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.

Top 5 Signs that You Should See a Chiropractor

Our bodies may try to communicate with us by sending us signals, but we don't always speak the same language. Here are my top 5 signs that our bodies are trying to say "go see your chiropractor".

1. Your body used to hurt and be sore for very specific reasons. Now it seems to hurt for absolutely no reason. People rarely see me for pain and soreness from a home project or overdoing it at the gym. This is because they can connect cause and effect. When the pain is more random, or without any significant change in activity level, it is a cry for help.

2. You are pretty certain that your hip pain and foot pain are related, but your MD says that it's just from arthritis. The same could happen with neck and arm pain. The body is likely trying to tell you that there is an underlying biomechanical dysfunction related to both of them. In truth, many people have arthritis without any pain, so why are you different? Looking beyond the point of pain is necessary to find the point of dysfunction.

3. Sitting for long periods gives you low back pain. "Sitting is the new smoking" is a popular phrase nowadays. However, it is unlikely that our cultural norms will be changing anytime soon. Many of us will still be expected to sit at a computer for our jobs, sit and drive, sit and eat, etc. So, let's train for it. Why not train yourself, much like athletes do, to better prepare you for the physical demands of daily life? Core exercises are a must for anyone who sits for their occupation. They will get you into a better posture, and prevent further pain.

4. Your neck pain has now become headaches or migraines. Chronic misalignments of the top 2 vertebrae are often the cause of headaches, including migraines. In such cases, posture is usually to blame, and core exercises are again necessary.

5. You've tried everything else. This is where a good history and assessment of biomechanics (how you move) is essential. To treat pain without properly assessing why it is hurting ultimately fails. Too many doctors want to only examine the point of pain. But as I have said previously, the point of dysfunction may be different from the point of pain. Sitting, sleeping, and workstation postures need to be investigated for habits that contribute to your pain.

3 Things You Probably Did Not Know About Plantar Fasciitis

1.Having a heel spur does not mean you have plantar fasciitis. Link here.
In this study, 50% of patients with plantar fasciitis have heel spurs. It also shows that 20% of people with NO heel pain DO have heel spurs. What all this really means is that a heel spur may develop due to the dysfunction of the entire foot over a period of time. This is why focusing on the dysfunction is much more important than focusing on expensive imaging.
2.High-load strength training may aid in a quicker reduction in pain and improvements in function, compared to stretching. Link here.. This study shows a positive effect of both stretching and strengthening, and a progressive approach to be best overall.

3. Chiropractic adjustments can improve foot alignment and therefore help decrease symptoms of plantar fasciitis. Excessive foot and ankle pronation (loss of medial arch) is associated with plantar fasciitis. Correction of this abnormal foot posture will improve foot function, and decrease the stress forces that lead to irritation of the plantar fascia.

You may be wondering why you should see a Chiropractor for plantar fasciitis. This is because a good chiropractor can see the connection between plantar fasciitis and low back pain. We can also see the connection betwen your knee pain last month, and your current hip pain. Going to a specialist may seem like a good idea, but they tend to put on blinders to what is going on in the rest of your body. There is no muscle, joint, or nerve that works in isolation. That is why it makes no sense to isolate your focus to just one area. It is often the case that the most dysfunctional areas are NOT painful. That's why you need someone with vision, and experience.

STOP THE POP!

There is much confusion around "popping" your spine. At least once per week, a new patient will ask "Is it OK to pop my back?" It is a fair question. It requires a fair explanation.

It would be wise to start with defining what exactly "popping" means. This noise happens when a stretching of a joint creates a vacuum. The vacuum pulls out gases from the synovial fluid. The release of gas creates a pop. This is called a cavitation. This is similar to what happens when you open a wine bottle (the cork-top kind, not the cheap screw cap). Improved range of motion is often felt immediately afterward. That is unless something goes wrong. And it could.

Stretching the joint to get a pop and re-aligning the joint are two different things. I can pop my own knuckles, but that does not necessarily re-align them. A real Chiropractic adjustment requires an assessment first. It requires that misalignments be identified before the adjustment, and checked afterward to see if any change occurred. Without this essential information, the chances of the joints moving in a "good" direction are minimal. Here is another curveball- the areas that are in pain are not always the areas that need to be adjusted!

Once in awhile, I see someone who has "popped" a joint in a bad direction, and they are stuck. The alignment is now worse, and sometimes painful. However, it more often happens that the person has popped their back numerous times a day, and have done so for years or even decades. When this happens, the joint tissues get stretched. It becomes difficult if not impossible to achieve any adjustment until the person STOPS THE POP. This patient is usually very disappointed on the first visit, because any further "popping" is unlikely.

It is surprising to me how many DIY videos there are on Youtube for those willing to try, but these are quite ridiculous. I will say that some of these movements are good as stretches. But there is a big difference between going for a stretch and going for a pop. If you are truly trying to stretch, and you feel a pop, there is no need to fear. Unless, of course, it was a button that popped off your clothes.

A pain by any other name

Being a good doctor means going further than a diagnosis. I remember talking to an acquaintance of mine at a backyard party. He was describing his recent development of neck pain and associated arm and hand pain. He had gone to his primary care physician for this very reason. He was relieved to have had a diagnosis after a very thorough exam and x-ray. He was told that he had "cervical radiculopathy". He was certain that he was on the right path to recovery, since he left the MD with a prescription for opiods.
I remember not being able to hold back a chuckle. My acquaintance asked why I thought it was funny. I replied "I knew you had cervical radiculopathy the very second you described it to me." He seemed astonished. I informed him that the phrase "cervical radiculopathy" only meant that you have neck pain and associated arm and/or hand symptoms. It is a way to classify a condition, and does not specify how one develops it. Nor what to do if you have it.
But I do understand where he was coming from. Sometimes doctors tend to minimize a pain or a problem when they feel that they don't have a good solution for it. They may suggest that the pain will go away on it's own, therefore any treatment beyond medication is unnecessary. The diagnosis of "cervical radiculopathy" meant that there was definitely something wrong, and that there was a good standard operating procedure for dealing with it.
What is even more important, however, is the reason that the person has the "cervical radiculopathy". Why this patient? Why now? Why on just this arm and not the other?

This where having a good doctor is helpful. Asking questions like the person's sleeping position, computer workstation setup, and exercise history are crucial. Looking at the entire body posture is also important. Assessing range of motion and core strength are essential.
After a few weeks of only slight improvement with the opiods, this acquaintance came to my office for the same reason. I was able to determine that his computer workstation did not have a pullout tray. This means that he had to lift his arm too much to mouse with the arm with the pain. Considering he spent 10 hours per day at the computer, this was significant. He also slept on this same side with his arm underneath his head. After a month of treatment, and improvement in his workstation and sleeping position, he was 75% better. His arm pain was completely gone.
I still see this patient periodically, as his 10 hr/day computer usage is still too much for his body to handle, even with improved ergonomics.