Each movement that we make places a demand on our body. Whether it is reaching down to the dishwasher or swinging a tennis racket. Our bodies are designed to cope efficiently with these demands and, when done successfully, our bodies will enjoy and condition themselves to the demands we place upon them.

As with any well-engineered structure, the demands placed upon it should be shared appropriately between the various parts of the machine. Some parts may be bigger and stronger than others and, therefore, be designed to cope with more demand. If one part of the machine begins to take on too much demand, or more demand than it is designed to cope with, the machine may begin to fail in that area. This, however, is often not the fault of the failed component that bravely did its best to handle the excess demand; it is, more likely, the fault of the component elsewhere that stopped sharing its part of the load appropriately.

Recently, I took my car into the garage and was told that the front two tyres were wearing out too quickly. Was this the fault of the tyres? Had I been sold soft tyres that weren’t able to cope with the demands of the road? No, it was due to a problem with the suspension and a resulting misalignment of the wheels causing excess wear. So, should the mechanic a) replace the wheels and hope for the best or b) fix the suspension to stop the wearing. The answer is obvious.

This logic is surprisingly misunderstood when dealing with the human body. The biggest bit of your body is your glutes (bum). The size of the glutes suggests that they are rather important and powerful, and should, therefore, take their fair share of the load. Sadly, with our sedentary lifestyles, the glutes have often lost some of their fine tuning and don’t quite pull their weight.

So, when you reach down to the dishwasher it is very possible that your glutes aren’t helping you quite as much as they should be. The demand of the movement is, therefore, placed somewhere else – usually your lower back. For a while your lower back will work harder and put up with this excess demand, but eventually (just like our well-engineered machine) you may reach a tipping point and pain and dysfunction may occur. Blaming the lower back in this situation doesn’t seem logical. Our mechanic would argue that we need to look harder for, and fix, the cause.
Let’s notch this up a level and move on from our dishwasher analogy to everyone’s favourite tennis player – Roger Federer. Look at the image below of Roger at the end of his forehand:

Do you notice how open his body is at the point of ball contact? It is almost like his hips and upper body have played the forehand already and his arm is the last thing to whip through. That is exactly what is happening. The powerful bits (this hips and the torso) have rotated through already and have created a whip like movement in the arm. The arm is going along for a free ride, as all the power has been generated elsewhere. It makes sense, we don’t want our poor little forearms to do all the work – we want our big bottoms and hips to do it for us. Roger won’t be getting tennis elbow if he plays like this, because the stress of the shot has been taken away from the arm.

If, however, you are a mere mortal on the tennis court, you may overuse your arm and shoulder without generating sufficient power in the bigger parts of the body. Tennis elbow and shoulder issues may then become a factor, as you are asking the smaller bits of you to take up all the demand, while underusing the big bits!

You could make a case for tennis elbow being renamed tennis pelvis! Ok, it sounds like an entirely different (and more unfortunate) type of injury, but it helps us to understand where the problem may originate from. It also might encourage us to think differently about how to tackle it.

This principle applies to all of us and you don’t have to be a superstar athlete to move well and avoid these problems. You just have to move regularly in the right ways in order to remind your body which bits should be doing what.

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The importance of the glutes is understood by practitioners and trainers all over the world. You may well have been told at one time or another that “your glutes aren’t firing”! A common problem for many of us! Unfortunately, the glutes are often blamed (and trained) in isolation. A lack of understanding of how the glutes work, leads to a very limited approach to gluteal training. The glutes are often referred to like a faulty fuse board, which can be rectified with the simple flick of a switch. It would be rather convenient if the glutes had simply decided to switch off but it’s a little more complicated than that I’m afraid. So, why do so many of us underuse our glutes and how do you actually get them to work harder for you?

Evolution lesson #1 – use it or lose it!

The often pedalled cliché of inactive and lazy glutes should be delivered with the caveat that it is, for the vast majority, a completely normal bi-product of modern life. It is not an unfair affliction; you should not curse your glutes for giving up on you when everyone else’s seem to be working just fine!

