Brian Schiff’s Blog

I am sure you or someone you know has suffered with or been affected by a frozen shoulder at some point.  Known in the medical world as adhesive capsulitis, this condition can be downright miserable for folks.

Who gets it?  It is often brought on after injury or a period of immobilization (e.g. arm in a sling after surgery or dislocation).  However, it also comes on insidiously too.  Statistics indicate it more commonly affects women and those with diabetes are at more risk for getting it in both arms.

Some feel it may ultimately be an autoimmune reaction that triggers it.  So, what is it exactly?  Well, in plain terms your shoulder joint has folds of connective tissue we refer to as a joint capsule.  In frozen shoulder cases, the capsule becomes shortened and inflamed making arm movement painful and limited at best. 

There are three distinct phases:

1. Freezing
2. Frozen
3. Thawing

These phases may progress over the course of months or in some cases last as long as 2-3 years to resolve.  In time, the condition will correct itself. 

Symptoms may include:

• Stiffness
• Difficulty sleeping
• Pain along the shoulder or down into the arm
• Certain movements more restricted than others
• Progressive worsening of motion and decreasing pain

No one wants to suffer with this for any prolonged period of time.  So, how do you accelerate the healing process?  You must move the shoulder daily within your available range of motion.  But doing the right exercise is critical.

In addition, I believe having an experienced therapist do joint mobilizations is critical in loosening up the capsule provided it is done within pain tolerance of the patient and followed up by appropriate stretching.  For those without insurance or looking to avoid the grueling stretching some docs and PT’s advocate, I recommend looking at my home therapy guide.

Want more info?  Visit www.frozenshouldertherapy.com for success stories and more details on my proven home remedy.  You can also click on the image below:

In addition, I think you can complement rehab with a tool like the Rotater to help restore mobility.  I have trialed this product myself and I really like the ease of use and control the patient has with the stretching intensity.  For more details, click on the image below:

Today I have some exciting news to share.  I have recently partnered with OpenSky to make some of my very favorite training and rehab tools available online to you as well.  Essentially, at OpenSky I am able to send my readers to my own personal supply shop. 

In this shop, I will be showcasing products I believe in and use in my daily practice to help my clients achieve peak health and fitness.  For now, I only have three products in my shop, so you are essentially only getting a “sneak peek” as I quickly pull the curtains back for you.

In a few weeks, I will have a grand opening of sorts with many more products to offer.  So, what’s in the shop and how does it relate to me?  Well, today, I wanted to briefly discuss the importance of using a rolling device to facilitate myofascial (soft tissue) release.  Many of you know I run and train runners and athletes of all sports.  One of the most common issues I see (especially in runners) is problems or pain related to trigger points or soft tissue tightness.

How do I solve this?  When I injured my soleus training for the half marathon last fall, I used a roller to resolve pain and tightness before and after each run.  Using a self roller such as the Tiger Tail is very effective in resolving these trigger points and areas of tightness.  You will not be able to enjoy maximal strength and power production in your workouts if these trigger points are interfering or limiting you because of persistent pain.

You would like to think stretching alone would rid you of such issues, but this is just not the case.  Once you effectively relieve the trigger points, the muscle balance is restored and you can get back to 100% again.  So if you or someone you know always complains of tightness or soreness in one calf, hamstring, IT band, etc., this may be just the answer. 

The best part the Tiger Tail is that it is very affordable and easily transportable if you are on the go.  You control the pressure and location of the release.  In just 5-10 minutes you will be on your way to feeling much better.

Be sure to check it out today at my store by clicking here or on one of the images above.  I look forward to sharing more of my favorite training tools in the near future.

Whether you are lay person, trainer or therapist reading this blog, I try to keep you up to date on science, training and my interpretation/application of exercise based upon the research and practical application in my practice.

Today, I want to touch on an article just published in the Journal of American Sports Medicine.  It was based on a  study conducted by Tim Tyler et al in New York.  They set out to determine what effect decreasing GIRD (aka glenohumeral internal rotation deficit) and posterior shoulder tightness had on reducing symptoms associated with internal shoulder impingement.

For those unfamiliar with GIRD, it basically looks at total shoulder motion side to side but focuses on deficits in internal rotation.  Throwers often lack internal rotation on their dominant arms and exhibit excessive external range of motion for cocking and ball velocity.  We tend to call this acquired laxity.  Pitchers tend to have higher GIRD as well.  Keep in mind total shoulder motion is critical as well.  So, you cannot assume one will have problems just becasue there is decreased internal rotation.

You may see similar GIRD and psterior shoulder tightness patterns in other overhead athletes (swimmers, tennis players, volleyball players, etc.)  This particular study looked at the effect on 11 men and 11 women who received manual mobilization by a PT combined with ER ROM, posterior shoulder stretches and scapular strengthening.

