Understanding Rotator Cuff-Related Pain
Rotator cuff related pain is a common musculoskeletal condition that affects millions of people worldwide. The rotator cuff consists of a group of four muscles and tendons that stabilize the shoulder joint and allow for a wide range of motion. When these structures become injured or damaged, they can lead to pain, discomfort, and limited mobility. In this blog post, we will delve into the causes, symptoms, acute phase management, and long-term outcomes of rotator cuff related pain.
Introduction:
Rotator cuff related pain is a common musculoskeletal condition that affects millions of people worldwide. The rotator cuff consists of a group of four muscles and tendons that stabilize the shoulder joint and allow for a wide range of motion. When these structures become injured or damaged, they can lead to pain, discomfort, and limited mobility. In this blog post, we will delve into the causes, symptoms, acute phase management, and long-term outcomes of rotator cuff related pain.
Causes:
Overuse and Repetitive Strain: Engaging in repetitive overhead activities such as painting, throwing, or lifting can strain the rotator cuff muscles over time, leading to inflammation and pain.
Trauma or Injury: A fall onto an outstretched arm, direct impact, or sudden force can cause tears or strains in the rotator cuff tendons or muscles.
Age-Related Degeneration: As we age, the blood supply to the tendons decreases, making them more susceptible to degeneration and tears.
Poor Posture: Bad posture can alter the mechanics of the shoulder joint, increasing the risk of impingement and rotator cuff irritation.
Muscle Imbalances: Weakness or imbalances in the muscles surrounding the shoulder can affect the stability of the joint and contribute to pain.
Symptoms:
Pain: Dull, aching, or sharp pain in the shoulder or upper arm, particularly during overhead movements or while sleeping on the affected side.
Limited Range of Motion: Difficulty reaching, lifting, or performing everyday activities that involve shoulder movement.
Weakness: Reduced strength during arm movements and difficulty holding objects.
Clicking or Popping Sensation: Some individuals may experience clicking, popping, or grinding sensations during shoulder movement.
Night Pain: Discomfort and interrupted sleep due to shoulder pain while lying on the affected side.
Acute Phase Management:
Rest from Aggravating Activities: Give your shoulder time to heal by avoiding activities that exacerbate the pain.
Avoid Overhead Activities: Minimize or modify activities that involve repetitive overhead movements.
Ice: Applying ice to the affected area for 15-20 minutes several times a day can help reduce inflammation and alleviate pain.
Pain Management: Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) can help manage pain and inflammation, but consult a healthcare professional before use.
Physiotherapy: We can design a tailored exercise program here in the clinic to improve range of motion, strengthen muscles, and correct any imbalances.
Long-Term Outcomes and Management:
Physiotherapy and Exercise: Regular participation in a structured rehabilitation program can lead to improved shoulder function, reduced pain, and enhanced muscle strength.
Posture Correction: Learning proper posture techniques can prevent unnecessary stress on the shoulder joint and reduce the risk of future injuries.
Gradual Return to Activities: As your shoulder heals, gradually reintroduce activities while maintaining proper form and technique to prevent re-injury.
Healthy Lifestyle: Maintaining a healthy weight, staying active, and avoiding smoking can promote overall musculoskeletal health and aid in recovery.
Surgical Intervention: In severe cases where conservative treatments are ineffective, surgical options such as arthroscopic repair may be considered, but should not be the first choice in most cases.
Conclusion:
Rotator cuff related pain can significantly impact daily life, but with proper management and treatment, most individuals can experience complete relief and restored function. Early intervention, adherence to a rehabilitation plan, and lifestyle modifications can contribute to long-term positive outcomes. If you're experiencing shoulder pain, get in touch for a thorough evaluation and personalized guidance on managing your pain.
Syndesmosis sprains : The high ankle injury
You may have heard various athletes suffering a high ankle sprain or injuring their syndesmosis. But what exactly is a syndesmosis injury? And how does it differ to a normal lateral ankle sprain?
The ankle syndesmosis is the joint between the distal (lowest aspect) of your tibia and fibula. It is comprised by three main supporting ligamentous structures – The Anterior inferior tibiofibular ligament, Posterior inferior Tibiofibular ligament, and interosseous membrane (see Figure 1). The role of the syndesmosis is to provide stability to the tibia and fibula and resist separation of these two bones during weightbearing tasks. It also plays a role in assisting with mobility of the ankle.
You may have heard various athletes suffering a high ankle sprain or injuring their syndesmosis. But what exactly is a syndesmosis injury? And how does it differ to a normal lateral ankle sprain?
