Shoulder pain is a frequent complaint of active individuals, especially as they start to progress in age. Due to the frequency of occurrence, people tend to self diagnose, because their symptoms are just like their friend’s, etc.etc. Trainers and therapists are frequently placed in the position of having to manage these problems in the early stages, and it is important to be able to identify certain signs and symptoms which will dictate the course of action.

Complex and Often Misunderstood
The shoulder is a very complex joint. It does not share the same bony stability that the knee or elbow has, therefore allowing for a great deal of movement. For the trainer or therapist, it is critical to understand how this joint works before helping people manage any painful issue.

FORE!

The easiest way to picture the complexity of the shoulder is to picture a golf ball sitting on a tee. The tee represents the glenoid component of the glenohumeral joint ( The ball at the top end of the arm bone fits into the small socket – glenoid, of the shoulder blade to form the shoulder joint-glenohumeral joint , and the ball represents the head of the humerus-the upper arm). If there is a shift in any direction of the golf ball on the tee, it will fall off. In order to function properly, the golf ball has to stay centered on the tee.
Next, imagine there is a ring around the tee, deepening it somewhat and offering more stability (of the golf ball). This ring is called the labrum. It is a “non-moving” stabilizer for the glenohumeral joint. Other static stabilizers would include the ligaments and the capsule. These static stabilizers all offer a great freedom of movement being that they are not completely rigid (much like a bushing). Sometimes, these structures are actually looser than normal, which is a condition called excessive joint laxity, which can lead to instability. Therefore, we rely primarily on musculature to provide stability at the shoulder. The critical factor in the shoulder is proper symmetry or balance, just as with the golf ball and the tee. The muscles are what contribute to this balance. If the muscles surrounding the joint have a balance in both strength and flexibility, then the shoulder will be able to function properly. If not, then a wide variety of problems may result, from impingement of the rotator cuff (not “rotator cup”) tendon and bursa, to chronic instability, to labral tears, and so on.

Weight Training Advice
Any weight-training program should adequately address ALL of the muscles and force couples (groups of muscles working together to perform an action, such as a rotator cuff and deltoid) to “keep the golf ball centered on the tee”. This would include a rotator cuff strengthening program, adequate strengthening for the back and scapular stabilizers, exercises such as press ups for the depressors, and shoulder exercises which do not compromise the mechanics of the shoulder. An example would be keeping all presses slightly in front of the head, allowing less compression at the AC joint (where the collar bone meets the shoulder blade). A good warm-up and post workout stretching will also help. With a properly balanced program, problems at the shoulder can easily be avoided.

Evaluation of the Muscle Chain: Identifying the Pain via observation of Movement and Posture

Postural evaluation is a reliable method of creating a precise treatment plan to facilitate efficient recovery from a painful muscular condition. Muscular asymmetries or imbalances are often implicated chronic pain and dysfunction, correcting the imbalance can be a long-term solution for chronic musculoskeletal imbalance.

Evaluating a client’s posture includes knowing what to look for and then knowing what to do about it.

What to Look For
Key physical points that are focused on when going through a postural evaluation:

Feet:

Pronation Distortion (one or both ankles falling in).

· Toe position (clenched or relaxed).

· Weight distribution (outside/inside of the foot or balanced over the ankles).

· Direction of foot position (toe in/out)

Knees :

· Knee position (in/out).

· Valgus / Varus (knock knee or bow leg).

· Are the knees locked, straight or slightly bent?

Torso :

· Hip Position (one high or lower, rotated).

· Mid-line deviation (is the middle of the hip in line with the bottom of the sternum).

· Hip position over the ankles (projection or retracted pelvic posture)

· Low back posture (lordosis or straight back)

Upper back / shoulders:

· Upper torso kyphosis (rounded) / Shoulders Back

· Shoulders leveled (one higher than another)

· Arm position (one arm longer than the other, one ahead of the other)

· Shoulder blade position (is one or both sticking out or rotated)

Neck and head :

· Head shift (side to side, rotated, backward or forward according to the shoulder position)

· Head position according to the body (draw a straight line from the top of the head through the nose, chin, and navel to the mid-point between the feet?