If you look at the images below of the Capuchin monkey and the Springbok, you should be able to easily spot their big bits and, therefore, have some idea of what activities they do regularly. The Capuchin’s tail suggests that he spends a lot of time hanging and swinging by his tail, which has evolved to become strong and powerful. The Springbok famously spends a lot of time jumping as a means of escape but also as a demonstration of physical prowess, and has the hind legs to prove it! These powerful areas have evolved through continued use, and their continued power and success is dependent on that usage continuing.

This is where the problems for humans arise. We are far more sedentary now than at any time during our evolution. The continued demands required to maintain the strength and power of our big muscles has reduced. Our anatomy has been fine tuned to cope with regular, unpredictable, multi-directional movement. By sitting and moving less, we are no longer putting these demands on our bodies.

The big muscles in our bottoms fire when they are placed under load through movement combined with the forces of body weight and gravity. They respond to three dimensional movement, so not just up and down, but side to side and rotational movements. We, not only, have a habit of being too sedentary but also training and exercising in a very one dimensional fashion. This leaves our glutes fairly underwhelmed.

So, how do we actually get the glutes to fire?

Although there is no literal need to throw out the trappings of modern life and return to an animalistic state in order to rescue our glutes, there may be a figurative one.
The best way to get the muscular system to activate and to make any long term changes to the firing of muscles is to make them do authentic movements. It is crucial for us to understand what the gluteal muscles do in real life human movement. Why are they so big?

The glutes are designed to slow down and control our hip movements, both from the ground up and the top down. The hips are our strongest joints and they act as an important hinge during the majority of our daily movements. Every time our foot hits the ground, the forces from above and below place a huge demand on our hips and the large glutes are there to cope with this significant work load. As the hips absorb movements such as landing or squatting, the glutes recruit elastic energy from the movement. This energy is then utilised to fire us off into the next part of the movement, whether it be the next step or a jump from our squat. If we want to train the glutes, then we need to create authentic movements at the hip in order to replicate this process.

Glute bridges don’t cut it.

If you have been told that you have lazy glutes then you may currently be doing regular glute bridges to turn the damn things on. This is where you lay on your back with your knees bent and lift your pelvis towards the ceiling.
Although this will indeed shorten the glute muscles and may cause them to fatigue – it is by no means an authentic movement. A glute bridge is not something that you are really required to do in daily life. The Capuchin doesn’t train his tail by lifting rocks with it; he trains it by using it for its true function.
Putting one foot out in front of you, while reaching forward to pick something up is an action you are required to do frequently. Landing on one foot, while rotating your upper body, is a movement that you do every time you walk. By exercising and challenging the hips in these authentic positions, we begin to re-educate the glutes as to their true purpose. Our nervous systems are very plastic; they have the potential to adapt quickly. If we actually encourage the body to move in the way that it is designed to, our nervous systems will soon catch on to what we are asking of the body and begin to adapt and create the appropriate firing of muscles. If we continue to train in a non-authentic way, our nervous systems will remain confused and will seek ways of compensating – often leading to dysfunction.

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The hip flexors are a group of muscles at the front of your hips that allow you to pull your knees up towards your chest. When seated, the hips are maintained in this flexed position. Although they allow you to achieve this movement, the hip flexors are not designed to spend prolonged periods doing it and, actually, their true function is quite the opposite. In order to explain the true function of the hip flexors, we firstly need to look at a key principle of the human body called “load to explode”!

Load to explode – what is it and why is it important?
You may often hear osteopaths or personal trainers using the world “load” when referring to muscles. The true meaning of the word “load” is when a muscle is active or tense while in a position of stretch. For example, when you are in a squat, the muscles in your bottom (glutes) are under stretch and also active in order to support your body weight under the force of gravity. We could describe the glutes in this position as being “loaded”. Muscles are like slings, they are designed to catch the body at the end of a movement such as a squat and fire you back in the other direction. If you wanted to “explode” out of a squat into a jump, you would have to go through the “load” phase first. Try jumping up without bending your knees first – you can’t do it. There is no “explode” without the initial muscle “load”.

