It's ONLY bursitis, nothing a little cortisone won't fix...

I've heard this a few times. And it really really annoys me.

What people fail to understand, is that cortisone is like a pain-relieving Band-Aid and that the problem is likely to recur somewhere down the track. If you don't figure out the WHY behind the bursitis, you probably will struggle to overcome it. Don't get me wrong, cortisone can be beneficial for some chronic conditions but the mechanics of why the problem started in the first place still needs to be investigated.

Bursitis in the shoulder is one of the most common causes of shoulder pain and the sub-acromial bursa is usually the culprit. The sub-deltoid bursa can also be a cause of shoulder pain but is less commonly seen.

So what is a bursa exactly?

A bursa is a fibrous sac located around tendons and the underlying bones in numerous locations in the body. Its main role is to act as a cushion between the tendon and bone, providing a smooth surface for the tendon to glide. When the bursa becomes inflamed, it fills with fluid, causing pain and restriction of movement.


There are a few things that can cause sub-acromial bursitis in the shoulder:

• repetitive overhead movements - overuse injury
• trauma - such as a fall
• poor shoulder biomechanics - poor posture, rounded shoulders, etc.
• weakness of scapular stability muscles such as rhomboids, lower traps
• weakness of rotator cuff - particularly subscapularis**
• tightness of the posterior capsule of the shoulder
• bony abnormality such as osteophytes, hooked acromion (primary external impingment)

I'm not going to discuss each of the points listed above, but do want to talk about the subscapularis muscle, which is a muscle of the rotator cuff, most commonly known as an internal rotator of the shoulder. However, the most important role of this muscle is to compress the humeral head into the glenoid fossa and prevent anterior and superior translation of the shoulder during functional activities. Restriction of the subscapularis muscle will limit external rotation ROM and trigger points in this muscle can refer pain into the back of the shoulder and down into the wrist.

Subscapularis trigger point referral pattern

There are a few tests to assess the subscapularis for tears - check out the link for the tests.
http://eorif.com/subscapularis-physical-exam. However, the subscap push off test is more a test of subscapularis strength. Try this at home to see if your subscapularis is working or not:

• Stand 3/4 of a foot length away from a wall
• Place one hand behind you, just in your lower back
• Keep your head and thoracic spine against the wall
• Bring your elbow forward so it is NOT resting against the wall
• Now, using only the heel of the hand (not the fingers), attempt to lift yourself away from the wall WITHOUT ALLOWING THE ELBOW TO DRIFT BACKWARDS
• Do not use your fingers or wrist to initiate the movement and do not allow the body to lean forward or head poke

 An inability to perform this test may be indicative of a weak subscapularis muscle.  If you cannot get your hand behind your back for this test, you either need to work on your internal rotation ROM or perhaps get further investigation for possible tear of subscapularis. For athletes requiring good rotator cuff strength, i.e. Crossfitters, you should be able to perform this movement properly 8-10 times. How many can you do??

So, if you are suffering with shoulder pain and the diagnosis is bursitis, I would think long and hard about getting that cortisone shot your Doctor will likely offer you. Yes, it may relieve your pain in the short term, but if you want it fixed permanently you need to address your faulty biomechanics and a lazy subscapularis.

Lower back pain

If you have ever suffered a lower back injury, you know it is something you never want to experience again. I, for one, can vividly remember all the time I spent suffering with crippling back and leg pain and feeling as though I would never be able to play sports again.

My story goes back a long time, to when I was playing volleyball at College. I don't actually remember doing anything to my back during practise, but can remember the walk back to my car afterwards. By the time I got to my car, I couldn't stand up straight without pain. 2 weeks later after numerous visits to the Chiropractor I recall my roommate at the time saying to me "It can't be THAT bad, just stand up and get over it". Years later, when she suffered a disc injury, I got an apology: "Now I understand what you went through all those years ago and I'm sorry for being so unsupportive".

Unless you have suffered with a back injury, it is difficult to understand what that person is going through.

My back eventually got better but every couple of years it would flare up. The next time was when I took up snowboarding. This time I saw a Physio for treatment who explained it was my SIJ and a pelvic rotation problem. Commence "core strengthening" exercises. A couple of years later, I dove for a ground ball playing softball and once again was crippled with pain, this time the pain started shooting down my leg - "sciatica". The Physio I saw this time suggested it may be a disc bulge. I was 24 at the time. The next time my back "went" I was living in Australia and when I saw a GP demanding a CT scan to figure out the problem once and for all, he hesitated and said "I was too young for such a back problem" but relented and wrote a referral for a CT.

Turns out I had a "severe L5/S1 disc herniation causing considerable deformity of the thecal sac". Hmmm, too "young" for a back problem hey Doctor?!?

MRI of my lumbar spine in 2005.

Three visits to three different surgeons resulted in three different answers:
Doctor 1: "Let's operate".
Doctor 2: "You're nowhere near bad enough to require surgery".
Doctor 3: "I'm surprised you're functioning at such a high level considering your scans. But lets wait 6 months and see what happens".