The Rings of Balance
Symmetric or balanced posture is when the (Ring 1) feet are directly under the hips and knees, while the torso, (Ring 3) shoulders and neck are balanced over the (Ring 2) hips with minimal muscular activity to hold this upright position. The knees and feet should point straight ahead (norm would be feet rotated out up to 5˚), and the client’s weight should be symmetrically balanced over the feet. From the side you should be able to draw a straight line through the ear, shoulder, hip and ankle. Any deviance from this balance or symmetry could mean either a current or eventual problem.

The Muscular Culprit
When to evaluation is final and the distortions are identified, the next step is to identify the muscles involved. The trainer or therapist must determine which muscles are abnormally stretched and which are shortened before choosing the most effective techniques to correct the imbalance . Neuromuscular Therapy is one such technique traditionally used to restore balance to the musculoskeletal system.

The Dot-to-Dot
Neuromuscular techniques can restore a client’s ideal alignment. There is one more step that must be taken – figuring out how the problem started. Detective work is often needed to determine where the poor posture originated from. Since the way we carry ourselves is an accumulation of our experiences, emotions, traumas, strengths and weaknesses, a trainer or therapist must typically ask the right probative questions and build a historical picture of the body (a dot-to-dot of the persons biopsychosocial make-up).

Poor posture (muscle weakness or tightness) will pull the body out of balance. In general, being conscious of maintaining proper posture, as well as finding a way to release stress will help many people maintain their realignment. However, lifestyle modifications such as nutrition, fitness and relaxation techniques may be necessary.

Key Books and Authors:

Tom Meyers, Anatomy Trains

Michael Clark, NASM – Corrective Exercise Continuum

Vladamir Janda’s tightness/weakness model

Neck pain is a common ailment that affects 50-70% of people some time in their lives. There are a number of potential causes of neck pain ranging from poor posture to whiplash. Neck pain is commonly caused by repetitive strain from prolonged sitting postures. 85% of the time the pain is mechanical coming from either the muscles, joints or ligaments. Fortunately, it is rare for the pain to be caused by a serious medical problem and such causes can be ruled out by a thorough history and evaluation from a neuromuscular therapist.

When should I see a Neuromuscular (NMT)?

Often neck pain episodes will get better on their own as nature takes its course. It’s important to stay as active as possible as the old adage of bed rest and trying to completely avoid pain is not the best advice. Most people do just fine by staying active, coping the best they can, and modifying daily activities as to not re-agitate the tender tissues.

You should see a doctor:

when you experience sharp shooting pain into your arms with or without numbness and tingling into your fingers.

when the pain is too much for you to cope with or there are specific activities important to you that you are having difficult undertaking.

When you have associated headaches, dizziness or nausea

When you experience weakness in your grip or you find yourself dropping items.

Neck pain is a very common problem and the chances that it is caused by serious disease are very rare. NMT’s can help suggest possible ways to control your pain and advise you of ways to deal with the pain and get on with your life. It is normal to worry about the cause of your pain and the impact it may have on your life. Talking with an NMT about these worries and concerns can be helpful. You will usually find there is no serious cause of the pain and that there are ways to relieve the symptoms and get you back to your normal activities. Make sure you work with the NMT to find ways to better manage and control the neck pain.

Rehabilitation

If there are specific activities which you are having difficulty with, an NMT can help. Once serious causes are ruled out and the pain is under control, the NMT evaluates where the dysfunction lies. You will identify specific goals or limitations you wish to overcome that are agreed upon by both the NMT and you. The NMT will perform a functional evaluation to determine what you are able to do and what areas may be causing some trouble. Bridging the gap between what you are able to do and what you want to do is the essence of rehabilitation. This may consist of specific exercises prescription that helps improve areas where you are having some difficulty. Make sure and voice your thoughts and concerns with your healthcare provider. Pain and “flare-ups” may happen from time to time. This is normal and should not be the focus in care. Rather, try to focus on the exercises that are bridging the gap to your goals and what activities you want to do.

Introduction

Tennis elbow is a common complaint of athletes involved in racket and throwing sports. It involves pain on and around the outside (or lateral) part of the elbow. The formal name for the elbow is the epicondyle. If there is tendonitis around the lateral elbow, it becomes known as tennis elbow, or lateral epicondylitis . When there is tendonitis on the inside (or medial) part of the elbow, the condition is known as golfer’s elbow , or medial epicondylitis . Young boys also can develop little league elbow from pitching too much or hard without enough rest or recovery time.