Let’s apply this to the hip flexors. This muscle group is under stretch when the leg is behind the trunk. Picture A below shows the hips in flexion (hip flexors short) and Picture B shows the hips in extension (hip flexors under stretch or load). The more time we spend in A, the less ability we have to do B!

The true function of the hip flexors is to catch and slow down the leg in the back stride of your walking cycle (Picture B) and then fire (or explode) the leg forward into your next step. This allows us to have a long, efficient stride length when walking. If our hips had no ability to extend behind our bodies, due to very tight hip flexors, then we may begin to walk very differently. Let’s imagine that we have such tight hip flexors that we can’t extend our hips when walking – this is more common that you think!! How do we think the body may adapt…

In Picture C, the leg is behind the body but, unlike Picture B, due to the trunk bending forward there is no actual hip extension being achieved. Stooping when walking is one of the adaptations the body might make if no hip extension is available. Try it for yourself – take a long(ish) stride forward while keeping your back heel on the ground. Can you keep your body upright, or does it want to lurch forward? If it’s lurching forward, it may suggest that your hip flexors are very tight.
The body, however, is smarter than this. Despite the fact that a lot of us have very tight hip flexors, we don’t all walk around looking at the ground with our bodies bent forward. The body will do what it can to lift the chest and the eyes so that you can see where you are going! But if it can’t get that extension from the hips, it will steal it from somewhere else. How about another part of the body nearby that has the ability to extend – the lower back! The lower back is happy giving you a small degree of extension when you walk, but it will soon become rather annoyed if it has to regularly work hard to extend your body because your hip flexors are not doing their job properly. Regular over extension of the lower back is a very common way to, not only, cause back pain but also to cause degenerative changes in the lower back over long periods.

The lower back invariably takes the blame when it becomes sore, but often it is only taking on excess work for another area of the body that is limited, tight hip flexors being a notable culprit. If you don’t use your hip extension then you will lose it, and your body find other ways to keep you upright. So, do your lower back a big favour and stretch those hip flexors – it’s about time the two of them got on a little better.

Have a look at the videos page here for a great 3D hip flexor stretch.

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R.I.C.E. (Rest, Ice, Compression, Elevation) has been the most common initial treatment of acute injury over the last 30 years, as introduced by Dr. Gabe Mirkin in his 1978 publication The Sports Medicine Book. A recent study by the American Journal of Sports Medicine (June 2013), however, has made Dr. Mirkin swallow a slice of frozen humble pie. The study demonstrated no evidence that ice hastened recovery, leading Dr. Mirkin in his 2014 article “Why Ice Delays Recovery” to admit that he was wrong.

So, why is ice not always the best solution?

Firstly, it is worth noting that the inflammatory process is vital for the repair and remodelling of tissues. Common sense would suggest that inhibiting this process may not be the best idea. Ice acts to constrict blood vessels thereby reducing the amount of inflammatory cells deposited by your blood stream.

Although this may reduce pain and pressure on an injury, it also stops healing cells from entering injured tissue. Ice, as well as constricting blood vessels, also constricts the lymphatic system which is responsible for clearing out inflammatory debris. So, you can begin to get a picture of the effect ice has on an injury; less healing cells and a reduced ability to remove inflammatory waste – not ideal for recovery.

So, what should you do?

Here are Dr. Mirkin’s new set of tips for acute injury treatment:

1. Stop exercising immediately; you don’t want to cause further damage.

2. If the injury is very painful, then cold has been shown to reduce pain, in these circumstances you can grab a bag of peas from the freezer but use intermittently – 10 minutes on, 20 minutes off.

3. As soon as possible, get yourself assessed by a health professional to ensure no serious damage has been done.

4. After 48-72 hours the inflammatory process will usually have done its job, movement and the correct exercises then become the order of the day.

