Shoulder pain: Is it really my shoulder that hurts?

Here's the scenario: You are having right shoulder pain located at the top of the shoulder going down the shoulder/deltoid area into your biceps area.  You haven't had really bad neck pain since this shoulder started hurting and you haven't seriously injured your neck before either.  But you do rub your neck quite a bit throughout the day. You have a hard time lifting your arm up with weights either in front of you or to the side, reaching in front of you, sometime even holding a glass or cup of coffee.  It's been coming on little by little and has gotten to the point where it's really affecting your normal day.

So which is it?  is it your shoulder or something else???

In a this type of scenario, you want to get your shoulder looked at first and do some basic strengthening for the shoulder.  This includes scapular stabilization exercises, scapular retraction exercises, stretching all your tight muscles (pecs and lats and teres), then some isolated strengthening for the rotator cuff both in static and dynamic positions.  

But after about 2-4 weeks, it's gotten a lot better, but still hasn't fully resolved.  What else could it be?!?!?

Well, when you go to an orthopedic doctor who specializes in the shoulder, more often than not, they are focused on the shoulder and the problem at the shoulder.  They may even get imaging at the shoulder as well to verify their findings.

But more often than not, there is also a component relating to the neck that might be the culprit.  This is due to a cervical radiculopathy, which in lay mens terms is a mild impingement at the neck that makes the shoulder weak and also be painful.

Treatment for this is pretty easy once you've identified it as this.  A physical therapist or a trained professional can perform gentle joint mobilizations to the neck, more specifically to the two vertebrae which are locked/impinged to loosen them up.  Also you will want to retrain your neck muscles to find midline again without any deviations.  Once you are aware that your neck is stronger, then you will want to slowly incorporate functional movements with keeping your neck muscles engaged and in midline while slowly incorporating shoulder strengthening so that you're whole system begins working together again.

Now your shoulder problem/pain should decrease.  But remember, strengthening quickly does no one any good.  Strength can take about 6-8 weeks to make a substantial change.  And most of all, remember that your neck muscles are endurance muscles, so the exercises should be repeated at least 2-3 times a week just to keep them in check!  =)

Knee Braces (Genutrain)

Have you ever twisted your knee, felt a little unstable in your knee, or had any kind of “pain” in or around your knee?  Did you have surgery to fix it and it feels about 80% back to normal?  And how many brace or taping products have you tried and had minimal relief?

As a volleyball player I know the importance of getting back on the court as soon as possible, but as a physical therapist I know the importance of proper training, muscle facilitation, and edema control.  Only if I could find a brace that could marry the two…..

And I have!! I found a Bauerfeind product, more specifically the Genutrain knee brace, that does just that!  I haven’t found a more form fitting knee brace out there that does what it’s suppose to do.  After two knee surgeries (right ACL and medial meniscus and left medial and later meniscus arthroscopies) my knee continued to swell no matter how much I iced it.  Even after it felt better and I was playing on it, it swelled up after 2 days of playing and I just knew I had to wait until the swelling went down.

Then my surgeon prescribed the Genutrain S (which gives you lateral support as well as edema control) and I played on the court and low and behold, my knee didn’t swell up at all!  Now that I’ve been post surgical for about 1.5 years, I use the regular Genutrain brace to make sure that my knee doesn’t click or swell. It also reassures me, as a physical therapist, that my knee is functioning with maximal muscle activation when jumping and landing.

So here’s why this product is much better than any other:

            1) The Omega pad delivers targeted pain relief at the patella and anterior meniscus with two friction points (Hoffa Pads) exerting pressure on the infrapatellar fat underneath the patella.

2) The “Train” line of Bauerfeind has a 3D active knit which helps reduce swelling while you play your sport.

3) The stability of the knee joint is positively influenced by the muscles through the focused stimulation of surface and deep-lying nerve tracts (proprioception increases).

