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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE March 2023 Improving Clinical Decision Making on Scapular Dyskinesis with Subacromial Shoulder Pain by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 50 yr old female with chronic shoulder pain and stiffness comes to the office for a consult after failing two prior bouts with physical therapy and numerous injections. Recent MRI shows RC tendinopathy and small labral tearing. She is not in acute distress but limited significantly with ADL and fitness/recreational activities. AROM into elevation and abd’d rotations is most restricted along with neutral ER. She has painful weakness with RC testing but no signs of frank tearing. Scapular dyskinesis noted during descent from flexion and with resisted flexion at 1300. She did have prior dx of Adhesive Capsulitis and did not recover fully but did not feel PT was helping. She demonstrated a typical PT HEP routine of GH stretches and scapular retraction, serratus protraction/plus, and RC PRE. My clinical thinking is: Consider arthroscopy since PT and injections failed. Consider MUA to recover ROM unable to be attained through standard PT care and compliant HEP. Refer to PT for more thorough manual therapy and customized exercise including specifically serratus work to reduce scapular dyskinesis contributing to ongoing RC overload/irritation. Refer for deep tissue work with LMT to attempt ROM recovery and then send back to PT. CURRENT EVIDENCE Tangrood ZJ, Sole G, Riberio DC. Is there an association between changes in pain or function with changes in scapular dyskinesis: A prospective cohort study. Musculoskeletal Science and Practice. (48) 2020. 1-7. https://doi.org/10.1016/j.msksp.2020.102172 (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Shoulder pain is a common diagnosis seen by physicians/orthopedists. Oftentimes scapular dyskinesis (SD) may be present. Testing for SD using reliable methods and determining potential meaningfulness contribute to clinical decision making regarding treatment recommendations, especially in the case of “failed” conservative care where more invasive procedures are not called for or necessary yet. Current data has both variable and contradictory findings surrounding SD and the related serratus anterior and/or lower trapezius involvement, along with a lack of clear causal level relationships to pain and/or injury. Tangrood et al demonstrated an association over 8 weeks in a group of 44 participants with shoulder pain that improvements in scapular dyskinesis testing was associated with improved PSFS self-report function scores. One confounding variable included that 65% of those completing all testing were receiving physical therapy and 35% were not. These groups were not separately analyzed which may have shed more light on causes for improvement. Common SD approaches in physical therapy often involve activation of the serratus anterior (SA) that utilizes a “plus” movement (i.e. protraction). While the SA certainly does and can protract the shoulder this risks activation of the pec minor as well with the ongoing risk of facilitating a protraction posturing that otherwise has been identified as a potential risk factor for shoulder pain. In overhead activities the scapula must tilt posteriorly while upward rotating. Many traditional methods of testing and training for SD also utilize long lever positions that painful shoulders struggle in. Authentic biomechanics approaches are necessary to promote scapular integrity via medial border stabilization (superior through inferior angles) along with upward rotation without compromising biceps or rotator cuff tendons or labral structures. A physician’s ability to identify SD in clinical exams in order to prescribe and monitor appropriate PT is often key in achieving optimal outcomes. Background: Scapular dyskinesis (SC) is a debated topic and it is unclear whether it is causative of shoulder dysfunction and subacromial pain or a consequence of symptoms, and, whether the presence of and changing of SD affects function or pain. Purpose: To assess the association of changes in subacromial shoulder pain or function with SD changes over time. Methods: Observational, prospective, cohort study of 44 participants (37 who completed baseline and 8 wk follow up testing), with 24 receiving physical therapy and 13 no treatment, using Numeric Pain Rating Scale (NPRS) 0-10 scale for “at rest” and “during movement” , self-report Patient Specific Functional Scale (PSFS), and the scapular dyskinesis test (0=normal scapular movement and 6= highest scapular dyskinesis, summing using Kibler et al system scoring). Findings: Improvement in function showed a fair association with improved SD (correlation coefficient = -0.4) while no associations found for pain at rest or pain with movement to changes in SD. 89% of patients showed subtle to obvious SD at baseline. Participants showed no changes in “pain at rest”, medium improvements of “pain during movement”, and large function improvements (28.0 mean PSFS score difference w p=0.000) but no significant SD changes. Author's Conclusion: Improved function in patients with subacromial pain was associated with improvements in scapular dyskinesis. Future studies needed to determine causal effects. THE PEAK PERFORMANCE PERSPECTIVE Shoulder pain is one of the most common orthopedic complaints seen by orthopedists and PCP’s alike. One of the most frequent diagnoses includes some form of RC syndrome (tendinitis, tendinosis, tears, impingement, etc.) which contributes to subacromial shoulder pain. Physicians discerning best practices for non-operative care recommendations are often tasked with determining obvious contributing factors they expect to be addressed in physical therapy. Understanding and testing for scapular dyskinesis underlies prescribing practices for these patients and especially for cases of “failed care” where more simple protocol based therapy approaches have not worked. It is also potentially a great example of the concept “because a muscle can doesn’t mean that it does” - in regard to how we classically test and exercise in comparison to how it actually functions. Directing care for shoulder pain of various sorts, whether it be tendon related, bursal, labral, or instability related can be difficult when considering there are few or even no clear truly “BEST practices” approaches that have been proven clearly superior to others. Many studied are more so “only practices” or “doing this happens to work” versus actually finding “bests” in treatment. That makes prescribing care and designing rehab difficult. Certainly there is a blending of science with “art”/experience etc. Secondarily, other kinetic chain contributing factors, whether local to the scapulothoracic articulation, the thoracic spine, or even related to more distal/distant joints (especially when considering complex body movements such as overhead athlete mechanics or total body lifting/reaching ADL demands) have construct validity but often lack clear “evidence” in the literature. Scapular dyskinesis (SD) is one of those entities that has been identified but suffers from conflicting evidence as to its contribution and meaningfulness. Nevertheless, it may be one of those important factors for physicians to consider when prescribing physical therapy. Physicians must therefore consider how SD should be assessed in the office and how are therapists/athletic trainers addressing this through exercises. Kibler et al (2013) and others have identified abnormal scapular mechanics, or scapular dyskinesis, as a potential contributing factor. Kibler proposed a four pattern grading system with Pattern I being inferior angle prominence (tipping), Pattern II being medial border prominence (winging), Pattern III being early scapular elevation or excessive upward rotation (elevation), and Pattern IV being normal rhythm. In-office measurement of scapular dyskinesis can be done utilizing the scapular dyskinesis test (SDT) by Kibler. Arms are raised into flexion to maximum elevation and lowered 3-5x (adding 3-5# to each hand for up to 10 repetitions may be used to accentuate abnormal findings). Most often altered motion occurs during the eccentric descent. Ramiscal et al (Clin Shoulder & Elb 2022) showed grouping Patterns I-III as a “yes” and Pattern IV as a “no” resulted in intra-rater reliability kappa of 0.92 and inter-rater values of 0.85 for expert PT’s with asymptomatic individuals. This sort of chunking certainly reduces potential for reliability errors related to the challenge of ensuring consistency with limited/poor objective measurable means of determining when exactly a “winging” event at the respective scapular reference points has occurred. Break tests of flexion at 1300, abduction at 130-1500, and extension with arms at the side - looking for significant scapular movement should also be done. Kibler wisely has reminded (Int J Sports PT 2022) that lack of research agreement is, in part, related to multiple muscles attaching to the scapula allow for simultaneous and synchronous activation and stabilization during arm movement” causing variability in how individuals perform the same task, thoracic anatomy and varied muscle fiber orientation does not allow for single plane scapular movement - scapular motion involves complex translations/rotations w coupled muscle activation. He differentiates “neurologic” winging that remains disconnected through ascent and descent phases while “altered scapular positioning” is more so evident in descent phases. This differentiation on the surface would seem plausible, however, length-tension relationships, impacts of tissue tightness at different arm positions, and nuances of force couples may otherwise explain why the dyskinesis of abnormal scapular movement often occurs with eccentric phases only or more so than during concentric phases. Causal effects of scapular dyskinesis to pain and/or injury has not been clearly established Finally, Kibler also cautions that scapular dyskinesis is not a “diagnosis” in medical terms but an impairment therefore clinical utility, measuring diagnostic accuracy, is difficult and even inappropriate when no gold standard exists for comparison. Tangrood et al provide some evidence of an association of scapular dyskinesis reduction with improved shoulder function on self-report PSFS questionnaire responses. Repeated measures correlation coefficient showed 16% of the variability in PSFS score changes is explained by scapular dyskinesis changes. Strength of findings are weakened because confounding factors (symptom duration, physical demands, etc.) were not controlled for, especially the fact that 65% of those completing all testing participated in physical therapy (without known parameters) while 35% did not, creating a heterogeneous sample. Data was not analyzed for differences between these groups. Since blinding was not done the risk of examiner bias cannot be ruled out. Subtle dyskinesis made up 57% of the baseline group test findings. Measurement properties make determining change for these subjects more difficult to ascertain. Clinically speaking we find not only for a high percentage of shoulder pain patients that SD is present in some manner but that especially for many of the “failed PT” cases we see that this has not been addressed in rehab or maybe more importantly was only addressed with simple protraction exercises. One consideration is determining the authentic function of a muscle in ADL or sport. Again, we would caution that “because a muscle can doesn’t mean that it does” in regard to certain tests traditionally done or exercises utilized. During elevation function so often related to shoulder overloads and pain the scapula does need to upward rotate but that is coupled with posterior tipping/adduction especially for cocking positions of overhead athletics. The majority of SD exercises, owing to the classically viewed Serratus Anterior role in its capacity to protract the scapula, are most often pre-engaged or emphasized by intentional or forceful protraction. We would contend that in many typical ADL and athletic arm movements the authentic biomechanics necessary contradict coupling upward rotation with anterior tipping/abduction (ie protraction). Yes, that “works” and “fatigues” the Serratus Anterior, leading to a self-fulfilling prophecy of sorts that the exercise is effective. Functional biomechanics would seem to differ with that conclusion. In unique demands of pushing and throwing/propelling the arm and related objects forward certainly serratus function protracting the scapula is an absolute necessity. Relegating the majority of serratus anterior training for the sake of reducing SD though may be oversimplifying muscle function. Because it can doesn’t mean that it is…in this movement or case. Most testing and exercises related to SD factors (i.e. serratus and lower traps) tend to place the arm in longer lever positions. While this creates loads that may quickly increase lever arm effects and identify inadequacies it also risks eliciting pain in inflamed or damaged tissues that causes inhibition of otherwise potentially normal muscles. This is especially true for the “T” and “Y” tests and exercises so often done to address SD. We attempt to approach SD with a functional biomechanics mindset that we are seeking scapular integrity on the thoracic cage wall, with whatever posterior or anterior tipping required, and with adequate and not excessive upward rotational mechanics. While this is not easy to measure objectively or to isolate to singular muscles, due in part to the related pain generating tissue implications noted above, it leads to what we believe is a more authentic approach to scapular dyskinesis through “de-winger” thinking versus promotion of protraction dominated successful activation of serratus anterior that risks over stimulus of pec minor and what would otherwise be abnormal posturing. Kinetic chain biomechanics involving facilitation of thoracolumbar coupling, for example, into same sided rotation and side bending along with extension during cocking phases for overhead athletes, must be addressed if scapular positioning is to be optimized. This involves testing for and addressing Type I and Type II spinal mechanics along with other core and hip function. Too often we see patients having failed traditional PT approaches because classic exercises essentially rely on long lever arm loading into at-risk positions that cause pain of the irritated rotator cuff tendons or labral injury. Care must be taken in many cases of shoulder pain to customize loading of the Serratus Anterior and/or Lower Trapezius to achieve scapular integrity while avoiding symptom exacerbation. The case below involves a patient who had scapular dyskinesis as a contributing factor that required careful attention in testing and exercise. THE PEAK PERFORMANCE EXPERIENCE Holli said: “I had tried a couple of rounds of physical therapy elsewhere with not a lot of improvement in my shoulder after two years of pain. I’m so happy I was finally able to get my range of motion back and not be in pain all day!” History: 50 yr old female nurse fell in 2020 injuring her wrist and then developing L non-dominant shoulder pain. She had PT at a local hospital based outpatient clinic and transitioned to HEP but developed adhesive capsulitis and was then seen for PT several more months. Pt had a total of 4 corticosteroid injections. Now presenting two years after the original fall to address ongoing issues. Subjective: 6/10 max pain with reported function at 80%. Symptoms aggravated by elevation ADL, unable to sleep L sidelying, unable to do pushups and other fitness exercises, cannot kayak. Objective: (*=pain) Eval 5 mo DC ReEval Flexion AROM 1330 / 1660 1670 900 Abd IR AROM 130 / 300 350 900 Abd ER AROM 950 / 1200 NT Wall Serratus Anterior test L @ 4 / 5 with < moderate winging 5- / 5 Pec minor Scapular Retraction (hand @ head) Mod L tight < Min Flexion isometric 1.8 kg * (24%) 5.5 kg (74%) OH reaching (pressing) 5# 33x ( < 66%) 12# 12x (71%) 800 Abd w 900 ER test NT 8# 76% painfree Key Findings: At evaluation Pt had limited elevation AROM along with posterior RC/capsule restriction in Horz Abd and Abd IR. Isometric testing revealed weak/painful elevation and Abd ER along w weak Serratus Anterior during wall scapular integrity resistive test - showing scapular winging medial border. Thoracic L rotation was asymmetrically limited. Impingement / RC tendonitis special tests were (+). Treatment: Manual therapy emphasis to pec minor release, thoracic rotation mobilizations, and especially GH jt mob’s for all motions and capsular restrictions using holding style techniques vs std oscillation approach. Sustained stretching HEP initiated including for pec minor and thoracic L rotation combined with AROM integration drills immediately following. Scapular dyskinesis addressed with Serratus drills in both NWB and WB environments, focusing on “de-winging” emphasis of maintaining scapular integrity during related modified lever arm loaded LUE movements to optimize successful maintenance of scapular positioning…first accomplished in scapular plane and increasingly loaded in sagittal plane. These were eventually moved to upright 900 and then overhead demand positions to mimic authentic biomechanics necessary for ADL and fitness needs. Progressive shoulder/scapular PRE were done moving from BID high reps/low load toward eventual TIW 3x10-12 reps work and including functional considerations for fitness goal movements. Outcome: Pt happy with her progress and wanted to continue remaining work on her own with (I) HEP only. She had had challenges with regular attendance due to other life and work schedule demands. Holli rated function at 90% with Quick DASH 7% and Sport rating 24%. