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...

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. 🙂

3Dec/090

Patellofemoral Pain – Runner’s Knee 501

After a week hiatus due to the Thanksgiving holiday, I am back into blogging action. Today's post will wind up our look at the five most common running injuries, and we picked the best for last.

Patellofemoral pain got it's nickname for obvious reasons. It is prevalent in runner's and information regarding its diagnosis, cause or treatment are vague at best. I thought I would start with a lesson about how the knee is built.

Crash Course in Knee Anatomy:

The knee is made up of the femur (thigh bone) and the tibia (shin bone) and the patella (knee cap). The patella has an interesting position in that sits between two big bumps of the femur (the femoral condyles), but it is tied to the tibia via the patellar tendon. Therein lies the rub (no pun intended). The femur takes it's cue from the hip. That is to say, the position of the seat the patella sits on is controlled from the hip above. The tibia takes its cue from the ankle and subtalar joint. The knee really is stuck in the middle with nowhere to run and nowhere to hide.

Can it be fixed?

Enough of that. Here is the point. It can be fixed, but not with just rest or medications. Sure, stopping running will eliminate the pain. But the pain will resume once you start running again if you don't address the cause of the problem.

For you runners out there, this means normal hip flexibility and normal ankle flexibility.

Try this test!

The squat test is a great test to try. Stand with your feet shoulder width apart and toes pointed straight ahead. Squat down as far as you can without your heels coming up off of the floor. What happens?

- If your knee falls in - stretch your calf muscle and strengthen the gluteus medius and maximus (your butt)

- If your knee falls out - stretch your ITB and gluteus medius and work on balancing on a foam roll to unlock your subtalar joint

- If your toe turns out - stretch your calf muscles and your lateral hamstring (the revolving triangle is our favorite for this)

- If you feel like you have to lean way forward or throw your arms in front or you will fall backwards, this is a sign of tight proximal hamstrings. We love the downward dog, the triangle and the revolving triangle for this!

To the clinicians:

Most people with unilateral patellofemoral pain have a pelvic asymmetry stemming from an SI joint problem. This will create a functional leg length discrepancy that can cause medial or lateral patellofemoral pain.

On your patient with this problem, make sure to check the following:

1. The Three Key Hip Test - 90/90 hamstring, piriformis and FABERS - and fix what you find!

2. Pelvic alignment - innominate flares, upslips, rotations and sacral torsions

3. Ankle dorsiflexion - in standing with gravity drop or anterior reach with the leg

4. Subtalar joint eversion - in standing with medial reach w/ the leg

Fix what you find on the table and then support your findings with a solid exercise program. Remember, if it is done right, exercises to solve patellofemoral pain rarely should be focused on the knee.

Now, get to work... there are a lot of laid up runners out there!

Until next time...