Part 4 - Shoulder Pain(Including Rotator Cuff Tears and Shoulder Impingement) The shoulder complex is a tricky body region to picture the moving parts and understand how they are all interrelated. I find myself teaching basic shoulder anatomy and kinesiology to almost all of my shoulder patients because most people don’t understand what the shoulder actually looks like and how it is attached to the rest of the body. I’ll kick-off this post with the same education I give my patients. First off, take a look at the pictures below. It is important to appreciate that the “ball-and-socket” joint doesn’t have much of a socket. And it is also important to appreciate how the shoulder blade has only one small boney connection to the rest of the body (the AC joint), and otherwise the entire scapula is just gliding over the ribs at the whim of the periscapular muscles that attach to it. Finally, we can see the thorax in which the shoulder blade sits on top of. This has a natural kyphosis, or forward bend, to it.
So take that third picture. Imagine that the thorax doesn’t have the ability to straighten out. You can see how this may limit the ability of the shoulder complex to perform in an overhead position. The thorax is the foundation for shoulder movement. If this are isn’t operating properly, then we can’t expect a fully functioning shoulder. Now let’s address the second pic. This shoulder blade isn’t your typical joint. The shoulder blade can move into MANY motions; upward rotation, downward rotation, elevation, depression, abduction, adduction, external rotation, internal rotation, anterior tilt, posterior tilt, retraction, protraction, winging, and any combination of the above. With a typical presentation of shoulder impingement, the main motion that is limited is upward rotation. And lastly, look back at the first pic. You can see the socket is actually part of the scapula. So you can imagine, in reaching overhead, the ball will roll up, and the socket should move too. If the ball moves too much with relation to the socket, you can get some nasty pinching type pains in the shoulder. Looking at this picture below, you can see that it is the rotator cuff tendons that suffer from this as they are located in this region. If this goes untreated, this may result in a tearing of these tissues. Sometimes, people can have a tear in these tissues, and walk around without any pain or symptoms! In fact, having a rotator cuff tear that goes unnoticed is extremely common. However, the treatment should be directed towards treating the aforementioned underlying issues instead of focusing solely on the tear.  So how may conventional powerlifting training help? Now that you have a better understanding of the injurious cascade of untreated shoulder pain. Let’s answer the question, “How can Powerlifting training be therapeutic?” The quick answer is, powerlifting training, with correct form, will address each of the typical impairments that you see in the textbook shoulder impingement patient.
How do I get started? Sold already, but don’t know where to start? No worries! I have posted directories below that will point you in the right direction so you can find skilled practitioners in your area. The Charlotte Athlete - If you’re local to the Charlotte Area, The Charlotte Athlete is a group of healthcare providers and highly accredited sports doctors that specialize in various sports setting including Powerlifting, Bodybuilding, Strongman, Olympic Weightlifting, Crossfit, and recreational athletes and youth athletes. There is also free, quality, information on how to improve your lifts and ways to work around common aches and pains. APTA Specialist Directory - This is the directory for the American Board of Physical Therapy Specialties (ABPTS). There are options to search within each specialty. An orthopedic specialist would be able to help best with nagging aches and pains and help get you back to sport specific training. A sport specialist may help you overcome, manage, or avoid injury within your sport. Some Sport Specialists have a subspecialty with a specific sport, or set of sports. The Clinical Athlete - This is a directory of healthcare providers that happen to be athletes themselves. Again, you can search by location and filter for specific providers. Peruse each providers website to see who is the best fit for you. RSCC Registry - This is a directory of Strength and Conditioning Specialists that are registered with the National Strength and Conditioning Association (NSCA). This directory allows you to filter by location and search based on years of experience. Peruse this directory to find a Strength and Conditioning Specialist in your area. Author: Dr. Michael Masi Masi Fitness, LLC IG: @Masi_Fitness
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Part 3 - Knee Pain(Including: Patella Femoral Pain Syndrome, Patellar Tendinopathy, Arthritis)The knee is arguably the largest joint in the human body. It is comprised of four bones, the patella, femur, tibia, and fibula. The three most common knee pain diagnoses I treat are Osteoarthritis, Patella Femoral Pain Syndrome, and Patellar Tendinopathy.  Osteoarthritis (OA) is part of a natural degenerative cascade that effects everyone. This is not to be confused with rheumatic arthritis which is an auto-immune related, chronic inflammatory disorder. Imaging reveals OA in both symptomatic and asymptomatic patients in various body regions, sometimes beginning as early as the third decade of life. Prevalence is highest amongst those over 65 years of age. Before becoming painful and restrictive, arthritic joints are often joints that get utilized most in the body. This is sometimes portrayed as a protective mechanism against uneven wear and tear on the body, perhaps due to an inability or unwillingness to allow neighboring joints to contribute to motion. Patellar Tendonitis is a pathology characterized by inflammation of the patellar tendon. Unlike arthritis, this is an acute condition that is reversible. It is brought on by improper loading of the tendons secondary to either poor mechanics of movement or improper loading rate/frequency. Patella-femoral pain syndrome (PFPS) is knee pain around the patella that otherwise cannot be attributed to anything else. It is a diagnosis that literally translates to “pain around the knee cap.” Unlike the aforementioned knee pathologies, with PFPS there does not have to be a compromise in structural integrity of the joint or