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester, and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE December 2021 New Evidence of Essential Thoracic Mobility for Normal Upper Limb Function by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario...What would you do? A 35 yr old male firefighter who enjoys playing volleyball on an intermediate level 6's team at the local indoor courts gradually developed complaints of R dominant hitting arm shoulder pain superior/anteriorly during volleyball hitting > blocking and with overhead work and ADL demands. Plain films are unremarkable. Clinical exam shows tenderness at the supraspinatus and LHB tendons, (+) impingement - Rotator cuff syndrome tests, weakness/pain especially with elevation and ER resistive tests. He has a typical "poor posture" both statically and also during AROM testing. You're ordering Physical Therapy and seeing him back in 4 weeks to consider if he is progressing adequately and to decide if further diagnostic testing is necessary. Your expectations of his PT evaluation/report......subsequent treatment would be...? Palpation, special testing, resistive testing.....modalities + simple shoulder stretching & strengthening program AROM shoulder/trunk, palpation, special testing, resistive testing....modalities, manual therapy to trunk/scap and shoulder prn, stretches prn, strengthening scapulothoracic and shoulder muscles/function per findings AROM, resistive testing...simple shoulder protocol (Jobe's exercises or Thrower's Ten) AROM shoulder + kinetic chain trunk/scapula, special testing, palpation, resistive testing... Class IV laser, stretching sleeper/pec major/Hor Add posterior RC, strengthening RC....address thoracic spine if not improving CURRENT EVIDENCE Heneghan et al. Thoracic Spine Mobility, An Essential Link In Upper Limb Kinetic Chains in Athletes: A Systematic Review. Translational Sports Medicine. 2019, 2(6). 301-305. https://doi.org/10.1002/tsm2.109 SUMMARY: Upper limb injury and pain is a commonplace issue, especially of the shoulder, for many athletes and non-athletes alike. Determining and prescribing what "standard care" is for shoulder and upper limb injuries/pain often focused solely on the local tissues but new evidence presented by Heneghan et al supports the concepts of kinetic chain "regional interdependence" that must understood by all musculoskeletal providers in order to optimally care for our patients. These biomechanics relationships, in this case with the thoracic spine, provide a potential source for contributing factors causing tissue overload and kinetic chain issues that also may delay recovery. Understanding these are critical for prescribing treatment and especially performing successful physical therapy in these cases. Heneghan et al provide some important insights into the relationship between normal shoulder ROM and associated thoracic spine mobility, especially noted during end ranges of shoulder flexion more so than other elevation directions and mutually more so than during other motions. Achieving unilateral or bilateral elevation ranges produced the greatest thoracic spine mobility demand, that being extension during shoulder flexion. Clinically we often see kinetic chain factors either addressed generically or not at all. Prescriptions rarely specify expectations of thoracic/scapular assessment and care. Patients seen due to "failed PT" elsewhere often report being handed a generic exercise sheet to learn and perform at home...the same sheet other shoulder patients were using. Assessing and restoring WNL thoracic/scapular kinetic chain function is necessary for the shoulder/upper limb to perform normally. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) You can read the full version below Background: Traditional exercising and rehabilitation for shoulder limitations and injuries continue to be heavily focused on GH joint function and strength/mobility, and active and athletic populations can at times have recovery programs falling short to achieve full function. This study looks at thoracic mobility in unilateral and bilateral UE overhead ROM to assess kinetic chain connections in regards to necessities with functional movement. Methods: A systematic review through June 2018 of 554 initially retrieved studies resulted in seven meeting eligibility criteria that included a population of healthy 18-40 year old men and women (Males= 33%) with a sample size of 168 individuals, including 20 athletes. Thoracic spine extension, rotation, and lateral flexion were assessed during upper limb abduction, right scapular elevation, flexion, extension and scapular elevation, flexion and abduction, external rotation, functional flexion and (B) elevation using various data acquisition/measurement systems. Results: Unilateral and bilateral UE full flexion elevation resulted in 6.7-8.0 deg and 12.0 – 15.0 deg of thoracic extension, respectively. Unilateral and bilateral UE abduction elevation resulted in 3-4 degrees 9.0 – 12.8deg of thoracic extension. Lateral flexion ranged from 2.7 – 9.0 deg between various studies during different planes of unilateral end ranges of elevation, most often in contralateral direction and at lower thoracic segments especially. Thoracic rotation ranged from 2.1 – 11 deg for the various planes of elevation, greatest being scaption and abduction. Lateral flexion and rotation were negligible during (B) maximal elevation. Thoracic movement in early/mid ranges of movement have poor evidence/agreement with singular studies reporting 11 deg extension at mid range flexion and 8.9 deg during ER AROM. Author's Conclusion: There was significant thoracic extension occurring in flexion, abduction and scapular elevation in unilateral and bilateral UE elevation. Although the evidence quality is low, sample size small, and more research would be beneficial in an athletic population, a more thorough thoracic spine focus is warranted for practitioners working with athletes on functional UE movements involving the kinetic chain. THE PEAK PERFORMANCE PERSPECTIVE: As a referring physician you’re often challenged by making determinations of what treatments to recommend or what “good” therapy entails when prescribing physical therapy for various upper limb conditions. Common expectations for traditional physical therapy would certainly include possibly local modalities to reduce pain and inflammation, manual therapy, and local stretching and strengthening. Evidence has been lacking regarding the kinetic chain importance of the thoracic spine’s mobility and shoulder/upper limb function. Heneghan et al provide some valuable data that helps identify the relationship of thoracic motion during arm movements, providing a basis for prescribing and expecting that shoulder/upper limb care will assess and treat related thoracic spine limitations that may be contributing factors or could be a source of slow recovery or “failed” conservative care. Individuals coming into a physical therapy clinic with pain and limitations with their shoulder or elbow do not expect that their pain is caused from joints or muscle limitations from a region not directly at the site of their pain. But what we find as movement specialists during kinetic chain assessments, supported by Heneghan et al's findings, is that thoracic spine limitations in any one of the three planes, can play a role in limiting arm mobility (especially thoracic extension related to overhead function) resulting in negative effects during work, ADL, and/or athletic activities performed. These limitations more proximally at the thoracic spine certainly happen for a variety of reasons, most commonly sedentary work duties (especially with prolonged neck flexion or computer screen use) , poor posturing in general, or activities involving prolonged/repetitive spinal flexion such as masonry and lifting from lower levels. Another key component can be attributed to classic forms of fitness training that many have become accustomed to involving isolated single plane movements such as weight machines or group fitness classe. These are commonly performed with bilateral upper extremities simultaneously which can be safe and effective for some, but if there are other mobility restrictions such as with the spine, then not just the shoulder but the more distal joints can be stressed more and in abnormal locations. Those forms of exercises also do not necessarily train one's body for the stresses of athletic events including spiking a volleyball, swimming freestyle or backstroke for example, or throwing/serving overhand in baseball, volleyball or tennis. The repeated stresses on those more mobile joints such as the shoulder, in the presence of thoracic mobility limitations, can then lead to instability and possible more serious tissue damage and even the need for surgery when not addressed in time. Heneghan et al reminds that there exists very little literature on how more proximal segments in the kinetic chain, including the thoracic spine and pelvis, affect more distal segments in athletic events. They do, however, cite that other researchers have discovered approximately 55% of total force and kinetic energy during a throw is derived from the thoracic spine and approximately 80% of total axial rotation is utilized. They also noted prior research demonstrating a 3x higher elbow/shoulder injury prevalence for softball players with limited trunk rotation mobiity. This leads to the question - “Why do so many shoulder rehab programs only focus the involved shoulder, elbow, or wrist?” It has been our experience that many traditional UE strength exercise movements are not tolerated well by patients in a rehabilitation program for "shoulder pain", including unilateral isolated, typically long lever type movements with either weights or resistance bands, as they can excessively stress GH jt structures, and sometimes even bring on more impingement symptoms or joint crepitus, and pain in general - especially because they are oftentimes taught in very strict postures that prevent thoracic mobility contribution to total motion. Some examples include traditional long lever exercises like flexion and abduction raises, empty cans, full can scaption, T-Y-I (mid/lower trap stimulus), wall walking, door sliders (abd press in ER) among others. While these aren't "bad" exercises, they can easily be inappropriately applied at the wrong time during recovery, through ROM that is irritating, and often are done intentionally preventing scapulothoracic motion under the auspices of "strict technique" and "isolation" concepts. These patients or fitness enthusiasts often have increased thoracic kyphosis and anteriorly tipped scapulae, which then prevents fluid and necessary humeral head mobility and control. So if proximal structures that are limited are not addressed, oftentimes recovery is slow or absent leading the patient to report back to their physician complaining that nothing has changed, or the pain has not decreased, or they still cannot play their favorite sport. The appearance of a potential “failed case” of PT then may trigger more expensive testing or injections etc when, in fact, it was simply more thorough kinetic chain care that was needed. Once addressing thoracic and lumbar spine limitations, the scapular and GH joint mechanics and ultimately functional use tends to improve. A great example would be the financial planner sitting 40 to 50 hours per week and then reporting he/she is feeling frustrated when one shoulder hurts when they play in their once weekly volleyball league. Working on transverse and frontal plane thoracic mobility, as well as thoracic extension, will allow for kinetic chain scapular posterior tipping/adduction/upward rotation. This will allow for full overhead GH jt mobility with successful humeral inferior gliding to prevent impingement when serving/hitting overhead, and ipsilateral lateral spinal flexion for loading into overhand serving. Without the thoracic mobility, the scapula will be blocked and rotator cuff impingement will likely happen. With all UE overhead movements, Heneghan et al’s systematic review noted a constant, that all UE movements initiated some level of thoracic ROM, but only at mid to end range of UE elevation. The greatest thoracic ROM needs were found to be thoracic extension with full UE overhead flexion elevation (6.7-8deg uniliateral and 12-15 degrees for B UE), followed closely by scapular elevation (4-8.9 deg unilateral ) and UE abduction (9-12.8 deg bilateral). The limitations for this systematic review do state only one study looked at an athletic population, and some sports with a greater proximal restriction including wheelchair basketball may require more focus and more thorough assessment. The meta analysis does have some limitations. The quality of studies was generally low, the study population was mostly females, and these were not athletes per say but “of athletic age” rather. Therefore the generalizability to other populations must be considered, however, there was a consistency among studies demonstrating thoracic motion relationship to shoulder elevation end ranges especially. Physicians prescribing PT for shoulder and UE conditions have an evidence basis for appreciating the importance of and expecting a full kinetic chain assessment, especially including the thoracic spine, for their patients being prescribed PT for UE pain or limitation, regardless of age, sex or activity. We may also want to consider including more spine focus in post-operative protocols, along with respect to healing the injured and repaired tissue. By considering the authentic biomechanics effecting and contributing to stresses and healing potential of involved tissues. We will be doing a more positive service to our patients and they may even have improved function and mobility than they have ever had prior. THE PEAK PERFORMANCE EXPERIENCE Greg stated: "I don't have any pain with activities!" HX: Greg was performing push-ups during a workout and felt a pop and grinding in his R shoulder and pain continued with even light exercises and movements from that point on for approximately one year. Using his R arm during his job tasks started to become uncomfortable. Pain levels could reach 8/10 at times. Any lifting and reaching with his R arm became an issue. Objective Data: MEASURE ( *=pain) Evaluation DC Thoracic Posture Kyphotic Scapular Posture Protracted Thoracic Rotation 59 / 50 Shoulder Abd IR 50 56 IR up back T10 T8 Overhead Press Reach Unable * 5# done 10x Speed's (+) (-) O'Brien's (+) (-) Jobe's (+) (-) Sulcus sign (+) (+) Treatment: Manual: Post/inferior humeral mobs, pec minor release, horizontal abd with IR stretching Exercises: Posterior capsule stretching, T-spine extension/SB/rotation stretching, T-spine frontal plane/transverse plane strength with dumbbells, T-spine extension drills with shoulder OH pressing with biases towards rotation, resistance tubing RC strength with in-sync T-spine rotation and SB, dumbbell push-pull drills for scap stability, serratus strength with tubing and DBs progressing in scaption and SG plane OH. Outcomes: Painfree ADLs, Painfree incline push-ups ~3ft elevation table, painfree plyo shoulder drills and no limitations with work tasks. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patient's functional goals.

