With one foot forward and one foot back, engage your lower quadrant core and bend through your hips while you cross both arms over the midline of your body over and under for 30 seconds. Do a total of 3 sets as a warm up.

This will get the the blood flow and circulation running into the shoulder muscles, tendons, ligaments and joints to prepare your shoulders before you take on a load like rock climbing. You can also utilize this exercise as a warm up before doing other sports or physical manual labour involving the shoulders.

If you have any pain or difficult doing this exercise, consult your local physiotherapist before continuing.

Tie a heavy duty resistance band to a 5 pound kettle bell. Secure it onto the middle of the handle. Stand with your feet in a square stance and engage your core stability muscles of your lower core to prevent your spine from moving and compensating.

Lift the kettle bell straight up by punching the fist to the ceiling. Make sure to reach a little higher with your fist without changing the alignment of your posture. With the shoulder blade fully engaged, bring the hand out to the outside a little more and keep your fist reaching towards the ceiling.

Then move the fist forward and backwards into an internal and external rotation motion. Repeat this for 30 seconds doing 3 to 5 sets on each side.

This kind of perturbation training is aimed towards a more progressive shoulder rehab strengthening for excelling in return to sports and play that require dynamic overhead shoulder rotator cuff strength and stability.

If you have any pain or difficult doing this exercise, consult your local physiotherapist before continuing. 

Standing with your arms out wide to the left and right, create circles in the forward direction for 30 seconds. Then do circles in the back direction for thirty seconds. Perform this for 60 seconds in total doing 3 sets as a warm up.

This will get the the blood flow and circulation running into the shoulder muscles, tendons, ligaments and joints to prepare your shoulders before you take on a load like rock climbing. You also utilize this exercise as a warm up before doing other sports or physical manual labour involving the shoulders.

If you have any pain or difficulty doing this exercise, consult your local physiotherapist before continuing. 

Place a ball underneath you between your hands. This will be the centre position for the ball as you will be moving it out to one of four positions each time and back to centre again.

Begin in a plank position and engage your lower core by trying to make yourself skinnier below your belly button at your waist line. Supporting yourself in a plank with your right side, move the ball from centre to up above, then back to centre, then from centre out to the left and then back to centre, and then from centre to below and then back to centre again.

Finally from centre out to the far right and back to centre again. Switch and plank on the left side now and move the ball with your right hand. Do 10 reps on each side daily.

You can utilize this exercise for rock climbing and many other different throwing sports such as baseball, volley ball or ultimate frisbee that require core stability and shoulder strength. 

Mark: Hi, it's Mark from TLR. I'm here with Wil Seto of Insync Physio in Vancouver. Multi time award-winning physiotherapy clinic. Wil's the owner, the big cheese and he's booked out all the time. It's really hard to get into because he's so good at what he does. Today we're going to talk about AC joint shoulder injuries. How are you doing Wil? 

Wil: Good. I'm good. Thanks Mark. Hey Mark, I was just wondering, you know, I know that you always love pumping up my tires, that's great., I thank you for that. But we also have a great team of other physios that actually, you know that, since we're talking about shoulder injuries that actually have a special interest in shoulders too.So I just thought I'd mention that. 

Mark: Of course, I having been to your clinic many times. I know that that's the case. You're the guy here that's the face of the business right now today though. So that's why I did that. All the team, you hold everyone to a really high standard. I know that's how you operate. That's just your nature. And so that's how the team is at Insync Physio. How does someone actually injure the AC joint? And what is it? 

Wil: Yeah, so let's start off with what it is first. So when we think of like the shoulder joint and shoulder injuries, we quite commonly think of like a part of the shoulder. That's the ball and socket. It gives us this 360 degrees range of motion. Well, we also have another part that's part of the shoulder complex, which is where the collarbone connects to your shoulder blade, which is basically called the AC joint or short for acromioclavicular joint. And it's not injured as common or the injuries that happen in the AC joint are not as common as the ball and socket joint area, but we are still seeing this in the clinic. 

Over last couple of weeks, we've had a few people that have come in with it. And so I thought we talked about it. And usually it's from a blunt force or trauma. So in the athletic population, you know, impact sports, when you have like a shoulder to shoulder contact. Really good example is we've had some of our therapists who've worked with hockey teams and they see one of their players get checked into the boards, kind of face first and the shoulder impacts the boards and that's a very common way of injuring the AC joint.

