Thoughts from the journey… Excerpts from a day in the life of Sherry McLaughlin

19Nov/100

Biceps Tendon Irritation – A Wrong Move

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I was blog surfing today and saw a link to an interesting article that came out two days ago: http://www.usatoday.com/sports/baseball/2010-11-16-shoulder_N.htm

Evidently, there is a bit of controversy regarding whether or not the biceps tendon is an important part of the throwing shoulder. One thing most can agree on is that chronic biceps tendonitis is often the cause of persistent anterior shoulder pain after a SLAP lesion repair.

Superior Labrum Anterior Posterior (SLAP) is a tear in the labrum, common in overhead athletes. As a student of biomechanics, my first question is, "What position of the humeral head would predispose one to a SLAP lesion?" And then, "What does the biceps tendon have to do with that?"

It is this author's experience that persistent biceps tendon pain occurs when the biceps tendon is placed in a long/weak position. Here are the options:
1. Elevated scapula (due to upper trapezius trigger point or elevated pelvis) - Sagittal Plane
2. Adducted scapula (uncommon) - Frontal Plane
3. Upwardly rotated scapula (due to upper trapezius or infraspinatus trigger points) - Transverse Plane

#1, 3 are the most common scapular positional faults that create overload to the biceps long head tendon. This is clinically confirmed by performing manual muscle test of the biceps pre- and post-treatment of the above trigger points.

In short, correct scapular position and the biceps irritation goes away. Interestingly enough, the elevated, upwardly rotated and protracted scapula is also a culprit in rotator cuff tendonitis and tears. And the position of the scapula is often a result of dysfunction somewhere else in the biomechanical chain.

It isn't surprising then that SLAP lesions, rotator cuff tendonitis and persistent biceps tendon pain are commonly associated. According the to article, if you just move the bicep tendon and affix it to the humerus, then you remove the offending tendon and the pain goes away. One study even sites that there was no change in performance. (Maybe it's because these guys actually are throwing from the hip).

I suspect we will find out the ramifications of moving or removing body parts that are part of our intricate design. Kind of like rebuilding an engine only to have a box of leftover parts. It might seem like everything works, but it always makes me a little bit nervous.

For those of you non-professional athletes out there suffering from chronic anterior shoulder pain, here is great news! There is a fix! And it doesn't include a knife or moving body parts around. I assure you these shoulders weren't injured because the bicep was in the wrong place. Moving it, at best, avoids the problem. It doesn't fix it.

For the clinicians out there, remember, the biceps tendon wasn't designed to work in a long/weak position. Fix it's starting length (i.e. fix scapular position) and restore normal functional rotational movement patterns (that means check the thoracic spine, the hip and the subtalar joint).

To quote Dr. James Andrews: The rotator cuff "is still the granddad of the problems" in pitchers' shoulders, but surgeons aren't satisfied with the success rate on SLAP repairs. We're all trying to figure it out — how to fix the damn thing.

My advice, put your ears to the shoulder and take your eyes and look elsewhere. There are real world solutions to this problem. It's our job to exercise those solutions and let the consumers at large know about their options. I promise you, when you solve one of these for yourself, you won't ever forget it--and neither will your patient.

8Nov/100

Scapular Alphabet – The “T”, “Y” and “W”

And just when you thought all letters were created equally...

I have had the opportunity to see some rotator cuff tendonitis and biceps tendonitis patient recently who reminded me of the importance of that first statement. A quick on-line search of the "T", "Y" and "W" exercises commonly prescribed for shoulder pathology confirmed that many clinicians use these exercises more as a general means of fixing scapular instability rather than for a targeted purpose.

I've made that mistake before. And when the patient returned with equal or worse pain, it sent me back to the drawing board to figure out why. Collectively, these exercises appear to all strengthen scapular muscles. But let's take a closer look at each one:

TThe "T" - This horizontally abducted row has been shown in studies to best activate the rhomboid and mid trapezius muscles. Remember, that the rhomboid is not only a retractor, but also an downward rotator of the scapula and a prime candidate to counteract the sometimes overwhelming pull of the upper trapezius (a very strong upward rotator).