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE October 2021 Subacromial Impingement RCT: Are We Being Fooled by the Literature…. Conservative Care Prescribing for SA Impingement Re-examined by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 50 yr old male c/o gradual onset R dominant side shoulder pain possibly related to a new fitness routine started 3 months ago with increasingly heavier loads and new exercises along with a weekend of trimming trees and other yardwork. He has (+) impingement test findings, tender at SS and LHB tendons, limited/painful elevation and Horiz Add AROM, and weakness/pain with resisted Abd, Jobe, and Abd’d rotations isometric screening. Plain radiographs show mild Type II acromion, no frank osteophytic or DJD changes. Patient has used NSAIDs, seen massage therapist several times, and tried 4 weeks of BIW Physical Therapy without significant improvement. My clinical thinking is: PT/ treatment failed: Do a dexamethasone subacromial injection and FU in 2-4 weeks to consider Physical Therapy again. PT /treatment failed: Order an MRI to better ascertain involved structures and ensure no labral pathology or cuff tearing that might explain lack of improvement, then determine best care. Keep things simple: Provide the patient your customized shoulder/RC HEP sheet and encourage specific adherence to that progression, place on prescription level NSAIDs and FU in 4-6 weeks. Prior care may be inadequate/limited: Briefly review what was done in PT. If excellent/thorough then consider A, B, or C, otherwise refer to more expert PT/group for more thorough assessment and individualized program involving manual therapy, customized exercise, and modalities if necessary then FU in 4-6 weeks. PT / treatment failed: Schedule MRI and prepare patient for likelihood of Arthroscopy to get a better look at the joint/tissues and address findings since prior care has failed. CURRENT EVIDENCE Clausen MK et al, Effectiveness of Adding a Large Dose of Shoulder Strengthening to Current Nonoperative Care for Subacromial Impingement. Am J Sports Med, 49:11, 2021, 3040 - 3049. https://journals.sagepub.com/doi/full/10.1177/03635465211016008 (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Shoulder impingement is a highly prevalent shoulder condition that is seen frequently in office by both primary care and orthopedic specialist physicians. Discerning best practices for prescribing conservative care is key, especially as more recent studies have recommended against subacromial decompression surgery ( BMJ 2019), at least as an early treatment option. But clinicians must be wary of quick scanning the literature to avoid misguided thinking based on inappropriate conclusions offered by study authors. As is said…”The devil is in the details” holds true! Clausen et al examined the addition of (an intended) 12 hrs of rotator cuff strengthening exercises over 16 weeks to increase the time under tension stimulus in an Intervention Group(IG) along with “usual care” compared to the control group receiving only “usual care” that reportedly could include modalities, education, exercise, and manual therapy (but were not standardized). There were no between group differences in SPADI score improvements noted from baseline to 4 months. The Intention to Treat analysis also showed no differences for change in Abd or ER strength, Abd AROM scores nor for Patient Acceptable Scale Score(PASS) or global rating of change. Also, only 48% control and 54% intervention groups reached the PASS. The authors concluded that larger strength doses during Subacromial impingement care do not result in superior results. The initial reaction to their conclusion for some may be that four months of therapy was only effective at a mediocre level and some might even characterize as “chance” since only approximately 50% reached the PASS. Others risk deeming this RCT a bit of a “nail in the coffin” of more extensive or lengthy therapy exercise routines, particularly strengthening. One might even be led to ponder “Maybe simple HEP sheets are adequate vs doing formal PT.” It risks serving as evidence that conservative care is inadequate and possibly become reason to entertain surgical intervention earlier. The authors’ conclusion seems premature and inappropriate once you “look under the hood” of this study though. This study’s failure to show superior results with “more strengthening” exercises alone is not disappointing but rather somewhat predictable, especially considering the design allowed in the “usual care” portion. Their findings would, if true, nevertheless, support our position that each patient’s care must be customized to determine not only which exercises are appropriate and when, but also the loading parameters and progressions, as well as pain or inflammation reducing modality/procedure use (ie Class IV laser, iontophoresis, etc) and manual therapy needs for hastening recovery of kinetic chain function. The patient case study demonstrates a comprehensive functional biomechanics and manual therapy based program using customized exercise progressions to achieve recovery in a patient with impingement/RC pain syndrome that is commonly seen in the clinic. Background: With recent recommendations against subacromial decompression non-operative care options become primary treatment, but some studies suggest current care approaches may lack adequate strengthening effect. Purpose: To determine effectiveness of adding a large dose of “time under tension” inducing strength exercises to “usual care” conservative care alone. Methods: RCT design double blind study allocating 200 consecutive patients diagnosed with subacromial impingement syndrome (SIS) aged 18-65 yrs into a Control Group of “usual care” ranging from BIW to 1/mo Physical Therapy over 16 weeks or an Intervention Group (IG) that had four sessions for added training and follow up with a time under tension optimizing strength exercise HEP added that involved eventually three exercises and progressed from 3x20 QD for the first and eventually became QOD for 2x10 for all three during Phase III portion. Measures included SPADI and secondary strength, ROM, quality of life rating, and Patient Acceptable Symptom State (PASS) score. Findings: Both per-protocol and intention-to-treat analysis showed no between group significant differences for any of the outcome measures. SPADI improved for both groups. At 4 months only 54% of IG and 48% of CG patients reached PASS. Author's Conclusion: The addition of larger doses of strengthening exercises to usual nonoperative care for shoulder impingement treatment did not result in superior outcomes. Only half of patients having conservative care achieved PASS by four months, leaving many with unacceptable symptoms. THE PEAK PERFORMANCE PERSPECTIVE It is subtly clear in the background presentation by these authors that the 2019 BMJ recommendation against subacromial decompression surgery was less than appreciated. They state “Such drastic changes to care pathways may leave patients without further treatment options if nonoperative care fails.” Their conclusion added “...leaving many of these patients with unacceptable symptoms. This study showed that adding more exercise is not a viable solution to this problem.” As orthopedic specialists and primary care physicians seeing patients diagnosed with subacromial impingement syndrome making correct decisions about conservative care options is a daily requirement, if not at least weekly. The search for evidence to base those decisions upon could easily land one on articles such as this month’s by Clausen et al in AJSM, considered a highly regarded resource for clinical judgement and introspection. While the data has increasingly supported non-operative measures as a first line of defense for shoulder impingement we do not believe that surgery is unnecessary, unwarranted, or inappropriate depending on the case. Again, the challenge may more so be in how studies are done and data presented. We go back to the concept that each patient is an individual and the patient’s history plus findings along with the professional scientific data can both inform that decision process. Both are necessary. This study does demonstrate, however, that “The devil is in the details” still holds true with scientific studies. In school we’ve all been warned to not simply read the abstract and move on, assuming an author’s conclusions are sincere and thoughtful and reasonable. The risks in Clausen et al’s conclusions here are several fold. One might be led to conclude that conservative care (ie, physical therapy) is generally inadequate and ineffective and thus that surgery may be a necessity earlier in the process of treatment, especially when apparent “failure of care” seems evident. Also, some may believe this data demonstrates that more extensive exercise regimens are unnecessary and ineffective compared to “keeping things simple” with a basic series of HEP from a prepared sheet that could be given out in the office or expected to be the level of “simple care” offered at a PT clinic. Their premise for adding strength exercises is based on evidence of inadequate strength gains from “standard” physical therapy, however, a careful look reveals this came from a design where patients only did strengthening during in-clinic visits and did not have any Home Exercise Program (HEP) responsibilities. That is hardly evidence the “usual” physical therapy is, as a proven standard outcome, falling short in restoring strength. Nevertheless, their contention that therapists oftentimes do underdose strengthening exercises is likely a very valid criticism/concern. Still, before simply throwing more volume of strengthening exercises at patients we must remember that other factors contribute significantly to exercise tolerance and design. ● How inflamed and pain sensitive (and reactive) are the tissues involved? ● Are we seeing true “weakness” having developed or is this potentially pain-induced inhibition that does not necessarily require substantial strengthening dosages/stimuli? ● Are there comorbidities to consider that impact common exercises choices? ● How will pain/discomfort during or after exercises be handled? ○ Attempting generally symptom free strengthening? ○ Allowing limited symptoms during and/or after that must resolve within 2-24 hrs (depending on rationale/philosophy)? ○ Encouraging intensity adequate to produce mild (or greater) symptoms lasting only 2-24 hrs? They also make the mistake of overgeneralizing the concept of “larger doses of strengthening” in the title and article. It more accurately should read “time under tension (including isometric phase) optimized HEP RC strengthening” instead. Clausen et al ignore external validity rules when stating that more “strengthening” exercises are no more effective than usual care. Actually, what is no more effective is utilizing a limited amount of isometric based time-under-tension emphasized home exercise reliance with limited 1/mo average provider training and feedback. A major factor also is the lack of clarity on what sort of strengthening the “usual care” group had already performed. Clausen et al utilized a thoughtful progression regarding QD exercise moving toward QOD, however, it was odd that they added one exercise per month with an eventual program of 2x15- - - > 2x10 QOD for each of the three added strengthening drills, two of which were for ER’s. It was a bit unusual that during the QD phase patients performed 3x20 as their “to failure” target. Normally in strength and conditioning if an athlete were performing a progressive resistive exercise for three sets to fatigue they’d very likely be taking 48 hr recovery between sessions. They utilize very specific slow contractions + isometric “time under tension” model program of only three additional Abd and ER exercises. This hardly qualifies as what many might deem “larger doses” of exercise and, in fact, the eventual compliance finding was that instead of 12 hrs of additional total exercise achieved that the IG only did 2.9 hrs of added exercise (per time under tension) over the course of the study. Despite being a “gold standard” RCT design, the findings here should be taken with caution in leading a clinician to forsake significant strengthening stimuli for impingement cases. It does also call to question the common concept of “protocol” type approaches to care. While the study individualized the loading used based on performance and symptom resolution within 24 hours, it nevertheless used very specific, limited exercises and did not allow for customizing angles, planes, exercise choices and sequencing/progressions or altering exercise parameters. It is not clear that cervicothoracic or scapular issues were adequately addressed as key contributing factors to the condition’s onset or recovery capacity. Decades of experience have shown us that individualized functional biomechanics screening and exercise progressions are very often necessary, instead of more simplistic protocol driven simple progressions. Customizing exercise selection, order, sequencing, and making unique adjustments (such as path of motion plane tweaks to avoid symptoms, hand placement to effect more RC stimulus, the use of or cueing away from allowing kinetic chain synergy among others. Manual therapy to address pec minor restrictions that are facilitating functional impingement along with ensuring thoracic extension and ipsilateral rotation especially ( due to more common same-side reaching with ADL) is crucial. With more advanced demands during goal activity then Type I and II thoracic motion can be considered. Finally, modalities such as the Class IV laser can be very helpful in reducing pain and inflammation to allow earlier intensive exercise. The case below illustrates a comprehensive approach that worked successfully, rather than a mere “extra-volume” of simple RC strengthening drills. A kinetic chain approach helps ensure that the key or at least some of the likely underlying contributing factors for having developed an overuse problem are addressed. THE PEAK PERFORMANCE EXPERIENCE Michael said: “I feel better than I have in years! Now I can lift weights again and golf without pain!" HX: 57 yr old male reports h/o five years with (B) shoulder pain that developed gradually with increasing fitness exercise and weight lifting as well as ADL use. His CC are frequent L and infrequent but more intense dominant side R shoulder pain with fitness/exercise, ADL lifting and reaching, sleep, and recreation (golf, shooting basketball with son). Subjective: Pt reports 80% function and pain L 2/10 and R 4/10. Quick Dash 11% and Sport module 19%. Objective: (Pt had inconsistent attendance due to job demands. Seen 14x over 4 months) (*=pain) Initial Eval DC Re-Eval Flexion AROM 1500/1500 1630/1520 IR AROM T9 * / T11 T6 / T9-10 Abd IR AROM 250/250 550/470 Pec Minor Tightness Mod/Mod Min+/Mod Isometric Flexion 6.6 kg* / 12.8kg 12.8kg / 14.5kg Abd 8.8kg * / 13.7kg 13.4kg / 13.4kg Overhead Press 1st sx L 3# / R> 45# 25# elliptical 16x/19x Abd ER NT 15# 27x / 30x Push ups ½ depth painful 10” box > 10x no sx Key Findings: Thoracic extension and rotation limited, pec minor very tight (B), posterior RC/capsule limited with Hor Add and Abd IR ROM. Elevation strength and Abd Rot’s all weak and painful. Impingement tests (+) in (B) shoulders. Treatment: Manual therapy targeting thoracic spine and pec minor along with GH joint capsule mobilizations for restoring especially inferior capsule length to allow elevation end ranges along with Horiz Add and Abd IR. Self stretching/mobilization/ROM program for same structures-tissues done. Painfree strengthening progression initiated for promoting better scapular retraction and also improving upward rotation ease (based on pec minor induced chronic protraction with reaching/lifting especially) and also 300 abd’d rotations. Strengthening progressed on to sx-free plane elevation with reduced depth starting motion on incline press to reduce gravity demand at 90 and end ranges of lift. Long lever strengthening began lying with tubing to again reduce demands at key impingement ROM zones will still proprioceptively stimulating independent function into full available elevation without pain. Early on parameters were BID 10- - ->30x and then later once a base established PRE were gradually progressed to 2x15 QD and then finally 3x 10-12 TIW for more intensive loading. Outcome: Pt had difficulty attending regularly due to demands of job. He was only infrequently seen BIW and more often 1/wk and still then bouts of 2-3 weeks without visits. Nevertheless he reached self reported > 90% function on each shoulder and had resumed canoeing, kayaking, shooting baskets with his son, playing golf and sleeping comfortably. