The shoulder is the most complex and unstable joint in the human body. With so many multi-dimensional movements, it is very easy to sustain an injury through sport or daily activities. The Glenohumeral joint relies on static stabilizers (ligaments, capsule) and dynamic stabilizers (tendon, muscles) for proper mechanical movements. If these elements are disrupted or weakened, the individual is susceptible to injury. As a physical therapist evaluating a client, it is common to find muscular imbalances of the shoulder complex that contribute to tendonitis, bursitis, instability and impingement syndromes.
One of the more common weaknesses that contribute to these injuries are deficits in scapula stability and the infraspinatus muscle (external rotators). Tightness in the internal rotators (subscapularis) also plays a key role in this imbalance.
The scapula stabilizers (serratus anterior, lower and middle trapezius, rhomboids) are the most often overlooked muscle groups in a shoulder injury. It is very important to strengthen these muscles FIRST so the scapula can “sit” properly providing a foundational base of support.
Once this is accomplished, progression to rotator cuff strengthening, especially the external rotators, is appropriate. It is crucial for the shoulder complex to be biomechanically efficient in order to prevent injury. This will promote return to overhead activities and sports such as throwing and swimming with minimal pain and improved performance. A physical therapist well-versed in the mechanics and function of the Glenohumeral joint can help address these injuries.
A major concern with younger athletes, ages 12-15 years, is throwing curve balls or breaking pitches. This can cause extreme torque on the adolescent’s shoulder and elbow, especially the growth plates leading to a condition known as “Little League Shoulder.” These guidelines can significantly minimize the risk of injury:
Running is the most popular and common form of exercise known. Because running transmits forces up to 4 to 5 times the body weight people are susceptible to numerous injuries. Injuries affect approximately 65% of all runners annually. Most running injuries are caused by recurring factors that runners can avoid such as training errors, improper footwear and paying attention to musculoskeletal symptoms. Some common injuries are:
Patellofemoral Syndrome: A generalized achy pain behind the knee cap that can feel creaky and noisy. It is an imbalance that causes the patella to “track laterally.” Usually caused by weakness of the glute and quad muscles with tightness of the IT Band, hip flexors and hamstrings. Also poor mechanics such as foot pronation contribute to knee pain. Orthotics may be needed for more structural support.
Shin Splints: Pain along the inner side of the lower leg (“tibia”) caused by repetitive stress. Usually due to imbalances of the calf and shin muscles. Brought on by a quick return to intense training or running on hard surfaces and slopes.
Achilles Tendonitis: Running up hills or increasing mileage drastically can lead to pain and tightness in the calves causing inflammation and irritation along the Achilles tendon at the insertion point of the heel.
Plantar Fasciitis: Inflammation of the connective tissue along the sole of the foot leading to fibrotic scarring usually along the arch or heel. Caused by increased mileage, flat feet or high arches as well as decreased flexibility in the calves and hamstrings.
By following a structured program of proper training, maintaining a balance between strength and flexibility and always keeping efficient running mechanics you can substantially minimize the risk of injury. Some guidelines to follow:
- There is a sharp increase in risk of injury running more than 40 miles a week.
- Training intensity- Do not increase total mileage by more than 10% per week especially after recovering from an injury.
- Change your running shoes every 350-400 miles. This is the most underrated aspect that most people do not pay attention to.
- A program of “harder” and “easier” runs during the week helps to avoid overuse injuries.
- Over the counter or custom made orthotics can be helpful in providing support and improving mechanics.
Pain Management with Heat or Cold Application;
which is best?
with pain and stiffness can be a debilitating and frustrating situation
for many. Pain relief from drugs and alternative therapies is also
a major, multi billion dollar industry in this country. However,
many are sensitive to these strong drugs or prefer not to risk their
health with prolonged use of analgesics. Many also find the side
effects almost as bad as the pain, or find little relief from pain
Therefore, finding safe yet effective pain management strategies
The most common pain relief used by pain sufferers is heat and
cold. However, many people question which to use and how.