5. Joint pumping is a fantastic way of naturally assisting the lymphatic system to remove excess waste, while the correct movements will stimulate tissue repair.

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Firstly, where is it?

The Multifidus is made up of many small, segmental muscles that run the entire length of your spine from your pelvis to the highest vertebra of your neck. It is a deep back muscle that, for the most part, is covered by larger muscles making it difficult to feel (or ‘palpate’). The best place to palpate the Multifidus is at the base of the lumbar spine, where it is only covered by a thin layer of fascia. If you locate the central bony aspects of at the base of your spine (called the spinous processes) and then drop off into the soft tissue either side, you will be sitting over the Multifidus.

What does it do?

The Multifidus muscle is highly active in almost all daily movements. The nature of the muscle attachments, some fibres travelling from one verterbra to another and others attaching groups of 2 or 3 vertebrae, mean that it is involved in gross movements as well as small segmental movements in the spine. In short, this means that the muscle fibres can group together to allow the spinal column to extend or side bend, for example, but can also control fine movements at an individual spinal level. The Multifidus is, therefore, a crucial back stabiliser and offers up to two thirds of the total muscular stability afforded to the back.

Why is it so important?

Each muscle must receive input from the nervous system in order to become active. For most large muscle groups, these innervations are received from nerves exiting the spinal column at a group of spinal levels. For example, the quads receive their power via the femoral nerve exiting the spine at L2, 3 and 4. The Multifidus at each level of the spine, however, receives its neural innervations from nerves exiting at only that level. To explain more clearly, your Multifidus at L1 is being innervated by the L1 nerve root. This means that there isn’t much of a backup plan if that spinal level is for any reason compromised. Research shows that the Multifidus can weaken and become smaller at an individual level if, for example, there is vertebral instability at that level.

What causes back pain?

There are many apparent causes of back pain, from disc injury to joint approximation or degeneration for example, but interestingly such presentations are far from black and white. Studies on pain-free people have shown that many of the things that you would expect to cause back pain are in fact present in those without pain. Jensen et al (1994) found that 64% of people reporting NO back pain showed abnormal discs on MRI. Hitselberger et al (back in 1968) found that 24% of those studied with NO back pain showed nerve compression using a Myelogram. I’m not arguing that disc injury and nerve compression do not cause pain, but it would seem that there are many people with apparent ‘abnormalities’ who are in fact asymptomatic.
This brings us onto the Multifidus. Is Multifidus weakness another abnormality that can either be painful or cause no pain? Well, it would seem not. Studies by Spine (1995) and Stein (1993), among others, have shown very few Multifidus abnormalities in asymptomatic patients. One could argue, therefore, that there are very few pain free people walking around with abnormal Multifidus muscles.

So when do Multifidus abnormalities happen?

Ultrasound techniques have show the Multifidus to be smaller on one-side of the back in patients with acute and sub-acute back pain, notably on the same side of the patients pain. Wasting has been found to occur mainly at a single vertebral level. In chronic patients, the Multifidus has been shown to be smaller over a number of vertebral levels when comparing patients to healthy control subjects. MRI tests also reveal a correlation between Mutlifidus wasting and leg pain in chronic pain patients. Multifidus changes have also been seen in cases of disc herniation, vertebral instability, post surgery and in those with back pain in pregnancy.

Strengthening your Multifidus as a solution to back pain…

It has been shown that Multifidus exercises can increase the size and symmetry of the muscles and lead to improved recovery from back pain, as well as less frequent and less significant back pain episodes in the future. As with any muscle building and strengthening, improving Multifidus muscle tone takes commitment. It is advisable to exercise the muscle at least 3 times a week and you may have to wait 4-6 weeks before you start seeing any improved stability in the spine. I have put an illustration of my favourite Multifidus exercise on a link here. This is a very functional exercise and mimics the activity of the Multifidus in your walking cycle. The benefit of this exercise is that you will begin to retrain the neurological input to the muscle so that it activates properly during walking, thereby, increasing its activity during your daily pursuits. For floor based exercise, have a look at the video on this link.