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE June 2021 Is Shoulder Pain and Mobility Loss Really The Shoulder’s Fault? by Allison Pulvino, PT, MSPT, CMP, FAFS CURRENT EVIDENCE Malmstrom et al. A Slouched Body Posture Decreases Arm Mobility And Changes Muscle Recruitment In The Neck And Shoulder Region. Euro J Appl Physiol, 2015. 115: 2491-2503. Background: Shoulder pain is one of the more common areas of the body to develop pain and limitations, and it is thought that having a slouched posture due to congenital reasons, prolonged desk work, or ADLs requiring repeated flexed postures. When the body alignment changes, joints, and muscles have to change how they move through their available range and Malmstrom et al. want to see if there is a correlation between increased thoracic kyphosis and increased work for shoulder muscles as a result, including upper trap, lower trap and serratus anterior. Methods: Twelve male subjects (23.3 +/- 1.5 years) performed maximum arm elevation in both upright and slouched postures with a 3D movement and EMG recording arm movement and spine movement, as well as EMG activity in the upper trap, lower trap, and serratus anterior. Results: Slouched posture resulted in a decreased total arm elevation by 15degrees and a decreased arm velocity by 8% during upward and downward arm movements. The peak muscle activity in a slouched posture also increased in all three muscles: UT +32.3%, LT +48.6%, SA +20.9%. The total muscle work with upward movements in a slouched posture increased significantly as well: UT +36.6%, LT +89.0%, SA +19.4%. Downward movements had increased total muscle work as well: UT +29.8%, LT +122.5%. Limitations: The main limitation in this study is the 12 participants being asked to create an increased thoracic kyphosis. Although the position of the spine will be the same nonetheless, the muscle recruitment could possibly be much different if there is a prolonged positional spinal change for true chronic spinal positions instead of an instantaneous forced conscious change. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: While there is not a singular “cause” underlying non-traumatic shoulder pain the topic of “poor posture” often is acknowledged but risks becoming so routine in the minds of clinicians and certainly the public that its role too often gets neglected or even dismissed during rehab. This study provides good foundational “mechanisms” of evidence to compel both clinicians and patients to fully appreciate the literal negative impact accentuated kyphosis has on shoulder demands and function. Malmstrom et al examined the association between an increased thoracic kyphosis and changes in shoulder kinematics and muscle recruitment/activity in the upper trap, lower trap, and serratus anterior. Their findings showed a positive correlation with both a decrease in maximal overhead shoulder ROM and an increase in muscle work required to elevate the shoulder overhead during increased thoracic kyphosis as compared to normal posture. This study provides valuable data to motivate patients to take the connection of postural-focused manual therapy and especially exercise to their shoulder recovery seriously. It also provides a valuable reminder to referring physicians as they order Physical Therapy and also are scrutinizing care choices for patients who may appear to be “failing” initial therapy. THE PEAK PERFORMANCE PERSPECTIVE It has been pretty commonplace to assess a patient with shoulder pain and hear the main aggravating movement is reaching overhead. Both doctors and physical therapists alike have heard this many times over, yet each patient may have other limiting factors needing further assessment. As a referring physician, the expectation most often is that the Physical Therapist must “play further detective” to see what body structures are potentially contributing to pain and limitations, determining how to address both the local tissue pain/inflammation along with necessary ROM/strength/neuromuscular retraining work. At Peak Performance PT we’re in full agreement with what Malmstrom et al confirmed in this particular study, that an increased thoracic kyphosis does affect overhead shoulder mobility and muscle efficiency. And while that fact may not seem like “rocket science” (and is generally well known and understood in musculoskeletal care), it all too often ends up being brushed by the wayside by all the various local shoulder exercises available. When hearing a patient’s history of their present shoulder complaint, repetitive overhead reaching activities obviously stand out in our mind as physicians or therapists as being potential causes for why this individual is in our office. For example, gardening for 4 hours in the afternoon which includes leaning over (kyphosis) and reaching out or maybe it’s painting walls...and then pain is felt later that night putting dishes away in the top kitchen cabinets or changing a light bulb. Malmstrom et al’s data help provide a “connecting of the dots” for many cases that help us as clinicians appreciate why the shoulder pain developed but also empowers patients to realize how this talk about posture is more than just your grandmother’s old warnings about sitting up straighter. It helps bridge the gap between a shoulder that is painful and the thoracic spine that “feels fine” to them and therefore seems unimportant and unrelated. For some patients, the thoracic kyphosis was induced by positioning, as in the gardening example with temporary thoracic flexion posturing. For others, they do have generally accentuated thoracic kyphosis, which leads also to the protracted scapula and pec minor shortening, affecting scapulohumeral mechanics. We see shoulder patients who’ve sometimes been given generic HEP sheets or found shoulder rehab programs on the internet that may even include “postural exercises” like simple scapular retractions. We don’t find those adequate at stimulating change in most patients, despite possibly “checking the box” as having addressed posture. Other times we see “failed PT” cases where plenty of appropriate local shoulder exercises were done but too often patients indicate “the therapist never put their hands on me” (ie. manual therapy) - especially for the thoracic spine and scapula. While as clinicians we both know these cases aren’t surgical, but as referring physicians it’s difficult to motivate patients to “try PT again” If they had already been through physical therapy and they only feel slightly better and are still limited at tennis or lifting their toddler into the car seat...etc. Patients are simply looking for answers and solutions that work...but they also often ask “what’s going to be different ‘this time with my PT?” As a referring physician, you also play a key role in prefacing the PT experience too. Providing patients evidence like Malmstrom et al found, noting the significantly increased load on muscles and the loss of ROM with increased kyphosis it helps “connect the dots” for the patient as to why “out of the blue” this developed. When you confidently note that their PT will be addressing their postural issues it also reinforces that their physician and PT are on the same page and to feel confident they actually don’t need shoulder surgery like their sister or neighbor did, and physical therapy can help them recover. Protocol type approaches may work for a limited number of patients long term but at Peak Performance, we find a very high percentage of our shoulder pain patients do have scapulothoracic factors that potentially are contributing. They’re evaluated on Day One as one of our clinical standards. It’s a simple concept associated with our specialization in Applied Functional Science – the kinetic chain components, especially adjacent joints/structures, must be evaluated as integral parts of understanding the stresses on that local injured/painful shoulder tissue. We find that working on the body as a whole system will always find other regions that are secondary factors of pain, but still affect ADL life. For example, if someone sits for work 40 hours per week and has a slightly increased thoracic kyphosis, they may also need to have their psoas and pectoralis minor flexibility in the sagittal (but also frontal and transverse) plane assessed likely potential kinetic chain limiters of full overhead shoulder mobility. Tight hip flexors can lead to a forward pitched spine in standing and therefore disadvantage full elevation similarly to a thoracic kyphosis pre-positioning. A restricted pec minor that prevents adequate posterior tipping, as per the commonly referred Upper Crossed Syndrome, and also popularized by Kibler and others will clearly lead to abnormal forces at the shoulder and impingement. Since flexion reaching while bent over in thoracic flexion or upright in kyphotic postures disadvantages normal shoulder function, then a key focus should be improving thoracic extension, scapular posterior tipping, and upward rotation. Although it’s not always easy to directly focus solely on gaining sagittal plane mobility. Traditional PT exercises work serratus anterior as a scapular protractor, isn’t scapular protraction related to more thoracic flexion? Is a lack of protraction function what the serratus was lacking? Asking a patient how their prior PT was going and what exercises they were doing can shed some light on this topic. They may have been performing typical overhead arm stretching, scapular protraction exercises with weights, and then standing or prone back extensions. But these exercises initiate movement in neutral (their kyphosis) where the maximum spinal range may already be achieved. Focusing away from the end range and tweaking spinal extension while biased in another plane may be more beneficial and help stay away from the pain provocation. Addressing the “other” thoracic planes of motion can also be critical, though not a specific point of the Malmstrom et al study. Seeing frontal plane thoracic limitations with proper mobility assessment can shed some light on why abduction or lateral overhead shoulder reaching is painful, as the scapular upward rotation has to happen to prevent impingement in the subacromial space. In the same way that a sagittal plane thoracic kyphosis affects especially sagittal plane scapular and thereby GH mechanics for elevation, we must remember that frontal and transverse plane thoracic to shoulder mobility connections also exist. It is not common to have pure sagittal shoulder overhead flexion without coupling in some side bending and rotational movement, for example with swimmers and throwers. Every individual has specific limitations when shoulder pain is the primary complaint. Directly assessing someone’s multiplane shoulder ROM but also especially adjacent (and distant) kinetic chain 3D function can shed some light on how many different regions of the upper quadrant or even the hips and pelvis can be affecting their life in a negative and inhibiting manner. Normal and pain-free shoulder elevation with proper scapulohumeral rhythm can be achieved when proper spinal mobility and the correct use of shoulder muscle recruitment is trained, always in a manner that is specific for each patient. The case below demonstrates how important manual therapy and specific functional exercise approaches were helpful in resolving symptoms and restoring function for a very typical shoulder pain case. THE PEAK PERFORMANCE EXPERIENCE Doris states: “Watch how I can lift my arm all the way now! It doesn’t even hurt!” HX: Doris is a 72-year-old female with ℅ L shoulder pain from “reaching too far and too much” she believes. Sx’s started to be referred down to the elbow and she lost the ability to reach her L arm in all directions. She also reported that sleep became almost impossible. No trauma reported in the past. Subjective: Doris reported 8/10 L shoulder pain with any active L shoulder movement. She was unable to use it for any ADLs initially and could not sleep well or lean on L arm. Objective: Unable to tolerate any active ROM so special tests NT. TTP all RC muscle bellies and tendons including proximal bicep. No neural involvement. All UE dermatomes intact. Cspine mobility screening negative for radicular sx’s. Severe Tspine kyphosis with dowager’s hump. MEASURE ( *=pain) Evaluation (limited due to severity of Sx) Discharge Shoulder flexion (deg.) 130* (PROM only) 1520 AROM Abduction (deg.) NT due to pain 1200AROM ERn (deg.) 42* 650 ER 90(deg.) NT due to pain 700 IR 90 (deg.) NT due to pain 800 Tspine rotation L 180, R 300 NT Cspine rotation L 50%, R 75% B 75% Cspine ext 50%* 75% Cspine SB L 50%, R 25% 50% B Tspine ext UNABLE d/t L pain 50% with L shoulder flexion overhead Apley's Scratch test ER L Unable, R T1 T1 B shoulders Apley's Scratch test IR L L5*, R L1 L3 B shoulder (no pain) Treatment: Modalities: High-intensity laser treatment, 2 sessions, entire L GH jt capsule, and periscapular soft tissue. Manual: Tspine rotation and extension mobs with WB lateral flexion mobs. GH mobs for post and inf capsular mobility. Soft tissue mobilization UT, levator, teres major, pec minor, and infraspinatus. Exercises: Spinal extension active self-mobilizations in WB, spinal AROM drills for FR and TR plane spinal mobility, PROM GH flexion/abduction/ER. AROM UE overhead drills with spinal extension and scapular elevation with BW and weights for progression, TR plane spinal rotation with weighted diagonal pattern TR plane loading and spinal extension loading in standing, FR plane spinal load for shoulder and ROM progressing from AAROM to AROM with weight. Outcome: Pt is able to sleep without pain, carry groceries in L arm, reach overhead in flexion and abduction without pain onset, and can grab objects in her kitchen cabinets overhead without pain.