Y

The "Y" - This is a strong activator of the lower trapezius muscle (also a functional antagonist to the over active upper trapezius). Remember, the lower trapezius muscle is activated with arm elevation past 90˚. One of the best ways to shut it off? Adopt a thoracic kyphosis or limit rotation to one side and this muscle will become neurologically insufficient (or what we call neurologically lazy).

W

The "W" - This exercise incorporates retraction with external rotation, so is a strong activator of the shoulder external rotators (infraspinatus and teres minor). Here is the caveat. If a patient has a trigger point in the infraspinatus or teres minor, doing this exercise can actually increase a person's pain! These muscles are not only external rotators, but relative upward rotators of the scapula (just take a look at a picture of them).

So, there you have it. I have seen biceps tenosynovitis and rotator cuff impingement patients gain pain-free status after doing the T, and then immediately have their pain return with resisted flexion or ER after doing the W. There are specific reasons to do specific exercises. Know the "Y" behind what you do. Your patients will thank you for it.

Until next time...

26Apr/102

The First Annual MIHP Lemonade 1/2 Marathon

You know what they say, when life hands you lemons...

I had been training for months for a spring half marathon. Normally, I do the Martian Half Marathon, but since they moved it a weekend up this year and put it on a Saturday, that took me out of the running (no pun intended). So, I decided to enter the Trail Half Marathon that was held this past weekend.

My crazy schedule and lack of immediate attention to detail left me high and dry when I tried to sign up three weeks ago, only to find out that all 1,100 slots had been taken. Now, if you know me, you know that I don't particularly enjoy running. I do it as a matter of discipline and so that when I take part in my yearly Olympic Distance Triathlon, I'm not dying running the 10K at the end of it.

So, with all of this crazy training behind me, I decided to run my own half marathon. That's right...just me. As the vision became clearer in my head, a smile grew on my face. Not only would I take the top spot in my age bracket, but I would also win the overall prize! Never before in my wildest dreams did I think I could ever win a half marathon and now, in just a few short days, I could be crowned champion of my own race.

The idea was brilliant and so I started telling people about it. If you know anything about my life, you realize it is far from private. And, yes, I know much of that is my own doing. As the story spread, I heard a client say, "I think I might want to join Sherry on that run." All of a sudden, what could be the best race of my life could turn into my worst. After all, with only two people running the race, coming in second also means I would be finishing dead last! This woman had never run a half marathon before, though she was certainly a runner.

Oh, the dilemma. But as one of my other patients said, "It might be like that tree in the woods scenario. If you win a race and nobody is around to witness it, did you really run the race at all?" Point taken.

So, the invitation was extended and the time set. 7:30 a.m. sharp, the starting "gun" would go off. We would leave from my house and follow a carefully mapped out route through Birmingham/Bloomfield, ending up at the Starbucks on Old Woodward in Downtown Birmingham.

Just so you know, I was taking this thing very seriously. I got up at 4 a.m. to eat my pre-race bowl of oatmeal with walnuts, then back to bed for a few more hours of sleep before getting up to down my pre-race supplements, Advocare Spark, O2 Gold and Catalyst. Marilyn arrived a little bit before 7:30 and we did final potty stops and took our pre-race photo (see below) before heading to the starting line.

The starting gun went off...well, there was no gun, but we said, "Go!" and started running. The day was gray and damp, threatening rain and with a bite in the air. The route went down tree-lined streets and on dirt roads. We navigated mud and pot holes and ran by some of the most beautiful homes in Oakland County. At mile 6, there was a torrential downpour that lasted for about 10 minutes. We were soaked to the skin. We ran past the Cranbrook Art Museum and through the campus. We negotiated some long hills and enjoyed the downhills that inevitably came. We talked about life and running as we paced each other mile after mile. And as the minutes ticked by and the miles were conquered, my competitor became my friend.

