Start by using a stool to step up to reach for grab bars or a chin up bar. Engage the core muscles of your low back and prevent it from arching. While gripping the bar above, pull the arm in towards your socket. Avoid pulling in a downward motion so you do not activate your lat muscle.

To make it easier keep both feet on the stool. To make it slightly harder leave one foot on the stool. To make it even more challenging remove both feet. Hold this for 10 seconds doing 3 sets x 10 reps daily to start.

This exercise works the shoulder muscles to help with more optimal stabilization and movement reactivation patterns after an injury. If you have any pain or problems performing this exercise please stop and consult with your local Physiotherapist before continuing.

Start in 4 point position on your hands and knees. Engage the lower core of your low back and pull in your low abs below your belly button. Pull the arm and the ball aspect of the shoulder joint into its socket on affected side.

Then straighten out one leg and then the other leg while maintaining your spine in neutral and your shoulder socket engaged. Avoid pulling down with your lat muscle. Hold for 10 seconds doing 10 reps 3 sets in total.

This exercise works the shoulder muscles to help with more optimal stabilization and movement reactivation patterns after an injury. If you have any pain or problems performing this exercise please stop and consult with your local Physiotherapist before continuing. 

At an arm’s length away from the wall, place your hand on the wall at the level of your eyes with your weight on it. Engage the lower core of your low back and pull in your low abs below your belly button.

Then pull the arm and the ball aspect of the shoulder joint into its socket while having your weight on the wall with your one hand. Avoid pulling down with your Lat muscle. Keep this engaged for 10 seconds x 10 reps 3 sets each side.

This exercise starts to work the shoulder muscles to help with more optimal stabilization and movement reactivation patterns after an injury. If you have any pain or problems performing this exercise please stop and consult with your local Physiotherapist before continuing. 

So I just got a five pound kettlebell. And we can also use a five pound double. And so we're gonna do an exercise to strengthen up the shoulder, I call it a straight arm rotations. 

So we're gonna just lie down at first. So if it's a heavier weight, so you want to do it in this way, so that way it's a lot easier to get into the position. So you want to be on your side. So with a five pound weight, obviously it's not too bad. So basically holding onto the weight like this. And then you're gonna roll over. And then you wanna make sure you sit the shoulder, so you engage basically the muscles into your shoulder blade. So you're gonna punch straight up and then engage.

And now from here, what I'm gonna do is I'm gonna actually turn. So keeping my arms straight, I'm gonna roll and turn this way with my arm up like this. And what I'm gonna do here is I'm just gonna rotate. And what I'm working on here is just strengthening, rotation strength, integral range of motion. That's really useful. I wanna do this for 30 seconds and do three sets. That's ideal to do both sides. Once per day. 

To get out of it, I'm gonna roll back and I'll just disengage and down.

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physio in Vancouver, one of Vancouver's best physiotherapist clinics. And we're gonna talk about rock climbing and shoulder pain. How you doing Wil? 

Wil: Yeah, I'm doing good, thanks. 

Mark: So shoulder injuries from rock climbing, I guess this is fairly common?

Wil: Yeah. So rock climbing injuries in the shoulder are quite common. I mean, they make up you know, one of the top three in terms of injuries when it comes to climbing injuries. You know, and primarily when we're looking at shoulder injuries, you can classify them as either you know, like traumatic type of injuries, acute injuries, or non-traumatic. Or I guess where you could say is chronic overuse type of injuries.

And sometimes when we get them, you know, these chronic overuse injuries, it can all of a sudden be like, Oh, that's like a sudden acute thing that never happened before. So what I'm speaking about specifically is this condition that is referred to as shoulder impingement.

So the big question is, well, what is that? It's kind of an umbrella term. Because when we think of shoulder impingement, basically the things that are kind of in the shoulders that you have, like basically certain structures like your, your tendons and, and the main structure in there, your rotator cuff tendons, that can get pinched.

And the main reasons for that is usually there's an imbalance. And with rock climbing, you tend to overemphasize a particular set of muscles. And then there's also a set of muscles that are under-emphasized. And so when you have this imbalance happening, then you can alter your mechanics in your shoulder.

And just with the nature of climbing and in terms of overhead loading repetitively. And then especially when you're looking at you know, the types of climbing, if you're doing a lot of what's called bouldering, where you're not using a rope and you're just sort of climbing up short distances. And these days when you go to the climbing gym, the bouldering gym specifically, where some of these problems that they call them root problems and bouldering problems, quite gymnastic like very parkour like and require a lot of like hanging and just with the arms. And then you do it over time and recognize like, you know, in terms of the recovery aspect of it, then you can really start to bring other problems. 