The ankle syndesmosis is the joint between the distal (lowest aspect) of your tibia and fibula. It is comprised by three main supporting ligamentous structures – The anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, and interosseous membrane (see Figure 1). The role of the syndesmosis is to provide stability to the tibia and fibula and resist separation of these two bones during weightbearing tasks. It also plays a role in assisting with mobility of the ankle.
Figure 1: Syndesmosis anatomy
How does it differ to a common ankle sprain?
Generally, a lateral ankle sprain is a result of and inversion injury and will result in an injury to the outside ligaments of your ankle (ATFL, CFL, PTFL). These ligaments are positioned slightly lower than the syndesmosis and provide stability to the true ankle joint.
Figure 2: Inversion sprain mechanism
Mechanisms of injury:
The most common mechanism for injuring your syndesmosis is a forced dorsiflexion combined with an Eversion movement. Essentially the foot/ankle moves in an upward direction and to the outside of the leg (See figure 3).
Figure 3: Syndesmosis Mechanism - Dorsiflexion + Eversion
The syndesmosis can also be injured with a typical inversion or lateral ankle sprain (Figure 2) mechanism. This usually occurs when the incident is of high force and will result with an injury to the lateral ligaments as well.
Signs and symptoms:
· Mechanism of injury consistent with a syndesmosis injury (forced dorsiflexion + Eversion)
· Pain location may extend above the ankle and into the lower shin
· Swelling may sit slightly above the cease line of the ankle joint
· Difficulty weightbearing, particularly when the foot is in dorsiflexion (knee over toe)
· Low confidence/feeling of instability
Gradings:
Grade 1: isolated injury to the AITFL
Grade 2: Injury to the AITFL and interosseous membrane
Grade 3: Injury to the AITFL, interosseous membrane and PITFL
Grade 4: Injury to the AITFL, interosseous membrane, PITFL and deltoid ligament
Immediate management:
As always if you have recently suffered an injury, please seek medical attention from your physio or doctor for accurate diagnosis and management.
If a syndesmosis injury is suspected acute management will initially involve offloading and protecting the tissues. This may be in the form of one or a combination of crutches, a cam walker (moon) boot and strapping.
Your physio or Doctor may also refer you for imaging such as an x-ray or MRI to assist with diagnosis and understanding the severity of the injury.
Following the acute period of offloading and protection a period of rehabilitation will be required to restore normal function of the foot and ankle. In more severe cases surgery may be required to stabilise the syndesmosis and therefore rehab will commence following a period of protection post-surgery.
If you have experienced an ankle sprain yourself, please book in with one of our physiotherapists for an individualised rehabiltation program.
Early Stage Ankle Sprain Rehabilitation
Ankle sprains are one of the most common lower limb injuries reported by active individuals, with a high reoccurrence rate. The lateral ligaments (outside of the ankle) are the most commonly injured, as discussed in one of our previous blogs as seen here https://www.eastvicparkphysiotherapy.com.au/news/2021/1/14/chronic-ankle-instability
Injury prevention and rehabilitation is an effective way to reduce the risk of post injury recurrence.
Key areas of a rehab plan include the following
Restoring full range of movement
Restoring range of motion is important in the initial stages of rehab, this can be achieved by correct heel toe walking (if needed with the assistance of crutches dependant on severity of injury). These exercises are used in the beginning phase of rehabilitation
Ankle Active range of motion
- Ankle Alphabets
- Ankle Pumps
- Calf Stretching
Pain free stationary cycling is also a great way to progress active range of motion exercises as well as re introducing a cardiovascular component to the program.
Muscle Strength
Strength needs to be addressed in all directions available in the ankle. These include dorsiflexion, plantar flexion, inversion, eversion. To increase the difficulty of these movements, your physiotherapist may use external resistance, such as therabands, or using your own body weight, through calf raise exercise. Body weight exercises are encouraged as soon as the injury is pain free.
Proprioception
Proprioception is the awareness of joint position and movement, and this becomes impaired after a ligament injury. It is an important part of ankle injury rehabilitation and can start early in your program. Examples of proprioception exercises include:
- Standing on one leg
- Balance Boards
The above exercises are only a guide and will need to be progressed to ensure a full recovery. If you have experienced an ankle sprain please book in with one of our physiotherapists to have your rehabilitation individualised to suit your needs.
Costochondritis - A real pain in the chest
There can be many medical reasons for chest, rib and upper back pain including heart and lung conditions, infections and trauma incidences like fractures.