 And another one, it doesn't have to be from athletics or from sports, but it could be like a car accident. Like you got the seatbelt on and it's an impact force with the seatbelt over the collarbone area. And then it's just a sudden jarring motion. 

Another one is also where you could be just maybe moving. I know a client of ours, one of the physios, they were helping someone move and then they're kind of holding something heavy in this position. And then they ended up just having a shoulder to shoulder sort of contact by accident. And then it caused a mild sprain in the AC joint. 

Mark: And I guess falling, that would be another cause, like with your arm out. Could that also do injury to that joint? 

Wil: Yeah, it can actually cause some impact loading forces onto that joint as well, causing some strain. And actually not what we're talking about. Sort of, other types that's non traumatic. It can actually be non traumatic. It can be something that presented as more wear and tear. And so there's special tests that we do in the clinic that kind of determine if your AC joint is affected. We don't just have one test. We have a few different ones that we do, and we cluster them and it actually provides good reliability and accuracy.

Mark: So once you've diagnosed it, which I'm sure is pretty complicated because it could feel like it's referring from the ball and socket joint into the AC, or is it specific to the AC, like someone's going to feel it there in the clavicle, in their collarbone, kind of where it inserts into the scapula. What's the symptoms that someone might notice?

Wil: Yeah, you definitely get like swelling. So there's the more obvious ones is you see it and be red hot and swollen. There's definitely pain and loss of this function. So even with an acute injury, that's something that you want to actually immobilize right away because it's going to be painful and you want to just let things settle down.

So if it's like an acute sprain into that AC joint and you see swelling in there and the pain and dysfunction is obvious. You want to just put it in a sling, for at least a few days you know, to let it settle down. But you do want to get it moving a little bit after that obviously. But you want to give it a chance to really settle down and heal. But the other symptoms too, that if you look at the AC joint, you have a lot of ligaments in there. And so we actually can test for it. But sometimes it can get to a degree where it's so severe where you can see not only a step deformity, so it's very obvious, but then you also get a lot of pain with that too.

Quite often too, if it is fully torn. And there's a step deformity, there can be no pain. Which is almost contradicting. And the reason why, and we've seen this a lot before, is because when there is a step deformity, but there's no pain is because the ligaments have been totally ruptured and the nerve supply is basically not there anymore. And so you can't feel it. But like there's a loss of range of motion. I mean, they feel the initial pain and swelling, but once that goes down and the step deformity is still there. They still have the dysfunction, but it just doesn't hurt. But they had the loss in strength and the loss and stability in that area.

Mark: So how would it present? Is it going to present similar to a broken collarbone? If that was up in that nearer to that area? 

Wil: No, that's a really good question, Mark, thank you. So when you're looking at the sprain of the AC joint, it's kind of more on the outside, closer to that ball and socket, and you can see the swelling in that joint area. And so in that area that you'll have the swelling. And whereas like with a fracture, you can feel along the line of the bone. And if it's a hairline fracture, it's gonna be a little bit tougher because you'll feel maybe sensitivity. It could be muscular is kind of hard to tell.

But if it's like something that's more obvious, then you're going to see a little more of a step deformity in there too. And that's obviously not good. But the presentation is different. And if there's any question, you know, especially if it's trauma related, then we probably want to go get that checked out more medically too. And that's important as a next step. 

Mark: So you've diagnosed it. If there need to be x-rays done. Medical consultation. Their course of treatment is underway, but now they come back. Okay. Now I want to get my range of motion and strengthening and proper function again. How does that course of treatment usually run?

Wil: Yeah. So stability is the key thing, because stability is the number one thing that we want to try and achieve in that joint, above strength and making sure that we progress that stability throughout the whole range and full mobility. And so we don't want to start doing things to strengthen it right away until we achieve that stability strength.

So what I'm talking about is like, you don't want to be doing like pushups and presses and stuff like that. Sort of an old school thinking of like, you know, if we can just strengthen it, which in other areas like your ankle, that's really good. You want to strengthen, you sprained the ligaments. In the AC joint, you got to really work on stabilizing strength. Specific things to actually really stabilize that joint, to make sure that then we can progress through the stages of healing properly.

And so depending on the severity of the injury, there's going to be different stages that you move through in terms of progressing back to like sport, especially, or to work if that's a big thing where you need to use your shoulder for. 