Cold, in the form of cold pack application or ice massage, is usually
the preferred method of pain management for most ailments, especially
in the first 72 hours of an injury. Cold increases blood flow,
thus speeding up healing. It also decreases swelling, numbs the
and decreases muscle spasms.
Cold packs are available in any drug store, made at home with wet
towels wrapped in a plastic bag, or made with a 2:1 ratio of rubbing
alcohol to water placed in doubled Ziploc bags. Cold packs should
be applied to the affected region with a wet towel between the
skin and cold pack to provide a deeper penetration of the cold.
kept on the area until the skin becomes numb, and then removed
after five minutes more (usually 20 minutes total). Cold packs
for large areas of pain (larger than your hand).
Ice massage can also be performed at home by rubbing an ice cube
or home made “ice water popsicle” over a region not
greater than the palm of your hand for approximately five minutes
the area becomes red and numb. This type of treatment is most often
used with bursitis, tendonitis, or over a pinpoint muscle spasm.
Use of cold is not recommended for individuals with circulatory
problems or diminished sensation. Cold application to the sacro-iliac
or a stiff, arthritic joint may cause more pain and is not recommended.
Heat application promotes circulation and decreases stiffness.
Admittedly, it also feels better than ice. Heat packs can be found
in any drug
store and electric, microwave, or hydroculator types are all acceptable,
so long as they allow use of a damp towel to enhance the penetration
of the heat.
A heating pad is used for 20 to 30 minutes at most to provide a
burst of moist heat. Prolonged use of heat will lose it’s
effectiveness over time, as the body can accommodate to the heat.
use of dry heating pads was found to dry out the skin and muscle
of thin or frail people, primarily the elderly. As with cold, persons
with circulatory or sensation problems should use caution. There
also exists a concern with heat or cold in cancer patients, as
the increased blood flow may spread the cancer cells.
Whether using heat or cold, a one hour break in between sessions
is recommended and no more than five or six sessions per day,
to prevent accommodation. One exception to this rule is consecutive
heat and cold application. For muscular conditions, such as myofascial
pain syndrome (MFPS), heat/cold/heat or the opposite cold/heat/cold
can be an effective pain management tool. Massaging the area
the cold and heat application has also been found helpful in
reducing muscle spasms.
If unsure if heat or cold could be problematic for a specific
medical condition you have, consult with your doctor or other
I have worked with children for many years and have found it
important to closely supervise the use of heat or cold and
watch for skin
burns or frostbite.
There are many other pain management techniques, such as
massage, traction, stretching, joint mobilization and others
be explored with the
a physical therapist or healthcare professional.
Regardless of the type of pain or the number of years a person
has suffered, pain relief is now available for many with the advent
and expanded information.
Judy Aranda, PT is a graduate of Notre Dame’s Physical Therapy
program and has recently begun practicing in the Lancaster area after
many years in Orthopedics, Rheumatology, and Pediatrics in Boston.
She may be reached at (617) 281-3890.
Fibromyalgia is a syndrome involving debilitating pain, sleep disturbance,
jaw pain, irritable bowel, headaches, difficulty with concentration, anxiety
and/or depression, and fatigue. In the United States, this condition affects
nearly 4 million people, or 2% of the population; twice the number as those
with rheumatoid arthritis. The primary symptom, pain, which often migrates
through the entire body, usually occurs between the shoulder blades, on the
forearms and outer thighs, and throughout the neck and back.
Fibromyalgia (FM) was called Fibrositis until 1991 when the American
College of Rheumatology officially recognized this unique collection
of symptoms and
classified the condition
as Fibromyalgia. Prior to FM, the syndrome was confused with mononucleosis,
arthritis, Lyme Disease, and Chronic Fatigue Syndrome. Many sufferers describe
years of seeking medical help, only to be brushed aside. They were told
by their physicians “it’s all in your head” or “there’s
nothing we can do; you’ll have to learn to live with it”. They
continued to feel invalidated, afraid, and alone.