People with tennis elbow frequently complain of pinpoint pain around the lateral elbow. The pain may travel around the elbow, down the forearm to the wrist, or up the arm to the shoulder. The pain is made worse during continued activities like practicing a backhand stroke in tennis, throwing a soft ball, or practicing handstands in gymnastics. Repetitive tasks, such as painting, hammering, inputting on a computer keyboard, or using a screwdriver also increase pain. As symptoms worsen, people complain of difficulty holding up a cup of coffee, turning keys in locks, shaking hands, doing needlework, or playing musical instruments.

Typically tennis elbow begins slowly over time due to repetitive movements using incorrect body mechanics. Continuing the activity after the initial injury occurs, overloads the tissues, causes inflammation, and complicates the injury.

When should you see a Neuromuscular Therapist (NMT)?

Even though lateral epicondylitis may be caused by a wide variety of conditions, usually it can be treated conservatively without surgical intervention. If your pain is so severe that you have difficulty with your normal activities, you should see an NMT. The provider you select will help you with ways to better control your pain and to improve your ability to perform desired activities.

Rehabilitation

An NMT will perform a functional examination to rule out serious conditions, discover functional weaknesses, and help you identify specific goals of treatment. There may be restrictions in your foot, hip or shoulder, which cause you to put unnecessary stresses on the elbow to complete your task. When striking a tennis ball 90% of the power is generated from your legs not your arms! Your rehab exam will uncover these hidden causes to your problem.

Once your pain is under control, and your doctor has ruled out serious conditions, there are simple exercises, which may help you to stabilize your elbow. By increasing your function, these exercises become the key to your healing.

Along with rehabilitation exercises, the NMT may perform gentle mobilizations to the restricted muscles, myofascial release, as well as recommend simple changes to your work or play activities. The goal of treatment is to relieve your pain and increase your function. Remember try not to focus on pain. Throughout the treatments, try to focus on your functional improvements. It is these improvements in what you can do and how long you can do it, which allow you to increase your activity level, and return you to your normal activities.

What is Patellar Tendinitis (PT)

A common complaint of athletes is pain in the front part of the knee. The medical term for this pain is patello-femoral pain syndrome, runners knee, anterior knee pain, extensor mechanism disorder, or patellar tendonitis (PT).

People with PT frequently complain of dull pain, which is worse running, squatting, jumping, or walking up or down stairs. Pain may feel worse after bending your knee when sitting. Sometimes the knee clicks or locks. Sometimes it feels like it is buckling under you when you walk. Sometimes it is swollen. This pain is usually chronic in nature.

Occasionally, direct trauma to the knee can cause PT, but usually it is caused by repetitive strain from overuse during activities. Knee pain is typically secondary to foot or hip dysfunction. Flat feet alter normal muscle relationships, and can force the knee into the wrong position while you are walking, running, or jumping. Even wearing the wrong shoes may cause stresses on the muscles around the knee. Repetitive movements in sports or work activities may exaggerate these imbalances and lead to PT.

When should you see a Neuromuscular Therapist (NMT)?

Even though PT may be caused by a wide variety of conditions, usually it can be treated without surgical intervention. If your pain is so severe that you have difficulty with your normal activities, you should see an NMT. The NMT provider you select will help you with ways to better control your pain and to improve your ability to perform desired activities.

Rehabilitation

An NMT will perform a functional examination to rule out serious conditions, discover functional weaknesses, and help you identify specific goals of treatment. This is important. There may be restrictions in your foot, hip or low back, which cause you to put unnecessary stresses on the knee. These stresses make it difficult to successfully complete your desired tasks. Your evaluation will uncover these hidden causes to your problem.

Once your pain is under control, and the NMT has ruled out serious conditions, there are simple exercises, which may help you balance the muscles, correct your posture, and free the entrapped nerves. By increasing your function, these exercises become the key to your healing.

One of the most basic knee exercises to improve the “tracking” of the knee cap (patella) is called the pillow push. Simply push the back of your knee into the pillow and hold it there for 5-6 seconds. Then release. Repeat 8-10 times. Perform twice a day.

If the exercises you are doing, increase your symptoms, do not continue them. Consult your NMT.