Mark: So what's the difference between them? What kind of exercises is that that are the stability, what you would classify as the stability exercises or steps that someone would need to take that you would guide them through?

Wil: Yeah so, a lot of it is like functional core starting off with basic core and progressing the functional core stuff. The rotator cuff strengthening is really essential. It will help and then working on a lot of stuff around that area to target certain muscles in addition to the rotator cuff, like into the shoulder blade. So there's all these stabilizing muscles.

So there's tests that we can do to look at which muscles are definitely weaker. And usually someone that has an injury, they'll show these patterns right away. And if you have a preexisting injury, like I'm thinking about a client who came in to see one of our physios, that had a pre-existing rotator cuff injury, didn't actually have trauma in the AC joint, but had some pain there as well, you know, they're presenting with other stuff.

So this is where we need to tailor and personalize the things that we need to do with you on a hands-on, you know, one-on-one sort of, okay, we gotta get this moving this way and realign the shoulder blade in this way, and then retrain the specific movement pattern for you. 

Mark: And movement pattern is really important for the shoulder joint. Is that a useful assumption?

Wil: Absolutely 100% because especially when I talked about earlier, that in the shoulder socket where it's ball and socket, it's 360 degrees of movement. And then you have your shoulder blade, which is basically a floating, it's like it's got all these other muscle attachments. And it's sort of floating around in there and it's only real attachment to like, your arm bone, and then your collar bone. So then you have all these other muscles that control and dictate how your shoulder moves. And so having that movement pattern and optimizing the best way to get it working again, especially after you know, like a sport injury, you want to get back to playing sports or work, you know, to be able to do, doing the repetitive motion, or whatever it is that you need your arm to be able to be in that position, is super important.

Mark: In other words, it takes an expert really diagnose it and help you through the process because you might think it's okay because you're free of pain and then you actually are using other muscles and other functioning is happening to take over something that didn't heal properly or hasn't been activated properly. Is that right? 

Wil: Yep. Pretty much. And then you made an interesting point about feeling like it's okay. And a lot of people, they get up to like maybe 85% and then, or they get back to being able to play their sport and they feel like they're 85% and we can get by. You know, and this is also where I talked about the getting intervention in terms of maybe on a medical aspect because like there's a lot of ligaments in there and the classification is quite complex, but you know, it may warrant a referral to see a specialist about what's another route to take. If the rehab approach is just not successful.

Mark: That whole knife thing. Perhaps. 

Wil: Possibly. So that's why we want to work with a team of sports medicine doctors as well and other doctors to kind of get that process going for that. Possibly. 

Mark: If you want a team that's going to really help you diagnose exactly what's going on, whether you have pre-existing injuries, whether it was a blunt force trauma, whether it's arthritic or some kind of thing like that. Insync Physio are the guys to get in touch with. You can reach them at their website insyncphysio.com. You can book for either office in Vancouver or in North Burnaby. And of course, if you want to book and see Wil, you can reach him at 604-566-9716. Or any of the team, they're all top notch. He wouldn't have them there if they weren't. Insyncphysio.com. Thanks Wil. 

Thanks, Mark.

To begin, each plank will be done with wide arms in 3 different hand positions putting the rotator cuff muscles at 3 different angles and then progressing each of them by flagging one foot out to the side. Engage your lower core by trying to make yourself skinnier below your belly button at your waist line.
 
The first plank position is with your fingers facing straight ahead. Hold it for 10 seconds. The second is with the fingers facing 45 degrees. Hold this for 10 seconds. The third position is at 90 degrees facing outside. Once again, hold it for 10 seconds. Hold each wide arm plank positions for 10 seconds. Then when doing all three wide arm planking positions with your foot flagged hold these for 10 seconds as well. Do one set of 10 reps for each of these on both sides after a training session or workout.
 
Being a rock climber, I came up with these exercises to progress the functional core, rotator cuff and entire shoulder strength to become stronger for rock climbing after recovering from a shoulder injury. You can also utilize this exercise for many different sports requiring similar static core and shoulder strength.

If you have any abnormal pain or are unsure about what you are doing, consult your local Physiotherapist before continuing.

Start on the hands and knees with your spine in neutral alignment. Engage the inner core stability muscles of your lower spine by pulling the muscles below your belly button inward without changing your neutral spine posture.