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE February 2021 Managing Shoulder Pain & Stiffness: Updated Treatment Approach to Frozen Shoulder Contracture Syndrome WHAT WOULD YOU DO? A 47yr old female with 5 mo h/o a shoulder overuse episode from painting her ceilings and trim that was followed by tennis OH serve lesson for 60min two days later. She developed shoulder soreness within hrs of her lesson that did not resolve over the next several weeks, causing limited elevation and reaching ADL. She noticed by the 3 month mark she was unable to fully reach overhead, behind her back, or out to the side, assuming her pain and limitations confirmed a tendonitis. Physical Exam showed AROM painfully limited to 1200 flexion, 500 ext, Abd ER 600, and IR to S2. Isometric screening shoulder was painful and weak especially for Jobe, Abd’d IR & ER, and Abd. Tender at supraspinatus insertion > LHB tendon. (+) Neer’s and Kennedy’s tests. PROM 600 ext. Which test would be key in determining whether the patient has RC tendinopathy vs frozen shoulder contracture syndrome? AROM horizontal adduction PROM Abd ER Abduction AROM Isometric flexion SUMMARY: Duenas et al demonstrate in 11 patients with frozen shoulder contracture syndrome (FSCS) that once weekly manual therapy customized to their acute condition/status combined with 5 d/wk HEP stretching results in significant gains in measures of pain, self-rated disability, ROM and strength impairment measures following 12 wks of the program as well as at 6 and 9 month follow ups. Reeves et al in a recent systematic review showed that complete resolution without treatment is unfounded. Clinically it’s critical to identify these cases early - an often missed key differential diagnosis finding for FSCS is PROM not signficantly higher than AROM. Many other studies have supported the contention that BIW manual therapy/joint mobilizations is effective in these cases. Our experience has certainly found faster and more substantial ROM gains leading to reduced sx and better function gains with BIW over once weekly sessions. A key finding of this study was confirmation that customizing mobilization intensity/type etc with symptom status/responsiveness is effective. CURRENT EVIDENCE Lirios Duenas, Merce Balasch-Bernat, et al. A Manual Therapy and HOme Stretching Program in Patients With Primary Frozen Shoulder Contracture Syndrome: A Case Series. J Orthopedic & Sports PT 2019: 49 (3): 192- 200 Background: Manual therapy has been a key factor to reducing pain and improving function in patients with frozen shoulder contracture syndrome (FSCS), however there is no one form of manual therapy that has been proven more beneficial over another. This series provides short and long term outcomes of specific impairments and level of tissue irritability in patients with FSCS. Methods: Eleven patients selected by an inclusion criteria were treated with an individually tailored, multimodal manual therapy approach of PT once a week for 12 visits, coupled with a home stretching program once daily, 5 days a week. Pain, disability, range of motion (ROM) , and muscle strength, of the affected shoulder, were measured at baseline,post treatment, at 6 months and 9 months. Results: Significant improvements in self reported pain, disability, shoulder ROM, and strength post treatment , 63.6% of the patients improved in their overall disability scores, 36% of patients pain improved exceeding minimal clinically important difference ( MCID) and 72.7% of patients pain improved at 6 and 9 months post treatment. Author’s Conclusion: Significant clinical changes were seen in pain, disability, ROM, and muscle strength with a multimodal and tailored approach of both manual therapy techniques and stretching exercises. THE PEAK PERFORMANCE PERSPECTIVE Rachele Jones, PTA, ATC, CAFS As a physician, that first exam opportunity of a painful, stiff shoulder has significant implications on treatment orders. While Physical Therapy is an appropriate starting point for a RC tendonitis/tendinopathy case, it would be projected to have an earlier positive outcome and manual therapy may or may not be a necessary component of treatment in comparison to someone with FSCS. For FSCS, PT orders will most definitely include manual therapy specifically. This is important because too often literature has suggested that “frozen shoulder” is a self-limiting condition that may/will spontaneously resolve within 1-2 years on its own. Other studies have suggested that PT is questionably effective. As clinicians we know that FSCS, also commonly termed adhesive capsulitis, lacks a definitive cause but is more likely to develop for primary risk factors such as: 40-60 y.o, female, has diabetes or thyroid disease, or secondary complications of shoulder surgery or shoulder injury (ie: humeral fx, biceps tendon repair etc). Classic signs of FSCS are significant pain and range of motion loss ( ROM) where PROM or AROM with overpressure are comparably limited to AROM. One critical criteria that is easily overlooked during an examination, which is the best indicator of diagnosis to differentiate between a tendonitis and FSCS is PROM. Typical shoulder tendonitis presentation typically would reveal PROM > AROM. Errors here could result in a provider recommending temporary sling use, rest + med’s, or not recognizing the need to order manual therapy techniques. While this may seem a routine consideration we see a surprising number of FSCS cases from prior “failed” therapy where little or no manual therapy was done outside of simple PROM overpressure. A recent systematic review by Reeves B. et al, The natural history of the frozen shoulder syndrome. Scand JRheumatol. 1975;4:193-196, https://doi.org/10.3109/03009747509165255,has reported early improvements in shoulder ROM with treatment and found that long term complete resolution back to normal without treatment is unsupported. And we can’t forget that Increased ROM can effect the reduction of pain however it does not always immediately result in optimal function. That may take more time and integration of ROM ease with strengthening stimuli. This article uniquely emphasized a multi-modal use of manual therapy, similar in concept to what we use at Peak Performance, based on the patient’s most recent symptom responsiveness. Most studies have simply applied the same grade and type of mobilization to all shoulders - possibly limiting the results. The home stretching program used the same “current irritability status” to guide stretching doses. The study by Duenas et al, despite the small population size, shows both good HEP compliance and a high success rate with customizing each patient's program of manual and HEP together. It was interesting that the authors did not specify whether the patients performed HEP stretching within some specific window of time after the once weekly PT visits. At Peak Performance we definitely find that immediately post-mobilizations is best for PROM and neuromotor integration AROM work to be done. Certainly in FSCS cases there are other areas often needing attention...thoracic spine extension, pectoralis minor hypertonus and shortening, 1st rib mobility. While this study did not address these it should be expected in a well rounded manual therapy approach. PEAK PERFORMANCE EXPERIENCE Chris said: “ My ROM is getting better. I hit tennis balls for about 15 minutes. I was surprised I tolerated it fairly well.” History: 53 y.o. female with symptom onset over 1 year ago lifting something overhead - then exacerbated 4 mo ago playing paddle tennis and the last month was worsening further regarding pain, ROM, weakness, and function limitations. Subjective: 7/10 intermittent pain 2x/wk , ADL’s limited ie: bra strap, taking care of son with special needs. Objective: * = sx R shoulder Eval ReEval 5 wks ( 7x @ BIW ) Quick Dash 69% 38% Self rating Overall 50% 70% AROM / PROM: Flexion 1300 */ 130* 1440 Horiz Abd 1250* / 125 * 550 Abd ER 650 */NT 1050 ER n 65 * /NT 65 deg * Abd IR 50 220 IR “applye’s scratch test” L2 * L1 * Pec Minor max limitation mod Thoracic Rot L/R 35 0 /350 420 /450 Isometric Flex 2.5 kg * 3.3 kg * ER 4.2kg * 5.8kg* IR 4.4 kg * 6.2 kg* Function Testing 3# Abd 120 * 140 * Lateral reach 23” * 30” * Treatment: Joint mobilization of shoulder, soft tissue release of pec minor; AROM, AAROM, PROM, resistance training, and eventually began speed/power training for functional racquet sport return. Discharge ReEvaluation: Pt was discharged prior to full recovery due to extenuating circumstances with family responsibilities. Pt was still in need of formal care but was advised to continue with her HEP. She showed increased ROM, increased strength, decreased symptoms and was able to get back to paddle tennis for at least 15 mins with very limited symptoms.

