Tag: tendonitis

Don’t Forget Your Back

Most of us spend a large portion of the day hunched forward.  Think about when you are working on the computer, cooking, driving or even relaxing.  Your typical posture during these activities is head and neck forward, shoulders rounded forward, back curved and hips flexed.    When you remain in this position for an extended period of time, the muscles in the front of the body tend to shorten or contract, while the muscles in the back of the body tend to weaken.    This can be a set up for back, neck and shoulder problems and in addition, tends to make you look shorter, heavier and less confident.

Stretching before and after exercise as well as during the day is often overlooked in the rush to “get your workout in”.   Stretching however, has numerous benefits.   According to a study published in the Annals of Physical Medicine and Rehabilitation Medicine in September 2016, by I Fekhfekh, et al, dynamic muscle stretching of the knee musculature actually resulted in an increase strength gain in those muscles.  Interestingly, this study also found a decrease in the postural stability of the knee after stretching.    In English, it appears that stretching helps your to build strength, but may decrease the stability of the muscles you stretch at least temporarily.

In general, stretching helps to improve flexibility, joint range of motion, and usually is helpful for injury prevention.    Stretching helps by increasing blood flow to the muscles stretched.  This increased blood flow carries important nutrients to your muscles to allow for muscle growth and repair.  In addition, the increased blood flow helps to wash away muscle “waste” which leads to decreased soreness and inflammation of the muscle.

If allowed to remain in a contracted position for a prolonged period of time, our muscles will shorten.  For example if you spend a large portion of your day sitting in a chair or driving, the muscles in the front of the hips, your hip flexors will shorten.  These muscles have a direct effect on both your posture and your back health.

 

So what should you do?

It is important to stretch the muscles in the front of the body at least daily.

Exercises that focus on the hip flexors:

-Kneeling hip flexor stretch  – in the position of a lunge, allow your back knee to touch the floor and drive the hip of your front leg forward.  This will stretch the hip flexor of the knee on the floor

–Pigeon stretch – extend your right leg straight back and bring the heel of your left leg underneath your right hip.  Then drive your hips forward towards the ground.  Stretch and repeat on the other side.

– Yoga poses such as: low lunge, crescent lunge, upward facing dog, and revolving side angle pose

 

Stretches that focus on the chest muscles and prevent rounded shoulders:

– Door Frame stretch- stand in a doorway or at the corner of a room with your arms up like you were going to stop traffic.  Line your arms up from the elbow to the hand with the doorframe or in the corners of the wall.   Step towards the door and you should feel a stretch in your chest (pectoralis “pec” muscles) and hold for 20-30 seconds.

– Wall slides – stand with your back to the wall and keep your shoulders against the wall.  Walk forward 1-2 steps and slide your arms up and down the wall and squeeze your shoulder blades together.  You should feel a stretch in your upper chest muscles.

–Shoulder squeeze stretch –  clasp your hands together behind your back and slowly try to lift your hands.  Squeeze your shoulder blades together to stretch out the chest wall.

– Yoga poses include : bridge pose, camel pose, cobra pose and cow face pose

 

Stretches for your neck:

– Chin Tucks (Neck Retraction) – keep your shoulders back and your head in a neutral position (eyes facing forwards, chin level) slowly move your head backwards until you feel a slight stretch in the back of your neck.  Hold for 10-20 seconds and repeat.  If needed you can apply a gentle pressure on your chin with your fingertips to press your chin backwards and deepen the stretch.

Incorporating these exercises into your daily routine will help to prevent shortening of the muscles in the front of the body which leads to poor posture and often pain of the neck and back.  As always, if you are having pain which persists you should be evaluated by a certified health care professional to ensure that these exercises are safe for you.

This week we primarily discussed stretching exercises to prevent muscle contraction, and next week we will discuss the importance of strengthening the back muscles to further combat the issues of a hunched posture.

Common Causes of Knee Pain

The primary function of the knee is to bend and straighten the leg, to allow for a smooth gait during walking and running and to allow for jumping.    It is very common to develop knee pain in both new and seasoned exercisers.  Often the type of pain which develops is related to the type of exercise being done.

To understand knee pain, it is helpful to have a basic understanding of knee anatomy.

The knee joint can be divided into intra-articular and extra-articular compartments.

Intra-articular – structure inside the knee  joint

Extra-articular – everything else

The knee joint is where the surfaces of the leg bones meet and interact.  In order for the bones to move smoothly against each other and to provide additional stability, there is articular cartilage or cushioning shock absorber called the meniscus on both sides of the knee joint.  There are also many important ligaments which connect one bone to another and provide stability.  In addition, there are fluid filled sacs called bursae which allow for separation between solid tissues so that smooth movement can occur.