Mark: So I'm sure it's probably a painful injury. What are other symptoms that are showing up? 

Wil: Yeah, so the biggest one is that you know, it can happen during your training session or your climbing session or might not appear until the day after. And you start to get pain just with like trying to carry something, like say you go to the grocery store and you notice, Oh, I'm starting to get a little bit of a pain. And and another thing is like, you're maybe just reaching up into your cup to grab your mug for coffee or tea or your beverage for thing in the morning to even just like lowering the shoulder down without any weight.

And then you get this like sharp pinching pain. And so what ends up happening is that you have this imbalance that's already been developing there for quite some time. And so the individuals that are more prone to having this happen, you know, are usually like beginners that are just starting up climbing.

Or even more advanced climbers who have taken a bit of time off who just start back up again and now they're just like learning how to reload their body. So you have sort of this muscle memory in your head, but then your body needs to also be conditioned. Or you may be like a seasoned climber, but now you're upping your training and you're upping your game and with doing more higher intensity workouts or climbing sessions. When you're pushing the envelope a little bit more, now you really gotta look at recovery in a different way.

And part of that recovery, it isn't just about stretching, it's really looking at, well, where are you tight? Where are you imbalanced? Is the primary key to all this? Like, where are you really tight and basically always using those muscles all the time? Or weak. Where are you not like up-trained enough, where certain things can stabilize. 

So in your shoulder you have muscles that work on stabilizing the shoulder so it moves properly. So you get better movement and mechanics happening when you're doing complex movements with loading and ballistic type of movements, sometimes when you're climbing.

Mark: So how are you diagnosing this when someone comes in? 

Wil: Yeah, so obviously, after taking a history and asking questions we run them through a bunch of tests. Cause you know, the biggest concern a lot of people have is like, Oh, did I tear something? Especially if they come in and it's been like a week or two weeks because you can actually have this type of faulty mechanics and you're getting this impingement, it could be going on for like 2, 3, 4 weeks and you just haven't done anything about it because you thought that maybe you could do it on your own. It just doesn't go away. 

So yeah, we take you through a bunch of different tests and look at what's going on. Our physio team, you know we see a lot of climbers and we run you through different things to do and we look at did you tear something? Did you actually tear a ligament in there? Did you actually potentially have a tear in your rotator cuff. Which we can talk about in a different segment as well. Or is it more of a higher probability that it's just a mechanical thing going on? 

So usually if it's just a mechanical issue of what's happening under the shoulder and the rotator cuff with the impingement, then we usually get really, really excellent result in as little as like a one to two, to up to three treatment kinda thing.

Mark: And so what is the typical course of treatment for this? 

Wil: Yeah, so like I was saying, you know, this kind of stuff usually doesn't happen overnight. So we look at the impairments, like the things that are not working properly. So maybe you've developed some stiffness in your actual shoulder capsule. So then we have do some things and manually work that out. You know, maybe there's a lot of this imbalance where we gotta manually facilitate mobility to go in that area. 

So we do certain things on a manual basis after we've assessed it. And it's pretty clear, like this very clear sign if it's impingement, we do these things. It almost like instantly better. If we're talking that it's just strictly a biomechanical thing and you don't have any tearing of a rotator cuff. 

And then what's really important after you feel this instant, sort of like gains, is the reinforcement of your mobility patterns that we give to you, to mobility exercises and specific strengthening for stability and for functional strengthening. Because we wanna try and keep you climbing you know, as safely and as hard as possible.

Mark: So if you're having some shoulder pain, that suddenly come on but maybe you've up your game, rock climbing, bouldering, or you're just a beginner and suddenly you're finding, ah, it's hurting. Get in to see the folks at Insync Physio. They're experts. They're rock climbers. They're people who know what's going on. They'll be able to diagnosis and get you feeling better. You can book online at insyncphysio.com. Or you can call the Vancouver office at (604) 566-9716 or in North Burnaby, have another office, (604) 298-4878. You can book either of them online. Thanks, Wil. 

Wil: You bet.

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physio in Vancouver, one of Vancouver's best pair of physiotherapy clinics. And we're gonna talk about rotator cuff tears from rock climbing. This sounds really sore and hurting already Wil. 

Wil: Yeah. So what is a rotator cuff tear? So, first of all, your rotator cuff, there's four tendons and muscles that make up what's called your rotator cuff in your shoulder. And there's one on the front that's called your subscapularis, they basically attach from your shoulder blade all onto your humerus, which is basically the bone of your arm.