At this point, I have trusted most of my limbs to Peak Performance Physical Therapy. From three sessions for a sprained ankle to long-term post-op recovery, the staff at Peak Performance has equipped me to target immediate needs and then establish exercise patterns that facilitate an active, strenuous and varied lifestyle. With their help, I’ve gone from immobilized and on crutches to hiking, swimming, team sports, and a job in remodeling. And doctors had said I might never run again! When I think about maintaining my strength and mobility, I think Peak Performance first! Daniel K.

I was diagnosed with frozen shoulder, which caused me right arm pain with most motion, and I was unable to continue my workouts or sleep through the night without being awoken by pain. Andrew taught me stretches that helped get things moving in my shoulder. Each week I got stronger and gained more mobility. By the end of my time at Peak Performance he had tailored exercises for the specific issues I was still having. Overall the personal attention and specific stretches/drills made a huge difference and I would definitely come back if I have other issues in the future. Teri M. Sept. 5, 2019

In August 2018 I slipped and fell on a muddy hill and broke my shoulder in three places. I elected to not have surgery and started PT in early September. I could barely straighten my arm and was in considerable pain. With Andrew’s guidance and encouragement, I’ve regained use of my arm and shoulder and am able to do almost everything I was able to do before my accident. I’ve started golfing again with no problems! Thank you to Andrew and all of the other wonderful staff at Peak Performance for helping me on my journey back! ~ Pamela "Pam" Narsisian May 24, 2019