To help visualize the components of the knee, let’s break it down into 3 parts.

  • The anterior (front) of the knee
    •  Knee cap or patella
    •  Quadriceps tendon
  •  The medial aspect (side) of the knee  closest to the other knee
    • Medial meniscus (cushion)
    • Medial part of the joint capsule (the whole joint capsule encloses the entire knee)
    • Medial Ligaments  (provide stability for the knee and connect bone to bone)
  •  The Lateral aspect (outer) part of the knee
    • Lateral part of joint capsule
    • Lateral meniscus
    • Lateral ligaments

The knee is actually more complex then described above and does have the ability for rotation in addition to bending and straightening and other components not described above.  For the purpose of this article, we will focus on basic knee motions and components.

Now that we have a basic understand of the knee, let’s focus on what can go wrong with the knee.

In general, knee pain can be caused by:

  • Injuries due to trauma
  • Overuse injuries due to
    • Body misalignment
    • Muscle imbalances
  • Degenerative conditions
  • Injuries in the hips or feet

Patellofemoral syndrome (Anterior knee pain – front of the knee)

Common in new exerciser, especially runners and jumpers.  This is usually due to irritation between the patella (knee cap) and femur (thigh bone).  This pain can occur with increased jumping, squatting, running and climbing stairs.  Usually pain occurs if there is repeated stress on the knee or if there is a sudden significant increase in physical activity.   It is often treated with rest, ice, elevation and compression (RICE) and specific exercises to strengthen muscles surrounding the knee, and core.

Structural Injuries 

Knee injury can also result from structural changes or damage such as a dislocation, slippage or tears of the menisci or ligaments surrounding the knee.

Meniscal Injuries – The meniscus serves as a shock absorber for the joint.  Injuries of the meniscus can be the result of a twisting injury and can cause considerable pain, joint swelling, difficulty with stairs and the sensation of locking of the knee.  Occasionally the pain in the joint due to meniscal injuries will cause the brain to “shut off” the quadriceps at the knee causing the knee to “give way”.

Ligament Injuries – Ligament tears, such as a tear of the ACL (anterior cruciate ligament) can occur with a twisting injury and results in knee instability and may require surgical intervention depending on the degree of the tear.  It is common to sense a “pop” and immediate leg instability with this injury.    If surgery is used to repair the ACL, recovery is long and only low impact exercises are recommended initially to strengthen the muscles around the joint.  In contrast, PCL (posterior cruciate ligament) tears often can be treated non surgically with physical therapy and if indicated bracing.   When ligaments are torn or lax (loosened) it is common to have the sensation of poor balance or joint instability.

Tendon Injuries – Tendons are tissues that connect muscle to bone.  Typically, complete tendon ruptures are abrupt and result in the inability to move the joint.  The quadriceps tendon is quite large and a significant amount of degeneration must be present for it to rupture.  More often this injury is the result of a high force injury.   A completely torn tendon requires surgical intervention, but a partially torn one, will likely heal with immobilization followed by physical therapy.

Overuse injuries

Overuse injuries such as bursitis (inflammation of bursae), tendonitis (inflammation of the tendons), muscle strains, and Iliotibial band syndrome are usually the result of repetitive stress on a muscle, tendon or bursa.  Usually there is a component of body malalignment, muscle strength imbalance, improper shoe wear, or poor form which leads to the development of these conditions.  Treatment may include RICE (rest, ice, elevation, and compression) along with a detailed musculoskeletal exam to determine the etiology of the injury.  This will allow for a proper treatment plan to prevent recurrence.

Arthritis

Arthritis can be divided into Osteoarthritis (wear and tear), Rheumatoid (immune mediated), Gout (due to gout crystal build up) and Septic (due to infections).   Arthritis may be the result of poor diet or gluten sensitivity in some individuals.   While some forms of arthritis are genetic, diet modifications, weight loss, proper shoe wear and exercise may help to offset the severity of these conditions.

Rotator Cuff Tendonitis

The shoulder joint, or glenohumeral joint, is like a ball in a socket.  The shoulder joint is the interface between the humerus (arm bone), the scapula (shoulder blade) and the clavicle (collar bone).  Because the bony part of the socket of the shoulder is not deep enough to fully contain the top of the arm bone, there is a cartilage ring surrounding the bony joint to further contain and stabilize the arm.  The shoulder capsule is made up of fibrous tissue, helps to hold the arm bone in place inside the joint.   This capsule is fairly lax and allows for a good deal of movement in this joint which is both beneficial and detrimental.