And the subscapularis is the one in the front and then you have one on the top called your supraspinatus. So that's one of the major ones as well. And then your other two, which is in the posterior part or the back part of the shoulder blade, which is basically your infraspinatus and your teres major.

So those are the four that make up your rotator cuff muscles. Now essentially when we look at which one usually tends to get injured, it's typically your supraspinatus. Or your infraspinatus and your teres major, sorry I said teres major before, I meant teres minor. Teres minor is the fourth rotator tear cuff. So the terrace minor and the infraspinatus are the two posterior ones that attach on the back of the shoulder blade. And then one that attaches on the top is the supraspinatus. Those are the ones that tend to be more prone. 

Now the reason why is because they tend to be the ones that get compromised in a few different ways. So you can either have an acute tear, which means like it's, you know, basically a traumatic thing can happen. You can fall on your shoulder and then all of a suddenly tear it and strain it. Or you can have something that's kind of more of like a chronic sort of overuse thing that happens over time.

I previously talked a little bit about shoulder impingement and how to distinguish between that and a rotator cuff. There are certain tests that we do to figure out if it's one or the other. But essentially, when you're looking at the more chronic aspect of a rotator cuff, it's sort of like that slow you know, boil. It's kind of like the frog and the hot water. You know you've done something like as soon as you go into the hot water, you know it's hot and something's happened. That's like the acute tear. 

Whereas like, you know, you kind of keep training and you go to the gym or you're going into the climbing crag outside, you know, three days a week or whatever you're doing. And you start to just get a little bit tighter. You start to notice it and you may not be doing any stretching or any mobility work, and then you just, like suddenly you just wake up one morning, it just feels a little bit more sore. And then now you start to get a bit of that impingement stuff. So it can present like an impingement type of pain for sure.

But then there's certain tests that we can determine whether or not that pain that you're getting is a result of like, maybe something going on more sinister like. In the rotator cuff, like a tear. And ultimately we can only assess in probability. You know, and based on our clinical experience that you know, you look at certain tests that can help you sort of determine whether it is or it isn't. But ultimately the better standard is getting some scans and that'll give you some more information. But rehab is actually very good for even rotator cuff tears. 

Mark: And what does the rehab actually consist of? 

Wil: If it's an acute sort of tear, then we wanna obviously address any of the acute inflammation or anything like that that's happened, like initially. And then as it kind of moves past to like, you know, as it starts to heal, we always wanna consider what that healing timeframe, right? You know, for any kind of soft tissue. But then particularly when you look at a rotator cuff injury tear you know, it's gonna be a little bit longer. So, typically you're looking at anywhere from four to six weeks as sort of a minor tear.

And even something that's more moderate, it can fully heal and it does really well with rehab and physiotherapy. So there's a lot of good studies out there that show that and our clinical experience, we've had a lot of good results with that. And so essentially you know, when we treat it, we wanna also treat the acute aspect of it looking at starting to like build the strength back up into that injured rotator cuff, that tear. But then we also need to address a lot of what's going on in the muscle imbalances, particularly in the shoulder blade. 

So if it was more of an impingement type of issue, where it's chronic, and it kind of led up to more, you know, like this last straw that broke the camel's back kind of thing. Then we want to look at, Okay, well why did this happen? And usually there is a lot that kind of stuff going on, you know, with climbing where there's imbalances. And so we need to address those at the same time because if you don't, then you're not really able to address the proper mechanics of what you wanna have occur in the shoulder joint as you start to rehab the actual tear.

Because you need to actually have a proper moving functioning shoulder blade with all the muscles working properly. Cause you have so much different motions even in and around the whole shoulder blade that help with your actual area of that rotator cuff. So it's not just like your arm and your shoulder moving.

Your shoulder also consists of your shoulder blade, which is called your scapula. And so there's that shoulder blade moves, it actually assists with the whole mobility of that whole shoulder joint. So that becomes a little bit more complex and we address what those deficits and deficiencies are.

And then if there's like tightness in certain areas in the capsule, then we need to address that and do a lot of things to help facilitate that manually. And then exercise is a really important aspect of making sure that we reinforce the mobility gains, and then also just proper specific ones for whatever's going on, like with a tear. So you make sure that we're not going too hard too fast, if you've come in acutely. Or, you know, doing the appropriate things when you've waited a long time and getting you activated. 