Andrew and Margaret have done a great job strengthening my shoulder so normal activities rarely give me any pain. Overall I’m very pleased with my results. I highly recommend Andrew and Peak Performance…and Margaret is going to be a great PT! Joseph Hinchman May 6, 2019

When I arrived, I had severe pain in both shoulders and could not reach the second shelf in my kitchen cabinets…or even lift a milk carton while reaching into the fridge. My doctors were suggesting surgery. After sessions with Mike (and with great assistance from Rachele), I can do my chores and so, so much more. And I’m no longer facing surgery! What a terrific team they have here! Each employee helping each other and all of the patients. Their professionalism is impressive. Thanks to Mike, Rachele, Karen, and all of you for giving me back my life! Virginia Graham April 25, 2019

This has been a remarkable experience. I had a standard AC Joint procedure done on my left shoulder. Four week post-op I was having a great recovery, but then things started to decline. The PT I was using was knowledgeable in the standard PT for the procedure, but was not experienced like Mike is at customizing the exercises to my body’s unique needs. I had developed intense muscle spasms in my pecs and it was compromising my ability to perform my PT. Mike did a full-person evaluation. He customized my exercises so I could make progress with the muscles needed without aggravating the muscles in spasm. I was in so much pain and had very little mobility in my shoulder when I started. I am now almost fully recovered! Yay! There were times when it didn’t seem possible and I felt discouraged because I wasn’t progressing as quickly as I wanted. Mike always had the right words to keep me motivated and feeling positive about myself and my body. *PRICELESS* Sarah Noblett

I had a major workplace injury in which I had to have my pectoral major tendon reattached on my right shoulder. I started working with Allison several weeks after surgery, in a sling with very limited mobility. Working with Allison over a 9+ month period, I went from almost no mobility to very close to 100%. I would like to thank Allison very much because I would not be where I am today without her help. She is very knowledgeable and professional, and a credit to her profession as a PT. I also would like to thank the staff for setting up my appointments and working with the insurance companies and doctor’s office. Thank you so much for giving me back my life! Leo Wlasowicz

Having been an elementary teacher for over 25 years, aches and pains were not uncommon to me. But, when I started losing motion in my left arm and was in pain, I was diagnosed with a frozen shoulder. From the first day I started at Peak Performance I knew I made the right decision. Mike knew what exercises I needed to regain movement in my shoulder and reassured me. He and Rachele worked together to make sure the program met my needs. It was a long process but they always were there with a positive word and a good laugh that made me feel comfortable and confident in their approach. Thank you, Peak Performance! ~ Christine “Tina” Maffucci

I developed problems with pain and limited range of motion in my left shoulder that only worsened with exercise and activity. Further evaluation revealed a torn rotator cuff injury that was repaired surgically in August 2018. Mike has guided me through a progressive regimen of stretching and strengthening exercises as my shoulder has healed. I am now well on my way to full recovery, not only from the injury and surgery, but in regaining my ability to engage in the full range of activities I used to do. I am so grateful for Mike’s expertise and persistence in bringing me through to full recovery. ~ William Morehouse