All I can say is that I am happy that I didn't listen to Doctor 1.  Even though at the time I couldn't sit for more than 15 minutes without pain and was honestly wondering if I would ever be able to play a sport again without reinjuring myself.

Fast forward to today. I have been participating in Crossfit for 4 years and can probably count on one hand the number of times my lower back has been a problem. I am doing all the exercises I remember avoiding at the gym for fear of hurting my back eg. deadlifts, situps, GHD situps, heavy squats, etc. So what's the secret to rehabbing/"fixing" a dud back? Here are my top tips:

1. Get it checked out by a professional and don't be afraid to get a scan (CT, MRI). It is the only TRUE way you can get an accurate diagnosis.

2. Do what your therapist tells you to do. If this involves not lifting for awhile, listen to them. If they give you exercises/stretches to do - do them consistently. It isn't going to help doing them for a week then going back to training because "you feel ok". If you have a disc injury it WILL take weeks to heal. Going back to training before you are ready will only set you back in the long run.

3. STOP if you feel a "niggle" during training. That niggle is your body warning you that something isn't quite right. So many times I get told by patients that they felt "something not right" but kept going, just before they hurt themselves. Stopping in a workout will not kill you. Push the ego aside and listen to what your body is telling you. Last week I overcooked a split jerk and threw it back over my head too far and landed with my lower back extended. I felt it niggle straight away and opted to stop the workout even though I wanted to keep going.

4. Get your technique right. Deadlifting 200kg with a bent back only makes you look like an idiot.

5. Do regular mobility. 

6. Get your glutes STRONG and functioning PROPERLY. This means that they should switch ON during squats, deadlifts, kettlebell swings, Oly lifts, push ups, etc. If you feel your back during any exercise then your glutes probably aren't working properly. And if your hip flexors are too tight (from sitting all day....), your glutes probably aren't working properly.

Tennis elbow

Thanks to everyone who requested a topic for the blog on the MobilizeMe Facebook page!

So, your elbow started hurting a couple weeks ago, just a dull ache on the outside of the arm. Nothing major, just a bit niggly after lifting. So you ignore it and keep on lifting. A couple months goes by and the pain gets a bit worse and now hurts when trying to open a jar at home. You try doing a few stretches here and there and consult Dr. Google to try and figure out the problem. You’re pretty sure it’s tennis elbow; satisfied with a “diagnosis” you buy a brace, wear it sometimes and keep on doing all your normal activities, maybe supplement your diet with a few painkillers or anti-inflammatories to dull the pain. Next thing you know, you can’t shake someone’s hand without pain and you have to ask someone else to open that jar for you.

 Sound familiar??

Tennis elbow or lateral epicondyalgia  is a repetitive “strain” injury (or RSI) that affects the lateral (outside) part of the elbow and is not limited to those who play tennis. It is an injury that limits your ability to grip with the hand, extend the wrist and pick up objects even as light as a cup of coffee and can last for a couple of weeks up to a couple of years.

Lateral epicondyalgia is commonly caused by chronic, non inflammatory changes in the extensor carpi radialis brevis (ERCB) tendon. This muscle of the forearm is responsible for extension of the wrist and its tendon attaches to the lateral epicondyle of the humerus.

Signs & Symptoms of Lateral Epicondyalgia:

·         Pain over the lateral part of the elbow that may or may not radiate down the forearm

·         Pain with gripping or shaking hands

·         Pain with wrist extension

·         Pain with extension of the 3^rd finger

·         Pain with lifting, especially with the palm pointing down

·         Reduced grip strength when compared to non-affected arm

Causes of Lateral Epicondyalgia

·         Repetitive gripping, typing, twisting movements of the forearm (using a wrench/hammer)

·         Repetitive wrist extension (such as in the backhand in tennis)

·         Trauma/direct blow to the outside of the elbow

·         Compression/constriction of the radial (C5/6) nerve

·         Tightness of wrist extensor muscles

·         Cervical pathology – C6/7 disc injury/radiculopathy may be associated with tennis elbow

Management of Lateral Epicondyalgia

·         Conservative management  has been shown to improve symptoms in 90% of patients (Hay et al., 1999)

·         Modification of activity: avoiding movements/activities that aggravate symptoms is necessary for treatment success.  This means that returning to Crossfit and continuing on with your daily WODs will NOT get rid of the problem...!!!

·         Stretching of tight muscles

·         Eccentric strengthening of extensor muscle group

·         Manual therapy

·         Acupuncture/Dry Needling

·         Deload Taping

·         “Tennis elbow” brace worn distal to lateral epicondyle

·         Neural glide exercises if indicated

·         Corticosteroid injections       

·         Autologous blood injections or Prolotherapy

 

All the gripping and lifting we do in Crossfit can cause lateral epicondyalgia and ignoring the problem will not make it go away. The longer you leave initiating treatment, the longer you will suffer.  Most cases of tennis elbow can be managed conservatively (without surgery) so get it sorted before it keeps you out of training.