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.

 

 

How's your form??

I know that for the most part, I tend to go on about mobility and how important it is to achieving good performance and longevity in Crossfit. But something I heard yesterday made me realize that no matter how much mobility you do, if you aren't performing the movements with correct form and technique, you will probably end up injuring yourself.

Imagine yourself turning up at the box and seeing your WOD for the day:

It has a weight for a movement that you KNOW you can just smash out. You want to get a killer time and beat every other person at your box. This is YOUR workout and has your name just written ALL over it. So you hit the workout with all your energy and gusto and leave everyone in the dust. But your form is crap. You don't care, you just want to go as fast as possible. You are a lion ripping the head off a zebra and NO ONE can stop you. Until you feel a "pop" in your lower back and next thing you know, you're on the ground, looking at the ceiling wondering WTF just happened. Getting up off the floor is a struggle and you can't stand up straight. Shit.

Your technique/form should not change regardless of the weight on the bar or how fast you want to go. No time on the whiteboard is worth sacrificing your form for. Especially considering you now have to spend a couple weeks at the physio getting your back sorted out.

I know most people have watched the Crossfit Games and have admired Rich Froning's physical abilities. But have you noticed that regardless of how many workouts he has done, how tired he may be, his form DOES NOT CHANGE. Have a look at him doing the Cinco WOD with the weighted pistols. His form is flawless. http://www.youtube.com/watch?v=KXGybheNPMU (Have a look at how Jason Khalipa's knee drops in while he does pistols).

There are really not many people out there who have the strength and stability to be able to perform single leg squats without losing pelvic/hip control, let alone with weight, at the end of FOUR days of gruelling competition. The single leg squat is actually a test that physios use to assess a person's ability to control the pelvis. The majority of people I see struggle to maintain control dropping into a 1/4 single leg squat.

If you are struggling with injuries, you probably need to get someone to really have a look at your technique, especially under load/fatigue with varying speed of movments. Videoing your movements is a great way of seeing what really happens as you get tired. You may have to push the old ego aside and scale all your weights right back, in order to get your movments perfected before you conquer the Crossfit world. It will take time and effort, but it will be worth it.

1st Rib Funkiness

I was asked to do a post on 1st rib dysfunction on the MobilizeMe page so here goes!

How do you know if you have a problem with the 1st rib?

• Neck/shoulder pain
• Upper trapezius tightness/spasm
• Headaches
• Jaw pain
• Referred pain into neck, shoulder, chest or arm
• Pins & needles into neck, shoulder, chest or arm
• Chest pain



Scalene trigger point referral

The first rib serves as an attachment point for your scalene muscles (anterior, middle and posterior), subclavius and serratus anterior. If your scalenes are  too tight, they can pull the 1st rib superiorly (upwards) and cause the joint to become stiff. Trigger points in the scalenes can refer pain into the chest, thoracic/scapular region and into the shoulder, arm and hand.

Upper Crossed Syndrome

First rib dysfunction is usually (but not always) the result of poor posture, which is commonly referred to as "Upper Crossed Syndrome" or "Forward Head Posture". This frequently seen posture occurs when the head sits anteriorly on the spine, which loads up the posterior musculature (upper trapezius, levator scapulae, etc). The normally lordotic cervical spine becomes more kyphotic, the shoulders round forwards due to tight pectoralis major/minor and the thoracic spine becomes stiff and hyperkyphotic. The deep neck flexors at the front of the neck become long and weak, as do the rhomboids, middle and lower trapezius. In addition, this posture results in altered biomechanics at the shoulder joint which can ultimately cause rotator cuff injuries, impingement, etc.

Thoracic Outlet Syndrome (TOS) is another condition which can be the result of a hypomobile or elevated 1st rib in which the nerve and blood supply from the superior thoracic outlet is compromised. The compression usually occurs between the anterior and middle scalenes, and can result in pain, paresthesia (pins and needles) and weakness of the upper limb. There are other mechanisms, such as a cervical rib, a Pancoast tumor or abnormalities of the clavicle, that can also cause thoracic outlet syndrome.

So what can be done about this?

• Stretch/trigger point release/mobilize/massage your scalenes, upper trapezius, levator scapulae, pectoralis major/minor
• Strengthen your lower trapezius, rhomboids and deep neck flexors
• Mobilize your thoracic spine (foam roller, massage balls)
• Mobilize the 1st rib  -->  http://www.youtube.com/watch?v=RfiTL-0sW_c
• Work on improving your posture
• Take regular breaks from your computer if you work at a desk
• Keep your head back against the headrest whilst driving. Girls - take your hair out of a ponytail (if you wear your hair in one) whilst driving.
• Strengthen your rotator cuff muscles

If you are experiencing any neurological symptoms (referred pain into the shoulder, chest or arm), pins & needles, weakness or loss/change of sensation - it is highly advised that you seek out Professional advice from your Physiotherapist, Chiro or Osteopath. They will be able to assess you thoroughly to figure out what is going on and then provide you with treatment to help ease your pain!