The rotator cuff is a group of four muscles the help to move the arm in the shoulder socket but also serve to further stabilize the arm bone to allow for proper joint alignment and motion.  The 4 muscles in the rotator cuff joint are the supraspinatus, the infraspinatus, the teres minor and the subscapularis.  Each of these muscles have tendons, which serve to connect the muscles to the bone.  The most commonly injured muscle/tendon is usually the supraspinatus.  This is because the supraspinatus runs between two bony surfaces.  Depending on the anatomy of your shoulder, you might be at more risk for injury, especially if there is not much space between theses bony surfaces.  Over time, constant repetitive shoulder motion and friction causes micro-tears and fraying of these tendons.  High velocity injuries such as falls, car accidents or other trauma can cause also partial tears or rupture of these tendons and muscles as well.

Typically, rotator cuff tendonitis pain is brought on by specific movements of the shoulder joint.  Pain is usually located in the front or side of the arm and can radiate down to the elbow.  If the pain radiates further then the elbow, it is more likely your pain is due to a pinched nerve in the neck, rather than from your shoulder.

Rotator Cuff related pain includes (but is not limited to):

  • pain with overhead movements
  • pain with movements behind the back
  • pain with specific motions, but not all shoulder and arm movements
  • difficulty sleeping on the affected shoulder (this pain is also related to other shoulder pathology as well)
  • pain when raising or lowering the arm

Pain from the rotator cuff can be due to three different but often related issues. If the space between the bones is limited, when you raise your arm overhead, the rotator cuff can get pinched.  This is called impingement, which can be painful on its own.  Repetitive impingement can cause frays and tears of the tendons.    When the rotator cuff tendons get frayed this causes inflammation which leads to further development of pain.  Finally, the third reason for pain is shoulder bursitis.  The shoulder bursa is a fluid filled sac which allows for smooth motion between the tendons.  This sac or bursa can become inflamed and cause a significant amount of pain and point tenderness over the shoulder.

One of the reason for shoulder pain in improper body alignment.  In order for the rotator cuff to work optimally, the scapula or shoulder blade needs to move properly against the back of the chest wall.  Often times, during an exercise routine, you focus more on strengthening certain muscles but not others.  This can lead to muscle imbalance and improper alignment.   In addition, it is important to select the proper weights which are neither too heavy, no too light.  Your muscles should start to fatigue after 8-10 reps of heavy weight lifting but your form should not alter.  If you find that your form deteriorating, then you need to choose slightly lighter weights.

In my personal experience treating rotator cuff tendonitis, it seems that the body has a remarkable ability to heal itself if given the time to do so.  Unless you have specific anatomy which predisposes you to tears and impingement syndrome, usually the shoulder will recover within 6-12 months without much intervention.

That being said, there are interventions which may help with symptom management and prevention of recurrence.   Surgery might be required if you have a full thickness tear, a partial thickness tear and are a high level athlete, or anatomical issues which will not correct on their own.

Generally speaking, rotator cuff tendonitis is treated with rest, ice, and anti-inflammatory measures (either medications or dietary changes).  Sometimes, a cortisone injection into the shoulder is helpful if conservative treatments fail.  In addition, treatments such as PRP (platelet rich plasma) are used to help with regeneration of tissue.   After the initial rest phase, which should be short, as you don’t want to create a frozen shoulder, progressive shoulder motion exercises are recommended.  Once you regain shoulder motion, the next step is strengthening the muscles which fix the scapula (shoulder blade) to the chest wall.

Exercises such as:

  • Punches
  • Shoulder shrugs
  • Rows

are recommended next because proper strength and alignment of these muscles will help to fix the scapula motion with respect to the chest wall.  After you have re-established proper motion and increased the strength of these muscles (such as the rhomboids, latissimus dorsi, trapezius, serratus anterior, pectoralis muscles, etc), then you can progress to specific exercises of the rotator cuff muscle.

The reason you are often referred for physical therapy is that therapists are trained in the proper progression of these exercises and can instruct/monitor you for proper form and technique.  In addition, modalities such as taping, heat, ice, ultrasound, phonophoresis (using ultrasound to help medications penetrate into the shoulder joint, and iontophoresis (using electric current to help medications penetratethe shoulder joint may be effective, though the research studies are equivocal for some of these treatments.    Finally using a shoulder brace may help however, it is important to remove it often to prevent a frozen shoulder.

If you have shoulder issues, make sure to get examined by a medical professional so that you can begin the appropriate treatments and start on the road to recovery.