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I think we can agree that the evolutionary development of human bipedalism (walking on 2 feet!) has generally been a success, right? There are, however, a couple of structures in the human body that seem rather retro-fitted to our new upright postures. Sacrifices that must have been deemed acceptable in the pursuit of the greater good. Women may argue that the pelvis has drawn the short straw. A narrowing of the pelvis has allowed us to successfully make the transition to two feet; it allows for more efficient movement, is more durable and is less likely to break – but it’s also not as accommodating during labour. Unfortunately, as we have moved to two feet our brains have grown in order to process the vast amount of motor control required for our arms and hands – combine this increase in cranial size with a reduction in the pelvic space through which the head of the foetus passes and you can see the problem.

The shoulder has also made sacrifices. What it has gained in mobility, it has lost in stability. We ask a lot of our shoulder joints; compare their range of mobility to a knee or an elbow, for example. We can, pretty much, put our hand in any position we please. Like the hip, the shoulder is a ball and socket joint. Unlike the hip, however, the ball doesn’t so much sit inside the socket as next to it. The acetabulum (the hip socket), is rather more protective of its ball – it clasps it, like a small hand picking up a tennis ball. Our hips, as a result, are less mobile than our shoulders, but hugely more stable. The ball in our shoulder has shuffled up awkwardly beside the socket but it hasn’t been welcomed in. The ball is connected via ligament and cartilage structures; there is very little mechanical support. This freedom allows the shoulder to travel in any plane of movement with very little mechanical obstruction, which is great news for our care free arms and hands, but it does leave the shoulder susceptible to pain and injury.

Dislocation is perhaps the most obvious consequence of reduced support and stability. But it’s the injuries to surrounding musculature, tendons and ligaments which are much more common place. The rotator cuff muscles, for example, are a hot bed of pain and dysfunction. Difficulty raising your arms over your head or reaching behind your back to put on a jacket? It’s most likely the rotator cuff (and the suprispinatus muscle specifically), that are causing the problem. The muscles working on the shoulder have had to strike up a good relationship to manage the vast workload required, however, subtle variances in posture and lifestyle habits can disrupt this balance and cause certain structures to be overworked and over stretched.

Thus bringing us back full circle to our evolutionary theme and the unstoppable rise of the human desk posture. It seems that just as the shoulder was beginning to cope with us walking on two feet, we’ve gone and thrown it another curve ball by maintaining a hunched computer posture for 8 hours a day. Keeping our shoulders rolled forward for long periods disrupts the balance of supporting musculature and leads to continued micro trauma to muscle tendons. Well that’s just great, I hear you say! It’s easy and clichéd to criticise and blame desk postures for shoulder and upper back pain. I can even see how it’s frustrating for patients, as there’s no real alternative for many people. But being aware of the issue is half the battle, if you take an interest in your work posture and your desk set up then you can make the right adjustments to put the shoulders in the optimum position to maintain proper structure and function.

Friedlander, Nancy & David K. JORDAN, 1995. Obstetric implications of Neanderthal robusticity and bone density. Human Evolution (Florence) 9: 331-342.

Cailliet, R., 1991. Shoulder Pain. 3rd ed. Jaypee Brothers, New Delhi, India
Jackson-Mansfield, P., Neumann, D.A., 2009. Essentials of Kinesiology for the Physical Therapist Assistant. 1st ed. Mosby Elsevier

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Let’s have a look at some relevant studies through the years;

1983 – Weber:
Weber looked at 126 patients with confirmed herniated discs on MRI. One group received surgery, while the other group received conservative non-surgical care. The groups were then examined at 1, 4 and 10 years after treatment.
After 1 year, the surgery group was doing better. At 4 and 10 years, there was no significant difference between the two groups.

