A man in his 70s came to the Nirschl Sports Medicine Center in Virginia. His chief complaint was mild weakness in his golf swing for several months, but no pain or other functional limitation. His exam was unremarkable except for asymmetric weakness in the right shoulder. We ordered a magnetic resonance imaging (MRI) scan to evaluate possible surgical options.
I had never seen an MRI like it in a patient with so few complaints. His rotator cuff muscles, including the supraspinatus, infraspinatus, subscapularis and teres minor, were mostly gone. Fluid from chronic inflammation was where the supraspinatus used to be, and the cartilaginous ring (labrum) which usually helped hold the head of the arm bone (humerus) in the shoulder (glenoid fossa), was in shreds. His posture was poor and his other supporting muscles weak, which is common for most patients.
This gentleman was the exception because he had such bad disease but so few symptoms and so few functional limitations. For every patient like him in our sports medicine clinic there are hundreds of others with chronic and debilitating shoulder pain, severe weakness and poor function. I have included information to help these patients and other readers below. The more people follow these instructions, the less they will need to go to the doctor, and the quicker they will improve when they injure themselves.
A patient told me this story:
“I went into my garage to find some tools to do some work around the house. I dug through piles of clutter and remembered how long I’d been telling myself to get rid of most of this stuff. I stepped over a broken down lawnmower and lifted a heavy box of old magazines. Finally I saw my toolbox on a back shelf. There were more boxes, folding chairs and an old computer in the way, but I was tired of moving things, so I reached across the stuff, twisted my body a little to avoid the floor fan on my right, and tried to lift the toolbox. Instantly severe pain shot through my low back and down into my butt. It hurt so bad that I couldn’t breathe and I could barely walk. I took a couple aspirin and came in.”
He had no evidence of serious neurological problems; just a bad case of musculoskeletal back pain I limited his activity and treated his pain. After several uncomfortable days he returned, feeling 90% better, and we discussed why this happened.
1. Weakness – He had not exercised for months, and had not exercised his core for years. His core, the abdominal, back, buttocks, and thigh muscles, was badly out of shape.
2. Poor range of motion – A good exercise program includes stretching to improve range of motion as well as strength training. The back moves in six directions: bending forward (flexion), bending backward (extension), bending to each side (left and right lateral flexion) and twisting to each side (left and right rotation). Gently going through the whole range of motion each day can help prevent injury.
3. Clutter – whether in the home, garage, or elsewhere, we all have stuff that needs to go. Moving boxes and other debris out of the way tired his already weak back, setting him up for a muscle strain. Getting rid of his unnecessary stuff may have prevented the injury.
4. Not standing directly in front of the item to be lifted – Twisting to avoid his fan made his back muscles less effective, because muscles work by shortening (contracting) and can exert more force when straight than they can when twisted. Twisting also put more strain on the small muscles (interspinalis, intertransversarii) which stabilize the spine rather than the larger, longer ones (erector spinae).
5. Not standing as close as possible to the item to be lifted – Reaching over other boxes lengthened the moment arm, requiring more force and making it harder to lift the tool box.
6. Not lifting with the legs – The muscles of the quadriceps (vastus lateralis, medialis, intermedius, and rectus femoris) and the hamstrings (semimembranosis, semitendinosis and biceps femoris) are far stronger than their counterparts in the back. Therefore the best way to lift is to keep the back in good posture and straight forward, bend at the knees, grab the object, and lift with the legs.
After our talk, he resolved to improve in all areas, and he did.
Strong Backs and Collision Sports
Another patient told me this story:
“Some guys at our church picnic decided to play football. I hadn’t played since high school but was pretty good back in the day. It was supposed to be an easy, friendly game, but after they scored the first touchdown, we stepped up our game. I was determined to win, even though my back was stiffer than it used to be and I got winded pretty quickly. I was playing linebacker at the end of the game are we were ahead 21-14. The quarterback ran outside to his right and lateralled the ball to the halfback. He was huge and about 20 years younger than me, but I slammed into him with everything I had. Instantly I felt a searing pain in my low back, fell to the ground, and couldn’t get up. Eventually my friends helped me off the field and brought me here.”
Fortunately, this patient had no serious neurological problems, and he improved over several days like the other man. He came back a few weeks later to ask me how to prevent another injury like this.
1. Weak and tight – I am the last guy in the world to tell people to stop exercising or doing sports. However I told this patient that to avoid injury, he needed to do these things smarter. The first step was to fix the weakness and range of motion problems.
2. Prepare for the position – General fitness for day to day life is not the same as performance fitness to excel in a specific task. Exercise which is specific to the task or sport that you want to do will help you do that task or sport. See also http://mdharrismd.com/2012/08/15/how-to-pick-your-fitness-goals/.
3. Consider your age and health – Some people, whether due to age, medical conditions, or both, simply should not engage in some activities, regardless of how much they enjoyed them in their youth. Tackle football can give way to flag or touch football, rugby to soccer, and downhill to cross country skiing. There are always good ways to exercise, but sometimes they need to change over the years.