4) Genutrain can stimulate the feedback mechanism (part of the reflex system) by allowing the proprioceptors in the muscles, tendons and joints to act as mediators (they send signals to activate active structures more).

5) With 8 different sizes and the potential to make a custom fit brace, the anatomically-contoured knitted support with integrated viscoelastic padding fits like a glove and is very easy to wear.

I wear this knee brace every time I play now for both security and for prevention. I highly recommend any person who has had any type of knee injury (acl strain, ligament reconstruction, patella tendonitis, patella dislocation, meniscus repairs, bursitis) to wear one and see the improvement in your focus for your sport rather than the pain in your knee.

Braces: helping or hurting you?

I commonly get asked about whether or not to wear braces.  So here's my thinking behind it all and when to wear it and when not to wear it.

Braces are intended to lend support to structures that are weak or be used to aid in recovery.  So there are two situations in which you want to wear a brace as I just mentioned.  When someone has a recent injury, i.e. throws out their back, sprains their ankle, sprains their knee, has a car accident, a brace can help keep things more stable and help prevent the injured area from getting any worse. In this case, the brace is there to help increase stability to the injured area, decreasing the movement, and ultimately decreasing the amount of pain.

The second situation is when there is no stability any more because the ligaments are too loose to support it, or when the ligaments have actually completely torn, causing excessive degrees of motion to the joint.  In this case, the motion in the joint cannot be restrained by the ligaments any more and in normal activity, may result in a new acute injury, if not braced.  The brace is used to replace the ligaments, or passive structures of a joint.

Now the do's and don'ts according to my logic.......

As I mentioned in the first situation, after severe pain  or recent injury, braces can help reduce pain and help in returning to daily activities.  BUT, if a brace is worn too long, it can begin inhibiting involuntary muscle contraction from deeper stabilizing muscles which are meant to help support the area, resulting in greater weakness.  So for example, after having back surgery, a brace may be recommended so that there is greater support to allow for normal activities of daily living.  But after pain and inflammation have gone done and are tolerable, there should be effort made to reconnect to the stabilizer muscles to engage them in bracing your back.  In all honesty, who wants to have to wear a brace the rest of their life unless they really had to?!?!??

The second situation, where a ligament, let's say an ankle sprain, has repeatedly been sprained for a soccer player over several years and now there are just about no ligaments left.  An ankle brace may be appropriate to help the soccer player feel more stable during running as to prevent any additional injuries to their ankle.  In this case, exercise is still important to make the musculature as dynamic and reactive as possible, but it will probably not be enough, so a brace would be important to add an additional layer of support/stability.

I hope this helps clear up any confusion as to when and when not to wear a brace.

Again, this is just advice, and the best thing would be to ask your local physical therapist for specific instructions.  Take care and don't "brace" yourself too much!! =)

Dr. J Wong

Posture: Part 1 - Sitting is more than "just sitting"

Posture:  How many times in your life have you been told, “stand up straight” or  “sit up taller” or “straighten out your back”?  Have you also been told to have an ergonomic adjustment to your workstation, but still find yourself getting the same aches and pains?

I would like to introduce you all to what I call “Active Sitting”. 

The difference between passive sitting and active sitting is that with passive sitting, you are letting your entire body stack on top of one another without any musculature support and possibly slowly stretching ligaments and making the wrong muscles work to hold you as well as letting your other foundational muscles become weaker.  Passive sitting is often considered to be slouch sitting.

Active sitting uses more of your postural stabilizer muscles to hold you up, releasing a lot of the tension and compression through your spine, especially your low back.  Compression of your low back in sitting can cause disc problems (herniations), nerve compression, bone spurs, and possibly some other pathologies. 

So the next logical question is, “How do you actively sit???”

Well, the easiest answer is “turn on your muscles while you sit!!” But there is a biomechanical method (or a way to move your body) to turn your muscles on without having to actually contract them.  I’m a firm believer that if you change the forces in your body, then the correct muscles will work automatically and resolution will happen.