Mark: So if you're having some shoulder pain and you suspect maybe it's a tear, get some expert diagnosis with the experts at Insync Physio. You can reach them and book at insyncphysio.com. They have two locations, one in Vancouver. You can also call to book if you wanna talk to a human being, (604) 566-9716. You can book, both clinics online or you can call the Burnaby office (604) 298-4878. They'll get you back moving well, back climbing again. Thanks Wil. 

Wil: Thanks Mark.

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum he is the clinical director of Insync Physio in North Burnaby. And we're going to talk about shoulder instability, something that I know quite a bit about just from not, well, I don't nothing about it, but I have experienced a lot of it. How are you doing Iyad? 

Iyad: Good, good Mark. How are you doing? Hopefully your shoulder's not unstable. 

Mark: Well, it's gotten a lot better, but what's sort of the typical cause of that sort of instability that people can have and the pain that comes with it. 

Iyad: Yeah, so broadly speaking, you're going to split them up into two categories. You're going to have somebody who falls into the traumatic category. So like, think of anywhere from a baseball player, diving in with their arms stretched or a mountain biker falling or you know, any kind of impact that causes this. So you have that in some of the contact sports like rugby. So there's a lot of different mechanisms that could cause a shoulder dislocations and then give you, what, basically presents like a loose shoulder where people feel like they can't control it. And it doesn't sit well, the ball, sits in the socket kind of thing. 

And then you have another group where it's a little more interesting. Where are they have a loose shoulder kind of congenitally in a way. So the ligaments and the things that holds the shoulder together passively are just a bit more mobile than you'd want them to be.

And then in that group, you'll get basically what we'd call a multi-directional instability. So it's not going to be just the movement is not going to be excessive in one direction. It tends to be excessive in all directions. Meanwhile, on the traumatic side, for the most part, people tend to acquire this looseness, let's call it, and they would tend to be more one or two directions.

So not necessarily in all planes with the movement, for the ball moving in the socket. So those are the two kind of broadly speaking, those are the two groups that get this. Obviously the treatment for each one will be a bit different. 

So for example, the traumatic people, we will not be the ones usually doing the relocations. It tends to be done by a physician. Most people will go to the ER when they dislocate their shoulder and then have it relocated there. And we're involved after they get it relocated. The care off of that is all ours. And we can talk about their treatment plan from there.

Now, the other group, the rehab tends to be a bit different. We will try to identify, I guess, that they are just that multi-directional instability. And then we would kind of deal with accordingly by a mix of strengthening and proprioception training, which is kind of like your joint position sense.

So help their body identify and figure out where the shoulder is in space to allow their muscles to react in an adequate way. So it's a mix of sensory training and motor training, which is kind of like the typical resisted based program. 

Mark: So weight training of some or resistance training of some kind basically is a big part of that.

Iyad: Of course, we would want to make sure that they're able to handle the forces that they need to put on their shoulder day-to-day. So that's going to be a part of it, but then it's not enough just to kind of do blind strengthening. Sometimes we'd need to also do some kind of coordination training. And this is where the proprioception exercises come in.

Mark: So that's sort of the, what do they call it where you're feeling things in a certain way. What do you call that kind of training? 

Iyad: So here's an example. So the easiest one that most of us are familiar with is how do you stand on one foot with your eyes closed, for example? And the way we do that is we get tons of signals from what we call Somato sensory fibres. So those are things like our skin. Our muscles, inside the muscle there's a thing called the spindle. We also have little organs in our tendons. So all of those things will feed back into our brain. Our brain kind of puts it all together and it responds according to changes in those signals. 

So in doing the training, for example, after an ankle sprain, we would do tons of balance training to help boost that system. And this is kind of, you could think of it, I guess, in loose terms like balance training for your shoulder, in a way.

So we would do you know anything from weight bearing to different kind of more, I call it kind of like when we get you to do a math problem with your shoulder, or we give you a task that involves you needing to balance or coordinate changes in weight and your shoulder just has to kind of learn to balance and stabilize itself.

And we can progress that sometimes by adding a little more complexity like weight-bearing, or like maybe removing some of the visual stimulus, like closing the eyes and things like that to help kind of boost that system a bit more. But that's just kind of broadly speaking in each person's going to come in at a different level. Some people are able to do a lot. They run and, some people are going to be moving a lot slower.

Mark: When these kind of things happen, is it possible for instance, to have like, the way it worked with me was I got throwing injuries without warming up properly, starting too young. And my shoulder was always stiff. Like I lost range of motion in my shoulder. And then doing martial arts, doing jujitsu, got arm barred a few times. And then finally a really good one, I heard a pop in my shoulder and then suddenly the range of motion is back, but it's unstable. Is that fairly typical or possible, obviously it's possible. Is that a typical? 