Then, bring your hands forward on the mat and straighten the knees one at a time so that you’re on your toes. kick back and extend with one heel while keeping the hip square and lined up with the other hip and reach the opposite hand and arm forward. Hold this for 10 seconds doing 10reps on each side for 2-3 sets.

This is a great core stability strength exercise to help progressively strengthen your shoulder and upper quadrant core strength after you have injured it. If you have pain or are unsure about what you are doing consult a local physiotherapist before continuing. 

Do you have a chronically sore or stiff shoulder? Do you use your shoulder repetitively or exert it intensely in sports like throwing, hitting, lifting or rock climbing? If yes, then this recovery exercise might just be one of the right exercises for you.

Start with a release ball, either a very soft one to start or a stiffer one like a lacrosse type of density) and place it under the back part of your shoulder blade lying down on top of it.

Take a big breath in then slowly exhale as you relax your body and the back of your shoulder into the ball. Then using the ball as a pressure point release gently and slowly roll over the ball while trying to keep the body relaxed. Do this for a few minutes and find 2 to 3 other areas in the muscle to repeat this on.

If you have any abnormal pain or discomfort or are unsure about what you are doing consult a local physiotherapist before continuing.

Mark:  Hi, it's Mark from Top Local. I'm here with my good friend Wil Seto of Insync Physio in Vancouver, many time winners of Best Physiotherapists and Wil himself voted Best Physiotherapist in Vancouver by his customers. How are you doing Wil? 

Wil: Hey I'm doing great. Thanks Mark and thanks for that shout out.

Mark: So we're going to talk about dislocated shoulders today. What's a dislocated shoulder? 

Wil: Yeah so I've been thinking a lot about this, currently I have several clients that I'm treating right now with dislocated shoulders and really what it is is basically, you have like a sprain that happens in the shoulder joint. So your shoulder, you have some kind of trauma. And so you have like this ligament and capsule tear usually. And what happens is that the actual arm bone or the head of the humerus basically goes out of alignment and physically goes out of its socket. And so it's actually extremely painful.

And when you have a dislocated shoulder you usually want to go to the doctor, go to the ER, get a doctor to relocate it. So if you ever actually experienced a dislocated shoulder from even just doing recreational sports, which is totally possible, like, you know, maybe just biking and then you don't clip out in time and then you go to put your arm out and you fall and you can dislocate your shoulder even just from something like that. And so your shoulder just goes out of alignment and it's a huge deformity that you can see. And it's, like I said, it's super painful. 

So what it is not. It's not like just a sprain, like it's not just the ligaments being torn and then, you know, the biggest thing is that it comes out of the socket. So when you relocate it, a few things can happen. You're kind of putting it back in the alignment, but like when it becomes dislocated, like I was saying the ligaments, the capsule, and also the cartilage and also the rotator cuff. So there's a lot of structures that could potentially be damaged.

And so that's why you do not want to relocate it yourself. And usually you get put under some kind of local anesthetic to have the doctor to help you relocate that. So my actual professional experience working with teams and the athletes, I've been there where athletes, I've had like a handful of athletes that have actually dislocated their shoulders and  brought them to the ER and on a few occasions, a few of them, the self relocate.

And so that's okay. But like, you don't want to try and do it yourself because even in that process of trying to put it back in yourself can actually cause damage to those structures that I mentioned, like from the ligaments, but especially the cartilage and the rotator cuff itself, so like the tendons and the muscles. 

Mark: So you're not doing the movie thing where you're pounding your shoulder to the wall, trying to relocate it yourself. It's way too painful for that. Am I right? 

Wil: Yeah, yeah, yeah right yeah. When you say that, I think of like what's his name? Mel Gibson from Lethal Weapon, right? Yeah. It's definitely not a party trick that you want to like show everybody when you're, I mean I guess as the zoom party thing, now, Hey look what I can do. But really it's definitely not something that you want to do because the more you dislocate it, and relocating it back you're increasing the chance of injuring the cartilage.

And, and like I said, the rotator and the muscle and tendons and stuff like that in there. So then when you do it enough times you know, like, let's say you do that like even three times in a period of three months, and it's like super loose and you go through a lot of rehab and it's still like, you know, you're never going to get a hundred percent and you're kind of wanting to probably look at the surgical option to really tighten things up in there. So basically, that's what you want to avoid. 