There is scalene and upper traps stretches in the MobilizeMe app - go check them out on the App Store or Google Play.


https://itunes.apple.com/ca/app/mobilizeme/id576108153?mt=8

https://play.google.com/store/apps/details?id=com.hongji&feature=nav_result#?t=W251bGwsMSwxLDMsImNvbS5ob25namkiXQ

Why Pec Minor can be a major pain

The pectoralis minor muscle isn't one that is often discussed, probably because it is overshadowed by it's larger and more superficial (closer to the surface) friend, pectoralis major.  Pec major is that big muscle on the surface of the chest that is responsible for bench press type movements. Pec minor is the smaller muscle underneath that arises from the 3rd, 4th and 5th ribs and attaches to the coracoid process of the scapula and contraction of this muscle causes the scapula tilt anteriorly (forward and down).

If this muscle is too tight, it can potentially cause the following:

• rotator cuff impingement
• forward head posture leading to neck pain and dysfunction
• increase in trigger points through the upper traps and levator scapulae which may lead to headaches
• referred pain into the shoulder and arm
• thoracic outlet syndrome



A. Normal
B/C. Tight pec minor

Try rounding your shoulders forwards and downwards to contract the pec major (like in diagram C above) and then attempt to lift your arms overhead. Notice how your ROM is majorly limited? That is, in effect, what happens when pectoralis minor is too tight. Combine that with tight pectoralis major and you pretty much have no chance at achieving full ROM of the shoulders. However, our bodies are pretty clever and will try find a way around this, forcing the shoulder to get into those positions. Do this thousands of times and it is a recipe for shoulder impingement, bursitis, rotator cuff tears - you get the picture.

The trouble with pec minor is that it is a difficult muscle to stretch and trigger point due to its location. That is where your Physio or Massage therapist comes in handy! You can try doing some trigger point releasing to your pec major but if the problem is really lying underneath, no amount of lacrosse ball smashing is going to help. You need another set of hands (literally) to get in there and release it.

Pec minor trigger point referral pattern

 

Set your scapulas free

Full shoulder range of movement not only requires good mobility at the glenohumeral (ball and socket) joint of the shoulder, but also at the scapulothoracic joint and the thoracic cage.

We need good shoulder mobility for so many different movements in Crossfit - Olympic lifts, push press/jerk, pull ups, muscle ups, thrusters, etc. If you are lacking in your shoulder ROM, chances are good that at some point, you will end up with an injury.

What is your shoulder flexion ROM? Can you lift your arm straight up in front of you and bring your arm past your ear? Make sure your arm stays straight and close to your body the whole time.

Normal shoulder flexion = 180 degrees

 

 

If you cannot achieve this, we need to figure out why. The WHY is what your physiotherapist is good for, as many of the tests we perform to work it all out cannot be performed easily on yourself. There could be many reasons why your shoulder range is lacking: stiffness of the glenohumeral joint, stiffness of the scapulothoracic joint, stiffness of the thoracic spine, weakness of the glenohumeral muscles and/or weakness of the scapular muscles.

 

One of the reasons you may be lacking full shoulder flexion may be due to a tight/overactive levator scapulae muscle. As the name suggests, the levator scapulae muscle elevates the scapula. It attaches to the border of the shoulder blade and the transverse processes of vertebrae C1 to C4. Try doing some trigger point to this muscle by lying on your back and placing a lacrosse ball at the corner of your shoulder blade, near the spine (this is called SHOULDER SLACKING in the MobilizeMe app). Then take your arm and bring it up over your head, keeping the elbow straight. Keep the arm moving for 2 minutes, then re-assess your shoulder flexion ROM.  If it has improved, you can attribute at least some of your problem to tightness in the levator scapulae.

 

 

 

If you got no joy from this, then it's probably a wise move to get a professional to check it out. Don't use Dr.Google. Good luck!

 

 

Don't forget to check out the MobilizeMe app! Available for iPhone and Android!

https://itunes.apple.com/ca/app/mobilizeme/id576108153?mt=8

 

https://play.google.com/store/apps/details?id=com.hongji&feature=nav_result#?t=W251bGwsMSwxLDMsImNvbS5ob25namkiXQ