I was referred to your organization, after rotator cuff surgery, by a trainer at Penfield Fitness who knew of your work. I was assigned to Andrew and that turned out to be a really good choice. I’d had this surgery 10 years before, but I must not have coalesced adequately, resulting in a more severe problem. I had neither strength nor range of motion in that shoulder when I met him. Andrew advised me intelligently, humorously, cajoling me to what will be a near-complete recovery. I can now wash my hair with that arm, scratch my back and lift weights overhead that I was unable to lift! During that time I also experienced a knee problem, so we soon transitioned to the other end of my 77-year-old frame. Same outcome…Andrew gave me exercises that have led to pain-free and flexible walking without surgery. I admit, he’s a better therapist than I am a patient, but his encouragement makes following through with his program less of a task and more of a healthy routine. Andrew is results-oriented, clearly knows his “stuff,” and is a true professional. Thank you, man! ~ Arthur North

As an active athlete and mother of two rambunctious young boys, it’s been easy for me to pretend that I have a bit of superhero inside. I was working out, golfing, and ballroom dancing with my husband-not to mention running, jumping, and roughhousing with my boys. I even had my eye on joining them in doing parkour, which nicely complemented my background as a gymnast and weightlifter. But then, I was derailed by the excruciating pain of sciatica twice in one year. The first time, I chose the less intelligent route and decided to “heal” on my own. Upon inevitable re-injury I wised up and went to see the team at Peak Performance. At that point, the burning, muscle-knotting pain extended from my lower back down to my knee every moment of the day. I was prevented from doing any normal activities, could barely concentrate on work and even sleep was a luxury…heck, just being able to put my shoes on would have been a major victory! Fortunately, my boys were more than happy to help me with that chore for almost three months. (So much for being a superhero!) From the moment I walked in the door, I could see that I had come to the right place. I’d been referred to Mike Napierala, who did a comprehensive review of my movements and abilities. He took a whole-body view, assessing past injuries along with the sciatica. He came up with a plan that addressed the root causes of my sciatica pain as well as identified immediate steps to alleviate ongoing pain. He even set out a plan to address a latent shoulder injury once my back was in a place to handle the additional exercises. My back and shoulder healed more slowly than either Mike or I preferred. It was the patience, ongoing customization of my healing plan and, most importantly, encouragement and upbeat attitude I got from Mike during every visit that inspired me to never give up. He looked at all of my activities and athletic pursuits from a holistic perspective and gave me exercises that built one upon the other to encompass the gamut of strengthening, neurological, and balance moves for my entire body—not just for my back. Today, I’m thrilled to have resumed my former life of golfing, dancing, playing with children and working out again. Even more exciting is that I’ve now become an avid parkour enthusiast! The confidence I have in my body now is such a far cry from the pain-filled sleepless nights I had…and I simply couldn’t have done it without Mike and Peak Performance! ~ Kelly Roland

The team at Peak Performance PT helped me work through a variety of exercises to reduce my shoulder pain/impingement. Andrew, Rachele, and the entire staff really care about your recovery (and work you hard They design a plan to get you well, and if you do your part, you will get well! ~ Eugene Rogalski

I came here before and after my shoulder surgery. Raising either arm was painful and only partially possible. I had to stand on a stool to use a microwave or take something out of the cabinet. Putting on a coat was painful. After my surgery, I faithfully followed the program that Karen designed for me. I now have almost full range of motion in all directions and much greater strength than I had before all this. It feels like a miracle! Mary R.

In a world with enemies and heroes, I was my own worst enemy with my long-standing shoulder problem and Karen was my hero! Although I came to Peak Performance for an elbow situation (which Karen also took great care of), it was so nice to address my shoulder pain that had bothered me during basic activities and sports for far too long. I’m excited to continue the exercises Karen taught me. Thanks, Karen! Jeff Welcher December 17, 2018

Note: This blog is Part II of a 3-part series on shoulder pain; click here for Part I. Hi Friend, Allison and Andrew here again. Last week we talked about some different causes of shoulder pain and the importance of NOT always being too quick to blame the shoulder joint itself for the pain you experience there. Right now, we going to dig a little deeper into understanding the importance of detecting and treating the right CAUSE and not just the symptom. A common mistake we see here in the clinic is patients rushing to get a “quick fix” using MRIs, injections, and medications to “treat” the pain in the shoulder. Unfortunately, this can lead to the pain coming back as the symptoms may have merely been “masked” and the underlying causes are still untreated.It's not easy to know or be able to assess these connections in our bodies, but a skilled clinician with working knowledge of Applied Functional Science (AFS) can help you connect the dots to not only reduce your pain...but keep it away.When properly addressing the condition, you want to make sure that treatment is thorough enough so that you don't only get better...but also STAY better! Shoulder pain can certainly be due to impingement or strains in the rotator cuff or bursae, which would require specific treatment in the clinic to mobilize and reduce inflammation at that tissue. As the pain decreases, the key to successful treatment would be to improve nearby joints that were aiding in the dysfunction in the first place. Poor posture of the neck and upper back play a major roll in increasing abnormal stress at the shoulder. Limitations are often found with trunk rotation and extension (back tipping) which alter the bio-mechanics of movement at the shoulder joint. A shoulder not functioning in an optimal position can lead to overuse strains and pains as we are more active in the summertime. Now to answer the question in the title…does the shoulder bone connect to the hip bone!? Understanding functional movement and anatomy can help us to draw connections from two areas of the body far apart that influence each other. Let's say that someone has tight hip flexers (not uncommon) and difficulty extending their hip. This will influence the trunk's ability to tip backwards with any overhead activity or reaching, which can in turn cause excessive glenohumeral (shoulder) joint stress. Lack of hip motion can result in shoulder pain! Hope this helps! Allison and Andrew

As the colder temperatures set in, we often see a rise in the number of patients who come to physical therapy for shoulder pain. Despite living in Rochester, the cold weather is not likely to blame for these problems! Overhead sports, all sorts of yard work and things like shoveling can really take a toll on your joints until they start to nag you so much that you change how you move. Eventually you’re forced to change the way you are functioning and...all too often...to STOP enjoying your favorite activities. Many different structures in the shoulder can cause pain. The rotator cuff ("rotor cup" as some would say), part of the biceps muscle, the labrum (shoulder socket cartilage ring), AC joint (small bump on top of shoulder), and multiple bursae (fluid sac friction reducers) can all be culprits that cause pain and limit function. But sometimes people are too quick to assume the cause is where the pain is and are "fooled" into blaming the shoulder when other nearby parts could really be at fault. Did you know that your shoulder pain can come from its nearby neighbors, the neck (cervical) or mid-back (thoracic spine)? Radiating pain from joints and nerves in both the neck and trunk can send symptoms to the shoulder blade and sometimes down the arm...which can be tricky as they pass right through the shoulder area. Pain doesn't have to be the only "feeling" that can raise a flag or concern; weakness or numbness/tingling can also be a sign that something is wrong. For those of you reading this thinking, "I know, stretching and strengthening exercises are the answer"…you might be right. Or you might not be. And do you know which ones are the right ones to do? You see, the real challenge is first doing an evaluation to determine the source of the pain, figuring out which tissue is making that shoulder hurt but then ALSO digging deeper to find any underlying causes for why it happened in the first place! Seeing a skilled, knowledgeable health care professional is that first step. A good history and a thorough physical exam are the key first steps to discovering why your shoulder hurts. Yes, there are times when "films” might be necessary. But be careful of ‘hanging your hat’ on X-ray or MRI findings. Studies remind us that plenty of people with no pain often have similar findings on imaging studies...so they’re sometimes part of discovering what’s going on, but they have to be interpreted alongside an excellent clinical exam. Too many of today’s common treatments focus on simply masking your symptoms. Temporary “feel good” options do work to block your pain or inflammation, but have they really helped handle the actual problem? Can you be confident this isn’t going to come right back again? Keep an eye out in your inbox for our next email and we’ll share a little more about understanding those different causes of shoulder pain better. Hope this helps!Allison Pulvino, PT, MSPT, CMP, CAFS and Andrew Neumeister, PT, DPT, FAFS

When I first came to Allison, I had severe pain in my shoulder and arm and expected to have surgery to unfreeze my shoulder. It was very hard to move my right shoulder, which made it hard to do everyday things like drive and get dressed. My arm and shoulder hurt even when I was sitting still and this made it hard to sleep. Since working with Allison, my arm has improved greatly, I have much better strength and mobility, it rarely hurts and my surgeon agrees that I no longer need surgery! I can also do most of my normal activities. Allison has done a great job of increasing my exercises as I’m able to do more. Thanks, Allison! Kathleen Dorr November 9, 2018

I injured my neck/shoulder playing volleyball and for weeks had trouble sitting/standing, playing piano, sitting at work and driving…because my neck and arm were constantly sore. After a few weeks, I was able to sleep through the night again, sit at my desk and drive comfortably! Thanks, Allison, for helping me return to doing the things I love! Cynthia A. November 5, 2018

Before starting PT with Karen, I had migraines for weeks and difficulty working and sleeping, along with pain while lifting, a stiff neck and shoulder, upper arm pain and reduced range of motion. After working with Karen, I have only slight pain when lifting heavy objects overhead. I’m enjoying improved balance, reduced pain in my neck and shoulder, and no migraines or pain in my upper arm! My range of motion is greater and I’ve got little to no pain; thanks, Karen! Christina C. September 12, 2018