Mark: So what's the course of treatment for a dislocated shoulder once it's, I guess after you've iced it and swellings down a little bit where you can actually start working on it. What's the course of treatment? 

Wil: Yeah I actually have a client right now, just dislocated his shoulder and he's done it multiple times. And now the interesting thing about him is that he's done it on both sides. So I was just like, wow. And so another thing I should also mention is that he does this thing called subluxing his shoulder. So I should just go over briefly what that means. So a subluxation is basically when a shoulder dislocates, but then relocate on its own pretty quickly.

So that's called a subluxation, so it kind of goes out and it goes back in. So those are obviously a lot better because it means that usually it doesn't come out as badly. And then when it kind of goes back in on its own, then it's less damage, like usually it's in and out. So, you can even have a little subluxations as well where it goes out a little bit and goes back in kind of thing. 

So thinking about this specific client who has multiple dislocations and subluxations at the same time. One of the things that also be aware of is that he has a tendency, he has loose joints to begin with. So right away the protocol for him definitely get his range of motion doing things to make sure that he stays mobile. That's super important. And then the second thing, like you said in addition to making sure the swelling go down, all that stuff, the range of motion and mobility, the second thing is actually doing some specific strengthening in that area to really just stabilize.

Strengthening what we call the stabilizers, not just the rotator cuff themselves, but even just the muscles around like the whole shoulder, like their shoulder girdle. So you know muscles like the serratus anterior, mid to lower traps especially and rhomboids. And then even like things that you know, where they're needing to just do a lot of specific things where they're trying to get specific ranges functionally with resistance, but even like into the rotator cuff proper, like I was saying, and making sure that that stabilizes the actual shoulder joint proper, which is where the ball sits right in the socket. So doing a lot of isometric stuff initially.

Mark: And what's the typical treatment course? 

Wil: It varies, depending on how much damage is done. One of the things that this specific individual asks is Oh, so like how badly is it sprained or is it just like, you know, dislocated and then my capsule torn or whatever, and he didn't even think about the rotator cuff. That was the interesting thing. So on assessment, he actually had damaged what I thought to the rotator cuff. And clear weakness and stuff going on in there, and certain tests test positive for that. So we have to address that as well. And so something like that, that's gonna take a little longer. 

When you're looking at something that's a little more mild and minor and, you know, and this is the thing that I don't like to say, like with a dislocated shoulder, there's never a minor dislocation. Like it goes out and it's out. And like I said, it's painful.

And so you're looking at anywhere, initially just to get it going, we want to maintain his range, but in order to even just to be like functional and doing things, and if he's like got a physical job, you know, you're looking at like at least four weeks, just to be able to do things functionally. 

To get back into doing a sport, that's very sports specific training on what he need to do. If they're a volleyball player, they're gonna have to train specifically for that ranges, right. That can be anywhere from two, three, four up to six months depending on the damage that's done in there. And it could be even longer if he needs a surgical intervention, you know, for other stuff that's happening.

My guess, you know, with a specific individual, because there was so much laxity there, he's probably going to need a specific procedure that tightens up that capsule a little bit more. But then there's going to be a little bit more data that can be needed to see what the integrity of the rotator cuff looks like. Because if that rotator cuff, which is basically the tendons that give the dynamic stability, which is basically the muscle tendons you know, because the shoulder is like a 360 degree sort of range of motion, joint. You know, if that's the damage, then that needs to be repaired, especially if he wants to get back to the sport that he wants to so avidly wants to do. And he's been doing this for decades now. 

Mark: So dislocated shoulder. If you've been the unfortunate recipient of this wonderful experience, the guys to call are Insnc Physio. The Vancouver Cambie Street office is at (604) 566-9716. The North Burnaby office near Willingdon on Hastings Street, (604) 298-4878. Or check out the website. You can book online there, very simple, very straightforward insyncphysio.com. Thanks Wil. 

Wil: You bet Mark.

Loop the band around your hands and have your elbows bent at 90 degrees by your side. Keeping your palms facing downwards towards the floor.

Spread your palms so that the hands are in line with your shoulders. Driving through the elbows, and keeping your hands shoulder width apart, slowly elevate your hands to the level of your face and up over your head.

Do not lose the parallel alignment of your hands and arms and do not bend your elbows (flexing your biceps). You should be feeling this work through the back of your shoulders, and through the rotator cuff muscles.

This is a great exercise to build more strength after a rotator cuff injury.