Along with rehabilitation exercises, the NMT may perform gentle mobilizations to the restricted muscles, myofascial release, as well as recommend simple changes to your work or play activities. The goal of treatment is to relieve your pain and increase your function. Remember try not to focus on pain. Throughout the treatments, try to focus on your functional improvements. It is the improvements in what you can do and how long you can do it, which allow you to increase your activity level, and return you to your normal activities.

Introduction

A common medical complaint is pain and tingling at the wrist and hand. The bones of the wrist are called the carpal bones. Across the inside of your wrist is a ligament, which forms a supportive, protective shield for the nerves, tendons, and vessels supplying the hand. This tight space is called the carpal tunnel. If the size of this area is reduced (for instance by inflammation), and the median nerve, which goes from the neck to the index, middle finger and the thumb, is compressed, carpal tunnel syndrome may result.

People with carpal tunnel syndrome frequently complain of pain, numbness, or tingling, from the fingers to the forearm, elbow, and shoulder. They may feel clumsy, and find they are dropping things more often than usual. Sometimes it becomes difficult grasping objects or opening jars. Some people experience pain turning their hand up and down, while others find that the pad between their thumb and wrist has gotten thinner. It is common to feel worse during the night.

Carpal tunnel syndrome is caused by compression of the median nerve. This may be from direct trauma to the area such as a fracture or sprain, or due to upper extremity repetitive strain from working long hours at a computer, or on an assembly line. It is also believed that obesity, arthritis, diabetes, pregnancy, and hypothyroidism, may all contribute to this syndrome. Carpal tunnel syndrome is a condition related to inflammation around, and compression of the median nerve. It is made worse by poor posture.

When should I see a Neuromuscular Therapist (NMT)?

Even though carpal tunnel syndrome may be caused by a wide variety of conditions, usually it can be treated without drugs or surgical intervention. The NMT you select will help you with ways to better control your pain and to improve your ability to perform desired activities.

Rehabilitation

An NMT will perform a functional examination to rule out serious conditions, discover functional weaknesses, and help you identify specific goals of treatment.

Once your pain is under control, and the NMT has ruled out serious conditions, there are simple exercises for carpal tunnel syndrome, which may help you balance the muscles, correct your posture, and free the entrapped nerves. By increasing your function, these exercises become the key to your healing.

While carpal tunnel syndrome is often described as an isolated injury at the wrist, there may be a problem any where along the path of the median nerve. Because of this, it is important to rehab the entire affected upper extremity, neck, and shoulder, wherever the entrapment is found. The NMT may perform gentle mobilizations to the restricted joints and muscles, recommend exercises like the ones listed above, and recommend simple changes to your workstation. In order to lessen your discomfort at night, we will recommend suggestions on sleeping positions, which may decrease your pain.

Introduction

Headache pain is a common problem which many individuals seek relief through health care assistance. While the pain is common, headache treatment and management can be an ongoing source of frustration for many individuals. There are many types of headaches with differing causes, presentations, durations and intensities. These may range from the common migraine, classic migraine, tension, cluster, temporalaritis, and sinus headache. While a headache’s presentation and symptoms may be similar or different from one patient to another, effective treatment strategies usually take an individualized approach to identify the cause for appropriate management.

The most common forms of headaches are tension and migraine headaches. Tension headaches are a non-specific headache which usually stem from overactive muscle tension in the head, shoulder and facial areas. Dull, achy, non-pulsating pain is often felt in the temples, TMJ, forehead and base of the skull. There is usually a correlation to daily stress and these headaches do not commonly associate with bouts of nausea, eye pain, facial numbness.

More than 28 million Americans suffer from migraine headaches which are generally more severe than tension headaches. Women are three times more likely to suffer migraine headaches than men. These headaches may be influenced by external factors such as alteration of sleep-wake cycle; missing or delaying a meal; medications that cause a swelling of the blood vessels; daily or near-daily use of medications designed for relieving headache attacks; bright lights, sunlight, and fluorescent lights; TV and movie viewing; certain foods; and excessive noise. Migraines often occur with nausea, visual pain or disturbances, facial and hand numbness, and sensitivity to light and sound. Migraine headaches usually last in bouts, lasting from a few hours to several days. Classic migraines differ from common migraines due to the aura (flashing lights, blind spots, or jagged lines in vision, smelling strange odors and difficulty speaking) that will precede the manifestation of the migraine by 10 to 30 minutes.