Iyad: Yeah, so what sometimes you can have is a shoulder that is not fully relocated, so it's kind of sitting slightly out of place. And that depends on if it actually was relocated or not. You could have had, for example, a different kind of stiffness. The stiffness could be protective. It could also be that you just stopped moving in that way to protect yourself. Could be there's a lot of reasons why that could happen.

Now, in your case with the arm bar, you said, yeah, you felt a bit looser, but then it became a bit more unstable. I mean, that would fall into the traumatic kind of thing. And you probably ended up moving the ball the too far forward in the socket. And that's what did that.

We want mobility sometimes, but sometimes too much mobility could be a detriment. Especially if you think about mobility with no end, it could be a bit detrimental sometimes, especially if your muscles and your ligaments are moving past their natural end. So I think that could happen.

But the most typical one would be if somebody's really, really stiff after an episode, it will tend to be because either that the shoulder was not relocated, then they think it's fine. It's just a bit stiff. Or sometimes it could be due to protective stiffness. And in some cases we do ask people to go get to the hospital and get it checked because a dislocation can impact a structure called the axillary nerve.

So usually people with axillary nerve issues will present with a slightly different set of symptoms. And we always are vigilant for that in clinic, just to make sure that there's no nerve involvement because the nerves tends to wrap around kind of the neck of the humerus, which is kind of your shoulder bone.

So yeah, there's lots of things that we'd want to keep an eye out for. And again, each person is different. Some people just have a dislocation, get it relocated and then do very well in rehab. And some people never really cope well with it and might have to consider a surgical route. I guess it depends for the most part on your age, your level of competitive involvement in sports and things like that and how you respond to rehab really. People do really well, but there's still a subset of people who will need a surgical intervention. And we would work really closely with an orthopedic surgeon on the management there. 

Mark: So with all the range of motion that's involved in the shoulder joint, what's kind of the process of diagnosis to try and determine what's going on?

Iyad: Yeah. So the story's a big one, of course. Like you have people coming in they're like I can just feel extra movement, extra clicking. I don't want to really pull my arm up. There's a lot of apprehension that comes with this and the apprehension is actually quite a good sign. Where people feel like their shoulder's, just a bit different and a bit looser.

And there are some clinical tests that we do to test for that, that potentially can strain or stress the capsule, which is, think of the white stuff that you'd see on a drawing. Not the red stuff that are the muscles, but more like the ligamentous tissue. So we would stress those in different planes.

Obviously we do it in a controlled way that we're not just yanking the shoulder really fast and that can help us identify the direction of potential injury. And then from there, we would try to also figure out the baseline for strength and function and then go from there. But yeah, we would want to do some testing to figure out if there has been movement, excessive movement in there, or if it's just apprehension, because sometimes you can create a bit of a fear response. So I've had lots of clients who have tested very normally on the tests, but have a ton of apprehension and they don't let you go there. But the second you rest your hand on their shoulder, they can move really well because the apprehension kind of eases up a bit.

So there are people who we need to train for confidence almost as much as, and kind of to help that nervous system attenuate that response just as much as we need to fix the structures sometimes, you know what I mean? So it's not always a structural damage issue or a structural stretch to the ligaments.

Sometimes people just come so protective of themselves, and this is something that happens, not at a conscious level always because the nervous system is pretty complicated that way. And that's your body's response to excessive movement. You just try to put the kibosh on everything and just pump the brakes.

Mark: So clearly there's no typical course of treatment, but what would, you've mentioned some of the things that are, can you give us some examples of what the people would look at in terms of treatment? 

Iyad: Yeah. So let's say if you come in with full range of motion to start, obviously that shaves off a bit of time. If you're not, then we'll have to look at improving your range of motion again. And then the reason we have that is well after the injury and after the reduction, there's a period sometimes for some people that are going to need to go into a sling. So the sling obviously, immobilizes the shoulder a bit, the sling will also sometimes cause a bit of stiffness. So that's going to be the first bit to start moving the shoulder. And we move it in a way that's not necessarily excessive, but we need to kind of push it a bit. 

And then we start identifying strike deficits. So we would do just kind of your typical rotator cuff strength and also scapular muscle strength. The muscles in the shoulder blade are really important, but the rotator cuff tends to be non-negotiable here again. And then we try to just see the quality of movement and coordination. But then again, this goes back to the same idea of previous things that we talked about.