1999 – Loupasis et al:
Loupasis followed 109 patients post discectomy (surgical removal of disc material) at an average follow up of 12 years after surgery. Satisfactory results were found in 64% of patients, 28% still complained of significant back or leg pain, 7% had repeat operations.

2006 – Weinstien et al:
501 patients studied, looking at the difference between surgery and non-surgery patients after a 2 year period post treatment. No significant differences could be found between the two groups.

2008 – Peul et al:
283 patients studied, 141 underwent “early” surgery i.e. within 6-12 weeks of symptom onset. 142 were consigned to conservative treatment for 6 months. Early surgery gave more rapid relief of sciatic pain versus the non surgical group, however, outcomes were very similar after one and two years post treatment.

To summarise, these studies show that surgery can be more effective than non surgical care in the short term, however, long term prognosis for surgery and non surgical intervention is very similar.

What happens to the disc material if it is not surgically removed?
Numerous studies have been done that have looked at non surgical patients with disc herniations over various periods of time. These studies have demonstrated that disc herniations can decrease in size substantially over a period of months without surgical intervention. Mother Nature is indeed a very powerful healer. It is also worth noting that many people are walking around with disc abnormalities and are completely pain free. 64% of pain free patients when studied on MRI were found to have disc abnormalities in a study conducted by Jensen et al (1994). You could argue, therefore, that the body has the capacity to cope with disc abnormalities and patients, by seeking non surgical care, can be helped to identify the appropriate movements, positions and postures which will allow for this.

Nikolai Bogduk, a leading voice on the aetiology of back pain, identifies that many structures in the back can cause referred pain into the lower limb. It may be the case, therefore, that the pain in your back and leg is in fact a multi-tissue event and removing the disc alone from this equation may not necessarily be the answer.

Conversely, however, you could argue that if the outcome of surgery versus non-surgical intervention is the same after 1 to 2 years, yet surgery offers quicker relief, then surely surgery sounds like the better option. And for some people it may well be. Microdiscectomy techniques now offer a neater and comparatively less invasive procedure than previous techniques. One should still consider, however, the tissue damage, scarring and reduced movement potential caused by surgery and how this may affect your ability to make a full, long term recovery.

Weber, H. 1983. Lumbar disc herniation. A controlled prospective study with ten year observation. Spine 8:131-140

Loupasis, G. A. Et al. 1999. 7 to 20 year outcome of lumber discectomy. Spine 24:2313 – 2317

Weinstien , J. N. Et al. 2006. Surgical vs nonoperative treatment for lumber disc herniation, Journal American Medical Association.

Peul, W. C. Et al. 2009. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation. BMJ, vol 336.

Jensen, M. C. Et al. 1994. MRI of the lumbar spine in people without back pain. New England Journal of Medicine.

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Each day as we sit at our desks and stand in the lunch queue, we are putting compressive force through our lower backs and the cushioning discs that sit between our vertebrae. Although common sense may suggest that sitting is less of a rigour than standing; in actuality, far more compressive force is put through the lumbar spine when seated. A supporting cast of muscles surrounding the spine allow us to maintain an upright position when standing and also allow fine adjustments in the pursuit of balance. When seated, these muscles are far less active thereby removing some of the scaffolding from the spine and allowing the vertebrae to drop further weight upon one another.

The discs between the vertebrae are, therefore, squashed and over time can become dehydrated. This gradual dehydration and degeneration of the discs is the first change to occur as the spine makes it’s inevitable journey towards a degenerative state in old age. The discs, like everything else in the body, need a rich supply of nutrients from the blood in order to stay plump and healthy. The nature of the blood supply to the discs, however, actually means that they suck up the majority of their required nutrients from the extra cellular fluid surrounding them. In this way, they are very much like sponges. As the vertebral bodies separate, the discs are able to open up and pull in the required nutrients. Unfortunately for those of us that sit at desks for long periods, the opening and closing of the vertebrae and pumping of the discs is not taking place regularly, leading to increased dehydration, increased susceptibility to injury and a speedier journey towards degeneration.