When should I see a Neuromuscular Therapist (NMT)?

Understand that while headaches are quite common, they can greatly impact the quality of your life and limit your daily activities. Seek care from an NMT when you are unable to manage or cope with your headache. The NMT will take a history to try and identify the cause of your headache and rule out sinister causes. Once “red flags” have been eliminated, treatment solutions are offered to control the pain and reduce future reoccurrence so you can get back to your daily activities. While serious pathology is a rare cause for most headaches, it is normal to worry about the cause of your headache

pain. Often fears of more serious disease may be of worry to you. Talking with The NMT about these worries and concerns can be helpful. You will usually find there is no serious cause of the headache pain and that there are ways to relieve the symptoms and get you back to your normal activities.

Rehabilitation

If the NMT determines that your headache is from a musculoskeletal origin a rehabilitation program may be ordered. This may consist of short term trial of spinal mobilization/manipulation, soft-tissue treatment, neck stability exercise training and/or sensory motor training all used to reduce headache intensity and prevent reoccurrence. Workplace and lifestyle advice is often incorporated to improve management skills.

The Brugger relief position is excellent stress “micro-break” which relaxes over-tense muscles.

Neck retraction is another exercise that helps to increase neck stability and stretch overactive muscles at the base of the skull.

Keep in mind that while headaches can be unpleasant and greatly affect the quality of our lives, there are emerging treatment strategies that can empower the patient to effectively control a headache’s intensity and frequency. Speak with your healthcare provider about any fears and concerns regarding your headache pain and discuss a management plan that works for you.

Introduction

Herniated discs are probably the most common diagnosis for severe back pain and sciatica (leg pain). Discs are large cushions that lie between the individual vertebrae of our spinal columns.

The disc is composed of layers of ligaments (annulus fibrosis) arranged in a criss-crossing matrix that hold in a gel-like substance (nucleus pulposus), giving the disc its "shock-absorbing" ability. Sometimes the gel swells (which is called a disc protrusion or bulge).

A more problematic situation occurs if the gel pushes through its ligamentous wall (which is a disc prolapse or extrusion). Both situations can led to pressure or irritation of the vulnerable spinal nerve roots. This can lead to sciatica - an abnormal sensation felt anywhere from the buttocks to the feet.

For more that 70 years, orthopedists have believed that most lower back pain and sciatica were caused by herniated discs. The "dynasty of the disc" led to the typical medical advice of bed rest and medication. Gordon Waddell, a renowned British orthopedic surgeon, wrote in the journal Spine, "There is remarkably little scientific or clinical evidence to support the value of bed rest for low back pain or even sciatica." Bed rest is now known to cause prolonged pain, muscle weakness, joint stiffness, and depression.

If bed rest failed, surgery was the usual next step. Unfortunately, due to poor patient selection, many unnecessary surgeries were performed. Waddell said, "surgical successes unfortunately only apply to approximately one percent of patients with low back pain." According to Alf Nachemson, M.D., editor of the journal Spine, bulging discs are found and taken as an excuse to do a lot of surgery and percutaneous discectomy. Discs are made to bulge; that is a normal finding."

Edward Carragee, M.D. the Dean of Neurosurgery at Stanford University reported that disc bulges are present even in 20 year olds, BUT by age 30 there are more episodes of back pain in individuals whose spines had no abnormalities when they were 20 than in those with the bulges! He has also written in the journal Spine that the long-term results of surgery vs. conservative care for pinched nerves is no different.

Back and even leg pain can arise from the muscles, joints, or ligamentous structures of the spine. Whatever the cause, evidence is growing showing that rehabilitation not surgery is the treatment of choice for most lower back disorders.

When should I see a doctor?

Anytime a person has pain radiating down their leg they should see a doctor to find out the reason why. This is not something urgent unless there is buckling of one or both legs, incapacitating pain, progressive pain or numbness, loss of bowel or bladder control, or numbness around the genitalia or anus.

Rehabilitation

Low back pain is a common ailment, which most people (80-85%) suffer with it at some time in their lives. The causes of low back pain are poorly understood and can range from trauma, poor lifting and overuse/under-use of the muscles. 85% of the time the pain is mechanical coming from the muscles, joints or ligaments. Fortunately, it is rare for the pain to be caused by a serious medical problem and such causes can be ruled out by a thorough history and examination from your healthcare provider.