FM often affects women who describe themselves as Type A, perfectionistic,
over-achievers. They also appear to have difficulty with stress management
and assertiveness. These personality traits may create the breeding ground
Many with Fibromyalgia describe an initial stressful situation
or physical injury which triggered the FM, like a car accident or
work stress. The
injury may have begun as a minor sleep problem or a painful joint,
but instead of
getting better, it progressed into Fibromyalgia. I personally believe
FM is the accumulation of stressful situations in a person’s life which can
no longer be handled by the mind, so the stress overflows into the person’s
body, sleep, and mood. Some researchers believe FM is a form of Post Traumatic
Stress Disorder. The fact that women are affected four times more often than
men also speaks to how women view themselves in society and how our society
Currently, Fibromyalgia affects six million Americans or up to
1 in 10 women. Its cause is unknown, but serotonin, growth hormones,
all being investigated. There are no tests, such as blood work or
X-Rays to see
FM. Diagnosis is made when 11 of 18 specific sites, called tender
points, are unusually painful to touch, along with the person’s collection of symptoms.
There are no medications to take Fibromyalgia away, although elavil,
desyrel, and serzone have been found to be helpful in lower dosages,
as well as
analgesics and mood elevators.
So what happens?
If left untreated, the symptoms of FM can persist or even worsen,
preventing many to fully function at work or at home because
of pain and fatigue.
But Fibromyalgia can be treated and the symptoms can be alleviated!
The most important issue in treating FM is helping a person to
recognize how stress and stressful situations specifically
affect their body.
have noticed that when they are stressed, their shoulders rise
up toward their ears, or they may hold their breath. They describe
walk and move
as “driving with the emergency brake on”. All the muscles of the
body tighten or contract with the simplest motion, like washing dishes, vacuuming,
or typing on the computer. This constant tension wears the body down, making
a person feel weak and tired. Not surprisingly, persons with FM have a high
rate of tendonitis, bursitis, carpal tunnel syndrome, and other musculoskeletal
Re-learning how to move smoothly and efficiently again is the
first step to healing. After identifying the exact problems,
may be as
simple as placing a post-it note over the kitchen sink or on
the computer screen
says “relax your shoulders” or “take a deep breath”.
Imagery also helps. For instance, a person could pretend their arm is like
a ballet dancer’s arm, as it slowly and softly floats up to put away
Sleep is another important issue to address. Persons with Fibromyalgia
may have a paroxysmal sleep pattern, which means they can’t maintain a deep
sleep. It may take longer than the normal 20 minutes to fall asleep or they
may awaken during the night and be unable to get back to sleep. Most distressing
is that they often awaken in the morning feeling stiff and tired; worse than
when they went to sleep. Sleep hygiene, techniques used to get a good night
sleep, is utilized. Creating a specific pre-sleep routine or ritual, avoiding
stimulants before bedtime (news on TV, Stephen King novels, certain foods,
etc), and learning how to turn off one’s mind so the body can slip into
a deep sleep are some examples.
Counseling is also helpful to control worrying or “ruminating” at
night, which fuels the insomnia. In fact, psychotherapy is recommended to fully
treat the FM, as lifestyle and the emotional dilemmas of Fibromyalgia can be
addressed by a trained counselor.
Aerobic exercise, as shown by research, is useful for many
stress/pain related problems like FM. Optimally, 30 to 45 minutes
exercise, to raise
the heart rate into the “target zone”, three times per week is
preferred. Unfortunately, persons with Fibromyalgia often have pain if they
do one activity for more than 10 to 15 minutes, much less exercise for 45 minutes.
So we trick the body. By combining three or four different activities (bike,
arm exercises, water walk, stairmaster) each for only five to ten minutes,
but performed consecutively, the heart gets its workout without hurting the
body or flaring up the FM. Thus endorphins are released and serotonin levels
are increased which can decrease the pain, the insomnia, and the FM itself.