However, once that has been ruled out a diagnosis to be considered is costochondritis.
The condition is classified as inflammation of the costochondral junction of the ribs (where the bone and cartilage meet) or of the costosternal joints (where the ribs connect to the chest bone). The issue is normally unilateral (one sided) but can sometimes be bilateral.
There can be many medical reasons for chest, rib and upper back pain including heart and lung conditions, infections and trauma incidences like fractures.
However, once that has been ruled out a diagnosis to be considered is costochondritis.
What?
The condition is classified as inflammation of the costochondral junction of the ribs (where the bone and cartilage meet) or of the costosternal joints (where the ribs connect to the chest bone). The issue is normally unilateral (one sided) but can sometimes be bilateral.
Signs and symptoms:
- Chest pain that can radiate into the upper chest near the shoulder, down the rib into the area under the armpit and even into the back near your shoulder blade
- Pain can be sharp with certain movements and a dull ache at rest
- Sometimes there is visible swelling over rib joints
- Neck and shoulder range can be affected
- Pain with laughing, coughing, sneezing and deep breathing
Why?
The exact reason for an individual developing inflammation of that particular area is yet to be determined. However, there are a few mechanisms that have been anecdotally found to trigger costochondritis symptoms including:
- Trauma to the area (eg. Direct fall/pressure or injury to the pec muscle)
- Intense exercise of the area
- A bout of illness with lots of coughing
Diagnosis methods
The condition is primarily diagnosed with clinical tests including:
- Palpation of the costochondral and costosternal joints (usually ribs 2-5)
- Assessment of thoracic, cervical and glenohumeral joint range
- Cough/sneeze/laugh test
- Deep breathing test
Scans would only be beneficial if you needed to rule out any of the below alternate diagnoses. Potentially a blood test would be beneficial if a multi joint inflammatory condition is suspected.
Examples of differential diagnosis
- Coronary artery disease (or other heart conditions acute or chronic)
- Pulmonary embolism or pneumothorax
- Rib fractures or subluxations
- Costovertebral sprain
- Tietze syndrome
- Pectoralis muscle injury
- Infections (e.g., pneumonia)
- Xiphoidalgia
Treatment
- A review with a physiotherapist can be helpful to accurately diagnose
- Ice over the joints or heat over the muscles
- Speak to your pharmacist regarding pain relieving medication
- Modification of aggravating activities
- Gentle massage to the neck, shoulder and chest muscles can be helpful in some cases
- Gentle stretches and strengthening exercises once the pain has reduced
If you believe you are suffering from costochondritis then book an appointment to see one of our friendly physiotherapists today!
Dietary Supplementation
The dietary supplement and health food market is massive and is continuing to grow. To gain that extra edge it is not a surprise that athletes of all backgrounds find themselves drawn to additional dietary help to improve their physical output. Unfortunately, most of the supplements on shelves are not what they are made out to be and there is no substitute for good old-fashioned hard work.
The dietary supplement and health food market is massive and is continuing to grow. To gain that extra edge it is not a surprise that athletes of all backgrounds find themselves drawn to additional dietary help to improve their physical output. Unfortunately, most of the supplements on shelves are not what they are made out to be and there is no substitute for good old-fashioned hard work. However, it is not all bad news, there are some foods and supplements that have been backed by science that can play a marginal performance enhancing role in sport and exercise.
Here we will briefly go over some of these health foods and supplements that may have a positive effect on performance directly. There are also many other dietary foods/supplements that claim to have an indirect on performance such as aiding recovery, assisting muscle development or improving immune function which we will not go into detail.
Caffeine:
One of the most commonly used supplements and widely used legal drug (in the form of coffee). There is significant scientific for caffeine as a positive performance enhancement for some athletes in range of different types of activities.
Possible benefits are improved endurance capacity such as exercise time to fatigue and time-trial activities of varying duration (5-150min). This has been shown across activities such as cycling, running, rowing and various team-sports. Improvement in performance measures such as time-trial time have shown to range from 3-7%.
How does it work?
Caffeine is a stimulant which can enhance vigilance and alertness, perception of fatigue and exertion during exercise and improve neuromuscular function. It can also stimulate an endorphin release which can assist in feelings of wellness.
A systematic review by Ganio et al (2009) has shown 3-6mg/kg of body mass consumed 60 min prior to exercise is sufficient to provide positive effects. However lower doses <3mg/kg of body mass has shown to also be effective. To put that in perspective the average cup of coffee has about 100mg of caffeine in it.