So for example, if I have a high level baseball player who needs to pitch at a very high speed, their recovery is going to be so different to somebody who fell down the stairs and just needs to be able to walk. And do their own activities of daily living, like, you know, washing their hair or doing your dishes and stuff like that. Brushing their teeth. It's just things like this, that really determined the length of treatment. 

Typically the more you need from your shoulder to the longer you should expect to need to work on it. But this is why it varies because, you know, you could have somebody who just had this at the age of 50 or an 18 year old who is super involved in five sports and just needs their arms for so much more than somebody else. And that's kind of where we can tinker with it and kind of look at developing a very comprehensive program for that person.

Mark: Complicated. Shoulders are complicated. You need expert help. If you're shoulder just doesn't feel right. It's clicking, it's making noise. It hurts to do things. You don't want to reach up over your head anymore. You need to get that looked at and get it looked after. And the experts on this are at Insync Physio. They have two locations. Cambie Street in Vancouver or the North Burnaby office. You can call and book (604) 298-4878. On Cambie at (604) 566-9716. Or for convenience, book online at Insyncphysio.com. Both clinics are there. You can see who's available and get in to see them. Get your shoulder looked after. And get back to living your life the way you wanna live it and your sporting life, the way you want to do it. Thanks Iyad. 

Iyad: Thanks Mark.

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum. He's the chief guy at Insync Physio in North Burnaby. He's an expert in many things physiotherapy. And today we're going to talk about fairly famous kind of thing. If you're into baseball at all, rotator cuff pain. What is the rotator cuff Iyad?

Iyad: Hey, Mark. Yeah, so the rotator cuff simply put is a collection of muscles that we have in our shoulders. There's four of them and they attempt to form a bit of a sling around their ball and socket joint. As you know, the shoulder is a ball and socket joint, and it moves through a big range of motion, more than any other joint in our body.

So when you have that much movement in a joint, you need some way of controlling and stabilizing it when you move and you initiate things. So simply, but that's what the shoulder needs is a nice sling of muscles that support it and help it do its function. So that's shortly put what a rotator cuff is and what it does.

Mark: So I know that there can be a lot of different symptoms. What are the typical symptoms that you see when somebody comes in and you start to diagnose what's going on with their shoulder pain? 

Iyad: Yeah. So rotator cuff related pain is very, very common, and you have like so many different things. So for example, you can have a traumatic injury, where somebody has a fall or some kind of direct impact on it, where it gets injured that way. And they tend to present very differently than the ones who, which are non-traumatic, which happened slowly over time. So typically, what we'll see is like in an acute case of traumatic or non-traumatic, they tend to present a bit differently.

So for example, in a non traumatic case, they'll tend to tell you that they are slowly feeling that their arms getting a bit weaker and they can't lift the coffee mug up anymore, can't pour the tea kettle, just basic things like that. And then over time they feel like they've lost more and more function and they feel like they can't use their arm the same way they did, and it's incredibly painful, tends to be anywhere around kind of this area. I can actually go down to the elbow even sometimes. And that's just where the structure tends to refer. Usually there's a complaint of weakness. So they can't be as strong as it used to be with shoulder pain. 

We don't see so much pain here. So this is kind of where a lot of people confuse shoulder pain with with the neck. You can actually have the neck referring to the shoulder too. And that's one of the things we'd want to rule out in the clinic. That it's not a neck that we're treating that it's actually just shoulder. 

And I guess the most common thing that we will see is that for non-traumatic shoulder pain is that people suddenly will tell you, Yeah, I did nothing different. And then when you dig into a bit more, It turns out that, you know, somebody had been out of the gym for two months or three months and then went back in or somebody out of nowhere, suddenly upped their weight or they were doing the usual stuff. And then if it's an elderly person, for example, who's not as active, they could be like, Oh, I did just all the weeding in my backyard, all at once. So it tends to be things like that where there's a sudden change in activity level. And then that kind of spike, you can think of it, that sudden spike in load and it can take a few weeks for it show up in some kind of injury.

Mark: So how does that differ from like throwing injuries where people are getting that, that rotator cuff problem? We've heard a lot about it in baseball pitchers and football quarterbacks, et cetera. Anyone who throws. What's the difference? 

Iyad: So the difference is, I guess in like, like you said, like the, the cuff has to do so many different things. So one of the things that we think about is think of a baseball pitcher. They have a huge amount of demand on that shoulder to launch a ball at a hundred plus kilometres, miles an hour. Like depending on what level you're working with versus let's say a break dancer has to be able to jump up and down on their arms. 

