Rotator Cuff Pain with Iyad Salloum

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 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.