Possible side effects:
Larger doses of caffeine have shown not to further increase performance enhancement and in fact increase likelihood of negative side effects.
Possible side effects include; nausea, anxiety, insomnia and restlessness. Caffeine is also a diuretic which can increase urine flow but is small when consumed at the doses that have shown to improve performance.
Sodium Bicarbonate:
Sodium bicarbonate is a commonly occurring substance in most foods. In fact, most households will have this In their kitchen without even knowing as it is commonly known as baking soda.
How does it work?
It helps regulate PH in the blood which commonly increases in acidity during exercise. Sodium bicarbonate is naturally occurring in the body and helps buffer excess acid that accumulates during bouts of high intensity exercise. By keeping muscle PH level closer to its normal it can enhance exercise capacity.
Sodium bicarbonate has shown to enhance performance during short term, high-intensity exercise of approximately 60s in duration of approximately 2%. Improvements reduce as duration of effort exceeds 10 min.
Protocol of use:
According to the evidence various strategies of consumption have been suggested.
1. Single dose of sodium bicarbonate of 0.2-0.4 g/kg of body mass, 60-150 mins prior to exercise
2. Split dosage (i.e multiple smaller doses totalling 0.2-0.4 g/kg) over 60-180 min
3. Serial loading with 3-4 smaller doses per day for 2-4 days consecutive prior to an event
Potential side effects:
It is well established that gastro-intestinal upset can be associated with sodium bicarbonate. Therefore, may not be appropriate for some athletes or ideal consumption strategies may be person dependant.
Creatine:
Creatine is naturally occurring substance in body where it is found in the substance creatine phosphate. Its use as a supplement has grown significantly over recent times. Creatine works by aiding resynthesis rate of the phosphocreatine energy system. In short aiding the use of the energy system in the body that is utilised in short, high-intensity bouts of exercise.
In term creatine has shown to have positive effects particularly in sports that involve repeated high-intensity exercise (eg. Most team sports). it has also shown to assist in increased gains of lean mass and muscle strength and power.
Potential side effects:
No negative health effects are noted with long-term use (up to 4 years) when appropriate consumption use is followed. However, a 1-2 kg of body mass increase has shown to be a possible side effect which is primarily the result of water retention. This is an important consideration as the possible detrimental effect of increase weight gain may outweigh the positive effect of creatine.
Nitrate or Beetroot Juice:
It may seem as an odd one to add in but nitrate which is readily found in beetroot has been shown to have positive performance enhancing benefits. High nitrate rich foods include leafy green and root vegetables, including spinach, rocket, celery and of course beetroot which accounts for one highest sources of nitrate.
How does it work?
Nitrate contributes to the production of nitric oxide in the body. Nitric oxide is a vasodilator which improves blood flow and oxygen delivery to muscles. It therefore can improve the muscle efficiency in utilising oxygen and can improve the performance and energy efficiency of type 2 or fast twitch muscle fibres.
Supplementation of nitrate has been associated with improvements of 4-25 % in time to exhaustion during exercise and 1-3 % in sport specific time trial events lasting less than 40 mins.
Protocol of use:
Nitrate consumption within 2-3 hours of activity as bee associated with improved performance. Prolonged use of nitrate also appears to be beneficial and has been suggested strategy for highly trained athletes where improvements from nitrate supplementation is smaller.
Potential side effects:
There appears to be few side effects or limitations to nitrate supplementation. It is suggested that there is potential of gastro-intestinal upset and therefore suggested to be trialled in trainings before the use in competition. It also appears that performance gains and harder to obtain in highly trained athletes.
Beta-Alanine:
A naturally occurring amino acid, beta-alanine plays a role in the development of a carnosine.
How does it work?
Similar to sodium bicarbonate, carnosine acts as a acidity buffer in the muscle and therefore helps maintain an optimal PH level for muscular performance. It helps resist muscle fatigue and in term potentially assists performance.
Protocol of use:
Beta-alanine is commonly found in meat, poultry and fish and therefore most people can get enough beta-alanine through their regular diet.
Dietary supplementation however can further assist our daily intake. It is suggested a daily consumption of 65mg/kg of body mass taken in 3-4 smaller doses throughout the day.
Potential side effects:
Possible side effects include skin rashes and/or transient paraesthesia (tingling feeling in the skin) when taken with high single doses. This effect is temporary and harmless.
It should also be noted the effectiveness of supplementation appears to be harder to realise in well-trained athletes.
It should go without saying please seek professional medical advice whenever considering whether additional dietary supplementation is right for you.