Finally, full restoration of strength, endurance, and coordination
is achieved with a specific exercise program.
Once thought of as a debilitating and chronic condition,
the symptoms of Fibromyalgia can be alleviated under an
- Sunlight first thing in the morning may help to set your body’s clock.
- Sunlight exposure at noon, exercise at noon, or exercise five hours before bedtime may also promote sleep (serotonin or dropping body temperature).
- Avoid napping more than one hour during the day or in the evening hours.
- Avoid chemical stimulants at night, such as nicotine, caffeine, dietary protein, citrus, fat, and >3oz. alcohol.
- Avoid emotional stimulation at night, such as certain types of television or literature, phone calls, or intense discussion/arguments.
- Create a time during the day called “worry time” to process the events of the day, to avoid rumination at night.
- Use the bedroom for sleep only (no TV, reading, phone calls, work). This associates the bedroom with sleep only.
- Use pain management or relaxation strategies, such as a warm shower or bath, stretches, pain meds, to decrease any pain or anxiety before bedtime.
- Use imagery to separate yourself away from the stressors of the day (tail pulling off).
- Create a pre-sleep ritual which, when used nightly, will signal your body that it is time for sleep.
- Have a light snack before bedtime; being too hungry or full can inhibit sleep.
- Keep the same bedtime and awakening hours.
- Go to sleep when your body feels ready, not when you feel you “should”.
- Cover up or turn away clocks in the evening to avoid anxiety about when to go to sleep or if you awaken during the night.
- Morning Routine: create a gentle transition from sleep to awakening. Awaken earlier to avoid rushing in the morning.
- Provide optimal lighting with window shades, heavy drapes, eye mask, night light.
- Decrease annoying sounds with earplugs, white noise, unplugged phones, family and neighbor cooperation.
- Create an optimal temperature and ventilation (fans, A/C, dual controlled electric blanket, socks and gloves).
- Cushion painful areas (shoulders, hips) with eggcrate mattress, featherbed, body pillow.
- Use pillows between the knees (or kneepads) for sidelying or under the knees for backlying. Use only enough pillow under the head to keep the ear and shoulder aligned.
SLEEP AIDES AND MEDICATIONS
- Vitamins: Calcium/Magnesium/ Zinc at bedtime.
- Restless Legs: Quinine or Parkinson’s disease meds.
- OTC: Valerian, Melatonin, Chamomile, Calms Forte , Silent Night, Lavendar
- (Caution: many are not FDA approved or may interact with prescription medications adversely)
- Meds: Tricyclics (elavil, trazadone at low doses), Restoril, Ambien, Sonata.
- Avoid: Valium, Benadryl, alcohol which do not promote normal sleep.
SLEEP INTERRUPTIONS/ INSOMNIA
- Prepare ahead of time for sleep interruptions by having enjoyable activities (reading, crafts) ready to do if you awaken and cannot return to sleep.
- If awake for longer than fifteen minutes, get out of bed. Research shows you will probably stay awake for one hour or more. Repeat your pre-sleep routine.
- If you can’t get something off your mind, write it down and discard it. Train yourself to deal with problems in the morning.
COMBATTING JET LAG
- Adjust your watch to the time of your destination at eat and sleep in that schedule.
- Remove your shoes and drink extra fluids, avoiding alcohol or caffeine.
- Get sunlight (back of knees, preferably) whenever possible during and after your trip to re-set your biological clock.
GOAL: Stage IV sleep 30% of the night and a good sleep 5/7 nights of the week.
Wegener, S. Fatigue and Sleep Disturbance in Arthritis
Lacks, P. Behavioral Treatment for Persistent Insomnia
Hauri, P. Sleep Disorders: Current Concepts
Waterhouse, D. Sleep, Diet, and the Brain (Seminar, 1994)
Melvin, J. Treatment of Chronic Pain (Seminar, 1993)
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