When should I see a Neuromuscular Therapist (NMT)?

Often low back pain episodes will get better on there own as nature takes its course. It’s important to stay as active as possible as the old adage of bed rest and trying to completely avoid pain is not the best advice. Most people do just fine by staying active, coping the best they can, and modifying daily activities as to not re-agitate the tender tissues.

You should see an NMT when the pain is too much for you to cope with or there are specific activities important to you that you are having difficulty undertaking. Understand that low back pain is a very common problem and the chances that it is caused by serious disease are very rare. NMT’s can help suggest possible ways to control your pain and advise you of ways to deal with the pain and get on with your life. It is normal to worry about the cause of your low back pain and the impact it may have on your life. Talking with an NMT about these worries and concerns can be helpful. You will usually find there is no serious cause of the pain and that there are ways to relieve the symptoms and get you back to your normal activities.

Make sure you work with your NMT to find ways to better manage and control the low back pain.

Rehabilitation

If there are specific activities which you are having difficulty with, our rehabilitation specialist can help. Once serious causes are ruled out and the pain is under control, the rehab specialist examines where the dysfunction lies. First identify specific goals or limitations you wish to overcome that are agreed upon by both the practitioner and you. The rehab specialist will perform a functional evaluation to determine what you are able to do and what areas may be causing some trouble. Bridging the gap between what you are able to do and what you want to do is the essence of rehabilitation. This may consist of specific exercises prescription that helps improve areas where you are having some difficulty. Make sure and voice your thoughts and concerns with your healthcare provider. Pain and “flare-ups” may happen from time to time. This is normal and should not be the focus in care. Rather, try to focus on the exercises that are bridging the gap to your goals and what activities you want to do.

Adhesive capsulitis, commonly referred to as frozen shoulder is a disease that can significantly affect quality of life for a year and sometimes up to two years. It is generally characterized by progressive pain and contracture that leads to a loss of passive and active ranges of motion (ROM) in the glenohumeral joint in all planes. It is commonly divided into three stages. The first stage is the painful stage where pain is generalized and occurs first with movement and then at rest. The second stage is the adhesive stage where the restrictions become extreme and movement is drastically reduced at the joint, however, pain begins to subside. The final phase is the “thawing” phase, where recovery generally is spontaneous, however may have residual ROM deficits in some patients. It effects women greater than men and generally occurs in the fifth to sixth decade of life. Anatomic, histologic, and surgical specimens have shown that although the joint capsule appears to be involved with frozen shoulder, the primary pathology that decreases ROM appears to be due to the soft tissue surrounding the capsule. While studies have shown varying degrees of success in either reducing pain, or increasing range of motion, there is little evidence to support any benefits in long term outcome, or any treatment protocol that is far superior. The use of neuromuscular therapy in clinical practice has shown benefits in decreasing the length of time in the adhesive stage of frozen shoulder. Commonly, patients have responded with significant increases in ROM after 6-8 sessions of neuromuscular therapy (NMT), with no return to the adhesive stage post treatment. A controlled study is needed to document the success rate of NMT, as well as establish long term ROM effects with this therapy compared to standard therapy.

Standard treatment will be determined by the patient’s primary physician. Patient status will be assessed before and after each treatment session with goniometric measurement of internal and external rotation, abduction, flexion, and extension. Pain will be assed on a visual analog scale of 1-10. Neuromuscular therapy techniques will be done 2 times per week for a total of 6-8 sessions and include all muscles effecting scapular and glenohumeral mobility of the effected shoulder. Techniques used in neuromuscular therapy include deep gliding with the fibers to produce elongation, static pressure to decrease neural activity, pin and stretch to create specific elongation and increase ROM, and cross fiber friction at tendons. Muscles will be treated individually in a systematic approach.

Example Live Assessment for a Headache Sufferer

What should you expect from your provider of care.

You will see a live assessment of a person dealing with headaches.

Wednesday, August 27th, 2008
6:30 p.m.

3221 Voyager Drive, Green Bay WI 54311
(920) 430-1348

R.S.V.P to reserve your spot.**