If must also be noted that inadvertently consuming a known banned/prohibited substance should be risk considered when weighing up the decision to pursue dietary supplementation. Please find some useful links below which can assist in determining whether a specific product is considered banned or has gone through the necessary batch testing to determine if it is safe for consumption under the anti-doping rules.
Useful resources:
https://www.informed-sport.com/
https://www.asada.gov.au/substances/check-your-substances
Common Adolescent Conditions – Part One: Ankle
This topic seems somewhat timely given these particular injuries are normally load related.
As discussed in my previous blog about Load Management, the last 6 months have played havoc with people’s Acute Chronic Workload Ratio and children/adolescents are no exception.
The conditions I will be discussing are usually related to a big spike in activity which has been the case this year with most sporting organisations eager to recommence their seasons. These spikes will be somewhat amplified in young athletes who participate in multiple sports or who are already specialising in their chosen sport which can mean numerous training sessions/games per week.
This topic seems somewhat timely given these particular injuries are normally load related.
As discussed in my previous blog about Load Management, the last 6 months have played havoc with people’s Acute Chronic Workload Ratio and children/adolescents are no exception.
The conditions I will be discussing are usually related to a big spike in activity which has been the case this year with most sporting organisations eager to recommence their seasons. These spikes will be somewhat amplified in young athletes who participate in multiple sports or who are already specialising in their chosen sport which can mean numerous training sessions/games per week.
Sever’s Disease
What?
An irritation of the insertion of the Achilles into the calcaneus. This differs from adult Achilles tendinopathy due to the immaturity of the adolescent skeleton which means it affects the actively remodelling trabecular metaphyseal bone.
How?
As mentioned previously, it is usually due to the area’s inability to deal with an increase in activity (particularly activity that uses that area eg running or jumping sports).
When?
More common in boys and usually between the ages of 10-15 compared with girls which is usually between the ages of 8-13.
How does it resolve?
Usually self resolves with time (6-24 months) however the reason it’s best to seek treatment/advice is due to the pain that accompanies the condition which can affect sports performance and most importantly day to day activities.
What is the treatment?
The main focus of treatment is to reduce pain levels. This can be done in a few different ways including:
- Manual therapy (eg muscle massage)
- Heel raises for footwear to offload the tendon
- Taping to offload the tendon
- Exercises to strengthen key areas
- Implementation of load management strategies (eg RPE scale)
- Advice regarding recovery (eg icing)
The main takeaways about the condition are:
- The adolescent will grow out of it
- It can still be quite painful however so there should be a focus on pain relief
- Load management with guidance from a physiotherapist can allow the continued participation in sport without compromising day to day function
If you would like your injury reviewed by one of our physiotherapists, then don’t hesitate to book an appointment. All of our physiotherapists specialise in sport and have had extensive experience with adolescent athletes.
RECOVERY TIPS: WHAT DOES THE EVIDENCE SAY
In a world focused on optimal performance, adequate recovery is paramount in allowing consistent high intensity effort. Exercise in general uses various body energy systems in which the waste products (eg lactic acid) can hinder performance. The quicker the waste is processed and cleared out from the body, the quicker the body returns back to homeostasis.
In a world focused on optimal performance, adequate recovery is paramount in allowing consistent high intensity effort. Exercise in general uses various body energy systems in which the waste products (eg lactic acid) can hinder performance. The quicker the waste is processed and cleared out from the body, the quicker the body returns back to homeostasis.
The head of Discipline at the AIS, Shon L Halson, reviewed different recovery techniques in a published article that sought to determine the most effective methods.
Firstly, she identified the different factors affecting athletic performance which included:
- Environment (Temperature, altitude, humidity)
- Training/Competition (volume, intensity, duration)
- Health Status (Infection, illness, injury, muscle soreness)
- Psychological stress (Stress and anxiety)
- Lifestyle (Sleep, schedule, housing situation, leisure/social activities, relationships, job/school situation)
She then reviewed 6 methods that were thought to enhance recovery from the above factors and her findings are summarised in the table below:
She concluded that:
- Sleep conditions are very important
- Massage, 1-2 x per week can be helpful for elite athletes
- Contrast therapy should be 1 min hot, 1 min cold x 7 (cold temp 10-15 deg, hot 38-40 deg)
Here at East Vic Park Physiotherapy, we can provide advice on stretching, active recovery and hydro therapy programs as well as providing massage for recovery. Click on the BOOK NOW button on the top of the page or call us on 9361 3777.