They studied all 22 subjects (range of symptoms from 1 to 24 months) and then compared data on the patients with and without symptom resolution.  In effect the study revealed that posterior shoulder tightness was significantly improved in 12 of the subjects that had complete resolution of symptoms (more so than in the 10 who did not).  In addition, changes in GIRD did not seek to impact the results.

What is the take away from this study?  In a nutshell, if you have symptoms related to internal impingement, you should be doing posterior shoulder stretches.  So, what are the best ones to do?  There was a recent article in the NSCA Strength and Conditioning Journal (December 2009) that laid out some effective stretches (two of which I will show you in the video).  Also, you should note that this pattern of tightness is common in weight lifters.

I have included a short video clip with 3 effective stretches that easily can be done at home.  The stretches are as follows:

1. Standing cross chest shoulder pull (across the chest) – this is a basic stretch I start most clients with who are experiencing pain.  The drawback is that the scapula is not stabilized (or fixed) so you do not isolate the posterior shoulder effectively.  However, it tends to be more comfortable for many early on and you will still get some benefit.  When you are ready, it can be done against a wall to fix the scapula.
2. Side lying cross chest shoulder pull – this would be equivalent to doing stretch number 1 against a wall.  The floor acts to stabilize the scapula and then you pull the arm up and hold.
3. The sleeper stretch – go easy with this one as pushing too hard may actually increase inflammation in my experience.  You may also vary the angle of the upper arm to hit different portions of the joint capsule.  For example, you may elect to stretch at 90, 70 and 45 degrees.

I advocate holding each stretch for 20-30 seconds and repeating 2-3 times daily.  If you are in therapy, the stretching should be done following the joint mobilization by your therapist.   Click the video below to see the stretches.

Well, I have an update on player x.  She saw my preferred soccer/knee orthopedist in town on Wednesday.  He examined her and read the comments I gave to her mother as well.  In summary, he agreed with me that she had patello-femoral pain/inflammation.

He also told the mother she had just gone back to soccer too quickly and never fully regained her quad strength.  He told her if she continued to work around the deficit, she would likely suffer another injury.  This is often the case.  So, at this point the plan of action is to take a one month hiatus from soccer and do formal rehab three times per week.

While this process will be much slower and less active for player x, it probably will be for the best in the long run.  In the short term, she may suffer some loss of fitness, but she needs to focus on strengthening right now.  I will keep you updated on her progress as time goes by.  She will likely return to me for conditioning to transition her safely back to full soccer once therapy winds down.

In the last post, I identified the issue I believed to be going on with player x.  Keep in mind the player returned to  see me the week of 12/15 intially.  The first line of treatment for PF issues in most clinical scenarios involves the following:

1. Rest
2. Ice
3. Stretching (quads, hamstrings, IT band and hip musculature)
4. Straight leg raises
5. Short arc quads (mini-knee extensions from 30-0 degrees if you will on a bolster) although I am not a huge fan of these
6. Mini-squats
7. Calf raises

I advocated relative rest, ice and stretching with my athlete in addition to the following exercises initially:

1. Single leg step-downs (side progressing to front version) in pain free range
2. Single leg stiff legged dead lifts
3. Single leg bent knee floor hamstring bridges
4. Lateral ankle band walks for gluteus medius work
5. Multi-planar lunges in pain free range of motion

She did well with all of the exercises after week one but noted pain with front step-downs and deeper lunges.  On 12/22 I made a significant discovery: she had adopted a compensatory hip strategy to avoid normal knee kinematics with deceleration.  What am I referring to?  I call it a quad avoidance lunge pattern.  She would shift her trunk into extension with foot contact when lunging onto the affected knee as a result of anticipation of pain. (See video clip below as I show a normal lunge pattern, a quad avoidance lunge pattern and the exericse I use to break it)

To help break this cycle, I used an 18 inch box to elevate her unaffected foot and force her into more normal hip flexion on the affected side in a pain free range.  This seemed to work so we added this to the home program using a stair step and eliminated front step-downs altogether, choosing instead to focus on the side step-down in the 40-0 range if you will.  I also added single leg soccer kicks (no ball) forward and in a crossing fashion to work on stability, strength and proprioceptive control.

The athlete returned on 12/31 and seemed to be progressing but still had discomfort with running.  So, I felt she was not ready for full go as of yet.  She also still had discomfort with short and long shuffles moving to the involved side.  At this point, her mom wanted to know what I thought. about practice.

I advised her that player x needed to continue with strengthening 3x/week and try to ease back into jogging as able.  She said the first indoor practice was coming up the week of 1/4.  My thoughts? Indoor soccer fields and PF pain are a bad fit – period.  But, I told her to let her daughter warm-up and do a few drills to get a feel for things.

The verdict?  I got an email on Saturday saying she could not practice due to the same discomfort.  Her next stop is back at the surgeon’s office for a closer look at the knee tomorrow.  I will keep you posted on the diagnosis and treatment as this is an issue that all of us who work with athletes face and struggle with.  Finding the right balance and progression between rest, rehab and return to play is tricky.  So stay tuned for more details.