First sit in a comfortable position (in any chair) with your hips equal to or slightly higher than your knees.  Then sit up tall, and possibly over extending through the back at first.  Next extend your head and neck, but bring it back so that your ears are just about in alignment with your shoulders (chin tuck motion) and keep your eyes level at all times. At this point, you may feel a slight stretch in the back of your neck at the suboccipital area (a point that often is tight and may bring on headaches).  Slightly squeeze your shoulder blades together so that you feel the muscles working between your shoulder blades (not your upper trap).  Then, keeping your chest up and head tall, then roll backwards through your pelvis, as to tuck your tail bone under you.  At this point, you should feel your lower abdominals work and should feel a sense of relief through your back.  (It is ok to shift your whole body backwards  to maintain a straight line through your spine.)

You are now “actively sitting”.  The initial goal is to do this as often as you can so you can correct your body’s form so it can begin to recognize what it should do.  My preference is to try to get into the position 10-15 times in an hour (for those who sit a lot for their jobs or in their day), but not to worry about holding or maintaining for any duration in the beginning.  After about 2 weeks of getting the body to recognize it’s position, then we can worry about the endurance of the muscles.

Congratulations on learning to “Actively Sit”.  Spread and share what your learn and start helping your body feel better while sitting!!

Stay tuned to more information about posture and exercises to help make it easeier.

Dr. J Wong

Stretching ..... The silent solution

How many times have you been told to stretch and you take about 2 minutes to stretch the entire body and you head on out to recreational sporting or begin your workout at the gym?  It becomes apparent in our lifestyles to dismiss what may seem very passive and "useless", especially as our time becomes more filled with work, driving, eating, recreation activity, and social obligations.  So this entry is to hopefully enlighten you or hopefully confirm your suspicions as to why stretching is SOOOOOOOO important in your daily routine.

So first I ask,

• Has anyone really explained the importance of stretching?  
• How much do you think you should stretch?
• Do you think the positions you stay in all day (for work or recreation) shape your body?

Here is a common scenario I hear.   I often ask, "Do you stretch?"  The response I often hear from my patients and friends is, "Of course I stretch!!"  And then I follow up with asking,  "...so how often are you doing it?"  And then I get one of two responses: A) "I stretch every time I go to the gym (or play said sport), or B) "3 times a week for X minutes."

Let me try to explain the damage a dysfunctional and abnormal muscle can do to your body..........

They can first of all, the more obvious problem, cause pain within the muscle itself or the attached joint;  They can pinch on superficial or deeper nerves in the body causing pain; They can be too short and can cause the antagonist (opposite sided) muscle to be weak and throw off the length-tension relationship; They can affect more distal, or farther away, joints by pulling on the entire body causing poorer body mechanics and increase stress across joints.

Now I'm a very analytical and more mathematical and statistical type of guy so I'm going to try to explain the importance in that manner.  Let's say for example that you work at a desk for 6-8 hours a day and you have been at this job for 5 years.  That's 7800-10400 hours in a sitting posture/position that you're body is not really meant to be in.  In order to counter balance that, let's say you need minimally 1% of that time to open up, which equates to 780-1040 hours across 5 years to just keep your body sane.  That's a lot of time!!!  But also much needed to keep your body in alignment without causing more stress.

So now the commonly asked question,  "How long should I stretch for?", and "How much should I stretch?"

Studies published have shown to prove that a minimum of 30 seconds at a sustained intensity is needed to show a physiological change in the muscular-tendinous junction.  That means no bouncing up and down and pushing your way farther in to the stretch, unless told to do so.  So that is the recommendation and I'm sticking to it. 

As far as how much stretching, it may vary.  But ideally I recommend the ratio of 1 minute per hour of your time (for those more sedentary jobs).  So that would mean a total of 8 minutes in your work day to stretch, whether it is once an hour, once every 2 hours for 2 minutes, or once you get in the office and after lunch for 4 minutes.  I will say, the most success I have with people is when they do it more frequently through their entire day (8-10 times in a day for 2-3 minutes at a time).  Now that being said, I usually recommend specific stretches, maybe 2-3 total to be done, so it shouldn't take a lot of time.  