So both of these people will demand a lot of good shoulder strength and stability, but their uses tend to be a bit different. So in the throwing athlete, one of the things that we see a lot is we see deficits in the chain. So think of the throwing movement, nobody just grabs her arm and just kind of launched it this way without kind of a full windup of their body.

And that's where the assessment of a throw work tends to be a little more complex because we want to look at them from the legs up. And we want to see where along that force transfer chain, does this you know, is there something missing. The shoulders having to pick up the slack more, for example? And it could just be a matter of throwing too much. Full-stop. So even if you have great form, ultimately there's a limit to how much we could kind of handle. And that's where you're seeing a lot of little league and like organizations controlling pitch counts, which is how much people are throwing. And that's really important I think, so that you're not getting a an adolescent, you know, completely destroying their shoulder by the time they're 18, just cause they threw too much at once.

So then in the thrower, if you think about it, what that shoulder's doing is it's trying to transfer force from your body into the shoulder. So from the hips, from the trunk, from your kind of core and then from your kind of rotational movement of your kind of upper back into the shoulder.

So think of it like a sling that transfers force versus generates the force. Meanwhile other things like think of like a powerlifter where they might have to just hold their position very stable when they're kind of pushing big weights. So it tends to be a bit different. But the principles are pretty similar. Shoulders really good at transferring force versus generating all of it on its own. It can still do quite a bit of it. 

That's why we still see somebody with a bit of, let's say a bit missing from their back and hip mobility, still be able to throw a really fast ball because that's their compensation mechanism, is that they could still kind of launch it that way. But yeah, that's where I would say it's a bit different than let's say the more sedentary population where they're doing just home-based stuff or think of like chores around the house and they start to develop these issues.

Mark: So when you're diagnosing it, obviously history is really important, but what are some of the other things that you're looking for when you're digging into what's actually going on in the rotator cuff? 

Iyad: Yeah, the history is the most important thing for sure, because it kind of helps you figure out where to go. We would want to measure a few things like their range of motion, obviously. And we want to look at just how they move, the quality of the movement. We tend to look at shoulder blade, the shoulder, their are upper back. We want to look at the movement that bothers them too. So there are tests that we do use for the shoulder specifically, but sometimes the most important test is that the person comes and tells you, they're like, I can't reach up to do this. I can't pour my thing. So that tends to be quite significant. 

So we would look at that and see what about that movement we could modify. What about that movement we could kind of identify issues with. We'd want to look at strengths for sure, if we're suspecting a rotator cuff issue. And then we kind of want to get them on a program to help address those deficits.

Mark: So what is a typical course of treatment? What does that look like? 

Iyad: It depends on where along the spectrum the person is. So some people tend to be very high functioning and they tend to actually just have, you know, kind of like a, like we said, last time about the Achilles tendon, like the person who hurts a 10 K versus, oh, I, I can't get out of bed and walk, are kind of different. So that's the same thing with rotator cuff related shoulder pain. You're not going to give a one size fits all treatment because you might be either under dosing someone or overdosing someone. 

So we'd want to look at obviously if there's mobility deficits, we'd want to get that back. Get the range going. We would want to look at their shoulder blade muscles. Tends to be a lot of strength work. Because we see actually pretty good value for resistance training. And a lot of the time, it's just the fact that people are engaging in resistance training really, really helps especially for shoulder pain.

So they'll tell you that they feel better even before that a strength comes back, which is really kind of good news. So you're not going to have to suffer too much through it. So it's a bit of that. We want to look at the functions that they need to do. And it's kind of trying to mimic that in an exercise program.

So think of, for example, if it's a thrower, we would want to do a lot of whole body conditioning and like working on that kind of pattern of throwing. So from the legs up. If it's somebody, like an example, we had a break dancer who couldn't just hold a handstand. We do a lot of work in weight-bearing and we want to work on that stability in weight-bearing and that strength in weight-bearing. And we'd kind of start with two arms progress to one, and we got really creative with how to apply resistance in those positions.

So that's kind of where we would start. We'd want to figure out where you're at and just start to take you to where you want to be. And it, but tends to be a lot of strengths work for the bulk of the program, if they have good range and they have good control. 

Mark: And recovery times? 

Iyad: Great question. According to a lot of studies, we're looking at, if it's the first time people have had this, for proper recovery, we're looking at 12 weeks. So the good news is a lot of people will recover their, let's say their pain and day-to-day use of the shoulder early on. But that might not mean that they're ready to go and throw you know, a full inning, for example.