To counteract this, a daily (evening) 10 minute stretching routine of the lower back will help to keep the discs hydrated and the disc tissue healthy, and will also improve blood supply to the surrounding muscles, thereby improving the lower back support framework. Everybody should consider doing such a routine even if they do not suffer from back pain.

On the link below, you will find a short routine of stretches that incorporate flexion and extension of the lumbar spine, a process which opens and closes the vertebrae and stretches the spinal muscles.

Click to view: Back stretching routine_BSM_2014

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Frozen shoulder is a puzzling and often misused diagnosis. There are a variety of injuries that can lead to reduced shoulder movement and it’s worth noting that the term “frozen shoulder” isn’t a catch-all term for such injuries, as sometimes assumed by patients. Frozen shoulder refers to the inflammation of one particular structure in the shoulder – the joint capsule. This capsule covers the head of the humerus (the upper arm bone) and affixes it to the cavity of the shoulder. In cases of frozen shoulder this capsule becomes inflamed, tightened and sticky – hence “frozen shoulder” being referred to clinically as adhesive capsulitis.

The cause of this inflammation remains somewhat of a mystery. It is thought that adhesive capsulitis is often proceeded by injury or degeneration in other areas of the shoulder; becoming, therefore, the final unwelcome culmination of various smaller pathologies. The cycle of inflammation and repair caused by tendinopathies of the rotator cuff or biceps tendon, for example, can lead to irritation of the shoulder capsule and a progressive tightening. This certainly doesn’t mean that all shoulder pain will lead to adhesive capsulitis if left untreated, far from it. It remains a fairly uncommon condition, affecting only 2 to 3 percent of the population and most commonly those over the age of 40. Frozen shoulder is also thought to affect certain people more than others; diabetics, for example, due to the associated damage to small blood vessels that accompanies the disease. Some studies have also suggested that adhesive capsulitis may even be an autoimmune condition, whereby the body attacks its own tissues, therefore more frequently affecting those with pre-existing autoimmune conditions. Such an autoimmune reaction is thought to be triggered by tendon degeneration in the area.

So how does frozen shoulder feel and what sets it apart from other shoulder conditions? Patients often complain, initially, of an inability to reach behind the back, for example, when fastening a garment. Pain tends to present as a general shoulder ache and is usually relieved with rest. Often it can interrupt sleep if the patient lies on the affected shoulder. These early symptoms, however, are also consistent with other shoulder pathologies such as rotator cuff tendinopathies. What sets a frozen shoulder apart on examination is pain and a reduced range of motion when the shoulder is passively moved by the examiner, i.e. the movement is performed by the practitioner, therefore removing the action of the patient’s shoulder muscles, and implicating a true shoulder joint pathology.

The development and progression of a frozen shoulder is described in 3 stages; the painful stage, the adhesive stage and the recovery stage, each said to last roughly 6 months. The painful stage involves a gradual increase in pain and immobility. The adhesive stage is the period during which active and passive movement of the shoulder is almost completely lost and the recovery stage is a painless stage with a gradual return of mobility. Although 18 months may be a dauntingly long amount of time to suffer from debilitating shoulder pain and immobility, it can often be reassuring for patients to at least hear that there is a fairly standard progression and prognosis. Often chronic pain can feel as though it will never recede, so having a timeline for recovery can be surprisingly comforting in itself.

So, can manual therapy help? Yes, but don’t expect miracles. Manual therapy can be a very useful catalyst for recovery assuming that there is a commitment from the practitioner and the patient. The time of recovery can be reduced with regular manipulation and passive articulation of the shoulder joint, as well as the appropriate homework from the patient. By keeping record of even the most seemingly insignificant improvements in range of motion, the practitioner can also help to install a feeling of positivity and optimism in the patient which will help further with recovery.