This gentlemen set some specific fitness goals and began a regular workout tailored to meet these goals. He also modified his activity, and has been active, healthy, and enjoying flag football since.
Motion is Lotion
My mother in law, Susan, regularly visits lonely residents in a nursing home in Cordova, Alaska. One lady had loved to knit as a younger woman, but had developed such bad arthritis that she could barely hold a needle. Her hands were painful and misshapen, and she could no longer enjoy this simple pleasure. During her visits Susan began knitting with this lady, placing the needle in her hands and helping with the yarn. The older lady would do whatever she could, and the more she tried the more she could do. The pain and disability gradually decreased. After several weeks she could knit on her own, almost without pain.
The body was made to move, and far from normal movement damaging our joints, it protects our joints. Movement stimulates joints to produce more joint fluid, strengthens the muscles that support the joint, and refashions the bones to handle greater loads. Keeping any part of the body in the same position for too long can damage tissues.
1. Put all of your joints through their entire range of motion every day.
2. Do not sit in the same position for more than a few minutes at a time. Shift your weight or better yet, stand up and walk, when you can.
3. Do not always sit in chairs. Sitting on exercise balls or even the floor can rotate your hips out and put pressure on different areas.
4. Lay with your head below your feet. Lying on a reverse incline for just a few minutes a day can help take the pressure of gravity off your back and neck.
To moisturize and lubricate still joints, the best thing is to move.
Picture Perfect Posture
Having been in the Army for over two decades I have heard many a sergeant correct a junior enlisted soldier, or even an officer, for poor posture. Shoulders slump from hundreds of hours at the computer, heads lean forward and necks ache from too much time reading or watching television, stomachs and bottoms stick out from weak back and abdominal muscles, and shoulders tilt from carrying heavy backpacks with one strap. Is it any wonder that neck, shoulder and back pain are as common as dirt?
Have you looked at young children sitting, standing, and playing? They almost always have terrific posture and they carry it with ease. Only after years of school, carrying heavy bags and living sedentary lives do we slouch and tilt. By being strong and healthy in every area of life, limiting the weight that we carry, and being consistently aware of our posture, we will have healthier and have less pain.
What does proper posture look like?
1. Stand with your heels, upper shoulder blades, and back of head against a wall.
2. Tighten your stomach and push your buttocks a little forward.
3. You are now close to good posture.
4. Step out from the wall, but maintain your body position.
Super Shoulders – Rehabilitate the Rotator Cuff and Strengthen the Scapular Stabilizers
A 30-something manager came into my sports medicine clinic one afternoon complaining of right shoulder pain. He was an athlete and weight lifter and couldn’t understand why, despite his rigorous exercise regimen, his shoulder hurt so much. On exam he had a body that most men wish they had, but one closer inspection he was weak in key areas. Like most men, this patient worked on his “beach muscles”, the pectoralis, deltoids, biceps, and trapezius, the ones that other men envy and women enjoy. Unfortunately he had neglected many smaller muscles, including his rotator cuff and shoulder blade (scapular) stabilizer muscles, that stabilize the shoulder and allow good function. This patient had the typical modern worker posture as described above, contributing to his discomfort.
The humeral head, the ball of the arm bone, sits in a shallow pocket in the scapula known as the glenoid. The shallowness of the glenoid allows the arm to move 180 degrees in many directions, but that same shallowness makes it easy for the humeral head to slide out. A fibrocartilaginous ring called the labrum and various ligaments help to hold the humeral head in its place. However as with all joints, the main stabilizers of the humeral head are muscles; the muscles of the rotator cuff.
Raises arm, provides upward stability
Raise your arm against resistance (ex. Lateral dumbbell raises, back presses)
Infraspinatus and teres minor
Rotates the arm outside (back), provides backward and downward stability
Rotate your arm outside (backward) against resistance (high pulley lateral extensions, low pulley bent forward lateral raises)
Rotates the arm inside (forward), provides forward stability
Rotate your arm inside (foreward) against resistance (put hand in opposite back pocket and push out)
The arm has only one bony attachment to the rest of the body; the place where the scapula, through the clavicle, attaches to the breastbone (sternum). The muscles between the spine, the rib cage, and the scapula, the “scapular stabilizers”, stabilize the scapula and even the whole arm. These muscles include the rhomboids, serratus anterior and posterior, and levator scapulae. Having good posture helps to strengthen these muscles, as do exercises that pull the shoulder blades together. Pretend that you are trying to hold a pencil between your shoulder blades, and you will be on the right track.
Chronic pain is more often caused by musculoskeletal problems than anything else. By practicing healthy lifting, strengthening the body in accordance with what they want to do, staying in motion, maintaining picture perfect posture, and having super shoulders, my patients have been able to eliminate or at least control chronic pain and get back to their active, healthy lives.