This blog post is dedicated to my clinical thought process when assessing patients with suspected shoulder impingement. I have broken it down to three different videos with explanation. Hope it helps.
In this video, I describe shoulder impingement and its types-
2. Here I discuss different causes for different kinds of shoulder impingement-
3. In this last video, I discuss certain examination points specific to the conditions like subjective history, site of pain & special tests-
What are your thoughts on this topic? Did I miss some points that you incorporate in your assessment and clinical reasoning? Comment on either WordPress, Facebook, instagram or YouTube to start a discussion. Also, follow me on these platforms for more physiotherapy and rehabilitation related content.
The thoracic spine (T-Spine) is an interesting part of the body. In recent times it has taken the brunt of the modern sedentary lifestyle of being hunched over on a chair and working on a computer for hours in a day for many months and years. These modern sedentary lifestyle changes and new work/office setups have had implications on our musculoskeletal system. What is interesting is that the T-Spine itself presents only with a few symptoms like mid back myofascial pain, stiffness, loss of mobility etc. However, other joints in proximity of the T-Spine are affected adversely due to this. Here is a list of problems we often see in an physiotherapy office that our closely related to an excessively stiff kyphotic T-Spine.
Shoulder impingement- An excessively kyphotic mid back places the scapula in a downwardly rotated, anteriorly tipping and protracted position. This position of the scapula has shown to decrease the sub acromion space in the shoulder when performing overhead activities leading to a common problem we see often; shoulder impingement/pain. Try this little test, try elevating your arm up to the maximum flexion elevation with a straight Tspine and shoulders pulled down and back and then with an excessive hunched over position. Which one feels better and which is worse? See the video below and try it yourself.
Neck pain- A kyphotic hunched over posture tips the head (weighing about 10-12 lbs approx.) anteriorly and extends our line of sight downwards to the floor. For compensation, we tilt the head backward which increases Cervical lordosis and causes upper cervical spine to go into extension to have a regular straight field of vision. This causes increase tone/tension in the cervical extensors often compressing the greater occipital nerve and other important cervical structures causing symptoms like neck pain, headaches, radiating symptoms etc.
Low back pain- An excessive kyphotic T-Spine pushes the thorax anteriorly and causes compensatory increase in the lumbar lordosis due to increased tension in the lumbar extensors causing pain at the low back. This is the classic presentation of the ‘Lower Crossed Syndrome’.
Breathing- Along with the above compensation, the thorax lifts up due to inability of the abdominal muscles to provide inferior stabilization (lower ribs flaring) decreasing overall chest expansion and causing poor breathing quality and control.
Furthermore, if you follow the joint-by- joint model of training by Cook and Boyle, you can see that the thoracic spine is meant to be mobile but has a tendency to get stiff.
So, here our some strategies/exercises we can use to maintain general T-Spine mobility. The angles drawn in the video are not exactly accurate and are used for demonstration purpose only-
Bench/chair thoracic spine extension with stick-
T-Spine extension on foam roller
T-Spine windmill rotation
Four point T-Spine rotation
Threading the needle
Closing thoughts, the mid back is meant to provide mobility but tends to get stiff and excessively kyphotic given our contemporary lifestyles. This can open the floodgates to a myriad of musculo-skeletal problems. It is paramount to keep working on its mobility.
This one resonates close to me. It was the winter of 2013, excited for having cleared my board exam to practice as a physical therapist in the US, I had just landed my first job overseas. However, apart from being my first job this was not just anywhere in the US, I was to begin working in ‘New York City’ (Oh the dream, I recall). Not just anywhere in NYC, this office was in Manhattan, and if you know anything about that awesome city, it was not just anywhere in Manhattan, it was right in the heart of it all in midtown Manhattan. It came with its pressures, servicing a relatively high end clientele in a very busy office. And if there is one thing I could tell you about New Yorkers it is this, they are extremely driven, outcome oriented and unapologetically blatant. There was no ‘see me for 3x/week for 4 weeks to see results’ or ‘physical therapy effects take time to show’. They would have none of that spiel. No pressure right (haha)? Dead wrong.
Within the first week I crumbled under the pressure like a house of cards(though I didn’t show it to anyone). But that’s New York, if you have lived there, you’d know what I mean. Lest I digress more, part of the problem along with me just being a new kid on the block was that doing countless patient charts looking down for hours apart from the non stop physical work that comes with working as a physio, I started developing neck pain with a burning sensation down my left shoulder blade. With the passing weeks, it only got worse. The problem was that a lot of my patients were seeing me for more or less a similar problem spending hours on their workstations. If I couldn’t fix myself, how could I help them? I did what I could for myself and them but it was no walk in the park. A few years and grey hair have imparted some wisdom and learning. Having seen hundreds of patients since then, I am now at a better position to tackle this issue. Below are some of the most common advice I give to patients/people who are at a risk of neck pain. A general advice though, these exercises and strategies are to prevent this unpleasant occurrence. If you are already in pain, You must seek professional help and not rely on the videos presented below. There could be many reasons why you could have neck pain and everything is not covered here.
We all have been in this position. It could be a busy day at work staring at your monitor for 8+ hours, staring down into your books pulling an all nighter before that big test, driving through endless traffic to get home ending up spending more time behind the wheel than you’d like to, maybe a car accident, a weight training injury at the gym or just sleeping wrong, very few have managed to escape this annoying and often debilitating condition. And just like if you hang around with the wrong company for too long, you’d find trouble, if the neck remains troubled and painful, chances are that the shoulders, upper back, arms and/or the head might feel some of that pain too. That’s right, often pain (or tingling/numbness) running down the arms, shoulder, upper back pain and/or headaches ‘might’ be because of that nagging neck pain. This is important so I’d like you to read that line again. However, like I mentioned before, neck pain is a complicated topic and beyond the scope of just one blog.
So today’s post and my first ever not for physios, but just people in general who might benefit from common advise we give to our patients is going to be preventative in nature. You probably won’t be surprised to know that a big chunk of neck pain clients that I have seen over the years come from just sitting wrong and too long, staring into a screen all day, snap chatting every few minutes etc than from car accidents (this might be different for the USA and Canada, there are a lot of MVA’s here).
So here are some exercises and strategies you could use if you are at a risk to experiencing neck pain or its related symptoms.
2. Chin tucks
3. Chin tucks and extension
(If you feel an increase in pain, tingling, numbness, dizziness etc with every repetetion, stop!!)
4. If you look on one side for extended periods of time, correction for that-
6. Neck stretches
7. Sitting posture and recommendations
(If you’re a image conscious New Yorker, I know your struggle. Don’t carry a sheet to work, shell out some $$ and get that lumbar roll, lol).
8. Setting timer/ reminder
9. Finally, don’t forget to MOVE!!
The key is to not think of them as exercises but as habits. Habits that are acquired and need to be incorporated into one’s routine on a daily note. Foremost remember, if you are in pain, go see a good physio and get it assessed. Some of the above advice might not be right for you depending upon what is going on. If some of the exercises seem to increase your pain, stop immediately. Comment below if you have questions.