• Cailliet, R., 1991. Shoulder Pain. 3rd ed. Jaypee Brothers, New Delhi, India
• Chila, A., 2010. Foundations of Osteopathic Medicine. 3rd ed.
• Siegel et al, 1999. Adhesive Capsulitis: A Sticky Issue. American Family Physician.

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So, we established in last week’s blog that evolution has entrusted the shoulder joint with a vast workload. The level of mobility we demand from our shoulders has inevitably left them less stable. For most of us, most of the time, however, our shoulders cope with our demands impeccably well. But when they do break down, what are the common injuries, what do they feel like and what is the best approach to treatment? Let’s tackle perhaps the most common injury this week, rotator cuff tendinopathy.

Rotator cuff tendinopathy:

It only takes about 4% tendon stretch to start causing micro trauma within tendon fibres. When you consider the varying degrees of internal rotation that most of us inflict on our shoulders via our forward / rounded shoulder postures – it’s not hard to imagine the degrees of stress we put through our tendons in everyday life. The most common site of tendinopathy in the shoulder is the rotator cuff and 1 rotator cuff muscle in particular – the suprispinatus. An anatomical anomaly is to blame for this. There is a ‘critical zone’ about 1cm from the attachment of the suprispinatus that happens to sit at the junction of 3 blood supplies.  Although this may sound as though the muscle has an abundance of fresh oxygenated blood to enjoy, it is actually quite the opposite. It is almost as though the 3 arteries can’t quite agree whose responsibility this small area is and consequently they all rather rudely ignore it. This leaves this section of muscle tendon more susceptible to damage and less able to repair itself.

Feeling pain when raising a straight arm above your head, or when reaching behind your back to put on a jacket? These are classic symptoms of rotator cuff tendinopathy. It may be due to a single incidence of trauma, such as over reaching during sport – but more often it is caused by continued small micro-trauma that builds up over time. The ‘Iceberg Theory’ of tendon pathology considers tendon pain to be, as the name suggests, the tip of the iceberg. By the time pain raises its head above the surface, you can be assured that the tendon has already been through a fair amount. Small cycles of inflammation and repair due to everyday stresses finally take their toll. The tendon does its best to deal with it without letting you know but eventually it concedes that a problem shared is a problem halved. The problem with this chronic development over time is that tendinopathy becomes quite mature and stubborn and recovery can take a while. So what are the best approaches to treatment?

Appropriate movement is the blueprint for repair. Inactivity doesn’t really cut it. If you rest a tendon too long, collagen will be laid down haphazardly and lead to a shortening of the tendon and a susceptibility to further injury. Movement encourages the tendon to lay down repairing collagen fibres in the appropriate lines of stress, the tendon will then be stronger in those planes of movement that we most often ask it to follow.

Before you can start appropriate movement and stretching, however, you may first need old adhesions and collagen patterns in the tendon to be broken down; this will provide a nice clean slate for appropriate repair. This is where manual therapy comes in. Tendon inhibition, soft tissue release and various other manual techniques will encourage break down of shortened painful adhesions and encourage blood flow to the area to kick start the repair and regeneration process – out with the old, in with the new.

Being aware of posture is also fundamental. A forward shoulder posture, which will be further aggravated by a desk based job or long periods in front of a computer, will put continual stress and strain through the rotator cuff tendons of the posterior shoulder. The shoulder joint is in the middle of a muscular tug of war between the posterior rotator cuff and the anterior pectoral and bicep muscles. If your shoulders are internally rotated, the anterior muscles are winning and the posterior rotator cuff muscles are weakened. By stretching shortened, strong pectorals you will be helping out team rotator cuff and giving them a fighting chance of re-addressing the optimum balance of the shoulder joint.

References:

• Cailliet, R., 1991. Shoulder Pain. 3^rd ed. Jaypee Brothers, New Delhi, India
• Chila, A., 2010. Foundations of Osteopathic Medicine. 3^rd ed.
• Lederman, E., 1997. Fundamentals of Manual Therapy: Physiology, Neurology and Psychology. Churchill Livingstone

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