So we would want to kind of give it a proper healing time and we also want to give it a proper rehab time. So the biggest mistake we could do is just stop when it's not painful anymore. Because most of the time when we see our athletes they're always dealing with some kind of pain. So they're not really averse to a bit of pain. So that's not why they're seeing it, they're seeing it because they're seeing a different performance. And they tend to see us because they're like, I can't throw as fast as I could before. And that's more distressing to them then, oh, my shoulder hurts a bit after I throw. If you would tell an athlete that they could just do whatever they want, despite the pain, they would probably push through it. They tend to be wired differently. 

But yeah, we would want to give it about 12 weeks. If this is the first time they've had a rotator cuff problem. What we see is when somebody had recurrent problems, the recovery tends to be a bit longer for them to regain normal function, but the good news is they'll be pretty busy. Like, so if you're an active person, you could be very busy with exercise and activity, despite your rotator cuff pain. And that's where I guess we come in. To kind of just put up a nice structured program for them to kind of follow. 

Mark: How important is the split between getting in to see you and getting diagnosed and getting a prescription of here's, how to exercise and making sure that they're actually doing the exercises right and seeing you once a week. Compared to the work they do at home. 

Iyad: Both are really important. So work is really important at home. Because even if you're seeing us weekly, the thing is, you got to remember it's half an hour a week, you have 23 and a half hours in that day. And then another six times 24 hours to do a lot of good or a lot of nothing.

So I think you can't really prop one up without the other. So home exercise is non-negotiable with this population for sure. Where we can help for example, is sometimes we're seeing people a lot less frequently. But one of the things that we can't do is for example, progress them without assessment.

So we're not going to just give them an arbitrary 12 week program all at once. We kind of want to see how they're at. Because some people progress way faster. And so we don't follow the time based measure specifically. Tends to be more by milestone. So if you're able to kind of clear the first hurdle, we get you into the second one right away.

So we don't have to wait two, three weeks to do that. And by that same token, and you're going to get some people who are slower responders. And if I was to progress you, yeah, it's been two weeks, let's push you to the next one. And you're actually going to not do as well because we're not following your own trajectory.

So each person's a bit different and that's where we need to be very aware of what every person's tolerance is. And it tends to also kind of carry a host of other things. We're not looking at just the shoulder with the shoulder. It tends to be a whole upper body assessment, versus assessing the whole upper limb.

And if it's a thrower, we're assessing literally anywhere from foot mobility, all the way up to shoulder, back and neck. So, so yeah, I would say most people will tend to have Googled a lot of exercises when they come in. And some of them have a bit of success, but then they say I hit a plateau and it tends to be because it's hard for you to self-assess your whole body.

And you don't have eyes in the back of your head to watch you from the third person point of view. So that's where we can add a lot of value and help out with quality of movement and just like proper programming. 

Mark: So if you want to get better, fast and permanently, the guys to see are Insync Physio in North Burnaby, you can book online at insyncphysio.com. Or you can book at the Vancouver office they're on Cambie, (604) 566-9716. The North Burnaby office is at (604) 298-4878 to book. You have to call and book ahead. They're always busy and they get a lot of fantastic reviews. They're multi time winners of best in Burnaby. Best in Vancouver at physiotherapy. Get yourself in there. Get some expert advice and get better quicker, permanently. Insync Physio. Thanks Iyad. 

Iyad: Thanks Mark.

Start in 4 point position on your hands and the forefoot or the balls of your feet with your knees greater than 90 degrees with 4 feet Resistance bands tied diagonally from opposite thumb webspace to ankles.

As you place one hand forward bring your opposite foot forward as well. Do this while you also keep the shoulder blade muscles and your neck position in neutral. Repeat this for 30 seconds 3 sets 2x/day.

This is a great progressive core stability muscle strengthening exercise for rehabbing your shoulder and rotator cuff injuries. 

Lie on your stomach on top of a built up mat 5-8 inches high. Keep your feet wide apart with toes to the ground, with your face and chin clearing the mat and your arms straight and wide grasping a large exercise ball on the ground.

Dribble the large exercise ball with both hands while you keep your front lower core engaged and lower back straight. Prevent your low back from going into extension. Activating the lower quadrant core muscles will enhance and optimize your strength and movement patterns to your full potential.

Repeat this for 10 seconds doing 10 reps 2sets daily. This can be progressed by increasing your dribbling up to 20 seconds for 5 reps 2 sets and ultimately to 30 seconds for 3 reps 2 sets.

Another great strengthening exercise to rehab from your rotator cuff shoulder injuries!