At mile 9, this guy jumped out of his car and ran past us and then turned around to take our picture. He cheered us on and then showed up a few blocks later to shoot more photos. "See you at Starbucks!" he said. Our race came complete with a fan and a photographer... (Thanks, Greg!)

At mile 11, we made a left hand turn to begin our run around Quarton Lake. At mile 12, we faced the long hill into downtown Birmingham. And on the final turn, as my legs were aching and my heart was pounding, I made a run for the finish. It was a slight uphill battle, but nothing could stop me now! My legs were churning and I could see the finish line just ahead. As I crossed the proverbial line, I stopped my watch. Marilyn crossed just 7 seconds behind me to complete her first half marathon. The winning time was 2:11:46. The Kenyans might laugh at that, but I was smiling. And as I hugged Marilyn after she crossed the finish line, I just knew in my heart that this was exactly the race I was meant to run this spring.

There were no crowds. No finishing medals. No speaker announcing our names. But at the end, there was our number one fan at Starbucks, reading the paper and waiting to take our picture. And two women who were now friends...bound by 13.1 miles of mud, rain, potholes, long hills and some great conversation.

Thanks, Marilyn, for coming out very early on a Saturday morning to take part in this inaugural race with me and thanks for letting me win. Thanks to our number one fan and race photographer, Greg. I'll see you guys next year...and maybe a few more of you will join us. But for now, please allow me to bask in the fact that I currently hold the course record. ;-)

Until next time...

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29Mar/101

When a weak quad isn’t…

OK, I've been sitting on this one for a while now just to make sure that what I'm seeing is actually happening.

I have a fair number of patients who exhibit functional quadricep weakness during squatting activities, and not all of these folks have knee pain. I regularly do a squat test during my initial evaluation on most of my out-patient orthopedic clients. Ironically, I have also observed a pelvic rotation (in the transverse plane) on these folks.

So, to cut to the chase, try this test:

3 repetitions of a single leg squat using the TRX or other strap to allow them to use their upper extremities to assist. Don't worry. Even if the "cheat" this a bit, it will be evident which leg is weaker.

IMG_1913Perform 3 x 12 of the kneeling tubing punch using the opposite hand of the weak quad. Here are the specific instructions:

1. Hold the tubing (must be strong resistance) in one hand and allow it to pull the body into rotation to that side.

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2. SQUEEZE THE GLUTEUS MAXIMUS on that side to drive the ASIS forward and correct the pelvic rotation.

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3. While maintaining this squeeze, have the person perform 12 repetitions of a punch while maintaining that pelvic position and gluteal squeeze. Rest. Reset the gluteus maximus and perform for a total of 3 sets of 12 repetitions.

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THEN, repeat the squat test. You just might be amazed at what happens. The quadricep often displays marked improvement following correction of a pelvic rotation.

Give this a try and let me know if it works for you and your patients. Then stay tuned for a little "add on" bonus on how this exercise can improve gluteus medius strength.

Until next time...

Filed under: MIHP Think Tank 1 Comment
26Mar/102

A knee that won’t bend

Ever seen a knee that has a hard time bending after a total knee replacement?

Next time before you stretch them, ask them if they feel the pain in the front or the back of the knee. More times than not, the limitation isn't due to scar tissue formation...and more times than not the pain sensation is in the back of the knee instead of the front.

If this applies to you, there is a real solution that doesn't require a manipulation. This is often due to a posteriorly displaced fibular head and is fixable with a simple technique.

What causes this displacement? Our best intelligent guesses are:
- a lack of subtalar joint eversion (stiff ankle)
- a tight lateral hamstring
- walking toed-out usually due to tight calf muscles

It takes about 120 degrees of flexion to walk up and down stairs normally, put your pants on standing up, get your socks on easily or ride a bike!

If you have this problem, I'd love to hear from you and help you fix it.

After all, spring is here. It's time to pull out the bicycle and enjoy it a little...and it doesn't hurt to have pants on while you do it. :-)