Another way I like to describe why the frequency of stretching is so important is with a rubber band.  If you stretch a rubber band out quickly, it is more likely to snap back and rebound.  If you give it a slow gradual stretch over a longer period of time, you can change the elasticity and tension of the rubber band without even really noticing a difference.  This is the same with muscles, you want to stretch it frequently so that you don't notice a back-lash from stretching at a high intensity and infrequently. 

Which brings me to the last component with stretching......... The Intensity!!  When stretching, you should feel a minimum to moderate/medium stretch in the muscle to achieve the best results.  Again, not stretching does zero good, but stretching too much will make the muscles rebound and they will hate you for it.

So the key points to stretching are: 

• minimum of 30 seconds at a sustained intensity
• the frequency in a day should be at a ratio of 1 minute per hour of your time (for those more sedentary jobs), or a blanket statement of 8-10 times in a day
• the intensity you should feel should be a minimum to moderate/medium stretch in the muscle

I hope this enlightens you and please feel free to comment and write back.  Take care and keep stretching!!!! ;)

Dr. J Wong

The Heat Versus Cold debate

The easy answer is, "ALWAYS COLD...... unless you have arthritis."

Usually by the time you have pain, your body has accumulated enough inflammation and "toxic soup substances" to elicit your body to respond.  So it's more than your normal, "typical" system can handle.  As a result, you have to take off the stresses and give it a chance to reabsorb back into the body, or else find a way to suck it all out of your body, i.e. needles and syringes (which is not always a fun experience.)  With cold, you can numb the pain away, decrease the blood flow to the area to stop the "toxic soup substances" from invading the damaged tissue (vasoconstriction) and sometimes even distracting an injury, thus allowing your body to begin reabsorbing the "bad things".

Heat, on the other hand, is a vasodialator, which means the (blood) vessels increase in diameter allowing for more blood and other substances to enter into the injured area.  Now, sometimes that is a good thing, but other times it is not.  If at the time, it makes you feel better, the odds are that it's working from a nerve stimulation standpoint, or "gate theory" for pain control.  I can bet you 80-90% of the time, the next day, the pain was about the same or worse.

Another factor to consider is how acute, or recent, the injury or pain started.  If it has been less than 2 weeks, definitely ice...... and even if it's been up to 6 weeks, I'd say ice more than heat, because the healing process is still in progress.  And if it is still a problem after 8 weeks, then a trained professional should really take a look at it and diagnose it to get the proper medical treatment.

COLD/ICE PACK TIPS:

1.  If you're using real ice, make sure you have at least 1 thin to medium thickness towel or sheet between the ice and your skin.  You don't want to run the risk of getting an ice burn, too!!  Old pillow cases work wonders as a barrier layer.

2.  Ice should remain on the injured area until it feels numb.  With a smaller body part, it may take less time versus a larger body part, i.e. wrist versus knee.  You will most likely experience 4 sensations when you apply the ice pack...... First, it will feel COLD; followed by STINGING, then BURNING; the last stage is NUMBNESS. At the point, you can take the ice pack off because anything more will do no good.  This process usually takes anywhere between 5 to 20 minutes depending on the body part.

3.  If you're low on money and need an easy solution, look in your freezer and just like the cartoons, grab the nearest frozen steak!!  Just kidding...... but do look in your freezer and look for some frozen veggies, preferably peas, corns or cubed carrots just because they all mold easily to most body parts.  Once you're done with them, just throw them back in the freezer.  Just be sure to label it and remember not to eat them.... (unless you really want to).  

4.  People with circulation issues or difficulty with sensation should NOT use ice!!!




Hope this information is useful and helps everyone make a better decision.  Please give me feed back and/or other ideas to write about!!!  Thanks for reading......

Dr. J Wong