Rotator Cuff Injury Without Accident or Trauma

It certainly seems a bit strange, how so many people get rotator cuff injuries with no real trauma or accident. Its not like they are challenging their shoulders by throwing fastballs or javelins. Most people do remember "tweaking" their shoulder during something like painting, or perhaps some other overhead work. Often times the pain can appear for no apparent reason at all. Doing an internet search on rotator cuff injury will often get you nowhere. "Tear" or "degeneration" is what you are told. So without any real trauma one is left to believe the degeneration theory, aka "wear and tear". But you CAN'T UNDO degeneration! So what CAN you do? Prepare for surgery? Not so fast.

Once again I will try to limit the use of medical jargon, as I feel it often used to confuse the patient instead of communicate the real problem. The rotator "cuff" is the band of four muscles around the top of the arm bone, which is the humerus. All 4 rotator cuff muscles are there to keep the arm from sliding out of the "socket". Three of the four muscles are also for moving the arm by turning it outwards, away from your belly button (external rotation). The remaining one muscle helps turn the humerus inwards, towards the belly button (internal rotation). This one muscle works in conjunction with some quite large muscles by comparison, the pectoralis major and the latissmus dorsi.

When we are in the upright position, we mostly use our deltoid and trapezius muscles to do the heavy lifting. These muscles are also a bit bigger than the rotator cuff set.

The problem occurs if we are not fully upright. Then the movement starts to resemble external rotation (arm twisting away from belly button). Even a slight bend forward can make your body shift to using the smaller, weaker rotator cuff muscles to a greater degree instead of the larger and bigger deltoid and trapezius. Gravity does not change just because out body position does.

The slight bend forward in the above picture is NOT UNLIKE a slouch. You may be thinking that perhaps this exercise is not a good idea. I would generally agree. If you have worked your rotator cuff muscles to the point of chronic pain, and occasional strain, I don't see the sense in working those muscles further. Yet this and other external rotation exercises is what most doctors and therapists would give you (including many chiropractors). It can sometimes help short term, but it is a poor choice for a long term solution.

What DOES make sense is correcting posture so this strain on the rotator cuff muscles LESSENS. But posture is more than "standing up straight". Because we cannot see ourselves, it very difficult for us to monitor our own body positions. Most people have a poor body awareness to begin with. A good postural analysis is therefor essential. This includes the whole body, not just the area of pain. What I mean is that if your knees are so stiff or damaged to the point that they don't fully straighten, this could be creating a forward bent posture. If you are doing this, you are likely straining your rotator cuff muscles. This is only one example, but there are many possible postural alterations that can contribute to rotator cuff stress. Any surgical solution is temporary at best unless you correct what has created the stress to begin with. And for the record, surgical repair is not as successful as you might think. A 2010 study in the Annals of Internal Medicine concuded:
"Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive."

Of course most people with postural faults don't realize they are doing it. This is why an integrated approach is often the best solution. If you have not had a head to toe evaluation in regards to your chronic rotator cuff pain, give us a call. We can also work on that knee problem.

"Do I Have Sciatica?"

This question is heard at least once per day here at Schafer Chiropractic. Which tells me it is a good topic for a blog. I will try to limit the use of fancy medical terminology. I often find that big words are used by people who don't fully understand the subject anyway. Sciatica is merely an irritation of the sciatic nerve that creates pain down the path of the sciatic nerve. This nerve runs down the back side of your leg. Not the front side of the leg. Not the outside of the leg. The BACK of the leg. Sometimes the pain goes to the back of the knee. Sometimes it goes to the back of the calf and the foot. See picture below.

The L4, L5 and sacral nerve roots are often compromised before they combine to make the very large sciatic nerve. Then the nerve exits the gluteal region from underneath the piriformis muscle. You may have heard of something called piriformis syndrome. This would be a swelling of the piriformis muscle to the point where it compresses the sciatic nerve. This is an unlikely cause. I say that because I have encountered very few cases in my 20 years of experience. In a very small percentage of people, the sciatic nerve actually runs THROUGH the piriformis muscle. In this small percentage of patients, it is much more likely to irritate the nerve.

Sciatica may be associated with pain in the low back. Usually this pain is unilateral (one-sided). Pain going down the back of both legs is usually due to other problems. Nerve pain can feel like a general ache, sharp jolt, burning, or tingling. How far the pain goes down the leg also can vary. More severe cases involve pain going into the foot. It is my humble opinion that most cases of real sciatica are due to a swelling or bulging of an intervertebral disc. This irritation occurs well before the piriformis muscle. Damage to the discs may be from direct trauma (fall onto your butt), or from poor posture and improper lifting techniques. Excessive sitting usually plays a significant role as well. This swelling or bulging can sometimes put pressure on, compress, tug, or pinch one of the nerves where it exits the spine. In this type of sciatica, the pain will usually be worse if you sit for too long, and when you first awake in the morning. If this sounds like you, we can help. DO NOT ASSUME that you need to be prepped for surgery.

Another possible cause for sciatica is spinal stenosis. "Stenosis" means closing. So spinal stenosis is a closing of the spinal canal. The canal is where the entire spinal cord runs through. This is often due to advanced arthritis, so if you are young, this is a very unlikely cause.

