario where we think we can help, we would love to do that you can book a free phone consult at fit for function comm with either the contact form or you'll see a button for a free phone consult. And we would love to help you out. If you're looking for a really good manual therapist. One of our neuro released treatment, their trained therapists are going to have all the skills to be able to look at that neural distribution, look at regional components, look at local local tissue structures to kind of help you get out of pain quickly. using either cupping, percussion massage, like your hypervolt and you're scraping your instrument assisted soft tissue massage, they will have the ability to do all of those things. And our integrative dry needling train therapists can add dry needling to that equation, if that's appropriate for you. So a lot of people in our system trained to be able to look at that neural segmental as we call it, and local components of pain. Were integrative dry So all those links will put in the show notes. We hope this helped. How we got to wrap your head around what a what shoulder impingement really is kind of the factors around why that pinch is happening. And ultimately, you know how keep you moving, keep react to keep using that shoulder so that you can do all the activities you love doing. And that's what this is all about getting fit for function. So, Alright guys, we'll see you on the next one. I appreciate it.

Written by Dr. Nicholas Sanders PT, DPT, CSCS, CIDN.  Dr. Sanders is the founder and owner of PHYT For Function where we provide a convenient and simple solution for people to continue to do the activities they love without muscle, joint, or nerve pain.  He is a national instructor for Integrative Dry Needling and Co-Creator of a Neuro-Inflammatory Manual Therapy course. 

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