its surrounding tissues. Oftentimes, symptoms are resolved with improving the quality of movement that the patient or client is performing. To be succinct, all of these diagnoses involve poor movement, stressing various tissues, and manifesting as knee pain. The knee joint is fundamentally a hinge joint, meaning, similar to opening your front door, it moves in one plane. With the exception of some rotary motion, the knee primarily flexes and extends (i.e. bends and straightens). For a hinge joint to get faulty motion, there is usually a force being enacted on the joint in directions outside of its intended range; think of hanging from your front door as its opening. But how and why are these sub-optimal forces placed on the knee? Well, most of the painful knee movements involved closed chain activity, meaning that the foot is affixed to a surface as the knee is moving (i.e. going up/down a flight of stairs, squatting, or stooping). Considering the foot is fixed, the main joint that determines where that knee will be in space, is the hip. The hip moves the leg side to side and will ultimately determine which forces are imposed at the knee. A commonly seen problem, is that when the hip is weak, the knee may move inwards during a lunge, squat, or a step.  So how may Conventional Powerlifting training help? Almost all main powerlifting movements involve utilizing the hip musculature. Even in a bench press, the client is trained do drive through the legs, utilizing the hips to improve stability of the body during the exercise. In order to generate more force, the hip must be trained to stabilize the knees in a neutral position, as the knees come outside of the position, the body sacrifices its structural integrity, which will result in poor performance. Proper alignment during movement and exercise will also yield increased joint space which is imperative when a space occupying lesion, such as osteoarthritis, is present in the joint. So, moving with proper mechanics will increase pain free range of motion within these movements. Many of the lower extremity movements we perform throughout the day involve a squat or hinge, which are key components of the back squat and deadlift exercise respectively. Mal-alignment of the joint may also result in PFPS considering the forces enacted around the patella may be stronger on one side than the other. Considering the patella is a free-floating bone, this may create issues on how that patella tracks during movement. One of the principles of a sound squat and deadlift includes aligning the knees with the toes in order to generate more force. When done correctly, this promotes proper strength and stability around the joint, and optimal movement around the functional patterns being trained. This also enables the hips to contribute more to the movement, which involves muscles that have larger force generating capabilities than those that surround the knee joint. Literature currently suggests that hip strengthening should be a key component of PFPS rehabilitation likely for the aforementioned reasons. As stated before, tendons respond to improper loading. Sometimes the form can be perfect, but the body is asked to do to much over too short of a time without the proper conditioning. This is usually seen when the total volume of work is increased beyond the body’s ability to recover. During rehabilitation, volume is scaled back considerably and exercise intensity increases as per the patient’s tolerance. This very closely emulates the programming of powerlifters! How do I get started?
Sold already, but don’t know where to start? No worries! I have posted directories below that will point you in the right direction so you can find skilled practitioners in your area. The Charlotte Athlete - If you’re local to the Charlotte Area, The Charlotte Athlete is a group of healthcare providers and highly accredited sports doctors that specialize in various sports setting including Powerlifting, Bodybuilding, Strongman, Olympic Weightlifting, Crossfit, and recreational athletes and youth athletes. There is also free, quality, information on how to improve your lifts and ways to work around common aches and pains. APTA Specialist Directory - This is the directory for the American Board of Physical Therapy Specialties (ABPTS). There are options to search within each specialty. An orthopedic specialist would be able to help best with nagging aches and pains and help get you back to sport specific training. A sport specialist may help you overcome, manage, or avoid injury within your sport. Some Sport Specialists have a subspecialty with a specific sport, or set of sports. The Clinical Athlete - This is a directory of healthcare providers that happen to be athletes themselves. Again, you can search by location and filter for specific providers. Peruse each providers website to see who is the best fit for you. RSCC Registry - This is a directory of Strength and Conditioning Specialists that are registered with the National Strength and Conditioning Association (NSCA). This directory allows you to filter by location and search based on years of experience. Peruse this directory to find a Strength and Conditioning Specialist in your area. Author: Dr. Michael Masi Masi Fitness, LLC IG: @Masi_Fitness Part 2 - General Low Back PainLow back pain (LBP) is the number 1 most common orthopedic issue treated by physical therapists and seen by sports medicine physicians. This is an extremely common problem, as the lifetime prevalence of LBP is upwards of 70%! This suggests that up to 70% of the population have, at some point in their life, experienced LBP. Furthermore, most people who experience activity-limiting LBP go on to have recurrent episodes. Estimates of recurrence at 1 year vary, but studies suggest these numbers may be as high as 80%. LBP causes more global disability than any other condition. This is the leading cause of activity limitation and work absence throughout much of the world, imposing a high economic burden on individuals, families, communities, industry, and governments. Let that sink in for a bit. LBP is a pandemic, experienced at some point by the majority of the population, which limits people from performing their activities at work and their activities of daily living. These activities primarily include, lifting, carrying, squatting, pressing, pulling, reaching, and prolonged positioning. So, it makes sense, when training for health and injury prevention, to use these movements in your training and to perform them well. It would not be a stretch to suggest that repeatedly performing these movements incorrectly, or not being conditioned appropriately to handle the stressors of these movements, can generate the symptoms of LBP. Let’s take a brief look into the anatomy of the lower back as it relates to the regions above and below. The lumbar spine is made up of 5 boney segments, otherwise known as vertebrae. These vertebrae are separated by gelatinous discs that absorb shock and allow considerable flexibility. If you look at the cross section of this area below, you will see the spine is not in the middle of the body. It resides along the back side. Leaving considerable surface area to be supported by the residing musculature.  