As stated above, sciatica is pain down the back of the leg. I have encountered many patients with pain down the SIDE of their leg, which they call "sciatica". Obviously this cannot be, as per the very definition of the word. Yet some of these people have been diagnosed by other medical doctors, chiropractors, and/or physical therapists. It is sloppy diagnosing. This pain often starts in the low back like sciatica, but quickly passes to the outside of the hips and stays lateral down the leg. This scenario is VERY COMMON.

This is called iliotibial band syndrome, or IT band for short. The low back muscles combine with the gluteal muscles and feeds into the iliotibial band (IT band). This band runs down the outside of the leg and connects to the outside of the knee. I often find that the patient has had knee problems of the painful side for many years prior to the "pseudo sciatica". The outside muscle of the lower leg can also be affected. These are called the peroneal muscles. It is well understood that muscles work together in systems. This is one of those systems. No muscle works in isolation. It is therefore unwise to point to one muscle and say "There's your problem!". In IT band syndrome, the IT band is not the real problem. The problem is usually weak gluteal muscles, combined with an unlevel pelvis. The pelvis may be unlevel due to poor posture, previous foot, ankle or knee injuries, or awkward sleeping positions. Successful treatment of the condition must include careful examination of all of these possibilities. If this sounds like you, we can help.

In all of the above scenarios, the condition is complex. The causes are many. A thorough history and exam are needed to properly diagnose the problem. MRI's can be helpful, but should not be the first course of action. Most insurance companies won't even cover them unless you have tried some sort of therapy first. As much as I would like to, I can't say that one adjustment, one stretch, or one massage will resolve the pain. Pain is a signal from your body. It is a cry for help. Most people just don't speak the language. We do.

Just try it: cross country skiing

It is my mission in life is to encourage everybody to exercise. This is because I know people will hurt less when they move more. Yet I hear all kinds of excuses. They say it is too costly, too high impact, too inconvenient, etc. Regardless, I believe there is an exercise out there for everybody. That's where this new blog series comes in. I will be attempting as many different exercises as possible. Taking you from trendy to old-school, from beginners to advanced, and from the common to the unconventional. I will try them all, and report back to you. I hope you enjoy.

Cross Country Skiing

If you are looking for something to keep you outside in the winter yet less dangerous than downhill skiing, try cross country skiing. The health benefits are truly impressive. And it's low-impact!

“New Records in Aerobic Power Among Octogenarian Lifelong Endurance Athletes,” a Ball State research project conducted in collaboration with several Swedish researchers, found that the long-time athletes in the study are enjoying vibrant and healthy lives. The study was published in the Journal of Applied Physiology. “In this case, 80 is the new 40,” said the study’s lead author Scott Trappe, director of Ball State’s Human Performance Laboratory. “These athletes are not who we think of when we consider 80-year-olds because they are in fantastic shape. They are simply incredible, happy people who enjoy life and are living it to the fullest. They are still actively engaged in competitive events.”

“To our knowledge, the VO2 max of the lifelong endurance athletes was the highest recorded in humans in this age group, and comparable to nonendurance-trained men 40 years younger,” Trappe said. “We also analyzed the aerobic capacity of their muscles by examining biopsies taken from thigh muscles, and found it was about double that of typical men. In fact, the oldest gentleman was 91 years old, but his aerobic capacity resembles that of a man 50 years younger. It was absolutely astounding.”

The benefits are no doubt related to the usage of the arms for propulsion via the ski poles. This differs from running and bicycling, which are primarily leg driven. Swimming has great benefits to, but cross country skiing is also a "weight bearing exercise" so it helps retain bone mass as we age. Swimming does not. Classic cross country skiing (see pic to the left) would also be a smart addition to any tri-athletes workout, as it reinforces the cross-crawl mechanism. This mechanism connects the upper body muscles on one side of the body, with the lower body muscles of the opposite side. Stimulating these connections can help prevent injuries, and improve performance in running and swimming, which also rely heavily on this pattern of muscle synchronization. The "skating" technique (not pictured) uses both arms simultaneously, and thus gives an even more impressive cardiovascular challenge. This requires a much wider and flatter snow surface, which may be harder to find.

On the right, you can see a photo of my first time out. Some coordination is required, but falling to the snow on a flat trail is certainly less painful than wiping out on the slopes. On my first time out, I fell twice, with only my pride being injured. The cost of equipment is minimal, and there are plenty of free trails around west Michigan. Some urban parks also show evidence of other cross country skiing enthusiasts. I skied Manhattan Park here is East Grand Rapids, because it is close to my house, and because I saw some trails when I took my daughter sledding there. Equipment includes skis, boots, and poles. A new set starts at about $250. If you want to try it first , rental may be the way to go. Second hand stores like Play It Again Sports will often have older models for purchase under $100. (I bought a set from a guy on Facebook Marketplace for $65.) Good or bad, this sport is weather dependent. t's a strictly limited-time option. Considering how much snow we get here in the Grand Rapids area, there is usually ample opportunity, so ski while you can.