The body region immediately above the lower back is the thorax. The thorax consists of the 12 thoracic vertebrae with their coinciding discs, and a rib on either side that wraps around the body connecting to the sternum or the surrounding cartilage. Some of these ribs do not connect, but still provide support and protection for the organs housed within. Though mobile, the thoracic spine provides considerable stability due to the its circumferential distribution.  The body region directly below the lower back is called the pelvis. The lumbar spine sits directly atop the sacrum, which is 5 boney vertebrae fused together to create a triangular structure. Connecting to the sacrum are the remaining pelvic bones that, much like the thorax, create a ring and attach together in the front of the body. Each articulation is supported by a network of ligaments that prohibits any substantial movement. These bones are also referred to as the hip bones because the femur articulates with them as well.  Considering the anatomy, one can’t help but appreciate the juxtaposition of the lumbar spine as it relates to the adjacent body regions. The lumbar spine is an inherently mobile, and relatively unstable, area of the body. The thorax and pelvis have some of the largest muscles of the body (Latissimus Dorsi and Gluteus Maximus respectively) as well as some of the strongest inert tissues (Sacroiliac Ligament, and the Y-ligament). It makes sense that low back pain is a very common problem, and the number 1 most treated orthopedic condition.
So how may conventional powerlifting training help? Well, first consider the seven most trained movements within the sport (i.e. squat, bench, deadlift, overhead press, pull-up, carry, and bent over row). These emulate functional tasks that we perform daily, tasks that my patients complain they cannot do well without pain (i.e. picking up objects, carrying child or briefcase, standing or sitting to various surfaces, lifting and reaching into cabinets overhead, pushing open doors, etc.). Next, consider that strength is the primary objective for powerlifters. That means that it would be in the competitors’ best interest to use muscles that have a greater ability to produce force. The glutes, being incredibly stronger than any muscle spanning the lumbar spine, create motion at the inherently stable hip joint. In this sport it is encouraged to exhaust the range of motion utilized from these joints and to mitigate motion from the lower back in an effort to produce the most force and move through heavier resistances. This requires incredible strength and control of core musculature and the ability to disassociate the hip from the lumbar spine during movement; two attributes that most physical therapists will be assessing and improving on most of their LBP patients. Lastly, lets look at the identified modifiable risk factors for low back pain; occupational posture, depressive moods, and obesity. That means these attributes are the risk factors somewhat without our control to modify in an effort to alleviate or avoid LBP. Exercise in general is effective at modifying mood by releasing endorphins, increasing serotonin, and normalizing sleep. Exercise is also effective at combating obesity, though powerlifting specific training may have the capacity to burn more calories per time spent training. This is in comparison to other styles of training that do not address multiple muscle groups and body regions simultaneously with little, if any, external support. Furthermore, body weight is an important factor considered when determining the best lifter in a powerlifting competition which may require athletes to manage their weight to remain competitive. How do I get started? Sold already, but don’t know where to start? No worries! I have posted directories below that will point you in the right direction so you can find skilled practitioners in your area. The Charlotte Athlete - If you’re local to the Charlotte Area, The Charlotte Athlete is a group of healthcare providers and highly accredited sports doctors that specialize in various sports setting including Powerlifting, Bodybuilding, Strongman, Olympic Weightlifting, Crossfit, and recreational athletes and youth athletes. There is also free, quality, information on how to improve your lifts and ways to work around common aches and pains. APTA Specialist Directory - This is the directory for the American Board of Physical Therapy Specialties (ABPTS). There are options to search within each specialty. An orthopedic specialist would be able to help best with nagging aches and pains and help get you back to sport specific training. A sport specialist may help you overcome, manage, or avoid injury within your sport. Some Sport Specialists have a subspecialty with a specific sport, or set of sports. The Clinical Athlete - This is a directory of healthcare providers that happen to be athletes themselves. Again, you can search by location and filter for specific providers. Peruse each providers website to see who is the best fit for you. RSCC Registry - This is a directory of Strength and Conditioning Specialists that are registered with the National Strength and Conditioning Association (NSCA). This directory allows you to filter by location and search based on years of experience. Peruse this directory to find a Strength and Conditioning Specialist in your area. Author: Dr. Michael Masi Masi Fitness, LLC IG: @Masi_Fitness |
This is where we share our expert opinion on hot topics in physical therapy, injury prevention, sports performance, strength and conditioning, nutrition, and sometimes other random thoughts. Enjoy.
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